Unit 3 - Orthopaedic conditions in childhood

Question 1

When does the average child:

• Sit independently?
• Stand?
• Walk?

Answer 1

9 months

1 year

20 months

Question 2

What are knocked knees & bow legs also known as?

Answer 2

Genu valgum

Genu varum

Question 3

By what age do children with genu valgum/varum usually develop normal knee alignment?

Answer 3

7

Question 4

What are the 3 causes of in-toeing?

Answer 4

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)

Question 5

What are the 2 types of flat feet?

Answer 5

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)

Question 6

What toe is most commonly affected by curly toes?

Answer 6

5th

Question 7

Describe Osgood Schlatter’s disease

Answer 7

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)

Question 8

Describe adolescent knee pain

Answer 8

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

Question 9

What is the underlying abnormality of congenital dislocation of the hip (CDH)

Answer 9

Dysplasia of femoral head, acetabulum or both

Question 10

Can CDH be bilateral?

Answer 10

Often is

Question 11

At what months are children screened for CDH?

Answer 11

Birth, 3, 6 & 12

With Barlow (tries to dislocate hip) or Ortolani (tries to relocate hip) while listening for a click

Question 12

If CDH is undetected in screening, what symptoms may be noticed?

Answer 12

Shortened limb

Asymmetrical skin creases

Limited abduction

Limp

(will require surgery to deepen acetabulum & reangulate femoral neck)

Question 13

How is CDH managed?

Answer 13

Pavlik harness

Maintains femoral head in acetabulum

Question 14

What is the medical name for clubfoot?

Answer 14

Talipes equino varus

Deformity that makes foot look like a golf club

Question 15

What are the 2 forms of clubfoot?

Answer 15

Postural - a mild from seen after a breech birth (related to position in utero)

Fixed - developmental abnormalities of nerves & muscles of the leg

Question 16

What is the management of clubfoot?

Answer 16

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

Question 17

What is spina bifida?

Answer 17

Abnormal development of spine during first 3-months of development which may result in abnormal function of spinal cord & vertebrae

Question 18

What is spina bifida occulta?

Answer 18

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)

Question 19

Describe spina bifida cystica

Answer 19

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)

Question 20

What support do children with spina bifida cystica require?

Answer 20

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

Question 21

What causes cerebral palsy (CP)?

Answer 21

Damage to the brain at birth resulting in delayed/arrested development of nervous & MSK systems

Question 22

How does spasticity come about in CP?

Answer 22

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

Question 23

What patterns are common in CP?

Answer 23

Hemiparesis (arm & leg on one side affected)

Paraparesis (both legs)

Quadraparesis (all limbs)

Question 24

What other issues might those with CP have?

Answer 24

Most mentally retarded & some blind +/- deaf (occasionally do not suffer mental/sensory impairment)

Orthopaedic - growth deformities, joint contraction etc

Question 25

What management can be offered to those with CP?

Answer 25

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)

Question 26

What causes scoliosis?

Answer 26

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)

Question 27

What is the presentation of scoliosis?

Answer 27

Girls > boys

Complaints of twisting of ribs which cause a hump on one side of shoulder

Usually not painful

Question 28

When should scoliosis be operated on?

Answer 28

If curve is progressive & causing distress

Question 29

Name causes of limp from:

• birth?
• 4-10?
• 10-15?

Answer 29

CDH & infection of the hip

Perthe’s disease

SUFE

Question 30

What is Perthe’s disease?

Answer 30

An osteochondritis (fragmentation of bone & cartilage) of femoral head epiphysis

Boys > girls (5/1000 children)

20% bilateral

Cause unknown

Question 31

What is the clinical presentation of Perthe’s?

Answer 31

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

Question 32

What is the management for Perthe’s?

Answer 32

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

Question 33

What does SUFE stand for?

Answer 33

Slipped upper femoral epiphysis

Question 34

What is the presentation of SUFE?

Answer 34

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

Question 35

What is the management of SUFE?

Answer 35

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