Paediatric Conditions

Question 1

What is a salter-harris fracture?

Answer 1

One which involves the epiphysea plate or growth plate of a bone. It is a common injury found in children and occurs in 15% of all childhood fractures.

Question 2

What are the five main levels of Salter-Harris fracture?

Answer 2

Type 1 - Slipped
Type 2 - Above
Type 3 - Lower
Type 4 - Through or Transverse
Type 5 - Rammed or Ruined

Question 3

What is the mnemonic for remembering?

Answer 3

SALTR

Question 4

Give seven causes of limp

Answer 4

• Femoral Fracture
• Slipped Capital Femoral Epiphysis
• Perthe’s disease
• Distal tibial buckle fracture
• Transient synovitis
• Developmental Dysplasia of the Hip
• Septic Arthritis

Question 5

What is a slipped capital femoral epiphysis?

Answer 5

Instability of the proximal femoral growth plate, and is one of the most common adolescent hip disorders.

Question 6

What occurs in a slipped capital femoral epiphysis?

Answer 6

the femoral shaft rolls into external rotation and the femoral neck is displaced forwards while the epiphysis remains in the acetabulum.

Question 7

Give two overall ways in which you can categorise slipped capital femoral epiphysis

Answer 7

Type of slip

Stable vs unstable

Question 8

Give four ways in which you can categorise a type of slip

Answer 8

Pre-slip – Wide epiphyseal line without slipping
Acute form – Slippage occurs spontaneously
Acute on chronic – Slippage occurs when there is an already exisiting chronic slip
Chronic slip – Steadily progressive slippage

Question 9

Outline the aeitology of slipped capital femoral epiphysis

Answer 9

The slip usually occurs through the hypertrophic zone of the cartaliginous growth plate Many patients are either fat and sexually immature or excessively tall and thin. This could mean that there is an imbalance between pituitary hormone activity, which stimulate rapid growth and increased physeal hypertrophy, and gonadal hormones which influence physeal maturation and epiphyseal fusion.
A disparity may result in the physis being unable to resist the shearing stresses imposed by an increase in body weight.

Question 10

What is the epidemiology of slipped capital femoral epiphysis

Answer 10

Most commonly in boys age 10-17, with peak age being 11.5 for girls, 13 for boys. Left hip more commonly affected than the right. Three times as common in boys.

Question 11

Give four overall risk factors for slipped capital femoral epiphysis

Answer 11

Mechanical: Local trauma, obesity
Inflammatory conditions: Neglected septic arthritis
Metabolic conditions: Hypothyroidism, hypopituitarism, growth hormone deficiency
Radiaiton of the pelvis: Chemotherapu, renal osteodystrophy induced bone dysplasia

Question 12

What is the usual presentation of the slipped capital femoral epiphysis

Answer 12

Often has a protracted history of minor episodes of pain – an “acute on chronic” slip. Patient is usually around puberty, overweight or very tall and thin.
Discomfort in the hip, groin, medial thigh and knee during walking. Pain accentuated by running/jumping/pivoting.
Pain in hip, external rotation and sometimes leg shortening (especially in chronic cases). Flexion, abduction and medial rotation are limited.

Question 13

What occurs on x-ray in slipped capital femoral epiphysis

Answer 13

Tretowan’s sign, which occurs when klines line does not intersect with the femoral head.

Question 14

Give four differenital diagnosis for slipped capital femoral epiphysis

Answer 14

• Perthe’s disease
• Acute hip fracture
• Septic Arthritis
• Acute transient synovitis

Question 15

What should be used to investigate slipped capital femoral epiphysis

Answer 15

AP and lateral x-rays show widening of the epiphyseal line or displacement of the femoral head.

Question 16

Outline the management of SCFE

Answer 16

Analgesia and immediate orthopaedic referral if the diagnosis is suspected – make sure leg is immobilised, either verbally or with a restrictor.

Surgical management is the definitive treatment, with screws inserted percutaneously. Corrective osteotomy for deformities after patient has stopped growing.

Question 17

What are the complications of SCFE

Answer 17

• Chondrolysis

- Avascular necrosis of the epiphysis (occurs in 10-25% of cases)

Question 18

What is the prognosis for SCFE?

Answer 18

Depends on the initial degree of slippage and prompt recognition by a general practicioner. End result is good to excellent in 95% of cases if fragments are displaced by less than 1/3 of the diameter of the femoral neck.

