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Phase 1b - Musculoskeletal & Rheumatology > Children's Orthopaedics > Flashcards

Children's Orthopaedics Flashcards

1
Q

How many bones are found within a paediatric skeleton?

A
  • 270 bones
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2
Q

Which regions of a paediatric skeleton is associated with growth post-natally?

A
  • Epiphyseal growth plates
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3
Q

Which bones are formed from intramembranous bone development?

A
  • Flat bones
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4
Q

What are the examples of flat bones (3)?

A
  • Facial bones
  • Mandible
  • Medial part of the clavicle
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5
Q

Outline the steps of intramembranous ossification (4 steps).

A
  1. Condensation of mesenchymal cells which differentiate into osteoblasts → Ossification centre forms
  2. Secreted osteoid traps osteoblasts which become osteocytes
  3. Trabecular matrix and periosteum form
    • Angiogenesis occurs and blood vessels are incorporated between woven bone)
  4. Compact bone develops superficial to cancellous. Crowded blood vessels condense into red bone marrow.
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6
Q

Which bones are associated with endochondral ossification?

A
  • Long bones
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7
Q

Where does long bone formation occur?

A
  • At primary & secondary ossification centres
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8
Q

What is the primary ossification centre?

A
  • Sites of pre-natal bone growth through endochondral ossification from the central part of the bone
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9
Q

What are the secondary ossification centre?

A
  • Occurs post-natally after the primary ossification centre and long bones often have several
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10
Q

Outline the steps of endochondral primary ossification (5 steps).

A
  1. Mesenchymal differentiation at the primary centre
  2. The cartilage model of the future bony skeleton forms
  3. Capillaries penetrate cartilage → calcification at the primary ossification centre → spongy bone forms → perichondrium transforms into periosteum
  4. Cartilage and chondrocytes continue to grow at ends of the bone
  5. Secondary ossification centres develop with its own blood vessel and calcification at the proximal and distal end
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11
Q

What happens at endochondral secondary ossification?

A
  • Post bone growth occurs, at the physis
    • ​Long bone lengthening occurs at the physeal plate, containing cartilage (proliferation of chondrocytes and subsequent calcification of the extracellular matrix into immature bone that is subsequently remodelled)
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12
Q

What happens at the epiphyseal side?

A
  • Hyaline cartilage active and dividing to form hyaline cartilage matrix
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13
Q

What happens at the diaphysial side of bone?

A
  • Cartilage calcifies and necroses - replacement by bone
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14
Q

What is the main difference between adult and paediatric skeleton (3)?

A
  • Elasticity
  • Physis
  • Speed of Healing & remodelling
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15
Q

Where does continuous endochondral ossification happen?

A
  • At secondary ossification centre
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16
Q

Compare the speed of healing in an paediatric skeleton compared to that of the adult.

A
  • The speed of healing is faster in a child
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17
Q

Why is paediatric bone more elastic than adult bone?

A
  • Has an increased density of Haversian canals
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18
Q

Why does plastic deformities occur within paediatric bone?

A
  • The energy is dissipated in altering the structure of the bone - (bending prior to fracture)
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19
Q

What is a buckle fracture?

A
  • The bone buckles forming a torus-column prior to fracturing (2nd bone in picture)
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20
Q

What is a stable fracture?

A
  • Bone fragments have no separated
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21
Q

What is a greenstick fracture?

A
  • One cortex fracture, however the other side remains intact (is bent) (3rd bone in picture)
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22
Q

When does gradual physeal closure occur in females?

A
  • Menarche
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23
Q

When does physeal closure occur in girls?

A
  • 15-16
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24
Q

When does physeal closure occur in boys?

A
  • 18-19
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25
Q

What classification is used to assess physeal injuries?

A
  • Salter-Harris Classification
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26
Q

Why does premature failure occur?

A
  • Due to physeal injuries - significant trauma can elicit growth arrest
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27
Q

What happens in patients with a partial arrest of bone growth?

A
  • Can manifest as deformities due to inconsistencies in bone growth between affected and non-affected areas
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28
Q

What factors does the speed of healing and remodelling potential are dependant on (2)?

A
  • Location
  • Age of patient
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29
Q

Which physis of the skeleton grows more?

A
  • Knee
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30
Q

Which bones within the skeleton exhibits faster growth rates?

A
  • Distal femur & proximal tibia exhibits faster growth rates as opposed to the proximal femur or ankle
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31
Q

Why does the humerus tolerate angulation and deformity?

A
  • Due to spontaneous rate of repair & remodelling potential or paediatric bone
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32
Q

What are the 4 common congenital conditions of bone growth?

A
  • Developmental dysplasia of the hip
  • Club foot
  • Achondroplasia
  • Osteogeneis imperfecta
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33
Q

What is developmental dysplasia of the hip?

A
  • Group of disorders of the neonatal hip where the head of the femur is unstable or incongruous in relation to the acetabulum
    • ‘Packaging disorder’
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34
Q

What does the normal development of the hip rely on?

