Paediatric orthopaedics Flashcards
What is the growth plate ?
- Part of the bone between the metaphysis and epiphysis found in the bones of children.
- Made of hyaline cartilage and allow bones to grow in length before fusing
What are the 8 types of paediatric fracture?
- Buckle (torus)
- Transverse
- Oblique
- Spiral
- Segmental
- Salter-Harris (growth plate fracture)
- Comminuted (brreaks into a no. of different pieces)
- Greenstick (one side of the bone breaks, the other remains in tact).
Explain the Salter-Harris classification of growth plate fractures.
- I : Physis only
- II : Physis and metaphysis
- III : Physis and epiphysis to include the joint
- IV : Physis, metaphysis and epiphysis
- V : Crush injury
What are the 2 principles of managing a fracture ?
- Mechanical alignment with either : closed or open reduction
- Provide relative stability
What are the two steps to pain management in children.
- Paracetamol or ibuprofen
- Morphine
what pain killers are avoided in children ?
-> Codeine and tramadol due to unpredictability of metabolism.
-> Aspirin : risk of reye’s syndrome
Explain the causes of hip pain in children related to age
~ 0-4 : septic arthritis, DDH, transient synvotitis
~ 5-10 : septic arthritis, transient synovitis, perthes disease
~ 10-16 : septic arthritis, SUFE and JIA
What are the 7 criteria for urgent referral for assessment in a limping child ?
- Child under 3 years
- Child older than 9 with a restricted or painful hip
- Not able to weight bear
- Evidence of neurovascular compromise
- Severe pain or agitation
- Red flags for serious pathology
- Suspicion of abuse
Give 10 red flags for hip pain
- 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
What is septic arthritis and when is it most common in children ?
- Infection in a joint
- <4 years
- M>F
How does septic arthritis present ?
Usually knee or hip :
- Hot, red, swollen and painful joint
- Refusing to weight bear
- Stiffness and reduced range of motion
- Systemic symptoms such as fever, lethargy and sepsis
What is the most common causative agent of septic arthritis ?
Staph aureus
How is the most likely cause of septic arthritis in sexually active teenagers
Neisseria gonorrhoea
How is septic arthritis managed ?
- Give empirical IV Abx until microbial sensitivities are known
- Joint aspirate and send for : gram staining, crystal microscopy, culture and antibiotic sensitivities.
- Abx continued for 3-6 wks.
what is the Kocher criteria for diagnosing septic arthritis ?
- Fever >38.5 degrees C
- Non-weight bearing
- Raised ESR (> 40)
- Raised WCC (> 12)
What is transient synovitis ?
- Temporary irritation and inflammation in synovial membrane of the hip associated with a viral URTI
In what age group is transient synovitis most common ?
Most common cause of hip pain in children aged 3-10 yrs
How does transient synovitis present ?
- Limp/refusal to weight bear
- Groin or hip pain
- Low-grade fever : high fever is more suggestive of septic arthritis
How is transient synvotitis managed ?
- Simple analgesia in primary care, if :
~ Limp is present for <48 hrs and are otherwise well
What is DDH
- Structural abnormality of the hip increasing the risk of subluxation and dislocation
Give 7 RF for DDH
- F>M
- Breech presentation
- First degree FHx
- Birth weight >5kg
- Oligohydramnios
When are babies screened for DDH
All babies are screened in the newborn check and 6 week baby check using Barlow and Ortolani test
Which infants will require a routine USS for DDH
- First-degree family history of hip problems in early life
- Breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery
- Multiple pregnancy
What is done on clinical examination when looking for DDH
~ Barlow test: attempts to dislocate an articulated femoral head
~ Ortolani test: attempts to relocate a dislocated femoral head
~ Other : Symmetry of leg length, level of knees when hips and knees are bilaterally flexed, restricted abduction of the hip in flexion
What imaging is used to confirm the diagnosis of DDH
- USS
- However if >4.5 mnths old, X-ray is used 1st line.
How is DDH managed ?
- <6mnths : Pavlik harness (6-8 wks)
- > 6mnths : surgery with hip spica cast afterwards
What is Perthe’s disease
- Degenerative conditon where there is disruption to the flow of blood leading to avascular necrosis of the femoral head (particularly the femoral epiphysis).
Who does perthe’s disease typically affect?
Boys aged 5-10
How does Perthe’s disease present ?
Slow onset of :
- Pain in the hip or groin
- Limp
- Restricted hip movements
- There may be referred pain to the knee
No Hx of trauma !
What other Ix are helpful in Perthe’s ?
- Technetium bone scan
- MRI scan
How is Perthe’s diagnosed ?
