Paediatrics Flashcards
What are the big 3?
DDH
Perthes’ disease
SUFE
What is DDH?
Development dysplasia of the hip
Structural abnormality in the hips caused by abnormal development of foetal bones during pregnancy
Risk of subluxation or dislocation
When is DDH diagnosed?
New-born examinations
Child presenting with hip asymmetry, reduced ROM in hip or limb
What age group is usually affected by DDH?
<2 years
What are the risk factors for DDH?
FH
Breech presentation
Multiple pregnancy
First born
High birth weight
What features in a neonatal examination suggest DDH?
Different leg lengths
Restricted hip abduction on one side
Significant bilateral restriction in abduction
Difference in the knee level when the hips are flexed
Clunking of the hips on special tests
What are 2 special tests to check for DDH?
Ortolani test- tests for anterior hip dislocation
Barlow test- tests for posterior hip dislocation
What investigations are done for suspected DDH?
Ultrasound of hips
X rays for older infants
What is the management of DDH diagnosed before 6 months?
Pavlik harness- kept on permanently to allow the acetabulum to develop properly. Keeps the babies hips flexed and abducted
What is the management for DDH diagnosed after 6 months?
Surgery
Hip spica cast after surgery to immobilise the hip
What is the general rule for DDH management?
The older the child the poorer the result
What is Perthes’ disease?
Disruption of blood flow to the femoral head causing avascular necrosis (AVN)
This affects the epiphysis of the femur
What is the pathology of Perthes’ disease?
Disruption of blood supply
AVN
Revascularisation or neovascularisation
Remodelling
What is the main complication of Perthes’?
Soft and deformed femoral head leading to early OA
What is the presentation of Perthes’?
Pain in the hip or groin
Limp
Restricted hip movements
Referred pain to the knee
No history of trauma
What age group is affected by Perthes’?
Primary school aged
What are the investigations for Perthes?
X ray
Bloods
MRI
What is Perthes treatment?
Bed rest
Crutches
Analgesia
Maintain hip motion
Surgery in severe cases
What is the surgery of choice in severe Perthes?
Osteotomy
What is SUFE?
Slipped Upper Femoral Epiphysis
Head of the femur is displaced along the growth plate
What group is affected by SUFE?
Boys
8-15 years
Obese children
Undergoing growth spurt
What is the typical presentation of SUFE?
Hip, groin, thigh or knee pain
Restricted hip ROM
Painful limp
Hip kept in external rotation
Restricted internal rotation
What is the initial investigation of choice for SUFE?
Lateral Xray
What is the management of SUFE?
Surgery to return the femoral head to the correct position
What are the complication of SUFE?
AVN
Chondrolysis
Deformity
Early OA
Limb length discrepancy
Impingement
What is the difference between bones in children vs adults?
Growth plates
More cancellous bone- spongy, highly vascular
More flexible but less strong
What is the difference between fractures in children vs adults?
Heal quicky- metabolic, cellular, vascular
High capacity for remodelling
What are the types of paediatric fractures?
Buckle (torus)
Transverse
Oblique
Spiral
Segmental
Salter-Harris (growth plate)
Comminuted
Greenstick
Plastic deformity
What is greenstick fracture?
Only one side of the bone breaks whilst the other side stays intact
What is buckle fracture?
Longitudinal compression
What is plastic deformity?
Sequence of small cracks in the bone
How are growth plate fractures graded?
Salter-Harris classification
What are the types of Salter-Harris fractures?
1- Straight across
2- Above
3- Below
4- Through
5- Crush
Which SH is most common?
SH2- ascends into metaphysis
What are the principles of fracture management?
- Mechanical alignment- closed reduction or open reduction (via surgery)
- Stability- casts, wires, braces, screws, splints
What is the fracture pain management?
- paracetamol and ibuprofen
- morphine
What painkillers are contraindicated in children?
Codeine
Tramadol
Aspirin
What causes joint pain in 0-4 years?
Septic arthritis
Transient synovitis
DDH
What causes joint pain in 5-10 years?
Septic arthritis
Transient synovitis
Perthes’ disease
What causes joint pain in 10-16 years?
