Paediatric orthopaedics Flashcards
What clinical features may raise suspicion of a clavicle or humerus fracture in a neonate?
o Pseudo-paralysis; baby is not moving the limb, as if it is paralysed, but the limb is not actually paralysed
How long does it usually take for a neonatal clavicle/humerus fracture to heal?
2 weeks
Which nerve palsy is associated with clavicle/humerus fractures?
Erb’s palsy; damage to brachial plexus
What are the risk factors for neonatal brachial plexus injury?
High birth weight Shoulder dystocia Maternal diabetes Forceps delivery Clavicle fractures Prolonged labour
What is the most common form of brachial plexus injury??
Neuropraxia due to myelin damage and axonal stretching
resolves within weeks
What is axonotmese?
Axonal rupture and myelin damage, nerve sheath intact
Resolves in months
What is neurotmesis?
Total nerve rupture requiring operative repair
Which nerve roots are implicated in Erb’s palsy?
C5, C6, (C7)
Describe the manefestation of Erb’s palsy
Waiter’s tip appearance:
- shoulder internally rotated
- elbow extended
- wrist flexed
What causes Horner’s syndrome?
Interruption of the stellate (cervicothoracic) ganglion
Describe the clinical manefestations of Horner’s syndrome
Ptosis (drooping of the eyelid)
Miosis (constriction of the pupil)
Enophthalmos (posterior displacement of the eyeball)
What are the “Paeds Big 3” in orthopaedics?
Developmental Dysplasia of the Hip (DDH)
Perthes disease
Slipped Upper Femoral Epiphysis (SUFE)
Name three clinical tests used in the diagnosis of DDH
Barlow’s test - dislocates the hip
Ortolani’s test - reduces the hip
Galeazzi test
What are the risk factors for DDH?
Female
Firstborn
Family history
Breech position in uterus
What proportion of babies with DDH have no risk factors?
Over 50%
When are neither Barlow’s nor Ortolani’s tests useful in diagnosing DDH?
If the hip is both dislocated and irreducible
Which imaging modality is most effective for diagnosis DDH?
Ultrasound; x-rays not useful because femur heads haven’t yet ossified so are not visible on x-ray
How may a child walk if they have undiagnosed DDH?
One leg appears shorter and is externally rotated
May walk on tiptoes on the affected leg
How is DDH treated?
Hip abduction brace
Important not to overtreat; many babies will grow out of it
What risks are associated with hip abduction braces used in the treatment of DDH?
Femoral nerve palsy
Avascular necrosis of the femoral head
How often should scans be repeated during the course of managing DDH?
Every 3 - 4 weeks until the hip is normal
What is Perthes Disease? In what population is it most common?
Idiopathic osteonecrosis of the femoral head
Most common in boys of primary school age, with peak incidence between the ages of 4 - 8
(This is a form of avascular necrosis)
Describe the typical presentation of Perthes Disease
Limp Intermittent knee pain (referred from the hip), brought on by exercise Hip stiffness Systemically well Usually no history of trauma
How is Perthes Disease diagnosed?
positive Roll test
X-ray
MRI and/or bone scan
Describe the management of Perthes Disease
Best rest –> no weight bearing
Physiotherapy
Surgical treatment may be required if severe
What are the potential complications of Perthes Disease?
Deformity of the femoral head, leading to shortening of the affected limb
Pain and loss of function
Osteochondritis dissecans of the femoral head (development of cracks in the articular cartilage and underlying bone)
What is SUFE?
Slipped Upper Femoral Epiphysis
Instability of the proximal femoral growth plate, causing displacement of the upper femoral epiphysis
Describe the typical presentation of SUFE
Boys aged 9 - 14, usually overweight
Hip and/or knee pain with associated limp
- often have only knee pain, referred from the hip
Limb is shortened and externally rotated
May be associated with mild trauma (but not always)
How is SUFE diagnosed?
Hip and pelvic X-rays
Investigate and endocrine cause if the child is not overweight
Describe the management of SUFE
Depends on severity; likely to need a screw/pin to fix the joint, and some cases may require surgery (femoral neck osteotomy)
What are potential complications associated with SUFE?
AVN of the femoral head Chondrolysis Early OA Deformity (e.g. coxa vara) Limb length discrepancy Contralateral femoral epiphysis slip
What is torticollis?
Shortening of the sternocleidomastoid muscle
What other conditions are associated with torticollis?
Plagiocephaly (flat-head syndrome)
DDH
Metatarsus adductus
