Paediatric Orthopaedics Flashcards by Roshan Patel

What is Developmental Dysplasia of the Hip?

Developmental dysplasia of the hip

Represent a spectrum of hip instabilities

How well did you know this?

Not at all

Perfectly

What are the types of Developmental Dysplasia of the Hip?

Typical - affect normal infants

Teratological - occur in neurological and genetic conditions (req. specialised management)

How well did you know this?

Not at all

Perfectly

Detail the epidemiology of Developmental Dysplasia of the Hip

1-3% of newborns
More often left hip
20% bilateral

How well did you know this?

Not at all

Perfectly

What are some risk factors for Developmental Dysplasia of the Hip?

Female
Born breech - inc. C Section
Birth weight >5kg
Family history
First born child
Oligohydramnios - restricted movement

How well did you know this?

Not at all

Perfectly

Why has Developmental Dysplasia of the Hip changed its name? (bit of a pointless card)

Used to be congenital hip dysplasia

Changed name as it can occur after birth in normal hips
Stops us getting sued

How well did you know this?

Not at all

Perfectly

How does Developmental Dysplasia of the Hip present?

Limited abduction
Leg length discrepancy
Asymmetrical gluteal/thigh skin folds
Delayed walking
Painless limp
Waddling gait

How well did you know this?

Not at all

Perfectly

How is Developmental Dysplasia of the Hip commonly picked up?

At the 6-8 week screening using Ortolani and Barlow manoeuvres

How well did you know this?

Not at all

Perfectly

What does Barlow’s manoeuvre do?

Attempt to dislocate articulated femoral head - apply backward pressure to each femoral head

Subluxable hip is suspected on basis of palpable partial or complete dislocation

How well did you know this?

Not at all

Perfectly

What happens in Ortolani’s manoeuvre?

Attempt to relocate dislocated femoral head - forward pressure to each femoral head

Positive test if clunk heard when relocating femoral head

How well did you know this?

Not at all

Perfectly

What is done if Developmental Dysplasia of the Hip is suspected following Ortolani’s and Barlow’s?

USS <4.5 months

Hip X-Ray

How well did you know this?

Not at all

Perfectly

When do hip X-Rays become useful?

After 4-5 months - once femoral head ossified

How well did you know this?

Not at all

Perfectly

What are the complications associated with Developmental Dysplasia of the Hip?

Re-dislocations
Avascular necrosis
Degenerative joint disease

How well did you know this?

Not at all

Perfectly

How is Developmental Dysplasia of the Hip managed in children under 6 weeks of age?

Wait to see if spontaneously resolve

How well did you know this?

Not at all

Perfectly

How is Developmental Dysplasia of the Hip managed in children <5 months old?

Pavlik harness - flexion and abduction to keep head in acetabular fossa

Must be adjusted every 2 weeks

How well did you know this?

Not at all

Perfectly

What may be required for older children with Developmental Dysplasia of the Hip?

Surgery

How well did you know this?

Not at all

Perfectly

What is galeazzi’s test?

Flex infant’s knees when lying down so feet touch the surface and the ankles touch the buttocks

If knees at different heights - suggest DDH

How well did you know this?

Not at all

Perfectly

What is Perthes’ disease?

Idiopathic disorder resulting in avascular necrosis of the femoral head. Bone remodelling leads to a flattened and enlarged head

How well did you know this?

Not at all

Perfectly

What part of the femoral head is specifically affected in Perthes’ disease?

Femoral epiphysis

How well did you know this?

Not at all

Perfectly

How long does the cycle of Perthes’ disease take? (from avascular necrosis to remodelling)

3-4 years

How well did you know this?

Not at all

Perfectly

What risk factors are associated with Perthes’ disease?

Boys
4-8yo
Family history

How well did you know this?

Not at all

Perfectly

How would Perthes’ disease present?

Insidious onset of limp
Stiffness and reduced range of motion
Pain can be intermittent - groin, thigh or knee

How well did you know this?

Not at all

Perfectly

How is Perthes’ disease diagnosed?

X-Ray changes

1 Widened joint space
2 Small flat femoral head

How well did you know this?

Not at all

Perfectly

How is Perthes disease managed?

<6yo - observe

>6yo - cast, braces and possible surgical intervention

How well did you know this?

Not at all

Perfectly

What complications are associated with Perthes’ disease?

Osteoarthritis

Premature fusion of growth plates

How well did you know this?

Not at all

Perfectly

What is osteomyelitis?

Inflammation of the bone marrow due to infection It may spread to the cortex and periosteum via Haversian canals

What can happen if the periosteum is involved in osteomyelitis?

Can become necrosed

Where is osteomyelitis likely to affect in children?

Distal femur | Proximal tibia

When do children commonly get osteomyelitis?

