Surgical Problems in children Flashcards
The head shape can recover to a normal
shape within about_____ weeks following birth
8
This is asymmetry of the skull with a normal head
circumference. The shape can be likened to a tilted
parallelogram.
It is the most common
cause of an abnormal head shape
Plagiocephaly
Plagiocephaly Mx
a _______________can be tried—best from 4 to 8 months
cranial remodelling helmet
This is premature fusion of one or more sutures of the
cranial vault and base, which act as lines of growth
Craniostenosis
Craniostenosis Mx
Prompt referral to a paediatric craniofacial surgeon is
necessary as planning for possible complex surgery,
best at________months, is required
5 to 10
Macrocephaly and microcephaly are defined as a head
circumference greater than the _______ percentile and less than the ______ percentile respectively
97th
3rd
The ears are almost adult size and firmness by _____
5
to 6 years of age
the ear cartilage is not strong
enough to cope with surgery under _____
3 years.
This dermoid cyst, which has a readily identifiable
constant position, lies in the outer aspect of the
eyebrow
External angular dermoid
Congenital clefts of the lip and palate occur in
approximately _______
1:600 of all births.
Type of CLAP
frequently not recognised in infancy because the palate appears to be intact
submucus cleft,
The ideal age for repair of the cleft lip is
under ________ months of age
3
The repair of the palate, which requires preliminary diagnostic ultrasound, is best performed before _______
the child begins to speak
Rhinoplasty is best deferred to ________
If performed early there is a higher incidence of
secondary surgery.
late adolescence.
-_______ may be unilateral, leading to
delayed diagnosis, or bilateral, where there is no
instinctive reaction to breathe through the mouth,
leading to asphyxia
Choanal atresia
What condition?
• tongue may appear heart-shaped
• infants unable to protrude the tongue over the
lower lip
• breastfeeding problems
Tongue tie (ankyloglossia)
The ideal time to release the ‘tie’ is in infancy,
under ______
4 months
This common condition can get recurrently infected
with pus discharge from a small opening immediately
anterior to the ear at the level of the meatus in front
of the upper crus of the helix
Pre-auricular sinus
This is a rare condition and is located inferior to
the external auditory meatus or anterior to the
sternomastoid muscle
Branchial sinus/cyst/fistula
A squint is rarely obvious in the first weeks of life,
but tends to show up when the baby learns to use the
eyes, from about__________
2 weeks to 3 or 4 months of age
Types of squint
• ___________ is one that is permanent—
always present.
• __________ is one that only appears under
stressful conditions such as fatigue.
• _________ is one that is noticeable for short
periods and then the eye appears normal.
Constant or true squint
Latent squint
Transient squint
Types of squint
• ___________ is one that changes between
the eyes so the child can use either eye to fix
vision.
• __________ is not a true squint but only appears
to be one because of the shape of the eyelids, i.e.
broad epicanthic folds
Alternating squint
Pseudosquint
A useful way to differentiate a true squint from a
pseudosquint is to observe the __________
(corneal reflections)
If one eye is ‘lazy’ (that is, not being used), it
is standard practice to _________
wear a patch (maybe on
glasses) over the good eye for long periods
The two serious squints are the _____ and _______ which require early referral
constant and
alternating ones,
Children with strabismus (even if the ocular
examination is normal) need specialist
management because the deviating eye will
become _________
amblyopic (a lazy eye with reduced vision
• hard painless lump (2–3 cm long) within
sternomastoid muscle
• tight and shortened sternomastoid muscle
• usually not observed at birth
Sternomastoid tumour/fibrosis
If surgery for a persistent fibrotic shortened muscle is required it is best before
__________
12 months.
Associations of shortened sternomastoid muscle
- rotation of the head to the affected side,
- hemihypoplasia of the face and a
- wasted ipsilateral trapezius muscle.
This is the most common childhood midline neck
swelling. It moves with swallowing and tongue
protrusion. It is prone to infection, including abscess
formation.
