paeds ortho Flashcards
how are fractures to the growth plate graded?
Salter-Harris classification (SALTR)
type 1 = Straight across type 2 = Above type 3 = beLow type 4 = Through type 5 = cRush
pain management in childrens fractures
- paracetamol or ibuprofen
- morphine
**codeine + tramadol are NOT used in kids, aspirin contraindicated in U16s (except Kawasaki)
risk factors for DDH
1st degree fam history breech presentation from 28 weeks (feet first) multiple pregnancy (twins) female down syndrome
presentation of DDH
different leg lengths
restricted hip abduction on one/both sides
difference in knee level when hips are flexed (positive Galeazzi sign)
clunking of hips on Ortolani + Barlow test
Ortolani test
DDH
starts dislocated will reduce - push from behind will pop upwards
Barlow test
DDH
starts reduced - will dislocate
pushing down so hip pops back
diagnosis of DDH
<3months = US >3months = x-ray
management of DDH
<6months = Pavlik harness - keeps hips flexxed + abducted, 6-8weeks
> 6months or harness fails = surgery - hip spica cast post-surgey
Slipped upper femoral epiphysis (SUFE)
head of femur is displaced (slips) along growth plate
- boys aged 8-15 + obese
- suspected if pain is disportionate to minor trauma
SUFE presentation
hip, groin, thigh, or knee pain (knee pain = examine hip)
restricted range of hip movement - esp. internal rotation
painful limp
patient will prefer to keep hip externally rotated
management of SUFE
surgery - pin femoral head in correct position + fix it preventing further slipping
transient synovitis
“irritable hip”
commonest cause of hip pain aged 3-10
associated with recent viral upper respiratory tract infection
NO fever if fever + joint pain urgent for septic arthritis
transient synovitis presentation
limp
refusal to weight bear
groin or hip pain
previous viral URT
management of transient synovitis
analgesia
safety net - attend A&E if develop fever
usually resolve 1-2weeks
follow up at 48hrs + 1 week
Pethes disease
disruption of blood flow to femoral head causing AVN
affects epiphysis of femur
idiopathic, severity varies
overtime there’s revascularisation of femoral head - remodelling of bone as it heals
what age and gender is Perthes disease more common in?
boys aged 4-12 yrs - particularly 5-8yrs
presentation of Perthes disease
slow onset of -
- pain in hip or groin
- limp
- restricted hip movements
- referred pain to knee
**no history of trauma - if trauma think SUFE (esp. in older kids)
complications of Perthes
soft + deformed femoral head (from remodelling as it heals)
leads to -
- early hip OA
- artificial total hip replacement in 5% of patients
Perthes investigations
x-ray
- femoral head deformity
- widening of femoral neck (coxa magna)
- sclerotic lie running across femoral neck
MRI if x-ray normal
management of Perthes
depends on severity
- bed rest, analgesia, traction/crutches, physio
- regular x-rays to assess healing
- surgery in v severe cases, older kids or those not healing
foot position in talipes equinovarus
plantar flexion + supination
foot position in talipes calcaneovalgus
dorsiflexion + pronantion
treatment of talipes (clubfoot)
Ponseti method
- repeated casts until in correct position - may require Achilles tenotomy
- after cast brace is used when not walking until kid 4ish y/o (“boots + bars”)
tarsal coalition
abnormal brige between talus + calcaneus
- painful fixed flat foot
Mx = splintage, orthotics, surgery to remove abnormal connection
spondylolithesis
slippage of one vertebra over another
– usually L4/5 or L5/S1
presents usually adolescence
developmental or recurrent stress fracture that fails to heal
presentation of spondylolisthesis
low back pain
radiculopathy (pinching of nerve root in spinal column) with sever slippage
“flat back” - due to muscle spasm
management of spondylolisthesis
minor = rest + physio
severe = stabilisation + possibly reduction (risk of neurological injury)
osteogenesis imperfecta
genetic mutations that affect maturation + organisation of type 1 collagen
brittle bones prone to fractures
8 types - vary in severity
presentation of osteogenesis imperfecta
*blue/grey sclera* reccurent + inappropriate fractures hypermobility triangular face short stature deafness from early adulthood dental problems bone deformities - scoliosis, varus
diagnosis = clinical
management of osteogenesis imperfecta
biphosphonates - to increase bone density
vit D supplementation
MDT - physio, occ., paeds, social workers
achondroplasia
(short stature/dwrfism)
- autosomal dominent or sporadic
- prominent forehead + widened nose
- recurrent otis media due to cranial abnormalities
Ehlers-Danlos syndrome
abnormal elastin + collagen
joint hypermobility, vascular fragility, scoliosis
Duchenne muscular dystrophy
boy starts to walk with difficulty standing (Gower’s sign)
can’t walk by age 20, progressive cardiac + resp failure in early 20s
how do you diagnose + treat Duchenne muscular dystrophy?
