Paediatric Orthopaedics Flashcards
What is stronger ligaments of growth plates? What does this mean?
Ligaments stronger than growth plate:
> easy to produce epiphyseal separation
> difficult to produce dislocations or sprains
What is the advantages/disadvantages of children’s bone being more porous?
> Tolerates more deformation (plasticity)
> Fails in compression as well as tension:
- Buckle fractures
- Green stick fractures
What is considered a normal variation?
> Describes a specific pattern of normality for that population/ age
> The range: conventionally lying between 2 Standard deviations from the mean, Gaussian distribution (97% of individuals for that group)
> Data is pop/ age specific
> By definition there will be children who fall out with the norm who have no underlying pathology
What are the subtle differences in physiological development?
> Change in shape/ angle/ appearance with growth
> Normal development:
- Femoral anteversion
- Bow legs
- Flat feet
Examples of self correcting or non-concerning pathologies?
> Persistent femoral anteversion
Metatarsus adductus
Posterior tibial bowing
Curly toes
Common presenting parental concerns (Excluding true pathology)
> Out toeing > In toeing > Bow legs > Knock knees > Tiptoe walking > Flat feet > Curved feet > Curly toes
David jones system of assessment - Normal variants?
David Jones system > Symmetrical- yes > Symptomatic- no > Systemic illness- no > Skeletal dysplasia- no > Stiffness-no
What is the aim of assessment in paediatric orthopaedics?
> What are the parental worries
> Is it a ‘normal variant’?
1) No
- Spot true pathology
- Is the pathology concerning, will it self correct?
2) Yes:
- Future development concerns
- Out of date practices
Rotational alignment is usually?
Axial
Angular alignment is usually?
Coronal
Why is there a change in feet-walking patterns throughout childhood?
Change is related to rotational changes at the hip, tibia and foot
When there is intoeing in a child what should be checked?
Identify origin of rotational concern:
- Hip
- Tibia
- Foot
At birth are the hips more internally or externally rotated, why?
Externally rotate due to the ST contractors of the hip at birth
If anteversion is excessive during development of the hip what occurs?
Internal rotation of the leg and will give the appearance of intoeing
What would you see with the knee cap in intoeing - What is the importance of this?
Face inwards if the pathology is arising from the hips - This is considered a correctable pathology
How is tibial torsion assessed?
Clinically assessed:
> Thigh foot angle technique
> Patellae position with feet/ ankles facing forward
Is internal tibial torsion normal?
> An element of internal tibial torsion is normal
> Combination of in utero moulding and tibial shape
What is normal forefoot adduction?
Normal is between the 2nd and 3rd toe
What is mild forefoot adduction?
The third toe
What is moderate forefoot adduction?
Between third and fourth toe
What is severe forefoot adduction?
Between the fourth and fifth toe
How is leg alignment in early life (1-2 yrs)?
Vanus
How is leg alignment in early life (2-4 yrs)?
Valgus
What is the mean age of walking age?
12 months
This isn’t normal though, it is common for children to not walk until up to 18months-2yrs it is more important that they show progress between crawling etc
Causes of intoeing as a child?
> Femoral anteversion
Int. tibial torsion
Metatarsus adductus
Is intoeing an issue as a child?
No it will not cause issues in degeneration or sports performance
What is the fix for intoeing?
Fracturing and fixation this is very rarely ever needed
Measuring femoral anteveriosn?
1) Lay in prone position
2) Flex knee 90o
3) Externally rotate and measure the degree
40o is normal at birth, 80% reach 10o by 16 years
How does someone present with internal tibial torsion?
Increased thigh foot angle, 90% spontaneously resolve though
At which age should intoeing be corrected, how?
At age 10, surgery can be considered
When is flexible flat foot normal?
At birth, this will diminish with age even if it doesn’t it is not a worry
What indicates flexible flat foot, what is important?
Plantar flexion demonstrate the arch appearing, referral is not required for fixed flat foot
How is gait analysed?
