Paediatrics

Question 1

Name Waddell’s triad

Answer 1

Pattern of injury seen in pedestrian children struck by motor vehicles - heavily injured until proven otherwise
• femur shaft fracture
• head injury
• thoracic or abdominal injuries

Question 2

Indication gallows traction?

Answer 2

Paediatric patients of <12kg with femoral fracture (or ddh) and intact skin

Question 3

Complication of gallows traction?

Answer 3

• Vascular pathology : severe compartment syndrome, volkmann’s ischaemic contracture due to elevated position of legs, straightness of knees and tightness of bandages. (Monitor every 4 hours for first day- cap refill)
• Aspiration! - prevent by small frequent feeds
• occipital pressure sore

Question 4

Describe the Gartland classification

Answer 4

Paediatric supra condylar fractures
• type 1: nondisplaced
• type 2: displaced in 1 plane. Angulated with intact posterior cortex. Hinged posteriorly
. Type 3: displaced in 2 or 3 planes (completely, can see on XR)
. Type 4: complete periosteal disruption with instability in flexion and extension (can only dx in theatre)

Question 5

Define greenstick fracture

Answer 5

Incomplete partial thickness fracture where cortex and periosteum are interrupted on one side of the bone but remain uninterrupted on the other. Angulated, not displaced. “Crack fracture”

Question 6

Describe the salter Harris classification

Answer 6

1: separation - metaphysis and epiphysis
2: above -Extend into metaphysis. Most common.
3: lower- through epiphysis to intra-articular
4: through - metaphysis, physis and epiphysis
5: cRush- physis
SALTR

Question 7

What is SUFE? (4)

Answer 7

• Slipped upper / proximal/capital femoral epiphysis
• common condition of proximal femoral physis that leads to slippage of metaphysis relative to epiphysis, paeds .
• usually idiopathic salter Harris type 1 fracture
• epiphysis slips posteriorly thus best appreciated on frog leg lateral view.
Usually age 10-18

Question 8

Risk factors slipped upper femoral epiphysis? (5)

Answer 8

• Adolescents especially prone, males 14-16 and females 12-14 (most common hip pathology in this age group)!
• obesity!
• males > females!
• hypothyroid risk of bilateral involvement
• more common in African children
• acetabular and femoral retroversion
• history previous radiation therapy to femoral head region

Question 9

SUFE presentation? (5)

Answer 9

Symptoms
• pain in hip > thigh > groin
• knee pain due to activation of medial obturator nerve

Examination
• limp/abnormal gait: antalgic, waddling, externally rotated! Or trendelenburg
• positive trendelenburg sign over affected side to to weakened gluteal muscles if chronic
• lower limb externally rotated
• limited internal rotation, flexion and abduction of the hip
• Whitman’s sign: obligatory external rotation during passive flexion hip

Question 10

Treatment sufe?

Answer 10

• Mild-moderate slip: surgical fixation stabilize physis with pins in current position
• severe slip: orif or pin physis without reduction, and osteotomy after epiphyseal fusion

Question 11

Complications slipped capital femoral epiphysis? (8)

Answer 11

• AVN (1/2 of unstable hips) !
• chondrolysis causing narrowed joint space, pain, decreased motion
• pin penetration / pin associated #
• contralateral hip SUFE
• residual proximal femoral deformity and limb length discrepancy caused by failure remodelling
• premature degenerative osteoarthritis
• infection
• loss range of motion, chronic pain

Question 12

Name device used in picture 22 and why.

Answer 12

Gallows traction for femoral # if <12kg and skin intact.

Question 13

How long is gallows traction left on?

Answer 13

• 1 week per year age + 1 week

* or until child starts turning- means its not painful

Question 14

Indication Dunlop traction?

Answer 14

Supra condylar # children to allow swollen elbow to settle

Contraindicated in open # and skin defects

Question 15

What is and causes a buckle #?

Answer 15

Aka torus #
• incomplete # of shaft of long bone characterised by bulging cortex
• occur when bony cortex compressed and bulges - trabecular compression due to axial loading force along axis of bone
• conservative treatment

Question 16

Name 5 methods of measuring limb length discrepancy

Answer 16

• Bryant’s triangle
• Galleazzi sign / Allis test
• block test to determine leg length difference (keep adding until iliac crests = height)
• Apparent length measurement
• true length measurement
• functional leg length ( feet apart them palpate iliac crests, ASIS, PSIS then again when together - leg structurally normal but abnormal when together ‘ )

Question 17

Name clinical and radiological features of non-accidental injury

Answer 17

Clinical:
• Waddell’s triad- fractured femoral shaft, intra-abdominal or thoracic injuries, contralateral head injury
• injury in non-ambulatory or totally dependant child
• multiple # With no family history of osteogenesis imperfecta
• retinal haemorrhage, torn frenulum

History:
• injury and history inconsistent
• history lack or excessive detail
• delay in seeking medical attention

Radiographic
• posterior rib fracture
• metaphysieal / bucket handle /corner #
• scapular #
• sternal #
• outer 1/3 clavicular #

Question 18

Name radiological features of developmental dysplasia of the hip DDH (5)

Answer 18

• false acetabulum
• acetabular index > 25° (angle formed by Hilgenreiner’s line and line from point on lateral triradiate cartilage to point on lateral margin acetabulum)
• broken Shenton’s line
• femoral neck above instead of below Hilgenreiner’s line (horizontal through r and L triradiate cartilage)
• ossification centre outside instead of medial to Perkins line (perpendicular to hilgenreiner, through point at lateral margin acetabulum)

Question 19

Etiology DDH?

Answer 19

• Ligamentous laxity, muscular underdevelopment, abnormal shallow slope of acetabular roof
• spectrum of conditions: dislocated head, dislocatable head, head subluxates when provoked, dysplastic acetabulum more shallow and vertical than normal

Question 20

Clinical findings in DDH? (5)

Answer 20

• Limited abduction of flexed hip (<60)
• affected leg shortening cause assymmetry in skin folds and gluteal muscles, wide perineum.
• Barlow’s test
• Ortolani’s test
• galeazzi sign

Question 21

Treatment DDH (3)?

Answer 21

• 0-6 month: reduce using Pavlik harness to maintain abduction and flexion
• 6-18 months: reduce under General anaesthesia, hip spica cast 2-3 months if Pavlik fail
• > 18 months: open reduction , pelvic and or femoral osteotomy.

Question 22

Name 4 complications DDH

Answer 22

• Redislocation
•inadequate reduction
. Stiffness
. Avn femoral head

Question 23

What is Blount’s disease?

Answer 23

Progressive, pathologic genu varum centered at the tibia