Paediatric Orthopaedics Flashcards
What is Developmental Dysplasia of the Hip?
Developmental dysplasia of the hip
Represent a spectrum of hip instabilities
What are the types of Developmental Dysplasia of the Hip?
Typical - affect normal infants
Teratological - occur in neurological and genetic conditions (req. specialised management)
Detail the epidemiology of Developmental Dysplasia of the Hip
1-3% of newborns
More often left hip
20% bilateral
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
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 does Developmental Dysplasia of the Hip present?
Limited abduction Leg length discrepancy Asymmetrical gluteal/thigh skin folds Delayed walking Painless limp Waddling gait
How is Developmental Dysplasia of the Hip commonly picked up?
At the 6-8 week screening using Ortolani and Barlow manoeuvres
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
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
What is done if Developmental Dysplasia of the Hip is suspected following Ortolani’s and Barlow’s?
USS <4.5 months
Hip X-Ray
When do hip X-Rays become useful?
After 4-5 months - once femoral head ossified
What are the complications associated with Developmental Dysplasia of the Hip?
Re-dislocations
Avascular necrosis
Degenerative joint disease
How is Developmental Dysplasia of the Hip managed in children under 6 weeks of age?
Wait to see if spontaneously resolve
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
What may be required for older children with Developmental Dysplasia of the Hip?
Surgery
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
What is Perthes’ disease?
Idiopathic disorder resulting in avascular necrosis of the femoral head. Bone remodelling leads to a flattened and enlarged head
What part of the femoral head is specifically affected in Perthes’ disease?
Femoral epiphysis
How long does the cycle of Perthes’ disease take? (from avascular necrosis to remodelling)
3-4 years
What risk factors are associated with Perthes’ disease?
Boys
4-8yo
Family history
How would Perthes’ disease present?
Insidious onset of limp
Stiffness and reduced range of motion
Pain can be intermittent - groin, thigh or knee
How is Perthes’ disease diagnosed?
X-Ray changes
1 Widened joint space
2 Small flat femoral head
How is Perthes disease managed?
<6yo - observe
>6yo - cast, braces and possible surgical intervention
What complications are associated with Perthes’ disease?
Osteoarthritis
Premature fusion of growth plates
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