Observational
> Equipment: Eyes and floor!
> Limitation: Single aspect, real time
Video
> Equipment: Camera and floor.
> Limitation: Single/orthogonal view
3D instrumented
> Equipment: Lab, force plates, EMG
> Limitation: >5y, walker
Normal gait?
> Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity
> Series of ‘controlled falls’
Gait cycle?
Gait Cycle =
> Single sequence of functions by one limb
> Begins when reference font contacts the ground
> Ends with subsequent floor contact of the same foot
Step length?
Step Length =
> Distance between corresponding successive points of heel contact of the opposite feet
> Rt step length = Lt step length (in normal gait)
Stride length?
Stride Length =
> Distance between successive points of heel contact of the same foot
> Double the step length (in normal gait)
Walking base?
Walking Base =
> Side-to-side distance between the line of the two feet
> Also known as ‘stride width’
Cadence?
Cadence =
> Number of steps per unit time
> Normal: 100 – 115 steps/min
> Cultural/social variations
Velocity?
Velocity =
> Distance covered by the body in unit time
> Usually measured in m/s
> Instantaneous velocity varies during the gait cycle
> Average velocity (m/min) = step length (m) x cadence (steps/min)
Comfortable walking speed?
Comfortable Walking Speed (CWS) =
> Least energy consumption per unit distance
> Average= 80 m/min (~ 5 km/h , ~ 3 mph)
Phase of gait?
1) Stance phase = Reference limb in contact with floor
2) Swing phase = Reference not in contact with the floor
Single support in gait cycle?
Single Support: only one foot in contact with the floor
Double support support in gait cycle?
Double Support: both feet in contact with floor
Stance phase of gait?
- Heel contact: ‘Initial contact’
- Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
- Midstance: greater trochanter in alignment w. vertical bisector of foot
- Heel-off: ‘Terminal stance’
- Toe-off: ‘Pre-swing’
Swing phase of gait?
- Acceleration: ‘Initial swing’
- Midswing: swinging limb overtakes the limb in stance
- Deceleration: ‘Terminal swing’
Time frame in gait?
A. Stance vs. Swing:
> Stance phase = 60% of gait cycle
> Swing phase = 40%
B. Single vs. Double support:
> Single support = 40% of gait cycle
> Double support= 20%
With increasing walking speed stand phase….
Decreases
With increasing walking speed swing phase…
Increase
With increasing walking speed double support…
Decreases
Definition of running?
> By definition: walking without double support
> Ratio stance/swing reverses
> Double support disappears. ‘Double swing’ develops
Centre of gravity?
Center of Gravity (CG):
> midway between the hips
> Few cm in front of S2
Least energy consumption if CG travels in straight line
Centre of gravity - Vertical displacement?
> Rhythmic up & down movement > Highest point: midstance > Lowest point: double support > Average displacement: 5cm > Path: extremely smooth sinusoidal curve
Centre of gravity - lateral displacement?
> Rhythmic side-to-side movement
Lateral limit: midstance
Average displacement: 5cm
Path: extremely smooth sinusoidal curve
Centre of gravity - overall displacement?
> Sum of vertical & horizontal displacement
> Figure ‘8’ movement of CG as seen from AP view
Forces that have the most significance influence on gait are?
(1) gravity
(2) muscular contraction
(3) inertia
(4) floor reaction
Common Gait abnormalities?
> Antalgic Gait
> Lateral Trunk tilt - Trendelenberg
> Functional Leg-Length Discrepancy
> Increased Walking Base
> Inadequate Dorsiflexion Control
> Excessive Knee Extension
Common Gait abnormalities - Antalgic gait?
> Gait pattern in which stance phase on affected side is shortened
> Corresponding increase in stance on unaffected side
> Common causes: Splinter in foot (!), OA, tendinitis
Common Gait abnormalities - lateral trunk tilt?
