Paediatric orthopaedics Flashcards
A 2yo boy is referred to a paediatrician due to poor growth. O/E you notice widened wrists + ankles, frontal bossing of skull and Harrison’s sulci.
What is the likely diagnosis and how would you investigate?
Rickets
Diagnosis:
- serum calcium: normal or decreased
- serum phosphorus: decreased
- 25-hydroxyvitamin D: decreased
- LFTs: ALP v. increased
- PTH: increased
- X-ray knees + wrists: widened epiphyseal plate, cupping + fraying of metaphysis
Possible causes:
- coeliac screen
- U+Es and creatinine: ?renal cause
A 2yo boy is diagnosed with rickets due to nutritional deficiency in vitamin D. How would you manage?
- dietary advice e.g. egg yolks + oily fish high in vitamin D
- calcium + cholicalciferol (vitD3) supplementation
Monitor recovery via vitD levels, ALP levels and X-ray.
A 3yo girl presents with stiffness + limp over several weeks. Insidious onset and worse in the mornings. One of her knees is swollen and cannot be straightened. No fever, rashes or other systemic symptoms.
What is the likely diagnosis and how would you investigate?
Juvenile idiopathic arthritis (oligoarthritis)
Ix:
- FBC: anaemia in some subtypes
- ESR + CRP: increased to varying degree
- ANA: +ve in oligoarticular JIA
- rheumatoid factor: +ve in RF +ve polyarticular JIA
What are the management options for JIA?
Management by paeds rheum MDT:
1. lifestyle modification + physio
2. NSAIDs e.g. naproxen
3. corticosteroid joint injections (if oligoarthritis) and/or METHOREXATE + FOLIC ACID
consider low dose PREDNISOLONE PO to allow methotrexate to take effect
4. immunotherapy e.g. ETANERCEPT (TNFa inhibitor) or IVMP if severe refractive disease
Suggest possible risk factors for developmental dysplasia of the hip.
- FHx
- female
- breech presentation
How is DDH screened for in neonates?
- Barlow manoeuvre (adduction): can hip be dislocated posteriorly out of acetabulum?
- Ortolani manoeuvre (abduction): is there a dislocated hip that is relocatable?
A neonate has a positive Barlow test. How should they then be investigated?
What investigation is prefered in children >6/12?
USS hips
AP pelvis X-ray: shallow acetabulum with increased extrusion index, loss of Shenton’s lign…
What are the Mx options for children of different ages with DDH?
Urgent referral to paediatric orthopaedic surgeon:
- <6/12: Pavlik harness with f/u X-ray at 6/12 old
- 6-18/12: closed reduction (+/- adductor tenotomy) + spica casting
- 18mths to 6yrs: open reduction + spica casting
- > 6yrs: salvage osteotomies to increase femoral head coverage and thus load-bearing area of joint
A 6yo boy with a history of corticosteroid use presents with a painless limp. O/E there is gluteal muscle wasting + positive Trendelenberg sign.
What is the likely diagnosis and how would you investigate?
Perthe’s disease
Ix
- bilateral hip X-ray (AP + frog leg)
What are the treatment options for Perthe’s disease?
- Monitoring + mobilisation (+/- spling/brace) if <5yrs or <7yrs with <50% epiphyseal involvement
- Femoral osteotomy (surgical containment to reposition femoral head): if >5 yrs with >50% epiphyseal involvement or >7yrs
- Hip replacement at skeletal maturity if >12 yrs + arthritis
An obese 14yo male presents with R hip + knee pain + limp. There is reduced ROM on that side and positive Trendelenberg’s.
What is the likely diagnosis and how would you investigate?
Slipped capital femoral epiphysis
Ix
1. bilateral hip X-ray (AP + frog leg)
How would you manage a person presenting with SUFE?
- In situ screw fixation (urgent if unstable SUFE)
2. +/- prophylactic pinning of other side (esp. if associated with obesity/metabolic probs)
A 6yo presents to ED with an acutely painful left hip. He can walk for short distances with a limp. O/E leg is abducted + externally rotated, there is reduced ROM and +ve leg roll. Temp. is 37.9.
What is the likely diagnosis and how would you investigate?
Transient synovitis
Bloods
- FBC: WCC <12,000 cells/mm3
- ESR: may be slightly raised but <40 mm/hr
- hip X-ray: typically normal but to rule out differentials
- his USS: if need to rule out septic arthritis
A 6yo boy is diagnosed with transient synovitis. How would you manage him?
advise rest (until no pain/limp) + ibuprofen/paracetamol
A 2yo girl presents to ED with fever (39 degrees) and a hot painful swollen restricted right hip. O/E the leg is held flexed, abducted and externally rotated and there is severe limitation of passive movement. She is unable to weight bear.
What is the likely diagnosis and how would you investigate?
Septic arthritis
- Bloods
- FBC: WCC >12,000 cells/mm3
- ESR: >40mm/hr
- U+Es and LFTs: ?end-organ damage
- blood cultures - synovial fluid aspiration under USS guidance: send for microscopy, culture, sensitivities, gram stain + WCC (>25,000 per high power field)
- hip X ray for baseline