Thyroglossal cyst
These usually present as soft cystic tumours of the
neck, face or oral cavity. They resemble clusters of
vesicles and are often poorly localised
Lymphatic malformation/
lymphangioma/cystic hygroma
Lymphatic malformation/ lymphangioma/cystic hygroma location
If located in the floor of the mouth or peripharyngeal
area they endanger the airway
These start soon after birth as a red
pinpoint lesion and grow rapidly for the first 6 months,
then involute and become pale
Infantile haemangioma
strawberry naevus
These are aggregations of abnormal subcutaneous
veins that may infiltrate deeper tissues.
Venous malformations
These appear sometimes as skin lesions because of
the red discolouration on the surface of the tumour
Lymphatic malformation
If giant naevi they can be dermabraded at ideally less
than _______
6 weeks
These pigmented lesions, which typically appear on
the face, are usually surgically excised because of their
rapid growth and family concerns
Benign juvenile melanoma
Spitz naevus
When to do surgery for macromastia
Reduction surgery should also be delayed until breast
growth is complete, at late adolescence
If it develops in the pubertal stage, gynaecomastia may resolve spontaneously within ________
1 or 2 years.
This syndrome is an absent sternal head of pectoralis
major with associated chest wall deformity plus a
hypoplastic or absent breast and nipple–areolar
complex
Poland syndrome
Poland syndrome
Surgical correction can be undertaken from
________
10 to 20 years.
_______ is the commonest congenital heart lesion (1:500
births).
VSD
What type of VSD
_________harsh murmur,
usually asymptomatic and closes spontaneously.
_______symptoms appear in infancy
Small VSD (‘maladie de Roger’):
Larger VSD:
VSD Tx,
A ______ can close the defect through open-heart surgery.
patch
As a general rule
about________ of all VSDs will close spontaneously
50%
VSD
The
________ type, unlike the muscular type, is less
likely to close spontaneously.
membraneous
In ASD the defect connects the two atria with two
distinct types—________ with holes higher
in the septum (most common) and _________
with holes lower in the septum (more serious)
ostium secundum
ostium primum
Signs of ASD
Signs are a mid-systolic murmur in the
pulmonary area, a split 2nd sound and a loud P2.
Symptoms are uncommon in infancy and
childhood with ostium secundum but ______ and ________develops early with ostium primum.
heart failure
with pulmonary hypertension
Prophylactic antibiotics
are needed for patients with ______
ostium primum
Mx of ASD
Options are repair by________ or an insertion
of a patch or a device closure using a ___________manipulated into the defect
via cardiac catheterisation.
direct surgical suture
self-expanding
‘double umbrella device’
The ductus fails to close after birth. A loud, continuous
machinery murmur is heard
Patent ductus arteriosus
Patent ductus arteriosus sx
The child presents with a murmur with
possible respiratory infections, failure to thrive and
heart failure.
This usually presents in infancy with heart failure.
Refer for early surgery to remove the narrowed
portion of the aorta
Coarctation of the aorta
Inguinal hernias
These usually present in the first _______ months
3 to 4
They and _______ hernias should be referred
urgently as early surgery is advisable to avoid the
high risk of bowel incarceration or strangulation and
ovarian entrapment and ischaemia in females
femoral
______ are painless cystic swellings
around the testis
Scrotal hydroceles
Problem in scrotal hydrocele
The opening of the processus
vaginalis is narrow and often closes spontaneously
Hydrocele
Two types can be identified—
1. _______ which disappear within 12 months,
- _____ which often persist after the first year
slack, often bilateral,
tense, often
unilateral,
Hydrocele
Ninety per cent resolve by 18 months of age; for
those that persist, referral is recommended with a
view to surgical intervention if present for longer
than _________
2 years.
Testes can still descend up to ____months after birth
3
Undescended testes
Refer by 6 months with a view to correction between
9 and 12 months but definitely before ______
2 years
What condition
Non-urgent cases should be evaluated by 6 months
with a view to surgery at around 12 months; these
patients should not be circumcised.
Hypospadias
uncommon and almost all cases of
tight foreskin with narrowing of the preputial orifice
resolve naturally
Phimosis
Phimosis
Probably the only indication for circumcision is
_________
persistent difficulty in passing urine
Surgery is not usually required for umbilical herniae
as most close naturally by _______
4 years of age
A good guideline is that if the hernial orifice is greater than 1 cm at ______ then surgical intervention is a possibility.
