Orthopaedics Flashcards
What does the term DDH stand for?
What is an alternative name for DDH?
DDH = developmental dysplasia of the hip
Another term you may hear to refer to it is congenital dislocation of the hip but this is no longer used as there are different degrees of abnormality (not just dislocated hips) and also isn’t always there from birth but can develop later.
What are some risk factors for DDH?
Why is this clinically important?
- Oligohydramnios - little amount of amniotic fluid in the womb. It can increase the risk of developing DDH because the baby isn’t able to move about within the uterus as much
- Breech presentation
- First degree family history of DDH
- Club foot (talipes)
If the baby has the risk factors of family history, breech presentation, foot (talipes) and spine abnormalities or neuromuscular disorder it is recommended they undergo an ULTRASOUND at 6 weeks
What is DDH?
DDH is an abnormality of the hip joint.
There can either be a problem with the acetabulum, a problem with the femur or a problem with the surrounding structures. This results in the acetabulum and femur not being in as close contact. If it is severe there is no contact between them are this is called dislocation.
What does clinical examination for DDH in a newborn involve?
What tests on physical examination can be done to screen for DDH? What do they tell you
- Asymmetrical gluteal or thigh skin folds.
- Limb length discrepancy (Galeazzi sign).
- Limitation and asymmetry of hip abduction when the hip is flexed to 90°.
Barlow and Ortolani tests can be used on newborn babies. They can tell you is the hip is unstable but are difficult to do after the age of 2-3 months.
Limited hip abduction (less than 60°) when the hip is flexed to 90° is the most important sign of a dislocated or dysplastic hip
How may DDH present later in life?
- Femur length discrepancy (galeazzi sign)
- Walking with one bent knee (longer leg) or walking with on foot on tiptoes - may present with a PAINLESS LIMP
- Limited abduction when fully flexed#
- Positive Trendelenburg’s test
- Difficulty putting nappies on
What is galeazzi’s sign?
The child is examined lying supine with the hips and knees flexed to 90° and the height of each knee is compared and unilateral femoral shortening is seen
What movement is often limited with children with DDH?
Limited abduction of a flexed hip
How may DDH present in a child 2-6 months of age?
Unilateral limitation and asymmetry of hip abduction is the most reliable sign of DDH after eight weeks
Galeazzi’s sign
What is the investigation of choice for DDH?
US in children <4.5 months
X-ray for older
What is the first line treatment for DDH? Who is it used for?
Pavlik harness
Used for children who’s hip remain unstable at 6 weeks
Treatment should ideally occur within 3 months of life. Pavlik’s harness can only be used up to the age of 6 months
If DDH presents later in life how can it be treated?
Open reduction and osteotomy is used for children who are > 6 months
When is the Pavlik harness contraindicated?
If the child is >4.5 months old
What are some differentials of _____in a child aged 1-3 years?
a) Acute painful limp
b) Chronic and intermittent limp
ACUTE + PAINFUL 1. Infection - septic arthritis, osteomyelitis 2. Transient synovitis 3. Malignant disease e.g leukaemia or neuroblastoma 4. Trauma - accidental/non-accidental, CHRONIC AND INTERMITTENT 1. DDH, talipes 2. Cerebral palsy 3. JIA
What are some differentials of _____in a child aged 3-10 years?
a) Acute painful limp
b) Chronic and intermittent limp
ACUTE + PAINFUL 1. Infection - septic arthritis, osteomyelitis 2. Transient synovitis 3. Perthes disease (acute) 4. Malignant e.g leukaemia 5. Trauma and overuse injuries 6. JIA 7. Complex regional pain syndrome CHRONIC AND INTERMITTENT 1. Perthes disease (chronic) 2. JIA 3. Neuromusclar - e.g duchennesmuscular dystrophy 4. Tarsal coalition
What are some differentials of _____in a child aged 11-16 years?
a) Acute painful limp
b) Chronic and intermittent limp
ACUTE + PAINFUL
- Mechanical - trauma, overuse injuries, sport injuries
- SUFE (acute)
- Infeciton - septic arthritis/osteomyelitis
- JIA
- AVN of the femoral head
- Bone tumours and malignancy
- Reactive arthritis
- Complex regional pain syndrome
- Osteochondritis dissecans of the knee
CHRONIC AND INTERMITTENT
- SUFE (chronic)
- JIA
- Tarsal coalition
In what age group does Perthes’ disease usually present in?
