Paediatric Orthopaedics Flashcards
Examples of paediatric ortho trauma
-Physeal fractures
-Non-accidental injury
-Slipped capital/ upper femoral epiphysis (SUFE)
Examples of elective paediatric ortho
-Transient synovitis
-Septic arthritis
-Osteomyelitis
-Developmental dysplasia of the hip
-Perthes’ disease
Presentation of Physeal fractures
-Natural point of weakness
-Growth arrest= progressive deformity difficult to correct in adulthood
Salter Harris classification of physeal fractures
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
Investigation of physeal fractures
X ray
Management of physeal fractures
-3/4 require anatomic reduction and fixation with surgery
Describe non-accidental injury
-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
Features of NAI in history
-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
Presentation of NAI
-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
Management of NAI
-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
Describe a corner fracture
-Pathognomic of nonaccidental trauma
-Perichondrium holds on to a piece of the corner of the metaphysis
-Mechanism: torsion under traction
=Bucket handle
Describe slipped capital// upper femoral epiphysis (SCFE)
-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)
Presentation of SCFE
-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
Investigation of SCFE
-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
Management of SCFE
-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
Overview of transient synovitis
-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)
How is septic arthritis investigated and managed differently in children?
-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
Kocher’s criteria for infection vs inflammation
-Refusal to weight bear
-Temp >38.5
-WCC >12
-CRP >20 or ESR >40
Likelihood of SA increases with number of points
Describe acute osteomyelitis
-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
Complications and causal organisms in acute osteomyelitis
-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
Presentation of acute osteomyelitis
-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
Investigation in osteomyelitis
-Blood cultures
-Mildly elevated WCC
-Elevated CRP and ESR
-(Aspirate if diagnosis uncertain)
-Imaging: XR – may be normal, MRI, Brodie’s abscess
Management of osteomyelitis
-Intra-articular/ subperiosteal abscess: incision & drainage + debridement, IV Abx
-None: IV Abx
What is DDH?
-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
