Orthopaedics: Calcanea apophysitis Flashcards
Describe what is meant by calcaneal apophysitis [1]
is the commonest cause of heel pain in children and adolescents
. It is an overuse injury caused by micro-fractures of the calcaneal apophysis at the site of attachment of the Achilles tendon.
Describe the age that calacneal apophysitis presents [1]
It typically presents between 8-14 years. It is rare after this age as the calcaneal apophysis should fuse around 15 years.
Describe the clinical presentation of Calcaneal apophysitis (Sever’s disease) [+]
It presents with gradual onset heel pain which may be worse on standing and with activity.
It is typically relieved by rest.
It can be unilateral but is often bilateral (60% of cases)
Medial and lateral compression of the heel i.e ‘squeezing’ causes pain.
Pain on ankle dorsiflexion, especially on active toe raise
Mild heel swelling
Calcaneal enlargement
* Only if chronic which is rare
Which red flag symptoms would indicate a patient wasn’t suffering from calcaneal apophysitis [3]
Red flag features suggestive of an alternative diagnosis include significant rest pain, night pain or large swelling.
What is talipes? [1]
What is talipes equinovarus? [1]
What is talipes calcaneovalgus? [1]
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.
Talipes equinovarus describes the ankle in plantar flexion and supination.
Talipes calcaneovalgus describes the ankle in dorsiflexion and pronation.
Talipes is treated with the “[] method” with good results.
Talipes is treated with the “Ponseti method” with good results. Surgery may be required if the Ponseti method fails or cannot be used.
Desribe the Ponseti method used to treat 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”.
Describe what is meant by positional talipes [1] and how it is treated [1]
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.
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 the pathophysiology of osteogenesis imperfecta? [1]
(most common type is type 1) where abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
Describe common features of osteogenesis imperfecta? [5]
presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common
Wheat is mneumonic for osteogenesis imperfecta presentation? [4]
BITE
Bones fracture
I(eye) blue sclera
Teeth imperfections
Ear hearing loss
TOM TIP: The key feature that often appears in exams that should make you think about osteogenesis imperfecta is the [].
This is a unique feature that examiners love to drop in.
The exam patient may be a [presentation]
TOM TIP: The key feature that often appears in exams that should make you think about osteogenesis imperfecta is the blue sclera.
This is a unique feature that examiners love to drop in.
The exam patient may be a young child with unusual and recurrent fractures that would normally make you consider safeguarding, however “you notice a blue discolouration to the sclera”.
Describe the management of osteogenesis imperfecta [2]
The underlying genetic condition cannot be cured. Medical treatments include:
Bisphosphates to increase bone density
Vitamin D supplementation to prevent deficiency
Management is done by the multidisciplinary team, with:
* Physiotherapy and occupational therapy to maximise strength and function
* Paediatricians for medial treatment and follow up
* Orthopaedic surgeons to manage fractures
* Specialist nurses for advice and support
* Social workers for social and financial support
Describe what causes achondroplasia [1] and how this presents [4]
The achondroplasia gene, fibroblast growth factor receptor 3 (FGFR3), is on chromosome 4.
- This results in abnormal cartilage
Presentation:
* short limbs (rhizomelia) with shortened fingers (brachydactyly)
* large head with frontal bossing and narrow foramen magnum
* midface hypoplasia with a flattened nasal bridge
* ‘trident’ hands
* lumbar lordosis
* Bow legs (genu varum)
Describe why people with achondroplasia have disproportionate skulls [2]
Different areas of the skull grow by different methods, some of which are affected more than others.
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 common associations that occur with achondroplasia? [5]
Recurrent otitis media, due to cranial abnormalities
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Foramen magnum stenosis can lead to cervical cord compression and hydrocephalus
