paediatric orthopaedics Flashcards
1
Q
What are the main causes of hip pain in 0-4 years?
A
Septic arthritis
Developmental dysplasia of the hip (DDH)
Transient sinovitis
2
Q
What are the main causes of hip pain in 5-10 years?
A
Septic arthritis
Transient sinovitis
Perthes disease
3
Q
What are the main causes of hip pain in 10-16 years?
A
Septic arthritis
Slipped upper femoral epiphysis (SUFE)
Juvenile idiopathic arthritis
4
Q
What conditions are you looking for when doing blood tests for hip pain?
A
inflammatory markers (CRP and ESR) for JIA and septic arthritis
5
Q
What conditions are you looking for when you do X-rays for hip pain?
A
fractures, SUFE and other boney pathology
6
Q
What are you looking for when you do an ultrasound in someone with hip pain?
A
effusion (fluid) in the joint
7
Q
What condition are you looking for when you do joint aspiration for hip pain?
A
septic arthritis
8
Q
What condition are you looking for when you do an MRI for hip pain?
A
osteomyelitis
9
Q
What might hip pain in a child present with?
A
Limp
Refusal to use the affected leg
Refusal to weight bare
Inability to walk
Pain
Swollen or tender joint
10
Q
What are the red flags for hip pain?
A
Child under 3 years
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen or red joint
11
Q
What are the criteria for urgent referral for assessment in a limping child?
A
Child under 3 years
Child older than 9 with a restricted or painful hip
Not able to weight bare
Evidence of neurovascular compromise
Severe pain or agitation
Red flags for serious pathology
suspicion of abuse
12
Q
What is another name for growth plates?
A
Epiphyseal plates
13
Q
In whom are growth plates found?
A
Bones of children, not adults
14
Q
What are growth plates made of?
A
Hyaline cartilage
15
Q
Where do growth plates sit?
A
Between the epiphysis and metaphysis
16
Q
What do growth plates become when they fuse in teenage years?
A
Epiphyseal lines
17
Q
What is cancellous bone?
A
spongy, highly vascular bone in the centre of long bones.
18
Q
What is cortical bone?
A
compact, hard bone around the outside
19
Q
Do children have more cancellous or cortical bone?
A
Cancellous which makes children’s bones more flexible but less strong
20
Q
Are children more likely to get fractures or breaks?
A
Fractures
21
Q
What fractures are children more likely to get?
A
Greenstick fractures and buckle fractures
22
Q
What is a greenstick fracture?
A
where only one side of the bone breaks whilst the other side of the bone stays intact
23
Q
What are the different types of fractures?
A
Buckle (torus)
Transverse
Oblique
Spiral
Segmental
Salter-Harris (growth plate fracture)
Comminuted
Greenstick
24
Q
How are growth plate fractures classified?
A
Salter-Harris classification
25
What is the pneumonic to remember the types of growth plate fractures?
SALTR
26
What are the types of growth plate fractures?
Type 1: Straight across
Type 2: Above
Type 3: BeLow
Type 4: Through
Type 5: CRush
27
What are the two ways to achieve mechanical alignment of a fracture?
Closed reduction via manipulation of the joint
Open reduction via surgery
28
What are the ways to provide relative stability of a fracture?
External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate and screws
29
What is the pain management ladder for children?
Step 1: Paracetamol or ibuprofen
Step 2: Morphine
30
What pain medications are not used in children?
Codeine and tramadol
31
Why are codeine and tramadol not used in children?
there is unpredictability in their metabolism, so the effects vary too greatly to make them safe and effective options.
32
Why is aspirin not used in children under 16 years old?
due to the risk of Reye’s syndrome
33
When is aspirin sometimes used in children under 16 years old?
In kawasaki disease
34
In what age is septic arthritis most common in children?
Under 4 years old
35
What is septic arthritis a common complication of?
