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MSK > Paediatrics > Flashcards

Paediatrics Flashcards

1
Q

How do bones grow?

A

Longitudinal from the growth plate (physis) by enchondral ossification
The growth plate (physis) – stacks of cartilage cells which swell up, die off and burst – bone recognises this and lays new bone in the scaffolding

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2
Q

Which physes tend to contribute toward limb development?

A

Upper limb - mostly proximal humerus and wrist

Lower limb - mainly around the knee

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3
Q

Define:
Geni valgum
Genu varum
How do these change with age?

A

Valgus = knock kneed
Varum = bow legged
Alignment varies with age – babies tend to start varus, than progress to valgus, and then to less severe valgus

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4
Q

Genu varum

What things might suggest it is pathologic?

A

Unilateral (asymmetry >5°)
Severe >2SD/16° from mean
Short stature >2SD
Painful

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5
Q

Give some causes of pathologic genu varum

A 
Skeletal Dysplasia
Rickets
Tumour e.g. enchondroma
Blounts disease
Trauma -> physeal injury
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6
Q

What is Blouts disease?

Treatment?

A

Blounts disease - growth arrest of medial tibial physis of unknown aetiology (?weight overload). Shows a typical Beak-like protrusion on xray, as shown opposite.
It can be treated surgically if risk of osteoarthritis; psychological problems etc.

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7
Q

Intoeing
What is this?
What are the three possible causes?
Treatment?

A

Child walks with toes pointing in AKA pigeon-toed.
1. Femoral neck anteversion - caused by sitting in a “W” position
2. Internal tibial torsion
3. Metatarsal
adduction
Work out the cause; reassure; chart/photo; review; discharge unless persisting and severe

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8
Q

If a child presents with knee pain, what should you check?

A

HIPS

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9
Q

How many vertebra are there and what are the five sections?

A 
33 vertebra are organized into five sections:
7 cervical
12 thoracic
5 lumbar
5 sacral (fused)
4 coccygeal (fused)
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10
Q

REVISE ANATOMY OF VERTEBRAE

A

REVISE ANATOMY OF VERTEBRAE

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11
Q

What is special about C7 vertebra?

A

Vertebra prominens - no foramena transverse process (vertebral artery)

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12
Q

Intervertebral disks allow which movements?
Different at thoracic/lumbar and why?
Which section of spine allows greatest movement?

A

Flexion, extension & lateral flexion at facet joints and intervertebral discs – cumulative effect
Less flexion / extension in thoracic spine due to constraint of ribs
Lumbar rotation less than thoracic due to more vertically orientated facet joints
Cervical spine allows greatest movement due to more horizontal facet joints

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13
Q

What is spondylosis?
What does it cause?
Treatment?

A

Intervertebral disc loses water content with ageing – this process is spondylosis
Leads to overload facet joints & 2° OA
Pain worse with extension spine
Facet joint injections under fluoroscopy can help – not for non-specific multi-level OA (most patients)
OA in one or two motion segments can be treated with localised fusion – screws in between the discs, as shown opposite
Controversial as OA will affect adjacent level by 5 years and results inconsistent
Again, not good for multi-level disease (most)

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14
Q

What are the two parts of the intervertebral disk?

A

his contains an outer annulus fibrosus and an inner gelatinous nucleus pulposus.

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15
Q

Acute disk prolapse
What causes it?
Symptoms?
Treatment?

A

Lifting a heavy object -> annulus tear -> “twang”
Pain on coughing
Most settle by three months

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16
Q

What do anterior and posterior spinal roots form at the vertebrae?

A

Anterior & posterior (dorsal) roots form a mixed spinal nerve which exits via intervertebral foramen

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17
Q

In the lumbar spine, what type of nerve roots run together with two pairs at each level?

A

Sensory and motor

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18
Q

Where does the cauda equina begin?

A

L1

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19
Q

What are the two types of nerve root in the cauda equina?

A

The exiting nerve root which is outside the thecal sac passes under the pedicle of the corresponding vertebra (i.e. L4 root passes under L4 pedicle).
The traversing nerve root pair whilst remaining in the thecal sac is positioned anteriorly (in an area known as the lateral recess) in preparation to penetrate the thecal sac and become the next exiting nerve root more distally. This is most commonly pressed on when you get a disk prolapse.

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20
Q

What are the differences in symptoms between upper vs lower junction motor neuron impairment?

A

Junction upper motor neuron (weakness spasticity, increased tone, hyperreflexia) & lower motor neuron (weakness, flaccidity, loss of reflexes.

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21
Q

Which type of nerve root is commonly affected in disc prolapse?

A

With disc prolapse it is commonly the traversing nerve root which is compressed i.e. L5 root for L4/5 prolapse and S1 root for L5/S1 prolapse (i.e. the level below).
However in a far lateral disc prolapse the

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22
Q

What does nerve root compression cause?

A

Nerve root compression causes a radiculopathy resulting in pain down the sensory distribution of the nerve root (dermatome), which in the lower leg is known as Sciatica.

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23
Q

What is sciatica?

