Orthopaedic Conditions of Childhood

Question 1

At what age is the average child:

• sitting independently?
• standing?
• walking?

Answer 1

Sitting - 9 months

Standing - 1 year

Walking - 20 months

Question 2

4 common minor gait and posture abnormalities in childhood?

Answer 2

Knock-knees & bow-legs
In-toeing
Flat feet
Curly toes

Question 3

Medical terms for:
knock knees?
bow legs?

Answer 3

Knock knees - gene valgum

bow legs - gene varum

Question 4

Features of genu valgum and genu varus?

Answer 4

Rarely serious. Normal alignment of the knee is in valgus and when the child stands to attention there is a 4cm gap between feet.

Smaller gap = varus
Larger gap = valgus

By 7 y/o almost all children will have developed normal knee alignment

Question 5

What is in-toeing?

Why are they commonly referred to orthopaedic?

Answer 5

Feet point inward, and this is often exaggerated by running. Common referral to orthopaedics because of ‘clumsiness’, and shoes constantly wear down at the heels

Question 6

3 causes of in-toeing?

Answer 6

FEMORAL NECK ANTEVERSION - during later stages of development as a foetus the leg rotates on the pelvis so the acetabulum points almost backwards and the femoral neck forwards. Sometimes this process is nor complete by birth so the femoral neck is more anteverted than normal. This means children can internally rotate femur a lot, and externally rotate only a little. This delayed development is usually rectified by 10y/o, although some are left with minor residual deformity. Rarely ever requires surgery

TIBIAL TORSION - the bone is twisted around the vertical axis - normal variation and should be ignored

ABNORMAL FOREFEET - adducted (‘hooked’) forefoot is commonly seen. Dubious whether surgery is ever warranted, definitely never before age 7. Vast majority correct spontaneously, and even if some abnormality still present it never really causes any functional difficulty. No evidence that special shoes make any difference

Question 7

What are flat feet?

Answer 7

Normal variation, in some races flat foot is the norm

Question 8

2 kinds of flat feet?

Answer 8

MOBILE - vast majority - all children’s feet are flat at birth and the normal arch may not form until 7y/o. Parents must be reassured about this.

RIGID - rare at any age - underlying bony abnormality of the foot. Occasionally a sign of serious disease e.g. RA

Question 9

What are curly toes?

Answer 9

Minor overlapping of toes, esp 4th and 5th, are common. Most correct spontaneously and should be left alone.

Occasionally cause discomfort in shoes, which can be fixed by surgery, but this should be discouraged

Question 10

What is osgood schlatter’s disease?

Symptoms?

Answer 10

inflammation of the tibial tuberosity, where the patellar tendon attaches, caused by excess traction of the quadriceps

It causes tenderness and discomfort, worse after exercise, along with swelling. The condition is usually episodic and improves with rest

Question 11

Who does Osgood Schlatter’s disease affect?

Answer 11

young, active children

Question 12

Management of Osgood Schlatter’s disease?

Answer 12

Rest

Rarely it is necessary to enforce with a plaster - the child will cease to have symptoms in middle adolescence when the epiphysis fuses normally

Question 13

What is adolescent knee pain?

Answer 13

Most commonly in girls, unknown cause. Most girls from out of the condition, but if symptoms persist arthroscopy may be necessary

Very rarely on arthroscopy the cartilage may be seen to be eroded - CHONDROMALACIA PATELLAE

Question 14

What is DDH/Congenital dislocation of the hip/congenital hip dysplasia?

Answer 14

An abnormality in the femoral head, acetabulum or both - it is usually in a normal position at birth but likely to become dislocated if ignored. More common in girls and there is a familial and racial tendency. A significant proportion are bilateral

Question 15

Clinical presentation of DDH?

