Paediatric T&O Flashcards
What is a greenstick fracture?
Fracture of one cortex but not the other, with angulation
Salter-Harris classification of epiphyseal fractures
I: Slipped
II: Above physis
III: Lower than physis
IV: Through physis
V: Rammed together (low threshold for MRI if suspected)
Indicates prognosis
Epidemiology of epiphyseal fractures
10% of paed fractures
Happen mainly in 10-16yo because muscles/tendons >> than growing bone
Order of ossification centres of the elbow
Capitellum - 1yo
Radial head - 3yo
Internal (medial) epicondyle - 5yo
Trochlea - 7yo
Olecranon - 9yo
External (lat) epicondyle - 11yo
Most common paediatric elbow injury
Supracondylar humerus fracture from FOOSH, commonly 4-10yo
MUST ASSESS N-V status
requires proper reduction to prevent varus malunion
Gartland classification of supracondylar fractures
I: Subtle, undisplaced, posterior fat pad, for splinting/cast 3-4w
II: Displaced but posterior cortex intact
III/IV: Completely displaced, comminuted/rotated, needs operative management (must check radial and median nerve!)
Red flags for NAI
Posterior rib fractures
Fractures in non-walkign children <1yo (esp long bone)
Multiple Hx of fractures (or diff stages of healing)
Bruising (or diff stages of healing)
Mechanism not compatible
Parental Hx contradictory
Delay in seeking treatment
Types of paediatric fracutre
Plastic deformation
Greenstick fracture
Complete fracture
Buckle/torus fracture (from axial force)
Limping child differential age 0-5
- Painful
- Septic arthritis, osteomyelitis
- DDH + dislocation?
- Painless:
- Cerebral palsy
- Limb length discrepancy
- DDH
Limping child differential age 5-10
Trauma
Perthes
haem disease
Malignancy
JRA/SLE
Limping child differential 10-15
SUFE
Trauma
Presentation of SUFE
Overwight, osteodystrophy, hypothyroid are risk factors
Weight-bearing trauma
Boys 10-15 during growth spurt
Needs operative stabilisation
May lead to knee pain, hip ext rot + abducts during flexion, limited internal rotation
Line drawn through outer femoral neck does not intersect epiphysis
Perthes disease pathophysiology
Idiopathic avascular necrosis of femoral head, 10% bilateral
Femoral head dissolves, reossifies, remodels
Presentation of Perthes
Males 4-8
Risk: 2nd hand smoke, ADHD, low birth weight
Limp, no history of trauma, hip/knee movement painful
Management of Perthes
<6 non-operative (activity modification, physio, analgesia)
>6 or collapsed head –> operative
Pathophysiology of septic arthritis
Haematogenous/bone spread
Proteolytic enzymes –> damage cartilage
Effusion –> bone head necrosis
Knee > hip > elbow/ankle
H. influenzae in kids most common
Risk stratification of septic arthritis
Not weight bearing
Fever
WCC >12
ESR >40
3,40,90,98% risk
Risk factors for septic arthritis in children
Neonates
Prematurity
C-section
Presentation of DDH
Young child, limp
Risk: FH, first-born, breech position, female
Bilateral in 20%
Pathophysiology of DDH
Intrauterine malpositioning and/or ligamentous laxity
Shallow acetabulum –> more prone to hip dislocation
Management of DDH
<6mo pavlik harness for 6w (discontinue if not reduced by 3w)
6-18mo: arthrogram hip spica for 3mo
>18mo: open surgical management
Presentation of transient synovitis
Hip pain
5-10 yo
Associated with recent URTI/viral illness
Able to weight bear, no fever or systemic unwellness
Management of transient synovitis
Analgesia, marked improvement in 24-48h
Osgood-Schlatter’s disease presentation
Boys 12-15yo
Frequent jumpers/sports
Pain + enlarged tibial tubrcle
Pathophysiology of Osgood-Schlatter’s
Extensor mechanism stronger than tibial apophysis –> fragmentation + irregular tubercle
Management of Osgood-Schlatter’s
Self-limiting, reduce activity until more manageable
Congenital talipes equinovarus pathophysiology
Strong genetic component (5% risk for future children)
Often bilateral
Cavus midfoot
Adducted forefoot
Varus hindfoot
Equinus hindfoot
Management of club foot
Ponseti cast/brace with weekly changes from birth to 5 years
Surgery if intractable
Syndactyly presentation
Fusion of fingers, may be soft tissue or bone as well
Commonly middle and ring fingers
Complex hand deformities assoc w/ VACTREL
Syndactyly association
Vertebral defects
Anal atresia
Cardiac defects
Tracheo-osophgeal fistula
Renal anomalies
Limb abnormalities
Pathophysiology of cerebral palsy
Non-progressive but permanent CNS injury in utero or <2yo
Presentation of cerebral palsy
Gait abnormalities, dyskinesia, spasticity
Contractures worsen with growth
Management of cerebral palsy
MDT + physio
Medical: botox, baclofen for spasticity
Surgical: Tnotomies or tendon lengthening or osteotomies
Investigating osteomyelitis
Radiographs may be non-specific/normal for 10-14d
WCC normal in 60%
CRP rises within 8h, peaks at 2d, normalises within 1 week
Diagnosis of DDH
Barlow’s + Ortolani’s tests (<3mo)
Older –> asymmetry of abduction
X-ray after 6mo
USS <6mo
What is the Ponseti method?
Serial casting in progressive corrective manipulation
Treatment of club foot
Barlow test
Adduct hip and push back (i.e. posteriorly)
Should passively dislocate hip if DDH present
Ortolani test
Done after Barlow to confirm
Aims to reduce hip back, should hear audible clunk
Hard sign of hip dislocation
Limited abduction of hip
