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Year 4- Paediatrics > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What is perthes disease?

A

A degenerative condition which affects the hip joint of children, typically between aged 4-8 years. It is due to a vascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction.

It can lead to destruction and softening of the femoral head, leading to early hip osteoarthritis.

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2
Q

What are the features of perthes disease?

A

Hip pain which develops progressively over a few weeks
Limp
Stiffness and reduced range of hip movement

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3
Q

How would you diagnose perthes disease?

A

Plain X Ray
Technetium bone scan or MRI if normal X-ray and symptoms persist.
Not always visible on X ray

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4
Q

What X Ray features would you see in someone with perthes?

A

Early changes= widening of joint space

Later changes= decreased femoral head size/flattening

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5
Q

What are the complications of perthes?

A

OA

Premature fusion of growth plates

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6
Q

How do you stage perthes?

A

Caterall staging

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7
Q

What is the management of perthes?

A

In less severe and younger patients, the management is conservative with the aim to prevent risk factors- traction, analgesia, crutches and bed rest.

Physio

Regular Xrays to assess the healing

Surgery in older and more complex cases.

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8
Q

What is a slipped capital femoral epiphysis?

A

A rare hip condition seen in children, classically obese boys, it is also known as slipped upper femoral epiphysis

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9
Q

What are the features of slipped capital femoral epiphysis?

A

Hip, groin, medial thigh or knee pain.
Loss of internal rotation of leg in flexion
Bilateral slip in 20% of cases

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10
Q

How do you manage a slipped capital femoral epiphysis?

A

Internal fixation (sinfle cannulated screw placed in the centre of the epiphysis).

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11
Q

What is the most common form of arthritis in childhood and what is it characterized by?

A

Reactive arthritis is the most common form of arthritis, it is characterized by transient joint swelling (<6 weeks) often of the ankles or knees.

It usually follows extra articular infection.

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12
Q

What are the most common causes of reactive arthritis in children?

A

Enteric bacteria- salmonella, shigella, campylobacter, yersinia

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13
Q

What are the most common causes of reactive arthritis in adolescents?

A

Sexually transmitted infections- chlamydia and gonococcus, mycoplasma and borrelia burgdorferi ( lyme disease)

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14
Q

What would you find on examination/investigations of reactive arthritis?

A

Low grade fever
Acute phase reactants will actually be normal or only mildly elevated
X rays are normal

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15
Q

What is the treatment of reactive arthritis?

A

Often none is required and NSAIDS if some is needed.

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16
Q

Why is septic arthritis so dangerous?

A

Serious infection of the joint space, it can lead to bone destruction

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17
Q

How does septic arthritis normally result?

A

Haematogenous spread, puncture wound, infected skin lesions (like chickenpox).
In young children it can spread from adjacent osteomyelitis into joints where the capsule inserts below the epiphyseal growth plate.

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18
Q

What is the most common organism causing septic arthritis beyond the neonatal period?

A

The most common organism is Staph aureus. H influenzae was was common prior to immunization and affected multiple sites.

Remember underlying and predisposing illnesses such as immunodeficiency and sickle cell need to be considered.

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19
Q

What is juvenile idiopathic arthritis?

A

Arthritis occuring in someone who is less than 16 years old that lasts for more than 3 months. Periarticular JIA refers to cases where 4 or less joints are affected, it accounts for around 60% of cases of JIA.

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20
Q

What are the features of periarticular JIA?

A

Joint pain snd swelling, usually medium sized joints- knees, ankles, elbows
Limp
ANA may be positive in JIA - associated with anterior uveitis

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21
Q

How would transient synovitis present?

A

It would be an acute onset
Usually accompanies viral infections, but the child is well or has a mild fever
It is more common in boys, aged 2-12 years

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22
Q

What are the causes of limp in a child?

A 
Septic arthritis/osteomyelitis
Juvenile idiopathic arthritis 
Trauma 
Developmental dysplasia of the hip 
Perthes disease 
Slipped upper femoral epiphysis
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23
Q

What is the difference between bones in children and bones in adults?

