Orthopaedics Flashcards
What are epiphyseal plates
Found in bones of children
Areas at the ends of long bones
Allow bone to grow in length
Made of hyaline cartilage
Usually stronger than the rest of the bone
What are growth plate fractures called, what are the different types
Salter-Harris fractures (SALTR)
Type 1: Straight across
Type 2: Above
Type 3: beLow
Type 4: Through
Type 5: cRush
How do children’s bones differ from adult bones
More cancellous bone
More flexible
Less strong (get greenstick and buckle fractures)
Have a very good blood supply (fast healing)
What is the management for fractures in children
Consider safeguarding
Get mechanical alignment (closed reduction, surgery)
Give stability (cast, K-wires, intramedullary wires, intramedullary nails)
What are the steps of the WHO pain ladder for children
Step 1: paracetamol, ibuprofen
Step 2: morphine
How might a patient with hip pain present
Limp
Refusal to use leg
Refusal to weight bear
Inability to walk
Pain
Swollen or tender joints
What are the red flags for hip pain
< 3 years
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in morning
Swollen or red joint
What are the causes of hip pain in 0-4s
Septic arthritis
Developmental dysplasia of the hip
Transient synovitis
What are the causes of hip pain in 5-10s
Septic arthritis
Transient synovitis
Perthes disease
What are the causes of hip pain in 10-16s
Septic arthritis
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis
What are the criteria for urgent referral for hip pain
< 3 years
> 9 with restricted or painful hip
Not able to weight bear
Neurovascular compromise
Severe pain or agitation
Red flags
Suspicion of abuse
What are the investigations for hip pain
Bloods (CRP, ESR, JIA (specific to septic arthritis))
X-ray
Ultrasound
Aspiration
MRI (for osteomyelitis)
What is septic arthritis
Infection inside a joint
Most common in < 4s
Can destroy joint and cause systemic illness
Common complication of joint replacement
Causative bacteria: staph aureus, neisseria gonorrhoea, group A strep, haemophilus influenzae, E coli
How might a patient with septic arthritis present
One single joint affected
Rapid onset
Hot, swollen, red, painful joint
Refusal to weight bear
Stiffness and reduced range of motion
Systemic symptoms
What is the management for septic arthritis
Low threshold for treatment until proven otherwise
Admit
Aspirate
Antibiotics (empirical IV, for 3-6 weeks)
Surgical drainage
What is transient synovitis
Aka irritable hip
Temporary irritation and inflammation of synovial membrane of hip
Most common cause of hip pain for 3-10s
Linked to recent URTI
Do not usually have fever
How might a patient with transient synovitis present
Limp
Refusal to weight bear
Groin or hip pain
Possible mild fever
What is the management for transient synovitis
Simple analgesia
Advise to go to A&E if develop fever
Follow up in 48 hours and at 1 week
What is the prognosis for transient synovitis
Improved in 24-48 hours
Fully resolves in 1-2 weeks
What is Perthes disease
Disruption of blood flow to femoral head
Avascular necrosis of bone
Usually in 5-8s
More common in boys
Idiopathic
Over time: revascularisation and healing, remodelling of bone
Can lead to early osteoarthritis
How might a patient with Perthes disease present
Slow onset
Pain in hip or groin
Limp
Restricted hip movement
Referred pain to knee
What are the investigations for Perthes disease
X-ray
Bloods
Technetium bone scan
MRI
What is the management for Perthes disease
Conservative (bed rest, traction, crutched, analgesia)
Physio
Regular X-ray (assess healing)
Surgery if: severe, older child, not healing
What is slipped upper femoral epiphysis
Aka SUFE
Head of femur displaced along growth plate
More common in boys
Usually 8-15s (slightly earlier in girls)
More common in obese children
Suspect when pain disproportionate to trauma
Usually during a growth spurt
How might a patient with slipped upper femoral epiphysis present
Hip, groin, thigh, or knee pain
Restricted range of hip movement
Painful limp
Restricted movement
Keeping hip externally rotated (limited internal rotation)
What are the investigations for slipped upper femoral epiphysis
X-ray
Blood
Technetium bone scan
CT/MRI
What is the management for slipped upper femoral epiphysis
Surgery (return femoral head to correct position, fix in place)
What is osteomyelitis
Infection of bone and bone marrow
Usually in metaphysis of long bones
Often due to staph aureus
Chronic: deep seated, slow growing, slow development of symptoms
Acute: develops quickly, acutely unwell child
What are the risk factors for osteomyelitis
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
TB
How might a patient with osteomyelitis present
Refusal to use limb
Refusal to weight bear
Pain
Swelling
Tenderness
Possible fever
What are the investigations for osteomyelitis
X-ray
MRI
