Paediatric and congenital orthopaedics Flashcards
what is osteogenesis imperfecta and autosomal dominant/recessive is more common
defect in maturation and organisation of type I collagen
autosomal dominant
how would bones appear in osteogenesis imperfecta
thin cortices
osteopenia
features of achondroplasia, proportionate/disproportionate, inheritance
disproportionate short limbs, prominent forehead and wide nose, joint laxity
autosomal dominant but usually sporadic
complicating features of skeletal dysplasias
learning difficulty spine deformity atlantoaxial subluxation cord compression joint hypermobility tumour organ dysfunction
patients with general joint laxity are more prone to?
dislocations and sprains - especially joint and patella
what is marfans syndrome
autosomal dominant/sporadic mutation of fibrillin gene leading to tall stature with disproportionately long arms and joint laxity
features of marfans syndrome
scoliosis, long arms, tall stature, joint laxity, high arch palate, aortic/mitral regurgitation, pectus excavatum, aortic aneurism/dissection
what is ehlers-danlos syndrome and common features?
heterogenous condition with autosomal dominance affecting collagen and elastin
easy bruising, vascular fragility, joint hypermobility and instability, scoliosis
what is duchenne muscular dysytrophy
x linked recessive dystrophin mutation in calcium transport causing progressive muscle weakness
what is CP
neuromuscular disorder with onset <2-3 due to immature brain before, during or after birth
causes of CP
genes brain malformation issues during labour meningitis intrauterine infection intra-cranial haemorrhage hypoxia during birth
most common type of CP
spastic
what does ataxic CP affect
cerebellum
features of athetoid CP
writhing, changes in tone and difficulty with speech
MSK manifestations of CP
hip dislocation, joint contacture, scoliosis
what is spina bifida
congenital defect where two halves of the vertebral arch fail to fuse
mildest is spina bifida occulta and most severe is spina bifida cystica
who is obstetric brachial plexus palsy more common in
larger babies, twins, shoulder dystocia
what nerve roots does erb’s palsy affect
C5-C6 upper nerve roots
what nerve roots are affected in klumpke’s palsy
C8-T1
at what age should a child be able to sit alone/crawl
6-9 months
at what age should a child be able to stand
8-12 months
at what age should a child be able to walk
14-17 months
at what age should a child be able to jump
24 months
at what age should a child be able to manage stairs independently
3 years
at what age should a child be able to move head
8 weeks
at what age should a child be able to speak a few words
9-12 months
at what age should a child be able to use a spoon or fingers eating
14 months
at what age should a child be able to stack 4 blocks
18 months
at what age should a child be able to understand 200 words and learn 10 new words/day
18-20 words
at what age should a child be able to be potty trained
2-3 years
describe child lower limb development
at birth children have varus legs that become neutrally alligned, then 10-15 degrees valgus at 3 years before 6 degrees valgus at 7-9 years old
what is femoral neck anteversion
femoral neck is slightly pointed anterior so gives appearance of intoeing and knock knee
describe formation of arch of foot
all feet flat at birth anf as we walk muscles develop to cause arch to form
true/false - flat feet is a problem
false - not always, it can be normal variation
what is jacks test
dorsiflexion of great toe causes arch of foot to form, positive sign of flexible flat footedness
causes of flexible flat footedness
ligament laxity, idiopathic, familial, tibialis posterior tendon dysfunction
what is a cause of rigid flat footedness
tarsal coalition
true/false - the first toe is most affected by overlapping of toes
false - fifth is
what is DDH, what hip is it more common in and who is more likely to get it
dilocation/subluxation of the femoral head affecting further development of the hip
more common in the left hip and women
risk factors for DDH
FHx
Breech position
first born
other congenital disorders and downs syndrome
untreated pathology of DDH?
acetabulum formed is shallow so false acetabulum may form proximal to original
severe OA may occur due to lesser SA
what is barlow’s test
dislocatable hip with flexion and posterior displacement
what is ortolani test
reduced dislocated hip with abduction and anterior displacement
true/false - DDH can be detected in a 3 month old by radiograph
false - USS should be used for up to 4-6 months as the head of femur is not ossified
what is transient synovitis of the hip
self limiting inflammation of hip joint following viral URTI (or other)
most common paeds hip pain and usually boys age 2-10
what is perthes disease, who gets it
idiopathic osteochondritis of fem head, transient lost blood supply so altered growth and possible collapse and OA
boys aged 4-9, short and active
what is SUFE, whos more likely to get it
slipped upper femoral epiphysis, overweight prepubescent boys, hypothyroidism and renal disease
a child has knee pain, what joint do you examine?
