Paediatric Orthopaedics Flashcards
1
Q
What is stronger ligaments of growth plates? What does this mean?
A
Ligaments stronger than growth plate:
> easy to produce epiphyseal separation
> difficult to produce dislocations or sprains
2
Q
What is the advantages/disadvantages of children’s bone being more porous?
A
> Tolerates more deformation (plasticity)
> Fails in compression as well as tension:
- Buckle fractures
- Green stick fractures
3
Q
What is considered a normal variation?
A
> 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
4
Q
What are the subtle differences in physiological development?
A
> Change in shape/ angle/ appearance with growth
> Normal development:
- Femoral anteversion
- Bow legs
- Flat feet
5
Q
Examples of self correcting or non-concerning pathologies?
A
> Persistent femoral anteversion
Metatarsus adductus
Posterior tibial bowing
Curly toes
6
Q
Common presenting parental concerns (Excluding true pathology)
A
> Out toeing > In toeing > Bow legs > Knock knees > Tiptoe walking > Flat feet > Curved feet > Curly toes
7
Q
David jones system of assessment - Normal variants?
A
David Jones system > Symmetrical- yes > Symptomatic- no > Systemic illness- no > Skeletal dysplasia- no > Stiffness-no
8
Q
What is the aim of assessment in paediatric orthopaedics?
A
> 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- Out of date practices
9
Q
Rotational alignment is usually?
A
Axial
10
Q
Angular alignment is usually?
A
Coronal
11
Q
Why is there a change in feet-walking patterns throughout childhood?
A
Change is related to rotational changes at the hip, tibia and foot
12
Q
When there is intoeing in a child what should be checked?
A
Identify origin of rotational concern:
- Hip
- Tibia
- Foot
13
Q
At birth are the hips more internally or externally rotated, why?
A
Externally rotate due to the ST contractors of the hip at birth
14
Q
If anteversion is excessive during development of the hip what occurs?
A
Internal rotation of the leg and will give the appearance of intoeing
15
Q
What would you see with the knee cap in intoeing - What is the importance of this?
A
Face inwards if the pathology is arising from the hips - This is considered a correctable pathology
16
Q
How is tibial torsion assessed?
A
Clinically assessed:
> Thigh foot angle technique
> Patellae position with feet/ ankles facing forward
17
Q
Is internal tibial torsion normal?
A
> An element of internal tibial torsion is normal
> Combination of in utero moulding and tibial shape
18
Q
What is normal forefoot adduction?
A
Normal is between the 2nd and 3rd toe
19
Q
What is mild forefoot adduction?
A
The third toe
20
Q
What is moderate forefoot adduction?
A
Between third and fourth toe
21
Q
What is severe forefoot adduction?
A
Between the fourth and fifth toe
22
Q
How is leg alignment in early life (1-2 yrs)?
A
Vanus
23
Q
How is leg alignment in early life (2-4 yrs)?
A
Valgus
24
Q
What is the mean age of walking age?
A
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
25
Causes of intoeing as a child?
> Femoral anteversion
> Int. tibial torsion
> Metatarsus adductus
26
Is intoeing an issue as a child?
No it will not cause issues in degeneration or sports performance
27
What is the fix for intoeing?
Fracturing and fixation this is very rarely ever needed
28
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
29
How does someone present with internal tibial torsion?
Increased thigh foot angle, 90% spontaneously resolve though
30
At which age should intoeing be corrected, how?
At age 10, surgery can be considered
31
When is flexible flat foot normal?
At birth, this will diminish with age even if it doesn't it is not a worry
32
What indicates flexible flat foot, what is important?
Plantar flexion demonstrate the arch appearing, referral is not required for fixed flat foot
33
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
34
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’
35
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
36
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)
37
Stride length?
Stride Length =
> Distance between successive points of heel contact of the same foot
> Double the step length (in normal gait)
38
Walking base?
Walking Base =
> Side-to-side distance between the line of the two feet
> Also known as ‘stride width’
39
Cadence?
Cadence =
> Number of steps per unit time
> Normal: 100 – 115 steps/min
> Cultural/social variations
40
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)
41
Comfortable walking speed?
Comfortable Walking Speed (CWS) =
> Least energy consumption per unit distance
> Average= 80 m/min (~ 5 km/h , ~ 3 mph)
42
Phase of gait?
1) Stance phase = Reference limb in contact with floor
| 2) Swing phase = Reference not in contact with the floor
43
Single support in gait cycle?
