Paediatric MSK

Question 1

tment of metatarsus adductus?

Answer 1

serial corrective casts, followed by straight-last shoes

serial casts may need to be supplemented by a release of abductor hallucis muscle

Question 2

when is the medial longitudinal arch of the foot formed?

Answer 2

by 4-6 years

Question 3

how does stiff (rigid) flat-foot (stiff pes planovalgus) differ from mobile (flexible) flat-foot?

Answer 3

mobile often appears in toddlers, and disappers after a few yrs when medial arch development is complete
stiff flatfoot cannot be corrected passively, and alerts to underlying abnormality: tarsal coalition- often bar of bone connecting the calcaneus to the talus or navicular, an inflam. joint condition or neurological disorder.

Question 4

how can a mobile flat foot be distinguished?

Answer 4

ptnt on standing has flat foot- medial border of foot in contact with ground, heel in valgus position and foot pronates at midfoot.
on going up on their toes, heels invert and medial arches form up
also checked by jack test- feet planted on ground with child sitting and great toe is firmly dorsiflexed, medial arch re-appears.

Question 5

tment of flexible flat foot?

Answer 5

will probably correct on its own
can use medial arch supports or heel cups
if symptomatic, may lengthen lateral side of foot through osteotomy in front of calcaneum and inserting a bone graft, or titanium implant in sinus tarsi to elevate neck of talus and restore arch

Question 6

presentation of Perthe’s disease?

Answer 6

pain in hip
limp
symptoms may persit for wks or occur intermittently
early on, all hip movements diminshed as joint is ‘irritable’
abduction, and IR, nearly always limited

Question 7

tment of Perthe’s disease?

Answer 7

usually resolves in a few years
physio and hydrotherapy
when pain, child should rest, but when asymptomatic, should be encouraged to exercise but avoid strenuous activities

may perform an osteotomy to contain femoral head in acetabulum, can do a varus osteotomy of femur or innominate osteotomy of pelvis or both

Question 8

characteristics of pes planovalgus?

Answer 8

heel in valgus
foot pronates at midfoot

medial border of foot in contact with ground

Question 9

characteristics of idiopathic club-foot (congenital talipes equinovarus)?

Answer 9

ankle in equinus- difficult for upward motion of ankle joint, dorsiflexion limited, occurs with tight Achilles tendon
hindfoot (heel) in varus
midfoot cavus- 1st MT drops, cavus= high arch
forefoot adducted (metatarsals and phalanges), flexed and supinated

Question 10

name given to congenital joint contractures in 2 or more areas of the body?

Answer 10

arthrogryposis multiplex congenita

Question 11

assoc disorders with clubfoot that must be investigated for?

Answer 11

spina bifida
developmental dysplasia of the hip- USS at birth
cerebral palsy?

Question 12

when is clubfoot detected?

Answer 12

antenatally

can be detected as early as 12 weeks

Question 13

favoured tment of clubfoot?

Answer 13

Ponseti method= weekly serial casting and manipulation, beginning within a few days of birth, supervised by physio.
Achilles percutaneous tenotomy at wk 8 to correct ankle equinus. Tendon is divided, foot casted in maximal abduction and DF and tendon re-grows in lengthened position-TAL(tendo achilles lengthening) performed if equinus deformity remains after correcting forefoot adduction.
then splinted in de-rotation boots until 3.

Question 14

how exactly is foot manipulated in clubfoot treatment?

Answer 14

cavus deformity of midfoot corrected first by supinating forefoot- align 1st MT with remaining metatarsals, if pronate then 1st MT plantar-flexed further which would worsen cavus
then correct forefoot adduction and heel varus by slowly abducting, rotating calcaneus and forefoot around talus

Question 15

disorders occurring within DDH?

Answer 15

shallow acetabulum without actual displacement
shallow acetabulum with subluxation of fem head
frank dislocation of fem head

Question 16

2 heritable features which could predispose to hip instability?

Answer 16

generalised joint laxity, *Beighton score

shallow acetabula

Question 17

why might hip instability be rare in premature babies?

Answer 17

ligamentous laxity aggravated by hormonal changes that take place in late pregnancy- oestrogen gives ligaments strength, so lax with reduced oestrogen

Question 18

factors which may account for DDH development?

Answer 18

genetic factors-shallow acetabula, generalised joint laxity
hormonal changes
intrauterine malposition- e.g. breech with extended legs
postnatal factors e.g. carrying position by parent

Question 19

what test can be used in DDH to show if a hip is dislocatable?

Answer 19

Barlow’s test- attempt to lever femoral head out of acetabulum during hip abduction and adduction

Question 20

how should every hip with instability be investigated?

Answer 20

USS- can assess shape of cartilaginous socket and position of femoral head

Question 21

early tment of DDH?

Answer 21

pelvic splint- holds hips flexed and abducted

Question 22

in which children is SUFE most likely to occur?

Answer 22

unusually tall and thin
obese and sex. underdeveloped
delayed gonadal development, as above

it may be in these children that during the pubertal growth spurt, the relatively immature physis might be too weak to resist the stress imposed by increased body weight

Question 23

pathology of SUFE?

Answer 23

femoral shaft rolls into ER following physeal disruption, and fem neck displaced forwards while epiphysis remains seated in acetabulum
epiphysis prematurely fuses

Question 24

presentation of SUFE?

Answer 24

classically boy of 14 or 15 yrs, presents with groin pain, or pain in anter thigh or knee
may also limp
onset may be sudden
may be history of trauma

leg ER and 1 or 2 cm short
limitation of abduction and IR
all hip movements painful if after an acute slip- pain following trauma history

Question 25

what is Trethowan’s sign?

Answer 25

a line drawn along superior surface of femoral neck remains superior to femoral head in SUFE, rather than passing through it

Question 26

complications of SUFE?

Answer 26

avascular necrosis- only after slip has been reduced or pinnned- 1 cancellous screw
slipping at opp. hip
coxa vara- due to epiphysis fusing in deformed position, may do osteotomy
secondary OA- likely if not reduced, and definite if AN

Question 27

tment of SUFE?

Answer 27

shouldn’t attempt closed reduction due to AN risk
minor displacement- pins or screws
moderate- pinning
severe-expose slip, remove small piece of FN to permit replacement of epiphysis and then pin
can fix epiphysis in displaced pos., then follow up later with compensatory osteotomy lower down

Question 28

most common cause of an acute limp and/or hip pain in children?

Answer 28

transient synovitis (the irritable hip)

Question 29

cardinal feature of transient synovitis?

Answer 29

restriction of all movements, with pain at extremes of range in all directions

lab investigations normal, X-rays show slight widening of medial joint space due to effusion, allowing slight subluxation of femoral head

Question 30

how can transient synovitis be confirmed?

Answer 30

USS- will show joint effusion

Question 31

how is transient synovitis treated?

Answer 31

symptoms usually reside spontaneously in 1-2wks
bed rest, reduced activity and observation
repeat USS at intervals
allow WB when symptoms disappear and effusion resolves

Question 32

how can transient synovitis be distinguished from Perthe’s disease?

Answer 32

Perthe’s disease- acute symptoms usually for >2wks, and characteristic X-ray features later= widening of radiographic joint space, increased bone density in epiphysis, then false fragmentation and lateral displacement of epiphysis.

Question 33

describe the differences in onset of SUFE?

Answer 33

acute slip= history of trauma, sudden onset
protracted symptoms= chronic slip
long period of pain culminating in sudden climax following minor trauma= acute on chronic slip