Orthopaedic Disorders in Children Flashcards Preview

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Flashcards in Orthopaedic Disorders in Children Deck (72):
1

Name 4 common postural abnormalities of the lower limb

In-toeing
Bow legs
Knock knee
Flat feet

2

Causes of in-toeing

Femoral anteversion
Internal tibial tortion
Metatarsus adductus

3

At what age does bowed legs (genu varum) usually resolve

3yo

4

Describe 2 pathological causes of bowed legs in children

Blount's disease
Rickets

5

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

6

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

7

What age is knock knees (genu valgum) associated with?

Usually develops around 3-4 years old; rarely persists into adolescence

8

A normal knee is in what degrees of valgus or varus

5-7degrees valgus

9

Why is pes planus (flat feet) more common in children?

Ligamentous laxity; appearance exaggerated by medial fat pad in sole

10

What are 2 pathological causes of flat feet in children?

Congenital vertical talus
Tarsal Coalition

11

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

12

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

13

In what age bracket does Perthe's disease commonly present?

5-10yo

14

In what age bracket does SUFE commonly present?

10-15yo

15

What is transient synovitis?

Transient inflammation of the synovium leading to hip pain - results in an unwillingness to weight bear and a limp

16

Clinical presentation - transient synovitis

Hip painful to move, tender and movements are restricted
Leg held in external rotation
Bloods (CRP, ESR, FBC) - normal

17

Treatment - transient synovitis

Short period of bed rest + analgesia
Benign condition; resolves spontaneously

18

What are the 3 stages to recovery in Perthe's disease

1. Bone death
2. Revascularisation and repair
3. Distortion and remodelling

19

Cause of Perthe's Disease

Osteochondritis
Transient disruption of blood supply to the capital epiphysis - probably due to pressure of a joint effusion tamponading vessels to the head

20

Are males or females more likely to have Perthe's Disease

Males - 4x more common

21

What % of Perthes has bilateral involvement

15%

22

Clinical findings - Perthe's Disease

Episodic pain
Antalgic gait
Abduction and internal rotation limited

23

Complication of Perthe's

Secondary osteoarthritis

24

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

25

Management of Perthe's Disease

NON-SURGICAL
- abduction splint
- limit activities
SURGICAL - consider osteotomy of pelvis or femoral neck if femoral head has extruded form the acetabulum

26

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

27

Common characteristics of a patient with SUFE

2/3 are fat and sexually underdeveloped (? hormonal imbalance)
4x more common in Pacific Islanders

28

What is the incidence of bilateral involvement in SUFE?

30-50%

29

Clinical presentation - SUFE

History of knee or hip pain
Antalgic gait
Leg short and externally rotated
Abduction and internal rotation limited
Obligate external rotation of the hip while the hip is passively flexed

30

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

31

Management - SUFE

SURGICAL
- 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

32

Complications of SUFE

Avascular necrosis
Coxa vara - reduced neck shaft angle (<120deg)
Slip of the opposite hip
Secondary osteoarthritis

33

Is DDH more common in males or females

Females

34

Is DDH more common in the left or right hip

Left

35

What is the % of bilateral involvement - DDH

20-30%

36

Risk factors for DDH

Family history
Breech intrauterine position
Female
First born

37

What are 4 clinical tests you can use to investigate for DDH

Barlow
Ortolani
Galleazzi
Trendelenburg - if walking

38

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

39

Describe ORTOLANI's test

Infant supine, hips flexed to 90deg
Gently abduct the leg while applying a anterior force
Positive if CLUNK is felt

40

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

41

Cause of false negative in Galleazzi's test

Bilateral DDH

42

DDx: Positive galleazzi's test

Femoral or tibial shortening

43

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
Dislocated hip

44

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

45

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

46

Complications of DDH

Complications of treatment - AVN, recurrent dislocation

General comp = persistent limp, hip pain, OA

47

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

48

Characteristic deformity - congenital talipes equinovarus

Small, underdeveloped calf
Small heel
Foot and heel in equinus and varus
Forefoot adducted and pronated

49

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

50

Which bone does Keinboch's disease affect?

Lunate

51

What bone does Kohler's disease affect?

Navicular of the foot

52

What bone does Frieberg's disease affect?

Metatarsal head

53

What is Sever's disease?

Traction apophysitis of the heel due to the pull of Achille's tendon

54

What is Osgood-Schlatter's disease?

Traction osteochondritis of the tibial tuberosity - due to overuse activity of the quadriceps through the patellar tendon

55

Management - Osgood Schlatter's

Reduce sporting activity
Period of splintage

56

Complications of Osgood Schlatters

Rarely -
Premature fusion of the anterior physis
Recurvatum

57

Common bones affected by osteochondritis dessicans

Medial femoral condyle
Tallus
Capitellum

58

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

59

What is the most common cause of locking knees in teenagers?

Osteochondritis dessicans

60

Where does osteochondritis dessicans usually occur on the knee?

Lateral side of the medial femoral condyle

61

Treatment of osteochondritis dessicans

Arthroscopic pin/screw fixation and drilling of the fragment to facilitate revascularisation

62

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)

63

Is Scheuermann's disease more common in males or females?

Males

64

When is surgery indicated - Scheuermann's disease

Cosmesis
Intractible back pain

65

Clinical presentation - Scheuermann's disease

Exaggerated thoracic kyphosis and hamstring tightening
Lumbar spine lordosis

66

Complications of scoliosis

Cosmetic deformity
Cardiorespiratory compromise

67

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

68

Management - neuromuscular scoliosis

Braces slow progression
Definitive treatment - surgical correction + stabilisation with spinal rods

69

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

70

Congenital deformities associated with congenital scoliosis

VATER syndrome
Spinal dysraphism - diastematomyelia, tight filum terminale, arnold cihari malformation

71

What percentage of idiopathic scoliosis patient are female?

90%

72

Treatment of idiopathic scoliosis

Bracing at 25-40deg of thoracocolumbar and lumbar curves during puberty
More than 40deg - can be treated surgically