Orthopaedics Flashcards
What is transient synovitis and what is it caused by?
Transient synovitis is sometimes referred to as irritable hip. It is caused by temporary (transient) irritation and inflammation in the synovial membrane of the joint (synovitis). It is often associated with a recent viral upper respiratory tract infection.
What is the most common cause of hip pain in children aged 3 – 10 years?
Transient synovitis
Transient synovitis vs septic arthritis presentation?
Both causes of hip pain
Transient synovitis usually associated with a recent viral URTI
Children with transient synovitis typically do not have a fever and are usually otherwise well. They should have normal paediatric observations and no signs of systemic illness. When other signs are present, consider alternative diagnoses.
Children with joint pain and a fever need urgent management for septic arthritis.
Presentation of transient synovitis?
Symptoms of transient synovitis often occur within a few weeks of a viral illness.
They present with acute or more gradual onset of:
Limp
Refusal to weight bear
Groin or hip pain
Mild low grade temperature
Children with transient synovitis should be otherwise well. They should have normal paediatric observations and no signs of systemic illness. When other signs are present, consider alternative diagnoses.
Management of transient synovitis?
General management of transient synovitis is symptomatic, with simple analgesia to help ease the discomfort.
The challenge is to establish the correct diagnosis and exclude other significant pathology, particularly septic arthritis.
NICE clinical knowledge summaries:
- Children aged 3 – 9 years with symptoms suggestive of transient synovitis may be managed in primary care if the limp is present for less than 48 hours and they are otherwise well, however they need clear safety net advice to attend A&E immediately if the symptoms worsen or they develop a fever.
- They should also be followed up at 48 hours and 1 week to ensure symptoms are improving and then fully resolve.
According to NICE, children aged 3 – 9 years with symptoms suggestive of transient synovitis may be managed in primary care when?
If the limp is present for less than 48 HOURS
and they are otherwise well
However they need clear safety net advice to attend A&E immediately if the symptoms worsen or they develop a fever.
How long does transient synovitis take to resolve?
Typically there is a significant improvement in symptoms after 24 – 48 hours.
Symptoms fully resolve within 1 – 2 weeks without any lasting problems.
Prognosis of transient synovitis?
Typically symptoms fully resolve within 1-2 weeks without any lasting problems.
Transient synovitis may recur in around 20% of patients.
What is SUFE?
Slipped upper femoral epiphysis (SUFE) is also known as slipped capital femoral epiphysis (SCFE).
It is where the head of the femur is displaced (“slips”) along the growth plate.
Which demorgaphic typically present with slipped upper femoral epiphysis (SUFE/slipped capital femoral epiphysis (SCFE))?
More common in males
Presents between 8 – 15 years, with the
Average age of 12 in boys, presenting slightly earlier in females, with an average age of 11 years
More common in OBESE children
What might you suspect in an adolescent, obese male undergoing a growth spurt presenting with a painful limp triggered by a minor trauma, with pain that is disproportionate to the severity of the trauma?
Slipped upper femoral epiphysis (SUFE/slipped capital femoral epiphysis (SCFE))?
When examining a patient with slipped upper femoral epiphysis (SUFE)/slipped capital femoral epiphysis (SCFE), they will prefer to keep the hip in what position?
When examining the patient, they will prefer to keep the hip in external rotation.
They will have limited movement of the hip, particularly restricted internal rotation.
When examining a patient with slipped upper femoral epiphysis (SUFE)/slipped capital femoral epiphysis (SCFE), which movement will be particularly restricted?
RESTRICTED INTERNAL ROTATION
When examining the patient, they will prefer to keep the hip in external rotation.
They will have limited movement of the hip, particularly restricted internal rotation.
Presentation of slipped upper femoral epiphysis (SUFE)/slipped capital femoral epiphysis (SCFE)?
Hip, groin, thigh or knee pain (often preceeded by minor trauma - disproportionate to the pain)
Restricted range of hip movement
Painful limp
Restricted movement in the hip (particularly internal rotation, with the patient preferring to keep the hip externally rotated)
The typical exam presentation is an adolescent, obese male undergoing a growth spurt. There may be a history of minor trauma that triggers the onset of symptoms.