> Trendelenberg gait
> Usually unilateral
> Bilateral = waddling gait
> Common causes: A. Painful hip B. Hip abductor weakness C. Leg-length discrepancy D. Abnormal hip joint
Common Gait abnormalities - Functional Leg-Length Discrepancy?
> Swing leg: longer than stance leg
> 4 common compensations: A. Circumduction B. Hip hiking C. Steppage D. Vaulting
Common Gait abnormalities - Increased Walking Base?
> Normal walking base: 5-10 cm
> Common causes: A) Deformities: - Abducted hip - Valgus knee B) Instability: - Cerebellar ataxia - Proprioception deficits
Common Gait abnormalities - Inadequate Dorsiflexion Control?
> In stance phase (Heel contact – Foot flat): Foot slap
> In swing phase (mid-swing): Toe drag
> Causes:
- Weak Tibialis Ant.
- Spastic plantarflexors
What does Trendelenburg sign indicate?
A positive test is one in which the pelvis drops on the contralateral side during a single leg stand on the affected side.
A positive Trendelenburg test usually indicates weakness in the hip abductor muscles: gluteus medius and gluteus minimus.
Think: A. Painful hip B. Hip abductor weakness C. Leg-length discrepancy D. Abnormal hip joint
The 5 S’s in Ortho?
Symptoms – night pain, NWB
Symmetry – lack of it!
Stiffness – of joints, paralysis, Knees = Hips
Syndromes – associated features
Systemic Illness - pyrexia
When there is knee pain what should you think of?
Hip
When there is night pain what should you think of in orthopaedics?
Infection or tumour until proved otherwise
When there is night pain what should you think of in orthopaedics?
Infection or tumour until proved otherwise
Angular alignment?
> Knocked knees
Bow legs
Flat feet
Occasional underlying pathology that may require treatment but usually a combination of normal physiology and variation
After what age id there is still bowing of the legs when should a pathology be considered?
The age of 8
Why do babies naturally have flat feet?
Due to a large medial fat pad in their arch and have not yet learnt to walk or weight bear
Tests to determine foot arch abnormalities?
> Heel raise test
> Jacks test
> Foot rotational alignment
> Foot progression in gait
> Standing:
- Alignment from front
- Patella position
- Heels/ arch/ toes/ leg length from behind
> Tip toes (If old enough)
> Staheli rotational profile
What is assessed in rotation profile examination - Supine?
Supine > Leg lengths > Hips > Galeazzi > FFD > ROM
What is assessed in rotation profile examination - Prone?
Prone > Staheli Rotational: - Profile - Hip rotation/ version - Thigh foot angle - Foot bisector line
When born is a child varus or valgas?
Varus up until around 2 at which point it begins to become valgas
At which age is valgas normal
Around 3 leading into teen years when they straighten
What is varus?
Outwards bowing of the legs, measure distance between knees
What is valgas?
Inwards bowing of the legs, measure distance between ankles to determine
At which age should varus be referred to an orthopaedic surgeon?
After >18 months old
When should Valgas be referred to an orthopaedic surgeon?
1) <18 months old
2) >7 years old
3) Non-symmetric
What is the mean waling age?
12 months
Causes of “intoeing” and tripping?
> Femoral anteversion
Int. tibial torsion
Metatarsus adductus
When is femoral anterversion normal?
At birth, it is usually around 40o and decreases 1-2o per year reaching 10o by 16years in most
How to measure internal tibial rotation?
Thigh foot angle
How to manage internal tibial torsion?
> 90% + spontaneously resolve
Splints
Wedges
Insoles
How to measure metatarsus adductus?
Forefoot alignment
When is flexible flat feet normal?
At birth, it diminishes with age, if not uses insoles
How is gait analysed?
1) Observation:
- Equipment: Eyes and floor
- Limitation: Single aspect, real time
2) Video:
- Equipment: Camera and floor
- Limitation: Single view
3) 3D instrumented:
- Equipment: Labe, force plates, EMG
- Limitation: >5y, walker
Gait definition?
Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity
series of ‘controlled falls’
Gait cycle?
Gait Cycle =
1) Single sequence of functions by one limb
2) Begins when reference font contacts the ground
3) Ends with subsequent floor contact of the same foot
Step length?
Distance between corresponding successive points of heel contact of the opposite feet
Right and left should be equal in normal gait
Walking base?
Walking Base =
> Side-to-side distance between the line of the two feet
> Also known as ‘stride width’
Cadence?
Cadence =
> Number of steps per unit time
> Normal: 100 – 115 steps/min
> Cultural/social variations
Velocity?
Velocity =
> Distance covered by the body in unit time
> Usually measured in m/s
> Instantaneous velocity varies during the gait cycle
> Average velocity (m/min) = step length (m) x cadence (steps/min)
Comfortable walking speed?
> Least energy consumption per unit distance
> Average= 80 m/min (~ 5 km/h , ~ 3 mph)
Gait cycles phases?
> Stance Phase = reference limb in contact with the floor:
- Heel contact: ‘Initial contact’
- Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
- Midstance: greater trochanter in alignment w. vertical bisector of foot
- Heel-off: ‘Terminal stance’
- Toe-off: ‘Pre-swing’
> Swing Phase = reference limb not in contact with the floor
- Acceleration: ‘Initial swing’
- Midswing: swinging limb overtakes the limb in stance
- Deceleration: ‘Terminal swing’
Single versus double support gait cycle?
(1) Single Support: only one foot in contact with the floor
(2) Double Support: both feet in contact with floor
Stance versus swing phase time frame?
Stance = 60% of gait cycle Swing = 40% of gait cycle
Single versus double support gait cycle time frame?
Single support = 40% of gait cycle
Double support = 20%
With increases walking speed what happens to the stance phase of the gait cycle?
Decreases
With increases walking speed what happens to the swing phase of the gait cycle?
Increases
With increases walking speed what happens to the double support of the gait cycle?
Decreases
What is the definition of running?
Walking without double support
What happens to the stance and swing phases during running?
1) Ratio of stance:swing phases reverse
2) Double support disappears. ‘Double swing’ develops
Where is the centre of gravity?
> Midway between the hips
> Few cm in front of S2
Vertical displacement of centre of gravity?
Up and down
Horizontal displacement of centre of gravity?
Side to side
Overall displacement of centre of gravity?
Sum of vertical & horizontal displacement
Forces that influence gait?
(1) gravity
(2) muscular contraction
(3) inertia
(4) floor reaction
Common gait abnormalities?
1) Antalgic Gait
2) Lateral Trunk tilt - Trendelenberg
3) Functional Leg-Length Discrepancy
4) Increased Walking Base
5) Inadequate Dorsiflexion Control
6) Excessive Knee Extension
Common gait abnormalities - Antalgic Gait?
> Gait pattern in which stance phase on affected side is shortened
> Corresponding increase in stance on unaffected side
Common gait abnormalities - Antalgic Gait, common causes?
> Splinter in foot
OA
Tendinitis
Common gait abnormalities - Lateral Trunk tilt?
> Trendelenberg gait
Usually unilateral
Bilateral = waddling gait
Common gait abnormalities - Lateral Trunk tilt, common causes?
Common causes: A. Painful hip B. Hip abductor weakness C. Leg-length discrepancy D. Abnormal hip joint
Common gait abnormalities - Functional Leg-Length Discrepancy?
Swing leg: longer than stance leg
Common gait abnormalities - Functional Leg-Length Discrepancy, compensations?
4 common compensations: A. Circumduction B. Hip hiking C. Steppage D. Vaulting
What is normal walking base?
5-10cm
Common gait abnormalities - increased walking base, causes?
Common causes:
> Deformities
- Abducted hip
- Valgus knee
> Instability
- Cerebellar ataxia
- Proprioception deficits
Common gait abnormalities - Inadequate Dorsiflexion Control?
