Paediatric Orthopaedics Flashcards
what is developmental dysplasia of the hip
spectrum of disorders ranging from subluxation to dysplasia
why is early identification of developmental dysplasia important
because it responds to conservative treatment early on but requires surgery if you leave it
how is developmental dysplasia of the hip screened for
ortolanis and barlows procedure in the newborn examination
if missed at screening, how does developmental dysplasia of the hip usually present
limping, or asymmetrical skin folds
what is the next line investigation for ?developmental dysplasia of the hip
paeds referral + ultrasound of the hip
what is the treatment for developmental dysplasia of the hip
pavlick harness for several months
monitoring via several xrays/USS
surgery if insufficient response or if detected late
why must a pavlick harness be set up by an expert?
incorrect splinting may lead to avascular necrosis
what are the risk factors for developmental dysplasia of the hip?
Breech presentation
Oligohydramnios
Female sex
Family history
Firstborn
what is pes planus
flat feet (loss of medial longitudinal arch)
what condition is marked flat feet common in
hypermobility
when is a rigid flat food pathological
in older children/adolescents as young most young children grow out of it
what are common causes of a pathological flat foot
Teno-achilles ocntracture
Juvenile inflammatory arthropathy
Tarsal coalition
what is positional talipes
mild inversion deformity of the foot due to intrauterine pressure
how do you treat positional talipes
passive manipulation
what is talipes equinovarus
aka club foot
entire foot is inverted and supinated
forefood adducted and heel rotated inwards in plantar flexion
foot is shorter and calf muscle thinner than usual
what are causes of talipes equinovarus
secondary to oligohydramnios
features of malformation syndrome
features of neuromuscular disorders such as spina bifiida
how do you treat talipes equinovarus
Caster plasting and bracing
May be required for many months
Surgery required if unsuccessful
what is scoliosis
abnormal lateral curvature in the spine
what are the causes of scoliosis
most commonly idiopathic
congenital (VACTERL, spina bifida, hemivertebrae)
secondary (neuromuscular imbalance, disorders of bone, leg length discrepancy)
how should you investigate scoliosis
look at spine whilst standing up straight
if disappears when they bend over its postural
what is the management for scoliosis
mild = resolves spontaneously/progresses minimally
severe = specialist referral for bracing
surgery only indicated if there is respiratory/cardiovascular/neurological interference
what is torticollis
flexion/extension/twisting of the muscles in the neck allowing the neck to move beyond what is normal
what is the most common cause of torticollis in infants
SCM tumour
what are common causes of torticollis in kids
muscular spasm
secondary ENT infection
cervical spine arthritis
spinal tumour
what is the management for acute torticollis
Painkiller
Possibly diazepam for muscle relaxation but caution
Exercise of head and neck important to prevent neck stiffening
Heat packs and good posture
Persistence = botox
Surgery reserved for very severe cases – involves severing nerves around the face to help with relaxation
what are common sites of non accidental fractures in children
posterior ribs
long bones
complex skull fractures
usually multiple
what should be ruled out whne reviewing possible non accidental injury fractures
osteogenesis imperfectica
copper deficiency
both can cause decreased fracture thresholds
what is osteomyelitis
infection of the metaphysis (head portion) of the long bones
what are the most common sites for osteomyelitis
distal femur/proximal tibia
what are common causative organisms for osteomyelitis
S.aureus
streptococcus
Hib
Tb
what pathogens are at an increased risk of causing osteomyelitis if the patient has sickle cell disease
salmonella/staph
what are clinical features of osteomyelitis
Painful immobile limb
Acute febrile illness
Local swelling/tenderness with erythema
Pain on movement
Sterile effusion in joint space
May be more insideous In infants where limb immobilisation/swelling is the first sign
when do radiographic changes begin to occur in osteomyelitis
7-10 days
what is the best imagine method to visualise osteomyelitis
MRI
what does chronic osteomyeltitis look like on an XR
periosteal reaction along the shaft
multiple hypodense areas with metaphyseal regions
how do you manage osteomyelitis
IV ABx for several weeks
surgical drainage if required (no rapid response to Abc)
immobilisation of the bone
what are the complications of osteomyelitis
Bone necrosis
Chronic infection
Limb deformity
Amyloidosis
how does subacute osteomyelitis present
insideous onset with mild symptoms over a period of months
Signs include: Swelling Erythema Warmth Pain on movement of the adjacent joint Some joint effusion present Surrounding muscle wasting
what is the average time of diagnosis from inital presentation of symptoms of subacute osteomyelitis
1-6 months
what are symptoms of chronic osteomyelitis
Bone pain
Persistent fatigue
Pus draining from a sinus
Local swelling
Skin changes
Excessive sweating
Chills
what are the risks of untreated osteomyelitis
Left untreated this can spread to other bones, causing widespread infection, sepsis or death
With chronic disease there is destruction of bone which is permanent and may result in the need for amputation due to poor vascularisation of remaining bone