Answer 15

All children should be screened at birth, then again at 3, 6 and 12 months. It is diagnosed using the Ortolani and Barlow tests

Barlow - examiner adducts the newborn’s hips, where it may dislocate posteriorly producing an audible “click” (suspicious)

Ortolani - examiner then flexes the hip to 90 degrees and abducts it again, where it may relocate into the acetabulum producing a “clunk” (confirmatory)

Clinical signs include asymmetrical skin creases, shortening of a limb, limited abduction, and a limp if not detected until the child begins to weight bear and walk

Question 16

Management of DDH?

Answer 16

All children who produce a ‘click’ - re-examine in a specialist clinic at 3 months and take XR

All children who produce a ‘clunk’ should be treated from birth

If the femoral head is relocated then splintage is the main treatment with a pavlik harness and the hip starts to develop normally

If discovered late but before weight bearing, gentle traction followed by open or closed manipulation, then splintage

If discovered late when walking, major surgery is required to deepen the undeveloped acetabulum and re-angulate the femoral neck (risk of secondary OA high)

Question 17

Consequences of not discovering DDH?

Answer 17

Limp and OA

Question 18

What is talipes equino varus?

Answer 18

Deformity of the foot which makes it look like a golf club. If treated early, mild cases can be fully treated and moderate cases can be much improved for function

Question 19

Aetiology of talipes equino varus?

Answer 19

Relatively common - has a mild, postural and fixed form

Mild - seen after Breech birth and related to baby’s posture in womb

Fixed - assoc w developmental abnormalities of nerves and muscles of the leg.

The condition can be uni or bi lateral

Question 20

Management of talipes equino varus?

Answer 20

Mild can easily corrected at birth by manipulation, more severe forms require surgery.

Both - initial treatment consists of gentle stretching in 2 phases. First phase corrects the hindfoot equinus, the second corrects the mid- and fore-foot varus. If mild 6 weeks of stretching and strapping can fix - if more severe then reassess after 6 weeks.

All children need to be followed up until their feet stop growing aged 14, as it can relapse late requiring surgery. The affected foot is often smaller than the other.

Question 21

What is spina bifida occulta?

Answer 21

Minor bony abnormality which affects 2% of the population, and is usually of no significance, although some people may develop mechanical backache and a very small number may get tethering of the spinal cord to a higher lumbar vertebra during growth - DIASTAMATOMYELIA

Question 22

What is spina bifida cystica?

Answer 22

Babies are born with neural plate tissues open, with little or no skin/bony cover.

Meningocele - the neural tissue is covered by a cyst

Myelomeningocele - the neural tissue is incorporated into the cyst

Question 23

Prognosis of spina bifida cystica?

Answer 23

Many die at birth or soon after. Some survive & go on to have the lesions on their backs closed. Those who survive suffer many problems:

paralysis, growth deformities through muscle imbalance, incontinence, hydrocephalus which may lead to mental retardation (by no means do all have learning difficulties)

Question 24

Management of spina bifida cystica?

Answer 24

Many ned early surgery to maintain a functional shape. Others develop joint contractions resulting in a fixed flexed position of the knees and hip dislocations - every effort should be made to keep them as mobile as possible until adolescence so they may grow to a reasonable size.

Many can walk aided by splints or hand-held aids but find wheelchairs easier for socialising when they’re older

Question 25

What is cerebral palsy?

Answer 25

Condition caused by lack of oxygen to aspects of the brain either before, during or slightly after birth, resulting in arrested development of nervous and MSK systems. The spinal tissue develops normally therefore all reflexes are normal, but there is no co-ordination or purpose of movement. Some muscles are spastic and some can be weak and flaccid - this imbalance leads to abnormal muscle and bone growth with secondary joint deformities

Question 26

Patterns of cerebral palsy?

Answer 26

Hemiparesis
Paraparesis
Quadriparesis

Sometimes only a single muscle group is affected - commonly toe-walking is noted in adolescence as a result of calf muscle spasticity - these patients may need tendo-achilles lengthening

Question 27

Mental and sensory deficits in cerebral palsy?