Neonatal period 9-11 yo

What commonly causes osteomyelitis?

Mostly staph aureus Can be H Influenzae, Group B Strep or E Coli (neonates) Sickle cell - salmonella osteomyelitis

How do children get osteomyelitis?

Haematological spread from remote source Direct contact with infection - trauma

How does osteomyelitis present?

Acutely febrile and bacteraemic Painful, immobile lower limb Swelling, erythema, warm tender limb Pain worse on movement

How is osteomyelitis diagnosed?

FBC - acute phase reactants (CRP, WBC, ESR) elevated Culture - blood. and bone MRI

How is osteomyelitis managed?

Surgical debridement | 4-6 weeks flucloxacillin

What is septic arthritis?

Purulent infection of a joint space that can result in bone destruction and considerable disability

When is incidence of septic arthritis highest?

<3yo

What can cause septic arthritis?

Staph Aureus Haematogenous origin Osteomyelitis Infected skin lesions Puncture wounds

Where does septic arthritis most commonly affect?

Infants - hip Older children - knee

How does septic arthritis present?

``` Often no localising signs Pain on active and passive movement Fever and acutely bacteraemic Limp Swollen warm joint Refuse to weight bear Infants often hold limb rigid ```

How is septic arthritis investigated?

FBC - CRP, WCC, ESR raised Culture Synovial fluid examination - leukocyte count, gram stain, culture USS - effusion Can use MRI/CT

How is septic arthritis managed?

Surgical drainage - if recurrent or affect hip | 3 weeks IV flucloxacillin then oral for 2 weeks

What is the most common cause of hip pain in children?

Transient synovitis

Between what ages do children typically get transient synovitis?

3-8 years old

What causes transient synovitis?

Inflammation of the synovium

How does transient synovitis present?

``` Post viral infection Hip, groin and thigh pain Reluctant to weight bear Passive movements painful at extreme range of motion Low grade fever but systemically well ```

What must be excluded if you consider transient synovitis as a diagnosis?

Septic arthritis

How would you investigate transient synovitis?

FBC - inflammatory markers Blood cultures Xray - frog, lateral and AP (can see increased joint space) USS and MRI - may show joint effusion and thickened synovium

How is transient synovitis managed?

Self limiting - resolve within week | Supportive measures - analgesia, avoid strenuous activity

If a child comes in with a limp, what differentials would you consider?

``` Transient synovitis Septic arthritis Osteomyelitis Juvenile idiopathic arthritis Trauma DDH Perthes disese Slipped upper femoral epiphysis ```

What history would point to a limp being due to transient synovitis?

Acute onset Accompanying viral infection - child only have mild fever Boy 2-12 yo

What would point to a limp being due to septic arthritis or osteomyelitis?

High fever | Unwell child

What would point to a limp being due to juvenile idiopathic arthritis?

Limp painless

What would point to Developmental Dysplasia of the Hip as the cause for a limp?

Detected in neonates | 6x more common in girls

What would point to Perthes disease as the cause for a limp?

4-8 yo | Avascular necrosis of femoral head

What happens in Slipped Upper Femoral Epiphysis?

Displacement of femoral head epiphysis postero-inferiorly 10-15yo Mostly obese boys

What features of a limp would require urgent same day assessment?

``` <3yo >9yo with reduced ROM particularly internal rotation Not weight beating Severe pain Neurovascular compromise Waking at night in pain Night sweat Weight loss Fever ```

What happens in rickets?

Inadequate mineralisation of bone matrix before closure of growth plates

What are causes of Rickets?

``` Lack of sunlight Reduced Vit D in diet Malabsorption Liver disease Renal disease Anticonvulsants Lack of dietary calcium ```

What are some key risk factors for rickets?

Dark skin Vegetarian Exclusively breast fed beyond 6 months

Where do we get vitamin d?

90% sunlight | 10% diet - oily fish, liver, egg yolk

What features are indicative of rickets?

``` Delayed closure of fontanelles Frontal bossing Dental hypoplasia Pectus carinatum Swelling in wrist and ankles Wide sutures Craniotabes Rachitic rosary Harrison's sulcus Bowing of legs Delayed growth Waddling gait and pain ```

What is rachitic rosary?

Prominent knobs of bone at the costochondral joints Can lead to chest infections

What is Harrisons's sulcus?

Horizontal groove along the lower border of the thorax corresponding to the costal insertion of the diaphragm

How is Rickets diagnosed?

Wrist X-Ray - metaphysical cupping, fraying and splaying

How would you investigate rickets?

LFT U&E FBC - anaemia - malabsorption Calcium, phosphate, PTH

How is rickets managed?

Normalise within 3 months of treatment Oral calciferol Calcium supplements Advice on sun and diet