Paediatric Orthopaedics Flashcards
Pain medication in children
Codeine and tramadol are not used in children as they are unpredicatble in their metabolism
Aspirin is not used in children younger than 16 yo due to Reye’s syndrome
Differentials for a limp
0 - 4 years:
- Transient synovitis
- Septic arthritis
- Developmental dysplasia of the hip
5 - 10 years
- Perthe’s disease
- Transient synovitis
10 - 16 yo
- Juvenile idiopathic arthritis
- Slipper upper femoral epiphysis
Presentation of hip pain
Limp Not bearing weight on affected side Delayed walking Pain Swollen and tender joint
Red flags for hip pain
Children under 3 yo Fever Waking at night with pain Weight loss and anorexia Night sweats Fatigue Persistent pain Stiffness in the morning Swollen or red joint
When to urgently refer a limping child
Children under 3 yo Child > 9 yo with a restricted or painful hip Unable to weight bear Neurovascular compromise Severe pain Suspicion of abuse
Investigations for hip pain
Bloods - CRP, FBC Xray - fracture, SUFE USS - effusion Joint aspiration - sepsis MRI - osteomyelitis
Causative organisms for septic arthritis
Staphylococcus aureus - most common Neiserris gonorrhoea Streptococcus pyogenes Haemophilus influenzae E. Coli
Management of septic arthritis
Antibiotics dependent on joint aspirate culture for 3 - 6 weeks
Surgicsl drainage and washout
Transient synovitis pathophysiology
Inflammation of the synovial membrane associated with a recent viral upper respiratory tract infection
What age range does transients synovitis typically affect
3 - 10 yo
Presentation of transient synovitis
- after viral URTI - coryzal symptoms
- limp
- refusal to weight bear
- joint pain
- low fever
Management of transient synovitis
Exclude septic arthritis
Symptomatic relief - analgesia
Can be managed in primary care if 3 - 9yo and limp present within 48 hours whilst systemically well
Prognosis of transient synovitis
Significant improvement after 24 - 48 hours
Symptoms fully resolve within 1 - 2 weeks without any lasting problems
Perthes disease pathophysiology
Avascular necrosis of the femoral head
Who does perthes disease typically affect?
Children aged 4 - 12 yo
Commonly between 5 - 8 yo boys
Complication of perthes disease
Early osteoarthritis of the the hip
Presentation of perthes disease
Pain in the hip or groin
Limp
Restricted hip movements
Referred pain to the knee
Investigations for perthes disease
Bloods - normal
Technetium bone scan
MRI scan
Management of Perthes disease
Under 6 yo mild to moderate disease - supportive:
- bed rest and analgesia
- traction
- crutches
- physiotherapy
- regular xrays - monitoring
Severe disease > 6yo - surgery
Slipper upper femoral epiphysis pathophysiology
Head of the femur is dispaced along the growth plate
Who does SUFE typically affect
Obese boys aged 8 - 15yo
Presentation of SUFE
- hip, groin, thigh or knee pain
- restricted hip movement - inability to internally rotate
- painful limp
Investigations for SUFE
Bloods - usually normal
Technetium bone scan
CT scan
MRI scan
Management of SUFE
Surgery - cannulated screws
Pathophysiology of osteomyelitis
Infection of the bone or bone marrow
Causative organism of osteomyelitis
Staphylococcus aureus
Risk factors for osteomyelitis
- open bone fracture
- orthopaedic surgery
- immunocompromised
- sickle cell anaemia - salmonella
- HIV
- TB
Presentation of osteomyelitis
Painful limp Refusal to weight bear Pain Swelling Tenderness May have fever if acute
Investigations for osteomyelitis
Joint xray - may be normal MRI - gold standard Bone scan Bloods - FBC, CRP Blood culture Bone marrow aspiration or bone biopsy
Management of osteomyelitis
Antibiotics - flucloxacillin
Surgical drainage and debridement
Features of osteosarcoma
- typically affects 10 - 20 yo
- commonly affects the femur, tibia and humerus
Presentation of osteosarcoma
Persistent bone pain
Particularly worse at night
Bone swelling - palpable mass
Restricted joint movements
Investigations for osteosarcoma
- urgent direct access xray within 48 hours of unexplained bone pain or swelling
- bloods - ALP
- Staging CT scan
- PET or bone scan
- Bone biopsy
Signs of osteosarcoma on xray
Sun burst appearance - fluffy due to periosteal reaction
Management of osteosarcoma
Surgical resection
Adjuvant chemotherapy
MDT
Developmental hip dysplasia pathophysiology
Structural abnormality of the hips causing instability and an increased tendency to sublux or dislocate as well as an abnormal gait and weakness
Risk factors for developmental hip dysplasia
- Family history
- breech presentation
- multiple pregancy
DDH screening
USS scan of hip if risk factors present
Neonatal exam - ortalani and barlow tests
Signs of DDH
Different leg lengths
Restricted hip abduction either unilateral or bilateral
Difference in knee level when hips are flexed
Clunking during the Ortolani and Barlow test
Ortolani test
Dislocate anteriorly whilst hips and knees are flexed by abducting
Barlow test
Whilst hips are adducted and flexed at 90 degrees. Gentle downwards pressure to see if hip dislocates posteriorly
Investigation for DDH
USS of hip
Management of DDH
Pavlik harness for 6 - 8 weeks - < 6 months yo
Surgery if > 6 months with hip spica cast
Pathophysiology of rickets
Defective bone mineralisation causing soft bones due to a vitamin D or calcium deficiency
Calcium deficiency stimulates parathyroid hormone which stimulates bone resorption
Presentation of rickets
Lethargy Bone pain Swollen wrists Bone deformity Poor growth Dental problems Pathological fractures
Bone deformities in rickets
Bowing of the legs - valgus deformity
Knock knees - varus deformity
Rachitic rosary - lumps along the chest where ribs expand at the costochondral junctions
Craniotabes - soft skull, frontal bossing and delayed closure of the sutures
Delayed teeth
Risk factors for rickets
Darker skin Low exposure to sun light - muslim women Live in colder climates Indoors CKD
Investigations of rickets
Bloods - vitamin D, calcium, PTH, ALP, phosphate, FBC, CRP, LFTs, U+Es, TFTs
Anti TTG - coeliacs (malabsorption)
Autoimmune and rheumatoid tests
Xray
Management of rickets
Vitamin D and calcium supplements
Osgood schlatters disease pathophysiology
Inflammation of the tibial tuberosity where the patella ligament inserts due to multiple small avulsion fractures
Who typically gets Osgood schlatters disease
10 - 15 year old boys
Presentation of Osgood Schlatters disease
Normally unilateral anterior knee pain
Pain exacerbated by activity
Visible lump below the knee - hard and non tender (initially may be tender)
Managament of Osgood schlatters
- reduce physical activity
- RICE
- NSAIDs
Stretching and physiotherapy
