Unit 3 - Orthopaedic conditions in childhood Flashcards
When does the average child:
- Sit independently?
- Stand?
- Walk?
9 months
1 year
20 months
What are knocked knees & bow legs also known as?
Genu valgum
Genu varum
By what age do children with genu valgum/varum usually develop normal knee alignment?
7
What are the 3 causes of in-toeing?
Femoral neck angle variation - abnormal development of femur in the foetus leads to it being anteverted meaning they internally rotate a lot & externally rotate little (usually corrects by 10)
Tibial torsion - where bone is distorted/warped along vertical axis
Abnormal forefeet - hooked (adducted) forefoot commonly seen. Majority correct spontaneously, unclear whether surgery is justified (never before 7)
What are the 2 types of flat feet?
Mobile (majority) - innocuous (all children’s feet flat at birth & arch of foot may not form until 7)
Rigid - rare & usually implies underlying bony abnormality (or RA)
What toe is most commonly affected by curly toes?
5th
Describe Osgood Schlatter’s disease
Inflamed attachment of patellar tendon to growing tibial epiphysis, caused by excess traction by quadriceps
Overuse injury
Causes tenderness, discomfort, swelling
Episodic & usually relieved by rest (ceases by mid adolescence)
Describe adolescent knee pain
Occurs most commonly in girls & is of unknown cause
May have an area of eroded patella cartilage seen on arthroscopy - chondromalacia patellae
Most grow out
What is the underlying abnormality of congenital dislocation of the hip (CDH)
Dysplasia of femoral head, acetabulum or both
Can CDH be bilateral?
Often is
At what months are children screened for CDH?
Birth, 3, 6 & 12
With Barlow (tries to dislocate hip) or Ortolani (tries to relocate hip) while listening for a click
If CDH is undetected in screening, what symptoms may be noticed?
Shortened limb
Asymmetrical skin creases
Limited abduction
Limp
(will require surgery to deepen acetabulum & reangulate femoral neck)
How is CDH managed?
Pavlik harness
Maintains femoral head in acetabulum
What is the medical name for clubfoot?
Talipes equino varus
Deformity that makes foot look like a golf club
What are the 2 forms of clubfoot?
Postural - a mild from seen after a breech birth (related to position in utero)
Fixed - developmental abnormalities of nerves & muscles of the leg
What is the management of clubfoot?
Initial stretching with 2 phases (for both forms):
- 1st = correcting hindfoot equinus
- 2nd = corrects mid & forefoot varus
In mild (postural) forms stretching for 6 weeks usually sufficient
In severe cases stretching usually does not correct foot & surgery is required
Children must be followed up until 14 (when feet stop growing) as late relapse is not uncommon. Affected foot often smaller
What is spina bifida?
Abnormal development of spine during first 3-months of development which may result in abnormal function of spinal cord & vertebrae
What is spina bifida occulta?
Minor bony abnormality (affects 2%)
Usually not significant - some develop mechanical back pain & some may get tethering of spinal cord to higher lumbar vertebrae during growth (diastamatomyelia)
Describe spina bifida cystica
Nerve tissue may be covered by a cyst (meningocele) or incorporated into cyst wall (meningomyelocele)
Many also have hydrocephalus - leads to mental retardation & increased head size
Many die at birth but some survive & undergo surgery to close the lesion. These children have many problems - paralysis, muscle imbalance (growth deformities, incontinence)
What support do children with spina bifida cystica require?
Surgery to feet to maintain functional shape (some develop joint contraction resulting in fixed flexed position of knees & dislocation of hips)
Should try and keep them mobile until adolescence so they grow to reasonable size (many manage to walk with splints & sticks etc). Many go to a wheelchair as they find is easier socially
What causes cerebral palsy (CP)?
Damage to the brain at birth resulting in delayed/arrested development of nervous & MSK systems
How does spasticity come about in CP?
Spinal tissue develops normally and has uninhibited spinal reflexes but lacks co-ordination and purpose of movement controlled by the brain.
Results in spastic paralysis - some muscles contract strongly in uncoordinated way (spastic) while others are very weak and flaccid.
This imbalance leads to abnormal muscle and bone growth, with secondary deformities of joints
What patterns are common in CP?
Hemiparesis (arm & leg on one side affected)
Paraparesis (both legs)
Quadraparesis (all limbs)
What other issues might those with CP have?
Most mentally retarded & some blind +/- deaf (occasionally do not suffer mental/sensory impairment)
Orthopaedic - growth deformities, joint contraction etc
What management can be offered to those with CP?
Surgery:
- lengthen tight muscles
- denervate/move muscles to maintain acceptable posture & function
(Splintage should be used with caution as it can lead to increased muscle spasm and deformity)
What causes scoliosis?
Curvature of the spine with a rotatory abnormality of vertebrae. It is a 3D deformity based on an abnormal lordosis of the spine, which leads to buckling and twisting of the vertebral column as a result of the action of muscles and gravity
Most idiopathic but may be congenital (abnormalities of vertebrae/neuromuscular imbalance)
What is the presentation of scoliosis?
Girls > boys
Complaints of twisting of ribs which cause a hump on one side of shoulder
Usually not painful
When should scoliosis be operated on?
If curve is progressive & causing distress
Name causes of limp from:
- birth?
- 4-10?
- 10-15?
CDH & infection of the hip
Perthe’s disease
SUFE
What is Perthe’s disease?
An osteochondritis (fragmentation of bone & cartilage) of femoral head epiphysis
Boys > girls (5/1000 children)
20% bilateral
Cause unknown
What is the clinical presentation of Perthe’s?
Painful limp followed by slow recovery
Radiologically – femoral head may be normal on 1st presentation but it fragments to a greater or lesser degree. If repeated after a month may show previously unrecorded changes. Ultrasound reveals excess fluid in hip joint.
Thought to be an avascular necrosis of growing femoral head. Eventually the head will re-vascularise and re-ossify but it may be enlarged and deformed
What is the management for Perthe’s?
Strategy is to maintain head concentrically within acetabulum until natural process of the disease runs its course
Minor cases involving <1/2 femoral head need no treatment. Older children with all femoral head affected have a worse prognosis
Severe cases may be helped by splitage to aid containment or osteotomy to enlarge actetabulum or redirect femoral head
Follow up with periods of traction to alleviate pain & limp probably all that can be done
What does SUFE stand for?
Slipped upper femoral epiphysis
What is the presentation of SUFE?
Boys around 12
Limp
Pain (at the knee due to sensory distribution obturator)
Slip may be acute or preceded by many months of discomfort without clinical/radiological signs.
All young adolescents with painful hip must be regarded as having SUFE until clinically and radiologically excluded.
Radiographs must include lateral view or minor degrees of slippage may be missed
What is the management of SUFE?
If slippage minor, hip should be pinned in its new deformed position.
If slippage is major, a gentle attempt to replace head on the neck by manipulation may be attempted although the risk of AVN is high
Other hip should be observed, using radiography at regular intervals, and pinned if any suspicion of slippage arises.
Pins best removed after fusion of epiphysis at around 18
