Orthopaedics Flashcards
1
Q
SCFE overview
A
Epidemiology
- incidence is approx 1/1,000
- usually presents at beginning of puberty (rapid growth)
- more common in boys
- bilateral disease in majority
Aetiology
- factors that weaken physis
- > physiological changes associated with pubertal growth
- > obesity
- > endocrine (hypothyroidism, GHD)
- > trauma
- > genetic disorder (Down)
- > radiation therapy
Pathophys
- displacement of proximal femor distal to capital physis
- shearing forces exceed strength of capital physis
Clinical manifestations
- usually chronic
- dull, aching, non radiating pain in hip (can be in knee)
- > worse with exercise, relieved with rest
- gait may be antalgic, trendelenburg or waddling
- > foot externally rotated
- ROM reduced
- > flexion, abduction, internal rotation
- tender anterior hip
- obligatory external rotation during passive flexion
- weakness
Classification
- stable
- > weight bearing
- unstable
- > non weight bearing
- > evidence of displacement
Imaging
- AP and flog leg lateral radiograph
- > posterior displacement of epiphysis on lateral view
- > kleins line on AP view
- > widened or lucency of physis
Treatment
- non weight bearing
- refer to orthopaedic surgeon
- stabilisation surgery
2
Q
DDH background
A
Epidemiology
- incidence = 5/1,1000
- most common neonatal orthopaedic condition
- left hip most common
- > often bilateral
Aetiology
- spectrum of disease
- > dislocation/subluxation
- > dysplasia
- > teratologic hip (eg. connective tissue disorder)
- risk factors
- > family history
- > female
- > breech positioning
- > swaddling (adduction and extension)
- associations
- > first pregnancy
- > oligohydramnios
- > multiple pregnancies
- > high birth weight
Pathophys
- initial instability due to
- > genetic laxity
- > intrauterine or post natal positioning
- > normal femoral head is <50% covered by acetabulum
- instability leads to dysplasia
- > normal development of femoral head/acetabulum needs normal contact
- > laxity of joint capsule
- > lengthening of ligament tires
- > eversion of labrum
- > shallow acetabulum
- dysplasia leads to dislocation/prevents relocation
- > hypertrophied ligamentum teres
- > thickened labrum (neolimbus)
- > pulvinar thickens
- > iliopsoas pulled against capsule (hourglass contracture)
3
Q
DDH evaluation and management
A
Hx
- risk factors
- associated factors
- development
- > most walk/reach milestones as usual with no pain
- family hx
Exam
<3 months
- ortolani
- > reducibility
- barlow
- > dislocatable = palpable clunk
- > subluxable = sliding posteriorly
- asymmetry
- > galeazzi
- > skin folds
> 3 months
- hip stabilised (no ortolani/barlow)
- asymmetry
- > galeazzi
- > skin folds
- klisic
- > fingers on ASIS and GT
- > line along fingers should pass through umbilicus
- > passes below umbilicus in DDH
- limited ROM
- > reduced abduction (most sensitive)
- > reduced internal rotation
Walking
- > trendelenburg/waddling gait
- > trendelenburg sign
- asymmetry
- > toe walking on affected side
- > vaulting on unaffected side
Imaging
- ultrasound (best for first 3 months)
- > static = abnormal morphology
- > dynamic = instability with stress manoeuvres
- AP xray (best after 3 months when hips ossified)
- > abnormal morphology
Management
- 0-4 weeks
- > laxity is very common
- > vast majority normalise by 2 months without intervention
- > serial examinations
- > refer to surgeon if still unstable at 4 weeks
- > if dislocated refer to surgeon
- 1-6 months
- > pavlik harness for several months
- > dynamic
- > prevents adduction/extension
- > permits abduction/flexion
- 6-18 months
- > by now the hip will be dislocated and stable
- > closed reduction under anaesthesia
- > open reduction if unsuccessful
- > spica cast for several months (flexion + slight abduction)
- over 18 months
- > consider open reduction
- > benefit compared to natural hx reduces with age
4
Q
Viral myositis
A
- aetiology
- > influenza A and B
- > enteroviruses
- clinical manifestations
- > preceding viral illness
- > bilateral myalgia (typically lower limb and back)
- > tenderness on palpation
- > muscle swelling
- > weakness
- > myoglobinuria (in rhabdo)
- laboratory findings
- > elevated CK
- > lymphocytosis
- > evidence of viral infection
- > rhabdo (transaminitis and myoglobinuria)
- management
- > supportive
- > vigilance for rhabdo
5
Q
Viral arthritis
A
- aetiology
- > enteroviruses
- > hepatitis A,B,C
- > parvovirus B19
- > rubella (including vaccine)
- > alphaviruses (ross river/barmah forest/chikungunya)
- > dengue
- > herpes viruses (mainly EBV)
- > HIV
- clinical manifestations
- > abrupt onset (suspect when symptoms <6 weeks)
- > symmetric, polyarticular
- > arthralgia alone or arthritis
- > often associated with rash
- lab findings
- > usually unnecessary
- > targeted serologic testing
- > synovial fluid analysis is non specific (excludes ddx’s)
- > consider CBC/ESR/CRP/LFTs/RF/CCP
- management
- > NSAIDs/paracetamol
- > treat serious underlying disease
