Paediatrics Flashcards
Describe the development of the femoral head
Mainly cartilage in childhood
Slowly ossifies with age
X-rays not as useful in paediatric hip assessment
What is developmental dysplasia of the hip
A disorder of abnormal development that results in dysplasia and possibly subluxation or dislocation
Instability of joint leads to dysplasia which gradually leads to dislocation
Which groups are most commonly affected by DDH
Left hips
Females
Native Americans and Laplanders
What is the pathophysiology of DDH
initial instability thought to be caused by maternal and fetal laxity, genetic laxity, and intrauterine and postnatal malpositioning
What are the risk factors for DDH
Firstborns - may be due to less intrauterine space
Females
Breech presentations
Family history
Oligohydramnios - low amniotic fluid volume
How does DDH present
Abnormality on screening - early
Limping child - short leg and trendelenberg
Decreased abduction, externally rotated leg
Pain later in life - due to arthritic changes
How do you diagnose DDH
Clinical exam - will have restricted abduction, different leg lengths
US
Radiographs in later years - AP X-ray
What is the Barlow test
Push backwards on hip joint to test if you can dislocate it
What is the ortolani test
If hip is already out of joint you abduct the hip to try and relocate
How can you treat DDH if it presents early
Pavlik harness - holds hips in position of safety
Worn 23hrs a day for up to 12 weeks
Serial USS to look for improvement
How can you treat DDH if it presents late
Surgery
Either a closed or open reduction
With tenotomy or osteotomy - cut tendon or bone
What is transient synovitis
Inflammation of the synovium
Often occurs secondary to a viral illness
Common in ages 0-5
How does transient synovitis present
History of viral illness but systemically well
Limp - antalgic
Hip/groin pain - may radiate to knee
Typically able to weight bear
Hip lies flexed and externally rotated
Pain at end range of movement - may decrease ROM
How do you diagnose transient synovitis
Blood tests
Kocher’s criteria
Ultrasound - looks for fluid in joint, may have effusion
Aspiration - rule out septic arthritis
What is Kocher’s criteria
Allows you to differentiate between transient synovitis and septic arthritis
List of clinical features - each one present increases risk of it being septic
How do you treat transient synovitis
Self-limiting condition
Rest
Analgesia or NSAIDs to cope with symptoms
If concerned offer review appointment
What is septic arthritis
Intra-articular infection of the joint
Why is septic arthritis (of the hip) a surgical emergency
High bacterial load in joint can lead to sepsis
Joint destruction due to proteolytic enzymes
Potential for necrosis
How does septic arthritis present in the hip
Short duration of symptoms
Unable to weight bear and hip/groin pain
Antalgic gait - limp
Hip lying flexed/externally rotated
Severe hip pain on passive movement - will have significantly decreased RPM
Usually pyrexial but may be haemodynamically stable
Raised WCC and CRP
How does septic arthritis arise
Direct inoculation - trauma or surgery
Hematogenous seeding - most common
Extension from adjacent bone (osteomyelitis)
Contiguous spread of osteomyelitis
What are some common causative organisms of septic arthritis
Neonates - Strep and gram -ve
Kids - staph aureus, haem influenza
Adults - staph aureus and strep
PWID - atypical
How do you diagnose septic arthritis
Blood tests - FBC, CRP Blood cultures Kocher's criteria Radiographs - rules out other pathology US +/- aspiration
How do you treat septic arthritis
Open surgical washout
Antibiotics - usually 6 weeks IV
What is Perthes disease
Avascular necrosis of the hip
Usually idiopathic
What are some risk factors for Perthes disease
positive family history
low birth weight
second hand smoke
Asian, Inuit, and Central European decent
Which groups most commonly get Perthes disease
Males - 5x more common
4-8 year olds
Low socioeconomic class
Describe the pathophysiology of Perthes disease
Disruption of blood supply to femoral head leads to osteonecrosis
Revascularisation occurs with subsequent reabsorption and collapse
Remodelling eventually occurs
What are some potential mechanisms of Perthes disease (e.g. how it develops)
May be associated with abnormal clotting factors
Repeated trauma and mechanical overload could lead to collapse and repair
The older you present with Perthes, the better the prognosis - true or false
False
Younger presentations have better prognosis
What are the 4 stages of Perthes disease
Initial
Fragmentation
Reossification
Remodelling
How does Perthes disease present
Gradual onset of painless limp
Sometimes intermittent groin or knee pain
Hip stiffness on
internal rotation and abduction - reduced ROM
Limp - short leg and trendelenberg
How do you diagnose Perthes
Radiographs - can be relatively normal in early stages
MRI
Look for flattened femoral head - progressive deformity
How do you treat Perthes disease
Aim is to keep femoral head round whilst the process self-terminates
Restrict weight bearing and rest the joint
Physio to maintain range of movement
Surgery (osteotomy) for people with severe deformity
What is SUFE
Slipped upper femoral epiphysis
Affects the proximal femoral physis which leads to slipping of the metaphysis relative to the epiphysis
What are the risk factors for SUFE
Males Obesity Endocrine disorders Rapid growth spurts = physis cant cope with sudden increase in weight/pressure Can be triggered by minor trauma
What ages are normally affected by SUFE
10-16
Common to have rapid growth
How do patients present with SUFE
Groin pain
Pain in the knee or thigh
Limp - antalgic or externally rotated foot
