Paed Ortho - Intro

Question 1

What are the “classes” of abnormal presentations in children that arn’t true pathologies?

Answer 1

Normal Variants
Physiological Development
Self-Correcting Pathologies

Question 2

How many pediatric referrals to orthopaedics are normal variation?

Answer 2

Well over 50% with intoeing and flexible flat feet being the commonest reasons for refferal

Question 3

What “pathologies” are part of physiological development and not pathology?

Answer 3

Young children with bow legs, knock knees, flat feet or excessive anteversion.
This is actually normal for their age and will grow into the adult shape

Question 4

What is a self-correcting pathology?

Answer 4

Not a true pathology, its a problem that mostly correct themselves during growth.

Question 5

How do you assess a childs hip rotation?

Answer 5

Get them to lie on their front with legs flat

Flex one knee and rotate the leg out for medial rotation of hip and in for lateral rotation. (pics in slides)

Question 6

What can cause normal intoeing in children?

Answer 6

Internal Tibial Torsion which is also normal for their age.
Metatarsus Adductus, meaning the metatarsals are bent medially
Femoral anteversion

Question 7

How do we assess for tibial torsion?

Answer 7

With the thigh foot angle.
while they’re lying on their front lift up the foot and look down the foot against the thigh to see the angle between them.

Question 8

How would you clinically assess a child? [4]

Answer 8

• Walking
• Standing (alignment from front / Patellar position / length from behind)
• Tip Toe
• Stahelli rotational Profile (done with child lying on front)

Question 9

What presentations of a child might require further investigation?

Answer 9

• Outside the normal age boundary for their presentation. E.g. Bow legged at the wrong age i.e. after age 2
• Assymetry. 1 leg intoeing/bowing/longer etc,

Question 10

What presentations may require treatment?

Answer 10

Metatarsus Adductus - Rarely
Tibial Torsion
Persistant Femoral Anteversion
Curly Toes

Basically only needs to be done if the child is past the age where they might outgrow it themselves

Question 11

Club foot OR Talipes equinovarus
Associated with [4] conditions
Aetiology [4]

Answer 11

Associated with:

• DDH
• Trisomy 21
• Larsens syndrome
• Neuromuscular disorders

Aetiology

• Pressure, oligohydramnios
• Abnormal fetal position
• Placental insufficiency
• Toxins

Question 12

Club foot OR Talipes equinovarus
Presentation [6]
Piriani score - 2 components
Describe difference between positional and structural club foot

Answer 12

Presentation (CAVE)

• Cavus
• Adductus of midfoot
• Varus of hindfoot
• Equinus of hind foot
• Mild limb length discrepancy
• Muscle wasting

Piriani score:

• Hind foot score
• Mid foot score

Positional vs structural:
o Positional: score 0.5 or 0; abnormal postural position entirely correctable passively but springs back to abnormal position
o Structural: foot does not correct (not fixed; may have variable amount of passive correction) and true bone anatomical misalignment

Question 13

Club foot OR Talipes equinovarus
Investigations
Mx for positional [2] and structural [3]

Answer 13

Diagnosis often antenatally on ultrasound

Management:
• Positional: reassurance and discharge +/- strapping
• Structure:
- Ponsetti serial casting
- Boots and Bars
- equinus correction via percutaneous tenotomy of Achilles tendon in 90%