paediatric orthopaedics

Question 1

talipes equino varus

Answer 1

clubfoot
foot points downards and inwards
can be corrected by splintage or is neurological or skeletal so cant
series of casts
percutaneous tenotomy of achilles tendon- 90% will need this

Question 2

MSK issues that cause concern

Answer 2

in toed gait
bow legs
flat feet
curly toes
late walkers

Question 3

how to check in toeing

Answer 3

gait angle
forefoot alignment
thigh foot angle (lies on front and look arial view when bent knee)
hip rotation
86% reassured at first visit, never operate before 10 years

Question 4

internal tibial torsion

Answer 4

increased thigh foot angle
90% resolve
no role for splints or physio etc

Question 5

metatarsus adductus

Answer 5

90% resolve by 1 year
5% persist to adulthood
toes point in

Question 6

normal physiological shape of legs

Answer 6

babies start off varus legs
then straight
then valgus
then straight
people concerned but reassure normal

Question 7

flat feet

Answer 7

normal at birth diminishes with age
jacks test lift toe up heel turns into varus
insoles no benefit

Question 8

curly toes

Answer 8

strong fam history
tightness in flexor tendons
mostly cosmetic problem
if functional problem consider flexor tenotomy if over 6 years

Question 9

walking age mean

Answer 9

12 months. 50% take longer than mean. beyond 18 months refer

Question 10

developmental dysplasia of hip

Answer 10

structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy
instability in the hips and a tendency or potential for subluxation or dislocation
can persist into adulthood

Question 11

the big 3

Answer 11

developmental dysplasia of hip DDH
slipped upper femoral epiphysis SUFE
perthes disease

Question 12

DDH signs

Answer 12

picked up during the newborn examinations or later when the child presents with hip asymmetry
Ortolani test
Barlow test
clunking
reduced range of movement in the hip
limp.
short femur
hamstring test

Question 13

DDH epidemiology

Answer 13

common in inuits
eastern europe
not african
commoner in girls
left hip commoner

Question 14

risk factors DDh

Answer 14

first born
breech
family history
increased weight

Question 15

DDH investiagtions

Answer 15

ultrasound gold standard
xrays also

Question 16

management DDH

Answer 16

pavlik harness if less than 3 months. permanent for 6-8 weeks
surgery if fail or if post 3 months of age then hip spica cast to immobilise
over age 6 and bilateral leave alone.
over aged 10 and unilateral leave alone
older child the poorer the results

Question 17

perthes disease

Answer 17

idiopathic disruption of blood flow to the femoral head, causing avascular necrosis of the bone. affects the epiphyses of the femur
children aged 4-12 years
more common in boys

Question 18

presentation perthes disease

Answer 18

short stature
pain in hip or groin
limp (random and sudden)
knee pain on exercise (referred)
stiff hip joint
systemically well
no history of trauma
familial tendency

Question 19

investigations

Answer 19

xray
blood tests normal
technitium bone scan

Question 20

prognosis perthes

Answer 20

younger do better
proportion of head involved- herring A B and C shows level of collapse, C being worst

Question 21

treatment perthes

Answer 21

maintain hip motion with physio
analgesia
restrict painful activities
regular x rays to assess
supervised neglect- improve in 2-3 years
osteotomy in selected groups of older children
if bilateral consider other conditions but 10% can be

Question 22

slipped upper femoral epiphysis

Answer 22

head of the femur is displaced (“slips”) along the growth plate
more common in boys
aged 8 – 15 years
more common in obese children.

Question 23

presentation SUFE

Answer 23

adolescent, obese male undergoing a growth spurt
may be a history of minor trauma trigger
pain disproportionate to the severity of the trauma
relieved on rest
painful to weight bear

vague symptoms- hip, groin, thigh, knee, painful limp, restricted movement in hip
hip in external rotation
reduced internal rotation esp in flexion painful to try
plain x rays- trethowans sign helps to show. ice cream falling off its cone

Question 24

classification of SUFE

Answer 24

acute- 3 weeks
chronic- beyond
magnitude of slip
stable v unstable - weight bearing

Question 25

management in SUFE

Answer 25

surgery to return femoral head to correct position and fix it in place to prevent slipping further
stable- usually pinned in situ
unstable- open reduction but avascular necrosis risk

Question 26

limping infant 1-3 years common causes

Answer 26

septic arthritis
fracture
DDH

Question 27

limping child 4-10 years common causes

Answer 27

transient synovitis
perthes
JIA

Question 28

limping child more than 10 common causes

Answer 28

SUFE
spondylolisthesis
overuse

Question 29

gowers sign positive

Answer 29

check creatinine kinase as muscular dystrophy

Question 30

infection- limp

Answer 30

SA wont walk
OM can
TS will walk
pain in SA and OM
recent URTI /ear infection- TS
general malaise- OM SM

Question 31

septic arthritis

Answer 31

> 38degrees
no weight bearing
12000/ml WBC
40mm/hr
CRP >30
surgery is treatment
empirical antibiotics

Question 32

transient synovitis

Answer 32

diagnosis of exclusion
spectrum of severity
history of viral infection
low CRP and normal WBC excludes sepsis
not that unwell
limping

Question 33

complex exceptional needs defined

Answer 33

severe impairment in at least 4 categories with enteral or parenteral feeding
or
severe impairment in at least 2 categories and ventilation/CPAP
AND
sustained for more then 6 months and ongoing

Question 34

examples of complex needs

Answer 34

spina bifida
syndromes
cerebral palsy
muscular dystrophy
neurofibromatosis

Question 35

Cerebral palsy

Answer 35

permanent and non progressive motor disorder due to brain damage before birth or during first 2 years of life
causes can be prenatal, perinatal or postnatal
can be spastic, athetoid, ataxia, mixed

Question 36

gross motor function classification system

Answer 36

1- walks without limits
2- walk with limits
3- walks using hand held mobility device
4- may use powered mobility themselves
5- transported in manual wheelchair

Question 37

problems in CP

Answer 37

spasticity
lack of voluntary limb control
impaired senses
weakness
poor coordination
hip displacement- early surgical intervention

Question 38

orthopaedic priorities in CP

Answer 38

spine, hip, feet
maintain sitting balance
improve standing posture
gait

Question 39

management non surgical CP

Answer 39

diazepam, baclofen
botulinum toxin, baclofen intra thecal pump
antiepileptics
glycopyronium bromide for excessive drooling
physio
OT
SALT
dieticians

Question 40

surgeries CP

Answer 40

soft tissue release
bony relaignment- osteotomy
risks and benefits need to be weighed up

Question 41

scoliosis

Answer 41

deviation in coronal plane
>10 degree deviation is clinically significant
non structural- due to extrinsic cause
structural - abnormal rotation of vertebrae

Question 42

high risk progression scoliosis

Answer 42

premenarchal
<12yo at presentation
size of curve at presentation
neuromuscular causes eg CP and muscular dystrophy

Question 43

types of scoliosis

Answer 43

congenital
idiopathic (most common)
neuromuscular

Question 44

examination of scoliosis

Answer 44

inspect posterior torso in forward flexion
abnormal neurology or pain should be noted as not normally a feature

Question 45

investigations in scoliosis

Answer 45

AP erect whole spine
MRI to show cause