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Orthopaedic Surgery > Paediatric Orthopaedic Surgery > Flashcards

Paediatric Orthopaedic Surgery Flashcards

1
Q

Describe the clinical deformities of the foot

A

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)

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2
Q

What is the scientific name for club foot?

A

Congenital talipes equinovarus

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3
Q

Describe the principles of serial correction and maintenance of correction of this foot according to today’s current gold standard of treatment

A

Ponseti method (1 week serial castings)

  1. Correct cavus with forefoot supination
    * (to correct the forefoot first – it aligns the forefoot with the midfoot)
  2. Correct ADduction using head of talus as a fulcrum
  3. Correct heel varus using head of talus as a fulcrum
  4. 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
  5. Boots – 23hours p/day for first 3 months after correction
  6. Boots – at night till the age of 4 years
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4
Q

What deformity will reoccur first in clubfoot and how will you manage it?

A

Reoccurrence is backwards – EVAC

  1. Equines
  2. Varus
  3. ADduction
  4. Cavus
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5
Q

List 5 risk factors for DDH

A

Genetics – family history

Coloureds/whites

Girls > Boys

First born

Prolonged labour

Breech babies

Swaddling to extend hips and knees

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6
Q

Which 2 examinations/screening tests would you do for DDH?

A

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
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7
Q

What are the clinical signs of DDH?

A

Asymmetrical skin folds

Limited hip ABduction

Pelvic obliquity

Trendenlenburg sign (walking)

Increased lumbar lordosis (walking)

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8
Q

What imaging studies will you do for DDH, when will you do it and what will you see?

A

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
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9
Q

What is the treatment for DDH?

A

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
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10
Q

What are the indications for a closed reduction and spica cast for DDH?

A

Delayed diagnosis at 6-18months

Failed Pavlik harness

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11
Q

What are the indications for an open reduction and spica cast for DDH?

A

Delayed diagnosis >18 months

Failed closed reduction and spica casting

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12
Q

What are the complications of DDH?

A

Joint contractures

AVN of femoral head

Re-dislocation

Early osteoarthritis

Back/knee pain

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13
Q

Define Legg-Calves Perthe’s disease

A

Idiopathic avascular necrosis of the proximal femoral epiphysis in children

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14
Q

What are the risk factors for Legg-Calves-Perthe’s disease?

A

Family history

Low birth weight

Abnormal birth presentation – breech

Exposure to second-hand smoke

Asian/central European decent

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15
Q

What are the stages of Legg-Calves-Perthes disease?

A

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

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16
Q

What are the clinical signs of Legg-Calves-Perthe’s disease?

A

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)

17
Q

What are the early x-ray findings of Legg-calves-perthes disease?

A

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

18
Q

What are the late x-ray findings of Legg-calves-perthes disease?

A

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)

19
Q

What is the treatment of Legg-Calves=Perthe’s disease?

A

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
20
Q

Define SUFE (Slipped Upper Femoral Epiphysis)

A

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

21
Q

What are the clinical findings of SUFE

A

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

22
Q

Classify SUFE

A

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)
23
Q

What are the X-ray findings of SUFE?

A

Klein’s line will not intersect femoral head

Epiphysiolysis – growth plate widening/lucency

Blurring of proximal femoral metaphysis

24
Q

What is the treatment for SUFE?

A

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

25
Q

What are the complications of SUFE

A

AVN of femoral head

Loss of cartilage of femoral head (Chondrolysis)

Residula proximal femur deformity and limb length discrepancy

Slip progression

Hip stiffness

Degenerative arthritis

Pin associated proximal femur fracture

26
Q

At what age can you give consent?

A

Medical treatment
* A child older than 12 may consent to medical treatment WITHOUT the assent of the parent/guardian

Surgical treatment
* A child older than 12 may consent to medical treatment WITH the assent of the parent/guardian

27
Q

What are the 4 elements of consent?

A

Step 1: Threshold
* Assessment of patients decisonal capacity

Step 2: Informational elements

  • Describe intervention
  • Risks, Benefits and Complications
  • Does the patient understand?

Step 3: Consent elements
* The patients decision

Step 4: Confirmation elements
* Remind that consent can be withdrawn

Orthopaedic Surgery (3 decks)

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