Orthopaedics Flashcards
What is osteogenesis imperfecta?
Genetic condition that results in brittle bones that are prone to fracture
What is osteogenesis imperfecta also know as?
Brittle bone syndrome
What makes up bone?
Collagen framework with mineral inbetween
What part of bone is affected in osteogenesis imperfecta and why is this important?
Collagen which maintains the structure of bone
How does osteogenesis imperfecta usually present?
Recurrent and inappropriate fractures
What are some features associated with osteogenesis imperfecta?
Hypermobility Blue/ grey sclera Triangular face Short stature Deafness Dental problems Bone deformities (bowed legs, scoliosis) Joint/ bone pain
How is osteogenesis imperfecta diagnosed?
Clinically
X-rays can diagnose fractures and bone deformities
Genetic testing is possible but not routinely done
What are the medical treatments for osteogenesis imperfecta?
Bisphosphonates
Vitamin D supplementation
What further actions can be taken to manage osteogenesis imperfecta?
MDT PT OT Paediatrician input Orthopaedic surgeons to manage fractures Specialist nurses Social workers
What causes osteogenesis imperfecta?
Autosomal dominant genetic condition causing defects in T1 Collagen genes
WHat is rickets?
Condition causing defective bone mineralisation
What happens to bones in rickets?
They become soft and deformed
What is rickets known as in adults?
Osteomalacia
What causes rickets?
Vitamin D or calcium deficiency
How do we acquire vitamin D?
In the body in response to sunlight
Obtained through foods such as eggs, oily fish or fortified cereals
What is a rare cause of rickets?
Hereditary hypophosphataemic rickets- genetic defects causing low phosphate in blood
What causes vitamin D deficiency?
Not enough UV radiation (worse for those with darker skin)
Not enough in diet
Malabsorption disorders
Chronic kidney disease
What is the action of vitamin D?
Causes calcium and phosphate absorption in the intestines and kidneys
Regulates bone turnover
Promotes bone reabsorption to boost serum calcium level
Why do inadequate vitamin D levels lead to defective bone mineralisation?
Leads to a lack of calcium and phosphate in the blood, both of which are needed for the construction of bone
What does low calcium lead to?
Secondary hyperparathyroidism, where the parathyroid gland tries to raise the calcium level by secreting PTH. This stimulated increased reabsorption of calcium from the bones
What are potential symptoms of rickets?
Lethargy Bone pain Swollen wrists Bone deformity Poor growth Dental problems Muscle weakness Fractures
What bone deformities can occur with rickets?
Bowed legs Knock knees Rachitic rosary Craniotabes Delayed teeth
What is rachitic rosary?
Where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest
What is craniotabes?
Soft skull with delayed closure of the sutures and frontal bossing
What investigations are done to diagnose rickets?
Serum 25-hydroxyvitamin D
X-ray
What result indicates vitamin D deficiency?
<25 nmol/L
What may Xray show in rickets?
Osteopenia (radiolucent bones)
What other investigations may indicate rickets?
Low serum calcium nad phophate
High serum alkaline phosphatase
High PTH
What other pathology should be looked for when diagnosing rickets/
FBC for iron deficiency anaemia ESR/ CRP for inflammatory conditions U&Es for kidney disease LFTs TFTs for hypothyroidism Malabsorption screen Autoimmune/ rheumatoid tests
How is rickets prevented?
If purely breastfeeding, mothers should take vitamin D supplement
Everyone should take vitamin D during winter months
How is rickets treated?
With vitamin D dosed depending on age
Calcium supplementation as needed
What are epiphyseal plates?
Growth plates found at the ends of long bones in children that allow bones to grow
What are growth plates made up of?
Hyaline cartilage sitting between the epiphysis and metaphysis
What to the growth plates during the end of puberty?
The epiphysis and metaphysis fuse, and the growth plates become epiphyseal lines
What is the difference between children and adults bones?
Children have more cancellous bone whereas adults have more cortical bone, making them more flexible but less strong
What is cancellous bone?
Spongy, highly vascular bone in the centre of long bones
What is cortical bone?
Compact, hard bone around the outside
Why do fractures heal better the younger you are?
Bones in children have very good blood supply
Fractures are more likely to be a clean break in children
What are the different types of fracture?
Buckle Transverse Oblique Spiral Segmental Salter-Harris Comminuted Greenstick
What is a buckle (/torus) fracture?
