orthopaediatrics Flashcards
child vs adult bones
Child's has 270 bones - in continuous change Physis (growth plates) Elasticity greater Speed of healing faster Remodelling always
development of flat bones
intramembranous ossification
development of long bones
endochondral ossification
intramembranous ossification
formation of ossification centre - condensation of mesenchymal cells to osteoblasts
secreted osteoid traps osteoblasts – osteocytes
trabecular matrix and periosteum form
compact bone develops superficially, crowded blood vessels become red bone marrow
ossificaiton centres
primary ossification centres - pre-natal bone growth through endochondral oss from central part of bone
secondary ossification centres - post-natal after primary ossification centres, forms the physis
what ossification centre is there pre-natally
primary
endochondral primary ossification
mesenchymal differentiation creates a cartilage model in diaphysis
angiogenesis penetrates, primary centre forms and spongy bone
continues up the shaft, cartilage and chondrocytes form bone ends.
secondary ossification centres form at bone ends now
endochondral secondary ossification
centre calcifies and dies to immature spongy bone
epiphyseal side contains active hyaline cartilage which continues dividing to form hyaline cartilage matrix (epiphyseal growth plate)
What happens if the physis are faulty
Any congenital malfunction or acquired insult – traumatic/infective or otherwise will have impact on growth of the child
why are childrens bones more elastic
increased density of haversian canals (need blood supply for growing tissue)
dissipation of energy means it can bend more before breaking
importance of childrens bone elasticity
plastic deformations - bends before breaking
buckle fractures - pushes outwards like roman column
greenstick fractures - one cortex fractures but other side doesnt break
when does bone growth stop
when physis closes - puberty
what is physis closure dependent on
parental height
menarche
puberty
when are boys and girls’ physis closed
boys - 18/19
girls - 15/16
what is a physeal injury
Categorised by salter harris
May lead to growth arrest -> deformity
What 2 factors impact remodelling potential of children?
AGE: greater the younger they are LOCATION: Physis at knee grows more Pysis at extreme of upper limb grows more
common congenital ortho conditions
developmental dysplasia of the hip
club foot
achondroplasia
osteogenesis imperfecta
what is developmental dysplasia of the hip (DDH)
Group of disorders where head of femur unstable or incongruous with acetabulum
A ‘packing disorder’- depending on how child sits in womb impacts how hip sits in acetabulum
Normal development relies of concentric reduction and balanced forces in hip
risk factors for developmental dysplasia of hip
female 6:1
first born
breech
family history
oligohydramnios (lack of fluid in amniotic sac)
native american/ laplanders- swaddling of hip
Rare in african american/ asian
examination for DDH
baby check- screening usually picks it up
Hip RoM:
- usually limitation in hip abduction
- leg length (Galeazzi test)
In 3 months and older, Barlow and Ortolani test (to check for hip instability) are non-sensitive
investigation for DDH
ultrasound (birth- 4 months) - measure acetabular dysplasia and hip position
If aster 4 months, X-Ray
treatment of DDH
If reducible hip and <6 months old - pavlik harness- holds femoral head in acetabulum
If failed/irreducible or 6-18 months old - MUA + closed reduction and spica
what is club foot?
Epidemiology?
congenital deformity of foot
Highest in hawaiians
M:F 2:1
50% are bilateral
what does CAVE mean in relation to club foot
Cavus - high foot arch: tight intrinsic muscles, FHL, FDL
Adductus of foot - tight tibialis post and ant
Varus - tight tendoachilles, tib post tib ant
Equinous - tight tendoachilles
treatment of club foot
Ponseti method
- Series of casts to fix deformity
- Many require operative treatment
- Foot orthosis brace
- Some will require further operative intervention
what is achondroplasia
Skeletal dysplasia - autosomal dominant
G380 mutation of FGFR3
inhibition of chondrocyte proliferation in proliferative zone of physis
results in defect in endochondral bone formation
Symptoms of achondroplasia
Rhizomelic dwarfism:
- Humerus shorter than forearm
- Femur shorter than tibia
- Normal trunk
- Adult height of around 125cm
- Significant spinal injuries
what is osteogenesis imperfecta
hereditary autosomal D/R
decreased type I collagen - decreased secretion OR production of abnormal collagen
leads to insufficient osteoid production
problems caused by osteogenesis imperfecta
Bone:
fragility fractures
short stature
scoliosis
Non-orthopaedic manifestations: Heart Blue sclera Brown soft teeth Wormian skull- abnormal fusion of cranial bones Hypermetabolism
classification of salter harris fractures
SALT:
- physeal Separation
- fracture transverse physics then exits metaphysis (Above)
- fracture transverse physics then exits epiphysis (Lower)
- Fracture passes Through epiphysis, physis, metaphysis
- crush injury
what type of salter harris fracture has greatest risk of growth arrest?
