Paeds Orthopaedics Flashcards
1
Q
Define DDH
A
A congenital spectrum of diseases characterized by varying displacement of the proximal femur from the acetabulum. (The acetabulum has not developed normally - too shallow and cannot contain the head of the femur)
2
Q
Define: dysplasia in DDH
A
Dysplasia is characterised bt a shallow underdeveloped acetabulum
3
Q
Define subluxation in DDH
A
There is superolateral migration of the femoral head in relation to the acetabulum
4
Q
Define Dislocation in DDH
A
The femoral head is completely dislocated from the acetabulum
5
Q
Defineteratologic hip in DDH
A
These hips were dislocated in utero and are irreducible on neonatal exam. Have to be associated with neuromuscular conditions or genetic disorders e.g. spina bifida, Ehler’s danlos, arthrogryphosis
5
Q
Describe the late (adolescent) dysplasia
A
The hip is stable and reduced but dysplastic (not completely congruent/ spherical)
6
Q
List the 6 risk factors for DDH + 2 other risk factors
A
- Female
- Fluid (oligohydramnios)
- Fat (macrosomia/ large fetal weight»_space; prolonged labour)
- Family hx +ve
- Firstborn
- Foot presentation (Breech)
Others: torticollis, swaddling to extend hips/ knees
7
Q
True or false: DDH is common in black babies
A
False: higher incidence in white and coloured babies
8
Q
True or false: DDH is commonest in the left hip
A
True: this is due to the fetal position (the left hip is typically laying against the maternal spine)
9
Q
Describe the pathoanatomy of DDH
A
DDH may be caused by instability due to maternal & fetal laxity, genetic laxity and intra-uterine and postnatal malpositioning. This instability leads to displasia of the anterior or anterolateral acetabulum.
10
Q
Describe 3 fetal conditions associated with DDH
A
- Congenital muscular torticolis
- Metatarsus adductus
- Congenital knee dislocations
11
Q
Describe the 2 ways in which DDH can be prevented
A
- Carrying infants with hip abducted (“Abba” child on your back)
- Klisic method - using a bulky diaper “ Hip package”
12
Q
Neonatal clinical examination for DDH is non-negotiable. Ultrasound screening at 6 weeks is recommended for infants with a normal examination but with which 5 risk factors?
A
- Breech presentation
- Family hx +
- Parental concern
- Suspicious exam
- Hx of tight lower extremity swaddling
13
Q
In which 2 ways will a child < 3 months with DDH present?
A
- Asymmetric skin folds.
- Limited abduction of the affected hip
14
Q
List and describe 3 tests you can do in a child < 3 months to dx DDH
A
- Ortolani’s test
- It is a test of reduction. Applied to an already dislocated hip. Lay a relaxed infant supine, flex hips and knees to 90 degrees and apply anterior pressure over the greater trochanter using index finger, gently abduct the hips using thumbs. This produces a “ clunk” with anterior dislocation of femoral head relative to the acetabulum. - Barlow’s test
- Test of dislocation. Applied to a dislocatable hip (but not already dislocated). Flax and adduct hips, apply light pressure on the knees, directing force posteriorly. + test if the hip is dislocated posteriorly. - Galleazzi’s test
- Only useful in unilateral dislocations. Check if the knees are of unequal height when the hips and knees are flexed.
15
Q
How will a child > 3 mo old but < 1 year old present and what test will you use to test them?
A
Limited hip abduction of the affected side.
Test using the Galleazi test.
16
Q
List 5 signs of the walking child (>1 yo) with DDH.
Which test can be done to make the dx?
A
- Limited hip abduction in the affected leg
- Increased lumbar lordosis
- Trendelenburg gait
- Equinus gait (toe walking)
- Pelvic obliquity
Galleazzi test can be one but only in unilateral DDH.
17
Q
Ix to dx DDH:
True or false: DDH is a clinical diagnosis
A
True
18
Q
From when can an ultrasound be done for DDH?
A
From 6 weeks and younger than 4 months
19
Q
X-rays for DDH are unreliable until the pt is at least how old? Why?
A
Until the pt is at least 4 months old because the epiphysis of the femoral head is only visible on x-ray after the epiphysis has ossified.
20
Q
List and explain the 5 radiological signs of DDH.