in children, what age group most commonly gets septic arthritis
<2 years
what organisms most commonly cause septic arthritis
staph aureus
Hib
what is the clinical presentation of septic arthritis
Erythematous, warm, acutely tender joint
Reduced range of movement
Unwell, febrile child
Infants cry and hold the limb
There may be joint effusion
In toddlers if the pathology is in the legs there may be a limb or referred knee pain (if hip)
how should you investigate ?septic arthritis in a child
Increases WCC/CRP
Positive blood cultures
USS of deep joints identifies effusions
XR excludes bony trauma and other lesions – but usually normal apart from joint space widening and soft tissue swelling
Bone scan may be helpful
MRI excludes adjacent osteomyelitis
DEFINITIVE MEASURE
Aspiration of joint space and culture under ultrasound guidance
what is the treatment for septic arthritis
Prolonged course of antibiotics – especially IV
Washing out of joint spaces/surgical drainage may be required if resolution does not occur rapidly
Immbolisation of joint in a functional position – but must be mobilised to prevent deformity
what is perthes disease
Avascular necrosis of the capital femoral epiphysis of the femoral head due to the interruption of the blood supply followed be revascularisation and reossification over the next 18-36 months
what is the common gender and age range for perthes disease
boys, 5-10 years old
how does perthes disease present
insideous onset of limping, knee pain hip pain
what is a common differential of perthes disease
transient synovitis
what % of cases is perthes disease bilateral
10-20%
how should perthes disease be investigated
AP, Lateral and frog legs XR
whar radiological signs indicate perthes disease
increased density of the femoral head, subsequently becoming fragmented and more irregular
what is the management for perthes disease
if found early and <50% of femoral head affected = bed rest and traction
more severe disease/late presentation: femoral + pelvic osteotomy with maintained hip abduction
whats the prognosis of perthes disease
Mostly good, Particularly those below the age of 6 with less than half of the epiphyses involved
In older children, or in those with more extensive involvement of the epiphyses, deformity of the femoral head and metaphyseal damage is more likely, with potential for subsequent degenerative arthritis in adult life
what is a slipped upper femoral epiphysis
Postero-inferio displacement of the femoral head requiring prompt treatment in order to prevent avascular necrosis
what patient population is slipped upper femoral epiphysis most common in
overweight 10-15 year old boys
what % of slipped upper femoral epiphysis cases are bilateral
20%
what metabolic abnormalities is slipped upper femoral epiphysis assoicated with
hypogonadism
hypothyroidism
how does slipped upper femoral epiphysis present
limp/hip pain
maybe referred knee pain
restricted abduction and external rotation of the hip
how do you confirm slipped upper femoral epiphysis
XR
frog legs lateral should be included
how do you manage slipped upper femoral epiphysis
Surgical
Pin fixation in situ
This should be based on if the condition is acute (<3 weeks) or chronic and if they can weight bear or not
Post-surgery rehab
Crutches for 6-8 weeks
Physio
Analgesia
NSAIDS
what is transient synovitis
acute hip pain associated with a viral infection
what is the most common cause of hip pain in children
transient synovitis
what is the age range for transient synovitis
kids 2-12
whats the presentation of transient synovitis
Sudden onset pain in hip
No pain at rest
Decreased range of movement
Specifically internal rotation
Afebrile or mild fever
Does not appear ill
what is an important differential for transient synovitis
septic arthritis
how do you manage transient synovitis
Bed rest
Traction
Usually improves within a few days
what kind of inheritence is achondroplasia
autosomal dominant - 50% are new mutations
what are clinical features of achondroplasia
Short stature
Marked shortening of limbs
Large head
Frontal bossing
Depression of nasal bridge
Short + broad hangs
Marked lumbar lordosis
Hydrocephalus – sometimes
what is thanatophoric dysplasia
cause of still birth - infants have large head, extremely short limbs and a small chest
how is cleidocranial disorder inherited
autosomal dominant
what are the features of cleidocranial disorder
Absence of clavicle, delay in closure of anterior fontanelle and/or ossification of the skull
short stature
normal intelligence
patients can bring shoulders to meet in front of their body
what is athorogryposis
Heterogenous group of congenital disorders in which there is stiffness and contracture of joints
what is athorogryposis associated with
oligohydramnios, widespread congeintal anomalies or chromosomal disorders
what type of deformities are common with athorogryposis
Marked flexion of the knees/elbows/wrists + dislocation of the hips and other joints, talipes equinovarus and scoliosis are common
skin is thin
intelligence usually unaffected
whats the management for athorogryposis
physio
correction of deformities
where possible - splints/casts/surgery
what is osteopetrosis
increased density of bone leading to over-deposition of calcium and brittleness
how is osteopetrosis inherited
autosomal recessive
how does osteopetrosis present
FTT
Recurrent infection
Hypocalcaemia
Anaemia
Thrombocytopenia
what cures osteopetrosis
bone marrow transplant
