Orthopaedics unit 3 orthopaedic conditions in childhood - deck 1

Question 1

During normal development we expect children to reach a certain milestone at a certain age. What is the average age that a child wil reach each of the following milestones:

1. Sits independently
2. Stands
3. Walks

Answer 1

1. Sit independently - 9 months
2. Stand - 12 months
3. Walk - 20 months

Note that there is a lot of variation in normal development and failure to reach a certain milestone is usually not a sinister sign

Question 2

When children start to walk their gait takes many months to mature and so minor variations are to be expected.

List the 4 main common, but minor, abnormalities that we should know about which can cause an abnormal gait in a child

Answer 2

1. Knock knees and bow legs (valgus and varus knees)
2. In-toeing
3. Flat feet
4. Curly toes.

Question 3

Define genu valgus and genu varus

Answer 3

Genu valgus = distal part of the joint is more lateral

Genu varus = distal part of the joint is more medial

• The terms valgus and varus refer to angulation (or bowing) within the shaft of a bone or at a joint.
• It is determined by the distal part being more medial or lateral than it should be.

Note that genu just means the knee

Question 4

What is the normal alignment of the knee ?

Answer 4

The normal alignment of the knee is valgus. When a child stands to attention there is normally a gap of 4 cm or so between the feet.

Question 5

In terms of the alignment of the knee what does it mean if:

• If the normal 4cm gap between the feet is diminished or increased

Answer 5

If diminished the knee are in varus and if increased the knees are in valgus (remember the normal alignment of knee is in valgus but in these cases it will be excessive valgus)

Question 6

Describe what in-toeing is

Answer 6

In-toeing refers to a child who, when walking and standing will have feet that point towards the midline (piegon-toed)

Question 7

What action often exaggerates a childs in-toeing ?

Answer 7

Running

Question 8

What are the typical presenting complaints of a parent with a child with in-toeing ?

Answer 8

• Clumsiness - although they often don’t actually fall more than other children
• Shoes tend to wear down at the heels.

Question 9

What are the 3 main anatomical causes of in-toeing ?

Answer 9

1. Femoral neck anteversion
2. Tibial torsion
3. Abnormal forefeet esp forefoot adduction

Question 10

Describe how femoral neck anteversion arises

Answer 10

• During normal development of the 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 rotatory process is not completed by birth and so the femoral neck is more anteriorly orientated (i.e. it is anteverted) than normal.
• Which can give the appearance of in‐toeing (as well as knock knees)

Question 11

For someone with femoral neck anteversion what findings on clinical examination will support this ?

Answer 11

• In-toed gait
• Can internally rotate their femur a lot and externally rotate it only a little

Question 12

What is the management of femoral neck anteversion ?

Answer 12

• Usually corrects itself by the age of 10, although some have a little residual deformity
• Almost never needs surgery

Question 13

Describe what tibial torsion is and should anything be done to correct it ?

Answer 13

• This is when the tibial bone is rotated inward about its vertical axis
• This is a normal variation and nothing should be done about it

Question 14

Describe forefoot adduction and its management

Answer 14

This is a deformity causing the forefoot to turn inwards (in-toeing)

Surgery is controversial and people are unsure if it is ever justified. It should not be considered before the age of 7 and the vast majority correct themselves.

Question 15

Is flat feet a normal or abnormal variation ?

Answer 15

Flat feet are a normal variation

Question 16

Do flat feet usually cause functional abnormalities ?

Answer 16

No they very rarely causes functional abnormalities apart from uneven shoe wear

Question 17

What are the 2 main kids of flat feet and how do you distinguish between them?

Answer 17

rigid and mobile flat feet

• Mobile/flexible flat feet are those where the flattened medial arch forms with dorsiflexion of the great toe (Jack test).
• In the rigid type of flat footedness the arch remains flat regardless of load or great toe dorsiflexion

Question 18

What is the more common of the two classes of flat feet and is it a problem?

Answer 18

Mobile - it is entirely harmless

Question 19

What is the cause of rigid flat feet and what can it also represent?

Answer 19

This implies there is an underlying bony abnormality e.g. tarsal coalition

It also may represent an underlying inflammatory disorder e.g. RA or a neurological disorder.

Question 20

Describe what curly toes are and state the most commonly affected toe

Answer 20

• Curly toes are minor overlapping, or crossing of the toes
• The 5th toe is most commonly affected

Question 21

Do curly toes cause discomfort and what is the management of them?

Answer 21

• Occasionally the crossed fifth toe causes discomfort in shoes. If fixed it requires surgical correction. (think kirsty)
• Surgery on other curly toes should be discouraged despite often heavy parental pressure.

Question 22

A very common cause of the referral of children is pain around the knee - between what ages are children most likely to develop pain around the knee and are m or f more common to get it ?

Answer 22

Between the ages of 10-12 is most common

Females more commonly get it than males, as they develop secondary sexual characteristics

Question 23

Name 2 common conditions which causes knee pain in children ?

Answer 23

• Osgood schlatters disease
• Adolescent knee pain

Question 24

Describe how osgood schlatters disease develops

Answer 24

• Osgood Schlatter’s disease is an inflammation of the attachment of the patellar tendon to the growing tibial epiphysis, caused by excess traction by the quadriceps.
• The cause is unknown but it may be an overuse injury as it is more common in very active children who are often involved in organised sport.