A
- Hip dislocation: Hilgenreiner line
- horizontal line through right and left triradiate cartilage.
- Femoral head ossification should be inferior to this line. - Perkin’s line
- vertical line perpendicular to Hilgenreiners line through a point at a lateral margin of the acetabulum.
- Femoral head ossification should be medial to this line - Shenton’s line
- Arc along the inferior border of the femoral neck and superior margin of the obturator foramen.
- The arc line should be continuous. - Ossification of femoral head
- Delayed ossification in cases of dislocation - Hip dysplasia: AI
- Angle drawn from a point on the lateral triradiate cartilage to a point at the lateral margin of the acetabulum. The angle should be less than 25 degrees.
21
Q
What is the treatment of choice for DDH if picked up < 6 months?
A
Abduction splinting/ bracing (Pavlik harness)
22
Q
What are 2 indications for Pavlik harness?
A
- < 6 months
- Reducible hip
23
Q
Name 1 contraindication for Pavlik harness
A
Tetatologic hip dislocation
24
Explain the regimen of Pavlik harness (as in, how it is worn/ frequency, duration etc.)
Full wear with hip ultrasound every 1-2 weeks (mother should not remove the hardness at any point). It takes 3 weeks to reduce and stabilise PLUS 6 weeks in brace after reduction PLUS 6 weeks intermittent brace = therefore 16 weeks in total.
25
At which point should a Pavlik harness be abandoned?
If not reduced by 3-4 weeks in a child < 6 months old, ti should be abandoned.
26
Describe and account for the 2 main complications of Pavlik harness.
1. Femoral nerve palsy >> quadriceps paralysis is over-flexed hip
2. AVn if incorrect placement of Pavlik harness (i.e too much abduction in the Pavlik harness)
27
True or false: The earlier the intervention, the higher the success rate of Pavlik harness management
True
28
Other management options for DDH are 1. Closed reduction and spica casting and 2. Open reduction.
List 2 indications for closed reduction and spica casting
1. DDH dx made at 6-18 months
2. If Pavlik harness failed, wait till the age of 6 months and then do a closed reduction and a spica cast. The child will wear the spica cast for 3 months.
29
What are the indications of open reduction and spica casting in DDH?
Describe this surgery
Indications: 1. If DDH diagnosis made after 18 months. 2. Failure of closed reduction
The surgery: The capsule is opened. Removal of soft tissue blocking reduction (pelvic osteotomy to reshape the acetabulum). Reduce the hip. Shorten the femur if needed (derotational osteotomy)
30
How is reduction confirmed post-surgery?
Xrays or CT or ultrasounds are done, with the patient in a spica.
31
The prognosis of DDH is better if treated earlier. List 5 complications of DDH or its management
1. Joint contractures
2. AVN of the femoral head
3. Redislocation
4. Early osteoarthritis
5. Back/ knee pain (referred)
32
Define Perthes (Legg-Calve-Perthes disease)
Idiopathic AVN of the proximal femoral epiphysis in children
33
Perthes epidemiology:
- What is the typical age of onset?
- Gender prevalence?
- Urban vs rural?
- Uni or bilateral?
- 4-8 yo
- More in males
- More in urban
- 12% bilateral
34
List risk factors for Perthes diseaase (HINT: LIMPING Boy mnemonic)
Low birth weight
IUGR
Male
Parent age (older) and smoking
Income (low socioeconomic)
Non-hispanic (more in whites, Asians, Inuit, Central Europeans)
Growth delay (short stature)
Breech
35
The precipitating cause of Perthes disease is unknown but the cardinal step in pathogenesis is?
Explain this.
Ischaemia of the femoral head.
Up to age 4 months: 3 vessels support the head of femur: metaphyseal vessels, lateral epiphyseal vessels and some scanty ligamentum teres vessels.
After 4 years, metaphyseal vessels decline and disappear. But, at this time, ligamentum teres vessels have developed.
Between 4-7 yo, the femoral head only depends on lateral epiphyseal vessels only, which are susceptible to stretching and to pressure from an effusion. This pressure may cause venous stasis >> rising intraosseous pressure >> subsequent disruption in vascular supply >> ischaemia
36
In addition to ischaemia of the femoral head and changes in blood supply, list 2 other known precipitating factors of Perthes disease
1. Clotting disorders
- Perthes is seen in 50% of children with thrombophilia or protein S and C deficiency
2. Bone collapse and repair
- Repetitive microtrauma >> damages result from epiphyseal bone resorption, collapse, and the effect of subsequent repair during the course of the disease.