It is usual to operate at 4–5 years
12 months
This is due to a defect in the linea alba adjacent to the
umbilicus proper. Most lie just above the umbilicus.
Para-umbilical hernia
An \_\_\_\_\_\_\_\_ (not to be confused with divarification of the rectus muscles) lies between the umbilicus and the xiphisternum.
epigastric hernia
epigastric hernia is likely to incarcerate and causes pain by strangulation of _______
herniated fat.
________are often seen in infants and toddlers
with uncomfortable defecation and minimal bright
bleeding
Anal fissures
________is caused by adhesions considered to be
acquired from perineal inflammation
Labial fusion
Dev dysplasia of hip
Detected by
1
2
clinical examination (Ortolani and Barlow tests) and ultrasound examination
DDH
Infants are usually treated successfully by
_________
abduction splinting (e.g. Pavlik harness).
Bow legs (genu varum)
• Consider _______ in children at risk.
• Toddlers are usually bow-legged until 3 years of
age.
rickets
What to monitor in pts with genu varum?
Monitor _____________: distance
between medial femoral condyles
intercondylar separation (ICS)
What to monitor in pts with genu valgus:
Monitor ___________
distance between medial malleoli
Refer if: _______
intermalleolar separation (IMS):
IMS >8 cm
Causes of in-toeing are 1 2 3 4
metatarsus varus, internal tibial torsion and medial femoral
torsion.
Children with __________ tend to sit in
a characteristic ‘W’ sitting position
femoral torsion
Have restricted internal rotation of hip due to an
external rotation contracture
Out-toeing
Characteristic posture of Out-toeing pts
Exhibit a ‘Charlie Chaplin’ posture between 3 and
12 months—up to 2 years
Most abnormal-looking feet in infants are not a
true club foot deformity; the majority have postural
problems referred to as _______ such as
talipes calcaneovalgus, metatarsus varus and postural
talipes equinovarus
‘postural talipes’
True club foot deformity is usually_____, and requires orthopaedic correction.
stiff and severe
What condition?
the femur tends to rotate
inwards especially when the child is about 5–6 years
old and is normal up to 12 years
Inset hips (medial femoral torsion)
Fortunately, most children outgrow inset hips before the age of_____
12.
All newborns have flat feet but 80%
develop a medial arch by their sixth birthday and
most by _______
11 years
The presence of the medial arch can be
demonstrated to parents by the _______
tiptoe test
MC type of curly toe
Usually the third toe curls inward under the second toe
so that the second toe lies above the level of the first
and third toes
________rattling respiratory
distress + excessive drooling and
secretions + choking with feeding (passage of
10F catheter stops about 10 cm)
Oesophageal atresia:
Oesophageal atresia MX
Action: nil orally, oropharyngeal suction,
IV fluids
severe respiratory
distress + barrel-shaped chest + scaphoid
abdomen (X-rays of chest/abdomen show loops
of bowel in chest)
Diaphragmatic hernia
Mx Diaphragmatic hernia
Give O 2 , nasogastric tube (avoid bag and
mask)
Bilious (green vomiting) = ____ or ______
bowel obstruction or
malrotation (abdominal X-ray)
bowel obstruction or malrotation MX
Action: nasogastric drainage and refer (do not feed)
Imperforate anus and rectum
Action: refer for surgery on day of birth,
_______ for low lesions; ______ for
high lesions
anoplasty
complex surgery
\_\_\_\_\_\_\_\_\_\_neonatal jaundice (conjugated bilirubin) (usually 4–6 weeks) → white stools
Bile duct atresia:
______________ respiratory
distress + cyanosis + signs of emphysema
Congenital lobar emphysema:
Congenital lobar emphysema MX
refer early for urgent assessment and
surgery to remove diseased lung
______________: respiratory
distress soon after birth
Congenital cystic disease of the lungs
______ (intestinal contents in a sac)
Exomphalos
_______(exposed bowel contents through
anterior wall defect
Gastroschisis
Action: as for exomphalos;_______
cover with plastic wrap
__________: micrognathia + cleft
palate + respiratory obstruction from tongue
Pierre–Robin syndrome
