Flashcards in Orthopaedic Disorders in Children Deck (72):
Name 4 common postural abnormalities of the lower limb
Causes of in-toeing
Internal tibial tortion
At what age does bowed legs (genu varum) usually resolve
Describe 2 pathological causes of bowed legs in children
What is Blount's disease?
Physeal defect resulting in abnormal growth of the upper tibia
Early disease - treated with a brace
Surgery may be required
What is Rickets?
Vitamin D deficiency due to nutritional deficiency or genetic abnormality
Results in failure of osteoid to calcify normally
Bone is soft and bends on weight bearing
What age is knock knees (genu valgum) associated with?
Usually develops around 3-4 years old; rarely persists into adolescence
A normal knee is in what degrees of valgus or varus
Why is pes planus (flat feet) more common in children?
Ligamentous laxity; appearance exaggerated by medial fat pad in sole
What are 2 pathological causes of flat feet in children?
Congenital vertical talus
Describe congenital vertical talus
Form of club foot
Tight Achilles tendon with heel in equinus
Head of talus displaced medially in a vertical position
Forefoot in calcaneo-valgus
Requires surgical correction
What is tarsal coalition?
Uncommon congenital foot condition
Occurs when the bones of the feet fail to separate during development leading to a stiff, painful flat foot
Surgery required if symptomatic
In what age bracket does Perthe's disease commonly present?
In what age bracket does SUFE commonly present?
What is transient synovitis?
Transient inflammation of the synovium leading to hip pain - results in an unwillingness to weight bear and a limp
Clinical presentation - transient synovitis
Hip painful to move, tender and movements are restricted
Leg held in external rotation
Bloods (CRP, ESR, FBC) - normal
Treatment - transient synovitis
Short period of bed rest + analgesia
Benign condition; resolves spontaneously
What are the 3 stages to recovery in Perthe's disease
1. Bone death
2. Revascularisation and repair
3. Distortion and remodelling
Cause of Perthe's Disease
Transient disruption of blood supply to the capital epiphysis - probably due to pressure of a joint effusion tamponading vessels to the head
Are males or females more likely to have Perthe's Disease
Males - 4x more common
What % of Perthes has bilateral involvement
Clinical findings - Perthe's Disease
Abduction and internal rotation limited
Complication of Perthe's
Radiological appearance - Perthe's
Sclerosis and irregularity of capital epiphysis
Head may be flattened and expanded laterally - and appear to be extruding from the acetabulum
Management of Perthe's Disease
- abduction splint
- limit activities
SURGICAL - consider osteotomy of pelvis or femoral neck if femoral head has extruded form the acetabulum
What is SUFE
Slipped Upper Femoral Epiphysis
Insufficiency fracture through the hypertrophic zone of the physis during the pubertal growth spurt
The capital epiphysis moves inferiorly and posteriorly on the femoral neck
30% have a Hx of trauma
Common characteristics of a patient with SUFE
2/3 are fat and sexually underdeveloped (? hormonal imbalance)
4x more common in Pacific Islanders
What is the incidence of bilateral involvement in SUFE?
