Paediatric Orthopaedics Flashcards
What are the risk factors in a diagnosis of developmental dysplasia of the hip (DDH)?
Breech position in utero or at delivery, FHx, other msk abnormailities, first born girls left hip
In diagnosing DDH what would you look/feel/move for on examination?
Asymmetry, position of leg, length, thigh creases. Feel for click/clunk. Move-check abduction
What instability tests do you use in diagnosing DDH?
Barlow-attempt to dislocate/sublux hip in joint by flexion adduction. Ortolani- attempt to relocate dislocated hip by abduction
What imaging do you use in diagnosis of DDH?
X-ray for calcified epiphysis >3-6months. US can also be used
What are the principles of treatment of DDH?
Relocate hip, splint it while it stabilizes. Monitor acetabular development
What is used to treat DDH in an early diagnosis (shortly after birth)?
Pavlik harness
What is used to treat DDH if diagnosed >3/12?
Closed reduction
What is used to treat DDH if diagnosed >9/12?
Open reduction likely
What is used to treat DDH if diagnosed >2yo?
Bony surgery required-femoral, pelvic osteotomy
What may be required in surgical correction of DDH?
Pre op traction followed by arthrogram. Immobilisation in hip spica for 3 months
What would be seen in late presenting CDH?
Painless limp, short leg, asymmetric creases, trendelenberg gait
What is Perthes disease?
A idiopathic osteochondritis of the femoral head comprising of idiopathic avascular necrosis, collapse, repair, and re-modelling
What is slipped capital femoral epiphysis (SUFE/SCFE)?
A weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis. SCFE is a misnomer; it is the metaphysis that displaces anteriorly and superiorly, leading to the slipped state.
Who would commonly present with SCFE?
10-16yo, adolescent in rapid growth phase, obese, M:F 2:1, Black:White 2:1, can be bilateral
What causes the characteristic widening and weakening of the physis in SCFE?
A variety of factors such as obesity, rapid growth during adolescence and endocrine disorders.
How is SCFE diagnosed in the history and exam?
RFs (puberty, obesity, endocrine disorders), weight (>90th percentile), gait with affected leg externally rotated. Internal rotation of the hip is the predominant clinical sign. Can present solely as pain in the knee
What tests are required to diagnose SCFE?
Bilateral AP x-ray(look for Trethowans sign), frog-leg lateral x-ray.
In how many acute unstable SCFE patients can AVN occur?
Up to 47%
What is osteogenesis imperfecta?
A defect of the maturation and organisation of type 1 collagen. AKA Brittle bone disease
What is the inheritance of osteogenesis imperfecta?
Autosomal dominant. Rarer cases are autosomal recessive
What are the features of osteogenesis imperfecta?
Multiple fragility fractures of childhood, short stature with multiple deformities, blue sclerae, loss of hearing.
What are the properties of bones in osteogenesis imperfecta?
Thin (gracile), thin cortices and osteopenic (particular premature births). Some cases can have normal XR, with Hx of low energy fractures.
How are fractures treated in osteogenesis imperfecta?
Tend to heal with abundant but poor quality callus, treated with splintage, traction or surgical stabilisation.
What will some cases of osteogenesis imperfecta which develop progressive deformity require?
Multiple osteotomies and intramedullary stabilisation for correction (Sofield procedure)
What is Type I osteogenesis imperfecta?
Mild bony deformities, blue sclerae, defective dentine, early-onset deafness, hypermobility of joints, heart valve disorders
What is Type II osteogenesis imperfecta?
Death in the perinatal period
What is Type III osteogenesis imperfecta?
Severe bone deformity, blue sclerae
What is Type IV osteogenesis imperfecta?
Fewer fractures, normal sclerae, normal lifespan
What is Cerebral palsy?
Neuromuscular disorder with onset before 2-3yo due to an insult to the immature brain before, during or after birth.
What are some of the causes of cerebral palsy?
Genetic problems, brain malformation, intrauterine infection in early pregnancy, prematurity, intra-cranial haemorrhage, hypoxia during birth and meningitis.
How many cases of cerebral palsy are due to problems during labour?
1 in 10
What is the variety in the expression of the disease and its severity?