A
  • The normal development relies on the concentric reduction and balanced forces through the hip
    • The hip needs to reside within the acetabulum (normal forces through the join)
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35
Q

How common is hip dysplasia?

A
  • 2:100
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36
Q

How common is hip dislocation?

A
  • 2:1000
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37
Q

Why does hip dysplasia occur?

A
  • Abnormal pressure through the acetabulum and hip dysplasia (not centrally placed within the socket)
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38
Q

What are the risk factors of developmental dysplasia (6)?

A
  • Female
  • First born
  • Breech
  • Family history
  • Oligohydraminos
  • Native American / Laplanders
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39
Q

What is oligohydraminos?

A
  • Insufficient fluid within the amniotic sac reducing the hydrodynamics and pressure exerted onto the developing foetus in utero
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40
Q

Which ethnicities are associated with developmental dysplasia of the hip?

A
  • Native American / Laplanders
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41
Q

How is developmental dysplasia of the hip diagnosed?

A
  • Usually picked up on baby check - screening in the UK
    • USS birth to 4/12
42
Q

What are the movements of the developmental dysplasia?

A
  • Range of motion of hip
    • Usually limitation in hip abduction
  • Leg length (Galeazzi)
43
Q

What investigations are conducted in patients with developmental dysplasia (2)?

A
  • Ultrasound - birth to 4 months
  • After 4 months - X-ray
44
Q

Why is an X-ray non-beneficial in patients with development dysplasia within the first 4 months?

A
  • The primary ossification centres of hip have no yet ossified
45
Q

What is the treatment for neonates with developmental dysplasia of the hip?

A
  • Reducible hip and < 6 months
    • Pavlik harness
46
Q

What is an abduction strap?

A
  • Maintains the abduction position of the hip joint such that the head of femur is held in the acetabulum, therefore, during development the concentric pressures through the joint an support normal growth
47
Q

What are the alternative treatments to dysplasia of the hip?

A
  • MUA + Closed reduction + Spica
48
Q

What is congenital talipes equinovarus (clubfoot)?

A
  • There is congenital deformity of the foot
49
Q

Congenital deformities of the foot are common in what demographic?

A
  • Hawaiian
  • M 2:1 F
50
Q

Which gene is implicated in congenital talipes equinovarus?

A
  • PITX1 gene
51
Q

What does CAVE deformity due to muscular contracture stand for?

A
  • Cavus – High arch: Tight intrinsic, flexor hallucis longus, flexor digitorum longus
  • Adductus of foot: Tight posterior and anterior tibialis
  • Varus: Tight Tendoachilles, tib post, tip ant
  • Equinous: Tight Tendoachilles
52
Q

What is cavus?

A
  • High arch
    • ​Tight intrinsic, flexor hallucis longus, flexor digitorum longus
53
Q

What is the treatment for club deformity?

A
  • Ponseti method (Gold standard)
54
Q

What is the Ponseti method (4 steps)?

A
  1. First a series of casts to correct deformity
  2. Many require operative treatment – soft tissue release
  3. Foot orthosis brace (Sufficient to treat the deformity)
  4. Some will require further operative intervention to correct final deformity
55
Q

What is achondroplasia?

A
  • Skeletal dysplasia that is characterised by an autosomal dominant condition
56
Q

Which gene is implicated in achodnroplasia?

A
  • G380 mutation of FGFR3
57
Q

Why does achondroplasia occur?

A
  • Inhibition of chondrocyte proliferation in the proliferative zone of the physis
    • Results in defect in endochondral bone formation
58
Q

What is rhizomelic dwarfism (4 charactersitics)?

A
  • Humerus shorter than the forearm
  • Femur shorter than tibia
  • Normal trunk
  • Normal cognitive development + significant spinal issues
59
Q

What is osteogenesis imperfecta?

A
  • Brittle bone disease
60
Q

What is the inheritance pattern of osteogenesis imperfecta?

A
  • Autosomal dominant or recessive
61
Q

Which type of collagen is decreased in osteogenesis imperfecta?

A
  • Decreased type I collagen due to decreased secretion and production of abnormal collagen
    • There is insufficient osteoid production
62
Q

What are the bone effects of osteogenesis imperfecta (3)?

A
  • Fragility fracture
  • Short stature
  • Scoliosis
63
Q

What are the non-orthopaedic manifestations of osteogenesis imperfecta (5)?

A
  • Heart
  • Blue sclera
  • Dentiogenesis imperfecta - brown soft tissue
  • Wormian skull
  • Hypermetabolism - affecting the parathyroid pathway
64
Q

What classification is used for paediatric fractures (4 + 1)?

A
  • Pattern
  • Anatomy
  • Intra/extra-articular
  • Displacement
  • Salter-Harris Classification for those affecting the physis
65
Q

What is an avulsion type fracture?

A
  • When a bone is being pulled by a ligament
66
Q

What is secondary bone healing characterised by?

