Children's Orthopaedics Flashcards
(101 cards)
1
Q
How many bones are found within a paediatric skeleton?
A
- 270 bones
2
Q
Which regions of a paediatric skeleton is associated with growth post-natally?
A
- Epiphyseal growth plates
3
Q
Which bones are formed from intramembranous bone development?
A
- Flat bones
4
Q
What are the examples of flat bones (3)?
A
- Facial bones
- Mandible
- Medial part of the clavicle
5
Q
Outline the steps of intramembranous ossification (4 steps).
A
- Condensation of mesenchymal cells which differentiate into osteoblasts → Ossification centre forms
- Secreted osteoid traps osteoblasts which become osteocytes
-
Trabecular matrix and periosteum form
- Angiogenesis occurs and blood vessels are incorporated between woven bone)
- Compact bone develops superficial to cancellous. Crowded blood vessels condense into red bone marrow.
6
Q
Which bones are associated with endochondral ossification?
A
- Long bones
7
Q
Where does long bone formation occur?
A
- At primary & secondary ossification centres
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
9
Q
What are the secondary ossification centre?
A
- Occurs post-natally after the primary ossification centre and long bones often have several
10
Q
Outline the steps of endochondral primary ossification (5 steps).
A
- Mesenchymal differentiation at the primary centre
- The cartilage model of the future bony skeleton forms
- Capillaries penetrate cartilage → calcification at the primary ossification centre → spongy bone forms → perichondrium transforms into periosteum
- Cartilage and chondrocytes continue to grow at ends of the bone
- Secondary ossification centres develop with its own blood vessel and calcification at the proximal and distal end
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)
12
Q
What happens at the epiphyseal side?
A
- Hyaline cartilage active and dividing to form hyaline cartilage matrix
13
Q
What happens at the diaphysial side of bone?
A
- Cartilage calcifies and necroses - replacement by bone
14
Q
What is the main difference between adult and paediatric skeleton (3)?
A
- Elasticity
- Physis
- Speed of Healing & remodelling
15
Q
Where does continuous endochondral ossification happen?
A
- At secondary ossification centre
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
17
Q
Why is paediatric bone more elastic than adult bone?
A
- Has an increased density of Haversian canals
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)
19
Q
What is a buckle fracture?
A
- The bone buckles forming a torus-column prior to fracturing (2nd bone in picture)
20
Q
What is a stable fracture?
A
- Bone fragments have no separated
21
Q
What is a greenstick fracture?
A
- One cortex fracture, however the other side remains intact (is bent) (3rd bone in picture)
22
Q
When does gradual physeal closure occur in females?
A
- Menarche
23
Q
When does physeal closure occur in girls?
A
- 15-16
24
Q
When does physeal closure occur in boys?
A
- 18-19
25
What classification is used to assess physeal injuries?
* **Salter-Harris Classification**
26
Why does premature failure occur?
* Due to **physeal injuries** - significant trauma can elicit growth arrest
27
What happens in patients with a partial arrest of bone growth?
* Can manifest as **deformities** due to **inconsistencies in bone growth between affected and non-affected areas**
28
What factors does the speed of healing and remodelling potential are dependant on (2)?
* Location
* Age of patient
29
Which physis of the skeleton grows more?
* **Knee**
30
Which bones within the skeleton exhibits faster growth rates?
* **Distal femur** **&** **proximal tibia** exhibits faster growth rates as opposed to the proximal femur or ankle
31
Why does the humerus tolerate angulation and deformity?
* Due to **spontaneous rate of repair & remodelling potential** or paediatric bone
32
What are the 4 common congenital conditions of bone growth?
* Developmental dysplasia of the hip
* Club foot
* Achondroplasia
* Osteogeneis imperfecta
33
What is developmental dysplasia of the hip?
* Group of disorders of the neonatal hip where **the head of the femur is unstable or incongruous in relation to the acetabulum**
* 'Packaging disorder'
34
What does the normal development of the hip rely on?
* 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)
35
How common is hip dysplasia?
* 2:100
36
How common is hip dislocation?
* 2:1000
37
Why does hip dysplasia occur?
* **Abnormal pressure through the acetabulum and hip dysplasia** (not centrally placed within the socket)
38
What are the risk factors of developmental dysplasia (6)?
* Female
* First born
* Breech
* Family history
* Oligohydraminos
* Native American / Laplanders
39
What is oligohydraminos?
* **Insufficient fluid within the amniotic sac** reducing the hydrodynamics and pressure exerted onto the developing foetus in utero
40
Which ethnicities are associated with developmental dysplasia of the hip?
* **Native American / Laplanders**
41
How is developmental dysplasia of the hip diagnosed?
* Usually picked up on **baby check** - screening in the UK
* USS birth to 4/12
42
What are the movements of the developmental dysplasia?
* Range of motion of hip
* **Usually limitation in hip abduction**
* Leg length (Galeazzi)
43
What investigations are conducted in patients with developmental dysplasia (2)?
* **Ultrasound** - birth to 4 months
* After 4 months - **X-ray**
44
Why is an X-ray non-beneficial in patients with development dysplasia within the first 4 months?
* The **primary ossification centres of hip have no yet ossified**
45
What is the treatment for neonates with developmental dysplasia of the hip?
* **Reducible hip** and \< 6 months
* Pavlik harness
46
What is an abduction strap?
* 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
What are the alternative treatments to dysplasia of the hip?
* **MUA** + **Closed reduction** + **Spica**
48
What is congenital talipes equinovarus (clubfoot)?
* There is **congenital deformity of the foot**
49
Congenital deformities of the foot are common in what demographic?
* **Hawaiian**
* **M** 2:1 F
50
Which gene is implicated in congenital talipes equinovarus?
