Spinal Ortho Flashcards
What is the normal variation of childhood alignment of the lower limb?
Newborn - varus alignment.
- 5-2 years - neutral alignment.
- 5-3.5 years - valgus alignment.
4-7 years - neutral alignment
How do bones grow?
Enchondral ossification - longitudinal growth from the growth plate (physis).
Appositional growth - circumferential from the periosteum (bone gets wider).
How does bone growth occur at the growth plate?
The epiphyseal plate is a layer of hyaline cartilage.
Chondrocytes are stacked on this plate which then ossify into bone.
This process repeats and bone grows.
Which physes contribute to bone growth more than others?
What factors affect the growth plate?
Diet/nutrition.
Sunshine, vitamins (D and A).
Injury.
Illness - growth arrest lines seen in bone from when the person was ill with flu etc.
Hormones (growth hormone).
What do you need to know in terms of growth percentiles and short stature?
1/5 children less than 2S.D. below the mean for their age will have an underlying pathologic reason e.g. low GH.
Age <3 growth much more variable – can cross centiles. Nutrition plays a big part.
Look at parents height.
What do dysmorphic features in a growing child mean?
Dysmorphic features -> increased chance underlying genetic or endocrine disorder.
When is it normal for a child to lose primitive reflexes (e.g. moro, grasp, stepping, fencing)?
1-6 months - loss of primitive reflexes (moro, grasp, stepping, fencing).
When does a child normally gain head control?
2 months - head control.
When does a child normally sit alone, crawl?
6-9 months - sits alone, crawls.
When does a child normally stand?
8-12 months - stands.
When does a child normally start speaking a few words?
9-12 months - few words.
When does a child normally start feeding themselves?
14 months - feeds self, uses spoon.
When does a child normally start to walk?
14-17 months - walks.
When does a child normally learn to stack 4 blocks and understand 200 words?
18 months - stacks 4 blocks, understands 200 words.
When does a child normally learn to jump?
24 months - jumps.
When does a child normally manage stairs alone?
3 years - manages stairs alone.
When does a child normally learn to potty train?
3 years.
What orthopaedic deformities are variations of normal?
Genu varum or valgum.
Intoeing.
Flat feet.
Curly toes.
When would you refer someone to orthopaedics for their genu varum?
Could be due to abnormal or underlying pathology if:
- Unilateral (asymmetry >5 degrees).
- >2S.D/16 degrees from mean.
- Short stature >2 S.D.
- Painful.
What are pathological causes of genu varum?
Skeletal dysplasia (dwarfism).
Rickets (vitamin D deficiency).
Tumour e.g. enchondroma.
Blounts disease.
Trauma -> physeal injury.
What is Blounts disease?
Growth arrest of the medial tibial physis of unknown aetiology.
How can you surgically correct Blounts disease?
Remove the lateral (growing) growing plate to arrest bone growth.
Remove the boney blockade of arrested growing bone from the medial physis.
What pathologies can cause genu valgum?
Tumours - enchondroma, osteochondroma.
Rickets.
Neurofibromatosis.
Idiopathic.
When would you refer someone with genu valgum to orthopaedics?
Asymmetric.
Painful.
Severe >2S.D.
If intermalleolar distance at age 11 is >8cm consider surgery.
What is intoeing?
Child walks with toes pointing in (pigeon-toed).
Often accentuated when running.
What is intoeing associated with?
Metatarsus adductus (foot).
Internal tibial torsion (knee).
Increased femoral neck anteversion (hip).
What is the mean femoral neck anteversion at birth?
30-40 degrees.
What is the mean femoral neck anteversion at maturity?
10-15 degrees.
What is the surgical treatment for severe femoral neck anteversion?
Femoral derotation osteotomy.
If metatarsus adductus does not resolve itself passively what can be done to correct it?
Serial casting may help between age 6-12 months.
What conditions can cause flat feet?
Neurological - cerebral palsy.
Muscular - dystrophy.
Syndromic - trisomy 21.
Connective tissue - Marfan’s, Ehlers Danlos.
What should you ask a patient presenting with back pain?
Pain - type; radiates/localised.
Loss of function - subjective; try to find out how the problem affects the individual.
Trauma - recent/past.
Previous surgery.
Symptoms suggesting other pathology: urinary tract (kidney stones, UTI); GI (pancreatitis); respiratory (pneumonia); systemic illness.