A
  • Callus formation
67
Q

What is primary bone healing characterised by?

A
  • By direct union, there is no associated callus formation
68
Q

What is the preferred healing pathway for intra-articular fractures?

A
  • Primary bone healing
69
Q

What is a shortened fracture?

A
  • The fracture gap is minimised due to overlap
70
Q

When is displacement optimised in a paediatric fracture?

A
  • In the best angle of function (remodelling does not occur in a rotated fracture)
71
Q

What is the SALT classification of physeal injuries?

A
  1. Physeal separation
  2. Fracture transverse physis and exits metaphysis (Above)
  3. Fracture transverse physis and exits epiphysis (Lower)
  4. Fracture passes Through epiphysis, physis, metaphysis
  5. Crush injury to physis
72
Q

Which type of SALT fracture is most common?

A
  • Type 2
73
Q

What happens to the risk of growth arrest between SALT type 1 and type V fractures?

A
  • Risk increases with type
74
Q

What happens in a whole physis growth arrest?

A
  • Limb length discrepancy
75
Q

What happens in a partial growth arrest?

A
  • Angulation as the non-affected side keep growing
76
Q

What happens during an injury at a period near to physeal closure?

A
  • There is a small degree of potential growth left
    • Therefore, the impact of growth arrest on the individual is less
77
Q

What are the 2 aims of treating growth arrest?

A
  • Limb length correction
  • Minimise angular deformity
78
Q

How is limb length correction performed?

A
  • Shorten the long side

OR

  • Lengthen the long side
79
Q

What are the 2 methods to which angular deformity is corrected (to shorten the longer side)?

A
  • Stop the growth of the unaffected side
  • Reform the bone (osteotomy)​
80
Q

How can growth arrest fractures be treated using cross-screws?

A
  • Prematurely fused the physis, the shorten the unaffected side
81
Q

Which device can be used to lengthen the short side of a limb?

A
  • Intramedullary device
82
Q

What is the first step to fracture management after resuscitation?

A
  • Reduce - correct the deformity and displacement
83
Q

What is closed reduction?

A
  • Reducing a fracture without making an incision (Traction and manipulation)
84
Q

What is open reduction?

A
  • Make an incision, and the realignment of the fracture under direct visualisation (Open reduction and internal fixation (ORIF))
85
Q

What is Gallows Traction (Closed)?

A
  • Holding the skin, the long bones of the lower limb can be reduced
  • Manipulation Under Anesthesia (MUA)
86
Q

What are the risks of healing in paediatric populations (2)?

A
  • Overgrowth and excessing healing
87
Q

What is a spica cast?

A
  • Holds the lower limb in place
88
Q

What is external restriction?

A
  • Splints and plasters
89
Q

Why can an ORIF be avoided in a paediatric fracture?

A
  • Due to remodelling and healing potential
90
Q

What is internal restriction?

A
  • Using plates and screws
  • Intra-medullary devices
91
Q

Why may operative restriction be required?

A
  • Operative intervention maybe required due to fracture affecting the physis (correct the deformity to avoid further trauma)
92
Q

What is recommended during the rehabilitation phase of a patient paediatric fracture?

A
  • Playing
93
Q

What is classified as an orthopaedic emergency in a paediatric patient presenting with a fracture?

A
  • Septic arthritis
94
Q

What is septic arthritis in a paediatric patient?

A
  • Presence of infection within the intra-articular space / synovium
    • ​Necrotic effect is exhibited by proteases and generates pressure effect on chondrocyets and cartilage due to oedema within closed space
95
Q

Why is there a risk of necrosis within septic arthritis?

A
  • Proteases generate pressure effect on chondryocytes and cartilage due to oedema within a closed space
96
Q

What classification criteria is used in a patient with septic arthritis?

A
  • Kocher’s classification
97
Q

What is Kocher’s classification?

A
  • Non-weight bearing
  • ESR > 40
  • WBC > 12,000
  • Temperature > 38 oC
98
Q

What is the treatment of septic arthritis in a paediatric patient?

A
  • Surgical lavage is required in order to clear the infection, in addition to antibiotic treatment
99
Q

How can transient synovitis be diagnosed?

A
  • Once septic arthritis has been excluded
  • Inflamed joint response to a systemic illness
100
Q

What is Perthe’s disease? What is its demographic (2)? What needs to be excluded first? What symptoms are absent (2)? What is the diagnostic test?

A
  • Idiopathic necrosis of the proximal femoral epiphysis
  • Demographic:
    • Usually in 4-8 years olds
    • Male 4:1 Female​
  • Septic arthritis needs to be excluded first
  • No hyperpyrexia or raised inflammatory markers
  • Radiograph is diagnostic test
101
Q

What is the treatment for slipped under femoral epiphysis (SUFE) disease?

A
  • The proximal epiphysis slips in relation to the metaphysis
  • Treatment is operative fixation with screw to prevent further slippage

Phase 1b - Musculoskeletal & Rheumatology (11 decks)

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