Bone and joint problems of childhood

Question 1

Common musculoskeletal problems of childhood are due to improper development of which structure? [1]

Answer 1

Epiphyseal growth plate

Question 2

Which age do each of the following occur at?

CDH [1]
Perthe’s []1
SUFE [1]

Answer 2

CDH: at birth: babies or neonates
Perthe’s: 5-8 yrs
SUFE: 13-16 yrs

Question 3

Name two pathologies in which toe walking commonly persists? [1]

Explain why this occurs [1]

Answer 3

Cerebral palsy; Duchenne Muscular Dystrophy

Imbalance of plantar flexors; causes pull foot into plantar flexion

Question 4

State three treatment options for toe walking [3]

Answer 4

• Surgical procedures can be done to release the tight calf muscles by tendon lengthening of the achilles
• Cast the foot and ankle for 6 weeks to help stretch the calf muscles out. Foot brace does the same
• Physiotherapy

Question 5

Describe shape of babies feet and how this changes with age [2]

How can this process be pathological? [1]

Answer 5

Flat foot: fat pad present for energy reserves. As they grow this dissapears

In some children the arch never fully develops: presents as weak ankles and turn inwards

Question 6

Flat feet aka? [1]

Answer 6

Pes planus

Question 7

Treatment of pes planus? [2]

Answer 7

Orthotics
Surgery

Question 8

Persistent toe walking in older children might be linked to other conditions. What are they? [3]

Answer 8

Cerebral palsy: (hypertonia of plantar flexors)

Duchenne Muscular Dystrophy (early stages causes hypertrophy in calf muscles)

Nervous system problems

Question 9

Toe walking can shorten which muscle? [1]

Answer 9

Achilles muscle

Question 10

Toe walking is a normal that is generally disappears after how many years? [1]

Answer 10

2

Question 11

How can you treat persistant toe walking? [3]

Answer 11

Castingthe foot and ankle for about 6 weeks to help stretch calf muscles
Physiotherapy
Surgery to release tight calf muscles: cerebral palsy

Question 12

Club foot aka? [1]

Answer 12

Talipes equinovarus

Question 13

Describe characteristics of Talipes equinovarus [2]

Answer 13

Fixed varus and equinus deformity due to calf underdevelopment

Can be bilateral or unilateral

Question 14

Name 5 causes of Talipes equinovarus

Answer 14

Breech presentation
Connective tissue disorders (Ehlers Danlos)
Oligohydramnios
Genetic syndromes (Edward’s Syndrome – trisomy 18)
Family history

Question 15

Describe the treatment of Talipes equinovarus [2]

Answer 15

Ponseti method – manipulative technique to correct clubfoot without invasive surgery

Wear in night everyday

Places the foot in abduction / valgum: as the skeleton continues to grow don’t have the deformity come back

Question 16

Describe pathophsiology of Congenital hip dysplasia [1]

Answer 16

Hip dislocated during birth [1]

Question 17

Describe risk factors for congenital hip dysplasia [5]

Answer 17

Females:
* relaxin produced

Breech delivery
Family history
Oligohydramnios
1st born

Question 18

Descibe the presentation of CDH [3]

Answer 18

Double crease
leg turned into external rotation
asymmetric gluteal folds

Question 19

State three tests used to diagnose CDH [3]

Answer 19

Barlow test
Ortolani test
Galeazzi sign

Question 20

Describe the mechanism of the following

Barlow test
Ortolani test

Answer 20

Barlow test: adduct and push downward to try and dislocate the hip

Ortolani test: abduct hips to try and reolcated hi[; fingers push femur forwards into acetabulum

Both tests are used together

Question 21

Describe what a Galeazzi sign is

Answer 21

The test is performed with infant supine, hips flexed to 45 and knees flexed to 90 with feet flat on examining surface. Examiner looks for symmetry in the level of the knees. An inequality in the height of the knees is a positive Galeazzi sign and usually is caused by hip dislocation or congenital femoral shortening.

Question 22

Describe ultrasound imaging results for CHD [4]

Answer 22

Ultrasound
A = gluteal muscle
B = ilium
C = acetabulum
D = femoral head

Question 23

Explain how you can interpret ultrasound to determine CHD level [4]

Answer 23

Ultrasound interpretation of CHD can also be done by interpretation of the alpha-angle, which is an angle formed by the acetabular roof to the vertical cortex of the ilium and thus reflects the depth of the bony acetabular roof.

The normal value is greater than or equal to 60 degrees. Less than 60 degrees suggests dysplasia of the acetabulum

1. Grade 1 > 60 degrees
2. Grade IIa,b 50-59 degrees
3. Grade IIc 43-49 degrees
4. Grasde IIIa, b, IV < 43 degrees

Green line = iliac margin, red = joint inclination and yellow arc = alpha angle

Question 24

What is this line called? [1]

Answer 24

Hilgenreiner’s line:
line drawn horizontally through the inferior aspect of both triradiate cartilages

Question 25

How is Hilgenreiner's line used in CHD diagnosis? [1]

Answer 25

It should be **horizontal** but is **mainly used as a reference for Perkin’s line and measurement of the acetabular angle**.