Bloods (high inflammatory markers, high white cell count)
Blood culture
Bone marrow aspiration
Bone biopsy
What is the management for osteomyelitis
Antibiotics (extensive and prolonged)
May need drainage and debridement
What is osteosarcoma
Bone cancer
Usually in 10-20s
Most commonly affects: femur, tibia, humerus
How might a patient with osteosarcoma present
Persistent bone pain
Waking from sleep
Bone swelling
Palpable mass
Restricted joint movement
What are the investigations for osteosarcome
Very urgent direct access X-ray (within 48 hours)
Bloods (possible raised ALP)
Staging CT/MRI/PET/bone biopsy
What are the X-ray signs of osteosarcoma
Poorly defined lesion in bone
Destruction of normal bone
Fluffy appearance
Periosteal reaction
What is the management for osteosarcoma
Surgical resection (often needs amputation)
Adjuvant chemotherapy
MDT input
What are the complications of osteosarcoma
Pathological bone fractures
Metastasis
What is talipes
Aka clubfoot
Fixed abnormal ankle position
Talipes equinovarus: ankle in plantar flexion and supination
Talipes calcaneovalgus: ankle in dorsiflexion and pronation
Presents at birth
What is the management for talipes
Ponseti method (immediately after birth, repeated foot positioning with a cast, use a brace when not walking when older)
Surgery
What is developmental dysplasia of the kip
Structural abnormality of hip
Instability of joint
Tendency for subluxation and dislocation
If persisting to adulthood, get: weakness, recurrent subluxations/dislocations, abnormal gait, early degenerative changes
How might a patient with developmental dysplasia of the hip present
Newborn examination
Hip asymmetry
Reduced range of movement
Limp
What are the risk factors for developmental dysplasia of the hip
1st degree family member
Breech presentation from 36 weeks onwards
Breech presentation at birth if 28 weeks onwards
Multiple pregnancy
What are the investigations for developmental dysplasia of the hip
Newborn examination: differences in leg length, restricted movement, difference in knee levels when legs flexed, clunking on special tests (Ortolani test (anterior dislocation), Barlow test (posterior dislocation))
Ultrasound
X-ray
What is the management for developmental dysplasia of the hip
Pavlik harness (if baby < 6 months, keep on permanently for 6-8 weeks, adjust as baby grows, holds femoral head in place so acetabulum can develop)
Surgery (harness fails, diagnosed at > 6 months)
What is rickets
Defective bone mineralisation
Causes soft and deformed bones
What are the causes of rickets
Vitamin D deficiency
Calcium deficiency
How might a patient with rickets present
Lethargy
Bone pain
Swollen wrists
Bone deformity
Poor growth
Dental problems
Muscle weakness
Pathological fractures
Bowing of legs
Knock knees
Rachitic rosary (ends of rips expand, get lumps along chest)
Craniotabes (soft skull, delayed closure of sutures, frontal bossing)
Delayed teeth
What are the investigations for rickets
Serum vitamin D, calcium, phosphate, ALP, PTH
X-ray
What is the management for rickets
Prevention
Breastfed babies at risk of vitamin D deficiency (take supplements)
Calcium and vitamin D supplements
What is achondroplasia
Most common cause of disproportionate short stature
A type of skeletal dysplasia
Autosomal dominant
Abnormal function of epiphyseal plates
What is achondroplasia associated with
Recurrent otitis media
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Cervical cord compression
Hydrocephalus
How might a patient with achondroplasia present
Disproportionate short stature
Average height around 4 feet
Proximal limb bones most affected
Short digits
Bow legs
Disproportionate skull (flattened midface, frontal bossing)
Foramen magnum stenosis
What is the management for achondroplasia
MDT input
Leg length surgery
What is Osgood-Schlatter disease
Inflammation at tibial tuberosity (where patella ligament inserts)
Mostly in 10-15s
More common in boys
Usually unilateral
How might a patient with Osgood-Schlatter disease present
Gradual onset
Visible or palpable hard and tender lump at tibial tuberosity
Pain in anterior knee
Exacerbated by: activity, kneeling, extension
What is the management for Osgood-Schlatter disease
Reduce physical activity
Ice
NSAIDs
Stretching and physio
What is the prognosis for Osgood-Schlatter disease
Spontaneously resolves over time
Left with hard bony lump
Can get avulsion fractures (tibial tuberosity separated from rest of tibia)
What is osteogenesis imperfecta
Brittle bones
Prone to fractures
Genetic mutation affecting formation of collagen
How might a patient with osteogenesis imperfecta present
Hypermobility
Blue/grey sclera
Triangular face
Short stature
Deafness from early adulthood
Dental problems
Bowed legs
Scoliosis
Joint and bone pain
What is the management for osteogenesis imperfecta
Clinical diagnosis
X-ray
Bisphosphonates
Vitamin D supplements
