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Orthopaedics Flashcards

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1
Q

What are growth plates ( epiphyseal plates ) ?

A

They are areas of at the ends of long bones that allow the bones to grow in length. They are made of hyaline cartilage and sit between the epiphysis and metaphysis.

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2
Q

What are some bone features that differ in children to adults ?

A

Children have growth plates where adults dont
Children have more cancellous bone - spongy
Adults have more cortical bone.
Children more prone to greenstick fractures due to increases flexibility.
Bones in children have a better blood supply so heal quicker

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3
Q

What are some types of fractures ?

A

Buckle
Transverse
Oblique
Spiral
Segmental
Salter-Harris ( growth plate fracture )
Comminuted
Greenstick

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4
Q

What can fractures at the growth plate cause ?

A

Issues of growth in that bone

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5
Q

What classification is used for growth plate fractures ?

A

Salter-Harris classification

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6
Q

What are the different types of fractures in the salter-Harris classification ?

A

Type 1 - straight across
Type 2 - above the growth plate
Type 3 - below the fracture
Type 4 - through the growth fracture
Type 5 - crush fracture

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7
Q

What is the first principle of fracture management and how is it achieved ?

A

Mechanical alignment :
- closed reduction via manipulation of the joint
- open reduction via surgery

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8
Q

What is the second principle of fracture management and how is it achieved ?

A

Relative stability done by fixing the bone in the correct position
-External cast
-K wires
- intramedullary wires
- intramedullary nails
- screws
- plate and screws

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9
Q

What is the pain management of fractures ?

A

Step 1 - paracetamol or ibuprofen
Step 2 - morphine

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10
Q

What can present alongside hip pain ?

A

Limp
Refusal to use the affected leg
Refusal to weight bear
Inability to walk
Pain
Swollen or tender joint

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11
Q

What are the most common causes of joint pain in 0-4 years old ?

A

Septic arthritis
Developmental dysplasia of the hip
Transient sinovitis

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12
Q

What are the most common causes of joint pain in 5-10 years old ?

A

Septic arthritis
Transient sinovitis
Perthes disease

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13
Q

What are the most common causes of joint pain in 10-16 years old ?

A

Septic arthritis
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis

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14
Q

What are some red flags for hip pain suggesting a serious pathology ?

A

Child under 3 years
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen and red joint

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15
Q

What are some criteria for an urgent referral in relation to a limping child ?

A

Child under 3
Child over 9 with a restricted or painful hip
Not able to weight bear
Evidence of neurovascular compromise
Severe pain or agitation
Suspicion of abuse

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16
Q

What investigations should be performed for hip pain and what will they show ?

A

Blood tests - CRP and ESR for juvenile inflammatory arthritis
X-rays - fractures, SUFE
USS - effusion
Joint aspiration - septic arthritis
MRI - osteomyelitis

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17
Q

What is septic arthritis ?

A

Refers to infection inside a joint and can occur at any age.
It is an emergency as the infection can quickly begin to destroy the joint and cause serious systemic illness.

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18
Q

What is septic arthritis a common complication of ?

A

Joint replacement

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19
Q

How does septic arthritis present ?

A

Usually affects a single joint
Rapid onset of :
- hot, red, swollen and painful joint
- refusing to weight bear
- stiffness and reduced range of motion
- systemic symptoms such as fever, lethargy and sepsis

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20
Q

What is the most common bacteria to cause septic arthritis and some others ?

A

Staph aureus - most common
Neisseria gonorrhoea
Group A strep
Haemophilus influenza
E.coli

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21
Q

What are some differentials for septic arthritis ?

A

Transient sinovitis
Perthes disease
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis

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22
Q

What investigations should be performed if septic arthritis is suspected ?

A

Joint aspirate - gram staining, crystal microscopy, culture and antibiotic sensitivities

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23
Q

What is the management of septic arthritis ?

A

Empirical IV antibiotics for 3- 6 weeks
Surgical drainage and washout

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24
Q

What is transient synovitis ?