Dependent on the area of brain affected, ranging from mild symptoms affecting 1 limb or total body involvement with profound learning difficulties. Milestones missed, ability to ambulate/perform tasks may be impaired
An insult to what during when can cause a limb malformation?
To the developing limb bud usually between the 4th and 6th weeks of gestation
What is syndactyly?
Commonest congenital malformation of limbs where 2 digits are fused together due to failure of separation of skin/soft tissues or phalanges (surgery may be req)
What is polydactyly?
Where an extra digit is formed and can be treated by amputating the extra digit
What is fibular hemimelia?
Partial or complete absence of the fibula often with absence of lateral foot rays leading to a shortened limb, bowing of tibia and ankle deformity
How can fibular hemimelia be treated?
Mild cases- limb lengthening with circular frame external fixator.
Severe- Through ankle amputation at 10/12 to 2yo and use of below knee prosthetic limb
What can occur in absence or hypoplasia of the radius?
Underdevelopment of hand (usually thumb absence) with marked deformity (radial club hand).
How can radial absence or hypoplasia be treated?
Surgical reconstruction with thumb reconstruction from index ray (pollicisation) and deformity correction
What is the most common congenital fusion?
Fusion between two of the tarsal bones of the foot (tarsal coalition) which may cause painful flat feet in later childhood. May need to be divided surgically
What is the incidence of brachial plexus injury during vaginal delivery?
2 in 1000
Who does brachial plexus injury during vaginal delivery commonly occur in?
Large babies (macrosomia in DM), twin deliveries and shoulder dystocia (difficult delivery of shoulder after head with compression of shoulder on pubic symphysis)
What is Erb’s palsy?
Brachial plexus palsy- injury to upper C5/6 nerve roots resulting in loss of motor innervation of deltoid. supra/infraspinatus, biceps and brachialis muscles
What does the loss of motor innervation of some muscles in Erb’s palsy cause?
Leads to internal rotation of humerus (from unopposed subscapularis) and may lead to classic waiter’s tip posture.
What is the treatment of Erb’s?
Physio required to prevent contractures early on, prognosis predicted by return of biceps function by 6 months with good outcome in 80-90%. Surgical release of contractures and tendon transfers may be required if no recovery
What is Klumpke’s palsy?
Rare, lower brachial plexus injury (C8/T1 roots) caysed by forceful adduction which results in paralysis of intrinsic hand muscles +/- finger/wrist flexors and possible Horner’s (due to disruption of 1st sympathetic ganglion from T1).
How do the fingers appear in Klumpke’s palsy?
Typically flexed due to paralysis of interossei and lubricals which assist extension at PIP joints
What is the treatment for Klumpke’s?
Less than 50% recovery, no specific treatment
What is Developmental dysplasia of the hip?
DDH involves dislocation or subluxation of the femoral head during the perinatal period which affects the subsequent development of the hip joint.
What can happen if DDH is left untreated?
The acetabulum is very shallow and in more severe cases a false acetabulum occurs proximal to the original one with a shortnened lower limb. Severe arthritis due to reduced contact area can occur at a young age and gait / mobility may be severely affected.
What is transient synovitis?
Self-limiting inflammation of the synovium of a joint, commonly hip.
When does transient synovitis commonly occur?
Shortly after URTI, sometimes idiopathic. Typical age is 2-10, commonly affects boys more so
What is the commonest cause of hip pain in childhood?
Transient synovitis
What is the presentation of transient synovitis of the hip?
Limp or reluctance to weight bear on affected side. Restricted range of motion (not as much pain/loss of motion as septic arthritis). May have low grade fever
What can be used in diagnosis of transient synovitis of hip?
Radiographs can exclude Perthes, normal/near normal CRP + clin picture suggestive of ts may exclude septic arthritis. Aspiration of hip to limit infection risk, MRI also to exclude osteomyelitis
What is the treatment of transient synovitis of hip?
NSAIDs and rest.
Who does Perthes commonly occur in?
Ages 4-9, boys 5:1
What happens in subsequent remodelling of the femoral head in Perthes?
Remodelling occurs, however the shape of femoral head and congruence of the joint is determined by age of onset (older children worse) and amount of collapse.
What can an incongruent joint in Perthes lead to?
Early onset of arthritis and severe cases may require hip replacement
How does Perthes present?