X-ray : early changes include widening of joint space, later changes include decreased femoral head size/flattening
How is perthe’s managed ?
AIM : maintain a healthy position and alignment of the joint.
- Younger : bed rest, traction, crutches, analgesia
- Older : surgery
What is the catterall staging of Perthe’s disease ?
- Stage 1 : Clinical and histological features only
- Stage 2 : Sclerosis with or without cystic changes and preservation of the articular surface
- Stage 3 : Loss of structural integrity of the femoral head
- Stage 4 : Loss of acetabular integrity
What are 2 complications of Perthe’s?
- OA
- Premature fusion of the growth plates
What is SUFE and who does it typically affecr ?
- Slipped upper femoral epiphysis
- The head of femur is displaced (posteriorly) along the growth plate.
- Obese boys aged between 10 and 15.
How does SUFE present ?
- Adolescent obese male going through a growth spurt.
- Minor trauma disproportionate with the pain.
- Hip, groin, thigh or knee pain
Restricted range of hip movement
Painful limp
Restricted movement in the hip
What movement of the hip is restricted in SUFE ?
- Internal rotation
What is the investigation of choice in SUFE ?
- AP and lateral X-ray
How is SUFE managed ?
Internal fixation
Give 4 complications of SUFE
- OA
- Avascular necrosis of the femoral head
- Chondrolysis
- Leg length discrepancy
What is an osteosarcoma, who does it usually effect and what bone is most commonly involved ?
- Bone cancer
- Aged 10-20 yrs
- Femur is most commonly affected BUT also affects the tibia and humerus
How does an osteosarcoma present?
- Persistent bone pain
- Pain is worse at night and typically disturbs or wakes them from sleep .
What do NICE recommend for a child presenting with unexplained bone pain or swelling ?
Urgent direct access xray within 48 hours
What is seen on X-ray in an osteosarcoma ?
- Poorly defined lesion
- Destruction of normal bone with a ‘fluffy’ appearance
- Periosteal reaction described to have a ‘sunburst’ appearance.
What might be seen on bloods in someome with an osteosarcoma ?
Raised alkaline phosphatase (ALP)
What are the main complications of an osteosarcoma ?
- Pathological bone fractures
- Metastasis
What is osteomyelitis and what part of the bone does it usually effect ?
- Infection of the bone and bone marrow
- Metaphysis of long bones
What are the most common causative agents of osteomyelitis ?
- Staph aureus
- In sickle cell anaemia -> Salmonella
What children and more commonly affected by osteomyeltitis
Boys <10 yrs
What RF predispose a child to osteomyelitis ?
- Open bone fracture
- Orthopaedic surgery
- Immunocompromised
- Sickle cell anaemia
- HIV
- TB
How does osteomyelitis present ?
- Refusing to use the limb or weight bear
- Pain
- Swelling
- Tenderness
- Afebrile / low grade fever. A high fever is more suggestive of septic arthritis
What is the initial imaging for osteomyelitis and what is the best imaging
- Initial : X-ray
- Best : MRI
How is osteomyelitis managed ?
- flucloxacillin for 6 weeks
- Clindamycin if penicillin-allergic
what is Osgood-Schlatter diease and when does it typically occur?
- Inflammation at the tibial tuberosity causing anterior knee pain
- Males aged 10-15 and causes anterior knee pain
How does Osgood-Schlatter present ?
- Visible or palpable hard and tender lump at the tibial tuberosity
- Pain in the anterior aspect of the knee
- Pain is exacerbated by physical activity, kneeling and on extension of the knee
How is Osgood-Schlatter’s managed ?
- Reduction in physical activity
- Ice
- NSAIDS (ibuprofen) for symptomatic relief
What is a rare complication of Osgood-Schlatter’s disease ?
- Avulsion fracture -> the tibial tuberosity separates from the rest of the tibia
Give the key features of
Chondromalacia patellae
- Softening of the cartilage of the patella
- Common in teenage girls
- Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
- Usually responds to physiotherapy
Give the key features of Osteochondritis dissecans
- Pain after exercise
- Intermittent swelling and locking
Give the key features of patellar subluxation
- Medial knee pain due to
- Lateral subluxation of the patella
- Knee may give way
Give the key features of patellar tendonitis
- More common in athletic teenage boys
- Chronic anterior knee pain that worsens after running
- Tender below the patella on examination
Define osteogenesis imperfecta
-Genetic condition resulting in brittle bones that are prone to fracture
What causes osteogensis imperfecta ?
- Genetic mutations that affect the formation of collagen
- 8 different genetic abnormalities with varying severities
How does osteogenesis imperfecta present ?