Investigating SUFE?
The initial investigation of choice in SUFE is X RAY
Other investigations that can be helpful in establishing the diagnosis are:
- Blood tests are normal, particularly inflammatory markers used to exclude other causes of joint pain
- Technetium bone scan
- CT scan
- MRI scan
How is SUFE managed?
Surgery is required to return the femoral head to the correct position and fix it in place to prevent it slipping further.
What is developmental dysplasia of the hip and why does it occur?
Developmental dysplasia of the hip (DDH) is a condition where there is a structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy.
This leads to instability in the hips and a tendency or potential for subluxation or dislocation.
What problems does developmental dysplasia of the hip cause?
Instability in the hips + tendency/potential for subluxation or dislocation
Structural abnormalities have the potential to persist into adulthood leading to:
- Weakness
- Recurrent subluxation or dislocation
- Abnormal gait with early degenerative changes
When might developmental dysplasia of the hip be detected?
During the newborn examinations
Later, when the child presents with:
- Hip asymmetry
- Reduced range of movement in the hip
- A limp
Risk factors for developmental dysplasia of the hip?
First degree family history
Breech presentation from 36 weeks onwards
Breech presentation at birth if 28 weeks onwards
Multiple pregnancy
When is DDH screened for?
At the neonatal examination at birth and 6-8 week old.
Public Health England provides newborn and infant physical examination (NIPE) guidance on picking up DDH.
What is looked for when screening for DDH and what findings may suggest it is present?
When examining, look for symmetry in the hips, leg length, skin folds and hip movements.
Findings that may suggest DDH are:
- Different leg lengths
- Restricted hip abduction on one side
- Significant bilateral restriction in abduction
- Difference in the knee level when the hips are flexed
- Clunking of the hips on special tests
- Positive tests:
1.Ortolani test
2. Barlow test
What special tests are used to look for DDH?
Ortolani test
Barlow test
What is the Ortolani test performed to look for, and what does it involved?
Ortolani test is a special test looking for developmental dysplasia of the hip performed during the NIPE
Looking for ANTERIOR DISLOCATION of the hip
- Baby is on their back with the hips and knees flexed.
- Examiner places their palms on baby’s knees
- Examiner places their thumbs on the inner thigh
- Examiner places four fingers on the outer thigh
- Examiner used gentle pressure to abduct the hips and apply pressure behind the legs with the fingers to see if the hips will dislocate anteriorly
What is the Barlow test performed to look for, and what does it involve?
The Barlow test is a special test looking for developmental dysplasia of the hip, performed during the NIPE
Looking for POSTERIOR DISLOCATION of the hip
- Baby is on their back with hips adducted and flexed at 90 degrees, and knees bent at 90 degrees
- Examiner places gentle downward pressure on the knees through the femur to see if the femoral head with dislocate posteriorly
Clicking vs clunking - DDH
CLICKING - a common examination finding, usually due to soft tissue moving over bone
(When this is the cause an ultrasound will be normal.
Isolated clicking without any other features does not usually require an ultrasound unless there are other concerns)
CLUNKING - more likely to indicate DDH, requires an ultrasound.
How is developmental dysplasia of the hip diagnosed?
ULTRASOUND:
Where children are suspected of having DDH, ultrasound of the hips is the investigation of choice and can establish the diagnosis. All children with risk factors or examination findings suggestive of DDH should have an ultrasound.
Xrays can also be helpful, particularly in older infants.
Below what age can a presentation of DDH be considered for management with a Pavlik harness?
Treatment typically involves a Pavlik harness if the baby presents at less than 6 months of age.
The Pavlik harness is fitted and kept on permanently, adjusting for the growth of the baby. T
The aim is to hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop a normal shape. This harness keeps the baby’s hips flexed and abducted.
The child is regularly reviewed and the harness is removed when their hips are more stable, usually after 6 – 8 weeks.
