Paediatric orthopaedics

Question 1

What clinical features may raise suspicion of a clavicle or humerus fracture in a neonate?

Answer 1

o Pseudo-paralysis; baby is not moving the limb, as if it is paralysed, but the limb is not actually paralysed

Question 2

How long does it usually take for a neonatal clavicle/humerus fracture to heal?

Answer 2

2 weeks

Question 3

Which nerve palsy is associated with clavicle/humerus fractures?

Answer 3

Erb’s palsy; damage to brachial plexus

Question 4

What are the risk factors for neonatal brachial plexus injury?

Answer 4

High birth weight
Shoulder dystocia
Maternal diabetes
Forceps delivery
Clavicle fractures
Prolonged labour

Question 5

What is the most common form of brachial plexus injury??

Answer 5

Neuropraxia due to myelin damage and axonal stretching

resolves within weeks

Question 6

What is axonotmese?

Answer 6

Axonal rupture and myelin damage, nerve sheath intact

Resolves in months

Question 7

What is neurotmesis?

Answer 7

Total nerve rupture requiring operative repair

Question 8

Which nerve roots are implicated in Erb’s palsy?

Answer 8

C5, C6, (C7)

Question 9

Describe the manefestation of Erb’s palsy

Answer 9

Waiter’s tip appearance:

• shoulder internally rotated
• elbow extended
• wrist flexed

Question 10

What causes Horner’s syndrome?

Answer 10

Interruption of the stellate (cervicothoracic) ganglion

Question 11

Describe the clinical manefestations of Horner’s syndrome

Answer 11

Ptosis (drooping of the eyelid)
Miosis (constriction of the pupil)
Enophthalmos (posterior displacement of the eyeball)

Question 12

What are the “Paeds Big 3” in orthopaedics?

Answer 12

Developmental Dysplasia of the Hip (DDH)
Perthes disease
Slipped Upper Femoral Epiphysis (SUFE)

Question 13

Name three clinical tests used in the diagnosis of DDH

Answer 13

Barlow’s test - dislocates the hip
Ortolani’s test - reduces the hip
Galeazzi test

Question 14

What are the risk factors for DDH?

Answer 14

Female
Firstborn
Family history
Breech position in uterus

Question 15

What proportion of babies with DDH have no risk factors?

Answer 15

Over 50%

Question 16

When are neither Barlow’s nor Ortolani’s tests useful in diagnosing DDH?

Answer 16

If the hip is both dislocated and irreducible

Question 17

Which imaging modality is most effective for diagnosis DDH?

Answer 17

Ultrasound; x-rays not useful because femur heads haven’t yet ossified so are not visible on x-ray

Question 18

How may a child walk if they have undiagnosed DDH?

Answer 18

One leg appears shorter and is externally rotated

May walk on tiptoes on the affected leg

Question 19

How is DDH treated?

Answer 19

Hip abduction brace

Important not to overtreat; many babies will grow out of it

Question 20

What risks are associated with hip abduction braces used in the treatment of DDH?

Answer 20

Femoral nerve palsy

Avascular necrosis of the femoral head

Question 21

How often should scans be repeated during the course of managing DDH?

Answer 21

Every 3 - 4 weeks until the hip is normal

Question 22

What is Perthes Disease? In what population is it most common?

Answer 22

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)

Question 23

Describe the typical presentation of Perthes Disease

Answer 23

Limp
Intermittent knee pain (referred from the hip), brought on by exercise 
Hip stiffness
Systemically well
Usually no history of trauma

Question 24

How is Perthes Disease diagnosed?

Answer 24

positive Roll test
X-ray
MRI and/or bone scan

Question 25

Describe the management of Perthes Disease

Answer 25

Best rest –> no weight bearing
Physiotherapy
Surgical treatment may be required if severe

Question 26

What are the potential complications of Perthes Disease?

Answer 26

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)

Question 27

What is SUFE?

Answer 27

Slipped Upper Femoral Epiphysis

Instability of the proximal femoral growth plate, causing displacement of the upper femoral epiphysis

Question 28

Describe the typical presentation of SUFE

Answer 28

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)

Question 29

How is SUFE diagnosed?

Answer 29

Hip and pelvic X-rays

Investigate and endocrine cause if the child is not overweight

Question 30

Describe the management of SUFE

Answer 30

Depends on severity; likely to need a screw/pin to fix the joint, and some cases may require surgery (femoral neck osteotomy)

Question 31

What are potential complications associated with SUFE?

Answer 31

AVN of the femoral head
Chondrolysis
Early OA
Deformity (e.g. coxa vara)
Limb length discrepancy
Contralateral femoral epiphysis slip

Question 32

What is torticollis?

Answer 32

Shortening of the sternocleidomastoid muscle

Question 33

What other conditions are associated with torticollis?

Answer 33

Plagiocephaly (flat-head syndrome)
DDH
Metatarsus adductus