Compression/ impact fracture- when one side of the bone bends, raising a buckle without breaking the other side of the bone
Which fractures are children much more likely to get than adults?
Greenstick fracture
Buckle fracture
Salter-Harris fracture
Why are children more likely to get a buckle fracture ?
Due to less strength against compression
What is a Salter-Harris fracture?
A growth plate fracture
What is a segmental fracture?
When the bone is broken in at least two places, leaving a segment of bone completely separated
What is a comminuted fracture?
Bone that is broken in to three or more pieces
What is a greenstick fracture?
Where only one side of the bone breaks whilst the other side stays intact
Why are greenstick fractures more common in children?
Because their bones are softer and more flexible so the bone bends and cracks instead of breaking into separate pieces
How are growth plate fractures classified?
Salter-Harris classification
What are the 5 types of Growth plate fracture? (SALTR pneumonic)
1= Straight across 2= Above 3= beLow 4= Through 5= cRush
Which type of growth plate fracture is more likely to disturb growth?
The higher the salter-harris grade, the more likely
What is the first principle in fracture management?
Mechanical alignment of the fracture
What are the two types of fracture alignment?
Closed reduction (manipulation of joint) Open reduction (surgery)
What is the second principle of fracture management?
Providing relative stability to allow healing
What are the different ways of fixing the bone to allow for healing?
External casts K wires Intramedullary wires Intramedullary nails Screws Plate & screws
What are the steps in pain management in children with fractures?
Step 1= Paracetamol or Ibuprofen
Step 2= Morphine
What pain relief is not used in children and why?
Codeine and tramadol due to unpredictability in their metabolism
Aspirin is contraindicated due to Reye’s syndrome
How may a child with hip pain present?
Limp Refusal to walk Refusal to weight bear Inability to walk Pain Swollen/ tender joint
What are the differential diagnoses of limp in 0-4 year old?
Septic arthritis
Developmental dysplasia of the hip
Transient sinovitis
What are the key differential diagnoses of limp in 5-10 year olds?
Septic arthritis
Transient sinovitis
Perthes disease
What are the key differential diagnoses of limp in 10-16 year olds?
Septic arthritis
Slipper upper femoral epiphysis
Juvenile idiopathic arthritis
What are the red flags for hip pain?
Child <3 Fever Waking at night Weight loss Anorexia Night sweats Fatigue Persistent pain Stiffness in the morning Swollen/ red joint
What is the criteria for urgent referall for assessment in a limping child?
<3 >9 with restricted/ painful hip Not able to weight bear Evidence of neurovascular compromise Severe pain/ agitation Red flags Suspicion of abuse
What investigations may be useful to diagnose the cause of a limp?
Blood tests (CRP/ ESR) XRays USS Joint aspiration MRI
In what age range is septic arthritis most common?
Children <4
Why is septic arthritis an emergency?
It can quickly begin to destroy the joint and cause serious systemic illness
What is the mortality of septic arthritis?
10%
What is the most common cause of septic arthritis?
Joint replacement
How does septic arthritis present?
Hot, painful, swollen joint
Refusal to weight bear
Stiffness, reduced ROM
Systemic features
What are the commonly affected joints in septic arthritis?
Knee or hip
What is the most common causative organism of septic arthritis?
Staph aureus
What other bacteria may cause septic arthritis?
Neisseria gonorrhoea
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
E. coli
What are the differential diagnoses of septic arthritis?
Transient sinovitis
Perthes disease
Slipped upper femoral epiphysis
JIA
How is septic arthritis diagnosed?
Joint aspiration for gram staining, crystal microscopy, culture and antibiotic sensitivities
How is septic arthritis treated?
Empirical IV antibiotics until sensitivities are known
How long are antibiotics usually continued after septic arthritis is confirmed?
3-6 weeks
What may be needed to clear the infection in severe cases?
Surgical drainage and washout of the joint
What is the most common cause of hip pain in children aged 3-10?
Transient synovitis
What is transient synovitis?
Temporary irritation and inflammation in the synovial membrane of the hip
What is transient synovitis often associated with?
Viral upper respiratory tract infection
How does transient synovitis usually present?
Within a few weeks of viral illness Limp Refusal to weight bear Groin/ hip pain Mild low grade fever
How is transient synovitis managed?
Symptomatic with simple analgesia
Give clear safety net advice
How is transient synovitis diagnosed?
Rule out septic arthritis
What is the prognosis of transient synovitis?