37
List 2 conditions often associated with Perthes disease in children
1. ADHD - found in 33% cases
2. Delayed bone age - seen in 89% of patients.
38
Important prognostic variables in Perthes disease are age of pt (bone age at presentation) and the sphericity of the femoral head and congruency at skeletal maturity (Stulberg classification).
List 3 poor prognostic factors
1. Age at presentation > 6 yo
2. Female sex
3. Decreased ROM at hip (decreased abduction)
39
Describe the natural history of the disease/ long term complications
Most patients do well until 5th-6th decades, in which degenerative changes of the hip become apparent.
50% of pts with Perthes disease develop premature OA due to the aspherical femoral head.
40
List and describe briefly the 4 stages of Legg-Calves-Perthes disease (Waldenstrom)
1. Necrosis
- Infarction produces a smaller, sclerotic epiphysis with widening of the medial joint space. Xray remains occult for 3-6 months
2. Fragmentation
- Femoral head appears to fragment or dissolve. This is the result of revascularization and bone resorption >> collapse and subsequent increased density. Here, hip symptoms are the most prevalent
3. Reossification
- The ossific nucleus undergoes re-ossification. Why: new bone appears and necrotic bone is resorbed. This may last up to 18 months.
4. Healing and remodelling
- Femoral head remodels until skeletal maturity. This process begins once ossific nucleus is completely re-ossified. Now, the trabecular pattern returns.
41
List 2 main symptoms that the parent or patient with Perthes will describe
1. Insidious onset pain in the hip (or knee or groin or thighs). The pain is intermittent or may fluctuate, depending on physical activity
2. Limp - antalgic limp (pain on the weight bearing leg ) or non-antalgic (painless limp - due to restricted ROM)
42
On physical examination, what signs may you pick up in Perthes? List (3 signs and 2 provocative tests)
Signs:
1. Hip stiffness (restricted ROM) with loss of internal rotation and abduction.
2. Gait disturbance - Antalgic or Trendelenburg (head collapse leads to decreased tension of the abductors)
3. Limb length discrepancy = late finding.
Provocative tests:
1. FABER test positive
2. Hinge abduction: refers to the lateral femoral head bumping into the ventrolateral acetabulum when the leg is abducted, possibly involving pain, a palpable clunk and restriction in the ROM.
43
Which Xray views will you request if you suspect Perthes? (these are critical in diagnosis and prognosis)
AP and frog leg view.
44
List 3 early radiological signs of Perthes disease
NB! X-rays are frequently without pathological findings during the early stages
1. Medial joint space widening (Earliest)
2. Irregularity of femoral head ossification (increased lucency of femoral head/ flattening or fragmentation of femoral head)
3. Crescent sign (represents subchondral fracture)
45
List 6 "Head-at-risk" signs of Perthes disease
1. Lateral calcification
2. Lateral femoral head subluxation
3. Lesions extending to the metaphysics e.g. cyst
4. Horizontal alignment of the epiphyseal plate
5. Gage sign (lateral triangle at femoral head)
6. Crescent sign
46
In the 4-8 yo child presenting with a painful hip and/or limp, what 4 other diagnoses should you exclude?
1. TB arthritis of the hip (can mimic Perthes exactly- biopsy may be NB)
2. DDH
3. Transient synovitis
4. Other rarer skeletal dysplasia of the hip
47
List 3 differential diagnoses of AVN of the hip in children (except for Perthes)
1. Sickle cell disease
2. Gaucher's disease (genetic disease: fatty substance deposition in body organs and tissues)
3. Hypothyroidism (decreases blood vessel diameter >> hypoxia>> ischemia >> necrosis)
48
The majority of patients with Perthes disease are treated conservatively (without surgery). What does conservative management involve? (5)
1. Observation alone
2. Activity restriction
3. Partial weight bearing
3. Traction
4. Physiotherapy
5. ? Abduction braces
49
List 2 main indications of conservative Mx in Perthes
1. Age < 6 yo
2. Herring A + B classification (i.e A= No density change and Full height maintained. B= > 50% height maintained. Only central collapse)
50
What are the main goals of conservative Rx of Perthes?