diagnosis = raised serum creatinine phosphokinase + abnormalities on biopsy
Mx = spplintage, physio
cerebral palsy
due to an insult to immature brain before, during, or after birth
onset before 2-3 yrs
expression + severity variable depending on where it is in the brain
causes of cerebral palsy
more often no identifiable cause genetic problems brain malformation, intracranial haemorrhage infection during early pregnancy prematurity hypoxia during birth meningitis
cerebral palsy presentation
failure to meet milestones
increased/decreased tone generally or specific limbs
hand preference <18months
problems with speech, coordination or walking
learning difficulties
types of spina bifida
2 halves of posterior vertebral arch fail to fuse - first 6 weeks gestation
occulta = mildest, dimple over area, high arched foot/clawing of toes
meningocele = herniation of meninges alone
myelomeningocele = herniation of meninges + cauda equina
treatment spina bifida
defect usually closed within 48hrs of birth
obstetric brachial palsy
brachial plexus injury during vaginal delivery
common in - large babies, twins, shoulder dystocia (shoulder stuck during birth)
Erb’s palsy (upper)
Klumpke’s palsy (lower) - prognosis WORSE than Erb’s (no treatment)
what part of the brachial plexus is injured in Erb’s palsy?
C5 + C6
Erbs palsy presentation
loss of motor innervation of arm muscle (biceps)
leads to internal rotation of humerus - may lead to waiters tip posture
management of Erbs palsy
(C5 + C6)
physio
surgical release of contracture + tendon transfers if no recovery
->prognosis is based on return of biceps function by 6 months
what part of the brachial plexus is injured in Klumpke’s palsy?
C8 + T1
Klumpke’s palsy
C8 + T1 injury
paralysis of intrinsic hand muscle +/- fingers+ wrist
possible horners syndrome
NO treatment
risk factors for rickets
breastfed babies - formula fed is fortified with vit D
darker skin, low exposure to sunlight, colder climate, lots of time indoors
presentation of rickets
may not have any symtpoms lethargy bone pain swollen wrists varus, valgus rachitic rosary soft skull delayed teeth abnormal fractures
what is rachitic rosary + craniotabes?
rachitic rosary = ribs expand at costochondral junc, causing lumps along chest
craniotabes = soft skull, delayed closure of sutures + frontal bussing
–> both signs of rickets
rickets investigations
serum 25-hydroxyvitamin D (<25 = deficient)
x-ray required to diagnose = translucent bones
serum ca + phosphate = low
serum alkaline phosphatase = high
parathyroid hormone = high
what would serum alkaline phosphatase + parathyroid hormone levels be like in rickets?
both HIGH
serum calcium + phosphate levels in rickets?
LOOOOW
management of rickets
breastfeeding women should take vit D supplement
ergocalciferol (vit D for kids) - dose dependents on age
calcium supplementation
what is Jacks test used for
flat feet
mobile/flexible = flattened medial arch forms with dorsiflexion of great toe
rigid = remain flat regardless of load or dorsiflexion - underlying tarsal coalition or inflammatory or neurological disorder
angulation of the distal segment of bone away from midline
valgus
angulation of distal segment of bone towards midline
varus
