Paediatrics Flashcards
1
Q
Describe the pathology of cerebral palsy
A
- scarring in PVL
- loss of inhibition LMN
- positive features of UMN syndrome
- spasticity, hyperflexia, clonus, co-contraction
- muscle shortening, bony torsion, joint instability, degenerative arthritis
2
Q
Why can CP patients have hip problems?
A
- adductors and psoas muscle involved a lot so can lead to hip problems
- high tone; spasticity
3
Q
Describe the natural history of hips in patients with CP
A
- 30% low risk of dislocation
- 30-60% 25% dislocation
- > 60% all dislocated
- hips stable at 18 years remain stable
xrays measure the migration percentile index (%^)
- shows how much the bone has come out of the socket
4
Q
What is the GMFCS?
A
- gross motor function classification score
- score 1 to 5
- 1 independent to 5 having no independence
- higher the GMFCS correlates with incidence of hip displacement
5
Q
What angle is used as measurement of scoliosis?
A
Cobb angle (assesses the severity of the curve)
6
Q
Describe spinal fusion
A
- cobb angle >45 degree
- T2 to pelvis
- major undertaking
- tertiary spinal centre
- early adolesence
- protect respiratory function
- carers; seating, comfort and appearance
7
Q
What are the two phases of walking?
A
- stance (60%)
- swing (40%)
8
Q
Describe driving ambulation
A
- muscles and or ground reactive forces provide the required force for motion
- the skeleton provide the rigid lever arm for the forces
- the joints provide the action point at which movement occurs
9
Q
Normal motion depends on what?
A
- an appropriate and adequate force acting via a rigid level of appropriate length on a stable joint
10
Q
What are the priorities of normal gait?
A
- stability in stance
- clearance in swing
- pre-position of foot in terminal swing
- adequate step length
- conservation of energy
11
Q
What types of gait problems do we encounter in cerebral palsy?
A
- primary (from injury to CNS)
- secondary (from growth)
- tertiary (coping responses)
12
Q
What is the ‘end of school’ arms race in CP?
A
- leaving the childrens service
- pain free hips in joint
- spine fused or mild scoliosis
- tone well managed
- good seating
- full support measures in place
- independence maximised
13
Q
What are the main orthopaedic problems in cp?
A
- hip dislocation
- scoliosis
- gait
14
Q
Describe tip toe walking
A
- age 3
- can have CNS, PNS, muscle or idiopathic causes
- if idiopathic, physio and sometimes casting is all thats required, generally grow out of it
15
Q
Describe clubfoot
A
- aetiology unknown
- postural talipes; feet are turned in but just needs exercises and physio etc, not a structural abnormality
16
Q
What is the pneumonic to remember club foot abnormalities?
A
C - cavus (high arch)
A - adductus (foot towards the midline)
V - varus (hindfoot towards the midline)
E - equina (foot pointing down, tight achilles tendon)
17
Q
Describe treatment of club foot
A
- gentle stretching and casting
- after casting; wear boots and bar
- if not compliant it may reverse
- PONSETI technique
18
Q
What is the treatment of rockerbottom feet?
A
casting, sometimes surgery is needed
19
Q
What is rockerbottom feet?
A
Talus is vertical
20
Q
Describe growing pains
A
- common
- females > makes
- usually bilateral
- growing pains DO NOT cause limp
21
Q
Name the red flags of leg pain
A
- asymmetry
- good localisation
- short history
- persisting limp
- not thriving
- pain worsening
22
Q
Describe the features of growing pains
A
- often long duration
- pain is not localised
- often bilateral
- doesnt alter activity or cause limp
- general health good
- everything else normal
23
Q
Describe anterior knee pain
A
- females > males
- adolescent
- localised patellar tenderness
- stairs / squats
- radiographs
- HIPS
- rx; physio
- any child with knee pain MUST have a hip examination
- referred pain more common in children
24
Q
What is the commonest cause of high arched foot?
A
Hereditary sensory motor neuropathy
25
Describe scoliosis presentation
- age; infantile, juvenile, adolescent
- menarche; onset of periods in females
- FHx
- size of curve
- refer
26
What is a scoliosis?
A 3 dimensional helical twist
27
What are the causes of scoliosis?