* **PITX1** gene
51
What does CAVE deformity due to muscular contracture stand for?
* **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
What is cavus?
* **High arch**
* ****Tight intrinsic, flexor hallucis longus, flexor digitorum longus
53
What is the treatment for club deformity?
* **Ponseti method** (Gold standard)
54
What is the Ponseti method (4 steps)?
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
What is achondroplasia?
* **Skeletal dysplasia** that is characterised by an **autosomal dominant condition**
56
Which gene is implicated in achodnroplasia?
* **G380** mutation of **FGFR3**
57
Why does achondroplasia occur?
* **Inhibition of chondrocyte proliferation in the proliferative zone of the physis**
* Results in **defect in endochondral bone formation**
58
What is rhizomelic dwarfism (4 charactersitics)?
* **Humerus shorter than the forearm**
* **Femur shorter than tibia**
* **Normal trunk**
* **Normal cognitive development** + significant spinal issues
59
What is osteogenesis imperfecta?
* Brittle bone disease
60
What is the inheritance pattern of osteogenesis imperfecta?
* **Autosomal dominant or recessive**
61
Which type of collagen is decreased in osteogenesis imperfecta?
* **Decreased type I collagen** due to decreased secretion and production of abnormal collagen
* There is **insufficient osteoid production**
62
What are the bone effects of osteogenesis imperfecta (3)?
* **Fragility fracture**
* **Short stature**
* **Scoliosis**
63
What are the non-orthopaedic manifestations of osteogenesis imperfecta (5)?
* **Heart**
* **Blue sclera**
* **Dentiogenesis imperfecta** - brown soft tissue
* **Wormian skull**
* **Hypermetabolism** - affecting the parathyroid pathway
64
What classification is used for paediatric fractures (4 + 1)?
* **Pattern**
* **Anatomy**
* **Intra/extra-articular**
* **Displacement**
* **Salter-Harris** Classification for those affecting the physis
65
What is an avulsion type fracture?
* When a **bone is being pulled by a ligament**
66
What is secondary bone healing characterised by?
* **Callus formation**
67
What is primary bone healing characterised by?
* By **direct union,** there is **no associated callus formation**
68
What is the preferred healing pathway for intra-articular fractures?
* **Primary bone healing**
69
What is a shortened fracture?
* The **fracture gap is minimised** due to **overlap**
70
When is displacement optimised in a paediatric fracture?
* In the **best angle of function** (remodelling does not occur in a rotated fracture)
71
What is the SALT classification of physeal injuries?
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
Which type of SALT fracture is most common?
* **Type 2**
73
What happens to the risk of growth arrest between SALT type 1 and type V fractures?
* Risk increases with type
74
What happens in a whole physis growth arrest?
* **Limb length discrepancy**
75
What happens in a partial growth arrest?
* **Angulation** as the non-affected side keep growing
76
What happens during an injury at a period near to physeal closure?
* There is a **small degree of potential growth left**
* Therefore, the impact of growth arrest on the individual is less
77
What are the 2 aims of treating growth arrest?
* **Limb length correction**
* **Minimise angular deformity**
78
How is limb length correction performed?
* Shorten the long side
OR
* Lengthen the long side
79
What are the 2 methods to which angular deformity is corrected (to shorten the longer side)?
* **Stop the** **growth of the unaffected side**
* **Reform the bone** (osteotomy)
80
How can growth arrest fractures be treated using cross-screws?
* Prematurely fused the physis, the shorten the unaffected side
81
Which device can be used to lengthen the short side of a limb?
* **Intramedullary device**
82
What is the first step to fracture management after resuscitation?
* **Reduce** - correct the deformity and displacement
83
What is closed reduction?
* Reducing a fracture **without making an incision** (Traction and manipulation)
84
What is open reduction?
* Make an **incision**, and the realignment of the fracture under direct visualisation **(Open reduction and internal fixation (ORIF))**
85
What is Gallows Traction (Closed)?
* **Holding the skin**, the long bones of the lower limb can be reduced
* **Manipulation Under Anesthesia (MUA)**
86
What are the risks of healing in paediatric populations (2)?
* **Overgrowth** and **excessing healing**
87
What is a spica cast?
* Holds the lower limb in place
88
What is external restriction?
* **Splints** and **plasters**
89
Why can an ORIF be avoided in a paediatric fracture?
* Due to **remodelling and healing potential**
90
What is internal restriction?
* Using **plates and screws**
* **Intra-medullary devices**
91
Why may operative restriction be required?
* Operative intervention maybe required due to **fracture affecting the physis** (correct the deformity to avoid further trauma)
92
What is recommended during the rehabilitation phase of a patient paediatric fracture?
* **Playing**
93
What is classified as an orthopaedic emergency in a paediatric patient presenting with a fracture?
* **Septic arthritis**
94
What is septic arthritis in a paediatric patient?
* 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
Why is there a risk of necrosis within septic arthritis?
* **Proteases generate pressure** effect on chondryocytes and cartilage due to **oedema** within a closed space
96
What classification criteria is used in a patient with septic arthritis?
* **Kocher's classification**
97
What is Kocher's classification?
* **Non-weight bearing**
* **ESR \> 40**
* **WBC \> 12,000**
* **Temperature \> 38 oC**
98
What is the treatment of septic arthritis in a paediatric patient?
* **Surgical lavage** is required in order to clear the infection, in addition to **antibiotic treatment**
99
How can transient synovitis be diagnosed?
* Once septic arthritis has been excluded
* Inflamed joint response to a systemic illness
100
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?
* **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
What is the treatment for slipped under femoral epiphysis (SUFE) disease?
* The **proximal epiphysis slips in relation to the metaphysis**
* Treatment is **operative fixation** with **screw** to prevent further **slippage**