6
Q
Osgoodslatter overview
A
- epidemiology
- > occurs with pubertal growth spurt
- > much more common in athletic children
- > more common in boys
- > often bilateral
- pathophys
- > over-use injury
- > ossicle of patella tendon chronically avulsed
- > area of separation becomes fibrous with healing
- clinical manifestations
- > chronic progressive anterior knee pain
- > worse with exercise/relieved by rest
- > antalgic gait when severe
- > soft or bony enlargement of tuberosity
- > tender over tuberosity
- > pain with knee extension against resistance
- management
- > non operative
- > may take 1-2 years to resolve
- > NSAIDs
- > no need to avoid activities (avoid extended squatting)
- > physio (tight hamstrings and quadriceps)
- > operative (ossicle excision) is rarely needed
7
Q
Servers overview
A
- epidemiology
- > occurs during pubertal growth spurt
- > more common in athletic children
- pathophys
- > over-use injury of calcaneal apophysis
- clinical manifestations
- > gradual onset pain with exercise/relieved by rest
- > pain when heel strike more pronounced (eg. barefoot)
- > pain when squeezing sides of heel
- > tender over calcaneal apophysis
- > tight achilles tendon
- treatment
- > heel cup
- > NSAIDs
- > physio
- > some rest
- > no indication for surgery
8
Q
Transient synovitis overview
A
- epidemiology
- > life time prevalence 3%
- > pre to primary school age
- > more common in boys
- aetiology
- > unknown
- > often follows URTI or trauma
- pathophys
- > inflammation of synovium of large joints (usually hip)
- > rarely bilateral clinically (may be on imaging)
- > recurrence is common
- clinical manifestations
- > acute or insidious hip pain
- > refusal to walk
- > improves over the day
- > afebrile or low fever
- > doesn’t appear systemically unwell
- > hips flexed, abducted, ext. rot. (least capsular pressure)
- > restricted internal rotation
- > painless arc of motion
- investigations
- > only if suspicious for septic arthritis
- imaging
- > ultrasound = synovial thickening, intracapuslar effusion (often bilateral which counts against septic arthritis)
- > AP and frog leg xray = normal
- > MRI if suspicious for osteomyelitis
- management
- > NSAIDs
- > rest
- > usual resolution within 2 weeks
9
Q
Legg calve perthes overview
A
- epidemiology
- > common cause of paediatric hip pain
- > mostly primary school aged
- > more common in boys
- > most common in caucasians
- > can be bilateral but rarely synchronous
- aetiology
- > unknown
- risk factors
- > family hx
- > delayed bone age
- > clotting disorder
- > obesity
- > low SES
- pathophys
- > avascular necrosis of proximal femoral epiphysis
- > collapse then remodelling
- clinical manifestations
- > insidious onset hip pain
- > worse with activity/sometime better with rest
- > antalgic or trendelenburg gait
- > loss of internal rotation and abduction
- imaging
- > bone scan = decreased perfusion of femoral head
- > xray = early is normal, then fragmentation and deformity
- > MRI = marrow changes
-management
<8 yrs = NSAIDs, non weight bearing, physio for ROM
>8 yrs = pelvic or femoral osteotomy (seats femoral head in acetabulum)
10
Q
Limping child ddx
A
Emergency (RANSOM)
- Radiating pain
- > back (discitis, spinal epidural abscess, psoas abscess)
- > abo (PID, appendicitis, ovarian torsion)
- > GU (testicular torsion)
- Abuse
- > multiple fractures at different stages of healing
- > metaphyseal corner fracture
- Neoplasia
- Septic arthritis
- Osteomyelitis
- Meningitis
Common (ADMIT TONS)
- Apophysitis
- DDH
- Myositis
- Inflammatory arthritis
- > rheumatological
- > reactive
- > serum sickness
- Trauma
- > fracture
- > soft tissue injury
- Transient synovitis
- Osteochondrosis
- Neuromuscular disease
- > peripheral neuropathies
- > neuromuscular junction
- > muscular dystrophy
- Slipped capital femoral epiphysis
11
Q
Evaluation child with a limp
A
Hx
- Red flags
- > duration >1 week
- > severe singular joint
- > complete inability to walk/weight bear
- > nocturnal pain
- > systemic symptoms (fever/sweats/rigors)
- > constitutional symptoms (weight loss/fatigue/anorexia)
- > urinary/bowel incontinence
- > rash
- Past
- > trauma
- > respiratory illness = synovitis
- > UI/GI infection = reactive arthritis
- > antibiotics = serum sickness
- > endocrine disorder = SCFE
Exam
- Vitals
- > fever
- Growth
- Development
- Gait
- Look
- > pallor
- > wasting
- > resting position
- > rash
- Feel
- > temperature
- > swelling
- Movement
- > pain
- > ROM
- > tone + power
- Neurovascular
- > pulses
- > sensation
- > reflexes
- Special tests
- > leg log roll = pain with infective/inflamm hip pathology
- > supine/knees flexed then IR = limited in SCFE/LCP/DDH
- > galeazzi = SCFE/LCP/DDH
- > trendelenburg = SCFE/LCP/DDH
- > FABERE = sacroiliac joint pathology
- Spinal exam
- > abnormal posture/deformity
- > limited ROM
- > tenderness
- > evidence of spinal dysraphism
- Still undifferentiated
- > inspect skin
- > abdomen
- > genitalia
- > neuro exam