Single Support: only one foot in contact with the floor
44
Double support support in gait cycle?
Double Support: both feet in contact with floor
45
Stance phase of gait?
1. Heel contact: ‘Initial contact’
2. Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
3. Midstance: greater trochanter in alignment w. vertical bisector of foot
4. Heel-off: ‘Terminal stance’
5. Toe-off: ‘Pre-swing’
46
Swing phase of gait?
1. Acceleration: ‘Initial swing’
2. Midswing: swinging limb overtakes the limb in stance
3. Deceleration: ‘Terminal swing’
47
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%
48
With increasing walking speed stand phase....
Decreases
49
With increasing walking speed swing phase...
Increase
50
With increasing walking speed double support...
Decreases
51
Definition of running?
> By definition: walking without double support
> Ratio stance/swing reverses
> Double support disappears. ‘Double swing’ develops
52
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
53
Centre of gravity - Vertical displacement?
```
> Rhythmic up & down movement
> Highest point: midstance
> Lowest point: double support
> Average displacement: 5cm
> Path: extremely smooth sinusoidal curve
```
54
Centre of gravity - lateral displacement?
> Rhythmic side-to-side movement
> Lateral limit: midstance
> Average displacement: 5cm
> Path: extremely smooth sinusoidal curve
55
Centre of gravity - overall displacement?
> Sum of vertical & horizontal displacement
| > Figure ‘8’ movement of CG as seen from AP view
56
Forces that have the most significance influence on gait are?
(1) gravity
(2) muscular contraction
(3) inertia
(4) floor reaction
57
Common Gait abnormalities?
> Antalgic Gait
> Lateral Trunk tilt - Trendelenberg
> Functional Leg-Length Discrepancy
> Increased Walking Base
> Inadequate Dorsiflexion Control
> Excessive Knee Extension
58
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
59
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
```
60
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
```
61
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
```
62
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
63
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
```
64
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
65
When there is knee pain what should you think of?
Hip
66
When there is night pain what should you think of in orthopaedics?
Infection or tumour until proved otherwise
67
When there is night pain what should you think of in orthopaedics?
Infection or tumour until proved otherwise
68
Angular alignment?
> Knocked knees
> Bow legs
> Flat feet
Occasional underlying pathology that may require treatment but usually a combination of normal physiology and variation
69
After what age id there is still bowing of the legs when should a pathology be considered?
The age of 8
70
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
71
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
72
What is assessed in rotation profile examination - Supine?
```
Supine
> Leg lengths
> Hips
> Galeazzi
> FFD
> ROM
```
73
What is assessed in rotation profile examination - Prone?
```
Prone
> Staheli Rotational:
- Profile
- Hip rotation/ version
- Thigh foot angle
- Foot bisector line
```
74
When born is a child varus or valgas?
Varus up until around 2 at which point it begins to become valgas
75
At which age is valgas normal
Around 3 leading into teen years when they straighten
76
What is varus?
Outwards bowing of the legs, measure distance between knees
77
What is valgas?
Inwards bowing of the legs, measure distance between ankles to determine
78
At which age should varus be referred to an orthopaedic surgeon?
After >18 months old
79
When should Valgas be referred to an orthopaedic surgeon?
1) <18 months old
2) >7 years old
3) Non-symmetric
80
What is the mean waling age?
12 months
81
Causes of "intoeing" and tripping?
> Femoral anteversion
> Int. tibial torsion
> Metatarsus adductus
82
When is femoral anterversion normal?
At birth, it is usually around 40o and decreases 1-2o per year reaching 10o by 16years in most
83
How to measure internal tibial rotation?
Thigh foot angle
84
How to manage internal tibial torsion?
> 90% + spontaneously resolve
> Splints
> Wedges
> Insoles
85
How to measure metatarsus adductus?
Forefoot alignment
86
When is flexible flat feet normal?
At birth, it diminishes with age, if not uses insoles
87
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
88
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’
89
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
90
Step length?
Distance between corresponding successive points of heel contact of the opposite feet
Right and left should be equal in normal gait
91
Walking base?
Walking Base =
> Side-to-side distance between the line of the two feet
> Also known as ‘stride width’
92
Cadence?
Cadence =
> Number of steps per unit time
> Normal: 100 – 115 steps/min
> Cultural/social variations
93
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)
94
Comfortable walking speed?
> Least energy consumption per unit distance
| > Average= 80 m/min (~ 5 km/h , ~ 3 mph)
95
Gait cycles phases?