How does it typically present?
Age 4-8 (3-10)
Affects boys more than girls with the ratio 5:1
Hip or knee pain, reduced range of motion and stiffness
What is Perthes’ disease?
What is the pathophysiology?
Perthes disease is avascular necrosis of the femoral head and is a self limiting disease. (There is specifically AVN of the nucleus of the proximal femoral epiphysis)
The subsequent bone remodelling that occurs distorts the epiphysis and generates abnormal ossification
What investigations are usually carried out to assess Perthes’ disease?
What is seen on these investigations?
X-rays
Initially x-rays may be normal
Early signs on x-ray include joint space widening
Later there can be a decrease in the size of the femoral head with patchy density
Even later on there may be collapse and deformity of the femoral head with new bone formation
A bone scan or MRI may also be useful
What is the aim of treatment with Perthes’ disease? (E.g to avoid what complication)
What types of treatment can be given to children with Perthes?
Main aim is to avoid OA
This is done by trying to maximise the contact between the femoral head and the acetabulum and also try to maintain the sphericity of the femoral head
TREATMENT: Physio Bed rest and NSAIDS for pain relief Traction Plaster casts If the child is >6 surgery may be required
What are the findings on examination of a patient with Perthes’ disease?
Reduced abduction
Limited internal rotation with flexed and extended hip
Antalgic gait
In what age group of children does transient synovitis commonly present in?
How does it commonly present?
Age 2-10 or 2-12
Sudden onset hip pain/limp
Commonly following a viral infection
Not systemically unwell
What are the main features in a history which help to differentiate transient synovitis from septic arthritis?
FEVER: TS fever is mild/absent, in septic arthritis fever is moderate/high
APPEARANCE: TS child often looks well, SA child looks ill
HIP MOVEMENT: TS comfortable at rest, limited internal rotation and pain on movement, SA - hip held flexed, severe pain at rest and worse on any attempt to move the joint
What movements are commonly affected in a child with transient synovitis?
Internal rotation
What is the difference in terms of the finding on bloods of a child with transient arthritis vs septic arthritis?
US findings?
Radiography findings?
CRP: SA raised TS: normal/slight increase
WCC: TS - normal, AS: normal/high
US: Fluid in joint for both TS and SA
Radiograph: Normal for TS, for SA can be normal or increased joint space
What is the management of transient synovitis?
Rest and analgesia
What are considered to be the 4 prognositic clinical signs for differentiating between transient synovitis and septic arthritis?
- Temp >38.5°
- WCC> 12
- CRP > 20
- Non-weight bearing
In what time period can septic arthritis destroy a joint in?
24 hours
Therefore early treatment of septic arthritis is essential to prevent destruction of the articular cartilage and bone
What are some risk factors for septic arthritis?
What age group in children does it most commonly occur
Diabetes Immunosuppression Chronic renal failure Recent joint surgery Prosthetic joints IVDU >80
In children, it affects children <2 most commonly
If there is any suspicion of septic arthritis what investigations should be carried out?
Joint aspiration for synovial fluid microscopy and culture
Blood cultures
What is the treatment of choice for septic arthritis?
How long is this given for?
Empirical Abx after aspiration is taken
Then follow guidelines once you know the organism
Given IV for 2 weeks then if a patient improves 2-4 weeks PO
Consider orthopaedic review for arthrocentesis, washout and debridement
What is it important to remember about osteomyelitis and septic arthritis?
In up to 15% of cases of osteomyelitis there is coexistent septic arthritis
How does septic arthritis typically present in a child?