A

Children have more cancellous bone, this is the spongy and highly vascular bone in the centre of long bones
Adult have more cortical bone, this is the compact, hard bone around the outside. Childrens bones are more flexible and less strong, making them prone to greenstick fractures, the fact they have higher vascular supply means they can heal more easily.

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24
Q

What are fractures at the growth plate also called and what are the types?

A 
Also called Salter Harris 
Types can be remembered by SALTR 
S= straight across    type 1
A= above     Type 2 
L= beLow    Type 3 
T= through     Type 4 
R= cRush     Type 5
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25
Q

What is the management of fractures?

A

Firstly you need to achieve mechanical alignment
Closed reduction via. Manipulation of the fracture or open reduction via. Surgery

The second principle is relative stability for a period of time to allow healing, this involves fixing the bine in correct position while it heals
. External casts
. K wires 
. Intramedullary wires 
. Intramedullary nails 
. Screws 
. Plates
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26
Q

What can you give in terms of pain management for children?

A

There is a pain ladder by WHO and it only has two steps

1) paracetamol or ibuprofen
2) morphine

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27
Q

Why shouldn’t aspirin be used in children?

A

Risk of reyes syndrome

It can be used in certain circumstances like kawasaki disease

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28
Q

What are the causes of hip pain in children?

A

0-4 years:
Septic arthritis
Developmental dysplasia of the hip
Transient synovitis

5-10 years:
SA
Transient synovitis
Perthes disease

10-16 years:
SA
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis

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29
Q

What are the red flags for hip pain?

A 
. Waking with the pain 
. Fever 
. Anorexia 
. Weight loss
. Children under 3 
. Night sweats 
. Fatigue 
. Persistent pain 
. Stiffness in the morning 
. Swollen or red joint
30
Q

What investigations should be done for hip pain in a child?

A

Blood tests- CRP and ESR can be measured, these are inflammatory markers and can indicate Juvenile idiopathic arthritis or septic arthritis
Xrays- used to diagnose fractures, SUFE and other bony pathology
US- used to establish effusion (fluid) in the joint
Joint aspiration- used to diagnose or exclude septic arthritia
MRI- used to diagnose osteomyelitis

The way the doctor explained it to the patient is that ultrasounds show the joint whereas MRI will show whats going on with the bone.

31
Q

How would septic arthritis present?

A

Usually only affects a single joint
It can lead to systemic illness and destruction of joint and therefore it is an emergency.

It presents with red, swollen, hot and painful joint, refusing to weight bear, stiffness and reduced range or motion, fever, lethargy and sepsis.

32
Q

What causes septic arthritis?

A

Most common causative organism is staphylococcus aureus

Other bacteria...
. Neisseria gonorrhoea (gonococcus) In sexually active teenagers 
. Group A strep (strep pyogenes) 
. Haemophilus influenza 
. E coli
33
Q

What is the differential diagnosis of SA?

A

Juvenile idiopathic arthritis
Perthes disease
Slipped upper femoral epiphysis
Transient sinovitis

34
Q

What is the management of septic arthritis?

A

Joint should be aspirated prior to giving antibiotics where possible, send the sample for gram staining, crystal microscopy, culture and antibiotic sensitivities.

Empirical IV abx should be given until the microbial sensitivities are known and they are generally continued for 3-6 weeks.

35
Q

What is transient synovitis?

A

This is often referred to as an irritable hip, it is temporary (transient) irritation and inflammation of the synovial membrane of the joint. It is the most common cause of hip pain in children aged 3-10 years. It is often associated with a viral URTI

36
Q

How does transient synovitis present?

A 
Symptoms 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
37
Q

When should transient synovitis normally improve?

A

There should be a significant improvement in 48 hours

Symptoms should resolve in one to two weeks without any lasting complications.

38
Q

What is slipped upper femoral epiphysis?

A

It is where the femoral head slips along the growth plate.

39
Q

How would a patient with a slipped upper femoral epiphysis present?

A

Adolescent, obese may undergoing growth spurt, history of minor trauma, normally a boy

Hip, groin, thigh or knee pain
Restricted range of hip movement
Painful limp
Restricted movement in the hip

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.

40
Q

How do you diagnose SUFE?

A

The initial investigation of choice in SUFE is xray.

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

41
Q

How do you manage SUFE?