What will you do in a physical examination for back pain?
LOOK:
- How the patient walks in (and out).
- Deformity e.g. scoliosis, kyphosis, scars - previous surgeries.
FEEL:
- Spinal tenderness.
- Paravertebral muscles.
- Get the patient to show you where the pain is.
MOVE:
- Flexion, extension, lateral flexion.
- Straight leg raise - only if there is sciatic pain.
- Tone, power, reflexes, sensation in legs if indicated.
What investigations will you do for back pain?
Usually none.
If systemic indication - ESR, PV, calcium, alkaline phosphatase.
Rarely xray.
MRI - if indicated.
What radiological findings are indicative of osteoarthritis?
Loss of joint space.
Osteophytes.
Sclerosis.
Subarticular cysts.
LOSS
What are the causes of backpain?
Mechanical/non-specific - >90%.
Tumour/metastases - 0.7%.
Ankylosing spondylitis - 0.3%.
Infection - 0.1%.
What are the red flags of back pain?
Age <20 or >50.
Thoracic pain – if pain isn’t in the ‘normal’ place (lumbar region).
Previous carcinoma (breast, bronchus, prostate).
Immunocompromise (steroids, HIV).
Feeling unwell – if been going on for a couple months and other associated factors.
Weight loss.
Widespread neurological symptoms - MS.
Structural spinal deformity.
What are the yellow flags of chronic back pain?
Low mood.
High levels of pain/disability.
Belief that activity is harmful.
Low educational level.
Obesity.
Problem with claim/compensation (secondary gain).
Job dissatisfaction.
Light duties not available at work.
Lot of lifting at work.
What is the management of (chronic) back pain?
Explanation.
Reassurance.
Encourage to mobilise.
Cultivate positive mental attitude.
Analgesics (paracetamol, co-analgesics, opiates).
NSAIDs - short term (a few weeks).
Muscle relaxants e.g. diazepam - short-term (3 days).
Physiotherapy.
Osteopathy and chiropractor.
Referral.
What are the causes of back pain?
Viscerogenic - pain from viscera (AAA, renal colic, pancreatitis, gall bladder, peptic ulcer, uterine/ovarian, colonic.
Spondylogenic - pain form the joints, muscles, ligaments/structural part of the spine excluding the disc.
Discogenic - pain from the disc.
Neurogenic - pain from the nerve roots.
Psychogenic.
Pain from the back going down the buttock and thigh. What is the likely cause?
Mechanical back pain.
Pain from the back going down the leg to the foot. What type of pain is it likely to be?
Sciatic pain.
What myotome is involved in hip flexion?
L1/L2.
What myotome is involved in knee extension?
L3/L4.
What myotome is involved in foot dorsiflexion & extensor hallicus longus?
L5.
What myotome is involved in ankle plantarflexion?
S1/S2.
What blood tests are useful in guiding you to a diagnosis of infection?
CRP.
Plasma viscosity.
What cellular activity is reflect in technetium scans?
Osteoblast activity.
What are the causes of acute osteomyelitis?
Post-traumatic, open fracture.
Children.
Immunosuppressed.
What microorganisms often cause acute osteomyelitis?
Staph. aureus.
Haemophilus - in children.
What is the pathogenesis of acute osteomyelitis?
Trauma -> endothelial damage to vessels in the bone -> thrombosis in the metaphysis.
If there is ongoing bacteraemia it can settle in the thrombosis in the bone causing infection in the bone.
What is the pathogenesis of chronic osteomyelitis?
Abscess in the bone and surrounding bone dies off -> sclerotic reaction of osteoblast activity.
Pus from abscess travels either into joint cavity (septic arthritis) or goes under the periosteum lifting it away from the bone forming an involucrum.
What are the principles of treatment of bone and joint infections?
Know what bug you’re dealing with.
Operate if there is pus, dead tissue or foreign body.
Target antibiotics for long enough.
What history post-arthroplasty suggests an infected arthroplasty?
Wound slow in healing or leaking or not looking right.
If it has not ever been pain-free.
What prophylactic measures are in place to prevent infected arthroplasties?
Clean air theatres and laminar flow.
Local antibiotics in the bone cement.
Systemic antibiotics - 24 hours starting with induction.
Avoid a long operation as its less time for bugs to get into the wound.
