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