paediatric orthopaedics Flashcards
what happens to displacement as GMFCS increases
displacement levels increase
how big is a problematic curve in scoliosis
> 40 degrees before 15yrs
what is spinal fusion
Spinal fusion is surgery to permanently connect two or more vertebrae in your spine
-done if curve is greater than 45 degrees
-T2 to pelvis
early adolescence
-to protect respiratory function
what happens during ambulation
muscles provide the required force of motion
problems from cerebral palsy
- primary - injury to CNS
- secondary from growth
- tertiary - coping responses
aims for cerebral palsy
- pain free hips in joints
- spine fused or mild scoliosis
- tone well managed
- good seating
- full support measures in place
- independence maximised
problems with tip toe walking
- CNS
- PNS
- muscle
- idiopathic
what is club foot
congenital deformity of foot due to in utero abnormal alignment of joint between talus, calcaneous and navicular
treatment for club foot
Ponseti method
-once alignment acheived, child placed in boots attached to a pole to keep boots apart
what can club foot cause
- ankle equinus
- supination of forefoot
- varus alignment of forefoot
do growing pains cause limp
no
red flags of leg pain
- asymmetry
- good localisation
- short history
- persisting limp
- not thriving
- pain worsening
features of anterior knee pain
- adolescent
- localised patellar tenderness
- stairs/squats
- radiographs
- examine hips
- treatment is physio
what can large scoliosis do to lungs
cause a restrictive lung disease
sign of dislocated hip in babies
- asymmetry
- loss of knee height
- crease asymmetry
- less abduction in flexion
treatment for early DDH
pavlik harness
what are the two types of bone formation
intramembranous ossification and intracartilage ossification
what happens in intramembranous ossification
occurs in mesenchyme that has formed a membranous sheath
what happens in intracartilaginous ossification
ossification that occurs in a pre-existing cartilaginous model
- primary ossification centre
- secondary ossification centre
when do joints form in feotus?
6-8 weeks
how do fibrous joints form
interzonal mesenchyme between 2 bones differentiates to fibrous tissue
how do cartilaginous joints form
interzonal mesenchyme differentiates into hyaline cartilage or fibrocartilage
how do synovial joints form
what are the four types of dysplasias
- chondrodysplasia
- tumour-like conditions
- altered bone density
- storage disorders
what classification is used for growth plate fractures
salter-harris fractures
causes of growth plate arrest
- trauma
- infection
- tumour
- irradiation
- surgery
- compression
is valgus inwards or outwards
inwards
is varus inwards or outwards
outwards
what are some disorders of growth
- growth plate injury
- growth plate over stimulation
- lack of nutrition
- vitamin definition
- skeletal deficiency
- hormonal
how can we asses growth
- 2nd birthday
- menelaus
- moseley charts
- lower limbs
- bone age
what are the three zones of the physes
hypertrophic
proliferative
resever
how do bones grow
from the physes - increase in length
periosteum - increase in width
what is swanson’s classification
- failure of formation
- failure of separation
- hypoplasia
- overgrowth
- duplication
- constriction ring syndromes
- skeletal dysplasia
what are the three stages of limb bud rotation
mid-axial
pre-axial
post-axial
when is the cartilaginous stage of vertebral development
6th week
when do mesenchymal bones form
4-5 weeks - LIMB BUDS
what is Perthe’s disease
avascular necrosis/compression osteochondritis of hip
pathophysiology of Perthe’s disease
femoral head transiently loses blood supply resulting in necrosis with subsequent abnormal growth
causes of Perthe’s disease
- positive family history
- low birth weight
- second hand smoke
- asian, Inuit and central european descent
symptoms of Perthe’s disease
- pain and limp
- mostly unilateral
- if bilateral then underlying skeletal dysplasia or thrombophilia
- loss of internal rotation followed by loss of abduction
- later there will be positive trendellenburg fro. gluteal weakness
investigations for Perthe’s disease
radiographs and MRI’s
treatment for Perthe’s disease
no specific treatment other than regular x-ray observation and avoidance of physical activity
what is developmental dysplasia of hip (DDH)
a disorder of abnormal development resulting in dysplasia and possible subluxation or dislocation of hip secondary to capsular laxity and mechanical factors
risk factors for DDH
- positive family history
- breech presentation
- first born
- down’s syndrome
- presence of other congenital disorders
symptoms of DDH
- shortening
- asymmetric groin
- thigh skin creases
- clink or clunk on Ortolani or Barlow manoeuvres
- limping
symptoms of DDH
- shortening
- asymmetric groin
- thigh skin creases
- clink or clunk on Ortolani or Barlow manoeuvres
- limping
treatment for DDH
- mild cases = closely observed to ensure hip remains reduced
- dislocated or persistently unstable = palvik harness
- persistent dislocation over 18 months or presents late = surgery
complications of DDH
- over flexing and abducting hip can cause AVN
