Orthopaedics Unit 3 Flashcards
what are the average age for child to sit independently, stand and walk
sit - 9 months
stand - 12 months
walk - 20 months
[however is a lot of variation, not always a problem if child does not reach the milestone at this point]
what is the medical term for knock knees
genu valgum
what is the medical term for bow legs
genu varum
what is the normal alignment of the knee
in valgus
when child stands to attention, normally a gap of 4cm between the FEET
how does the gap change between the feet in varus and valgus
varus - gap decreases
valgus - gap increases
what is important to note in relation to genu varum and genu valgum in children
almost all children by the age of 7 with this condition will have normal knee alignment t
what is in-toeing and how can you spot it
children stand with their feet pointing inwards “pigeon-toed”
often exaggerated when they run and causes clumsiness
shoes tend to wear down at the heels
what are causes of in-toeing
femoral neck angle variation
tibial torsion
abnormal forefeet
how does femoral neck angle variation develop
During later stages of the normal development of foetus, the leg rotates on the pelvis so that the acetabulum points almost backwards and the femoral head on the neck is orientated forwards
sometimes this process is not completed by birth and the femoral neck is more anteriorly orientated (i.e. anteverted)
what can children who are born with femoral neck angle variation do more than other children
internally rotate their femur a lot and externally rotate it only a little
- causes the in-toeing posture
when is femoral neck angle variation often corrected by
10 y/o
surgery rarely needed
what is tibial torsion
bone is warped along vertical axis
is normal variation and can be ignored
what is abnormal forefeet
hooked (adducted) forefoot
vast majority correct spontaneously
what is important to remember about flat foot
it is normal variation which rarely causes functional abnormalities
all children’s feet are flat at birth, normal arch may not form until child is 7
what are the 2 types of flat foot
rigid
- rare
- implies bony abnormality
- sometimes seen in RA
mobile
- vast majority
- no issue
what is curly toes
minor overlapping, commonly of the 5th toe
most correct spontaneously and should be left alone
when would surgery on curly toes be required
if the overlapping toes becomes fixed or if people are getting discomfort from shoes
when is pain around the knee most common in girls
as they develop secondary sexual characteristics.
what is Osgood Schlatter’s disease
inflammation of the attachment of the patellar tendon to the growing tibial epiphysis, caused by excess traction by the quads
Sx of Osgood Schlatter’s disease
tenderness, discomfort worse after exercise
swelling
what are features of the Osgood Schlatter’s disease
thought to be overuse injury, seen most common in active children
episodic
Tx w/ rest
when will children cease to have Osgood Schlatter’s disease
in middle adolescence when the epiphysis fuses
what is features of adolescent knee pain
most common in girls
not the same as dislocation of patella
most girls grow out of the condition
if Sx persist, arthroscopy may be necessary
what is chondromalacia patellae
erosion of an area of patella cartilage
what is the rate of Congenital Dislocation of the Hip (CDH) [or congenital hip dysplasia CHD]
occurs in 1 or 2 births per thousand
epidemiology of CHD
girls > boys
significant number of children, condition is bilateral
what is the screening program for CHD
screened at birth, 3 months, 6 months and 12 months
what are the two screening tests for CHD and what are they doing
Barlow maneuver
- adduct the hip, apply light pressure
- if hip dislocates = +ve test
Ortolani test
- try to relocate the hip
- if you hear a click or a clunk = +ve test
what are the Sx of CHD if it is not discovered till later life
shortening of the limb
asymmetrical skin creases
limited abduction
limp
what should be the next stages if a “click” is heard in CHD
re-examined by specialist at 3 months
radiograph
Mx of CHD
Tx from birth
- Pavlik harness
Tx if discovered late but before weight bearing
- period of gentle traction followed by open or closed manipulation
- then splinted in plaster for 3 months
Tx if discovered late and is weight bearing
- major surgery to deepen the undeveloped acetabulum and re-angulate the femoral neck to stabilise the hip
why is it important to Tx CHD from birth
If the femoral head is relocated and maintained in the acetabulum using splintage then the vast majority will settle with no further development issue
what is the issue with the Tx of CHD if discovered late and child is weight bearing
results are at best moderate,
Secondary OA is highly likely.