the hip, never forget it as it follows referred pain from obturator nerve
what is apophysitis
inflamation of a growing tubercle where a tendon attaches
what is osgood-schlatter disease
apophysitis of tibial tubercle
what is sinding-larsen-johnasen disease
apophysitis of inferior pole of patella
what is osteochondritis dissecans and where is it most common
hyaline cartilage breaks off joint surface, knee
what is talipes equinovarus and what deformity does it cause
abnormal in uero alignment of joints between talus, calcaneus and navicular
ankle equinus, forefoot supination and varus alignment
who is talipes equinovarus more common in
oligohydraminos and breech presentation, twice as common in males
red flags for paediatric leg pain?
asymmetry good localisation short hx persisitent limp fail to thrive worsening pain tender and guarding reduced ROM
what is a salter harris I fracture and what prognosis does it carry
pure physeal seperation
best prognosis and least likely for growth arrest
what is a salter harris II fracture and what prognosis does it carry
mostly physeal frcture
most common and small metaphyseal fracture attached to epiphysis and metaphysis
low likelihood growth disturbance
what is a salter harris III/IV fracture and what prognosis does it carry
intra articular fracture with splitting of physis so greater risk growth arrest
reduce and stabilise to ensure congruent joint surface - this minimises post traumatic OA and growth arrest
what is a salter harris V fracture and what prognosis does it carry
compression to physis with subsequent growth arrest
not disgnostic on xray and only once angular deformity has occurred
features of NAI
poverty, special needs, substance abuse bruising/injury of different age multiple trips to A&E inconsistent or changing injury discrepancy in hx with parents/carers injury not consistent with child age dental injury, LL and trunk burn, torn frenulum, genital injury and cigarette burns rib fracture metaphyseal fracture in the young infant
how is a distal radius buckle fracture managed
splint for 3-4 weeks as stable
how is a distal radius greenstick fracture managed
manipulation if angulated and casting if there is deformity
what salter harris fracture is common in fracture to distal radius and how is it managed
manipulate to correct angulation/deformity
casting
salter harris II - low risk growth arrest
in a complete childrens distal radius fracture, how is it managed and what displacement/angulation is most common
dorsal displacement/angulation
if stable then cast
unstable - wires or plate fixation
how would you manage a childrens monteggia and galeazzi fracture
plates and screws with rigid anatomical fixation
how would you manage a fracture of both bones of forearm
if there is one plane of angulation then casting may be okay
displaced fractures are unstable so flexible IM nail is often used
types of fracture to supracondyle of elbow
extension type most common due to fall on outstretched hand
flexor type can occur due to fall on point of elbow
managing undisplaced supracondylar elbow fracture
splint as stable
managing an angulated, rotated or displaced elbow fracture
closed reduction with wire pinning
manage quickly to avoid swelling
if severely displaced brachialis may be tethered and needs open reduction
if radial pulse absent emergency surgery to reduce/explore
why cant people with off ended extension fracture of elbow supracondyle make an OK sign
distal fragment displaces posterior to stretch and put pressure on brachial artey and median nerve
loss of FPL and FDP
how should nerve injury on supracondylar elbow fractures be managed
manage urgently in theatre
majority are neuropraxia but can be axonotmesis
neuralgic pain ongoing may be entrapment needing surgical release
how may a childrens femoral shaft fracture ccur
flexed knee, indirect bending/rotation
why can shortening in femoral fractures be tolerated
there is usually overgrowth
true/false - in <2y 1/4 fem shaft fractures are NAI
false - 1/2 are
how is femoral shaft fracture in <2 managed
gallows traction and hip spica cast
how is femoral shaft fracture in 2-6 managed
thomas’ splint or hip spica cast
how is femoral shaft fracture in 6-12 managed
flexible IM nail
how is femoral shaft fracture in >12 managed
Adult IM nail
if there is no obvious hx for femur shaft bone fracture what may it be
NAI
benign/malignant bone tumours
true/false - the risk of compartment syndrome during a paeds tibial fracture is more than that of an adult
false - it is less
how much angulation is tolerated in paeds tibial fracture
10 degrees, above that manupulation and casting needed
true/false - shortening and rotation can be accepted in tibial fracture
false - never
why are serial x rays important in a tibial fracture
ensure there is no angulation drifting in AP/lat
when would you offer casting for a tibial fracture in children
undisplaced spiral fracture, usually in toddlers
stable fractures that have little to no angulation or are manipulated
how would you stabilise an unstable/open tibial fracture in children
flexible IM nail or in closed prox tibial physis an adult one
plates and screws
external fixator