- persistent DDH poorer prognosis as acetabulum very shallow and in more severe cases false acetabulum occurs proximal to original one with shortened lower limb
- severe arthritis
what is slipped upper femoral epiphysis
condition which mainly affects overweight pre-pubertal adolescent boys where femoral head epiphysis slips inferiorly in relation to femoral neck
what are causes of SUFE
- hypothyroidism
- renal disease
- growth plate not strong enough to support weight
- growth plate may preclude onset and puberty may be delayed
symptoms of SUFE
- pain and limp
- externally rotated foot
- pain in groin
- pain in knee
- loss of internal rotation of hip
treatment for SUFE
urgent surgery to pin femoral head to prevent further slippage
- percutaneous pinning of hip
- +/- pinning of other side
- +/- open reduction of very severe slip
what is transient synovitis of the hip
self-limiting inflammation of synovium of joint
what commonly causes transient synovitis of hip
an upper respiratory tract infection
symptoms of transient synovitis of hip
- lump or reluctance to weight bear
- may have referred pain to knee
- hip lying flexed
- range of motion restricted
treatment of transient synovitis
NSAIDs
-pain usually resolves in a few weeks
what is osteogenesis imperfect
defect of the maturation and organization of type 1 collagen
what are the bones like in osteogenesis imperfecta
thin with thin cortices and osetopenic
symptoms of osteogenesis imperfecta
- multiple fragility fractures
- short stature with multiple deformities
- blue sclerae
- loss of hearing
what is skeletal dysplasias
short stature (dwarfism is no longer used) and is due to genetic error (hereditary or sporadic mutation) resulting in abnormal development of bone and connective tissue
what is the commonest type of skeletal dysplasia
achondroplasia
what is marfan’s syndrome
Marfan’s syndrome is an autosomal dominant or sporadic mutation of the fibrillin gene resulting in tall stature with disproportionately long limbs and ligamentous laxity
symptoms of Marfan’s
-high arched palate
-scoliosis
-flattening of the chest
-eye problems
-aortic aneurysm
-cardiac valve incompetence
-
what is Ehlers-Danlos syndrome
abnormal elastin and collagen formation
msk features of down syndrome
- short stature
- joint laxity
- possible recurrent dislocation
- atalnto-axial instability in the c-spine my occur
what is Duchenne muscular dystrophy
A defect in the dystrophin gene involved in calcium transport results in muscle weakness which may only be noticed when the boy starts to walk with difficulty standing
presentation of duchenne muscular dystrophy
can’t walk by age of 10 then usually death by age of 20 because of cardiac and resp problems
causes of cerebral palsy
- genetics
- brain malformation
- intrauterine infection
- prematurity
- intra-cranial haemorrhage
- hypoxia during birth
- meningitis
what is the commonest expression of cerebral palsy
spastic cp
how does spastic CP happen
injury to the motor cortex, upper motor neurons or corticospinal tract
msk problems with CP
- joint contractures
- scoliosis
- hip dislocation
non-surgical treatment for CP
- physio
- splintage
- baclofen
- botox
surgical treatment for CP
- hip excision or replacement
- surgical release of joint contractures
- correction of severe scoliosis
- joint fusions
- tendon transfers
what is spinal bifida
Spina bifida is a congenital disorder where the two halves of the posterior vertebral arch fail to fuse, probably in the first six weeks of gestation.
orthopaedic management for spinal bifida
- scoliosis correction
- reduction and containment procedures for the hip
- contracture released
- correction of foot deformities
examples of limb malformations
- extra bones
- absent bones
- short bones
- fusions of bone and/or skin and soft tissue
what is syndactyly
the commonest congenital malformation of the limbs where two digits are fused due to failure of separation of the skin/soft tissues or phalanges of adjacent digits either partially or along the entire length of the digits
what is polydactyly
where an extra digit is formed
what is fibular hemimelia
partial or complete absence of the lateral foot rays leading to a shortened limb, bowing of the tibia and ankle deformity
what is Erb’s palsy
injury to the upper nerve roots resulting in loss of motor innervation of the deltoid, supraspinatus, biceps and brachilais muscles
what causes genu varum
a growth disorder of the medial proximal tibial physis known as Blount’s disease resulting in marked and persisting (beyond 4‐5 years) varus deformity
causes of genu valgum
- rickets
- tumours
- trauma
- neurofibromatosis
what is developmental dysplasia of the hip (DDH)?
dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint.
risk factors for DDH
- family history
- breech presentation
- first born babies
- down’s syndrome
signs of DDH
- shortening
- asymmetric groin/thigh skin creases
- click or clunk on the Ortolani or Barlow manoeuvres
who gets slipped upper femoral epiphysis
overweight pre-pubertal adolescent boys
what happens in SUFE
the growth plate is not strong enough to support body weight and the femoral epiphysis slips due to the strain
treatment of SUFE
-urgent surgery to pin the femoral head to prevent further slippage
