Paeds: Ortho Flashcards
Developmental Dysplasia of the Hip
what bedside test would you use to indicate whether the shortening is femoral or tibial?
Galleazi test
Developmental Dysplasia of the Hip
what is it
structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy.
This leads to instability in the hips and a tendency or potential for subluxation or dislocation.
Developmental Dysplasia of the Hip
RFs (4)
- 1st degree FH
- breech from 36w
- breech at birth if 28w onwards
- multiple pregnancy
Developmental Dysplasia of the Hip
when is it screened for
on the neonatal examination at birth and 6-8 week old
Developmental Dysplasia of the Hip
Findings that may suggest DDH (5)
- different leg lengths
- restricted hip abduction on one side
- significant bilateral restriction in abduction
- difference in the knee level when the hips are flexed
- clunking of the hips on special tests
Developmental Dysplasia of the Hip
what are the 2 special tests
Ortolani test
Barlow test
Developmental Dysplasia of the Hip
what is the ortolani test
- baby on back with hips and knees flexed
- abduct hips and apply pressure behind the legs
- see if hips dislocate anteriorly
Developmental Dysplasia of the Hip
what is the Barlow test
- baby on back with hips adducted and flexed at 90 degrees and knees bent at 90 degrees
- Gentle downward pressure is placed on knees through femur
- to see if the femoral head will dislocate posteriorly.
Developmental Dysplasia of the Hip
Clicking is a common examination finding, what is it due to
soft tissue moving over bone
Developmental Dysplasia of the Hip
what sound is likely to indicate DDH and requires US
Clunking
Developmental Dysplasia of the Hip
diagnostic inx
US of the hips
Developmental Dysplasia of the Hip
who should get an US
All children with risk factors or examination findings suggestive of DDH
Developmental Dysplasia of the Hip
when are x-rays helpful
in older infants
Developmental Dysplasia of the Hip
mnx if <6m
Pavlik harness
Developmental Dysplasia of the Hip
what is a Pavlik harness
hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop a normal shape.
keeps the baby’s hips flexed and abducted.
Developmental Dysplasia of the Hip
when is the Pavlik harness removed
when their hips are more stable, usually after 6-8w
Developmental Dysplasia of the Hip
mnx if Pavlik harness fails or >6m
surgery, then a hip spica cast is used to immobilise the hip for a prolonged period.
Slipped Upper Femoral Epiphysis
what is it
head of the femur is displaced (“slips”) along the growth plate.
Slipped Upper Femoral Epiphysis
who is it more common in
obese 8-15yr old boys
adolescent, obese male undergoing a growth spurt. Hx of minor trauma. Likely dx?
SUFE
Slipped Upper Femoral Epiphysis
presenting sx
- Hip, groin, thigh or knee pain
- Restricted range of hip movement
- Painful limp
- Restricted movement in the hip
Slipped Upper Femoral Epiphysis
examination findings
prefer to keep the hip in external rotation
restricted internal rotation
Slipped Upper Femoral Epiphysis
initial inx of choice
x-ray
Slipped Upper Femoral Epiphysis
Other investigations that can be helpful in establishing the dx (apart from x-ray)
- normal blood tests
- Technetium bone scan
- CT scan
- MRI scan
Slipped Upper Femoral Epiphysis
Mnx
Surgery
to return the femoral head to the correct position and fix it in place to prevent it slipping further.
Transient Synovitis
aka
irritable hip
Transient Synovitis
what is it
temporary (transient) irritation and inflammation in the synovial membrane of the joint (synovitis)
what is the most common cause of hip pain in children aged 3-10yrs
transient synovitis
Transient Synovitis
what is it often associated with
a recent viral upper respiratory tract infection.
Transient Synovitis
what is the difference between this and septic arthritis
Children with transient synovitis typically do not have a fever
Transient Synovitis
presentation
viral illness, then a few weeks later:
- limp
- refusal to weight bear
- groin or hip pain
- mild low grade temp
normal paediatric observations and no signs of systemic illness
Transient Synovitis
mnx
symptomatic: analgesia
A&E if the sx worsen or they develop a fever.
followed up at 48h and 1w
Transient Synovitis
prognosis
significant improvement in sx after 24 – 48 h
resolve within 1 – 2w without any lasting problems.
