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MSK > Paediatrics > Flashcards

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
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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
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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

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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
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5
Q

What angle is used as measurement of scoliosis?

A

Cobb angle (assesses the severity of the curve)

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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
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7
Q

What are the two phases of walking?

A
  • stance (60%)

- swing (40%)

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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
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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
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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
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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)
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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
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13
Q

What are the main orthopaedic problems in cp?

A
  • hip dislocation
  • scoliosis
  • gait
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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
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15
Q

Describe clubfoot

A
  • aetiology unknown

- postural talipes; feet are turned in but just needs exercises and physio etc, not a structural abnormality

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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)

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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
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18
Q

What is the treatment of rockerbottom feet?

A

casting, sometimes surgery is needed

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19
Q

What is rockerbottom feet?

A

Talus is vertical

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20
Q

Describe growing pains

A
  • common
  • females > makes
  • usually bilateral
  • growing pains DO NOT cause limp
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21
Q

Name the red flags of leg pain

A
  • asymmetry
  • good localisation
  • short history
  • persisting limp
  • not thriving
  • pain worsening
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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
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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
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24
Q

What is the commonest cause of high arched foot?

A

Hereditary sensory motor neuropathy

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25
Q

Describe scoliosis presentation

A
  • age; infantile, juvenile, adolescent
  • menarche; onset of periods in females
  • FHx
  • size of curve
  • refer
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26
Q

What is a scoliosis?

A

A 3 dimensional helical twist

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27
Q

What are the causes of scoliosis?

A
  • commonest cause is usually postural

- scherumans kyphosis also a cause albeit rare

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28
Q

Describe the aetiology of developmental hip dysplasia

A
  • females 8:1
  • demographics
  • L>R hips
  • breech
  • FHx
  • oligohydramnios
  • moulded baby (feet, neck, head, spine)
  • first born
  • > 4kg
  • multiple pregnancy
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29
Q

Describe the diagnosis of DDH

A
  • early diagnosis is essential
  • neonatal baby checks
  • selective US screening in scotland
  • 6-8 week GP check
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30
Q

Describe baby hip examination

A
  • 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
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31
Q

Describe barlows test

A
  • to see if hip will dislocate

- adduction with downwards pressure

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32
Q

Describe ortolanis test

A
  • abduction with upward lift

- CLUNK

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33
Q

Describe imaging for DDH

A
  • US; non ionising, dynamic, need no ossific nucleus (<3 months), operator dependent
  • radiographs; cheap and simple, need ossific nucleus, ionising radiation
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34
Q

Describe the early treatment of DDH

A
  • 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
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35
Q

Describe the current screening model for DDH

A
  • neonatal / 6-8 week GP / selective US
  • poor (picks up about 60% DDH)
  • universal ultrasound?
  • expert examiner?
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36
Q

What is the cut off time for early DDH?

A

Up until about 3 months

37
Q

What can be seen on xray for late DDH

A
  • a false joint cavity is created
38
Q

Describe late DDH

A
  • > 3 months
  • older; worse outcomes
  • surgery; CR spica OR spica
  • not normal hip
  • 30% will need further surgery
39
Q

What is slipped upper femoral epiphysis?

A
  • SUFE
  • also known as SCFE
  • where the ball of the hip starts to slip off the growth plate
40
Q

Describe epidemiology for SCFE

A
  • 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
Q

Describe the diagnosis of SCFE

A
  • hip / groin / thigh or knee pain
  • limp
  • diagnosis delayed or missed
  • lifelong hip problems
  • 250 thousand payout
42
Q

Describe examination of SCFE

A
  • antalgic gait
  • lower limb; short, externally rotated, loss of internal rotation, loss of deep flexion
  • pain at extreme hip ROM
43
Q

What is transient synovitis?

A
  • inflammation of the synovium, often secondary to a viral illness
44
Q

Describe the patient presentation of transient synovitis

A
  • 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
Q

Describe the diagnosis of transient synovitis

A
  • kochers criteria

- ultrasound +/- aspiration

46
Q

What is septic arthritis of the hip?

A

Intra-articular infection of the hip joint

47
Q

Why is septic arthritis of the hip a surgical emergency?

