Paediatrics

Question 1

What are the risk factors for developmental dysplasia of the hip?

Answer 1

Female sex,
Breech presentation,
Positive family history,
Firstborn child,
Oligohydramnios,
Birth weight > 5kg,
Congenital calcaneovalgus foot deformity

Question 2

What is developmental dysplasia of the hip?

Answer 2

Structural abnormality in the hips caused by abnormal development of fetal bones during pregnancy. Causes instibility of the hips and tendancy for subluxation or dislocation.

Question 3

Screening for DDH?

Answer 3

All infants screened at newborn baby check and the 6 week baby check using the Barlow and Ortolani tests.

Following babies require routine ultrasound: First degree relative with hip problems early in life. Breech presentation at or >36 weeks gestation. Multiple pregnancy

Question 4

Clinical examination and investigations in DDH?

Answer 4

Barlow test: attempts to dislocate an articulated femoral head.
Ortolani test: Attempts to relocate a dislocated femoral head.
Other key features: symmetry of leg length, level of knees when hips and knees are bilaterally flexed. Restricted abduction of the hip in flexion.

Investigations - Ultrasound if < 4.5 months. X-ray if > 4.5 months.

Question 5

Management of DDH?

Answer 5

Most unstable hips will spontaneously stabilise by 3-6 weeks.
Pavlik harness in children younger than 4-5 months.
Surgery for older kids.

Question 6

Predisposing factors for Rickets?

Answer 6

Dietary deficiency of calcium or Vitamin D deficiency.
Prolonged breastfeeding.
Unsupplemented cow’s milk formula.
Lack of sunlight - vitamin D def.

Question 7

Presentation, investigations and management of Rickets

Answer 7

Presentation - Aching bones and joints, lower limb abnormalities (bow legs or knock knees), rickety rosary (widening of anterior ribs), kyphoscoliosis, craniotabes (soft skull) and Harrison sulcus.

Ix - Bloods: Low vitamin D, hypocalcaemia, raised ALP.

Rx - oral vitamin D

Question 8

What is Talipes Equinovarus?

Answer 8

Also known as club foot - it is inverted (inward turning) and plantar flexed foot.

Usually diagnosed at newborn exam.

Question 9

Associations of Talipes equinovarus?

Answer 9

Spina bifida,
Cerebral palsy,
Edward’s syndrome,
Oligohydramnios,
Athrogryposis (congenital joint contracture in two or more areas of the body)

Question 10

Management of Talipes Equinovarus?

Answer 10

Ponseti method - manipulation and progressive casting which starts soon after birth.

Deformity usually corrected after 6-10 weeks however Achilles tenotomy is required in most cases.

Night time brace should be applied until child is 4 years old.

Question 11

Classification of Salter-Harris fractures

Answer 11

1 - Fracture through physis only (x-ray often normal),
2 - Fracture through physis and metaphysis.
3 - Fracture through physis and epiphysis to include joint.
4 - Fracture involving physis, metaphysis and epiphysis,
5 - Crush injury involving physis

Question 12

Presentation of slipped upper femoral epiphysis?

Answer 12

What - Head of femur is displaced along growth plate.

Presentation - Obese adolescent will presents with history of minor trauma, high/ groin/ thigh. knee pain. Restricted range of movement and painful limp. Child will keep leg externally rotated and will have limited internal rotation

Question 13

Diagnosis and management of SUFE>

Answer 13

Ix - Xray and bloods, CT scan and MRI scan.

Rx - Surgery

Question 14

Causes of joint pain in paeds?

Answer 14

0-4 years: septic arthritis, DDH, transient sinovitis.

5-10 years: Septic arthritis, transient sinovitis, perthes disease.

10-16 years: Septic arthritis, SUFE, juvenile idiopathic arthritis

Question 15

Red flags for hip pain in paeds?

Answer 15

Child under age 3,
Fever,
Waking at night with pain,
Weight loss,
Anorexia,
Night sweats,
Fatgiue,
Persistent pain,
Stiffness in morning,
Swollen or red joint

Question 16

When should a child be referred for urgent assessment of a limp?

Answer 16

Child under age 3,
Child older than 9 with restricted or painful hip,
Not able to weight bear,
Evidence of neurovascular compromise,
Severe pain or agitiation,
Red flags for serious pathology,
Suspicion of abuse.

Question 17

What are the features of transient synovitis?

Answer 17

Presentation - begins a few weeks after URTI in children age 3-8. Presents with limp, refusal to weight bear, groin/hip pain, mild low grade temperature.

Rx - Fever is red flag and requires urgent specialist assessment.
Pt can be monitored in primary care if age 3-9, well, afebrile, mobile but limping and has had symptoms < 72hr.
Self limiting - rest and analgesia.

Question 18

What is Perthes’ disease and its presentation?

Answer 18

Degenerative condition which occurs due to AVN of the femoral head.
It is 5x more common in boys.
It presents with:
Hip pain,
Limp,
Stiffness and reduced ROM,
X ray changes: Widening of joint space, decreased femoral head size/flattening.

Question 19

Diagnosis, management and complications of Perthes’ disease?

Answer 19

Ix - Plain x-ray, technetium bone scane or MRI if symptoms persist or x-ray normal.
Rx - Bed rest, traction, crutches and analgesia for most cases. Physio and regular x-rays can also be used and surgery in severe cases.
Complications - Osteoarthritis, premature fusion of the growth plates.

Question 20

Genetics and features of Achondroplasia?

Answer 20

Genetics - sporadic mutation on fibroblast growth factor receptor 3 on chromosome 4. Main risk factor is advancing parental age.

Presentation - Disproportionate short stature (limbs are most affected by reduced length), brachydactyly, large head with frontal bossing and narrow foramen magnum, midface hypoplasia and flattened nasal bridge, trident hands and lumbar lordosis.

Question 21

What is the presentation and investigations for juvenile idiopathic arthritis?

Answer 21

Presentation - pyrexia, salmon-pink rash, lymphadenopathy, arthritis, uveitis, anorexia and weight loss.
Investigations - Ana positive, Rh factor negative
Periarticular JIA is when 4 or less joints affected.