Answer 27

Most are mentally retarded
Some are blind and/or deaf

Sometimes, however, patients have neither

Question 28

Management of cerebral palsy?

Answer 28

Orthopaedic problems are similar to spina bifida but often more severe.

Deformities can be minimised with careful physiotherapy

Splintage should be used with caution as overzealous splint age can increase spasm and ultimately deform

Careful use of surgery to either lengthen or tighten muscles, or to denervate them or (occasionally) move them may maintain acceptable posture and some function

Question 29

What is scoliosis?

Answer 29

curvature of the spine with rotary abnormality of the vertebrae

It is a 3D deformity based on abnormal lordosis of the spine, leading to tickling and twisting of the vertebral column as a result of the action of muscles and gravity

Question 30

Aetiology of scoliosis?

Answer 30

May be caused by congenital abnormalities of the vertebrae or neuromuscular imbalance, but most are idiopathic

Most idiopathic cases occur in adolescence, more common in girls.

Question 31

Consequences of scoliosis?

Answer 31

Principally poor appearance due to spinal contracture

Can also cause physiological disturbances

Question 32

Clinical presentation of scoliosis?

Answer 32

Child usually complains of twisting of the ribs, which causes a hump on one side of the shoulder.

Girls may complain their skirt hangs crooked

It may be painful although this is usually secondary to anxiety and distress

Question 33

Management of scoliosis?

Answer 33

Not all curves progress - if it is progressive or causing distress then treatment should be offered early. Braces have no benefit and should not be used as they add to distress (stigma)

Surgical correction is essential if treatment is required - the rotary element must be corrected to remove the hump. It is a very complex surgery. Earlier treatment = better results.

Question 34

Possible causes of limp:

• from birth?
• age 4-10
• age 10-15

Answer 34

From birth - DDH or infection of hip

Age 4-10 - Perthe’s Disease

Age 10-15 - SUFE

Question 35

What is Perthe’s Disease?

Aetiology?

Answer 35

Osteochondritis (fragmentation of bone and overlying cartilage) of the femoral head epiphysis. It is thought to be an AVN, but eventually the head will revascularise and re-ossify, but it may be enlarged and deformed

More common in boys, 20% bilateral. Cause unknown

Question 36

Presentation of Perthe’s Disease?

Answer 36

Child presents with a painful limp followed by a slow recovery

On XR the femoral head may be normal initially, but fragments may be seen.

XR after a month may show changes

USS reveals excess fluid in hip joint

Question 37

Management of Perthe’s Disease?

Answer 37

Strategy is to maintain head concentrically within acetabulum until the natural process of disease runs its course.

If it involves half), splintage may help. There is a belief that osteotomy to enlarge the acetabulum or redirect the femoral head may help. All these treatments are of dubious value.
Mainstay of treatment = careful follow-up with periods of traction to alleviate pain and limp.

Question 38

What is SUFE?

Who is it seen in?

Answer 38

Slipped Upper Femoral Epiphysis - slippage of the epiphysis of the femoral head on the neck, so that the head is abnormally tilted

Condition seen in boys around 12y/o who are sexually immature for their age, and in girls who are a little older and have recently undergone an adolescent growth spurt

Question 39

Clinical presentation of SUFE?

What tests must be performed?

Answer 39

Child has a new limp, which may not be uncomfortable, or may have pain radiating to the knee (obturator nerve). Any child with knee pain should have their hip examined.

The slip may occur acutely or may be preceded by months of discomfort without any clinical or XR signs.

All adolescents with unexplained painful hip have SUFE until proven otherwise

XR must include a lateral view, or minor degrees of slippage may be missed

Question 40

Management of SUFE?

Answer 40

Surgical

If minor slippage, hip should be pinned in its new, deformed position

If major slippage, may attempt to gently replace the head on the neck, although AVN risk is high.

The other hip should be observed using XR at regular intervals and pinned also if any suspicion of slippage arising.

The pins are best removed after fusion of the epiphysis, at around 18y/o