A
  • 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
Q

Describe the patient presentation of septic arthritis of the hip

A
  • 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
Q

Describe the pathophysiology of septic arthritis of the hip

A
  • 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
Q

Describe the diagnosis of septic arthritis

A
  • blood tests (FBC, CRP +/- ESR)
  • blood cultures
  • kochers criteria
  • radiographs to rule out other pathologies
  • ultrasound +/- aspiration (usually in theatre)
51
Q

Describe treatment of septic arthritis

A
  • open surgical washout
  • with samples prior to antibiotics
  • repeat washout if not improving
  • usually anterior approach
  • antibiotics; 6/52, PICC line
52
Q

Name the common organisms in neonates for septic arthritis

A
  • streptococcus

- gram negative organisms

53
Q

Name the common organisms in infants and children for septic arthritis

A
  • staph aureus
  • haemophilus influenza
  • salmonella
54
Q

Name the common organisms in adolescents for septic arthritis

A
  • staph aureus

- nesseria gonorhoea

55
Q

What is perthes disease?

A
  • 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
Q

Name risk factors for perthes disease

A
  • positive family history
  • low birth weight
  • passive smoke
  • asian, inuit and central european descent
57
Q

Describe the typical patient for perthes disease

A
  • 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
Q

Describe the treatment of perthes

A
  • containment
  • movement
  • seeing through fragmentation
  • restrictions
  • crutches / wheel chairs
  • haling
  • minimise degenerative changes
59
Q

Describe embryonic limb development

A
  • 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
Q

Describe the apical ectodermal ridge

A
  • sonic hedgehog gene

- hand development

61
Q

Describe swansons classification

A
  • failure of formation
  • failure of separation
  • hypoplasia
  • overgrowth
  • duplication
  • constriction ring syndromes
  • skeletal dysplasia
62
Q

What do you need for growth?

A
  • diet
  • sunshine
  • vitamins
  • growth plates
  • hormones
63
Q

Describe growth plate stimulation

A
  • heuter-volkmann law
  • periosteal release
  • fractures
64
Q

Describe ways to predict growth

A
  • 2nd birthday height x 2
  • menalasus
  • moseley charts
  • paley multiplier; lower limbs
  • bone age; g and p, sauvegrain
65
Q

Describe the menelaus process for predicting growth

A
  • 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
Q

Name reasons for disorders of growth

A
  • growth plate injury / arrest
  • growth plate over stimulation
  • lack of nutrition
  • vitamin deficiency
  • skeletal dysplasia
  • hormonal
67
Q

Describe growth plate arrest

A
  • physeal injury
  • trauma
  • infection
  • tumour
  • irradiation
  • surgery
  • compression
68
Q

How do bones grow?

A
  1. longitudinal from the growth plate (physis) by endochondral ossification
  2. circumferential from the periosteum by appositional growth
69
Q

When should a child be able to sit alone or crawl?

A

6-9 months

70
Q

When should a child be able to stand?

A

8-12 months

71
Q

When should a child be able to walk?

A

14-17 months

72
Q

When should a child be able to jump?

A

24 months

73
Q

When should a child be able to manage stairs alone?

A

3 years

74
Q

When should a child have head control?

A

2 months

75
Q

When should a child say a few words?

A

9-12 months

76
Q

When should a child be able to feed itself, uses spoon?

A

14 months

77
Q

When should a child be able to stack 4 blocks and understand 200 words?

A

18 months

78
Q

Describe genu varum

A
  • 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
Q

Name causes of pathologic genu varum

A
  • skeletal dysplasia
  • rickets
  • tumour eg enchondroma
  • blouts disease
  • trauma > physeal injury
80
Q

What is blounts disease?

A
  • growth arrest of medial tibial physis of unknown aetiology
  • typical beak like protrusion on xray
81
Q

Describe genu valgum (knock knees)

A
  • usually normal; peak at age 3 1/2
  • chart and monitor
  • refer if asymmetric, painful, severe
  • > 8cm intermalleolar distance at age 11 > refer
82
Q

Name causes for genu valgum

A
  • tumours; enchondroma, osteochondroma
  • rickets
  • neurofibromatosis
  • idiopathic
83
Q

Describe in-toeing

A
  • 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
Q

Describe femoral neck anteversion

A
  • femoral neck normally points anteriorly
  • XS anteversion > increased IR hip
  • tend to sit in W position
85
Q

Describe internal tibial torsion

A
  • 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
Q

Describe metatarsus adductus

A
  • common
  • benign
  • resolves
  • if not, passively correctable serial casting may help age 6 - 12 months
87
Q

What do you do for in-toeing?

A
  • define cause
  • reassure
  • chart / photograph
  • review
  • discharge unless persisting and severe
88
Q

Describe flat feet

A
  • 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

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