1. Keep femoral head contained to limit deformity, minimise loss of sphericity and minimise subsequent degenerative changes
2. Relieve pain
3. Restore ROM
51
Regarding operative management of Perthes disease:
1. What is (are) the procedure (s) ?
2. List 2 indications
3. True or false: improvement is seen in all patients operated.
1. Femoral and/or pelvic osteotomy
2. Indications: Age > 8 yo, To improve containment of femur head in hip joint
3. False>> only in carefully selected patients is improvement seen.
52
Define SUFE
A disorder of the femoral physis (growth plate) that leads to slippage of the femoral neck (superior and anterolateral displacement) relative to the epiphysis due to weakening of the proximal femoral epiphyseal growth plate and mechanical forces acting on the susceptible physis.
53
PATHOANATOMY:
Why is SUFE a misnormer?
It is a misnomer because the epiphysis stays in the acetabulum while the neck displaces anteriorly and externally rotates (the epiphysis is posterior)
54
What is the main concern with SUFE?
Compromised blood supply as the slipping may kink or tear the retinacular arteries >> AVN of the femoral head.
55
EPIDEMIOLOGY:
Describe the typical patient who presents with SUFE (and account for it)
This is the most common disorder affecting adolescent hips.
The typical patient is a male currently in puberty (13 yo average. Risk period: 10-15 yo. For girls- 12 yo). During the period of rapid growth. Obese children.
Why: puberty-induced hormonal changes, endocrine disorders, inflammation >> poor cartilaginous organization and maturation >> wide and unstable physis.
56
List 3 associated endocrine disorders that need to be ruled out in SUFE. list other associated disorders/ risk factors.
ENDOCRINE:
- Hypothyroidism (high TSH)
- Osteodystrophy in chronic renal failure (U+e)
- GH treatment
OTHER:
- pituitary tumors
- craniopharyngioma
- Down's syndrome
+ family hx
57
CLINICAL PRESENTATION
There are 2 possible scenarios in terms of clinical presentation of these patients. Explain
Explain the symptoms
- Acute severe pain with inability to walk OR
- An episode of acute pain that gradually resolves and the child comes with mild pain and a limp.
The pain is in the groin or knew. Minor trauma is frequently reported.
58
SIGNS:
You are now examining this patient. Explain the findings on
- General exam
- MSK exam (LOOK, FEEL, MOVE, Provocative test)
- General exam:
Obese with delayed secondary sexual development
MSK:
Look: antalgic or trendelenburg gait, externally rotate leg. The affected limb is shortened and held in an externally rotated position (out squinting patella)
Feel: thigh atrophy
Move: Drehmann sign positive (Obligatory external rotation on passive flexion of the hip). Loss of hip internal rotation, abduction and flexion.
59
SUFE is classified into stable and unstable (this gives us prognostic information). Explain what these classifications mean.
Stable = able to weight bear with or without crutches. Minimal risk of AVN.
Unstable = Unable to ambulate (not even with crutches). High rate of osteonecrosis.
60
What Xray views will you request for the patient with suspected SUFE?
1. AP hips
2. Frog leg lateral >> lateral to identify subtle slips
Of both hips
61
Describe the 3 radiological findings of SUFE that are found on AP of pelvis.
1. Klein line
- Line drawn along the superior border of the femoral neck will not intersect femoral head in a child with SUFE
2. Epiphysiolysis (growth plate widening or lucency)
- An early x-ray finding
3. Blurring of proximal femoral epiphysis (metaphyseal blanch sign of steel)
- Seen on AP due to overlapping of the metaphysics and posteriorly located epiphysis
62
What is the role of an MRI in SUFE?
It can diagnose a pre-slip conditoin when xrays are negative. With pre-slip, slippage has not occurred yet but the child has symptom and MRI shows irregular, widened and abnormal physis.
63
Describe the initial management of SUFE
As soon as SUFE is diagnosed, prevent the risk of AVN, esp if unstable SUFE by:
1. Place the child in a trolley/wheelchair (strict non-weight bearing)
2. Counsel parents
3. If there is a delay between diagnosis and referral hospital: place child in light traction with 1.5 kg suspended over a pulley (for unstable SUFE)
4. Refer the pt on a semi-urgent basis. (Urgent if unstable SUFE.)
64
What are the indications of endocrine workup in children with SUFE?