For how long is a Pavlik harness used?
Until the hips are more stable, usually after 6-8 weeks
When might surgical management be required for DDH?
When the harness fails or the diagnosis is made after 6 months of age.
After surgery is performed, an hip spica cast is used to immobilises the hip for a prolonged period.
What is the role of the Pavlik harness in DDH?
The Pavlik harness is used when the child presents before 6 months of age
It is fitted and kept on permanently, adjusting for the growth of the baby.
It aims to hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop a normal shape.
This harness keeps the baby’s hips FLEXED AND ABDUCTED
The child is regularly reviewed and the harness is removed when their hips are more stable, usually after 6 – 8 weeks.
Management of developmental dysplasia of the hip?
PAVLIK HARNESS - if presenting before 6 months of age, fitted for around 6-8 weeks
SURGERY - if Pavlik harness fails or if child presents after 6 months of age, followed by immobilisation of the hip for a prolonged period with A HIP SPICA CAST
What is osteosarcoma and which sites are most commonly affected?
Osteosarcoma is a type of bone cancer.
The most common bone to be affected is the femur. Other common sites are the tibia and humerus.
What age range is usually affected by osteosarcoma?
Children and young adults 10 – 20 years.
How does osteosarcoma present?
The main presenting feature is persistent bone pain, particularly worse at night time. This may disturb or wake them from sleep.
Other symptoms that may be present include:
- bone swelling
- a palpable mass
- restricted joint movements
Osteosarcoma - investigations?
NICE guidelines recommend a very urgent direct access xray within 48 hours for children presenting with unexplained bone pain or swelling.
If the xray suggests a possible sarcoma they need very urgent specialist assessment within 48 hours.
Blood tests may show a raised alkaline phosphatase (ALP).
Further investigations is used to better define the lesion and stage the cancer:
CT scan
MRI scan
Bone scan
PET scan
Bone biopsy
X ray in osteosarcoma?
Xrays show a poorly defined lesion in the bone, with destruction of the normal bone and a “fluffy” appearance.
There will be a periosteal reaction (irritation of the lining of the bone) that is classically described as a “sun-burst” appearance.
There can an associated soft tissue mass.
Management of orthopaedics?
Management involves surgical resection of the lesion, often with a limb amputation.
Adjuvant chemotherapy is used alongside surgery to improve outcomes.
They will require support and input from the multidisciplinary team in addition to treatment of the tumour:
Paediatric oncologists and surgeons
Specialist nurses
Physiotherapy
Occupational therapy
Psychology
Dietician
Prosthetics and orthotics
Social services
The main complications are pathological bone fractures and metastasis.
What blood marker may be raised in osteosarcoma?
ALP
What investigations may be done to stage osteosarcoma?
CT scan
MRI scan
Bone scan
PET scan
Bone biopsy
What is talipes and when does it present?
Talipes is a fixed abnormal ankle position that presents at birth.
It is also known as clubfoot. It can occur spontaneously or be associated with other syndromes.
It is usually identified at birth or during the newborn examination.
What talipes equinovarus?
Talipes equinovarus describes the ankle in plantar flexion and supination.
What is seen here?
Talipes equinovarus
What is talipes calcaneovalgus?
Talipes calcaneovalgus describes the ankle in dorsiflexion and pronation.
How is talipes managed?
Talipes is treated with the “Ponseti method” with good results.
Surgery may be required if the Ponseti method fails or cannot be used.
What is the ‘‘Ponseti method’’ of treating talipes?
The Ponseti method is a way of treating talipes without surgery.
It is usually very successful.
Treatment is started almost immediately after birth. It is performed by a properly trained therapist.
The foot is manipulated towards a normal position and a cast is applied to hold it in position.
This is repeated over and over until the foot is in the correct position.
At some point an achilles tenotomy to release tension in the achilles tendon is performed, often in clinic.
After treatment with the cast is finished a brace is used to hold the feet in the correct position when not walking until the child is around 4 years old. This brace is sometimes referred to as “boots and bars”.
