Ortho unit 3

Question 1

knock knees and bow legs

and management

Answer 1

bow legs = genu varum (knees out, space between feet deminishes)
knock knees = genu valgum (knees in, space between feet increases)
normal space between feet is 4cm.
by the age of 7 most will have developed normal alignment

Question 2

milestones for sitting independently, standing and walking

Answer 2

9 months
12 months
20 months

Question 3

in toeing (pigeon toed) - what is it and what are the causes

Answer 3

often exaggerated when running
often referred because of clumsiness

causes :

• fem neck angle variation (during late development of foetus the leg rotates on the pelvis so the acetabulum points backwards and the fem head on the neck is forward. sometimes this rotary process inst complete by birth so the neck is more anteriorly rotated (anteverted) than normal. so kids born like this can internally rotate their femur lots and not externally rotate much. this is reflected in their posture and gait - in toeing)
• tibial torsion (bone is distorted/warped along its vertical axis). this is a normal variation and should be ignored
• abnormal forefeet - partic the hooked (adducted) forefoot is common. majority correct and residual hooking rarely causes functional difficulties

Question 4

flat foot - types and management

Answer 4

normal variation, rarely causes functional abnormalities except uneven shoe wear
can be rigid or mobile
most are mobile and innocuous
all kids feet are flat at birth and arch may not form until 7.
rigid flat foot is rare and implies bony abnormality - occasionally it is a sign of a more serious disease eg RA

Question 5

curly toes - management

Answer 5

minor overlapping especially 5th toe is common.
most correct
occasionally the crossed 5th toe causes discomfort in shoes - surgery to fix but it is discouraged

Question 6

knee pain in adolescence causes

Answer 6

common cause of referral
usually 10-12yrs
more common in girls when they develop secondary sex characteristics

osgood schlatters
adolescence knee pain
congenital dislocation of hip

Question 7

simple walking problems and difficulties in posture in childhood causes

Answer 7

knock knees and bow legs
in toeing
flat foot
curly toes

Question 8

osgoods schlatters - describe, cause, who gets it, what are the symptoms and management

Answer 8

inflammation of the attachment of the patella tendon to the growing tibial epiphysis caused by excess traction by the quads.
cause unknown
more common in active kids
causes tenderness and discomfort. worse after exercise. may be swelling episodic and can be treated with rest
symptoms cease in middle adolescence when epiphysis fuses

Question 9

adolescent knee pain - who, what is it, management

Answer 9

more common in girls
rarely on arthroscopy an area of patella cartilage is seen to be eroded - chondromalacia patellae.
most grown out of it but if symptoms persist - arthroscopy

Question 10

congenital dislocation of hip

incidence
screening
test
signs
management

Answer 10

1-2/1000 births
better name is congenital hip dysplasia - it reflects the abnormality of the fem head, acetabulum or both.
more common in girls, with familial and racial tendency
can be bilateral
all kids are screened at birth, 3,6 and 12 months.
test - try to dislocate and relocate. may produce a slight click (suspicious) or definite clunk. if undetected it will be obvious in later life.
clinical signs = shortening of limb, asymmetrical skin creases, limited abduction and a limp

if a click - reexamine at 3 months when a radiograph can be justified
clunks - treat from birth. fem head is relocated and maintained in acetabulum using splintage
if discovered late but before wt bearing - treat with gentle traction then open/closed manipulation. then splint in plaster for 3 months.
if late and walking has commenced - major surgery is needed to deepen the underdeveloped acetabulum and reangulate the fem neck to stabilise the hip/ not great results and 2nd arthritis is common.

Question 11

club foot

diff forms and causes of these
treatment for diff forms
follow up

Answer 11

talipes equino varus
if treat early - fully correct mild cases and major cases result can be much improved and functional.
common
mild postural form and fixed form

mild form = after breech birth (related to position in womb).

fixed form = ass. wth developmental abnormalities of nerves and muscles in leg.
can be bilateral

mild form is corrected by manipulation at birth
severer forms need surgery
both cases begin with gentle stretching, firstly correcting the hindfoot equinus and secondly correcting the mid and forefoot varus
mild cases - 6 weeks stretching and strapping in a corrected/overcorrected position is enough
in severe cases - reassess after 6 weeks if correction is incomplete - surgery.

follow up all kids until feet stop growing (14yrs) as late relapse needs surgery. the affected foot is usually smaller

