Paediatric Orthopaedic Surgery Flashcards
Describe the clinical deformities of the foot
C – Midfoot cavus (high medial arch)
A – Forefoot ADductus (tight tibialis posterior)
V – Hindfoot varus (tight Achilles tendon and tibialis posterior)
E – Hindfoot equines (tight Achilles tendon)
What is the scientific name for club foot?
Congenital talipes equinovarus
Describe the principles of serial correction and maintenance of correction of this foot according to today’s current gold standard of treatment
Ponseti method (1 week serial castings)
- Correct cavus with forefoot supination
* (to correct the forefoot first – it aligns the forefoot with the midfoot) - Correct ADduction using head of talus as a fulcrum
- Correct heel varus using head of talus as a fulcrum
- Correct equines with Achilles lengthening
* Perform once foot in 70ᵒ Abducted and heel in varus
* If unable to dorsiflex 10ᵒ past neutral then need to do a percutaneous achilles tenotomy - Boots – 23hours p/day for first 3 months after correction
- Boots – at night till the age of 4 years
What deformity will reoccur first in clubfoot and how will you manage it?
Reoccurrence is backwards – EVAC
- Equines
- Varus
- ADduction
- Cavus
List 5 risk factors for DDH
Genetics – family history
Coloureds/whites
Girls > Boys
First born
Prolonged labour
Breech babies
Swaddling to extend hips and knees
Which 2 examinations/screening tests would you do for DDH?
Barlow (only < 3 months)
- Test for dislocation
- Flex and ADduct hips, apply light pressure on knees directing force posteriorly
- Positive = Posterior hip dislocation
Ortolani (only for < 3 months)
- Test of reduction
- Lay infant supine, flex hips and knees to 90ᵒ and apply anterior pressure on the greater trochanters using index fingers, then gently ABduct the hips using thumbs
- Positive = Hip reduction
Galeazzi
- Check if knees are at unequal heights when the hips and knee are flexed
- Positive = Dislocated side will be shorter
What are the clinical signs of DDH?
Asymmetrical skin folds
Limited hip ABduction
Pelvic obliquity
Trendenlenburg sign (walking)
Increased lumbar lordosis (walking)
What imaging studies will you do for DDH, when will you do it and what will you see?
U/S
* Done after 6 weeks
X-ray
- After 4 months - Epiphysis is only visible after 4 months after the epiphysis has ossified
- Hip dislocation
- Disruption of shenton’s line
- Femoral head is not inferior to Hilgenreiner’s line
- Femoral head is not medial to Perkin’s line
What is the treatment for DDH?
Pavlik harness
- Birth – 6 months
- Full time wear for atleast 8 weeks (2 + 6 weeks) with U/S every 1-14 days
- Abandon harrnes after 3-4 weeks if not reduced
- If reduced and stable, continue harness for another 6 weeks
- Part-time harness for another 6 weeks after full-time harness
Closed reduction and spica casting
* Worn for 3 months
- Open reduction and spica casting
What are the indications for a closed reduction and spica cast for DDH?
Delayed diagnosis at 6-18months
Failed Pavlik harness
What are the indications for an open reduction and spica cast for DDH?
Delayed diagnosis >18 months
Failed closed reduction and spica casting
What are the complications of DDH?
Joint contractures
AVN of femoral head
Re-dislocation
Early osteoarthritis
Back/knee pain
Define Legg-Calves Perthe’s disease
Idiopathic avascular necrosis of the proximal femoral epiphysis in children
What are the risk factors for Legg-Calves-Perthe’s disease?
Family history
Low birth weight
Abnormal birth presentation – breech
Exposure to second-hand smoke
Asian/central European decent
What are the stages of Legg-Calves-Perthes disease?
Necrotic
- Smaller sclerotic epiphysis
- Medial joint space widening
Fragmentation
* Femoral head appears fragmented/dissolved as a result of bone resorption causing collapse and subsequent increased density
Reossification
*New bone appears
Healing or remodelling
* Femoral head remodelling until skeletal maturity
What are the clinical signs of Legg-Calves-Perthe’s disease?
Painless limp
- Trendelenburg
- Antalgic limp
Intermittent knee, hip, groin or thigh pain
Hip stiffness with loss of internal rotation and ABduction
Limb length discrepancy (Late finding)
What are the early x-ray findings of Legg-calves-perthes disease?
Joint effusion: widening of the medial joint space
Asymmetrical femoral epiphyseal size (smaller on affected side)
Apparent increased density of the femoral head epiphysis
Blurring of the physeal plate (stage 1: see staging of Legg-Calve-Perthes syndrome or Catterall classification)
Radiolucency of the proximal metaphysis
What are the late x-ray findings of Legg-calves-perthes disease?
Femoral head deformity with widening and flattening (coxa plana)
Proximal femoral neck deformity: coxa magna
“Sagging rope sign” (thin sclerotic line running across the femoral neck)
What is the treatment of Legg-Calves=Perthe’s disease?
Conservation management
- Activity restriction
- Partial weight-bearing
- Traction
- Physiotherapy
Surgery - Femoral and/or pelvic osteotomy
- Indications
- > 8 years
- To improve containment of femur head in hip joint
Define SUFE (Slipped Upper Femoral Epiphysis)
A disorder of the proximal femoral physis that leads to slippage of the femoral neck relative to the epiphysis due to mechanical forces of the susceptible physis
What are the clinical findings of SUFE
Acute pain and inability to walk / acute pain > resolves > mild pain with a limp
Groin/thigh pain (sometimes presents as knee pain)
History of minor trauma
Antalgic gait
Atrophy of the thigh
Limb shortened and in external rotation
Externally rotated foot progression angle
Loss of hip internal rotation, ABduction and flexion
Classify SUFE
Stable
- Able to bear weight with/without crutches
- Minimal risk of osteonecrosis
Unstable
- Unable to bear weight
- Ass. with high risk of osteonecrosis (AVN of femoral head)
What are the X-ray findings of SUFE?
Klein’s line will not intersect femoral head
Epiphysiolysis – growth plate widening/lucency
Blurring of proximal femoral metaphysis
What is the treatment for SUFE?
Prevent further slippage
- Strict non-weight bearing
- Place affected limb in skin traction with 1.5kg suspended over a pulley (unstable)
Operative
* Percutaneous in situ fixation
