Paediatric Orthopaedics (inc Limping Child) Flashcards
What are paediatric specific fracture types and why do they occur?
Thicker, more active periosteum results in:
- Greenstick
- Buckle
- Plastic / Bowing
Why do intraarticular fractures have worse consequences in children?
Usually involve the growth plate
What are the ossification centres of the elbow?
CRITOE
- Capitellum: 1y
- Radial head: 4y
- Internal (med) epicondyle: 6y
- Trochlea: 8y
- Olecranon: 10y
- External (lat) epicondyle: 12y
What is SUFE?
Type I Salter Harris epiphyseal injury at proximal hip. Most common adolescent hip disorder.
What are the RFx for SUFE?
Male, obese, hypothyroid
What are the Hx of SUFE?
- Acute: sudden, severe pain with limp
- Chronic: limp with medial knee or anterior thigh pain.
What are the PEx features of SUFE?
- +ve Trendelenburg on affected side due to glut weakening
- Tender over joint capsule
- Restricted IR, abduction, flexion, Whitman’s sign
- Pain at extremes of ROM
What is Whitman’s sign?
With flexion there is obligate external rotation of the hip
Aetiology SUFE?
- Cartilaginous physis thickens rapidly with GH
- Sex hormone secretion (stabilises physis) not yet commenced
- Overweight = mechanical stress
- Trauma = acute slip
Ix SUFE?
-XR: frog leg, AP, lateral
XR findings in SUFE?
- posterior and medial slip
- disruption of Klein’s line (line on superolateral border of femoral neck should cross some femoral epiphysis)
Rx SUFE?
Mild/mod: stabilise physics with pins
Severe: ORIF or pin without reduction and osteotomy after epiphyseal fusion
What are the complications of SUFE / Mx?
- AVN
- Chondrolysis (loss of articular cartilage = joint space narrowing)
- Pin penetration
- Premature OA
- Loss of ROM
What is Legg-Calve-Perthes Disease?
Self limited AVN of femoral head usually presenting at 4-10y
Pethes disease associations?
- FHx
- Low birth weight
- Abnormal pregnancy / delivery
- Hx of trauma to affected hip
What are the key features of Perthes disease?
- AVN of proximal femoral epiphysis
- Abnormal growth of the physis
- Eventual remodelling of regenerated bone
CFx of Pethes disease?
- Child with hip pain and limp
- Tender over anterior thigh
- Flexion contracture (decreased IR and abduction of hip)
Goal of Rx of Perthes?
Preserve ROM and femoral head in acetabulum
What are the KEY diagnoses for a child with limp by age?
- Under 2: DDH
- 3 - 5y: Transient synovitis
- 5 - 9y: Perthes
- 11-16: SUFE
What are the red flags for organic causes of a limp / leg pain?
• Pain on passive internal rotation
• Pain during both night and day
• Pain occurs on weekends and vacations i.e. true pain
• Pain interrupts play and other pleasant activities
• Pain localised to joint *
• Unilateral pain * cf. growing pain is bilateral
• Child limps or refuses to walk
• Pain fits with local anatomic explanation
• Concurrent symptoms and signs of systemic disease
Acute onset in last 3 months
What are the indicators of a non organic cause for pain / limp?
• No pain on passive internal rotation
• Pain occurs only at night and on school days
• Pain does not interfere with normal activities
• Pain located between joints
• Bilateral symptoms
• Child is able to walk normally without a limp
• Pain patter does not fit any recognizable anatomy
Systemic signs and sypmtoms absent
Mx of Perthes?
- Physio for ROM
- Anti inflammatories
Containment: - Bracing in abduction
- Femoral osteotomy
- Pelvic osteotomy
What are congenital talipes?
Club foot. 3 parts:
- talipes: talus invertedand internally rotated
- equinus: ankle plantar flexed
- varus: heel and forefoot are in varus
Aetiology of congenital talipes?
- Intrinsic: neuro, muscular or CT diseases
- Extrinisc: IUGR
What causes Osgood-Schlatter disease?
Repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causing minor avulsion at the site and thus inflammatory reaction (tibial tubercle apophysitis)
FX of OS disease?
- Tender lump over tibial tuberosity
- Pain on resisted leg extension
- anterior knee pain exacerbated by jumping or kneeling, relieved by rest
Rx OS disease?
- benign, self limited
- may restrict activities
- flexibility, isometric strengthening exercises
What must always be excluded in a non weight bearing child?
- osteomyelitis
- septic arthritis
- malignancy
Mx limping child with no specific cause?
Depends on diagnosis. If no specific cause identified, or suscpected transient synovititis:
• Bed rest important (esp TS)
• Analgesia: NSAID (ibuprofen) +/- paracetamol
• Review with LMO 3d
• Return to hospital if febrile, unwell or getting worse
Pts with symptoms >4w ==> referr to rheum clinic
When should ortho / paeds be consulted in NWB child?
- suspect infection, Perthes, SUFE or malignancy
- multiple presentations
- uncertain
Hx approach to limping child?
Pain = SQSTCARA CONTEXT: trauma, preceding illness AFx: - fever - morning stiffness - S/R - systemic symptoms (infective or inflammatory cause) PLUS: - previous injuries or CP notifications
What is a Monteggia fracture?
Fracture of proximal third of Ulna with dislocation of radial head
Mechanism of supracondylar fracture?
FOOSH
Which artery may be injured in supracondylar fracture?
Brachial artery
Which nerves at potential risk of injury in supracondylar fracture?
- median
- radial
- ulnar
XR to order in ?supra condylar fracture?
- True lateral of elbow
- AP and lat views of forearm
Classification system of supracondylar fractures?
Gartland (I-III)
