Clinical (Weeks 3, 4 +5) Flashcards
What are risk factors for childhood hip disorders (Developmental Dysplasia of the Hip [DDH])?
Breech birth FHx Other MSK abnormalities: - Club foot - Torticollis
What populations are most commonly affected by childhood hip disorders?
1st born
Girls
What hip is more commonly affected?
Left
What should you look for on examination of a suspected DDH?
Asymmetry: - Leg position - Leg length - Thigh creases Feel for click Check abduction!
What special instability tests are useful in diagnosing hip disorders?
Barlow: - Attempt to dislocate/sublux - By flexion adduction Ortolani: - Relocate dislocated by abduction
In a 2 month old child what is the best imaging technique for a suspected hip problem?
Ultrasound
In a 6 month old child what is the best imaging technique for a suspected hip problem and why?
X-ray
Epiphysis has calcified
What is the most successful treatment for DDH?
Pavlik harness (95% success)
What surgical options for treatment are available for DDH at the following ages:
- Age > 3/12 - Age > 9/12 - Age > 2 years
> 3/12: - Closed reduction > 9/12: - Open reduction > 2 years: - Bony surgery (?Femoral/?Pelvic Osteotomy)
A preschool child presents with a limp. What questions are important to ask?
Painful or painless?
History of injury?
Generally well or ill?
What questions may help include/exclude infection?
Pain at rest/movement? Resistance to movement? Fever? Infection elsewhere? Susceptibility to infection?
If there is a joint effusion what investigation might we carry out?
Ultrasound
How would a late DDH present?
Painless limp
Short leg
Asymmetric creases - Xray
Trendellenburg limp
A 7 year old boy is brought to the GP with a painful right hip and limp. His mother informs you he enjoys playing football regularly. On examination he is in the 5th height centile for his age (short) and has a positive Trendellenburg gait.
Perthes Disease
What is Perthes disease?
Idiopathic AVN of the femoral head
How is Perthes treated?
Influencing the shape of the recovering femoral head:
- Ensure it is contained in acetabulum
A 14 year old African-American boy is brought to you with the inability to bear weight on his left leg, with associated knee pain. On examination he is obese, pre-pubescent and his hip cannot be internally rotated
Slipped Upper Femoral Epiphysis (SUFE)
What is seen on x-ray of a SUFE?
Trethowans sign (AP) Lateral view is imperative
What ages is transient synovitis most common in?
2-5 year olds
What typically precedes transient synovitis?
An URTI (viral)
What is the commonest cause of hip pain in kids? What conditions must be excluded?
Transient synovitis Exclude: - Septic arthritis - Perthes - Juvenile OA - RA
What must you prevent in a patient who cannot bear weight?
Any weight bearing - Assume SUFE until it is excluded
What are red flag symptoms in back pain?
Non-mechanical pain: - No variation with exercise - Night pain Systemic upset Major, new neurological defect Saddle anaesthesia: - Painless urinary retention - Overflow - Bowel incontinence
What signs might be seen on observation of a patient presenting with back pain?
Deformity
Hair patches
Asymmetry
Neurofibroma
What neurological symptoms can be present in back pain?
Numbness
Weakness
Paraesthesia
Temperature disturbance
What myotomes should be tested in the presentation of back pain?
L1/L2: - Hip flexion L3/L4: - Knee extension L5: - Foot dorsiflexion and EHL S1/S2: - Ankle plantarflexion
What is the sciatic stretch test?
Straight leg raise with foot extension
Testing for nerve irritation
What is the bowstring test?
Straight leg raise with pressure behind knee
Testing for nerve irritation
When will an x-ray be useful in back pain?
If spinal stenosis:
- Degenerate + hypertrophic spine - Narrow interpedicular distance - Obliteration of IV foraminae
What signs may be seen on a spinal MRI?
White triangle: - Annular tear 'Hamburger' sign: - Disc inflammation - White patches either side in vertebral bodies
What are features of sciatica?
Buttock and/or leg pain
Dermatomal distrubution
Neurological disturbance
A patient presents with episodic back pain with new onset of leg pain and weakness. The leg pain has become the dominant pain.
Disc prolapse
When is surgery considered in disc prolapse?
Cauda equina syndrome
No resolval in 3 months
Back pain patients should get long-term bed rest. True or false?
False
They need early return to normal activity and physical therapy
What symptoms may suggest a behavioural problem?
Pain at coccyx Whole leg pain/numbness Absence of pain free spells Treatment intolerance Emergency admission
A 59 year old man presents to the GP with back pain. He notes that he has been unable to walk very far. He also informs you that he used to be a builder. He says that his symptoms get better on sitting and leaning forward. On examination he is obese.
Spinal claudication
How is spinal stenosis treated?
Step 1. Decompression -> Destabilises spine
Step 2. Stabilisation:
- Fusion and Fixation
What pattern of pain does disc degeneration follow?
Worse as day goes on
Worse on flexion
Worse on activity
Central, lower back pain
A patient presents with morning stiffness. They explain how they have a ‘loosening up’ routine. They have difficulty sitting and standing. They note the pain is better on exercise. Sometimes it radiates to the buttocks. On examination the pain is worsened on back extension.
Facet arthropathy
Between 6-9 months what should a child be able to do?
Sit alone and crawl
Between 8-12 months what should a child be able to do?
Stand (holding furniture)
Between 14-17 months what should a child be able to do?
Walk alone
At what age should a child be able to run/jump?
2 years
At what age should a child be able to climb up and down stairs?
Up - 3 years
Down - 4 years
How does the foot arch develop?
As we walk the muscles strengthen
What are the types of flat foot?
Mobile/Flexible
Fixed/Rigid
What is Jack’s test in terms of a flat foot?
Great toe dorsiflexion:
- Arch will form in a mobile flat foot - Due to tight tibialis anterior
What are some causes of in-toeing?
Femoral neck anteversion
Internal tibial torsion
Metatarsus adductus
How do we diagnose femoral neck anteversion?
Measure hip rotational range
What features are present in patients with femoral neck anteversion?
Age > 4 years
Ligamentous laxity
Unwinds slowly
What do we measure in suspected internal tibial torsion?
Ankle rotation
What features are present in patients with internal tibial torsion?
Age
When are bow legs physiological? What causes this?
In infants
Medial tibial torsion
When should bow legs be referred?
Asymmetry
Not resolving
Painful
Height
What is the medical term for bow legs?
Genu varum
What is the normal intermalleolar distance at 11 years?
8cm
When do you refer for knock knees?
Asymmetry
> 8cm distance at 11
What is the medical term for knock knees?
Genu valgum
What is the commonest cause of adolescent knee pain in girls?
Patellofemoral dysfunction
What are some of the risk factors for adolescent knee pain?
Imbalance Ligamentous laxity Skeletal problems: - Valgus - Wide hips - Femoral neck anteversion
What is chondromalacia patellae and what can it be seen in?
Softening of patella’s hyaline cartilage
Adolescent knee pain
What must you examine in an adolescent presenting with anterior knee pain?
Hips
Abnormalities in what bones causes clubfoot?
Talus
Calcaneus
Navicular
What soft tissue contractures can result from clubfoot?
Ankle equinus (plantarflex)
Varus forefoot
Forefoot supination
What are some risk factors for clubfoot?
Male
Breech birth
Oligohydramnios (reduced amniotic fluid)
How is clubfoot treated?
Ponseti technique:
- Splintage after birth - Weekly casts (5-6 weeks) - 80% have Achilles tenotomy - Braced (23 hours/day for 3 months)