A

Sciatica – not the sciatic nerve which is compressed; it is one of the nerves which goes on to form the sciatic nerve.

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24
Q

Which roots contribute to the sciatic nerve?

A

L4, L5, S1, S2, S3

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25
Q 
What is spinal stenosis?
What causes it?
Symptoms?
Treatment?
What makes the pain less?
A

This is generalized narrowing of the lumbar spinal canal or its lateral recesses, causing nerve ischaemia
Nerve roots can also be compressed by osteophytes and hypertrophied ligaments in OA – known as Spinal Stenosis; this is caused by bony overgrowths in osteoarthritis
-> radiculopathy or burning leg pain on walking = neurogenic claudication
Some cases may benefit from surgical decompression
Less pain on bending over and walking uphill as it gives more space for the spinal root

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26
Q

What is a myetome?

A

Myetomes – different nerve roots have different functions, as shown below.

27
Q

What is cauda equina syndrome?
Symptoms?
Treatment?

A

Cauda equina syndrome is caused by pressure (usually prolapsed disc) on all lumbosacral nerve roots at level of lesion including sacral nerve roots for bladder and bowel control
-> bilateral lower motor neuron signs, bladder and bowel dysfunction, saddle anaesthesia and loss of anal tone
Compression of this is a surgical emergency – patients will have bilateral pain or similar, and some form of problem with bowels/UG

28
Q

What are the three muscles of the spine?

What are they collectively known as?

A

Iliocostalis
Longissimus thoracis
Spinalis thoracis
All of these are known as the Erector Spinae.

29
Q

What is an apophysitis?

A

Inflammation of a growing tubercle where a tendon attaches

30
Q

Which arches of the foot are babies born with?

A

None - they have completely flat feet

31
Q

Which area of the brain is affected in ataxic cerebral palsy?

A

Cerebellum

32
Q

What are the Ortolani and Barlow tests?

A

Barlow - femoral head is posteriorly dislocated from the acetabulm
Ortolani - the dislocated femoral head in relocated into the acetabulum

33
Q

In spina bifida cystica which structures herniate through the defect?

A

CSF
Meninges
Spinal cord/cauda equina
(myelomeningocele)

34
Q

What may be the cause of a rigid flat foot?

A

Tarsal coalition - the bones of the midfoot have an abnormal bone or cartilaginous connection

35
Q

What is inflammation of the the tibial tubercle apophysis called?
What is inflammation of the inferior pole of the patella called?

A

Osgood-Schlatter’s disease

Sinding-Larsen-Johanssen disease

36
Q

What anatomically does poliomyelitis affect?

A

Motor neurons, typically manifesting as weakness of a group of muscles within a single limb

37
Q

Infection in a child with a limp
What are the two main types?
Describe the similarities and differences between the two

A
  1. Transient synovitis of the hip
    - This is the chef cause of hip pain in those aged 4-10 years
    - Acute onset and self limiting with rest and analgesia
    - Bloods and radiology are normal
  2. Septic arthritis
    - This is an emergency but can be difficult to differentiate with TS
    - Clinical signs - high temp, WCC >12, CRP >20
    - Investigation - urgent blood culture + US-guided aspiration
    NB – the hip is a deep joint so local signs (e.g. warmth, erythema) will appear late in the disease process.
38
Q 
Perthes disease
What is this?
What is it that causes the problem?
What age group?
Male or female?
Long term complication?
A

For no known reason, avascular necrosis of the femoral head occurs. Although this ischaemia is self-healing, it is the subsequent bone remodelling that distorts the epiphysis and generates abnormal ossification
- Age 4 - 8
- Boys: girls 4:1
Osteoarthritis

39
Q

How does perthes disease present?
What does examination show?
What does imaging show?

A

It presents with pain in hip or knee and causes a limp. On examination all movements at the hip are limited and, especially internal rotation and abduction.
Early x-rays ± MRI show joint space widening. Later there is a decrease in size of the femoral head with patchy density. Later still, there may be collapse and deformity of the femoral head with new bone formation.

40
Q

How is Perthes disease treated?

A

For those with less severe disease (< ½ of the femoral head affected, and joint space depth preserved), treatment is bedrest and NSAIDs until pain-free, followed by x-ray surveillance. For more severe disease, surgery may be indicated.

41
Q

DDH
What is this?
Male: female ratio?
Left: right hip incidence?

A

This refers to a spectrum of pathology from stable acetabular dysplasia to established hip dislocation. It has replaced the term congenital dislocation of the hip (CDH) to reflect the progressive course of the condition.

1: 6
4: 1

42
Q

What are some risk factors for DDH?

If a baby has any of these, what action should be taken?

A 
Breech position in utero or at delivery  X 10
Family history X 10
↑ birth weight 
Primip/older mother 
Postmaturity
Other musculoskeletal anomalies e.g. club foot, torticollis
Also - girls, first born, left hip
Ultrasound at 2-4 weeks
43
Q

What are the two instability tests for DDH?

Describe them.