Septic arthritis
SUFE
Juvenile idiopathic arthritis
What are red flags for hip pain?
<3
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Morning stiffness
Swollen or red joint
What is the most common cause of hip pain in 3-10 years?
Transient synovitis (irritable hip)
What is the presentation of transient synovitis?
Limp
Refusal to weight bear
Groin or hip pain
Not that unwell
Apyrexial
What is the management of transient synovitis?
Simple analgesia
Safety net if they develop fever
What does joint pain AND a fever suggest?
Septic arthritis
What is rickets?
Osteomalacia in children- defective bone mineralisation
What causes rickets?
Vitamin D or calcium deficiency
What is the presentation of rickets?
Lethargy
Bone pain
Swollen wrists
Bone deformity
Poor growth
Dental problems
Muscle weakness
Pathological or abnormal fractures
What is the labaratory investigation for rickets?
Serum 25- hydroxyvitamin D (<25nmol/L is diagnostic)
What is required for rickets diagnosis?
X ray (osteopenia)
What other investigations are used for rickets?
Serum calcium low
Serum phosphate low
Serum ALP high
PTH high
What is rickets management?
Prevention- vitamin D supplements for breastfed babies
Treat rickets with vit D and calcium supplements
What are some normal orthopaedic variants?
In toed gaits
Bow legs
Flat feet
Curly toes
Late walkers
What is varus bow legs?
Ankles closer together than knee
<2 years
What is valgus bow legs?
Knees closer together than ankle2-7 years
What is the mean age to start walking?
12 months
50% of children walk later
Name some manufacturing defects?
Spina bifida
Proximal femoral focal deficiency
Thrombocytopenia absent radius (TAR syndrome)
Congenital scoliosis
Name some packaging defects?
Metatarsus Adductus
Infantile postural scoliosis
Plagiocephaly
Congenital torticollis
What is cerebral palsy?
A permanent and non-progressive motor disorder due to brain damage before birth or during first 2 years of life
What are the prenatal causes of cerebral palsy?
Placenta insufficiency
Toxaemia
Smoking, alcohol, drugs
Infection
What are the perinatal causes of cerebral palsy?
Prematurity
Anoxic injuries
Infections
Haemolytic diseases
What are the postnatal causes of cerebral palsy?
CMV, rubella infection
Head trauma
What is the physiological classification of cerebral palsy?
Spastic
Athetoid
Ataxia
Mixed
What is the anatomical classification of cerebral palsy?
Monoplegia
Hemiplegia
Diplegia
Quadriplegia
What is Juvenile Idiopathic Arthritis? (JIA)
Autoimmune inflammation occurring in the joints
What are the subtypes of JIA?
Oligoarticular (pauciarticular)
Polyarticular
Systemic
Enthesitis related
Psoriatic
What is oligoarticular JIA?
4 joints or less
Affects larger joints
Associated with anterior uveitis
No systemic symptoms
What is anterior uveitis significantly related to?
ANA positivity
Causes potential blindness
What is polyarticular JIA?
5+ joints
Symmetrical, small and large joints
Mild systemic symptoms
Which RIA is the equivalent of adult RA in children?
Polyarticular JIA
Most children are seronegative
What is systemic JIA?
Extraarticular features define the disease
Fever is characteristic- rises daily then normal in morning
What are the features of systemic JIA?
Subtle salmon pink rash
High swinging fevers
Enlarged lymph nodes
Weight loss
Joint inflammation and pain
Splenomegaly
Muscle pain
Pleuritis and pericarditis
What is enthesitis related JIA?
Child version of the seronegative spondyloarthropathies
HLA B27 gene
Associated with anterior uveitis
Tender to localised palpation of the entheses
What is juvenile psoriatic arthritis?
Seronegative inflammatory arthritis associated with psoriasis
What are the features of psoriatic JIA?
Psoriasis plaques
Nail pitting
Onchylosis
Dactylitis
Enthesitis
What is the management of JIA?
Analgesia
NSAIDs- ibuprofen
Steroids
DMARDs- methotrexate, sulfalazine
Biologics- infliximab