1. Child < 10 yo
2. Weight < 50th percentile
65
True or false: Non-operative management is the mainstay of treatment in SUFE
False. Mainstay of Rx is internal fixation, bilaterally.
66
Describe the operative treatment options of SUFE
1. Percutaneous in situ fixation
- Indicated in both stable and unstable SUFE.
2. Bilateral in situ fixation (contralateral prophylactic pinning)
2. Alternative: open reduction
67
List 2 indications for bilateral in situ fixation in SUFE
1. If positive endocrine workup (even if the other side is asymptomatic)
2. Children < 10 yo
68
List 7 complications of SUFE
1. AVN of the femoral head (most common complication, higher with unstable slip)
2. Chondrolysis (loss of cartilage at femur head)
3. Residual proximal femoral deformity and limb length discrepancy.
4. Slip progression following single screw fixation
5. Hip stiffness
6. Degenerative arthritis
7. Pin-associated proximal femur fracture.
69
Clinical measurements of the tibiofemoral angle and intercondylar distance in the normal children depends on age.
Explain what happens in the following ages:
- 6mo-12 months (1 year)
- 18-24 months (2 years)
- 4 years
- 7 years
6mo-12 months (1 year) > maximal varus
- 18-24 months (2 years) > neutral
- 4 years> maximal valgum
- 7 years > decreased in genu valgum to a mean of 6 degrees.
70
True or false: The presence of genu varum after 2 years is considered normal
False: it is abnormal
71
Define : the normal mechanical axis
This is a line extending through the middle of the femur head, knee joint and ankle joint with parallel joint lines. This line is drawn on a full length weight bearing x ray with the patella facing forward.
72
DEFINE THE FOLLOWING TERMS, USED TO DESCRIBE ANGULAR VARIATIONS:
Valgus
2 limb segments create an angle that points towards the midline
The distal segment forms an angle that points away from the midline in the coronal plane
73
DEFINE THE FOLLOWING TERMS, USED TO DESCRIBE ANGULAR VARIATIONS:
Varus
2 limb segments create an angle that points away from the midline
The distal segment forms an angle that points towards from the midline in the coronal plane
74
DEFINE THE FOLLOWING TERMS, USED TO DESCRIBE ANGULAR VARIATIONS:
Recurvatum
A backward curvature with the apex posterior and distal fragment angulated anteriorly in the sagittal plane
75
DEFINE THE FOLLOWING TERMS, USED TO DESCRIBE ANGULAR VARIATIONS:
Procurvatum
A forward curvature with the apex anterior and distal fragment angulated posteriorly in the sagittal plane
76
DEFINE THE FOLLOWING TERMS, USED TO DESCRIBE ANGULAR VARIATIONS:
Genu valgum
Deformity at the knee in which the tibia and the foot deviate away from the midline when the body is in the anatomical position, with the patella facing forward.
i.e the knees are abnormally closer together with space between ankles increased >> knock knee
The deformity may be in the thigh or leg or both
77
DEFINE THE FOLLOWING TERMS, USED TO DESCRIBE ANGULAR VARIATIONS:
Genu varum
Deformity at the knee in which the tibia and the foot deviate towards the midline when the body is in the anatomical position, with the patella facing forward.
i.e the knees are abnormally separated and lower extremities are bowed inwardly >> bow legs
78
NORMAL LOWER LIMB ROTATIONAL PROFILE
The normal rotational profile changes as the child matures.
- Describe femoral version from birth to adult (>10 yo)
Children are born with 30-40 degree anteversion. As they grow older, anteversion lessens to 15-20 degrees at age 10.
79
NORMAL LOWER LIMB ROTATIONAL PROFILE
The normal rotational profile changes as the child matures.
- Describe tibial rotation changes
The tibia rotates laterally with growth:
- Foetus: medial malleolus is behind lateral malleolus, i.e internal tibial torsion.
- At birth: neutral
- On walking: 20 degrees lateral tibial rotation
80
Define foot progression angle
What value is in-toeing given vs out-toeing?
The angle of the foot relative to an imaginary line in the patients path as she/he walks .
