Paediatric orthopaedic problems Flashcards
What do we consider a limp?
Asymmetric gait
Deviation from normal, age-appropriate gait pattern
Splinter in toe to Malignancy
What questions do we ask in a history for orthopaedics?
Age?
Where?
When?
How?
Pain?
Nature
Aggravating and relieving factors
Diurnal variation
Associated symptoms
Fever
Swelling
Deformity
Weight loss
Progression of symptoms
What are some red herrings?
Trauma
Fever
Site
What do we look at in a physical exam?
General appearance
Ill or toxic appearing
Fever
PEWS (Paediatric Early Warning Score
What do we do in a Local physical exam looking at certain/ specific limbs?
Expose the child/ limb adequately
Look
Feel
Move
Measure
What are the types of gait we need to look at on inspection?
Antalgic gait
Short limb gait
Trendelenberg gait
Spastic gait
When inspecting the injury what do we need to look/ make a note on?
Attitude
Swelling
Asymmetry
Redness, bruise, rash
Muscle wasting/ atrophy
When palpating on a physical exam what do we need to make a note of?
Limb temperature
Swelling
Effusion
Tenderness
Lymph nodes
In a physical exam what notes do we need to make on movement?
Compare with normal side
Characteristics
Active and passive movements
Pain
Stiffness
Muscle tone
Muscle strength
What measurements do we need to make?
Limb length measurement
Galleazi test
What are the other symptoms that need to be looked at in physical exams?
Abdomen
Genitourinary
Inguinal swelling
If there is a history of trauma and focal bony tenderness what investigation should we use?
X-rays
If there is localised collection what do we use?
US
If there is suspected infection/ malignancy what is used?
MRI
What bloods are needed?
FBC
CRP
Blood culture
What are red flag symptoms in an examination?
Unable to weight bear
Fever
Systemic illness
Severe pain
Limp or pain - worsening
Pain- waking the child at night
Redness, swelling and stiffness
Weight loss, anorexia
When do we give a specialist referral?
Cause of limp cannot be managed in primary care
Uncertainty of cause of limp
Septic arthritis/ Osteomyelitis
Kocher’s criteria for septic arthritis?
Fever > 38.5 C
Inability to weight bear
CRP > 20 mg/L
WBC >12
0 points - 0.2% chance
1 - 3%
2- 40%
3 - 93%
4 - 99%
What is Perthe’s disease
Decreased blood flow to femoral head which leads to a damaged femoral head bone
Could lead to avascular necrosis
Occurs in children aged 4-10 years
Boys more than girls
Bilateral in 10%
What is slipped upper femoral epiphysis (SUFE)
3 grades
Grade 1
Grade 2
Grade 3
Occurs aged 11-14 years
Obese children and boys
Bilateral 20-40%
May present as knee pain
Same day Xray essential - delayed treatment associated with poor outcome
Toddlers fracture
Age <3
Transient synovitis of the hip
Less common below age of 3
3-10
Typically acute onset following viral infection
NO systemic upset
Peak onset age 5/6 years, more common in boys
Managed with oral analgesia
No pain at rest and passive movements are only painful at extreme range of movement
Recurs in up to 15% of children
What is the ACR criteria for Juvenile idiopathic Arthritis
Age at onset <16 years
Arthritis in one or more joints
Duration 6 weeks or longer
Onset type defined by type of disease in first 6 months:
- polyarthritis: 5 or more inflamed joints
- Oligoarthritis: <5 inflamed joints
Systemic: arthritis with characteristic fever
Exclusion of other forms of juvenile arthritis
Septic arthritis/ OM in age less than 3 years
Usually febrile
Commonly occurs under 4 years of age
Pain + inability to bear weight
If SA hip often held flexed and abducted
Child often looks unwell and passive movement of the joint extremely painful
SA - medical emergency that requires urgent treatment
Femoral OM similar presents as SA but children have some passive range of motion unless there is extension of infection to the joint
What are some things you might miss on examination?
Occult fractures
Cerebral Palsy
But delayed diagnosis may not have a very detrimental outcome
What are some diseases you must not miss?
Early diagnosis
Septic hip
Malignancy
SUFE
Spinal cord pathology