> In stance phase (Heel contact – Foot flat): Foot slap
> In swing phase (mid-swing): Toe drag
Common gait abnormalities - Inadequate Dorsiflexion Control, causes?
Causes:
> Weak Tibialis Ant.
> Spastic plantarflexors
Common gait abnormalities - Excessive knee extension?
> Loss of normal knee flexion during stance phase
> Knee may go into hyperextension
> Genu recurvatum: hyperextension deformity of knee
Common gait abnormalities - Excessive knee extension, common causes?
Common causes:
> Quadriceps weakness (mid-stance)
> Quadriceps spasticity (mid-stance)
> Knee flexor weakness (end-stance)
What are the 5 S’s?
Symptoms
Symmetry
Stiffness
Syndromes
Systemic Illness
If there is knee pain what should you think?
Hip
if there is night pain what should you think?
Infection or tumour (Until proven otherwise)
Children’s fracture principles?
1) Children’s fractures are often simple, incomplete & heal quickly
2) Remodel well in plane of joint movement
3) A thick periosteal hinge is (usually) a friend
4) Fractures involving physes can result in progressive deformity:
- Deformity = elbow
- Arrest = Knee, ankle
- Overgrowth = Femur
Types of fractures of the forearm in children?
1) Shaft fracture
2) Special cases:
- Galeazzi
- Monteggia
3) Distal radial fractures
What is a Galeazzi fracture?
The Galeazzi fracture is a fracture of the distal third of the radius with dislocation of the distal radioulnar joint.
What is a Monteggia fracture?
The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius
Low energy leads to which type of fractures?
1) Greenstick
2) Buckle
High energy leads to which type of fractures?
Open, displaced, soft tissue injury
Forearm fractures make up what percentage of all paediatric fractures?
25-50%
Which part of the forearm is usually damaged in children forearm fractures?
Distal
How is a fracture assessed?
1) History – Mechanism
2) Deformity
3) Soft tissues
- Whole limb
- Wounds
- Sensation, Motor fcn
- Vascular status
4) Radiographs
Repeat after intervention
Surgical indications in <9 years forearm fractures?
> 15 angulation
>45 malrotation
Surgical indications in >9 years forearm fractures?
1)Proximal:
> 10 angulation
> 30 malrotation
2) Distal:
> 15angulation
How many years of growth needs to be remaining to allow flexible nailing?
Need 2yrs predicted growth remaining
Complications of forearm fractures and repair?
1) Compartment syndrome can lead to Volkmann’s contracture due to muscle damage (Ischaemic Necrosis)
2) 5% nonunion or 5% refracture
3) Radioulnar synostosis
- Proximal>distal
- High energy, same level
- Single incision
4) PIN injury
5) Superficial radial nerve injury
6) DRUJ / Radiocapitellar problems
In terms of distal radius fractures what are the acceptable ranges?
Acceptable range > 30 degrees angulation > 45 degrees rotation > 10 degrees angulation > 30 degrees rotation
How is a buckle fracture of the distal radius managed?
Cast 3-4 weeks
How is a greenstick fracture of the distal radius managed?
Cast 4-6 weeks
Risk for remanipulation in distal radius fractures?
Complete fractures
failed anatomic reduction
NOT B/E pop
Knee trauma differential?
Infection Inflammatory arthropathy Neoplasm Apophysitis Hip Foot Sickle, Haemophilia ‘Anterior knee pain’
Bony injuries of the knee?
Physeal/Metaphyseal Tibial spine Tibial tubercle Patellar fracture Sleeve fracture Patellar dislocation Referred
How many physeal plates within the femur and tibia?
2 Femoral: 1 tibial
What is the importance of physeal injury?
Importance = Blood vessels have high risk of injury and femurs grow rapidly and large
Why might there be physeal injury?
Why = due to attachment of the ligaments being below the physes in the femur
> Hyperextension – vascular injury
Varus – CPN injury
SH not predictive
Average growth of the femur per year?
11mm
Average growth of the tibia per year?
