Paediatric Orthopaedics Flashcards

1
Q

Examples of paediatric ortho trauma

A

-Physeal fractures
-Non-accidental injury
-Slipped capital/ upper femoral epiphysis (SUFE)

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2
Q

Examples of elective paediatric ortho

A

-Transient synovitis
-Septic arthritis
-Osteomyelitis
-Developmental dysplasia of the hip
-Perthes’ disease

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3
Q

Presentation of Physeal fractures

A

-Natural point of weakness
-Growth arrest= progressive deformity difficult to correct in adulthood

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4
Q

Salter Harris classification of physeal fractures

A

I - Straight across the physis
II - Above the physis (in metaphysis): most common
III - Lower than the physis (intraarticular)
IV - Through the physis
V - ER Everything Ruined (‘Rammed’)

III/IV generally require anatomic reduction+/- fixation
II is most common

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5
Q

Investigation of physeal fractures

A

X ray

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6
Q

Management of physeal fractures

A

-3/4 require anatomic reduction and fixation with surgery

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7
Q

Describe non-accidental injury

A

-You require a high index of suspicion when assessing all injured children
=50% will experience further physical abuse
=15% die as result
-Address issues of non-accidental injury before discharge in all children with femoral fractures. This is particularly important for children who are not walking or talking

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8
Q

Features of NAI in history

A

-Delayed presentation
-History does not match the injury (i.e. non-ambulant infants with long bone fractures)
-Inconsistent or vague histories
-‘Unwitnessed’ injuries
-Multiple injuries

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9
Q

Presentation of NAI

A

-Bruises – clustered; contain petechiae; pattern in keeping with an implement / slap
-Bites – human (‘U-shaped’) vs animal (‘V-shaped’)
-Fractures:
=Skull – linear parietal fracture; complex; multiple; occipital
=Spine – any spinal fracture in young children
=Thorax – rib fracture (-> child being gripped)
=Upper limb – spiral fracture of the humerus
=Lower limb – femoral fractures in immobile children, corner fractures
-Burns – well-defined edges; appearances of an implement
-Non-accidental head injury (NAHI) – intracranial bleeds; brain injury; retinal haemorrhage; neck fractures; spinal cord injuries; abrasion on head; skull fractures
-Corner fractures (perichondrium on piece f=of corner of metaphysis

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10
Q

Management of NAI

A

-Early escalation to your senior is mandatory.
-Record clinically
-Check if the child is on the Child Protection Register
-Keep the child in hospital if any concern about their surgery
-Ensure any other children at home are safe
-Document everything carefully, precisely and extensively
-Consider some basic investigations
=Coagulopathies -> easy bruising; haemarthrosis
=Metabolic bone diseases -> fractures

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11
Q

Describe a corner fracture

A

-Pathognomic of nonaccidental trauma
-Perichondrium holds on to a piece of the corner of the metaphysis
-Mechanism: torsion under traction
=Bucket handle

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12
Q

Describe slipped capital// upper femoral epiphysis (SCFE)

A

-A SH1 fracture through the proximal femoral growth plate (N.B., it is a ‘slip’, rather than a fracture, since it occurs more slowly, but the consequence is similar)
-It occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis.
-Similar to a hip fracture, the metaphysis(i.e., femoral neck) externally rotates and translates anteriorly.
-Displacement of the femoral head epiphysis postero-inferiorly
-May present acutely following trauma or more commonly with chronic, persistent symptoms

-Who?
=Age ~10-15 y/o, boys
=Obesity
=Endocrine disorders (hypothyroidism, GH deficiency, panhypopituitarism)

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13
Q

Presentation of SCFE

A

-Painful limp, of acute/ insidious gradual onset (weeks, 2 months)
=Pain normally in hip/groin, but can be referred to the thigh and knee (15-50%)
-May be acute pain after trauma
-Associated systemic disease may be present (obesity, and endocrine disorders such as panhypopituitarism, hypothyroidism, and renal osteodystrophy)

-Gait: Antalgic, with ER foot, Trendelenburg’s gait
-Look: Short, ER leg (i.e., like a hip fracture)
-Feel: NAD
-Move:
=During passive hip flexion, their leg will obligatorily externally rotate (Drehmann sign)
=Limited IR of leg in flexion

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14
Q

Investigation of SCFE

A

-Irregular, widened physis
=AP and lateral frog leg
-X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity
-Klein’s line: A line drawn along the superior femoral neck on the AP radiograph
-Trethowan sign: when Klein’s line does not intersect the femoral epiphysis

-Metabolic panel
-Serum TFT
-Serum GH

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15
Q

Management of SCFE

A

-Stable
=Able to walk, even with walking aids, Loder classification
=Pin in situ (PIS)
=Prophylactic contralateral fixation in high risk groups (obese, endocrine disorders or young)
=Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.

