Orthopaedics (Unit 3: Orthopaedic Conditions in Childhood) Flashcards
By what age does the average child sit independently?
9 months
By what age does the avergae child stand?
1 year
By what age does the average child normally walk?
20 months
What is the normal gap between the feet when a child stands to attention?
4cm
By what age should children with genu valgum & varus have developed normal allignment?
7 years
When is in-toeing exaggerated?
When children run
What are the 3 causes of in-toeing?
Femoral neck angle variation
Tibial torsion
Abnormal forefeet
Clinically how can children with an anteverted femoral head move their femur?
Can internally rotate their femur alot and externally rotate only a little
By what age should femoral neck angle variation correct itself by?
10 years
What is the treatment for tibial torsion?
It is normal variation and should be ignored
By what age should surgery on abnormal forefeet definitely not be considered before?
7 years
What are the 2 kinds of flat foot?
Rigid & mobile
What type are the majority of flat feet?
Mobile
What is a rigid flat foot?
Rare at any age
Underlying bony abnormality
Occasionally a sign of a serious disease such as RA
When might it be appropriate to operate on curly toes?
If causing severe discomfort in shoes
What is Osgood Schlatter’s disease?
Inflammation of the attachment of the patellar tendon to the growing tibial ephiphysis caused by excess traction by the quadriceps
Who is Osgood Schlatter’s more common in?
Very active children who are often involved in organised sport
What are the symptoms of Osgood Schlatter’s?
Tenderness & discomfort which is worse after exercise (episodic)
When do symptoms of Osgood Schlatter’s cease?
Middle adolescence when the epiphysis fuses
What is chondromalacia patellae?
When an area of patella cartillage is eroded (causes adolescent knee pain)
What might predispose a child to CDH?
Female
Familial & racial tendency
When are children screened for CDH?
Birth, 3, 6, & 12 months
What technique is used to diagnose CDH?
Barlow’s (dislocate) & Ortolani’s (relocate) manouevre
If missed in screening how might CDH present?
Shortening of the limb
Asymmetrical skin creases
Limited abduction
Limp
If a “click” is found on B & O what is the next step?
Re-examined in a specialist clinic at 3 months old (radiograph)
If a “clunk” is found on B & O what is the next step?
Should be treated from birth
Splintage required
What is the management of CDH if it is discovered late but not walking?
Period of gentle traction followed by open or closed manipulation then splintage for 3 months
What is the management of CDH if discovered late and walking has commenced?
Major surgery required to deepen undeveloped acetabulum and re-angulate femoral neck
Results are at best moderate and secondary arthritis is likely
What is talipes equino varus?
Deformity of the foot which makes it look like a golf club
What are the 2 forms of talipes equino varus?
Postural (mild)
Fixed
When is the postural mild form of talipes equino varus seen?
After a breech birth (probably related to baby’s position in the womb)
What is the fixed form of talipes equino varus associated with?
Developmental abnormalities of nerves and muscles of the leg
Describe the initial treatment of talipes equino varus
Gentle strestching in two phases
1 - corrects hindfoot equinus
2 - corrects mid & forefoot varus
How long is treatment in mild forms of talipes equino varus?
6 weeks of stretching and srapping in a corrected ro over-corrected position
How long is treatment in severe cases of talipes equino varus?
6 weeks then reassessed
If incomplete surgery required
What age do feet on avergae stop growing?
14 years old
What is spina bifida occulta?
Minor bony abnormality usually of no significance
What orthopaedic problems might be caused by spina bifida occulta?
Mechanical backache
Diastamatomyelia
What is diastamatomyelia?
Tethering of the spinal cord to the higher lumber vertebrae during growth
What is spina bifida cystica?
When a baby is born with the neural plate tissues open with little or no skin or bony cover
What is a meningocele?
When the open neural plate tissues are covered by a cyst
What is a meningomyelocoele?
When the open neural plate tissue is incorporated in the cyst wall
What is hydrocephalus?
Abnormal increase in the amount of fluid in the brain which leads to mental retardation and increase in head size
What is the prognosis of spina bifida cystica?
Many die at or soon after birth
Those that survive with surgery have profound problems
What problems do children who survive surgery for spina bifida cystica suffer from?
Paralysis, growth deformities, muscle imbalance, incontinence
What orthopaedic problems need corrected in spina bifida cystica?
Feet
Joint contraction resulting in fixed flexed knees
In the treatment of children with spina bifida cystica what non-surgical management is important?
Keep mobile until adolescence so they can grow to a reasonable size
What is cerebral palsy?
Abnormality of the brain often cause by damage to the brain at birth that results in delayed or arrested development of the nervous and MSK systems
What would be found on a neuro exam of a child with CP?
Uninhibited spinal reflexes
Lack of coordination and purpose of movement
Why do patients with CP have a spastic type of paralysis?
Some muscles contract strongly in an uncoordinated way whilst others are very weak and flaccid
What are the clinical presentations of CP?
Hemiparesis Paraparesis Quadraparesis Mental retardation Blind and/or deaf Some do not siffer mental or sensory impairment
What is a common presentation of a person with CP who has only minor degrees of spasticity?
Toe-walking in adolescence
What is the treatment for a CP adolescent with toe-walking?
Tendo-achilles lengthening
How can orthopaedic problems in CP be managed?
Careful physiotherapy
Cautious use of splintage
Careful use of surgery to either lengthen tight muscle or to denervate them or (occasionally) to move them
What is Scoliosis?
Curvature of the spine with a rotatory abnormality of the vertebrae
What can cause scoliosis?
Congenital abnormalities of the vertebrae
Neuromuscular imbalance
Idiopathic (most cases)
How does scolisosis present?
Twisting of the ribs which causes a hump on one side of the shoulder
Skirts hang crookedly
What ar indications for surgery in scoliosis?
Curve is progressive
Causing distress
What are 2 causes of a limp from birth?
CDH
Infection of the hip
What is the likely cause of a limp between the ages of four and ten?
Perthe’s disease
What is the likely cause of a limp from age ten to fifteen?
SUFE
What is Perthe’s disease?
Osteochondritis (fragmentation of the bone and overlying cartilage) of the femoral head epiphysis
How does Perthe’s disease present?
Painful limp followed by slow recovery
What would investigations for Perthe’s reveal?
Femoral head may be normal radiographically at first presentation but change when repeated after a month
US - excess fluid in hip joint
What is the pathological process of Perthe’s disease?
AVN of the growing femoral head
Will eventually re-vascularise and re-ossify but may be enlarged and deformed
What is the strategy of management for Perthe’s disease?
Maintain head concentrically within the acetabulum until the natueral process of the disease runs it’s course
What are older children who develop Perthe’s prone to?
Secondary arthritis
What are the treatment options for severe Perthe’s disease/
Splintage may help
Osteotomy (enlarge acetabulum or redirect femoral head)
Careful follow-up with periods of traction
What pateint demographic does SUFE present in?
Boy around 12 y/o who are sexually immature
Girls who are a little older and have recently undergone an adolescent growth spurt
What is SUFE?
Slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted
How does SUFE present?
Limp
Pain radiating to knee
Which nerve causes pain to radiate to the knee in SUFE?
Obturator
What view must be included when imaging a suspected SUFE?
Lateral (so minor degrees of slippage aren’t missed0
What is the surgical management of SUFE if the slippage in minor?
Pinned in its new deformed position
What is the surgical management of SUFE if the slippage is major?
Gentle attempt to replace head on neck by manipulation (risk of AVN is high)
When should pins for SUFE be removed?
After fusion of the epiphysis at around 18 y/o
