paediatric orthopaedics Flashcards
talipes equino varus
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
MSK issues that cause concern
in toed gait
bow legs
flat feet
curly toes
late walkers
how to check in toeing
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
internal tibial torsion
increased thigh foot angle
90% resolve
no role for splints or physio etc
metatarsus adductus
90% resolve by 1 year
5% persist to adulthood
toes point in
normal physiological shape of legs
babies start off varus legs
then straight
then valgus
then straight
people concerned but reassure normal
flat feet
normal at birth diminishes with age
jacks test lift toe up heel turns into varus
insoles no benefit
curly toes
strong fam history
tightness in flexor tendons
mostly cosmetic problem
if functional problem consider flexor tenotomy if over 6 years
walking age mean
12 months. 50% take longer than mean. beyond 18 months refer
developmental dysplasia of hip
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
the big 3
developmental dysplasia of hip DDH
slipped upper femoral epiphysis SUFE
perthes disease
DDH signs
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
DDH epidemiology
common in inuits
eastern europe
not african
commoner in girls
left hip commoner
risk factors DDh
first born
breech
family history
increased weight
DDH investiagtions
ultrasound gold standard
xrays also
management DDH
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
perthes disease
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
presentation perthes disease
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
investigations
xray
blood tests normal
technitium bone scan
prognosis perthes
younger do better
proportion of head involved- herring A B and C shows level of collapse, C being worst
treatment perthes
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
slipped upper femoral epiphysis
head of the femur is displaced (“slips”) along the growth plate
more common in boys
aged 8 – 15 years
more common in obese children.
presentation SUFE
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
classification of SUFE
acute- 3 weeks
chronic- beyond
magnitude of slip
stable v unstable - weight bearing
management in SUFE
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
limping infant 1-3 years common causes
septic arthritis
fracture
DDH
limping child 4-10 years common causes
transient synovitis
perthes
JIA
limping child more than 10 common causes
SUFE
spondylolisthesis
overuse
gowers sign positive
check creatinine kinase as muscular dystrophy
infection- limp
SA wont walk
OM can
TS will walk
pain in SA and OM
recent URTI /ear infection- TS
general malaise- OM SM
septic arthritis
> 38degrees
no weight bearing
12000/ml WBC
40mm/hr
CRP >30
surgery is treatment
empirical antibiotics
transient synovitis
diagnosis of exclusion
spectrum of severity
history of viral infection
low CRP and normal WBC excludes sepsis
not that unwell
limping
complex exceptional needs defined
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
examples of complex needs
spina bifida
syndromes
cerebral palsy
muscular dystrophy
neurofibromatosis
Cerebral palsy
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
gross motor function classification system
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
problems in CP
spasticity
lack of voluntary limb control
impaired senses
weakness
poor coordination
hip displacement- early surgical intervention
orthopaedic priorities in CP
spine, hip, feet
maintain sitting balance
improve standing posture
gait
management non surgical CP
diazepam, baclofen
botulinum toxin, baclofen intra thecal pump
antiepileptics
glycopyronium bromide for excessive drooling
physio
OT
SALT
dieticians
surgeries CP
soft tissue release
bony relaignment- osteotomy
risks and benefits need to be weighed up
scoliosis
deviation in coronal plane
>10 degree deviation is clinically significant
non structural- due to extrinsic cause
structural - abnormal rotation of vertebrae
high risk progression scoliosis
premenarchal
<12yo at presentation
size of curve at presentation
neuromuscular causes eg CP and muscular dystrophy
types of scoliosis
congenital
idiopathic (most common)
neuromuscular
examination of scoliosis
inspect posterior torso in forward flexion
abnormal neurology or pain should be noted as not normally a feature
investigations in scoliosis
AP erect whole spine
MRI to show cause