-Unstable
=Unable to walk, even with walking aids
=PIS vs ORIE (controversial)
=Internal fixation (single cannulated screw in centre of epiphysis)
=prophylactic fixation of the contralateral hip may be necessary when concomitant metabolic disease is present.

-Complications
=osteoarthritis
avascular necrosis of the femoral head
chondrolysis
leg length discrepancy

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16
Q

Overview of transient synovitis

A

-common cause of paediatric limp
-Pathophysiology: non-specific inflammation of the synovium, irritable hip, self-limiting
-Commonly following a recent (viral) illness
-Symptoms and signs similar to SA: acute hip pain following a recent viral infection. It is the commonest cause of hip pain in children. The typical age group is 3-8 years. (2-12), boys

limp/refusal to weight bear
groin or hip pain, abducted and externally rotated
a low-grade fever is present in a minority of patients
high fever should raise the suspicion of other causes such as septic arthritis

-Rx: NSAIDs and observation (admit +/- USS if uncertainty)

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17
Q

How is septic arthritis investigated and managed differently in children?

A

-Infants= USS, presence and size of joint effusion
-Hip (Faber sign least pressure on hip capsule) >knee> shoulder>wrist
-Older children: XR (Widened joint space) +/- MRI (helpful but practically challenging)

-Joint aspiration generally done in theatre, send for urgent MC&S
-Emergency surgical washout with IV Abx

18
Q

Kocher’s criteria for infection vs inflammation

A

-Refusal to weight bear
-Temp >38.5
-WCC >12
-CRP >20 or ESR >40

Likelihood of SA increases with number of points

19
Q

Describe acute osteomyelitis

A

-Bacterial infection of bone
=Typically due to haematogenous spread
=Occasionally, direct spread from a contiguous septic arthritis
-Usually arises in the metaphysis, due to rich blood supply but relatively stagnant blood flow

20
Q

Complications and causal organisms in acute osteomyelitis

A

-Intra-osseous abscess (‘Brodie’s abscess’)
-Subperiosteal abscess (if the metaphysis is extra-articular (i.e., knee))
-Septic arthritis (if the metaphysis is intra-articular (i.e., hip, ankle, shoulder, knee))

-Neonates: Group B strep
-Infants and children: S. aureus
-Sickle cell: salmonella

21
Q

Presentation of acute osteomyelitis

A

-Pain – generally less acute and severe than SA
-Limp / refusal to WB
+/- systemic features of infection

+/- fever
-Look: Erythema
-Feel: Point tenderness over the affected area, Calor, Swelling
-Move: Restricted ROM due to pain, but no pseudoparalysis

22
Q

Investigation in osteomyelitis

A

-Blood cultures
-Mildly elevated WCC
-Elevated CRP and ESR
-(Aspirate if diagnosis uncertain)
-Imaging: XR – may be normal, MRI, Brodie’s abscess

23
Q

Management of osteomyelitis

A

-Intra-articular/ subperiosteal abscess: incision & drainage + debridement, IV Abx
-None: IV Abx

24
Q

What is DDH?

A

-Dysplasic, shallow acetabulum and proximal femur conditions
-> Progressive subluxation / dislocation of the femoral head
-> Results in further dysplastic changes of the acetabulum and femoral head, which prevent stable reduction of the hip joint

-Who?
=1:100 live births
=‘Packaging disorder’ – first born, breech, oligohydramnios
=1st degree family history
=Female

25
Q

Describe developmental Dysplasia of the Hip

A

Ideally picked up on new-born examination or through screening of high risk children (-> USS)

Refer for USS if:
-Breech
-Positive family history in 1st degree relative
-Co-current foot deformities ie. Clubfoot
-Positive Ortolani (good- click in) / Barlow (Bad- push hip) test
-Asymmetrical groin creases
-Leg length difference
-Limited hip abduction