Question 12

spina bifida

diff types
incidence
symptoms and consequences
management

Answer 12

abnormal development in the first 3 months of developing foetus

spina bifida acculta

• minor bony abnormality
• 2 % population
• usually no significance but some develop mechanical back pain and some may get tethering of the spinal cord to the higher lumbar vertebrae during growth - diastamatomyelia

spina bifida cystica
- neural plate tissue open with little/no skin or bony cover
- nerve tissue may be covered with a cyst (meningomyelocele)
- may have hydrocephalus leading to mental retardation and increased size of head
-many die soon after brith
- some survive surgery to close the lesion but will have many problems eg paralysis, growth deformaties through muscle imbalance and incontinence
- many need early surgery to feet to maintain functional shape
- others develop joint contraction causing fixed flexed knees and dislocation of hips
- keep kids mobile so they grow to reasonable size
- many walk with splints and aids
at adolescence they may go into a wheelchair as its easier

Question 13

what is diastamatomyelia

Answer 13

in spina bifida acculta - may get tethering of the spinal cord to the higher lumbar vertebrae during growth

Question 14

cerebral palsy

what is it and cause
diff types
symptoms/signs
management

Answer 14

caused by abnormality in brain, often damaged at birth and results in delayed or arrested development of mervous and MSK system

spinal tissue develops normally so children have uninhibited reflexes but lack co-ordination and purpose of movement. normally controlled b brain - spastic paralysis. some muscles contract strongly in an uncoordinated way (spastic) whilst others are weak and flaccid. this imbalance = abnormal muscle and bone growth with secondary deformities of joints

one arm and one leg on same side = hemiparesis
2 legs = paraparesis
all 4 limbs = quadraparesis

most are retarded and some are blind/deaf. some will only have one muscle group affected so v minor spasticity - common sign is toe walking in adolescence - when examined it shows calf spasticity and some need tendo-achilles lengthening before growth ceases

deformaties are minimised by physio. splintage used with caution as it can cause increased spasm and deformity. careful use of surgery to lengthen/tighten tight muscles or denervate them or occasionally to move them

Question 15

scoliosis

what is it and who gets it
cause
complaints and symptoms
management

Answer 15

curvature of the spine with rotatory abnormality of vertebrae. 3D deformity based on abnormal lordosis of spine which leads to bucking and twisting of vertebra column as a result of the actions of muscles and gravity

most idiopathic cases occur in teens and more common in girls
rarely causes physiological disturbances

complains of twisting ribs - causes hump on one side of shoulder. girls complain skirt hangs crooked. may be painful but this is usually secondary to anxiety

not all curves progress. if it is progressive offer treatment early. braces have NO BENEFIT and increase stigma of disease. surgical correction - v complex

Question 16

cause of limp in kids - diff ages

Answer 16

from birth - CCD, infection of hip
4-10yrs - Perthes
10-15 - SUFE

Question 17

Perthes

incidence
cause
symptoms 
investigations 
management 
follow up

Answer 17

osteochondritis (fragmentation of bone and cartilage) of fem head ephiphysis. more common in boys and 20% are bilateral
cause is unknown
5/1000 kids

painful limb followed by slow recovery. Repeat radiographs as may be normal at the start but more fragments will be obvious
us - excess fluid in hip joint
thought to be an AVN of growing fem head. eventually the head will revascularise and re-ossify but it may be enlarged and deformed

maintain head with acetabulum until disease runs it course. minor degrees (half the fem head) need no treatment and prognosis is good - prone to secondary arthritis in early middle age
in severe cases splintage may help, some believe osteotomy to enlarge acetabulum/redirect fem head helps but this is dubious

lots of follow up with periods of traction to alleviate symptoms of pain and limp is all that can be done really

Question 18

SUFE

who?
what is it
symptoms 
investigation
treatment

Answer 18

boys aged 12 who are sexually immature
girls who are a bit older and have recently had a growth spurt

slipped epiphysis of fem head on fem neck so the head is tilted. child has limp, may have pain radiating to the knee (child with knee pain always examine the hip)
All teens with painful hip must be regarded as having this condition until proven otherwise - clinically and radiographically excluded (must include lateral view or minor degrees of slippage may be missed)

treat - surgery.
if minor pin hip in new deformed position
if major attempt to replace head of neck by manipulation but risk of AVN is high
observe other hip by radiography regularly and pin if any suspicion of slippage
remove pins after fusion of epiphysis at about 18 years of age