6mm
How to manage physeal injury?
> Cast immobilise
Percutaneous fix
ORIF articular displacement
ROM early <6/52
How to monitor physeal?
Harris lines, angulation & length
How to manage physic arrest?
> Resect Bar
Complete epiphysiodesis
Contralateral epiphysiodesis
Corrective osteotomy
How is hinged tibial spine classified by Meyers & McKeever?
Group II
How is displaced tibial spine classified by Meyers & McKeever?
Group III
How is undisplaced tibial spine classified by Meyers & McKeever?
Group I
How are Group I/II Meyers & McKeever classification of tibial spine managed?
Long leg cast
How are Group II/III Meyers & McKeever classification of tibial spine managed?
ORIF/AxIF
How are tibial spine classified?
Meyers & McKeever classification
How are tibial tubercle classified?
Ogden classification
Group I Ogden classification - Tibial tubercle?
Distal avulsion
Group II Ogden classification - Tibial tubercle?
To prox tibial physis (not joint)
Group III Ogden classification - Tibial tubercle?
To prox tibial physis (into joint)
How to manage an undisplaced patellar fracture?
Cylinder cast
How to manage an displaced patellar fracture?
ORIF
Risk factors for patella dislocation?
Risk factors
- Laxity,
- Poor VMO,
- Q angle,
- Femoral anteversion,
- Tibial ext rotation
- Patella alta
How to image osteochondral lesions?
Plain films (Tunnel view) \+/- MRI
How to manage type I osteochondral lesions?
Type I (cartilage intact) - immobilise
How to manage type II and III osteochondral lesions?
Type II (flap) & III (fragment) - drilling/fix
Why is the risk of growth arrest in ankle fractures of children?
As physis is weaker than ligaments so high risk of physis fracture and injury
Ankle fracture classification - Mechanistic ?
Lauge-Hansen, Dias-Tachdjian
- Helpful with reduction
- Poor interobserver reliability
Ankle fracture classification - Anatomical?
> Salter-Harris
- Good reproducibility
- Prognostic value
> Vahvanen & Aalto
Assessment of an ankle fracture?
> History – Mechanism
Deformity
Soft tissues
AP & lateral radiographs – Ottawa rules
Assessment of an ankle fracture?
> History – Mechanism
Deformity
Soft tissues
AP & lateral radiographs – Ottawa rules
Management of ankle SH1?
> Displaced <3mm – POP 6
> Displaced >3mm – MUA,POP 6
Management of ankle SH2?
> Displaced <3mm – POP 4+2
> Displaced >3mm – MUA,POP
> Persistent displacement - Open reduction
Management of ankle SH3?
> Undisplaced – POP 6
> Displaced – (Open) red’n
& interfrag screw
Management of ankle SH4?
> ORIF
> Monitor for growth arrest
Ankle - Transitional Fractures - Tillaux?
> External rotation
> Anterior tibiofib lig avulsion
> SH3
> Closed/Open reduction
Ankle - Transitional Fractures– Triplane?
> External rotation
> SH3 on AP + SH2 on lat = SH4
> 2 - 3 - 4 part
> CT, ORIF
Pros and cons of physis in children?
Pro = Remodelling
Con = Slip, arrest, overgrowth
Pros and cons of bone in children?
Pro = Simple fractures, Quick heal
Con = Plastic deformity
Pros and cons of periosteum in children?
Pro = Hinge
Con = Block red’n
Pros and cons of ligaments in children?
Pro = Protect joint
Con = Physis fracture
Pros and cons of cartilage in children?
Pro = Resilient
Con = Imaging
Overuse injuries in children?
1) Osgood-Schlatter’s Disease
2) Sever’s Disease = Growth plate inflammation on the calcaneus
What are the warning signs of non-accidental injury?
> Incongruent hx
> Bruising – pattern
> Burns
> Multiple fractures, multiple stages of healing
> Metaphyseal #, Humeral shaft #
> Rib #s
> Non-ambulant #