> Stance Phase = reference limb in contact with the floor:
1. Heel contact: ‘Initial contact’
2. Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
3. Midstance: greater trochanter in alignment w. vertical bisector of foot
4. Heel-off: ‘Terminal stance’
5. Toe-off: ‘Pre-swing’
> Swing Phase = reference limb not in contact with the floor
1. Acceleration: ‘Initial swing’
2. Midswing: swinging limb overtakes the limb in stance
3. Deceleration: ‘Terminal swing’
96
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
97
Stance versus swing phase time frame?
```
Stance = 60% of gait cycle
Swing = 40% of gait cycle
```
98
Single versus double support gait cycle time frame?
Single support = 40% of gait cycle
| Double support = 20%
99
With increases walking speed what happens to the stance phase of the gait cycle?
Decreases
100
With increases walking speed what happens to the swing phase of the gait cycle?
Increases
101
With increases walking speed what happens to the double support of the gait cycle?
Decreases
102
What is the definition of running?
Walking without double support
103
What happens to the stance and swing phases during running?
1) Ratio of stance:swing phases reverse
| 2) Double support disappears. ‘Double swing’ develops
104
Where is the centre of gravity?
> Midway between the hips
| > Few cm in front of S2
105
Vertical displacement of centre of gravity?
Up and down
106
Horizontal displacement of centre of gravity?
Side to side
107
Overall displacement of centre of gravity?
Sum of vertical & horizontal displacement
108
Forces that influence gait?
(1) gravity
(2) muscular contraction
(3) inertia
(4) floor reaction
109
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
110
Common gait abnormalities - Antalgic Gait?
> Gait pattern in which stance phase on affected side is shortened
> Corresponding increase in stance on unaffected side
111
Common gait abnormalities - Antalgic Gait, common causes?
> Splinter in foot
> OA
> Tendinitis
112
Common gait abnormalities - Lateral Trunk tilt?
> Trendelenberg gait
> Usually unilateral
> Bilateral = waddling gait
113
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
```
114
Common gait abnormalities - Functional Leg-Length Discrepancy?
Swing leg: longer than stance leg
115
Common gait abnormalities - Functional Leg-Length Discrepancy, compensations?
```
4 common compensations:
A. Circumduction
B. Hip hiking
C. Steppage
D. Vaulting
```
116
What is normal walking base?
5-10cm
117
Common gait abnormalities - increased walking base, causes?
Common causes:
> Deformities
- Abducted hip
- Valgus knee
> Instability
- Cerebellar ataxia
- Proprioception deficits
118
Common gait abnormalities - Inadequate Dorsiflexion Control?
> In stance phase (Heel contact – Foot flat): Foot slap
> In swing phase (mid-swing): Toe drag
119
Common gait abnormalities - Inadequate Dorsiflexion Control, causes?
Causes:
> Weak Tibialis Ant.
> Spastic plantarflexors
120
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
121
Common gait abnormalities - Excessive knee extension, common causes?
Common causes:
> Quadriceps weakness (mid-stance)
> Quadriceps spasticity (mid-stance)
> Knee flexor weakness (end-stance)
122
What are the 5 S's?
Symptoms
Symmetry
Stiffness
Syndromes
Systemic Illness
123
If there is knee pain what should you think?
Hip
124
if there is night pain what should you think?
Infection or tumour (Until proven otherwise)
125
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
126
Types of fractures of the forearm in children?
1) Shaft fracture
2) Special cases:
- Galeazzi
- Monteggia
3) Distal radial fractures
127
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.
128
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
129
Low energy leads to which type of fractures?
1) Greenstick
| 2) Buckle
130
High energy leads to which type of fractures?
Open, displaced, soft tissue injury
131
Forearm fractures make up what percentage of all paediatric fractures?
25-50%
132
Which part of the forearm is usually damaged in children forearm fractures?
Distal
133
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
134
Surgical indications in <9 years forearm fractures?
>15 angulation
| >45 malrotation
135
Surgical indications in >9 years forearm fractures?
1)Proximal:
> 10 angulation
> 30 malrotation
2) Distal:
> 15angulation
136
How many years of growth needs to be remaining to allow flexible nailing?
Need 2yrs predicted growth remaining
137
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
138
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
```
139
How is a buckle fracture of the distal radius managed?
Cast 3-4 weeks
140
How is a greenstick fracture of the distal radius managed?
Cast 4-6 weeks
141
Risk for remanipulation in distal radius fractures?
Complete fractures
failed anatomic reduction
NOT B/E pop
142
Knee trauma differential?