- Recurrent and inappropriate fractures
- Hyper-mobility
- Blue/grey sclera
- Triangular face
- Short stature
- Deafness from early childhood
- Dental problems
- Bone deformities : esp bowed legs and scoliosis
- Joint and bone pain
How is osteogenesis imperfecta diagnosed ?
- Usually clinical
- X-ray used in fractures and for bone deformitis
How is osteogenesis imperfecta managed ?
- Bisphosphonates to increased bone density (e.g. alendronate)
- Vit D supplementation to prevent deficiency
- Physio and occupational therapy
Define rickets
-Defective bone mineralisation causing ‘soft’ and deformed bones
What 2 vitamin deficiencies cause rickets ?
- Vitamin D
- Calcium
What are the sources of vitamin D?
- Sunlight
- Eggs, oily fish or forified cereals
What are the sources of calcium ?
- Dairy productes
- Green vegetables
What is a rare form of rickets?
- Hereditary hypophosphataemic rickets
- Genetic defect causing low phosphate
- Most common : X-linked dominant
What are the potential symptoms of rickets ?
- Lethargy
- Bone pain
- Swollen wrists ! widening of joint space
- Bone deformity
- Poor growth
- Dental problems ! no teeth development
- Muscle weakness
- Pathological or abnormal fractures
What 5 bone deformities can occur in rickets?
- Bowing of the legs
- Knock knees
- Rachitic rosary : ribs expand at the costochondral junctions causing lumps along the chest
- Craniotabes : soft skull with delayed closure of sutures and frontal bossing
- Delayed teeth
What are the RF for rickets ?
Anything that increases the risk of vit d deficiency
- Darker skin
- Low exposure to sunlight
- Live in colder climates
- Spend majority of their time indoors
What are the 5 common blood results in rickets ?
- Serum 25-hydroxyvitamin D of less than 25 nmol/L
- Calcium : low
- Phosphate : low
- Alkaline phosphatase : high
- Parathyroid hormone : high
What investigation is required to diagnose rickets ?
- X ray
- May show joint widening and osteopenia (more radiolucent bones)
How is rickets prevented ?
- Breastfeeding women should taken vitamin D supplements (10 micrograms per day)
- Formula fed babies are at lower risk as it is fortified with vitamin D
How is rickets managed ?
- Vitamin D (ergocalciferol) : 6mnths to 12 yrs is 6,000 IU per day for 8-12 wks
- Calcium supplementation
Explain the pathophysiology behind rickets
- Low vitamin D
- This leads to malabsorption of calcium and phosphate
- Low calcium and phosphate leads to defective bone mineralisation
- Low calcium leads to secondary hyperparathyroidism
- Increased parathyroid hormone leads to increased calcium reabsorption from bone and further issues with bone mineralisation
What is Talipes ?
- Clubfoot : fixed abnormal ankle position
- Fixed abnormal ankle position presenting at birth
What is talipes equinovarus ?
-Ankle in plantar flexion and supination
What is talipes calcaneovalgus ?
-Ankle in dorsifelxion and pronation
How is clubfoot managed ?
-Ponseti method
What is the ponseti method ?
- Used to treat club foot
- The foot is manipulated towards a normal position and a cast used to hold it in position. This is repeated until the foot is in the correct position
- A brace is then used to hold the feet in the correct position when not walking until around 4 yrs of age
What is positional talipes ?
- The ankle is in a plantar flexion and supination position but is not fixed
- The muscles around the ankle are tight but the boney structure is not affected
- Managed using physio
What is achondroplasia ?
- Most common common cause of disproportionate short stature (dwarfism)
- It is a type of skeletal dysplasia
What is the cause of achondroplasia?
-Genetic mutations in the FGFR3 gene (fibroblast growth factor receptor 3) on chromosome 4 leading to abnormal function of the epiphyseal plates.
What kind of genetic inheritance leads to achondroplasia ?
- Autosommal dominant -> heterozygous
- > Homozygous gene mutations are fatal in the neonatal period
What are the main features of achondroplasia ?
- Average height of 4 feet
- Short digits
- Bow legs
- Disproportionate skull
- Foramen magnum stenosis
- Frontal bossing
Give 6 associations with achondroplasia
- Recurrent otitis media
- Kyphoscoliosis
- Spinal stenosis
- Obstructive sleep apnoea
- Obesity
- Cervical cord compression and hydrocephalus as a result of foramen magnum stenosis
<3 presenting with acute limp
Urgent paediatric assessment
Estimated probability of septic arthritis based om kocher’s criteria
- 0 points = very low risk
- 1 point = a 3% probability of septic arthritis
- 2 points = a 40% probability of septic arthritis
- 3 points = a 93% probability of septic arthritis
- 4 points = a 99% probability of septic arthritis