Affected children present with pain and a limp. Mostly unilateral, bilateral representing an underlying skeletal dysplasia or thrombophilia. Loss of internal rotation, loss of abduction, positive Trendellenburg test
What is treatment of Perthes?
No specific treatment, regular XR observation and avoidance of physical activity.
What are some poor outcomes of Perthes?
In some cases femoral head becomes aspherical, flattened, widened. Lever arm of abductor muscles is altered resulting in weakness. Femoral head may sublux requiring osteotomy or femur/acetabalum
Why is knee extensor mechanism pain a fairly common occurence during adolescence?
As body weight increases and sporting activities increase
What is the possible aetiology of anterior knee pain (patellofemoral dysfunction)?
Due to muscle imbalance, ligamentous laxity and subtle skeletal predisposition (genu valgum, wide hips, femoral neck anteversion).
Softening of what cartilage can occur in patellofemoral dysfunction?
Hyaline cartilage of patella (chondromalacia patellae)
What is the treatment of patellofemoral dysfunction?
Usually self limiting, physio. Occasionally surgery to shift forces on the patella (tibial tubercle transfer), however this has unpredictable results
What can some children have which can be a source of pain and a popping sensation in the knee?
Abnormally shaped discoid meniscus (usually lateral) which is circular rather than C-shaped. Arthroscopic partial menisectomy may help
What is Talipes Equinovarus (clubfoot)?
A congenital deformity of the foot affecting 1 in 800 births and is due to in utero abnormal alignment of the joints between talus, calcaneus and navicular. 50% cases bilateral
What does the abnormal alignment of the joints in clubfoot result in?
Contracture of the soft tissues, resulting in a deformity consisting of ankle equinus (plantarflexion), supinatiion of the forefoot and varus alignment of the forefoot which are not immediately correctable
What are the risk factors of having Talipes Equinovarus?
Boys (2:1), genetic link with +ve FHx, more common in breech presentation, oligohydramnios (low amniotic fluid content)
What is the treatment of Talipes Equinovarus?
Early splintage- ponseti technique commenced soon as possible after birth. Deformities corrected in stages, held in casts with 5 or 6 weekly changes. 80% require tenotomy of Achilles to maintain full correction. After this brace is used, 23h/day for 3/12 up until 3/4
What can occur in delayed presentations of Talipes Equinovarus?
Fixed deformity with child walking on outside of food
How is late deformity treated in Talipes Equinovarus?
Very difficult to correct, requires extensive surgery (soft tissue +/- bony procedures) with mixed results.
What is Tarsal coalition?
There is an abnormal bridge (bony, fibrous or cartilaginous) between calcaneus and navicular or between talus and calcaneus.
What can tarsal coaltion lead to?
A painful fixed flat foot deformity in older children
How is Tarsal Coalition treated?
Symptoms may improve with splintage/orthotics, whilst resistant pain may need surgery to remove connection
What is scoliosis?
Lateral curvature (and rotational deformity) of spine which can be idiopathic or secondary to neuromuscular disease, tumour, skeletal dysplasia or infection
Who more commonly has idiopathic scoliosis?
Females, presents in adolescence
What does painful scoliosis warrant?
Urgent investigation (MRI for tumour/infection)
How is scoliosis treated?
Mild, non-progressive cases do not require surgery. Larger curves may require it for cosmesis or to improve wheelchair posture (neuromuscular disease). Severe curves can cause restrictive lung defect, surgery may be needed to prevent breathing difficulties
What does surgery in scoliosis involve?
Requires vertebral fusions and long rods connecting posterior elements of spine. Large curve correction carries risk of spinal cord injury
What is Spondylolisthesis?
Slippage of one vertebra over another and usually occurs at L4/5 or L5/S1 level.
What are the causes of Spondylolisthesis?
Developmental defect or recurrent stress fracture of the posterior elements which fails to heal.
How does Spondylolisthesis present?
In adolescence, increased body weight and sporting activity have been implicated. Low back pain, radiculopathy with severe slippage. May have paradoxical flat back due to spasm, characteristic waddling gait acutely
How is Spondylolisthesis treated?
Minor degrees of slippage observed-rest and physio. More severe slips may require stabilisation and possibly reduction (risks neuro injury)