This value represents the sum total effect of the child's structural alignment (i.e femoral version, tibial torsion and foot contour)
in-toeing = negative value
out-toeing= positive value
81
What is the normal foot progression angle in normal adults?
10 degrees positive thigh foot angle
82
DEFINE:
In-toeing
Individual stands or walks with medial border of foot pointing inwards
83
DEFINE:
Out-toeing
Individual stands or walks with medial border of foot pointing outwards
84
DEFINE:
Version -femur
Rotational alignment between axis of the femoral neck and the place of the femur as defined by the flexion axis of the knee.
85
DEFINE:
Femoral anteversion
Normal, thus femoral neck points anterior to the plane of knee flexion axis
86
DEFINE:
femoral retroversion
When the angle between the femoral neck and the plane of knee flexion is less than the average amount
87
DEFINE:
Torsion
The act or process of twisting, turning or rotation about an axis.
88
DEFINE:
Internal tibial torsion
The ankle is rotated inwards in relation to the knee due to the internal rotation of the tibia in the axial plane. INTERNAL tibial torsion is always normal
89
DEFINE:
External tibial torsion
The ankle is rotated outwards in relation to the knee due to the external rotation of the tibia in the axial plane.
Mild external tibial torsion (< 20 degrees) is normal and is called external rotation of the tibia.
90
The normal foot contour is neutral or straight. Name and describe the 2 pathological foot contours
Foot abducted outwards >> pes planus
Foot adducted inwards >> metatarsus adductus or clubfoot
91
These patients require a comprehensive history anf clinical exam.
What should the history entail? List 4 main things.
1. Main complaint: concerns of the parent: pain/deformity/disability/gait/cosmesis/ progression- statis? worsen? better?
2. Medical and developmental hx : perinatal hx, developmental milestones, duration of complaint, when did the problem start?
3. Family hx of similar problem?
4. Sitting habits: how does the child sit? ( "W position?" >> femoral anteversion; sitting on the feet >> internal tibial torsion
92
When working up a child with rotational or angular deformities, certain conditions must be excluded.
List 6 of these.
1. Neuromuscular disease e.g. CP
2. Metabolic abnormalities e.g. Rickets
3. Skeletal dysplasia
4. Congenital hip dislocation or SUFE
5. Trauma/ infections causing growth plate arrest (angular deform)
6. Hyperlaxity (angular deform)
93
List 5 signs of hyperlaxity
1. Thumb touches forearm
2. fingers hyperextend to be parallel to the forearm
3. Elbows hyperextended beyond zero degrees
4. Knees hyperextended beyond zero degrees
5. Ankle dorsiflex > 45 degrees
94
Special investigations vary, depending on the clinical picture:
e.g. special Ix will differ in a child presenting with severe genu varum & short stature vs a child presenting with severe neurodevelopmental delay, lower limb contractures and deformities vs a 2 yo presenting with genu varum and nothing else.
What will you always request for any child presenting with angular or rotational abnormalities?
Full length standing AP xray of the lower limbs with patella forward; blocks under ankles where needed and pelvis parallel to the xray.
95
FEMORAL ANTEVERSION
- What is the typical hx you will receive
- What will physical examination reveal?
- T/F This is a condition requiring immediate surgery
- Hx: The child is clumsy, hx of falling and sits with legs in W shape.
- O/e: increased internal hip rotation, decreased external rotation
Benign condition, resolves in 80% of pts. Conservative Rx e.g. splints are useless
96
FEMORAL ANTEVERSION
List 5 indications of surgery (surgical derotation surgery)
1. > 10 years
2. Severe deformity creating serious cosmetic and functional disability
3. Anteversion of > 50 degrees
4. Internal rotation of > 75 degrees
5. Family aware of risks of surgery
97
INTERNAL TIBIAL TORSION
- What is thought to cause internal tibial rotation
- T/F it is usually symmetrical
- Describe the natural progression of this condition
- How will you counsel the parents?
- T/F Treatment with night splints, shoe wedges, and orthotics is the mainstay of treatment
- Why is surgery not wanted in these patients? (osteotomy of the tibia)
- List 3 indications for operative correction in these patients.
1. It is believed that the cause is: intrauterine position, sleeping in the prone position after birth and sitting on the feet.