Clinical presentation - SUFE
History of knee or hip pain
Leg short and externally rotated
Abduction and internal rotation limited
Obligate external rotation of the hip while the hip is passively flexed
Radiological appearance - SUFE
Widening and irregularity of the physis
Capital epiphysis lies below a line along the superior surface of the femoral neck instead of through the epiphysis
Epiphysis is tilted posteriorly on lateral view
Management - SUFE
- fixation of the capital epiphysis with one or more pins along the neck
- osteotomy of the femoral neck (risk of AVN) if severe
- femoral rotation osteotomy if deformity
Complications of SUFE
Coxa vara - reduced neck shaft angle (<120deg)
Slip of the opposite hip
Is DDH more common in males or females
Is DDH more common in the left or right hip
What is the % of bilateral involvement - DDH
Risk factors for DDH
Breech intrauterine position
What are 4 clinical tests you can use to investigate for DDH
Trendelenburg - if walking
Describe BARLOW's test
Flex hips to 90deg
Place index and middle finger over greater trochanter
Place thumb medially at inner thigh inguinal crease
Adduct the hip and apply a downward force
Positive if CLUNK is felt
Describe ORTOLANI's test
Infant supine, hips flexed to 90deg
Gently abduct the leg while applying a anterior force
Positive if CLUNK is felt
Describe GALLEAZZI's test
Child supine, flex knees to 90deg with feet flat on table
Observe for inequality of knee height - affected side is lower
Cause of false negative in Galleazzi's test
DDx: Positive galleazzi's test
Femoral or tibial shortening
What is the DDx for a positive Trendelenburg's sign in a paediatric patient
Gluteus medius weakness
Fixed adduction of the hip
Short femoral neck
Radiological appearance - DDH
Axis of femur should pass through the centre of the acetabulum and below the lumbosacral disc
DDH assumed if axis lies outside the centre of the acetabulum and projects above the lumbosacral disc
Treatment - DDH
First few months of life - hold the hips in abduction and flexion using Pavlick Harness or Von Rosen splint
2-12mo - abduction traction followed by plaster immobilization; can consider percutaneous tenotomy of the adduction tendons in the groin
12-18mo - open reduction with subsequent osteotomy or the pelvis or femur
Complications of DDH
Complications of treatment - AVN, recurrent dislocation
General comp = persistent limp, hip pain, OA
Discuss the causes of talipes equinovarus
- POSTURAL - due to intra-uterine moulding
- CONGENITAL - underdevelopment of the posteromedial calf muscls and abnormal devleopment of the os calcis and forefoot
Characteristic deformity - congenital talipes equinovarus
Small, underdeveloped calf
Foot and heel in equinus and varus
Forefoot adducted and pronated
Treatment - congenital talipes equinovarus
Serial stretching and casting - PONSETI method
Casts are changed every week, stretching the foot towards the correct position
Once it has been corrected - wear a brace at night for 2 years
Which bone does Keinboch's disease affect?
What bone does Kohler's disease affect?
Navicular of the foot
What bone does Frieberg's disease affect?
What is Sever's disease?
Traction apophysitis of the heel due to the pull of Achille's tendon
What is Osgood-Schlatter's disease?
Traction osteochondritis of the tibial tuberosity - due to overuse activity of the quadriceps through the patellar tendon
Management - Osgood Schlatter's
Reduce sporting activity
Period of splintage
Complications of Osgood Schlatters
Premature fusion of the anterior physis
Common bones affected by osteochondritis dessicans
Medial femoral condyle
What causes osteochondritis dessicans?
Shearing force leads to a fragment of articular cartilage and underlying bone becoming separated from the main bone
Fragment becomes avascular and sclerotic
Fragment may separate and become a loose body in the joint
What is the most common cause of locking knees in teenagers?
Where does osteochondritis dessicans usually occur on the knee?
Lateral side of the medial femoral condyle
Treatment of osteochondritis dessicans
Arthroscopic pin/screw fixation and drilling of the fragment to facilitate revascularisation
What is Scheuermann's disease?
Crushing osteochondritis affecting the spine in adolescence
Presumed to be due to pressure on the vertebral growth plate anteriorly
Leads to premature disc degeneration -->
Leads to wedging of the vertebral bodies, irregularity of end plates, nuclear herniation through the end paltes (SCHMORL'S NODES)
Is Scheuermann's disease more common in males or females?
When is surgery indicated - Scheuermann's disease
Intractible back pain
Clinical presentation - Scheuermann's disease
Exaggerated thoracic kyphosis and hamstring tightening
Lumbar spine lordosis
Complications of scoliosis
What is ADAM's FORWARD BENDING TEST?
Test to clinically confirm scoliosis - bend the patient forward and look tangentially from the back for an asymmetrical appearance of the trunk
Management - neuromuscular scoliosis
Braces slow progression
Definitive treatment - surgical correction + stabilisation with spinal rods
Causes of congenital scoliosis
Failure of part of 1+ vertebrae to form or
Failure of part of a disc or facet joints to form resulting in fusion of 2+ vertebrae
Congenital deformities associated with congenital scoliosis
Spinal dysraphism - diastematomyelia, tight filum terminale, arnold cihari malformation
What percentage of idiopathic scoliosis patient are female?