Usually significant improvement in 24-48 hours
Symptoms resolve within 1-2 weeks
Recurs in 20% patients
What is Perthes disease?
Disruption of blood flow to the femoral head, causing avascular necrosis to the bone
What part of the femur is affected in Perthes disease?
The epiphysis of the femoral head
What age range is affected by Perthes disease?
4-12 years (most commonly 5-8 year old boys)
What is the cause of Perthes disease?
Idiopathic
What happens over time with Perthes disease?
There is revascularisation or neovascularisation and remodeling of the femoral head
What is the main complication of Perthes disease ?
Soft, deformed femoral head, leading to early hip osteoarthritis
How does Perthes present?
Slow onset of: Hip pain Limp Restricted hip movements Referred knee pain
What is the initial investigation of choice in Perthes disease?
Xray
What other investigations may be done to diagnose Perthes?
Blood tests (should be normal)
Technetium bone scan
MRI scan
How is Perthes disease managed?
Conservative: maintain healthy alignment and reduce risk of damage (bed rest, crutches ect)
PT
Regular Xrays
Surgery in extreme cases
What should you think of if there is hip pain and a history of minor trauma?
SUFE
What is SUFE?
Slipped upper femoral ephiphysis
What is SUFE also known as?
Slipped capital femoral epiphysis (SCFE)
What happens in SUFE?
The head of the femur is displaced along the growth plate
In which patients is SUFE more common?
Boys 8-15
More common in obese children
Does SUFE tend to present earlier or later in girls?
Earlier
What is the typical presentation of SUFE?
Adolescent, obese male undergoing a growth spurt and a history of minor trauma
What are the presenting symptoms of SUFE?
Vague
Hip, groin, thigh or knee pain
Restricted ROM
Painful limp
What will the patient be like on examination of SUFE?
Prefer to keep hip in external rotation
Restricted internal rotation
What is the investigation of choice in SUFE?
Xray
How is SUFE managed?
Surgery to return femoral head to correct position and fix it in place
What is osteomyelitis?
Infection in the bone and bone marrow
Where does osteomyelitis typically occur?
Metaphysis of the long bones
What is the most common causative organism of osteomyelitis?
Staph aureus
What is chronic osteomyelitis?
Deep seated, slow growing infection with slowly developing symptoms
How can osteomyelitis occur?
Either by direct infiltration into the bone (open fracture) , or infection travelling to the bone through the blood
In which patients is osteomyelitis more common?
Boys and children <10
What factors increase the risk of osteomyelitis?
Open bone fracture Orthopaedic surgery Immunocompromised Sickle cell anaemia HIV TB
How does osteomyelitis present?
Refusal to weight bear Pain Swelling Tenderness Acute= fever
What investigations are done into osteomyelitis?
Xrays
MRI
Inflammatory markers and WCC
Blood culture
How is osteomyelitis managed?
Extensive antibiotic therapy
May need surgery for drainage and debridement
What is the initial vs gold standard investigation for osteomyelitis?
Initial= osteomyelitis
Gold standard= MRI
What is osteosarcoma?
Type of bone cancer
In what age range does osteosarcoma usually present?
10-20 year olds
What is the most commonly affected bone in osteosarcoma?
Femur
tibia and humerus
What is the main presenting feature of osteosarcoma?
Persistent bone pain (particularly worse at night time)
What other symptoms may be present in osteosarcoma?
Bone swelling
Palpable mass
Restricted joint movements
How is osteosarcoma diagnosed?
Urgent Xray
What will Xray show with osteosarcoma?
Poorly defined lesion
Destruction of normal bone
Fluffy appearance
Periosteal reaction= ‘sun-burst’ appearance
What other tests are done into osteosarcoma?
Blood tests CT MRI Bone scan PET scan Bone biopsy
What may blood test show with osteosarcoma?
Raised ALP
How is osteosarcoma managed?
Surgical resection of lesion (often with limp amputation)
Adjuvant chemotherapy
What are the main complications of osteosarcoma?
Pathological bone fractures
Metastasis
What is talipes?
Clubfoot- a fixed abnormal ankle position
When does talipes present?
At birth or at newborn examination
What is talipes equinovarus?
The ankle in plantar flexion and supination
What is talipes calcaneovalgus?
The ankle in dorsiflexion and pronation
How is talipes treated?
Ponseti method
May require surgery
What is the Ponseti method?
