Revision - Hip Problems, Rickets & OI Flashcards
Clinical features of DDH?
1) asymmetrical skin folds
2) leg length discrepancy
3) clunking on special tests
4) limited hip abduction
5) significant bilateral restriction in abduction
What 2 special tests are used to check for DDH?
1) Barlow test
2) Ortolani test
What is Barlow vs Ortolani test attempting to do?
Barlow –> Gentle downward pressure is placed on knees through femur to see if the femoral head will dislocate posteriorly.
Ortolani –> Gentle pressure is used to abduct the hips and apply pressure behind the legs with the fingers to see if the hips will dislocate anteriorly
Clicking vs clunking in DDH exam?
Clicking - normal
Clunking - more likely to indicate DDH and requires an US
In DDH, if the baby presents <6 months of age, what does 1st line treatment involve?
Pavlik harness
What is a Pavlik harness?
A soft splint with the aim to hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop a normal shape.
What position does a Pavlik harness keep the baby’s legs in?
Abduction & flexion
How long is a Pavlik harness typically on for?
6-8w
Management of DDH if the harness fails or the diagnosis is made after 6 months of age?
Surgery
What are some red flags for hip pain in children?
- age <3 y/o
- fever
- waking at night due to pain (malignancy)
- weight loss etc
- stiffness in morning (inflammatory)
- swollen or red joint
What are the 2 most common organisms causing septic arthritis in children?
1) Staph. aureus
2) Strep. pyogenes
What age in children is septic arthritis most common?
<4 y/o
What is the most common cause of hip pain in children aged between 3-10 years old?
Transient synovitis
How will children with transient synovitis typically hold their leg?
In a flexed, abducted and externally rotated position.
This position results in the least amount of intracapsular pressure within the joint and is therefore the least painful.
What movement is limited in transient synovitis?
Internal rotation
What special manoeuvre is indicated in transient synovitis?
Log roll test
What is the log roll test?
Ask the patient to lay supine with the hip and knee extended.
The examiner then passively rotates the entire limb internally and then externally.
A positive test is defined as involuntary muscle guarding when the leg is rolled passively
What is a positive result on a log roll test in transient synovitis?
Involuntary muscle guarding when the leg is rolled passively.
When can a working diagnosis of transient synovitis can be managed in primary care?
- afebrile
- mobile but limping
- symptoms have been present for <48 hours
What are the 4 aspects of the Kocher criteria?
1) non-weight bearing
2) fever >38.5
3) raised WCC
4) raised ESR
3 xray results in septic arthritis?
1) joint effusion
2) narrowing of the joint space
3) destruction of the subchondral bone
What is the main complication of Perthes?
Early hip osteoarthritis
There is remodelling of the bone as it heals –> causing a soft and deformed femoral head.
What staging system is used in Perthe’s?
Catterall staging
Describe stage 1 to 4 of the catterall staging
Stage 1: clinical and histological features only
Stage 2: sclerosis with or without cystic changes and preservation of the articular surface
Stage 3: loss of structural integrity of the femoral head
Stage 4: loss of acetabular integrity
1st line imaging in Perthe’s?
XR
What movement is typically affected in SUFE?
Limited internal rotation in flexion
When examining the patient with SUFE, how will they prefer to keep their hip?
In external rotation
What movement is particularly limited in SUFE?
Internal rotation
Mx of SUFE?
Internal fixation with a cannulated screw placed in the center of the epiphysis
What is hereditary hypophosphataemic rickets?
A rare form of rickets caused by genetic defects that result in low phosphate in the blood.
How is vitamin D created?
Created from cholesterol by the skin in response to UV radiation
What skeletal deformities may be seen in rickets?
1) Craniotabes
2) Frontal bossing
3) Rachitic rosary
4) Bowing deformities e.g. bowlegs (genu varum) or knock-knees (genu valgum)
5) Pectus carinatum (pigeon chest) or pectus excavatum (funnel chest)
What is craniotabes?
A condition where an infant’s skull bones are soft and thin, causing them to collapse when pressure is applied
What is rachitic rosary?
Swelling of the ends of the ribs
What condition does rachitic rosary indicate?
Rickets
What serum 25-hydroxyvitamin D establishes a diagnosis of vitamin D deficiency?
<25 nmol/L
What imaging is required to diagnose rickets?
XR
Which babies are at higher risk of vitamin D deficiency?
Breastfed babies are at higher risk than formula fed babies –> as formula feed is fortified with vitamin D.
Prevention of rickets?
Breastfeeding women and all children should take a vitamin D supplement: 400 IU (10 micrograms) per day for children and young people.
Management of children with vitamin D deficiency?
vitamin D (ergocalciferol)
What is talipes?
A fixed abnormal ankle position that presents at birth.
AKA clubfoot.
Is talipes bilateral or unilateral?
50% of cases are bilateral
What is talipes treated with?
The Ponseti method
A way of treating talipes without surgery. It is usually very successful
What is the most common type of osteogenesis imperfecta?
Type 1 (this is also the mildest)
When does osteogenesis imperfecta typically present?
In childhood with fractures following minor trauma.
Clinical features of osteogenesis imperfecta?
- recurrent and inappropriate fractures
- hypermobility
- blue/grey sclera
- short stature
- otosclerosis
What are the 2 medical treatments involved in the mx of osteogenesis imperfecta?
Bisphosphonates & vit D supplementation
How are calcium, phosphate, parathyroid hormone and ALP affected in osteogenesis imperfecta?
Usually normal
What is a rare complication of Osgood-Schlatter disease?
A full avulsion fracture.
This is where the tibial tuberosity is separated from the rest of the tibia.
What is the most common cause of intestinal obstruction in infants and young children?
Intussusception
Peak age incidence of intussusception?
6m-3y
Presentation of mesenteric adenitis?
RLQ pain
What is the most common cause of chronic diarrhoea in infants in the developed world?
Cow’s milk intolerance
What is Hirschsprung-associated enterocolitis (HAEC)?
Inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s.
This is life threatening as can lead to toxic megacolon and perforation of the bowel.
Management of HAEC?
Urgent Abx, fluid resuscitation and decompression of the obstructed bowel
What is the definitive management of Hirschsprung’s?
surgical removal of the aganglionic section of bowel.