A

Surgery is required to return the femoral head to the correct position and fix it in place to prevent it slipping further.

42
Q

What is osteomyelitis?

A

Infection in the bone and bone morrow which typically occurs in the metaphysis of long bones.
Chronic osteomyelitis= deep seated, slow growing infection
Acute infection presents more quickly with an acutely unwell child.

43
Q

What is the main causative organism of osteomyelitis.

A

Staph aureus

44
Q

What are the risk factors of osteomyelitis?

A 
Open bone fracture 
Immunocompromised 
Ortho surgery 
Sickle cell anaemia 
HIV 
TB
45
Q

How does osteomyelitis present?

A

Osteomyelitis can present acutely with an unwell child, or more chronically with subtle features. Signs and symptoms are:

Refusing to use the limb or weight bear
Pain
Swelling
Tenderness
They may be afebrile, or may have a low grade fever. Children with acute osteomyelitis may have a high fever, particularly if it has spread to the joint causing septic arthritis.
46
Q

How do you investigate osteomyelitis?

A

Xrays are often the initial investigation, but can be normal in osteomyelitis. MRI is the best imaging investigation for establishing a diagnosis. A bone scan is an alternative.

Blood tests will show raised inflammatory markers (CRP and ESR) and white blood cells in response to the infection.

Blood culture is important in establishing the causative organism. A bone marrow aspiration or bone biopsy with histology and culture may be necessary.

47
Q

How do you manage osteomyelitis?

A

Treatment requires extensive and prolonged antibiotic therapy. They may require surgery for drainage and debridement of the infected bone.

48
Q

What is osteosarcoma?

A

Osteosarcoma is a type of bone cancer. This usually presents in adolescents and younger adults aged 10 – 20 years. The most common bone to be affected is the femur. Other common sites are the tibia and humerus.

49
Q

What is the presentation of osteosarcoma?

A

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 and restricted joint movements.

50
Q

How do you diagnose osteomyelitis?

A

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.

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.

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
51
Q

How would you manage osteosarcoma

A

Surgical resection of the lesion, often with limb amputation :( adjuvant chemo is often used alongside surgery

52
Q

What are the complications of osteosarcoma

A

The main complications are pathological bone fractures and metastasis.

53
Q

What are talipes?

A

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.

54
Q

How is talipes managed?

A

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”.

55
Q

What is developmental dysplasia of the hip?

A

A condition where there is structural abnormality in the hips which is caused by abnormal development of the fetal bones during pregnancy. It leads to an instability in the hips and a tendency or potential for subluxation or dislocation.

. These structural abnormalities have the potential to persist into adulthood leading to weakness, recurrent subluxation or dislocation, an abnormal gait and early degenerative changes.

56
Q

How do you diagnose DDH?

A

NIPE- look for clicking, ortolani, barlows

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.

57
Q

How do you manage DDH?

A

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. 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.

Surgery is required 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.

58
Q

What is rickets and what are the causes?

A

Rickets is a condition affecting children where there is defective bone mineralisation which leads to soft and deformed bones.

Rickets is caused by a deficiency in Vit D or calcium. Vit D is either produced by the body in response to sunlight or obtained through foods such as: eggs, oily fish, fortified cereals, nutritional supplements.

Calcium is found in dairy products and some green vegetables

There is a rare form of rickets caused by genetic defects

59
Q

What does vit D do?

A

It is essential in calcium and phosphate absorption from the intestines and kidneys. Vit D is also responsible for regulating bone turnover and promoting bone reabsorption to boost serum calcium level.

Inadequate vitamin D leads to a lack of calcium and phosphate in the blood. Since calcium and phosphate are required for the construction of bone, low levels result in defective bone mineralisation. Low calcium causes a secondary hyperparathyroidism as the parathyroid gland tries to raise the calcium level by secreting parathyroid hormone. Parathyroid hormone stimulates increased reabsorption of calcium from the bones. This causes further problems with bone mineralisation.

60
Q

What is the presentation of rickets?

A 
Lethargy
Bone pain
Swollen wrists
Bone deformity
Poor growth
Dental problems
Muscle weakness
Pathological or abnormal fractures
61
Q

What bone deformities can occur in rickets?