- commonest cause is usually postural
| - scherumans kyphosis also a cause albeit rare
28
Describe the aetiology of developmental hip dysplasia
- females 8:1
- demographics
- L>R hips
- breech
- FHx
- oligohydramnios
- moulded baby (feet, neck, head, spine)
- first born
- >4kg
- multiple pregnancy
29
Describe the diagnosis of DDH
- early diagnosis is essential
- neonatal baby checks
- selective US screening in scotland
- 6-8 week GP check
30
Describe baby hip examination
- warm, relaxed and fed baby
- inspection; asymmetry (leg lie), loss of knee height, crease asymmetry, less abduction in flexion (best test)
- specific tests; barlows, ortolani
31
Describe barlows test
- to see if hip will dislocate
| - adduction with downwards pressure
32
Describe ortolanis test
- abduction with upward lift
| - CLUNK
33
Describe imaging for DDH
- US; non ionising, dynamic, need no ossific nucleus (<3 months), operator dependent
- radiographs; cheap and simple, need ossific nucleus, ionising radiation
34
Describe the early treatment of DDH
- pavlik harness
- 23-24 hours a day for up to 12 weeks until the USS i normal
- night time splinting for a few more weeks
- abducted and flexed
- remember serial USS to document improvment
35
Describe the current screening model for DDH
- neonatal / 6-8 week GP / selective US
- poor (picks up about 60% DDH)
- universal ultrasound?
- expert examiner?
36
What is the cut off time for early DDH?
Up until about 3 months
37
What can be seen on xray for late DDH
- a false joint cavity is created
38
Describe late DDH
- > 3 months
- older; worse outcomes
- surgery; CR spica OR spica
- not normal hip
- 30% will need further surgery
39
What is slipped upper femoral epiphysis?
- SUFE
- also known as SCFE
- where the ball of the hip starts to slip off the growth plate
40
Describe epidemiology for SCFE
- 1 in 10,000
- age 8-18 (12.5 girls / 13.5 boys)
- pubertal growth
- racial differences
endocrine / metabolic thyroid hypo / hyper, hypopituitary, renal osteodystrophy
- weight
41
Describe the diagnosis of SCFE
- hip / groin / thigh or knee pain
- limp
- diagnosis delayed or missed
- lifelong hip problems
- 250 thousand payout
42
Describe examination of SCFE
- antalgic gait
- lower limb; short, externally rotated, loss of internal rotation, loss of deep flexion
- pain at extreme hip ROM
43
What is transient synovitis?
- inflammation of the synovium, often secondary to a viral illness
44
Describe the patient presentation of transient synovitis
- often Hx of viral illness
- limp and hip / groin pain
- may present with referred pain to knee (but less common)
- hip lying flexed / externally rotated
- pain at end range of hip movements
- usually systemically well, apyrexial
45
Describe the diagnosis of transient synovitis
- kochers criteria
| - ultrasound +/- aspiration
46
What is septic arthritis of the hip?
Intra-articular infection of the hip joint
47
Why is septic arthritis of the hip a surgical emergency?
- high bacterial load that causes sepsis
- destruction of the joint due to proteolytic enzymes
- potential for osteonecrosis of the hip due to increased pressures
48
Describe the patient presentation of septic arthritis of the hip
- short duration of symptoms
- unable to weight bear and hip / groin pain
- hip lying flexed / externally rotated
- severe hip pain on passive movement
- usually pyrexial but may be haemodynamically stable
49
Describe the pathophysiology of septic arthritis of the hip
- direct inoculation from trauma or surgery
- haematogenous seeding
- extension from adjacent bone (osteomyelitis)
- can develop from contiguous spread of osteomyelitis
- often spread from highly vascular metaphysis
- common in neonates who have transphyseal vessels that allow spread into the joint
- joints with intra-articular metaphysis include; hip, shoulder, elbow, ankle
50
Describe the diagnosis of septic arthritis
- blood tests (FBC, CRP +/- ESR)
- blood cultures
- kochers criteria
- radiographs to rule out other pathologies
- ultrasound +/- aspiration (usually in theatre)
51
Describe treatment of septic arthritis
- open surgical washout
- with samples prior to antibiotics
- repeat washout if not improving
- usually anterior approach
- antibiotics; 6/52, PICC line
52
Name the common organisms in neonates for septic arthritis
- streptococcus
| - gram negative organisms
53
Name the common organisms in infants and children for septic arthritis
- staph aureus
- haemophilus influenza
- salmonella
54
Name the common organisms in adolescents for septic arthritis
- staph aureus
| - nesseria gonorhoea
55
What is perthes disease?