What is positional talipes and how does it differ from talipes?
Positional talipes is a common condition where the resting position of the ankle is in plantar flexion and supination, however it is not fixed in this position and there is no structural boney issue in the ankle.
The muscles are slightly tight around the ankle but the bones are unaffected.
The foot can still be moved into the normal position.
This requires referral to a physiotherapist for some simple exercises to help the foot return to a normal position.
Positional talipes will resolve with time.
What is seen here?
Talipes calcaneovalgus
What happens in Perthe’s disease and which part of the bone is affected?
Perthes disease involves disruption of blood flow to the femoral head, causing avascular necrosis of the bone. This affects the epiphysis of the femur, which is the bone distal to the growth plate (physis)
Over time there is revascularisation or neovascularisation and healing of the femoral head.
There is remodelling of the bone as it heals.
Which ages and sex are mostly affected by Perthes disease?
It occurs in children aged 4 – 12 years, mostly between 5 – 8 years, and is more common in boys.
Why does avascular necrosis of the femoral head occur in Perthes disease?
It is described as idiopathic, meaning there is no clear cause or trigger for the avascular necrosis.
One theory suggests that repeated mechanical stress to the epiphysis may interrupt the blood supply.
What is the main complication of Perthes disease?
The main complication is a soft and deformed femoral head, leading to early hip osteoarthritis.
This leads to an artificial total hip replacement in around 5% of patients.
How does Perthes disease?
Perthes disease present with a slow onset of:
Pain in the hip or groin
Limp
Restricted hip movements
There may be referred pain to the knee
There will be no history of trauma.
In Perthes disease there will not be a history of trauma - what might you consider as a DDx instead?
If the pain is triggered by minor trauma, think about slipped upper femoral epiphysis, particularly in older children.
Investigating ?Perthes disease?
The initial investigation of choice in Perthes disease is an xray, however this can be normal.
Other investigations that can be helpful in establishing the diagnosis are:
Blood tests are typically normal, particularly inflammatory markers that are used to exclude other causes
Technetium bone scan
MRI scan
What bony deformity is seen here?
Bowing of the legs, where the legs curve outwards
seen in Rickets
What bony deformity is seen here?
Knock knees, where the legs curve inwards
seen in Rickets
What bony deformity is seen here?
Rachitic rosary, where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest
seen in Rickets
What bony deformity is seen here?
Craniotabes, which is a soft skull, with delayed closure of the sutures and frontal bossing
seen in rickets
Features of Achondroplasia?
Patients with achondroplasia have disproportionate short stature.
The average height is around 4 feet.
The limbs are most affected by reduce bone length.
The femur and humerus (proximal limbs) are affected more than the bones of the forearm and lower leg.
The spine length is less affected and patients have a normal trunk length. Intelligence and life expectancy are not affected by the condition.
Other features of the condition:
Short digits
Bow legs (genu varum)
Disproportionate skull
Foramen magnum stenosis
Different areas of the skull grow by different methods, some of which are affected more than others.
This leads to a disproportionate skull.
The skull base grows and fuses via endochondral ossification, which is affected by achondroplasia and leads to a flattened mid-face and nasal bridge and foramen magnum stenosis.
The cranial vault grows and fuses via membranous ossification, which is unaffected by achondroplasia and leads to a normal sized vault and frontal bossing (prominent forehead).
What are epiphyseal plates?
Growth plates (epiphyseal plates) are found in the bones of children but not adults.
They are the area at the ends of long bones that allow the bones to grow in length.
They are made of hyaline cartilage and sit between the epiphysis and the metaphysis.
Types of fracture
Buckle (torus)
Transverse
Oblique
Spiral
Segmental
Salter-Harris (growth plate fracture)
Comminuted
Greenstick
Salter-Harris classification of growth plate structures?
Use the SALTR mnemonic to remember the types:
Type 1: Straight across
Type 2: Above
Type 3: BeLow
Type 4: Through
Type 5: CRush