A

Barlow – this attempts to dislocate/sublux a hip that is unstable (in joint by flexion adduction); you will feel a “clunk” if the hip dislocates
Ortolani – this attempts to relocate a dislocated/subluxed hip by abduction; you will feel a “clunk” if the hip relocates; the test will be negative if there is an irreducible hip

44
Q

What is the treatment for early diagnosis DDH?

A

Relocate the hip
Splint while is stabilises - Pavlik harness
Monitor acetabular development

45
Q

Treatment for DDH:
>3/12?
>9/12?
>2 yr?

A

> 3/12 – examination under anaesthetic, arthrography and closed reduction are performed followed by a period of immobilization in a spica hip bandage for ~3 months
9/12 open reduction likely
2 yr bony surgery required? Femoral? Pelvic osteotomy?

46
Q

How may late DDH present?

A 
Painless limp
Short leg
Asymmetric creases
Trendeleberg limp
X-ray especially if there is asymmetry at this age
47
Q

Slipped Upper Femoral Epiphyses
What age group?
Male: female ratio?

A

This affects those aged 10-16 years; 20% are bilateral.
Male:female ratio = 3:1.
NB - around 50% are obese

48
Q

What actually occurs in SUFE?
How does it usually present?
What is diagnosis based on?

A

There is displacement through the growth plate with the epiphyses always slipping down and back. It usually presents after minor injury (or atraumatic) with limping and pain in the groin, anterior thigh and knee. 90% are able to weight-bear (stable) and 10% are not (unstable). Flexion, abduction and medial rotation are limited (e.g. lying with foot externally rotated).
Diagnosis is based on anteroposterior + frog-leg lateral x-ray of both hips. Delayed diagnosis can lead to progression of slip with increased risk of early OA and stable lesions becoming unstable.

49
Q

Which sign does AP x-ray of SUFE show?

A

Trethowans sign

50
Q

Treatment and prophylaxis of SUFE?

A

Treatment is surgical with early internal fixation to stabilize any slippage and encourage physeal closure.
Propylactic fixation remains controversial and is assessed on an individual basis. If untreated, consequences may be avascular necrosis of the femoral head, or malunion predisposing to arthritis.

51
Q 
What is the most likely cause of a limp in a child of the following ages:
0-18m? 
2-5 yr?
5-10 yr?
11-15 yr?
A

CDH in pre or peri-walker 0-18m +
Transient synovitis 2-5 yr
Perthes 5-10 yr
SUFE 11-15 yr

52
Q

What is Talipes?
What are the two broad types anatomically?
What other way can you divide them?

A 
Clubbed foot
Equinus – plantar flexed
Calcaneus – dorsiflexed
Physiological - "positional talipes" -> fully correctable
Pathological
53
Q

How is equinovarus talipes treated?

A

Ponseti casting

54
Q

What are the three types of spina bifida?

Describe each

A
  1. Occulta - vertabral body fails to seal over the spinal cord
  2. Meningocele - cerebral fluid and meninges herniate through the gap
  3. Myelomeningocele - CSF, meninges and neural tissue herniate through the gap
55
Q

How does spina bifida cause joint problems?

A

The problem with joints is low muscle tone, leading to dislocations.
You can also get severe foot deformations, as mentioned above.

56
Q

What are the phases of walking?

A 
Swing phase
Stance phase
- Contact
- Midstance
- Propulsion
57
Q

What are some prerequisites for normal gait?

A 
Stability in stance
Sufficient foot clearance 
Appropriate swing phase prepositioning of the foot
Adequate step length – for efficiency
Energy conservation
58
Q

Name five types of limp

A 
Antalgic - pain while walking so minimize pan to joint by minimizing stance phase
Trendelenburg 
Short leg
Tip toe
Neurologic
59
Q

What is a positive Trendelenburg sign?

A

You lurch over to one side to assist swinging of the pelvis – this changes the centre of gravity -> Trendelenberg lurch.

60
Q

What are the three possible causes of a positve Trendelenburg sign?

A

Weak abductors – e.g. poliomyelitis, muscular dystrophies, MND
Defective fulcrum – e.g. CDH, pathological dislocation of the hip
Defective lever – perthes disease, Coxa vara

61
Q

What are the three types of tip toe gait?

A
  1. Habitual – children get into the habit of walking on the top toes
  2. Structural – default in the Achilles tendon – do Silverskiold test to see if their Achilles length is long or not; this is something to do with the Gastrocnemius
  3. Neurological – spasticity
62
Q

What does the term cerebral palsy mean?

What is the aetiology?

A

Inclusive term describing a group of non-progressive disorders in which disease of the brain causes an impairment of motor function.

  • Prenatal - intrauterine infections; TXMS/CMV; congenital malformations of the brain
  • Perinatal – birth trauma; asphyxia
  • Postnatal – infections e.g. meningitis; NAI; cerebral haemorrhage
63
Q

What are some important things to ask about in a history of suspected cerebral palsy?

A

Normal pregnancy and delivery
Preterm
Delayed walking
Any additional problems?

MSK (19 decks)

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