Unit 3: Orthopaedic Conditions in Childhood Flashcards
Describe genu valgum and genu varum
The normal alignment of the knee is in valgus and when a child stands to attention there is normally a gap of 4cm or so between the feet. If this gap is increased the knees are in varus and if it is increased they are in valgus
What is the prognosis of genu valgum/varum?
Rarely, if ever serious, and by the age of 7 nearly all children with these conditions will have developed a normal knee alignment
List the three causes of in-toeing
Femoral neck variation, tibial torsion, abnormal forefeet
Describe femoral neck angle variation
During the later stages of the normal development of the fetus, the leg rotates on the pelvis so that the acetabulum points almost backwards and the femoral head on the neck is orientated forwards. Sometimes this rotatory process is not completed by birth so the femoral neck is more anteriorly orientated than normal. This reflects in a child’s posture and they will have an in-toed gait. This delayed development will correct itself by age 10, very rarely surgery may be required
Discuss tibial torsion
The bone is warped along its vertical axis; this is a normal variation and should be ignored
Discuss abnormal forefeet
It is dubious whether corrective surgery is ever justified, vast majority correct spontaneously by age 7 and any residual hooking rarely causes functional difficulties
Discuss flat feet
A flat foot is generally a normal variation. Mobile flat feet are entirely innocuous. A rigid flat foot is rare at any age and usually implies an underlying bony abnormality of the foot, occasionally can be a sign of a serious disease such as rheumatoid arthritis
Describe curly toes
Minor overlapping or crossing of the toes is common. Most correct spontaneously and should be left alone
List four minor childhood disorders
Knock knees/bow legs, in-toeing, flat feet, and curly toes
What are the two types of flat feet?
Mobile and rigid
What is Osgood Schlatter’s disease?
Osgood Schlatter’s disease is an inflammation of the attachment of the patellar tendon to the growing tibial epiphysis, caused by excess traction by the quadriceps. The cause is uncertain but it may be an overuse injury
Describe the management of Osgood Schlatter’s disease
The condition is episodic and can usually be treated by rest. The child will cease to have symptoms in middle adolescence when the epiphysis fuses
What is adolescent knee pain?
Adolescent knee pain occurs mostly in girl and is of unknown cause. Rarely on arthroscopy chondromalacia patellae may be seen
Describe the management of adolescent knee pain
Most girls grow out of the condition, if symptoms persist an arthroscopy may be necessary
What is congenital dislocation of the hip?
Child is born with an abnormal femoral head, or acetabulum, or both, which predisposes to dislocation
What is the frequency of occurrence of CDH?
One/two live births per thousand
List the ages at which children should be screened for CDH
Children should be screened at birth, three months, six months and twelve months
How do we treat early CDH?
Early CDH is treated by splintage
How do we treat late CDH?
If picked up late but before weight bearing, management involves a period of gentle traction followed by open or closed manipulation. It is then splinted in plaster for three months
If picked up late and once walking has commenced, major surgery is required
What are the long-term consequences of CDH if the diagnosis is missed?
Osteoarthritis and limp
What is talipes equino varus (club foot)?
This is a deformity of the foot which makes it look like a golf club
Discuss the management of talipes equino varus (club foot)
The mild form is usually easily corrected by manipulation. The severer forms require surgery
What are the two stages of manipulative treatment of the talipes?
The stages of manipulative treatment of the talipes is stretching to correct varus, then stretching to correct equinus
What are the long-term risks of talipes?
Difficulties in shoe fitting, and sores are both long-term risks of talipes
Describe two causes of talipes
Posture in the womb and defects of nerves and muscles are two causes of talipes
What is spina bifida occulta?
Spina bifida occulta is the mildest type of spina bifida. There is a small gap in the spine, but no opening or sac on the back
What is diastamatomyelia?
Although most patients with spina bifida occulta usually develop no serious problems, a very small number may get tethering of the spinal cord to the higher lumber vertebrae during growth (diastamatomyelia)
What is spina bifida cystica?
Babies born with spina bifida cystica have neural plate tissues open with little or no skin or bony cover. The nerve tissue may be covered by a cyst (meningocele) or the nerve tissue may be incorporated in the cyst wall (meningomyelocele)
Discuss the management of spina bifida cystica
Many children need early surgery to their feet to maintain a functional shape. Many children manage to work aided by splints and hand-held aids. As they reach adolescence many transfer to a wheelchair
Define cerebral palsy
Cerebral palsy is an abnormality of the brain usually associated with musculoskeletal abnormalities
What are the different types of spina bifida?
Spina bifida cystica and spina bifida occulta
Describe hydrocephalus
Hydrocephalus is an abnormally large amount of fluid in the brain
What is meant by a hemiparesis?
A hemiparesis is paralysis of one arm and one leg on the same side
What is meant by a quadraparesis?
A quadraparesis is paralysis affecting all four limbs
What is meant by a paraparesis?
A paraparesis is paralysis affecting both legs
Discuss the management of cerebral palsy
Deformities can be minimised with careful physiotherapy. Splintage should be used with caution. Careful use of surgery e.g. to lengthen tight muscles may help preserve posture/some function
Define scoliosis
Scoliosis is an abnormal curvature of the spine
Which type of scoliosis is most common?
Idiopathic scoliosis is the most common type
Discuss the management of scoliosis
Not all curves progress so no treatment may be required. If treatment is demanded due to the progress of the curve or the distress caused by it, surgical correction is essential
What are the most common causes of limp in a child from birth to four years of age?
CDH, infection of the hip
What is the most common cause of a limb in a child between the ages of four and ten?
Perthe’s disease
What is the most common cause of a limb in a child between the ages of ten to fifteen?
Slipped upper femoral epiphysis
What is Perthe’s disease?
Perthe’s disease is an osteochondritis (fragmentation of the bone and overlying cartilage) of the femoral head epiphysis. It is thought to be an avascular necrosis of the growing femoral head
Discuss the management of Perthe’s disease
The strategy of treatment is to maintain the head concentrically within the acetabulum untill the natural process of the disease runs its course. Minor degrees of this condition may require no treatment. In severe cases, splintage or osteotomy may help but their effectiveness is of dubious value. Careful follow-up with periods of traction is likely all that can be done
What is slipped upper femoral epiphysis?
SUFE consists of a slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted
Why should any child with knee pain have their hip examined?
In SUFE pain may radiate to the hip (following the sensory distribution of the obturator nerve)
Discuss the management of slipped upper femoral epiphysis
Treatment is surgical - pinning if minor slippage, manipulation if major slippage
What are the possible causes of a limp in childhood?
CDH, infection, Perthe’s disease, SUFE
At which age is SUFE more common in boys?
SUFE is more common in boys aged 12 - typically boys around 12 who are sexually immature for their age
At which age is SUFE more common in girls?
SUFE is more common in girls aged 14 - typically girls who have recently undergone an adolescent growth spurt
What age should the average child be able to sit independently?
Nine months
What age should the average child be able to stand?
A year
What age should the average child be able to walk?
Twenty months
Which gender is most commonly affected by idiopathic scoliosis?
Females