2. Mostly asymmetrical
3. 90% of cases resolve with time as the child reaches 8 years of age
4. Counsel parents:avoid prone sleeping position and sitting on the feet.
5. Orthotics, splints etc. are useless.
6. High complication rate with tibial osteotomy >> compartment syndrome, peroneal nerve palsy
7. Indications for surgery:
- Age > 8 yo
- Significant functional disability
- Thigh-foot angle greater than 3 SD beyond the mean
98
METATARSUS ADDUCTUS
- What is the most common cause of metatarsus adductus?
- Describe findings on examination
- There are 2 types of metatarsus adductus, namely?
- Describe the natural progression of this condition
- Most common cause: intrauterine packing
- O/e: + adduction of the forefoot and convex lateral border. Ankle is in normal motion.
- 2 types: flexible and rigid deformity metatarsus adductus
- 90% of cases resolve without treatment by age 1.
99
METATARSUS ADDUCTUS
- Describe the management of flexible metatarsus adductus
-Stretching exercises during the first 8 months of life by the parents.
HOW: (Hold the infant's hindfoot in one hand and the forefoot in the other. Stretch the midfoot, opening the c-shaped curve and slightly overstretching it. Perform this exercise at each diaper change)
100
METATARSUS ADDUCTUS
How are flexible deformities that persist > 8 months and rigid deformities managed?
Serial casting:
- Refer pt to orthopaedic surgeon
- Casts changes biweekly with correction after 3-4 casts.
- Residual adductus causes no long-term disability
101
METATARSUS ADDUCTUS
Surgery is usually not performed because of high complication rates.
In which cases is surgery indicated and what procedure?
If the deformity persists > 6 yo.
Op: soft tissue release and an opening wedge osteotomy medially and a closing wedge osteotomy lateral in the midfoot area
102
FEMORAL RETROVERSION
- Why is this common in infancy?
- Describe the common physical examination findings.
- When do you refer these patients for further examination?
- List 3 complications for femoral retroversion that is not managed,
- Common in infancy because of external rotation contracture of the hip caused by intrauterine packing.
- O/e increased external rotation to almost 90 degrees and decreased internal rotation.
- Refer to Ortho if resolution is nor evident and persistent external rotation is present on successive visits at age 2-3.
- 1. osteoarthritis
2. SUFE
3. Increased risk of stress fractures.
103
EXTERNAL TIBIAL TORSION
- This usually becomes a cosmetic issue, often unilateral, and seldom resolves spontaneously.When is surgery indicated and what is the prerequisite?
The child must be at least 10 yo and the condition should be severe with a thigh-foot angle of > 40 degrees
104
PES PLANUS (flat foot)
This is a widely common condition in children. Differentiate between flexible and rigid flat foot.
Flexible flat foot: The arch is reconstituted on toe standing (Jack's test). The arch should also be recreated when the foot is non-weight-bearing. No treatment indicated.
Rigid flat foot: Stiff and painful
105
List 6 possible causes of rigid flatfoot (these patients need to be referred to Ortho )
1. Trauma
2. Infection
3. Foreign body
4. Bone tumours
5. Tarsal coalition
6. Osteochondrosis of the navicular bone
106
VARUS DEFORMITIES: Tibia Vara (Blount's disease)
- Define Blount's disease
- List at least 7 causes
Def: Tibia vara is an asymmetric growth arrest on the medial part of the distal femur and proximal tibia
Causes:
1. Infection
2. Tumour
3. Fracture
4. Rickets
5. Bone dysplasia - achondroplasia, metaphyseal dysplasia, osteogenesis imperfect
6. Lead/ fluoride intoxication
7. Fibrocartilagenous dysplasia
107
VALGUS DEFORMITIES
List 9
possible causes of valgus deformities
1. Developmental - i.e physiologic
2. Congenital - d/t longitudinal deficiency of the fibula
3. Iliotibial band contracture
4. Trauma - e.g. malunion f#, growth stimulation in greenstick f#
5. Asymmetric growth arrest d/t f# separation in lateral upper tibial physis
6. Infection >> asymmetric growth disturbance
7. Inflammatory arthritis >> RA, Haemophilia
8. Bone dysplasias >> e.g. Ollier's disease
9. Osteogenesis imperfect
Rickets
