Ortho unit 3

Question 1

Child milestones

Answer 1

sits- 9 months
stands- 12 months
walks- 20 months

Question 2

knock knees

Answer 2

genu valgum

Question 3

bow legs

Answer 3

genu varum

Question 4

normal alignment of knees

Answer 4

valgus- when child stands to attention there is normally a gap of 4cm or so between the feet

Question 5

what age should normal knee alignment be achieved by

Answer 5

7 yrs

Question 6

in toeing

Answer 6

children stand with feet pointing inwards- often exaggerated when they run. Often referred to oath because of clumsiness. Shoes tend to wear down at the heel

Question 7

causes of in toeing

Answer 7

femoral neck angle variation- anteverted femoral neck - children born like this can internally rotate their femur a lot and externally rotate it only a little- reflected by posture- in toed gait. Should correct itself by age of 10 although some are left with residual deformity
Tibial torsion - normal variation and should be ignored
Abnormal forefeet- hooked forefoot- commonly seen. Dubious whether surgery to correct this is ever justified, defs shouldn’t be considered before 7yrs. vast majority correct spontaneously - no evidence that special shoes make any difference

Question 8

Flat foot

Answer 8

Normal variation- rarely causes any functional abnormalities apart from uneven shoe were.

Question 9

2 kinds of flat foot

Answer 9

Mobile- vast majority- flat feet at birth, normal arch may not form until the child is 7
rigid flat foot- rare- implies underlying bony abnormality of the foot

Question 10

curly toes

Answer 10

minor overlapping of toes, particularly of the 5th toe. Most correct spontaneously, occasionally crossed 5th toe can cause discomfort in shoes- if fixed requires surgical correction

Question 11

Osgood schlatters disease

Answer 11

inflammation of attachment of patellar tendon to growing tibial epiphysis- caused by excess traction by the quads. Cause unknown but more common in very active children

Question 12

Osgood schlatters disease symptoms

Answer 12

tenderness and discomfort, worse after exercise, may also be swelling. Episodic and may be treated by rest. Rarely necessary to reinforce with plaster. Child will have symptoms until middle adolescence when epiphysis fuses

Question 13

Adolescent knee pain

Answer 13

more common in girls. Rarely chondromalacia patellae is seen on arthroscopy. Most girls grow out of the condition

Question 14

Congenital dislocation of the hip (CDH)

Answer 14

1-2/1000 live births. Better name would be congenital hip dysplasia (reflecting underlying abnormality of femoral head, acetabulum or both) as hip usually abnormal but rarely completely dislocated. Bilateral in a significant no. of children

Question 15

clinical presentation of CDH

Answer 15

all children screened at birth and checked again at 3,6 and 12 months. Diagnosed at birth using a technique where examiner tries to dislocate or relocate the hop- may produce a click (suspicious) or a clunk as the hip dislocates or relocates

Question 16

clinical signs of CDH if goes unnoticed at birth

Answer 16

becomes apparent either before weight bearing (sitting) or after weight bearing (standing). Clinical signs- shortening of limb, asymmetrical skin creases, limited abduction and limp

Question 17

management of CDH

Answer 17

children who produced a click sound should be reexamined by specialist at 3 months- radiograph usually justified. All clunks should be treated from birth.
If femoral head is relocated and maintained in the acetabulum using splint age- then the vast majority will settle and give no further trouble as the hip starts to develop normally
If discovered late- traded by period of gentle traction followed by open or closed manipulation. Then splinted in plaster for three months
If walking has commenced- major surgery required to deepen the undeveloped acetabulum and re angulate the femoral neck to stabilise the hip- secondary arthritis likely

Question 18

clubfoot

Answer 18

talipes equino varus

Question 19

talipes equino varus

Answer 19

deformity- makes foot look like a golf club. If treated early, mild cases can be fully corrected and major cases much improved

Question 20

talipes equino varus

Answer 20

relatively common- mild postural form and fixed form.
Mild- after breech birth- probs related to babies position in womb
Fixed- developmental abnormalities of nerves and muscles of the leg. Both cases can be bilateral

Question 21

management of talipes equino varus

Answer 21

Mild form- easily corrected at birth by manipulation
Severer forms- require surgery
Both forms- initial treatment- gentle stretching in 2 phases- first corrects hind foot equinus and second phase corrects mid and forefoot varus. Mild cases- - 6 weeks of strapping and stretching. Severe- may require surgery after this 6 weeks
Children need to be followed up until feet stop growing- relapse not uncommon

Question 22

spina bifida occulta

Answer 22

minor bony abnormality- affects around 2% of the population - usually of no significant- some people develop mechanical backache and v small number may get tethering of spinal cordite higher lumbar vertebrae during growth- diastamatomyelis