Think david

Question 25

What is the typical presenting features of osgood schlatters disease?

Answer 25

• Tenderness and discomfort, which are worse after exercise.
• There may also be swelling.
• Bony lump below your knee cap - this is where the tenderness originates

Question 26

What is the treatment of osgood schlatters disease?

Answer 26

• The condition is episodic and usually can be treated by rest.
• Only rarely is it necessary to enforce rest with a plaster.

Symptoms cease in middle adolescence when the epiphysis fuses.

Question 27

Who is adolescent knee pain most common in ?

Answer 27

Girls

Question 28

How does adolescent knee pain present ?

Answer 28

As anterior knee pain

Question 29

How should patients with adolescent knee pain be managed?

Answer 29

• Most grow out of it so conservative management
• Arthroscopy may be required if symptoms persist

Question 30

What rare finding may be seen on arthroscopy in patients with adolescent knee pain ?

Answer 30

chondromalacia patellae - an eroded area of patellar cartilage

Question 31

What is congenital dislocation of the hip (CDH)?

Answer 31

This is dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint. Note it is rarely completely dislocated

Question 32

How common is CDH ?

Answer 32

1-2 per 1000 births

Question 33

Who is CDH most common in?

Answer 33

Girls - 80% of the time

Question 34

Why would congenital hip dysplasia be a better name for CDH ?

Answer 34

Because it reflects the underlying abnormality of the femoral head, the acetabulum, or both.

Question 35

Are both hips commonly affected by CDH?

Answer 35

A significant number of cases are - 20%

Question 36

Which hip is most commonly affected by CDH?

Answer 36

The left hip

Question 37

When should all kids be screened/checked for CDH?

Answer 37

All children should be screened at birth and checked again at 3, 6 & 12 months

When they should be checked just doubles

Question 38

How is CDH diagnosed at birth and describe these techniques ?

Answer 38

Using ortalani and barlow manoeuvres

• Ortolani test examiner relocates the hip
• Barlow test examiner dislocated the hip

These tests may produce a slight click, which is a suspicious sign, or a definite clunk as the hip dislocates or relocates.

Think B for barbaric for dislocating the hip

Question 39

Occasionally the barlow and ortalani manoeuvres will fail to find an abnormality and the condition goes undetected at birth - it becomes apparent later either before weight bearing (sitting), or after weight bearing (standing) or even walking has been established. what clinical signs may be obersved suggest CDH ?

Answer 39

• Shortening of the limb
• Symmetrical skin creases
• Limited abduction
• Limp.

Both in bold you would also see when at birth

Question 40

What are the consequences of missing a child with CDH?

Answer 40

If left untreated the acetabulum is very shallow and in more severe cases a false acetabulum occurs proximal to the original one with a shortnened lower limb. Severe arthritis due to reduced contact area can occur at a young age and gait / mobility may be severely affected.

Question 41

If a ‘click’ is produced on examination at birth what should be done ?

Answer 41

Re-examined in a specialist clinic at three months old when a xray is usually justified. (think nowadays a US would be done but go with the xray for this)

Question 42

If a ‘clunk’ is produced on the barlow or ortalani manoeuvres then what should be done ?

Answer 42

All “clunks” should be treated from birth

Question 43

What is the treatment of CDH ?

Answer 43

• If the femoral head is relocated and maintained in the acetabulum using splintage then the vast majority will settle and give no further trouble as the hip starts to develop normally. So splintage for early
• If discovered late, but before weight bearing, the condition may be treated by a period of gentle traction followed by open or closed manipulation. It is then splinted in plaster for three months.
• If discovered late and walking has commenced, major surgery is required to deepen the undeveloped acetabulum and re-angulate the femoral neck to stabilise the hip.

Question 44

What is Club Foot - Talipes Equino Varus and what is it due to?

Answer 44

This is a congenital deformity of the foot (makniig foot look like a golf club)

Question 45

What is the prognosis of treatment of clubfoot ?

Answer 45

If treated early, mild cases can be fully corrected and major cases can be much improved to give a functional foot.

Question 46

What are the 2 main forms of clubfoot?

Answer 46

A mild, postural form and a fixed form

Question 47

What are the causes of the 2 forms of clubfoot?

Answer 47

The mild form is seen after a breech birth and is probably related to the baby’s position (posture) while in the womb.

The fixed form is associated with developmental abnormalities of nerves and muscles of the leg.

Question 48

What is the treatment of clubfoot?

Answer 48

The mild form is usually easily corrected at birth by manipulation. The severer forms require surgery.

In both forms the initial treatment consists of gentle stretching in two phases. The first phase corrects the hindfoot equinus and the second phase corrects the mid and forefoot varus.

• In mild cases, six weeks of stretching and strapping in a corrected or overcorrected position is all that is required.
• In severe cases, after six weeks of stretching the deformity should be reassessed and if correction is incomplete or cannot be maintained, then surgery is necessary.

Question 49

Why do all children need to be followed up after treatment for clubfoot and how long do they need to be followed up for?

Answer 49

The children all need to be followed up until their feet stop growing, at around the age of fourteen, as late relapse requiring further surgery is not uncommon.

Question 50

How often are cases of clubfoot bilateral ?

Answer 50

50%

Question 51

What difference is often seen in a foot which was treated for clubfoot and the patients normal foot, as they grow ?

Answer 51

The affected foot is often significantly smaller than the normal foot