What is the most common type?
Risk of growth arrest increases from 1-5
Type 2 most common
Type 5 have greatest risk
How can the location of growth arrest affect the limbs?
whole physis - complete arrest- limb length discrepancy
partial physis - angulation as non affected side keeps growing
principles of treatment of salter harris fractures
correct deformity - minimise angular deformity and limb length difference
limb length correcting
shorten long side (prematurely fuse physis)
OR
lengthen short side - plates
angular deformity correction
stop growth of affected side
reform bone - osteotomy
closed reduction for paediatric fracture
gallows traction for long bone fractures
Closed reduction to correct for deformity
4 rs of paediatric fractures
resuscitate
reduce
restrict
rehabilitate
restriction for paediatric fractures
Plasters and splints most common (External)
Remodelling and huge healing potential means operative internal fixation can usually be avoided
Sometimes operation is needed:
Internal- plates and screws or intramedullary device
Titanium nails more used due to being flexible so can help tension and hold fractures
rehabilitation techniques for children
play
use it move it strengthen it
differential Dx for limping child
septic arthritis
transient synovitis
perthes
slipped upper femoral epiphysis
What classification is used to diagnose probability of septic arthritis in children?
Kochers classification: non-weight bearing ESR over 40 WBC over 12,000 temp over 38
when can transient synovitis be diagnosed in children
after exclusion of septic arthritis
perthes disease
idiopathic necrosis of proximal femoral epiphysis
Affects boys 4-8 more likely
SUFE usual presentation
obese adolescent males
12-13 yo
associated with hypothyroid/pituitarism
treatment for SUFE
operative fixation with screw to prevent further slip and minimise long term growth problems
what is transient synovitis
inflamed joint in repsonse to a systemic illness
treated by antibiotics
What does SUFE stand for and what is it?
Slipped upper femoral epiphysis
Proximal epiphysis slips in relation to metaphysis
What do you need to exclude first before diagnosing SUFE?
Septic Arthritis
What is treatment for Perthes disease?
Supportive
What is important about septic arthritis?
Orthopaedic emergency- can cause irreversible joint problems
What is typical presentation of septic arthritis?
Prev. fit and well
Over last 24hrs off food and drink
Last 12hrs- fever, don’t move hip or knee
What’s the treatment for septic arthritis?
Surgical washout
What is transient arthritis?
How is it treated?
Inflamed joint in response to systemic illness
Supportive treatment with ABs
What are the aims for reducing a fracture?
Correct deformity and displacement
Reduce secondary injury to soft tissues and neurovascular structures
What are 2 ways a fracture can reduced?
Closed- without incision such as traction and manipulation
Open- make incision and realign fracture
What are the different ways a bone can be displaced?
Angulated
Displaced
Shortened
Rotated (can’t be remodelled)
When looking at a paediatric fracture, what are the 5 things we need to consider?
Pattern Anatomy Intra/Extra-articular Displacement Salter-Harris
What are the different patterns of fracture?
Transverse Oblique Spiral Comminuted Avulsion (pulled of ligament) Torus (thiscker at one bit) Greenstick
What are the different anatomical location we have to consider for a fractured bone?
Proximal 1/3
Middle 1/3 / diaphysis
Distal 1/3
What is the preferred route of healing in an intra-articular fracture?
Primary bone healing- heals by direct union, no callus
Minimises risk of post traumatic arthritis
What is the preferred route of healing in an extra-articular fracture?
Secondary bone healing- healing by callus
How do outcomes of Developmental dysplasia of th hip vary?
Dysplasia- acetabular socket does not develop into right place (more common)
Subluxation- shallow socket
Dislocation