A

Bowing of the legs, where the legs curve outwards
Knock knees, where the legs curve inwards
Rachitic rosary, where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest
Craniotabes, which is a soft skull, with delayed closure of the sutures and frontal bossing
Delayed teeth with under-development of the enamel

62
Q

How do you investigate rickets?

A

Serum 25-hydroxyvitamin D is the laboratory investigation for vitamin D. A result of less than 25 nmol/L establishes a diagnosis vitamin D deficiency, which can lead to rickets.

Xray is required to diagnose rickets. X-rays may also show osteopenia (more radiolucent bones).

Other investigation results include:

Serum calcium may be low
Serum phosphate may be low
Serum alkaline phosphatase may be high
Parathyroid hormone may be high

63
Q

How do you manage rickets?

A

Prevention is the best management for rickets. Breastfed babies are at higher risk of vitamin D deficiency compared with formula fed babies, as formula feed is fortified with vitamin D. Breastfeeding women and all children should take a vitamin D supplement. NICE clinical knowledge summaries recommend supplements containing 400 IU (10 micrograms) per day for children and young people.

Children with vitamin D deficiency can be treated with vitamin D (ergocalciferol). The doses for treatment of vitamin D deficiency depend on the age (see the BNF). The dose for children between 6 months and 12 years is 6,000 IU per day for 8 – 12 weeks.

Children with features of rickets should be referred to a paediatrician. Vitamin D and calcium supplementation is used to treat rickets.

64
Q

What is achondroplasia?

A

Achondroplasia is the most common cause of disproportionate short stature (dwarfism). It is a type of skeletal dysplasia.

The achondroplasia gene, fibroblast growth factor receptor 3 (FGFR3), is on chromosome 4. Achondroplasia results from either a sporadic mutation or inheritance of an abnormal copy of this gene. The condition is inherited in an autosomal dominant pattern.

Parents will be carriers as if a neonate had two copies of the gene its fatal they wouldnt survive.

65
Q

What is osgood schlatter disease?

A

It is caused by inflammation at the tibial tuberosity where the patella ligament inserts. It is a common cause of anterior knee pain in adolescents.

66
Q

What is the presentation of osgood schlatter disease?

A

Visible or palpable hard and tender lump at the tibial tuberosity
Pain in the anterior aspect of the knee
The pain is exacerbated by physical activity, kneeling and on extension of the knee

67
Q

What is the pathophysiology behind osgood schlatter disease?

A

The patella tendon inserts into the tibial tuberosity. The tibial tuberosity is at the epiphyseal plate. Stress from running, jumping and other movements at the same time as growth in the epiphyseal plate result in inflammation on the tibial epiphyseal plate. There are multiple small avulsion fractures, where the patella ligament pulls away tiny pieces of the bone. This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially this bump is tender due to the inflammation, but has the bone heals and the inflammation settles it becomes hard and non-tender.

68
Q

How do you manage osgood schlatter disease?

A

Reduction in physical activity
ICE
NSAIDS
Once symptoms have settled, then stretching and physio can be used to strengthen the joint and improve function.

69
Q

What is the prognosis of osgood schlatters disease?

A

Usually resolves over time but a rare complication is a full avulsion fracture (tibial tuberosity is separated from the tibia).

70
Q

What is osteogenesis imperfecta?

A

Genetic condition which results in brittle bones that are probe to fractures, it is also known as brittle bone syndrome. It is caused by a range of genetic mutations that affect the formation of collagen (protein that is essential in maintaining the structure and function of bone as well as skin, tendons and other CT). There are 8 types of osteogenesis imperfecta, and it depends on the genetic mutation.

71
Q

How does osteogenesis imperfecta present?

A 
Hypermobility 
Blue sclera (an exam question may mention blue sclera, multiple fractures in a young person) 
Triangular face 
Short stature 
Deafness from early adulthood 
Dental problems 
Bone deformities 
Joint and bone pain
72
Q

How do you investigate/manage osteogenesis imperfecta?

A

Xrays can be helpful in diagnosing fractures and bone deformities, genetic testing is possible but not always done routinely.

Can use bisphosphonates and vit D

Year 4- Paediatrics (21 decks)

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