```
Infection
Inflammatory arthropathy
Neoplasm
Apophysitis
Hip
Foot
Sickle, Haemophilia
‘Anterior knee pain’
```
143
Bony injuries of the knee?
```
Physeal/Metaphyseal
Tibial spine
Tibial tubercle
Patellar fracture
Sleeve fracture
Patellar dislocation
Referred
```
144
How many physeal plates within the femur and tibia?
2 Femoral: 1 tibial
145
What is the importance of physeal injury?
Importance = Blood vessels have high risk of injury and femurs grow rapidly and large
146
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
147
Average growth of the femur per year?
11mm
148
Average growth of the tibia per year?
6mm
149
How to manage physeal injury?
> Cast immobilise
> Percutaneous fix
> ORIF articular displacement
> ROM early <6/52
150
How to monitor physeal?
Harris lines, angulation & length
151
How to manage physic arrest?
> Resect Bar
> Complete epiphysiodesis
> Contralateral epiphysiodesis
> Corrective osteotomy
152
How is hinged tibial spine classified by Meyers & McKeever?
Group II
153
How is displaced tibial spine classified by Meyers & McKeever?
Group III
154
How is undisplaced tibial spine classified by Meyers & McKeever?
Group I
155
How are Group I/II Meyers & McKeever classification of tibial spine managed?
Long leg cast
156
How are Group II/III Meyers & McKeever classification of tibial spine managed?
ORIF/AxIF
157
How are tibial spine classified?
Meyers & McKeever classification
158
How are tibial tubercle classified?
Ogden classification
159
Group I Ogden classification - Tibial tubercle?
Distal avulsion
160
Group II Ogden classification - Tibial tubercle?
To prox tibial physis (not joint)
161
Group III Ogden classification - Tibial tubercle?
To prox tibial physis (into joint)
162
How to manage an undisplaced patellar fracture?
Cylinder cast
163
How to manage an displaced patellar fracture?
ORIF
164
Risk factors for patella dislocation?
Risk factors
- Laxity,
- Poor VMO,
- Q angle,
- Femoral anteversion,
- Tibial ext rotation
- Patella alta
165
How to image osteochondral lesions?
```
Plain films (Tunnel view)
+/- MRI
```
166
How to manage type I osteochondral lesions?
Type I (cartilage intact) - immobilise
167
How to manage type II and III osteochondral lesions?
Type II (flap) & III (fragment) - drilling/fix
168
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
169
Ankle fracture classification - Mechanistic ?
Lauge-Hansen, Dias-Tachdjian
- Helpful with reduction
- Poor interobserver reliability
170
Ankle fracture classification - Anatomical?
> Salter-Harris
- Good reproducibility
- Prognostic value
> Vahvanen & Aalto
171
Assessment of an ankle fracture?
> History – Mechanism
> Deformity
> Soft tissues
> AP & lateral radiographs – Ottawa rules
172
Assessment of an ankle fracture?
> History – Mechanism
> Deformity
> Soft tissues
> AP & lateral radiographs – Ottawa rules
173
Management of ankle SH1?
> Displaced <3mm – POP 6
> Displaced >3mm – MUA,POP 6
174
Management of ankle SH2?
> Displaced <3mm – POP 4+2
> Displaced >3mm – MUA,POP
> Persistent displacement - Open reduction
175
Management of ankle SH3?
> Undisplaced – POP 6
> Displaced – (Open) red’n
& interfrag screw
176
Management of ankle SH4?
> ORIF
> Monitor for growth arrest
177
Ankle - Transitional Fractures - Tillaux?
> External rotation
> Anterior tibiofib lig avulsion
> SH3
> Closed/Open reduction
178
Ankle - Transitional Fractures-- Triplane?
> External rotation
> SH3 on AP + SH2 on lat = SH4
> 2 - 3 - 4 part
> CT, ORIF
179
Pros and cons of physis in children?
Pro = Remodelling
Con = Slip, arrest, overgrowth
180
Pros and cons of bone in children?
Pro = Simple fractures, Quick heal
Con = Plastic deformity
181
Pros and cons of periosteum in children?
Pro = Hinge
Con = Block red'n
182
Pros and cons of ligaments in children?
Pro = Protect joint
Con = Physis fracture
183
Pros and cons of cartilage in children?
Pro = Resilient
Con = Imaging
184
Overuse injuries in children?
1) Osgood-Schlatter's Disease
| 2) Sever's Disease = Growth plate inflammation on the calcaneus
185
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 #