Foot manipulation and application of a cast to return foot to normal position
Will also need achilles tenotomy
After treatment brace is used to hold foot in correct position until 4
What is positional talipes?
Where the resting position of the ankle is in plantar flexion and supination, but there is no structural bone issue
How is positional talipes managed?
Referral to physiotherapist for simple exercises
What is developmental dysplasia of the hip?
Condition where there is a structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy
What does developmental dysplasia lead to?
Instability in the hips and a tendency for subluxation or dislocation
May persist into adulthood with abnormal gait and early degeneration
When is DDH picked up?
At NIPE or later when child presents with hip assymetry or limp
What are the risk factors for DDH?
First degree family history
Breech presentation
Multiple pregnancy
Where is DDH screened for?
NIPE at birth and 6-8 weeks
What examination findings may suggest DDH?
Different leg lengths
Restricted hip abductino
Significant bilateral restriction
Difference in flexed knee level clunking on special tests
What two special tests are used to check for DDH?
Ortolani test
Barlow test
What is the Ortolani test?
Gentle pressure used to abduct babies hips to see if they will dislocate anteriorly
What is the Barlow test?
Gentle pressure placed on knees through femur to see if the femoral head will dislocate posteriorly
What is done is clunking is found on NIPE?
USS
How is DDH managed if the baby is <6 months?
Pavlik harness
What is the Pavlik harness?
Harness kept on permanently that hold the femoral head in the correct position to allow the hip socket to develop into a normal shape
At what stage is the Pavlik harness removed?
6-8 weeks
When would surgery be used for DDH?
When the harness fails or diagnosis if after 6 months
What is achondroplasia?
Type of skeletal dysplasia
What is achondroplasia the most common cause of?
Dwarfism
What is the achondroplasia gene?
FGFR3 gene on chromosome 4
What causes achondroplasia?
Sporadic or inherited mutation of FGFR3 gene
What is the inheritance pattern of achondroplasia?
Autosomal dominant
What does inheritance of two achondroplasia genes cause?
Death in neonatal period
What do mutations in the FGFR3 gene cause?
Abnormal function of the epiphyseal plates, restricting the bone growth in lenght
What is the average height of a patient with achondroplasia ?
4 feet
What parts of the body are most affected by achondroplasia?
Limbs- particularly proximal limbs (femur and humerus)
What are the features of achondroplasia ?
Short stature Short digits Bow legs Disproportionate skill Foramen magnum stenosis
Why do patients with achondroplasia have a disproportionate skull?
Different ares of the skull grow by different methods, some of which are more affected than others
What other conditions is achondroplasia associated with?
Recurrent otitis media Kyphoscoliosis Spinal stenosis Obstructive sleep apnoea Obesity Cervical cord compression/ hydrocephalus (due to foramen magnum stenosis)
Why do you get foramen magnum stenosis in achondroplasia?
The skull base grows and fuses via endochondral ossification which is affected by achondroplasia
What is the management of achondroplasia?
MDT
What is the prognosis of achondroplasia?
Normal life expectancy
What is Osgood-Schlatter disease?
Condition that causes pain and swelling below the knee joint
What causes Osgood-Schlatter disease?
Inflammation of the tibial tuberosity
Where on the tibial tuberosity does the inflammation occur?
Where the patella ligament inserts
In what age range does Osgood-Schlatter disease typically occur?
Patients aged 10-15
More common in males
Where does the patella tendon insert?
At the tibial tuberosity, whcih is at the epiphyseal plate
Why does inflammation occur in Osgood-Schlatter disease?
Due to stress from movement at the same time as growth in the epiphyseal plate
Why do you get a visible lump in Osgood-Schlatter disease?
There are multiple avulsion fraction where the patella ligament pulls away tiny pieces of bone, leading to a growth of the tibial tuberosity
What are avulsion fractures?
When a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone
What happens to the lump in Osgood-Schlatter disease?
It it initially tender but eventually becomes hard and non-tender
How does Osgood-Schlatter disease present?
Gradual onset of:
Visible/ palpable hard and tender lump at tibial tuberosity
Pain in anterior knee, exacerbated by activity
How is Osgood-Schlatter disease managed?
Reduction in activity
ICE
NSAIDS
What is the prognosis of Osgood-Schlatter disease?
Symptoms will fully resolve but patient will be left with hard boney lump
What is the rare complication of Osgood-Schlatter disease?
Full avulsion fracture- tibial tuberosity is separated from rest of tibia