ERythematous, warm, acutely tender joint
Reduced ROM in an acutely unwell, febrile child
Infants often hold the limb still and have no spontaneous movement.
What is a major risk factor for SUFE?
What does SUFE stand for?
Obesity
Slipped upper femoral epiphysis
What is SUFE?
It is when the epiphysis of the femur moves postero-inferiorly
What association is there of SUFE with metabolic endocrine abnormalities?
There is associations with hypothyroidism and hyogonadism
What age group does SUFE present in most commonly?
10 - 15 year olds.
What is a complication of SUFE?
AVN
What movements are most commonly restricted in SUFE?
Flexion, abduction and internal rotation (e.g the patient may be seen to have a leg that is externally rotated)
But remember - on clinical examination there may not always be a gross abnormaility.
How does SUFE commonly present?
With hip, groin or knee pain following a minor accident
How is the diagnosis of SUFE confirmed?
X-ray
Plain radiograph and frog lateral should be requested
Frog lateral to pick up minor degrees of subluxation (can be missed in AP views)
What is the management of SUFE?
Surgical, usually with pin fixation in situ
What is the difference between the diaphysis, epiphysis and metaphysis?
Epiphysis is the end of the bone
Diaphysis is the shaft part of the bone
Metaphysis is in between the epiphysis and diaphysis and is the growth plate region
How does osteomyelitis commonly present?
Markedly painful limb, immobile, in a child with a fever
What are the most common causative organisms of osteomyelitis?
Staph aureus is most common
Streptococcus and haem influenzae (if not vaccinated)
Who is at an increased risk of osteomyelitis?
Diabetics (foot ulcers)
People with long standing pressure ulcers
IVDU
Describe the pathophysiology behind osteomyelitis
Infection enters bone - this can be haematogenous spread, from an infected wound or from trauma.
Pus develops and causes the periosteum to be lifted away, interrupting the blood supply to the underlying bone
Necrotic fragments of bone may form (sequestrum)
New bone formation is created by the elevation of the periosteum and this is called involucrum
What is the treatment for osteomyelitis?
IV antibiotics until general pain/tenderness/symptoms improve
Then oral antibiotics - may be required for 6 weeks
What do different investigations show in osteomyelitis?
Initially in osteomyelitis there are no changes seen on x-ray because it takes 10-14 days for changes to be apparent
Bloods - raised CRP and WCC
MRI, Bone scan and US can be helpful but shouldn’t delay treatment
What may be seen on examination of a patient with osteomyelitis?
Swelling over the infected site Tenderness Erythema Warmth Joint movements are generally not affected
What sites in the body are most commonly affected by osteomyelitis is a)children b) adults?
In children the METAPHYSIS of the femur and the proximal tibia are most commonly affected in children
In adults to vertebrae (in IVDU) and feet (in diabetics) are most commonly affected
How long does it typically take for changes to be seen on a plain film in a patient with septic arthritis?
2-3 weeks
What is the most common causative organism of septic arthritis?
Where does the infection usually come from?
Staphylococcus aureus
There is usually haematogenous seeding from a distant source of infection
What is the Kocher criteria?
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
If a patient has osteomyelitis but is not responding to antibiotics (e.g shows a deterioration in presentation) what further management is required?
If the patient is unresponsive to antibiotic therapy then surgical drainage is required
Within how may hours of birth should a baby’s hips be assessed?
Within 72 hours
Describe how barlow and ortolani’s tests are carried out
Barlow’s test: adducting the hip while pushing the thigh posteriorly. If the hip goes out of the socket, it is called “dislocatable” and the test is termed “positive”.
Ortolani manoeuvre: the contralateral hip is held still while the thigh of the hip being tested is abducted and gently pulled anteriorly. The sensation of instability in a positive Ortolani manoeuvre is the palpable and sometimes audible “clunk” of the femoral head moving over the posterior rim of the acetabulum and relocating in the cavity.