Joint replacement- occurs in around 1% of straight forward hip or knee replacements
36
How many joints does septic arthritis tend to affect?
only one joint normally
37
What organism is the most common cause of septic arthritis?
Staphylococcus aureus
38
What organisms can cause septic arthritis apart from staph aureus?
Neisseria gonorrhoea (gonococcus) in sexually active teenagers
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
Escherichia coli (E. coli)
39
What is the presentation of septic arthritis?
Rapid onset of:
Hot, swollen and painful joint
Refusing to weight bare
stiffness and reduced range of motion
systemic symptoms such as fever, lethargy an sepsis
40
What are the differential diagnosis for septic arthritis?
Transient sinovitis
Perthes disease
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis
41
What is the sample from joint aspiration sent for if concerned about septic arthritis?
gram staining, crystal microscopy, culture and antibiotic sensitivities
42
How long are antibiotics usually given for in septic arthritis?
3 to 6 weeks- given empirically
43
What is transient synovitis also known as?
Irritable hip
44
What is transient synovitis caused by?
temporary (transient) irritation and inflammation in the synovial membrane of the joint (synovitis)
45
What is the most common cause of hip pain in 3-10 year olds?
Transient synovitis
46
What is transient synovitis associated with?
Viral upper respiratory tract infection
47
What is the difference in presentation of septic arthritis and transient synovitis?
Children with transient synovitis typically do not have fever
48
What is the presentation of transient synovitis?
Limp
Refusal to weight bare
Groin or hip pain
Mid low grade temperature
Otherwise well
49
How long does it take transient synovitis to fully resolve?
1-2 weeks
50
In what percentage does transient synovitis tend to reoccur?
20%
51
What is the management for transient synovitis?
simple analgesia
52
What is Perthes disease?
Disruption of blood flow to the femoral head, causing avascular necrosis of the bone
53
What part of the femur does perthes disease affect?
The epiphysis of the femur which is the bone distal to the growth plate (physis)
54
What is the full name of perthes disease?
Legg-Calvé-Perthes disease
55
In whom does perthes disease most commonly occur in?
children aged 4 – 12 years, mostly between 5 – 8 years, and is more common in boys
56
What is the main cause of perthes disease?
It is idiopathic
57
What is the main complication of perthes disease?
Revascularisation or neovascularisation, there is remodelling of the bone as it heals. Soft and deformed femoral head, leading to early hip osteoarthritis
58
what is the onset like of perthes disease?
Slow
59
What is the presentation of Perthes disease?
Pain in the hip or groin
Limp
Restricted hip movements
There may be referred pain to the knee
No history of trauma
60
If a child has pain triggered by minor trauma what condition should you think of instead of perthes disease?
slipped upper femoral epiphysis
61
What is the initial investigation for perthes disease?
X-ray although this is often normal
62
Other than xray, what investigations can be done for Perthes disease?
Blood tests are typically normal
Technetium bone scan
MRI scan
63
What is the management for Perthes disease?
Bed rest
traction
crutches
analgesia
Physiotherapy
Regular xrays to assess healing
64
What is slipped upper femoral epiphysis also known as?
Slipped capital femoral epiphysis
65
What is slipped upper femoral epiphysis?
where the head of the femur is displaced along the growth plate
66
Who is slipped upper femoral epiphysis (SUFE) more common in?
boys and typically presents aged 8-15 years- average of 12. Presents slightly earlier in females- average age 11 years. More common in obese children
67
What is the typical presentation of SUFE?
Adolescent, obese male undergoing a growth spurt. Mya be a history of minor trauma
Hip, groin, thigh or knee pain
Restricted range of hip movement
Painful limp
Restricted movement in the hip
68
How will children with SUFE prefer to keep their hip?
In external rotation- limited movement, especially restricted internal rotation
69
What is the investigation of choice for SUFE?
Xray
70
What investigations can be helpful for SUFE?
Blood tests are normal
Technetium bone scan
CT
MRI
71
What is the management for SUFE?
Surgery
72
What is osteomyelitis?