Question 19

What is a synonym for developmental dysplasia of the hip?

Answer 19

Congenital dislocation of hip

Question 20

What does a DDH entail?

Answer 20

Developmental dysplasia of the hip refers to a spectrum of severity ranging from mild acetabular dysplasia with a stable hip, to more severe forms of dysplasia with neonatal hip instability, to established hip dysplasia with or without later subluxation or dislocation.

Question 21

Give four factors which play a role in the genesis of DDH

Answer 21

Genetic factors
Hormonal factors
Intrauterine malposition
Post-natal factors

Question 22

What are the epidemiological features of DDH?

Answer 22

Developmental dysplasia of the hip effects 1-3% of new borns and is responsible for 30% of hip replacements in those under 60 years of age. The left hip is dislocated more often than the right, and it is more common in cultures with swaddling.

Question 23

What are three risk factors for DDH?

Answer 23

• Having a sibling with hip dysplasia
• Being a girl
• Vaginal delivery of children in breech positions

Question 24

How does screening for DDH work?

Answer 24

Screening for DDH is part of the physical examination of newborn and 6-8 week old babies. Sometimes Ultrasound is used, if there is a family history or if the child was delivered breech.

Question 25

What are two tests done for DDH on under 6 month olds?

Answer 25

Ortolani test

Barlow test

Question 26

What is the ortolani test?

Answer 26

The examiner applies forward pressure to each femoral head in turn, in an attempt to move a posteriorly dislocated femoral head forwards into the acetabulum. Palpable movement suggests that the hip is dislocated or subluxed, but reducible.

Question 27

What is the Barlow test?

Answer 27

backward pressure is applied to the head of each femur in turn, and a subluxable hip is suspected on the basis of palpable partial or complete displacement

Question 28

What is looked for in patietns >6 months

Answer 28

• The child is examined lying supine with the hips and knees flexed to 90° and the height of each knee is compared.
• A positive sign is that one leg appears shorter than the other.
• This is usually due to dislocation of the hip; however, any discrepancy of limb length will produce a positive sign.
  Other physical signs for late dislocation include asymmetry of the gluteal thigh or labral skin folds, discrepancy in leg length, a widened perineum on the affected side, buttock flattening, and asymmetrical thigh skin folds, decreased abduction on the affected side, and standing or walking with external rotation of the affected leg.

Question 29

Give four investigations for DDH

Answer 29

Ultrasound, athrography, CT and MRI.

Question 30

How is DDH managed?

Answer 30

Bracing is used for children

Question 31

What is perthe’s disease/

Answer 31

Avascular necrosis of the femoral head in children. The precipitating cause is unknown but the cardinal step is ischaemia of the femoral hea1

Question 32

Outline the pathophys of perthe’s disease?

Answer 32

Up to the age of 4 months the femoral head is supplied by 1) metaphyseal vessels which penetrate the growth disc, 2) lateral epiphyseal vessels running in the retinacula and 3) some vessels running in the ligamentum teres. Between 4 and 7 years of age the metaphyseal vessels are gone and the ligamentum teres vessels are undeveloped, and thus blood supply comes soley from lateral epiphyseal vessels. These are vulnerable to effusion, stretching and pressure – such pressure could cause venous pressure, increasing intraosseous pressure and leading to infarction.

Question 33

What are the three stages of Perthe’s disease

Answer 33

Stage 1 – Ischaemia and bone death
Stage 2 – Revascularization and repair
Stage 3 – Distortion and remodelling

Question 34

What is a condition found in 50% of perthe’s sufferers?

Answer 34

Thrombophillia is reported in 50% of patients.

Question 35

What is the classification for Perthe’s?

Answer 35

Herring classification

Question 36

What is the epidemiology of perthe’s?

Answer 36

• 4-8 years is most common age of presentation
• Male to female ratio is 5:1
• More commonly seen in urban populations versus rural

Question 37

What are the presenting features of perthe’s?

Answer 37

• 4-8 years is most common age of presentation
• Male to female ratio is 5:1
• More commonly seen in urban populations versus rural

Question 38

What are the four main investigations for Perthe’s?

