W13 - PAEDIATRIC ORTHOPAEDIC; THE BIG 3; THE ACUTE LIMPING CHILD Flashcards
Common Presentations of Bow Legs & Knock Knees
- varus leg can progress to normal period or valgus period
- mostly resolve by the teens
- physiological cause commonly
> Treat rarely!!
Common Presentations of In Toeing & Examination
Negative angle on gait
- newborn = problem in foot (commonest)
- infant = tibia
- school age = femur
- Internal tibial torsion; spontaneous resolution
- Metatarsus Adductus; also resolves
*doesnt improve w/ neuromuscular disorders
> reassurance; resolution
Never operate before 10yo!
Common Presentations of Flexible Flat Feet
Nil medial long. arch
- flat foot normal at birth, and diminishes with age
- if foot mobile - normal variant
- in soles = no benefit
- obesity, ligament laxity
- Jacks Test
Common Presentations of Curly Toes
- Strong family hx; tightness flexor tendons
- mostly cosmetic issue, 1/4 improve spontaneously
> Flexor tenoromy (over 6yo) when posing functional problem
Common Presentations of Variable Walking Age
12 mos mean average, but not the normal
Recognize MSK symptoms that suggest need for referral (5 S)
S ymptoms - e.g pain causing problems
S ymmetry (lack of)
S tiffness - hindfoot = underlying bony abn.
S yndromes - associated syndromes = unlikely resolution
S ystetmic Illness
Significance of bone or joint pain that is worse at night is
infection or tumour until proven otherwise.
Manufacturing Defects Vs Packaging Defects
- Interruption during critical time window of development can give rise to MSK disorders
+alongside congenital defects - In-utero positioning giving rise to altered forces once birthed; can correct over time once birth
What phenomenon contributes to Bent Legs
dt rotational deformities
FEMORAL ANTEVERSION
40º at birth and decreases w/ age = 10º anteversion by 16yo
⇧femoral anteversion = ⇧ability for medial rotation
Describe the common presentation, management and complications of DDH
Development Dysplasia of the Hip
* congenital short bone, gait lack of confidence evident
F>M, Left hip > Right hip
* RF: first born, breech presentation, FHx, additional LL deform., Increased wt.
- ORTOLANI’S SIGN = dislocated hip
- BARLOW’S SIGN = dislocated hip
- Piston Motion Sign
- Hamstring Sign
- Examination
- USS for early dx (Vs late dx via XR)
- universal USS Vs selective
> Simple splint <3mos
Closed reduction and spica cast
> Open reduction and capsule reefing 1yr+
“” w/ femoral shortening 18mos+
*6yo+ and bilateral; 10yo+ and unilateral = leave alone
Describe the common presentation, management and complications of Perthes’ disease
Typically: male, primary school age, short stature, limp, knee pain on exercise, stiff hip joint
*Avascular necrosis of hip, rpt minor trauma, familial hx
> Maintain hip motion; avoid painful activities
Analgesia
Splints, physio
?Osteotomy in 7yo+
Describe the common presentation, management and complications of SUFE
Slipped Upper Femoral Epiphysis = post-trauma, displacement through growth plate, w/ epiphysis always slipping down and back
- Teen, overweight, left groin pain, painful wt. bearing;
- external rot. posture and gait
- XR = best @ lateral view + AP view
=> Line of Klein = cut epiphysis parallel to gr. trochanter
+ endocrine abn
+ bilateral progression
Chronic @ 3weeks
Angle or Proportion
Stable = able to wt. bear Vs Unstable = Prognosis
> Stable = Pinned in-situ
Unstable = open reduction but AVN high risk
Stages and progression of Perthe’s Disease
1) Initial Stage
2) Fragmentation Stage
3) Reossification Stage
4) Healed Stage
- younger pres = better prognosis
- with nearer the head being round, the better the outlook
What can delayed diagnosis of SUFE lead to
- Progression of slip w/ increased risk of early OA
- Stable lesions becoming unstable
- AVN of femoral head
- Impingement
- chondrolysis
- Limb shortening
Significance of chronic slips
New bone formation at the slipped site, making it difficult to group; hypertrophic zone nil ossification
Understand the investigation of the limping child
?foreign bodies, erythema, swelling, deform
? shoes
? scoliosis, midline dimples+hair = older children = spinal pathology
Common pres:
limp; pain; general malaise; temp; recent infection; trauma; pseudoparalysis
- PHYSICAL EXAM.
- TEMPERATURE
- XR
- USS
Know the importance of presenting features and treating septic arthritis
Limp, pseudoparalysis, swollen and redness, refusal to move joint, pain, temperature
- mainly knee and hip affected
- multiple routes of entry: think spread and direct insult
- inflamm investigations
- XR, USS
- Synovial fluid: wcc, gram stain, culture
> IV Abx, empirically for 2w; 6w in total
Know the importance of presenting features and treating acute osteomyelitis
*10-15yo commonest: pain, local symptoms, fever, reduced movement
- RF: blunt trauma, recent ifnection
- Terminal branches/vasc loops; low pO2 = inhibited phagocytosis, trauma
- S. aureus
- Inflamm bloods workup
- Followed by imaging + bone biopsy
- Blood cultures
> IV Abx
Sx: indicated by culture/abscess = drainage, debridement; failed abx
Understand aetiology of transient synovitis
Commonest cause (bar trauma) of limping child between 5-10yo (0-5 common behind variant and trauma) * Limp, slight unwell, Hx of infection, APYREXIC
- low CRP, normal WCC = bloods not as inflamm as OM or Septic Arth. *
Know subtypes, and symptoms/signs suggestive of JIA
Juvenile Idiopathic Arthritis subtypes
=> PAUCIARTICULAR = 1 or 2 joints
=> POLYARTICULAR
=> SYSTEMIC ONSET
- Persistent arth. of at least 6w
- F>M
- Post-strep infection
Understand why children with pauciarticular JIA need eye screening.
Early Onset Pauciarticular JIA, commonly associated in boys, has associations with the eyes
- Glaucoma, cataracts and permanent visual damage (including blindness) are all complications that could result from severe uveitis
Know how to apply Kocher’s criteria
Points on
PYREXIA
NIL WT BEARING
WBC >12,000/mL
ESR >40mm/hr
Chance of septic arth. = increases w/ greater points
Know the importance of presenting features and treating infective myositis
Presentation of infective myositis is with pain localised to one or more muscles (although in most cases it is a single muscle), with variable degrees of systemic inflammatory manifestations, depending on the pathogen
*S. aureus
> Drainage of abscess (CT guided)
Abx
!progression to compartment syndrome, infective osteomyelitis, or systemic shock (sepsis)
Red Flags to Consider with Limping Child
Neoplastic concern
- NIGHT PAIN
- INCIDENTAL TRAUMA
- CESSATION OF SPORT/GOING OUTSIDE
- SWEATS, FATIGUE
- ABN BLOODS: atypical Hb, blood film, platelets
> Paediatric/Oncology Opinion
