Paediatric Conditions Flashcards
What is the clinical presentation of septic arthritis? (5)
- Acute monoarthritis with erythema, warmth and swelling
- Intense pain on passive movement
- Joint held in mid-range of movement (i.e. decreased range of movement)
- Fever
- Irritability/poor feeding in infants
What investigations are required in septic arthritis? (4)
- FBE, CRP, ESR
- X-ray
- US in painful hip
- Joint aspirate and blood culture (BEFORE starting antibiotics)
Name three risk factors for getting slipped capital femoral epiphysis
Male, obese, hypothyroid
In what age group does SCFE occur?
During pubertal growth spurt (10-12 in females, 12-14 in males)
What are the clinical features of SCFE? (5)
- Acute - sudden, severe pain with limp
- Chronic - limp with medial knee or anterior thigh pain and positive Trendelenberg sign on affected side, due to weakened gluteal muscles
- Hip appears externally rotated and shortened
- Restricted internal rotation, abduction, flexion
- Can be bilateral
What investigations are required if you suspect SCFE?
X-ray of pelvis, frog-lateral of affected hip
What is the management of SCFE? (2)
- No weight-bearing
2. Urgent orthopaedic referral for surgery (usually pins)
What is transient synovitis and in which age group does it occur?
Benign, self-limited disorder that usually occurs after URTI/pharyngitis/otitis media i.e. history of recent viral illness
Age 3-10
What is the clinical presentation of transient synovitis? (4)
- Afebrile or low-grade fever
- Pain typically occurs in hips, knees
- Painful limp but still capable of ambulating
- Symptoms resolve over 7-10d
What investigations are required if you suspect transient synovitis?
- WBC, ESR, CRP - normal
- X-ray - normal
- US may show joint effusion
How is transient synovitis managed?
Bed rest and analgesia
What are the risk factors for developmental dysplasia of the hip? (6)
- Breech delivery
- Caesarian section
- Family history
- Congenital anomalies
- Being first born and female
- Oligohydramnios
What is Ortolani’s test?
Flex hips and knees to 90 degrees and grasp thigh. Try to reduce hips during abduction (middle finger on greater trochanter, trying to bring femur forward). Positive sign = clunk or jerk where a dislocation reduces, allowing hip to abduct fully
What is Barlow’s test?
Flex hips and knees to 90 degrees and grasp thigh. Fully adduct hips, push posteriorly to try to dislocate hips
What is Galeazzi’s sign?
Knees at unequal heights when hips and knees flexed. Dislocated hip on side of lower knee.
How are infants screened for developmental dysplasia of the hip?
General screening (Ortolani’s, Barlow’s, Galeazzi’s) and hip U/S (at 6 weeks) in infants in high risk group + those with abnormal general screening.
Use radiography after 6 months (due to ossification nucleus of femoral head developing
How is developmental dyplasia of the hip managed? (2)
THE EARLIER THE DIAGNOSIS, THE EASIER THE MANAGEMENT
- In neonates, abduction bracing with Pavlik harness
- If later diagnosis, operation (open reduction) required
What is Perthes disease?
Aka coxa plana
Self-limited AVN of femoral head of unknown aetiology, generally unilateral and usually presenting in males at 4-10 years of age
How is Perthes disease investigated?
X-rays - may be negative early (if high index of suspicion, move to bone scan or MRI). Eventually, will show characteristic collapse of femoral head (diagnostic)
How does Perthes disease present?
Limp - if pain present, usually in thigh or knee
Flexion contracture, loss of abduction compared to opposite side, loss of hip IR
What are the two most significant predictors of long-term outcome in Perthes disease?
Age at presentation and ROM of hip
Children with bone ages less than 5 years and children who exhibit relatively minor involvement rarely need treatment
What is rickets?
Osteopaenia with disordered calcification leading to a higher proportion of osteoid (unmineralised) tissue prior to epiphyseal closure (in childhood)
Describe the pathophysiology of rickets (2)
- Vitamin D deficiency leading to secondary hyperparathyroidism and hypophosphataemia
- Mineralisation defect - instead or arranging themselves in orderly columns, the cells in the proliferative zone pile up irregularly
How is rickets investigated?
- Blood tests - vitamin D, calcium balance, phosphate, kidney function, and bone turnover (ALP)
- X-ray:
Who is at risk of getting rickets? (4)
- Children with very dark skin
- Children who do not expose their skin to sun
- Children with conditions affecting how the body controls vitamin D levels - liver and kidney disease etc.
- Breastfed babies (with other risk factors) - breast milk does not contain much Vitamin D
How is rickets treated? (4)
- Treat underlying cause
- If rickets caused by low Vit D -> vitamin D supplements
- Phosphate supplementation if low serum phosphate present
- Calcium supplementation
List 6 features of rickets
- Tetany or convulsions in infants
- FTT, listlessness, muscular flaccidity
- Early bone changes - deformity of the skull (cranotabes) and thickening of the knees, ankles and wrists from physeal overgrowth
- Chest changes - enlargement of the costochondral junctions (‘rickety rosary’) and lateral indentation of the chest (Harrison’s sulcus)
- Lower limb deformities - distial tibial bowing, valgus deformities
- Severe - coxa vara, fractures of long bones, spinal curvature
What is Osgood-schlatter disease?
Repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causes minor avulsion at the site and subsequent inflammatory reaction (tibial tubercle apophysitis)
What are the the clinical features of Osgood-Schlatter Disease? (4)
- Tender lump over tibial tuberosity
- No history of injury and sometimes condition is bilateral
- Pain on resisted leg extension
- Anterior knee pain exacerbated by jumping or kneeling, relieved on rest
How would you investigate Osgood-Schlatter disease?
X-rays: fragmentation of the tibial tubercle +/- ossicles in patellar tendon
How would you treat Osgood-Schlatter disease?
Benign,self-limited condition
restrict activities such as basketball or cycling
Re: salter-harris fractures, what are the complications of each?
Type 1 and 2: if properly reduced - excellent prognosis and bone growth not adversely affected
Type 3 and 4: may result in premature fusion of part of growth plate or asymmetrical growth of bone end
Type 5: cause premature fusion and growth retardation
What are the three deformities in cognenital talipes equinovarus (club foot)?
- Talipes: talus is inverted and internally rotated
- Equinus: ankle is plantar flexed
- Varus: heel and forefoot are in varus (supinated)
What is a torus fracture and where does it most commonly occur?
Incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex; most commonly occurs at the distal radius following a fall on an outstretched arm
What is a greenstick fracture and where does it most commonly occur?
incomplete fractures of long bones; commonly mid-diaphyseal, affecting the forearm and lower leg
What can DDH be due to?
Ligamentous laxity, muscular underdevelopment and abnormal shallow slope of acetabular roof - remember mostly painless - (if painful, suspect septic dislocation)
Which is the weakest part of the bone in children?
Epiphyseal growth plate, therefore highly susceptible fractures
Growth plate injuries in children - mechanism compared to adults, intra-articular fractures
- Tensile strength of bone is less than that of ligaments in children, therefore mechanism which causes ligamentous injury in adults causes growth plate injury
- Intra-articular fractures have worse consequences in children because they usually involve the growth plate
Describe the injury that occurs in a Salter-Harris type 1 fracture. How is this managed?
I - “straight through” - transverse fracture through growth plate. Closed reduction and cast immobilisation - heals well, 95% do not affect growth
Describe the injury that occurs in a Salter-Harris type 2 fracture. How is this managed?
II - ‘Above’ - transverse fracture through growth plate and oblique/vertical fracture through metaphysis
Usually reduced but not always easy to hold reduced in a cast - sometimes torn perisosteum gets trapped in fracture site, preventing full reduction through closed means, so open operation may be required.
Describe the injury that occurs in a Salter-Harris type 3 fracture. How is this managed?
III - ‘ below’ - transverse fracture through growth plate and vertical fracture through epiphysis
Anatomic reduction through ORIF to prevent growth arrest
Describe the injury that occurs in a Salter-Harris type 4 fracture. How is this managed?
IV - ‘Through and through’ - vertical fracture through all three components: metaphysis, physis and epiphysis
Displaced Type 4 requires ORIF
Describe the injury that occurs in a Salter-Harris type 5 fracture. How is this managed?
V - ‘ram’ - crush injury of growth plate
Injuries always diagnosed retrospectively, when growth arrest has occurred. No specific treatment
What is the growth plate?
Translucent, cartilaginous disc separating epiphysis from the metaphysis and is responsible for longitudinal growth of long bones
What is the difference between an insufficiency fracture and a fatigue fracture?
Insufficiency fracture - stress applied to a weak or structurally deficient bone
Fatigue fracture - repetitive, excessive force applied to normal bone
Both are stress fractures
In which population are stress fractures more common?
Adolescent male athletes, sudden increase of activity
Where do stress fractures most commonly occur?
Tibia most common, also in fibula or MTs
What DDxs are often considered when stress fractures are suspected?
Osteomyelitis and bone tumours
What investigations can be ordered in diagnosing a stress fracture?
X-rays - may not show fracture
Bone scan - positive in 12-15 days
With which type of paediatric injuries are bone scans superior to X-rays? (3)
- Rib fractures at costovertebral junction
- Undisplaced fractures
- Subperiosteal haemorrhages in NAI
When is CT used in paediatric populations? (2)
- Preferred method for assessing head injuries, fractures of spine and pelvis
- Only if benefits outweigh risk given ionising radiation exposure
BUT good b/c short scanning times, no need for anaesthesia
Discuss the use of MRI in paediatric populations. (when used, disadvantages and advantages compared to CT)
Bone and soft tissues
- Definitive tool to assess degree of brain and spinal cord injury after major trauma (e.g SCIWORA - spinal cord injury without radiological abnormality)
- Useful in distinguishing between stress fracture, osteomyelitis and bone tumours
- Good vs CT because - able to image soft tissues, no ionising radiation
- Bad vs CT because - very long scanning time therefore need for anaesthesia in most children
List 4 indirect radiological signs of fractures in children.
- Avulsion - children less likely to tear ligament. Avulsions are equivalent to a complete tear of ligaments in adults (similar treatment principles)
- Haemarthrosis
- Displacement of ossification centres
- Anatomic alignment - using mid-diaphyseal signs
When is callus formation seen on X-ray in children?
7-14 days after injury, depends on age of child and nature of injury - the younger the child, the earlier callus will be seen
What is the remodelling potential of a child’s bone fracture dependent on? (3)
- Age of child - the younger the child is, the better
- Proximity to joint - the closer the better, joint movement strengthens bone
- Plane of joint - if fracture is within plane of joint, more likely to heal properly - muscle movement contributes to healing