Restricted IR and abd
How do you diagnose SUFE
Radiographs
MRI
-Looks like ice cream falling off the cone (head of femur off)
How do you treat SUFE
Surgery
Percutaneous pinning of the hip
May have to do open reduction if severe
Often do the other side prophylactically
List 4 common congenital paediatric orthopaedic condtions
Clubfoot
Rocker bottom foot
Neurofibromatosis
Skeletal dysplasia
List 4 common neruromuscualr paediatric orthopaedic condtions
Cerebral palsy
Duchenne muscular dystrophy
Cavus foot
What is the proper medical name for clubfoot
Congenital Talipes Equinovarus CTEV
What are the key features of clubfoot
Cavus - high arch
Adductus - foot turned inwards
Varus - heel points inward
Equinus - fixed flexion
Who gets club foot
More boys than girls
1/2 of cases are bilateral
What causes club foot
Mostly idiopathic
May be associated with more severe neuro conditions such as spina bifida
How do you treat club foot
Ponseti method
Repeated casting of feet that gradually brings them to normal position
Sometimes the Achilles is cut to allow this but it will heal
What is the proper name for rocker bottom feet
Congenital vertical talus
What causes rocker bottom feet
Irreducible dislocation of talus on navicular
Associated with more serious pathologies
What are the features of rocker bottom feet
rounded plantar surface
Equinus hindfoot -fixed position
What is neurofibromatosis
Congenital disorder - autosomal dominant
Affects the extremities, spine and skin
What are some key signs of neurofibromatosis
>6 café au lait spots >2 neurofibromas Freckles in axilla or inguinal Optic glioma (optic nerve tumour) >2 lisch nodules (in sclera) Cortical thinning or pseudoarthritis
What are skeletal dysplasia’s
Refers to many congenital disorders that involve the bone and cartilage
Abnormal development
What are features of skeletal dysplasia
Shorterning of involved bone
Often short stature
Can be proportionate or disproportionate
How can you classify skeletal dysplasia
According to area of bone affected
OR
According to pathophysiology
What is the most common form of skeletal dysplasia
Achondroplasia
Autosomal dominant condition but mostly caused by spontaneous mutations
What are the features of achondroplasia
Normal trunk with short limbs
Genu varum
Normal intelligence
Motor delay
What is cerebral palsy
Non-progressive neuromuscular disorder
Common condition
what can cause cerebral palsy
Prematurity
Traumatic birth
Infection
Meningitis
what are some signs of cerebral palsy
Muscle weakness
Spasticity
Abnormal muscle forces leading to dynamic deformity
Contracture and fixed deformity
What is the most common type of muscular dystrophy
Duchenne muscular dystrophy
What Duchenne muscular dystrophy
Inherited disorder that presents at 2-5 years old
X-linked recessive - affects boys
Muscle gets replaced by fibrofatty tissue - leads to progressive weakness
What are the features of Duchenne muscular dystrophy
Muscle weakness - greater in proximal muscles
Clumsy walking
Positive Gower’s sign
Scoliosis
How do you diagnose Duchenne muscular dystrophy
creatine phosphokinase
muscle biopsy
What is the prognosis for Duchenne muscular dystrophy
Diagnosed age 2-5
Need walking assistance by 10
Wheelchair bound by 15
Many die by 20
What is Gower’s sign
Walk hands up legs and thighs to get to upright position
Seen in Duchenne muscular dystrophy
Describe cavus feet
Have an elevated longitudinal arch and varus hindfoot (points in)
What can cause cavus feet
Idiopathic
Familial
2/3 due to neurological disorder such as polio or cerebral palsy
How do you assess cavus feet
X-ray
Coleman block test - place block under toes and see if it corrects heel position
How do you manage cavus feet
Surgery
Soft tissue if flexible deformity
Bone if not flexible
What is a greenstick fracture
When the break only occurs in one cortex - seen if force applied to one side of bone
The other cortex only bends
Seen in children
In children, bones tend to bow rather than break - true or false
True
What causes a buckle fracture in children
Compressive force
Bone buckles in on itself
What is a plastic deformation
When neither cortex of the bone is broken but it is deformed as bone bends
Seen in very young children
Point at which metaphysis connects to physis is an
anatomic point of weakness - true or false
True
Children’s fractures heal faster than adults - true or false
True
What are the pros and cons of quick healing fractures in children
Pro - shorter immobilization times
Con - mal-aligned fragments become “solid” sooner
Until what age can you expect bone remodelling after a fracture
Anticipate remodeling if child has > 2 years of
growing left
What is the most common elbow fracture seen in children
Supracondylar
This is the weakest part of the elbow joint
What is the fat pad sign
Sign of supracondylar elbow fracture
Sail shaped fat shadow seen on X-ray - anterior portion may be normal but posterior is always pathological
It may be the only sign in a non-displaced fracture
What other system must you always check in a supracondylar fracture
Vascular!
Always check the pulse as there is a risk of vascular compromise - may need reduced
Neuro - check function is intact
How do you treat a supercondylar fracture
Mostly conservatively
If displaced and damaged you can manipulate under anaesthetic and place wires
Majority of fractures in child < 1 year are from
abuse - true or false
True
Must consider NAI in all cases
Where are the most common fracture sites in NAI
Femur
Humerus
Tibia
What would make you suspect NAI
Unexplained fractures in different stages of
healing
Femoral fracture in child < 1 year
Scapular fracture in child
Epiphyseal and metaphyseal fractures of the long
bones