Question 26

Describe the points that Perkins line is found [1] How is it used for assessment for CHD? (affected v unaffected)

Answer 26

Top of the acetabulum going down: ID where the femoral head is Affected side will be more lateral to the side Unaffected side: femoral head more medial

Question 27

Explain how you treat CHD? [1] What does this treatment have a risk for? [1]

Answer 27

**Pavlik harness**: closed reduction and immobilization causing hip flexed and abducted (while still allowing movement) **Avascular necrosis** is a risk

Question 28

Which treatment do you give for CHD treatment if pavlik harness does not work: Initially [1] If ^ treatment doesn't work after 18months? [1]

Answer 28

**Closed reduction with hip spica** If not resolved in 18 months: **Open reduction:** femoral osteotomies with or without pelvic osteotomies

Question 29

In cases of unilateral developmental dysplasia of the hip, leg length discrepancy can be defined as the difference between the distances between which two places?

Answer 29

In cases of unilateral developmental dysplasia of the hip, leg length discrepancy can be defined as the difference between the distances from the **inter-teardrop line and the greater trochanter tip**

Question 30

Consequences of not treating CDH? [2]

Answer 30

**Head of femur** will form a **new acetabulum on the back of pelvis:** creating a **leg length discrepancy** due to the moving of the femur further onto the back of the ilium. The **acetabulum also forms of fibrocartilage** rather than **hyaline**, further affecting the joint properties.

Question 31

Describe the pathophysiology of Perthes disease (Legg-Calve-Perthes disease) [3]

Answer 31

**Idiopathic** Self limiting **avascular necrosis of the femoral head** Dual blood supply to femoral head. **Secondary ossification centre suffers blood loss** and causes avascular necrosis. If left untreated, the **femoral neck grows** and over time t**here is revascularisation or neovascularisation** and **healing of the femoral head**.

Question 32

Describe imaging of a Ptx with Perthes disease

Answer 32

Femoral head looks fragmented

Question 33

Describe and explain the 4 different stages of Perthes disease

Answer 33

Question 34

Describe prognosis of Perthes disease [1]

Answer 34

Most cases: go away without treatment If develop at later age (8-11) have much less time for the femoral head to remodel and for the **blood supply to re-establish**

Question 35

x-rays of perthes disease

Answer 35

Question 36

Describe treatment of Perthe's disease: Children less than 5 [1] Children older than 5 [1]

Answer 36

Less than 5: * **self limiting**; treat with observation, physiotherapy and bed rest with plaster casts Older than 5: * **Osteotomy surgery** is the best option to realign the femoral head in the acetabulum and **prevent avascular necrosis.**

Question 37

Slipped upper femoral epiphysis (SUFE) is more common in [left / right] hip

Answer 37

left

Question 38

Describe the movement of the joint that occurs in SUFE [2]

Answer 38

Epiphysis actually stays in place it’s the neck and **shaft of the femur that moves** **Epiphysis** moves **posteriorly and medially**

Question 39

State what type of Salter-Harris fracture SUFE is [1]

Answer 39

Type 1

Question 40

State 4 causes of SUFE [4]

Answer 40

**Obesity** **Hypothyroidism** **Deficiency or increased androgens** * Adolescent growth spurt **Trauma** * SUFE = obese, underdeveloped sexual characteristics with sudden growth spurt

Question 41

State 4 different presentations of SUFE [4]

Answer 41

**Pre-slip**: wide epiphyseal line, no slippage **Acute**: slippage is sudden **Acute on chronic**: slippage occurs acutely on existing chronic slip **Chronic**; steady progressive slip (most common) *When looking at x-ray think of ice cream slipping off the cone*

Question 42

Where in the epiphyseal growth plate does a fracture occur in SUFE? [1] How does this change the structure of the epiphyseal growth plate? [1]

Answer 42

Fracture occurs at **hypertrophic zone** Changes to the epiphyseal plate zones **hypertrophic zone is 80% of the plate** (normal hypertrophic zone is 15-30% of the plate width)

Question 43

Where is Klines line? [1] How can you use this to diagnose SUFE? [1]

Answer 43

Klein’s line is drawn along **superior border of femoral neck should cross at least a portion of the femoral head.** When SUFE the femoral head drops below this line.

Question 44

Perthes disease can lead to which MSK disease? [1]

Answer 44

Osteoarthritis [1]

Question 45

Describe the pathophysiology of Osgood-Schlatters disease

Answer 45

**Inflammation** at the **tibial tuberosity** where the patella ligament inserts. The patella tendon inserts into the tibial tuberosity. In **patients with Osgood-Schlatter disease**, multiple minor **avulsion fractures** occur where the **patella ligament pulls away tiny pieces of the bone.** This leads to **growth of the tibial tuberosity,** causing a **visible lump below the knee**. Initially, this lump is tender due to inflammation. Lead to **heterotopic ossification** at site of tibial tubercle As the bone heals and inflammation settles, the lump becomes hard and non-tender.

Question 46

Consequences of not treating CDH? [2]

Answer 46

**Head of femur** will form a **new acetabulum on the back of pelvis:** creating a **leg length discrepancy** due to the moving of the femur further onto the back of the ilium. The **acetabulum also forms of fibrocartilage** rather than **hyaline**, further affecting the joint properties.

Question 47

Blount's disease is a growth problem of which part of which bone? [2] What deformity does this create? [1]

Answer 47

**medial** **compartment** of the **distal tibia** Causes: **irreversible** **tibia varus**

Question 48

State 3 risk factors for Blount's disease [3] State 2 methods of treating Blount's disease [2]

Answer 48

Risk factors: * **obesity** * **walking too early** * **genetic** factors Treatment * **brace**, * **surgery if brace fails** (osteotomy with gradual distraction)