Infection in the bone and bone marrow
73
Where does osteomyelitis typically occur?
metaphysis f the long bones
74
What is the most common bacteria in osteomyelitis?
Staphylococcus aureus
75
What is the difference between chronic and acute osteomyelitis?
Chronic is deep seated and slow growing whereas acute presents more quickly with an acutely unwell child
76
What are the RFs for osteomyelitis?
More common in boys under 10 years
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
Tuberculosis
77
What are the presentations of osteomyelitis?
Refusing to use the limb or weight bear
Pain
Swelling
Tenderness
Can present with acutely unwell child or more chronic with subtle features
78
What is often the initial investigation in osteomyelitis?
Xray but can be normal
79
What is the best diagnosis for osteomyelitis?
MRI
80
What will blood tests show in osteomyelitis?
Inflammatory markers (CRP and ESR) and white blood cells
81
What is the management for osteomyelitis?
Antibiotics
May require drainage and debridement
82
Who does osteosarcoma usually present in?
adolescents 10 to 20 years
83
What is the most common bone and other two sites that osteosarcoma presents?
Femur
Tibia and humerus
84
What is the main presentation of osteosarcoma?
Persistent bone pain, particularly worse at night time
Other symptoms may be bone swelling, a palpable mass and restricted joint movements
85
What will an xray show in osteosarcoma?
poorly defined lesion in the bone with destruction of the normal bone and a fluffy appearance. Periosteal reaction (irritation of the lining of the bone) described as a sunburst appearance. There can be associated soft tissue mass
86
What might blood tests show in osteosarcoma?
alkaline phosphatase (ALP)
87
What further investigations are used for osteosarcoma?
CT scan
MRI
Bone scan
PET scan
Bone Biopsy
88
What is the management for osteosarcoma?
surgical resection often with limb amputation
Adjuvant chemotherapy
89
What are the main complications of osteosarcoma?
Pathological bone fractures and metastasis
90
What is talipes?
fixed abnormal ankle position that presents at birth
91
What is talipes also known as?
clubfoot
92
What is talipes equinovarus?
Ankle in plantar flexion and supination
93
What is talipes calcaneovalgus?
dorsiflexion and pronation
94
What is talipes treated with?
Ponseti method or surgery if this fails
95
What is the Ponseti method?
Foot is manipulated towards a normal position and cast holds it in place. And repeated. Achilles tenotomy releases tension in the achilles tendon. Brace holds it in place when not walking until the child is around 4 years old. (Boots and bars)
96
What is positional talipes?
Common condition where the resting position of the ankle is in plantar flexion and supination however not fixed and no structural issues
97
What is developmental dysplasia of the hip? (DDH)
structural abnormality in the hips caused by development of the fetal bones in pregnancy. This leads to instability in the hips and a tendancy or potential to persist into adulthood
98
What can DDH cause in adulthood?
weakness, recurrent sublaxation or dislocation, an abnormal gait and early degenerative changes
99
What re the RF for DDH?
First degree family history
Breech presentation from 36 weeks onwards
Breech presentation at birth if 28 weeks onwards
Multiple pregnancy
100
What findings on a NIPE suggest DDH?
Different leg lengths
Restricted hip abduction on one side
Significant bilateral restriction in abduction
Difference in the knee level when the hips are flexed
Clunking of the hips on special tests
101
What are the two special tests for DDH?
Ortolani test
Barlow test
102
What is the ortolani test?
done with the baby on their back with the hips and knees flexed. Palms are placed on the baby’s knees with thumbs on the inner thigh and four fingers on the outer thigh. Gentle pressure is used to abduct the hips and apply pressure behind the legs with the fingers to see if the hips will dislocate anteriorly.
103
What is the Barlow test?
done with the baby on their back with the hips adducted and flexed at 90 degrees and knees bent at 90 degrees. Gentle downward pressure is placed on knees through femur to see if the femoral head will dislocate posteriorly.
