Paediatric orthopaedic problems

Question 1

What do we consider a limp?

Answer 1

Asymmetric gait
Deviation from normal, age-appropriate gait pattern
Splinter in toe to Malignancy

Question 2

What questions do we ask in a history for orthopaedics?

Answer 2

Age?
Where?
When?
How?
Pain?
Nature
Aggravating and relieving factors
Diurnal variation
Associated symptoms
Fever
Swelling
Deformity
Weight loss
Progression of symptoms

Question 3

What are some red herrings?

Answer 3

Trauma
Fever
Site

Question 4

What do we look at in a physical exam?

Answer 4

General appearance
Ill or toxic appearing
Fever
PEWS (Paediatric Early Warning Score

Question 5

What do we do in a Local physical exam looking at certain/ specific limbs?

Answer 5

Expose the child/ limb adequately
Look
Feel
Move
Measure

Question 6

What are the types of gait we need to look at on inspection?

Answer 6

Antalgic gait
Short limb gait
Trendelenberg gait
Spastic gait

Question 7

When inspecting the injury what do we need to look/ make a note on?

Answer 7

Attitude
Swelling
Asymmetry
Redness, bruise, rash
Muscle wasting/ atrophy

Question 8

When palpating on a physical exam what do we need to make a note of?

Answer 8

Limb temperature
Swelling
Effusion
Tenderness
Lymph nodes

Question 9

In a physical exam what notes do we need to make on movement?

Answer 9

Compare with normal side
Characteristics
Active and passive movements
Pain
Stiffness
Muscle tone
Muscle strength

Question 10

What measurements do we need to make?

Answer 10

Limb length measurement
Galleazi test

Question 11

What are the other symptoms that need to be looked at in physical exams?

Answer 11

Abdomen
Genitourinary
Inguinal swelling

Question 12

If there is a history of trauma and focal bony tenderness what investigation should we use?

Answer 12

X-rays

Question 13

If there is localised collection what do we use?

Answer 13

US

Question 14

If there is suspected infection/ malignancy what is used?

Answer 14

MRI

Question 15

What bloods are needed?

Answer 15

FBC
CRP
Blood culture

Question 16

What are red flag symptoms in an examination?

Answer 16

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

Question 17

When do we give a specialist referral?

Answer 17

Cause of limp cannot be managed in primary care
Uncertainty of cause of limp
Septic arthritis/ Osteomyelitis

Question 18

Kocher’s criteria for septic arthritis?

Answer 18

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%

Question 19

What is Perthe’s disease

Answer 19

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%

Question 20

What is slipped upper femoral epiphysis (SUFE)

Answer 20

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

Question 21

Toddlers fracture

Answer 21

Age <3

Question 22

Transient synovitis of the hip

Answer 22

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

Question 23

What is the ACR criteria for Juvenile idiopathic Arthritis

Answer 23

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

Question 24

Septic arthritis/ OM in age less than 3 years

Answer 24

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

Question 25

What are some things you might miss on examination?

Answer 25

Occult fractures
Cerebral Palsy
But delayed diagnosis may not have a very detrimental outcome

Question 26

What are some diseases you must not miss?

Answer 26

Early diagnosis
Septic hip
Malignancy
SUFE
Spinal cord pathology