what is the medical name for club foot
Talipes Equino Varus
what are the 2 types of club foot
postural form (mild) - seen after breech birth
fixed form
- associated with development abnormalities of nerves and muscles of the leg
both CAN BE bilateral (not always)
Mx of mild talipes equino varus
initial Tx for both forms
- gentle stretching in two phases
- 1st phase = corrects hindfoot equinus
- 2nd phase = corrects mid and forefoot varus
= 6 weeks of stretching and strapping in a corrected or over-corrected position
Mx of fixed talipes equino varus
6 weeks of stretching
Reassessed - if correction is incomplete or cannot be maintained
Surgery
what is the follow up period for talipes equino varus
until feet stop growing
- around age 14
[affected foot often significantly smaller than normal foot which causes difficulties in shoe fitting]
what are the 2 types of spina bifida
spina bifida occulta
spina bifida cystica
what is spina bifida occulta
minor bony abnormality which affects 2% of the population
- usually of no significance
develop mechanical backache
what is a possible consequence of spina bifida occulta
diastamatomyelia
- tethering of the spinal cord to the higher lumbar vertebrae
what is spina bifida cystica
babies born with the neural plate tissues open with little or no skin or bony cover
what is a meningocele
nerve tissue covered by a cyst
what is meningomyelocele
nerve tissue may be incorporated in the cyst wall
what are the consequences of spina bifida cystica
hydrocephalus
> can lead to mental retardation
paralysis
growth deformities [due to muscle imbalance]
incontinence
joint contraction resulting in a fixed flexed position of their knees and dislocation of their hips
Mx of spina bifida cystica
most babies die at, or soon after, birth
some survive to undergo surgery
- early surgery to feet to maintain functional shape
- try to keep the children mobile
what causes cerebral palsy
damage to the brain at birth
what are the pathological features of cerebral palsy
spinal tissue develops normally
> have uninhibited spinal reflexes
> lack co-ordination and purpose of movement, normally controlled by the brain
> causes SPASTIC PARALYSIS
abnormal muscle and bone growth
> due to some spastic muscle [muscles contracting strongly in uncoordinated way]
> and due to some muscles being weak and flaccid
secondary deformities of joints
what are the patterns of cerebral palsy
Hemiparesis
- 1 arm and 1 leg on the SAME side
Paraparesis
- 2 legs are affected
Quadraparesis
- all limbs affected
what are other Sx of cerebral palsy
some are mentally retarded
some are blind and/or deaf
some are neither
what is the management of patients with only minor degrees of spasticity
spasticity may only affect 1 muscle group
- common sign is toe-walking in teens
- often calf muscle spasticity
Tx = tendo-achilles lengthening before growth ceases
Mx of cerebral palsy
similar to spina bifida
maintain mobility
physiotherapy
surgery to lengthen tight muscles or to denervate them to maintain posture and function
what is scoliosis
Curvature of the spine with a rotatory abnormality of the vertebrae
what causes the curve of the spine in scoliosis
abnormal lordosis of the spine, which leads to buckling and twisting of the vertebral column as a result of the action of muscles and gravity.
what is the aetiology of scoliosis
most are idiopathic
- seen in adolescence
- girls more than boys
- principal effects are cosmetic but cause great distress
can be caused by congenital abnormalities of the vertebrae or by neuromuscular imbalance
clinical presentation of scoliosis
usually complaints of twisting of the ribs which causes a hump on one side of the shoulder
skirts hang crooked
may be painful
Mx of scoliosis
not all curves get worse
if curve is progressive or causing distress Tx should be offered early
- surgical correction of the ROTATORY element of the deformity
what is the most likely cause of a limp at birth, between 4-10 and between 10-15
birth
- CDH
- infection of the hip
between 4 and 10
- Perthe’s disease
between 10 and 15
- SUFE
what is Perthe’s disease
blood supply to the femoral head epiphysis becomes inadequate
causes AVN of the femoral head
aetiology of perthe’s disease
more common in boys than girls
20% of cases are bilateral
clinical presentation of perthe’s disease
child has painful limp which is followed by a slow recovery
radiological appearance of perthe’s disease
femoral head may be normal on 1st presentation
- month later it may show changes
USS reveals fluid around hip joint
Mx of Perthe’s disease
maintain the head within the acetabulum until the natural process of the disease runs its course
minor cases [up to half of femoral head involved]
- need no Tx
- good prognosis
severe cases
- splintage to achieve containment
- Careful follow-up with periods of traction to alleviate symptoms of pain and limp
what are children who have had Perthe’s disease at an older age prone to
secondary OA
what is SUFE
slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted.
aetiology of SUFE
seen mostly in boys around 12 y/o who are sexually immature for their age
and in girl who are little older and have recently undergone an adolescent growth spurt
clinical presentation of SUFE
child has a limp
may be pain radiating to the knee [due to the obturator nerve supplying both the hip and knee joint]
ANY CHILD WITH KNEE PAIN HAS TO HAVE THEIR HIP EXAMINED
loss of internal rotation of the hip is the predominant clinical sign
what imagining must be obtained for SUFE and why
a lateral view or minor degrees of slippage may be missed
if a child has hip pain, what is the working diagnosis
All young adolescents with a painful hip must be regarded as having SUFE until it is clinically and radiologically excluded
Mx for SUFE
Tx is always surgery
Minor slippage
- hip should be pinned in its new deformed position
Major slippage
- gentle attempt to replace the head on the neck by manipulation
- does carry risk of AVN
Always observe the other hip for slippage using imaging
- pinned if any slippage
when are the pins from surgery removed in SUFE
removed after fusion of the epiphysis at around eighteen years of age.