104
What is the difference between clicking and clunking on NIPE test?
common examination finding and is usually due to soft tissue moving over bone. When this is the cause an ultrasound will be normal. Isolated clicking without any other features does not usually require an ultrasound unless there are other concerns. Clunking is more likely to indicate DDH and requires an ultrasound.
105
What is the investigation of choice for DDH?
Ultrasound
106
What is the management for DDH?
Pavlik harness if less than 6 months of age- aim is to hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop normally. Keeps hips flexed and abducted
Surgery required if harness fails or diagnosis after 6months.
Hip sica cast used to immobilise hip after surgery
107
What is rickets?
condition affecting children where there is defective bone mineralisation causing soft and deformed bones
108
In adults, what is rickets called?
osteomalacia
109
What is the cause of rickets?
deficiency in vitamin D or calcium
110
What is the rare form of rickets?
hereditary hypophosphataemic rickets- most common form is x-linked dominant
111
How is vitamin D created?
From cholesterol by the skin in response to UV radiation
112
Who are more likely to have vitamin d deficiency?
people with malabsorption disorders
people with CKD- kidneys are essential metabolising vitamin d
113
What is vitamin D needed for?
Essential in calcium and phosphate absorption from the intestines and kidneys
needed for regulating bone turnover and promoting bone reabsorption to boost serum calcium level
114
What does low calcium cause?
secondary hyperparathyroidism as the parathyroid gland tries to raise the calcium level by secreting parathyroid hormone which stimulates increased reabsorption of calcium from the bones
115
What is the presentation of rickets if symptomatic?
Lethargy
Bone pain
Swollen wrists
Bone deformity
Poor growth
Dental problems
Muscle weakness
Pathological or abnormal fractures
116
What bone deformities may be found in rickets?
Bowing of the knees
Knock knees
Rachitic rosary- where the ends of the ribs expand at the costochondral junctions
Craniotabes
Delayed teeth
117
What is the laboratory investigation for vitamin D?
Serum 25-hydroxyvitamin D
118
What serum 25-hydroxyvitamin D level establishes a diagnosis of vitamin D deficiency?
less than 25 nmol/L
119
What investigation is required to diagnose rickets?
X-ray- may also show osteopenia
120
What other signs may be seen on bloods for rickets?
Serum calcium may be low
Serum phosphate may be low
Serum alkaline phosphatase may be high
Parathyroid hormone may be high
121
When looking for rickets, what investigations may help to look for other pathology?
FBC and ferritin for iron deficiency anaemia
Inflammatory markers such as ESR and CRP
Kidney function tests for kidney disease
Liver function tests for liver pathology
Thyroid function tests for hypothyroidism
Malabsorption screen such as anti-TTG antibodies for coeliac disease
Autoimmune and rheumatoid tests for inflammatory autoimmune conditions
122
What is the prevention for rickets?
Fortified breast milk as opposed to breast fed
Breastfeeding women and all children should take vitamin D deficiency
123
What is the management of vitamin D deficiency in children?
ergocalciferol- vitamin D and calcium
124
What is the vitamin D dose for children between 6 months and 12 years?
6,000 IU per day for 8-12 weeks
125
What is achondroplasia?
most common cause of disproportionate short stature (dwarfism). It is a type of skeletal dysplasia
126
What is the achondroplasia gene and where is it found?
fibroblast growth factor receptor 3 on chromosome 4
127
How does achondroplasia occur?
results from sporadic mutation or inheritance of an abnormal copy of the gene. homozygous gene mutations is fatal in the neonatal period therefore patients with achondroplasia have one normal and one abnormal gene
128
How do achondroplasia mutations lead to dwarfism?
mutations in the FGFR3 causes abnormal function of the epiphyseal plates. This restricts the bone growth in length, leading to short bones and short stature
129
What is the average height of those with dwarfism and which bones are most affected?
4 feet- femur and humerus are more affected than forearm and lower leg, patients have a normal trunk
130