- avascular necrosis of the hip; idiopathic
- 1 in 10,000 children
- 5 x more common in males
- most common in 4-8 year olds
- commoner in lower socioeconomic class
- bilateral in 12% of cases but never at the same time
56
Name risk factors for perthes disease
- positive family history
- low birth weight
- passive smoke
- asian, inuit and central european descent
57
Describe the typical patient for perthes disease
- delayed bone age
- retarded growth soon after diagnosis later catch up on growth
- undersized at Dx
- small hands and feet
- 30% have an attention disorder
58
Describe the treatment of perthes
- containment
- movement
- seeing through fragmentation
- restrictions
- crutches / wheel chairs
- haling
- minimise degenerative changes
59
Describe embryonic limb development
- 4 weeks limb buds
- mesoderm covered with ectoderm
- lateral mesoderm; bone
- somatic mesoderm; muscle
- HOX gene; mass and growth
- ZPA; AP growth and AER
- chondrification of mesenchyme
- cartilage anlage
- segmentation
- primitive joint
- primary ossification centre (in all long bones by 12/52)
- secondary ossification centre (distal femur 36/52)
60
Describe the apical ectodermal ridge
- sonic hedgehog gene
| - hand development
61
Describe swansons classification
- failure of formation
- failure of separation
- hypoplasia
- overgrowth
- duplication
- constriction ring syndromes
- skeletal dysplasia
62
What do you need for growth?
- diet
- sunshine
- vitamins
- growth plates
- hormones
63
Describe growth plate stimulation
- heuter-volkmann law
- periosteal release
- fractures
64
Describe ways to predict growth
- 2nd birthday height x 2
- menalasus
- moseley charts
- paley multiplier; lower limbs
- bone age; g and p, sauvegrain
65
Describe the menelaus process for predicting growth
- 10mm per year from distal femur
- 6mm per year from proximal tibia
- LLD at maturity c 3.5mm
- ablation of both physes 2 years before maturity
- plan epiphysiodesis at age 14
66
Name reasons for disorders of growth
- growth plate injury / arrest
- growth plate over stimulation
- lack of nutrition
- vitamin deficiency
- skeletal dysplasia
- hormonal
67
Describe growth plate arrest
- physeal injury
- trauma
- infection
- tumour
- irradiation
- surgery
- compression
68
How do bones grow?
1. longitudinal from the growth plate (physis) by endochondral ossification
2. circumferential from the periosteum by appositional growth
69
When should a child be able to sit alone or crawl?
6-9 months
70
When should a child be able to stand?
8-12 months
71
When should a child be able to walk?
14-17 months
72
When should a child be able to jump?
24 months
73
When should a child be able to manage stairs alone?
3 years
74
When should a child have head control?
2 months
75
When should a child say a few words?
9-12 months
76
When should a child be able to feed itself, uses spoon?
14 months
77
When should a child be able to stack 4 blocks and understand 200 words?
18 months
78
Describe genu varum
- normal in age <2
- persisting mild genu varum can run in families
- may be abnormal or underlying pathology if; unilateral, severe, short statues or painful
79
Name causes of pathologic genu varum
- skeletal dysplasia
- rickets
- tumour eg enchondroma
- blouts disease
- trauma > physeal injury
80
What is blounts disease?
- growth arrest of medial tibial physis of unknown aetiology
- typical beak like protrusion on xray
81
Describe genu valgum (knock knees)
- usually normal; peak at age 3 1/2
- chart and monitor
- refer if asymmetric, painful, severe
- >8cm intermalleolar distance at age 11 > refer
82
Name causes for genu valgum
- tumours; enchondroma, osteochondroma
- rickets
- neurofibromatosis
- idiopathic
83
Describe in-toeing
- child walks with toes pointing in AKA pigeon-toed
- often accentuated when running
- may be related to; femoral neck anteversion, internal tibial torsion, metatarsus adductus or combination
84
Describe femoral neck anteversion
- femoral neck normally points anteriorly
- XS anteversion > increased IR hip
- tend to sit in W position
85
Describe internal tibial torsion
- usually seen in toddlers (1-4 years)
- vast majority resolve by6 years
- bracing and orthotics ineffective and not required
- surgery very rare for severe cases
86
Describe metatarsus adductus
- common
- benign
- resolves
- if not, passively correctable serial casting may help age 6 - 12 months
87
What do you do for in-toeing?
- define cause
- reassure
- chart / photograph
- review
- discharge unless persisting and severe
88
Describe flat feet
- common, 1 in 5 adults
- we are born with flat feet but most develop medial arch once walking as tibialis posterior strengthens
- flat feet usually asymptomatic