may recur in around 20%
Perthes Disease
what is it
disruption of the blood flow to the femoral head causing avascular necrosis of the bone
Perthes Disease
which bone does it affect
the epiphysis of the femur (the bone distal to the growth plate: physis)
Perthes Disease
epidemiology
4-12yrs
mostly 5-8yrs
more common in boys
Perthes Disease
cause
idiopathic
Perthes Disease
main complication
a soft and deformed femoral head leading to early hip OA
Perthes Disease
presentation
slow onset of:
- pain in hip or groin
- limp
- restricted hip movements
- referred pain to the knee
- NO HX OF TRAUMA
difference between SUFE and Perthes
if pain is triggered by minor trauma, think SUFE
Perthes Disease
initial inx of choice
x-ray
Perthes Disease
other inx helpful in establishing dx (other than xray)
- normal blood tests
- technetium bone scan
- MRI scan
Perthes Disease
initial mnx in younger and less severe disease
conservative:
- bed rest
- traction
- crutches
- analgesia
- physio
- regular x-rays
maintain alignment
Perthes Disease
mnx in severe cases, older children or those that are not healing
surgery
Talipes (clubfoot)
what is it
a fixed abnormal ankle position that presents at birth
Talipes (clubfoot)
what are the 2 types
Talipes equinovarus
Talipes calcaneovalgus
Talipes (clubfoot)
what is Talipes equinovarus
ankle in plantar flexion and supination.
Talipes (clubfoot)
what is Talipes calcaneovalgus
ankle in dorsiflexion and pronation.
Talipes (clubfoot)
trx
Ponseti method
surgery if it fails
Talipes (clubfoot)
what is the Ponseti method
foot is manipulated towards a normal position and a cast is applied to hold it in position.
repeated over and over until the foot is in the correct position.
At some point an achilles tenotomy to release tension in the achilles tendon is performed
Talipes (clubfoot)
Ponseti method: mnx after cast
a brace is used to hold the feet in the correct position when not walking until the child is around 4 years old ‘‘boots and bars’’
Talipes (clubfoot)
what is Positional Talipes
the resting position of the ankle is in plantar flexion and supination, however it is not fixed in this position and there is no structural boney issue in the ankle.
muscles are slightly tight around the ankle but the bones are unaffected.
Talipes (clubfoot)
mnx of positional talipes
physio
resolves over time
Osteosarcoma
what is it
a type of bone cancer which usually presents in in adolescents aged 10-20 years
Osteosarcoma
what is the most common bone to be affected
femur
tibia and humerus are also common
Osteosarcoma
main presenting features
persistent bone pain
worse at night
bone swelling, palpable mass, restricted joint movement
Osteosarcoma
child presents with unexplained bone pain or swelling. What do you do
very urgent direct access x-ray within 48h
Osteosarcoma
If the xray suggests a possible sarcoma, what next
need very urgent specialist assessment within 48 hours.
Osteosarcoma
what would x-ray show
- poorly defined lesion in the bone
- destruction of the normal bone and a “fluffy” appearance
- periosteal reaction (irritation of the lining of the bone) classically described as a “sun-burst” appearance
Osteosarcoma
what may blood tests show
a raised ALP
Osteosarcoma
what further investigations is used to better define the lesion and stage the cancer
- CT scan
- MRI scan
- Bone scan
- PET scan
- Bone biopsy
Osteosarcoma
mnx
- surgical resection of the lesion, often with a limb amputation
- adjuvant chemo
Osteosarcoma
main complications
- pathological bone fractures
- metastasis
Osteomyelitis
what is it
infection in the bone and bone marrow.
Osteomyelitis
where does it typically occur
in the metaphysis of the long bones
Osteomyelitis
what is the most common bacteria
staph aureus
Osteomyelitis
what is chronic osteomyelitis
a deep seated, slow growing infection with slowly developing symptoms
Osteomyelitis
how would acute osteomyelitis present
more quickly with an acutely unwell child
Osteomyelitis
who is it more common in
boys and children under 10 years
Osteomyelitis
RFs
- Open bone fracture
- Orthopaedic surgery
- Immunocompromised
- Sickle cell anaemia
- HIV
- Tuberculosis
Osteomyelitis
presentation
- refusing to use the limb or weight bear
- pain
- swelling
- tenderness
Osteomyelitis
initial inx
x-ray but can be normal in osteomyelitis
Osteomyelitis
diagnostic inx
MRI
or bone scan
Osteomyelitis
what will bloods show
raised inflammatory markers and WBCs
Osteomyelitis
how to establish causative organism
blood culture
bone marrow aspiration or bone biopsy with histology and culture may be necessary
Osteomyelitis
mnx
extensive and prolonged antibiotic therapy.
may require surgery for drainage and debridement of the infected bone.
