Paediatric Orthopaedics Flashcards by Alice McQuade

2 normal variants most commonly referred

Intoeing

Flat feet

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3 variations in normal development

Flat feet
Femoral anteversion
Bow legs

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4 self-correcting pathologies in childrens bones

Metatarsal adduction
Persistent femoral anteversion
Posterior tibial bowing
Curly toes

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David Jones 5 S’s for assessing

Symmetry
Symptomatic
Systemic illness
Skeletal disease
Stiffness

Rotational alignment- axial
Angular alignment- coronal

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What effect does excessive femoral anterversion have on rotation of the hip?

Internal rotation
Leads to intoeing
Correctable pathology

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Position of knee cap if intoeing is arising from the hip?

Inwards

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Why might tibial torsion occur and what form is normal?

Internal torsion normal to extent

Occurs due to in utero moulding and tibial shape

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3 variations relating to anhular alignment

Bowed legs
Knock knees
Flat feet

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3 assessments for angular alignment

Heel raise and Jack’s test
Foot rotational alignment
Foot progression in gait

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4 points of clinical assessment

Walking
Standing
Tip toe
Staheli rotational profile

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3 points to assess in standing

Alignment from the front
Patellar position
Heels/arch/toe/leg length from behind

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Staheli rotational profile

Hip rotation/version
Thigh foot angle
Foot bisector line

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What is a limp?

Abnormal gait due to pain, weakness or derformity

Shorter stance phases (weight bearing) on affected limb

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Common causes of limp

Toxic synovitis
Septic arthritis
Trauma - teens
Osteomyelitis
Viral syndrome
Perthe's disease
Fracture
Soft tissue infection

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What is associated with antalgic gait on examination?

Tenderness (shortened stance phase)

Reduced range of motion

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Conditions causing antalgic gait

Infection
Inflammation
Trauma
Overuse syndrome
Toddlers fracture

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Which sign indicates Abductor lurch

Trendelendburg sign

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What conditions are associated with abductor lurch?

Cerebral palsy

Hip dysplasia

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Describe an equinus gait

Toe to heel gait

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What conditions are associated with equinus gait?

Cerebral palsy
Idiopathic toe walker
Club foot

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Circumduction is seen during which phase in a circumduction gait?

During swing phase

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Which 3 things should be examined for if a patient has a circumduction gait?

Assess limb length
Neurological exam
Check range of mption

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Which conditions are associated with a circumduction gait?

Painful foot

Leg length inequality

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Which investigation can be ordered if a patient has an antalgic gait?

Radiograph

Bone scan

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Which investigation should be ordered if a patient has an abductor lurch?

Pelvic radiograph

Slipped capital femoral epiphysis is most commonly seen in which patients?

Obese male adolescent

Slipped capital femoral epiphysis is likened to which object?

Ice cream falling off the cone | Displaced femoral head

Why is the femoral head displaced in slipped capital femoral epiphysis?

Disruption of growth plate

Symptom of slipped capital femoral epiphysis?

Painful limp | Referred pain to thigh or knee

Treatment for slipped capital femoral epiphysis

Percutaneous screw fixation

Differentials for infectious and inflammatory causes of limp

Osteomyelitis Transient synovitis Septic arthritis

History for infectious causes of limp

``` Limp Pain General malaise/loss of appetite/listless Temperature Recent URTI/ ear infection Trauma Pseudoparalysis ```

Initial investigations acute limping child

Temperature X ray USS Bloods - CRP, ESR, FBC, WCC, CK, cultures

Signs and symptoms of septic arthritis

``` Limp Psuedoparalysis Swollen red joint Refusal to weight bear/ move joint Pain Temperature ```

Routes of infection leading to septic arthritis

``` Puncture or trauma Dissemination from osteomyelitis Haematogenous route Adjacent soft tissue infection Diagnostic or therapeutic procedures ```

Investigations for septic arthritis

``` Full Blood Count White cell count ESR CRP X ray Ultrasound Synovial fluid - WCC, gram stain, culture ```

Clinical Predictive Criteria for Septic arthritis

Kocher 1. Pyrexia 2. Not weight bearing 3. WBC > 12000/ml 4. ESR >40 mm/hr Score 3-4 indicative - 90% chance septic arthritis

Treatment for septic arthritis

Antibiotics - IV 2 weeks Aspiration Arthroscopy Arthrotomy

Common infection in septic arthritis

Staphylococcus aureus

Risk factors for osteomyelitis

Blunt trauma | Recent infection

Mean age for osteomyeltiis in chidren

6 years

Symptoms for osteomyelitis

``` Pain Reduced Range of Movement Fever Localised signs Reduced weight bearing ```

Investigations for osteomyelitis

WCC CRP ESR Microbiology - staph aureus

Indications for surgey in osteomyelitis

``` Aspiration needed for culture Drainage of subperiosteal abscess Drainage of joint sepsis Debridement of dead tissue Failure to improve Biopsy ```

How to differentiate transient synovitis from osteomyelitis or septic arthritis?

``` Diagnosis of exclusion Child will allow joint to be examined Relatively not as unwell Recent infection Low CRP, normal WCC ```

Red flag symptoms in paediatric orthopaedics

``` Night pain Stops doing sport/going out Sweats and fatigue Abnormal bloods - low Hb, atypical film, atypical platelets Refer to paediatrics and oncology ```

Classification for fractures with physeal injury in forearm

``` Salter Harris Type 1 - same level Type 2 - Above physeal plate Type 3- Below Type 4 Through Type 5 Crush ``` SALTR - 12345`

Describe a Galeazzi fracture

Shaft fracture of forearm | Distal 1/3 of radius with dislocation of radioulnar joint

Describe a Monteggia fracture

Shaft of ulna | Dislocation of radial head

What percentage of paediatric fractures occur in the forearm?

50%

Which fractures are most common in the forearm?

80% occur distally | 5% pproximal to elbow

What type of impact results in a buckle fracture?

Low energy

High energy fractures can lead to what type of injury?

Open fracture | Soft tissue displacement

Complications of Fractures

``` Compartment syndrome - Volkmann's Non union Refracture Radioulnar synostosis PIN injury Superficial radial nerve injury Distal radioulnar joint/ Radiocapitellar problems ```

Management of buckle fracture in distal radis

Cast 3-4 weeks

Management of greenstick fracture in distal radius

Cast 3-4 weeks

Complete fracture of distal radius management

Cast with Kirschner wires 6 weeks

Risk for manipulation

Complete fracture Failed anatomic reduction Not B/E pop

Knee trauma differential

``` Infection Inflammation Neoplasm Apophysisits Foot Hip Sickle cell, haemophilia Anterior knee pain ```

Bony injury of the knee

``` Physeal/metaphyseal Tibial spine Tibial tubercle Patellar fracture Sleeve fracture Paterllar dislocation Referred ```

Ratio of femoral to tibial physeal injury

2:1

Treatment for physeal knee injury

Cast to immobilise Percutaneous screw fixation ORIF articular displacement Range of movement wihtin 6 weeks

Elements of physeal arrest

``` Monitor harris lines, angulation and length Resect bar Complete epiphysiodesis Contralateral epiphysiodesis Corrective osteotomy ```

Why are patellar fractures rare?

Cartilaginous until age 4

Management for patellar fracture

Undisplaced - cylinder cast | Displaced - Orif

Risk factors for patellar dislocation

``` Laxity Poor VMO Q angle Femoral anteversion Tibial external rotation Patella alta ```

Overuse injuries

Osgood Schlatters - prominent patella | Sever's - inflammation of calcaneus