26
Q

Presentation of developmental dysplasia of the Hip

A

Signs if presenting late:
-If non-ambulatory:
=Leg length discrepancy (Galeazzi sign if unilateral)
=Reduced abduction of the hip/ asymmetrical jip abduction
=Klisic sign +
-If ambulatory:
=Limp
=Toe walking (due to short leg)
=Trendelenberg gait (due to weak abductors)
=Abnormal positioning of leg or delayed crawling/walking

27
Q

Investigation of DDH

A

Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc

28
Q

Management of DDH

A

-Pavlik harness
-Spica cast
-Femoral osteotomy (bilateral)
-Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision

29
Q

Describe Perthes’ Disease

A

-Idiopathic avascular necrosis of the proximal femoral epiphysis> Femoral head collapse &deformity-> Develop OA in later life (~50% in their 40s / 50s)

-Who
= 5 :1♂ ♀
~5-10 ylo
=Lower socioeconomic status
=Passive smoking
=ADHD

30
Q

Presentation of Perthes disease

A

-May present as:
=Painless limp
+/- intermittent pain (may be in groin, but often referred to the knee and thigh)

-Stiffness - limited abduction and IR
-Trendelenberg gait

31
Q

Investigation in Perthes’ Disease

A

XR
-Increased medial joint space
-Femoral head
=Flattened
=Widened
=Sclerotic
=+/- fragmented
=-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.

-Bone scintigraphy? Col spot in early process (ischaemic stage)

32
Q

Management of Perthes’ Disease

A

Management is complex and nuanced, depending on the age of the child and the degree of femoral head involvement/ collapse

-Manage pain: NSAIDs
-Preserve function/ ROM: Physiotherapy
-Prevent Sublaxation: NWB (-> crutches)

-Surgery may be required for older children, or those with significant femoral head collapse, to prevent extrusion of the hip. Typically, a femoral and / or acetabular osteotomy
=Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly.

33
Q

Surgical sieve of limping child differentials

A

-Vascular: Perthes (AVN)I
-Infection: (septic arthritis; osteomyelitis; spondylodiscitis; iliopsoas abscess; (pyomyositis)) or Inflammatory (transient synovitis; JIA; tendinopathies)
-Trauma: Fracture or SUFE; Always think NAI.
-A - Nil
-Metabolic bone disease (osteogenesis imperfecta, osteomalacia, rickets)
I - Nil
-Neoplasm: Sarcoma; Haemotological
C – DDH
D – (Neurodegenerative disorders; Neuromuscular disorders)
E – Endocrine / Environment: Obesity (risk of SUFE)
F – Functional: Yes, in adolescence

34
Q

Hip pain in children <4 years

A

-Transient synovitis
-Osteomyelitis/ SA
-Juvenile idiopathic arthritis
-NAI
-Referred pain from limb

-Uncommonly
=Leukaemia
=Eosinophilic granuloma
=Metastases neuroblastoma

35
Q

Hip pain in children 4-10

A

-Transient s
-Perthes
-OM/SA

-Leukaemia
-Ewing

36
Q

Hip pain in children 10-16

A

-SCFE
-Avulsion fractures
-OM/SA

-Leukaemia
-Osteoid osteoma
-Ewing
-Osteosarcoma

37
Q

Types of paediatric fractures

A

Complete fracture= Both sides of the cortex are breached
Toddlers fracture= Oblique tibial fracture in infants
Plastic deformity= Stress on bone resulting in deformity without cortical disruption
Greenstick fracture= Unilateral cortical breach only
Buckle (‘torus’) fracture= Incomplete cortical disruption resulting in periosteal haematoma only

38
Q

Salter Harris System for paediatric fractures

A

Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphysis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

39
Q

Brodie’s abscess

A

-Bubble that doesn’t take up entire space
Infective abscess inside bone
Acute osteomyelitis

40
Q

Simple bone cyst

A

-UBC : expand
-Whole width of cortical bone
-Metaphyseal region-Multiloculated (pockets and bubbles)

41
Q

Ewing sarcoma

A

Sunburst appearance
Soft tissue involved; expands beyond bone

=Pain, swelling or palpable mass
=Impaired function, pathological fractures
=Systemic features

=X rays, CT, MRI, PET
=Biopsy

-Surgery
-Radiotherapy
-Chemotherapy
-Targeted therapy

42
Q

Causes of avascular necrosis

A

-DDH
-SA
-Perthes
-Long-term inhaled steroid use