Question 23

spina bifida cystic

Answer 23

neural plate tissues open with little or no skin or bony cover- nerve tissue may be covered by a cyst (meningocele) or nerve tissue may be incorporated into a cyst (meningomyelocele). Many have hydrocephalus which leads to mental retardation and increase in size of head

Question 24

spina bifida cystic treatment

Answer 24

many die at or soon after birth. some survive and undergo op to close lesion on their back - these children have issues-paralysis, growth deformities, incontinence, many are mentally retarded. Many need early feet surgery to maintain functional shape, others develop joint contraction resulting in a fixed flexed position of their knees and dislocation of their hips. Every effort should be made to keep the children mobile until adolescence so that they may grow to a reasonable size. Many children manage to walk aided by splints and hand-held aids until then. As they reach adolescence many go into a wheelchair as they find this easier for themselves socially.

Question 25

Cerebral palsy

Answer 25

caused by abnormality of the brain often caused by damage to the brain at birth. Delayed or arrested development of the nervous and MSK systems. Spinal tissue develops normally- uninhibited spinal reflexes but lack of co ordination and purpose of movement. Results in spastic paralysis - abnormal muscle and bone growth, with secondary deformities of joints

Question 26

hemiparesis

Answer 26

one arm and leg on same side affected

Question 27

paraparesis

Answer 27

2 legs affected

Question 28

quadraparesis

Answer 28

all limbs affected

Question 29

CP symptoms

Answer 29

most but not all are mentally retarded. Deformities can be minimised by careful physio. Splint age used with caution as can lead to muscle spasm. careful use of surgery to either lengthen high muscles or denervate them

Question 30

spina bifida meningomyelocele

Answer 30

abnormal developments of spine during first 3 months of newly forming baby may result in abnormal formation of spinal cord and vertebrae

Question 31

scoliosis

Answer 31

curvature of spine with rotatory abnormality of vertebrae, abnormal lordosis of spine leading to buckling and twisting of the vertebral column as a result of the action of muscles and gravity

Question 32

scoliosis aetiology

Answer 32

may be caused by congenital abnormalities of vertebrae or neuromuscular imbalance, most are idiopathic. Most occur in adolescence. More common in girls, principle effects are cosmetic

Question 33

scoliosis clinical presentaation

Answer 33

twisting of ribs causing a hump on one side of shoulder. Girls skirts hang crookedly. May be painful

Question 34

Management of scoliosis

Answer 34

Not all curves get worse. Treatment offered early if curve is progressive- surgical correction- very complex

Question 35

Limp at diff ages

Answer 35

from birth0 CDH, infection of hip
4-10yrs- perches
10-15 yrs- SUFE

Question 36

Perthes

Answer 36

Osteochondritis of femoral head epiphysis. More common in boys, 20% bilateral. Cause unknown, incidence up to 5/1000

Question 37

Perches clinical presentation

Answer 37

painful limp followed by slow recovery.
Radiologically- femoral head may be normal at first presentation, radiographs after a few months may show previously unrecorded changes. Thought to be due to AVN of femoral head. Eventually head will re vascularise and re ossify but may be large and deformed

Question 38

management of perches

Answer 38

maintain the head concentrically within the acetabulum until the natural process of the disease runs its course. Minor degrees of the condition, involving up to half of the femoral head, need no treatment as the prognosis in such children is good. In older children, when the condition affects the femoral head, the prognosis is less good. The child will return to normal in the short term, but will be prone to secondary osteoarthritis in early middle age.
In severe cases, splintage to achieve containment may help.

Question 39

SUFE

Answer 39

Boys around 12yrs, girls little older recently undergone an adolescent growth spurt- slippage of femoral head on femoral neck so head is abnormally tilted

Question 40

SUFE clinical presentation

Answer 40

child has a limp, which may not be particularly uncomfortable, but there may be pain radiating to the knee. Any child with knee pain must have their hip examined. The slip may occur acutely or it may be preceded by many months of discomfort without clinical or radiological signs. All young adolescents with a painful hip must be regarded as having this condition until it is clinically and radiologically excluded. Radiographs must include a lateral view or minor degrees of slippage may be missed.

Question 41

why must radiographs include lateral view when testing for SUFE

Answer 41

minor degrees of slippage may be missed

Question 42

management of SUFE

Answer 42

surgical treatment. Minor slippage- hip pinned in deformed position. Major slippage- gentle attempt to replace head on neck by manipulation attempted - risk of AVN is high. Other hip should be observed at regular intervals and pinned if any suspicion arises. Pins are best removed after fusion of epiphysis at around 18 years of age

Question 43

Perches management

Answer 43

Careful follow-up with periods of traction to alleviate symptoms of pain and limp is probably all that can be done to help these children.