Week 3

Question 1

How do bones get a) longer and b) wider?

Answer 1

a) from the growth plate (physis) by enchondral ossification
b) from the periosteum by appositional growth

Question 2

What are the % contributions of each physis in bone growth in the a) upper limb and b) lower limb?

Answer 2

a) 40% from head of the humerus, 20% from base of humerus/heads of radius and ulna, and 40% from base of radius and ulna
b) 12% from head of the femur, 70% from the base of the femur and knee, 18% from the end of the tibia and fibula

Question 3

Name some factors that affect the growth plate

Answer 3

• Diet/nutrition
• Sunshine, vitamins (A, D)
• Injury
• Illness
• Hormones (GH)

Question 4

Growth is very variable! Up until what age is it especially so?

Answer 4

3

Question 5

What are some of the motor milestones for “normal growth”?

Answer 5

• 6-9 months - sits, crawls
• 8-12 months - stands
• 14-17 months - walks
• 24 months - jumps
• 3 years - manages stairs alone

Question 6

When should a growth disorder first be considered?

Answer 6

After multiple milestones have failed to be met

Question 7

What are some of the common “variations of normal”?

Answer 7

• Genu varum and valgum
• Intoeing
• Flat feet
• Curly toes

Question 8

How does the angle of knee to hip alignment generally vary during development?

Answer 8

• Age 0-2 - Genu varus
• Age 2-6/7 - Genu valgum
• From 7 onwards, slight genu valgum (approx 5%)

Question 9

What are some of the pathologic causes of Genu Varum?

Answer 9

• Skeletal dysplasia
• Rickets - Vit. D deficiency
• Tumour e.g. enchondroma
• Blount’s disease
• Trauma

Question 10

What is Blount’s Disease?

Answer 10

Growth arrest at the medial tibial physis of unknown aetiology

Shows a typical beak-like protrusion on X-rays

Question 11

What are some of the pathologic causes of Genu Valgum?

Answer 11

• Tumours - enchondroma, osteochondroma
• Rickets
• Neurofibromatosis (growth of tumours in the nervous system)
• Ideopathic

Question 12

When would you refer a child suffering from Genu Valgum?

Answer 12

If asymmetric, painful, severe

Genu Valgum is usually normal, peaking at age 3 ¹/₂

Chart and monitor

Question 13

When is intoeing typically accentuated?

Answer 13

When running

Question 14

Femoral neck anteversion - normal values, and what might it predispose to?

Answer 14

• Mean is 30-40^o at birth, slowly unwinds and settles at around 10-15%
• Usually of no consequence, but can predispose to patellofemoral problems

Question 15

Intoeing - patient presents, what do you do?

Answer 15

• Define cause
• Reassure
• Chart/photograph
• Review
• Discharge unless persisting and severe

Question 16

What needs to be determined when considering flat feet? How is this done?

Answer 16

Is it flexible or fixed?

Ask patient to stand on tip toes - if flexible, arch of the foot reappears.

Fixed may be indicative of underlying pathology

Question 17

What scoring system is used to assess hyperflexibility?

Answer 17

Beighton’s score - touching thumb to forearm, placing hands flat on floor, hyperextension of knees and elbows

Question 18

What underlying bony connection may present as fixed flat feet?

Answer 18

Tarsal coalition

Question 19

Name some common spine conditions

Answer 19

• Mechanical back pain and spondylitis
• Facet joint arthritis
• Multi-level degenerate back pain/OA
• Discogenic back pain
• Disc prolapse, sciatica and radiculopathy
• Spinal stenosis and bony route entrapment
• Trauma and osteoporotic fracture

Question 20

Name some less common spine conditions

Answer 20

• Ankylosing spondylitis
• Scoliosis
• Spondylolithesis
• Benign tumours - osteoid osteoma
• Malignant tumours - metastatic disease
• Discitis and osteomyelitis
• Cauda equina syndrome

Question 21

Describe the anatomy of the vertebral column

Answer 21

33 vertebrae

• 7 cervical
• 12 thoracic
• 5 lumbar
• 5 saccral (fused)
• 4 coccygeal (fused)

4 curves

• Cervical lordosis
• Thoracic kyphosis
• Lumbar lordosis
• Saccral/coccygeal kyphosis

Question 22

Which are the atypical vertebra? Why?

Answer 22

C1 and C2 (atlas and axis) - no vertebral bodies, articulate with one another via the odontoid process to allow head rotation

C7 (vertebra prominens) - no foramina transversa process

Question 23

Describe the structure of an intervertebral disc

Answer 23

Outer layer - anulus fibrosus

Inner layer - nucleus pulposus

Question 24

Briefly describe the pathophysiology of spondylitis and secondary OA

Pain in the spine is worse during flexion/extension

Answer 24

• Intervertebral disc loses water content over time with aging
• Facet joints become overloaded, resulting in secondary OA
• Pain is worse during extension of the spine

Question 25

Intervertebral discs lose fluid over time resulting in increasing pain and possibly the development of bulges and prolapses. At what vertebral levels is this most common? How common are disc bulges? Is MRI definitively diagnostic?

Answer 25

L4/L5 and L5/S1 Disc bulges are very common, 60% of asymptomatic individuals over 45 have disc bulges MRI is not definitively diagnostic alone!

Question 26

In acute disc prolapse, what is the recommended treatment and how long might this take?

Answer 26

Initial rest if required, but focus on mobilisation and a return to normal work as early as possible Prolapsed discs should settle in around 3 months

Question 27

Motor neurones originate anteriorly/posterior and their cell bodies are contained in the anterior grey horn/dorsal root ganglion. Sensory neurones originate dorsally and their cell bodies are contained in the anterior grey horn/dorsal root ganglion.

Answer 27

Motor neurones originate **anteriorly**, cell bodies are contained in the **anterior grey horn** Sensory neurones originate **dorsally**, cell bodies are contained in the **dorsal root ganglion**

Question 28

The spinal canal is formed by the \_\_\_\_\_ The anterior and posterior spinal nerves come together to form the mixed spinal nerve, which exits the spinal canal via the \_\_\_\_\_\_

Answer 28

Vertebral foramina Intervertebral foramen

Question 29

At what level does the spinal cord end and the spinal nerves run as "cauda equina"?

Answer 29

L1

Question 30

Compression of a nerve root results in pain running down the sensory distribution of the nerve. What is the name of the sensory distribution path of a nerve? What is the term used to describe the group of muscles supplied by this nerve? What is the term used to describe this kind of pain? Specifically in the leg?

Answer 30

Sensory distribution of a nerve - **dermatome** Group of muscles supplied by this sensory distribution - **myotome** Compression resulting in pain running down a dermatome - **radiculopathy** Radiculopathy specifically in the leg - **sciatica**

Question 31

Nerve roots from which vertebral levels make up the sciatic nerve?

Answer 31

L4, L5 and S1

Question 32

What disease process brings about nerve compression in Spinal Stenosis?

Answer 32

Development of osteophytes and hypertrophied ligaments, as seen in OA

Question 33

Briefly describe Cauda Equina syndrome

Answer 33

* Excess pressure (usually due to prolapsed disc) is placed on ALL lumbosacral nerve roots at the level of the lesion * This includes the sacral nerve roots for bladder and bowel control * Signs include loss of bladder and bowel control, loss of anal tone and **saddle anaesthesia**

Question 34

Between what two vertebral levels (and associated anatomical landmarks) should lumbar punctures be performed?

Answer 34

Between L4 (posterior iliac crest) and S2 (PSIS)