Answer 38

X-ray – May show some widening of the joint space and asymmetry of the ossific centres.
FBC and ESR
Hip aspiration – rule out septic arthritis

Question 39

What ius the management for Perthe’s for those

Answer 39

There is no consensus for the optimum treatment. The aim of treatment is to maintain the sphericity of the femoral head and the congruency of the femur-acetabulum relationship to prevent secondary degenerative arthritis. Early diagnosis and management can help prevent the collapse of the femoral head, progressive femoral head deformity, and impingement.
Children who have a skeletal age of 6.0 years or less at the onset of the disease do well without treatment. Operative treatment should be considered in children who are six years old or older and have over 50% femoral head necrosis when the diagnosis is made.

Question 40

How is physio used in perthe;s?

Answer 40

Physiotherapy using muscle strengthening and stretching exercises, produces significant improvement in articular range of motion, muscular strength and articular dysfunction, but these improvements are not seen on X-ray.

Question 41

What is the prognosis of perthe’s?

Answer 41

Physiotherapy using muscle strengthening and stretching exercises, produces significant improvement in articular range of motion, muscular strength and articular dysfunction, but these improvements are not seen on X-ray.
50% do well with no treatment, and patients less the 6 years of age the outcome is good regardless of treatment (this is due to higher remodelling potential). More than 80% have good outcome that persists into fourth decade of life, although many will require an artificial hip.

Question 42

What are the complications of Perthe’s?

Answer 42

Residual deformities may include coxa magna (broadening of the head and neck of the femur), coxa plana (osteochondritis of the femoral head), coxa breva (structural shortening of the neck of the femur) and hinged abduction (this occurs when an enlarged femoral head is pushed laterally and it impinges on the acetabular rim when the hip is abducted).

Question 43

What is the other name for club foot and what is it?

Answer 43

as talipes equinovarus, club foot is characterised by an excessively turned in foot and high medial longitundinal arch.

Question 44

What happens if club foot is left untreated?

Answer 44

If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative or surgical.

Question 45

What is the incidence of club foot?

Answer 45

The incidence of club foot is 1 in 1000 births. Males are more commonly affected than females and up to 50% of cases are bilateral.

Question 46

What is the pathology of club foot?

Answer 46

In 20% of cases club foot is associated with distal arthrogryposis (congenital joint contractures), myelomeningocele (spina bifida), amniotic band sequence, or other genetic syndrome such as trisomy 18 or cnromosome 22q11 deletion.
Maternal associations with club foot include teratogenic agents, oligohydraminios and congenital uterus constriction rings.

Question 47

What is presentation of a patient with club foot?

Answer 47

• Calf muscle and the foot smaller than normal
• Hindfoot is in rigid equinovarus (foot is turned inward and downward) and the forefoot is short, wide, adducted and supinated. The sole of the foot points mediall.
• Heel is high and fibula prominent

Question 48

Give three conditions which are associated with club foot

Answer 48

Congenital hip dislocation, Spina Bifida, Cerebal Palsy, Arthrogryposis

Question 49

What imaging is used in club foot?

Answer 49

AP is taken with foot 30 degrees plantarflexed and the tube likewise angled 30 degrees perpendicular. Lines can be drawn through the long axis of the talus parallel to its medial border.
Lateral film I taken with foot in forced dorsiflexion.

Question 50

Wat is the scoring system for club foot?

Answer 50

Pirani Scoring system

Question 51

Outline the pirani scoring system

Answer 51

Pirani scoring system used to determine the likely success of treatment. It consists of 6 categories, three in the midfoot and three in the hindfoot, and each category is scored with 0, 0.5 and 1.
Categories
Mid-foot
Curvature of the lateral border
Medial crease
Uncovering of the lateral head of the talus
Hind-foot
Posterior crease
Emptiness of heel
Degree of dorsiflexion.
The scoring system (worst 6, best 0) can be used to identify severity of club foot and to monitor success of correction.

Question 52

What is the treatment for club foot?

Answer 52

Ponseti Method
Foot is reduced using weekly casts followed bya percutaneous tenotomy of the Achilles tendon to correct the equinus. Twenty four and then night-time splinting in abduction is the maintained for a period of 3-4 years.
When compared with surgical intervention, both the Ponseti method and surgery have a relatively high recurrence rate, but the ponseti method was associated with significantly less revision surgery.
Ponseti method (non-surgical correction) has an initial correction rate of 90% in idiopathic feet.
French functional method
Involves special physiotherapists and daily manipulation
Surgery
Soft-tissue responsible for shortening (tibialis posterior, abductor halluces and Achilles tendon) released. Complete soft tissue release performed between 6 and 12 months.