Orthopaedics

Question 1

Summary of transient synovitis?

Answer 1

Irritable hip

Commonest cause of hip pain in children.

3-8y/o

Acute hip pain following recent viral infection
Limp/ refusal to WB
Low grade fever in minority. ↑ fever, worry of septic arthritis

Self-limiting
Requiring only rest + analgesia.

Question 2

What is Perthes disease?

Answer 2

Degen condition affecting hip joints of children 4-8yrs

AVN of femoral head, specifically femoral epiphysis

Impaired blood supply causes bone infarction

M>F

Question 3

Features of Perthes disease?

Answer 3

Hip pain: develops progressively over few wks

Limp

Stiffness + ↓ROM of hip
Catterall staging:
1 (only clinical + histology features)
2 (sclerosis with/ w/o cystic changes articular surface preserved),
3(loss of structural integrity of femoral head),
4 (loss of acetabular integrity)

Question 4

Complications of Perthes disease?

Answer 4

Osteoarthritis

Premature fusion of growth plates

Most cases resolve with conservative management.

Early diagnosis improves outcome

Question 5

Investigations for Perthes disease?

Answer 5

XR: early (widening of joint space), late changes (↓femoral head size/ flat)

Technetium bone scan/ MRI: XR normal, Sx persist

Question 6

Management of Perthes disease?

Answer 6

Keep femoral head within acetabulum: cast, brace

<6: observation

Older: surgical management

Operate on severe deformities

Question 7

What is developmental dysplasia of the hip?

Answer 7

disorder of abnormal development resulting in dysplasia, subluxation, and possible dislocation of the hip secondary to capsular laxity and mechanical instability.

RF: F>M, breech, pos FH, 1st born child, oligohydramnios, BW >5kg, congen calcaneovalgus foot deformity

More common in left hip

Question 8

Features of developmental dysplasia of the hip?

Answer 8

Barlow: dislocate an articulated femoral head.

Ortolani: reduce a dislocated femoral head

Restricted abduction of hip flexion

Asymmetry of leg length

Level of knees when hips + knees bilat flexed

Question 9

Screening for DDH?

Answer 9

Screening: USS if > 1st degree FH of hip problems in early life, breech at/after 36 wks, irrespective of mode of delivery or presentation at birth, multiple preg.

Question 10

Diagnosis of DDH?

Answer 10

USS: to confirm diagnosis if clinically suspected

Infant >4.5 mnths, XR 1st line investigation

Question 11

Management of DDH?

Answer 11

Most unstable hips spontaneously stabilise by 3-6 wks of age

Pavlik harness in children <4-5 mnths

Older children may require surgery

Question 12

What is SUFE?

Answer 12

typically age group is 10-15 years

More common in obese children and boys

Displacement of the femoral head epiphysis postero-inferiorly

May present acutely following trauma or more commonly with chronic, persistent symptoms

Question 13

Features of SUFE?

Answer 13

hip, groin, medial thigh or knee pain

loss of internal rotation of the leg in flexion

bilateral slip in 20% of cases

Question 14

Investigations for SUFE?

Answer 14

AP and lateral (typically frog-leg) views are diagnostic

Question 15

Management of SUFE?

Answer 15

internal fixation: typically a single cannulated screw placed in the center of the epiphysis

Question 16

What is osteogenesis imperfecta?

Answer 16

more commonly known as brittle bone disease) is a group of disorders of collagen metabolism resulting in bone fragility and fractures.

The most common, and milder, form of osteogenesis imperfecta is type 1

autosomal dominant

abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

Question 17

Features of osteogenesis imperfecta?

Answer 17

presents in childhood

fractures following minor trauma

blue sclera

deafness secondary to otosclerosis

dental imperfections are common - blue/grey or yellow/brown

Basilar skull deformities, can compress CNs

Short stature, scoliosis

Easy bruising

Hypermobility of ligaments, joints, skin

Breathing problems

Complications - Cervical a or aortic dissection

Question 18

Investigations for osteogenesis imperfecta?

Answer 18

adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta

Prenatal USS: severe micromelia (small undeveloped extremities).

Postnatal XR: mild thinning of cortical bone, Wormian bones (small irregular bones between cranial sutures)

Biopsy: disorganised bone, ↓of cortical trabecular width, cancellous bone volume, ↑bone remodelling

Dermal fibroblast culture: abnormalities in quality/quantity of collagen synthesis

Question 19

Management of osteogenesis imperfecta?

Answer 19

Prenatal DNA mutation analysis for at risk pregnancies

Physio to strengthen, ↓ chance to fractures

Bisphosphonates e.g. IV pamidronate

management with intramedullary rod placement, telescoping rods for actively growing individuals

Question 20

What is scoliosis?

Answer 20

Lat curvature of spine in frontal plane due to rotation of vertebral bodies.

Apparent unequal leg length, F>M. Idiopathic in 85%, either <5 or during puberty

VACTERL

2° to NM imbalance: CP, muscular dystrophy, spina bifida, SMA

2° to disorders of bone/CT: Marfan’s/Ehler’s-Danlos, DDH

Question 21

Features of scoliosis?

Answer 21

Elevated shoulder on convex side.

Rib humping on bending = asymmetry

Often mild just requiring XR monitoring

Pain + restrictive resp failure if severe

Question 22

Management of scoliosis?

Answer 22

Monitor
Bracing
Surgical