Orthopaedic Conditions of Childhood Flashcards
At what age is the average child:
- sitting independently?
- standing?
- walking?
Sitting - 9 months
Standing - 1 year
Walking - 20 months
4 common minor gait and posture abnormalities in childhood?
Knock-knees & bow-legs
In-toeing
Flat feet
Curly toes
Medical terms for:
knock knees?
bow legs?
Knock knees - gene valgum
bow legs - gene varum
Features of genu valgum and genu varus?
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
What is in-toeing?
Why are they commonly referred to orthopaedic?
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
3 causes of in-toeing?
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
What are flat feet?
Normal variation, in some races flat foot is the norm
2 kinds of flat feet?
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
What are curly toes?
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
What is osgood schlatter’s disease?
Symptoms?
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
Who does Osgood Schlatter’s disease affect?
young, active children
Management of Osgood Schlatter’s disease?
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
What is adolescent knee pain?
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
What is DDH/Congenital dislocation of the hip/congenital hip dysplasia?
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
Clinical presentation of DDH?
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
Management of DDH?
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)
Consequences of not discovering DDH?
Limp and OA
What is talipes equino varus?
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
Aetiology of talipes equino varus?
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
Management of talipes equino varus?
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.
What is spina bifida occulta?
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
What is spina bifida cystica?
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
Prognosis of spina bifida cystica?
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)
Management of spina bifida cystica?
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
What is cerebral palsy?
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
Patterns of cerebral palsy?
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
Mental and sensory deficits in cerebral palsy?
Most are mentally retarded
Some are blind and/or deaf
Sometimes, however, patients have neither
Management of cerebral palsy?
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
What is scoliosis?
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
Aetiology of scoliosis?
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.
Consequences of scoliosis?
Principally poor appearance due to spinal contracture
Can also cause physiological disturbances
Clinical presentation of scoliosis?
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
Management of scoliosis?
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.
Possible causes of limp:
- from birth?
- age 4-10
- age 10-15
From birth - DDH or infection of hip
Age 4-10 - Perthe’s Disease
Age 10-15 - SUFE
What is Perthe’s Disease?
Aetiology?
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
Presentation of Perthe’s Disease?
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
Management of Perthe’s Disease?
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.
What is SUFE?
Who is it seen in?
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
Clinical presentation of SUFE?
What tests must be performed?
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
Management of SUFE?
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