A

Irritable hip - temporary irritation and inflammation in the synovial membrane of the joint.
Often associated with a viral URTI

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25
What is the presentation of transient synovitis ?
Symptoms of a viral illness Limp Refusal to weight bear Groin or hip pain Mild low grade temperature
26
What is the management of transient synovitis ?
Simple analgesia Safety netting
27
What is the prognosis of transient synovitis ?
Resolution within 1-2 weeks
28
What is Perthes disease ?
Involves disruption of blood flow to the femoral head causing avascular necrosis of the bone. This affects the epiphysis of the femur which is the none distal to the growth plate.
29
What is the main complication of perthes disease and how does it occur ?
Hip osteoarthritis - over time there is revascularisation or neovascularisation and healing of the femoral head. There is remodelling of the bone as it heals.
30
How does perthes disease present ?
Slow onset of : - pain in the hip or groin - limp - restricted hip movements - referred pain to the knee
31
What investigations should be performed when suspecting Perthes disease ?
X ray Blood tests - especially inflammatory markers Technetium bone scan MRI scan
32
What is the management of perthes disease ?
Bed rest Traction Crutches Analgesia Physiotherapy Surgery - older children that might not have healed properly
33
What is slipped upper femoral epiphysis ?
It is where the head of the femur is displaced along the growth plate.
34
When does slipped upper femoral epiphysis usually present ?
More common in boys 8-15 years old - average age of 12 Slightly younger in females at 11
35
How does Slipped upper femoral epiphysis present ?
Adolescent obese males History of minor trauma Hip, groin, thigh or knee pain Restricted range of hip movement Painful limp Restricted range of motion Limited internal rotation
36
What investigations should be used to help the diagnosis of Slipped upper femoral epiphysis ?
X ray Blood tests - usually normal but used to exclude other pathologies Technetium bone scan CT scan MRI scan
37
What is the management of Slipped upper femoral epiphysis ?
Surgery is required to correct the position and fix it from further slipping
38
What is osteomyelitis ?
An infection in the bone and bone marrow and typically occurs in the metaphysis of the long bones
39
What is the most common bacteria to cause osteomyelitis ?
Staph aureus
40
What is chronic osteomyelitis ?
A deep seated slow growing infection with slow developing symptoms.
41
What are some risk factors of osteomyelitis ?
Open bone fractures Orthopaedic surgery Immunocompromised Sickle cell anaemia HIV TB
42
How does osteomyelitis present ?
Refusing to use the limb or weight bear Pain Swelling Tenderness Afebrile / low grade fever
43
What investigations should be performed when suspecting osteomyelitis ?
X rays as initial MRI or bone scan as an alternative Blood tests - inflammatory markers ( CRP or ESR and WBC ) Blood culture Bone marrow aspiration or bone biopsy
44
What is the management of osteomyelitis ?
Extensive and prolonged antibiotic therapy Surgery - drainage and debridement
45
What is osteosarcoma ?
A type of bone cancer usually affecting the femur
46
How does osteosarcoma present ?
Persistent bone pain particularly worse at night May disturb or wake them from sleep Bone swelling Palpable mass Restricted joint movement
47
How is osteosarcoma diagnosed ?
Very urgent direct access X-ray within 48 hours for children presenting with bone pain or swelling X-rays Blood tests - ALP CT scan, MRI scan, bone scan, PET scan, bone biopsy
48
How does osteomyelitis present on X-ray ?
Poorly defined lesion in the bone, with destruction of the normal bone and a fluffy appearance. Periosteal reaction that is classically described as a sun-burst appearance.
49
What is the management of osteosarcoma ?
Surgical resection of lesion often with limb amputation. Adjuvant chemotherapy is used alongside surgery
50
What is the main complication of osteosarcoma ?
Pathological bone marrow Metastasis
51
What is talipes ?
A fixed abnormal ankle position that presents at birth It is also known as clubfoot
52
What is talipes equinovarus ?
The ankle is in plantar flexion and supination
53
What is talipes calcaneovalgus ?
The ankle is in dorsiflexion and pronation
54
What is the Ponseti method ?
A way of treating talipes without surgery. It is usually very successful. Treatment is started immediately after birth.
55
How is talipes treated by the Ponseti method ?
The foot is manipulated towards a normal position and a cast is applied to hold it in position. This is repeated over and over until the foot is in the correct position. At some point an Achilles tenotomy to release tension in the achilles tendon is performed
56
What is positional talipes ?
A common condition where the resting position of the ankle is in plantar flexion and supination. The muscles are slightly tight around the ankle bu the bone is unaffected.
57
How is positional talipes treated ?
Physiotherapist
58
What is developmental dysplasia of the hip ?
A condition where there is a structural abnormality in the hips caused by abnormal development of the foetal bones during pregnancy. This leads to instability in the hips and a tendency or potential for subluxation or dislocation.
59
What can occur if you have structural abnormalities from developmental dysplasia of the hip into adulthood ?
The potential for weakness, recurrent subluxation or dislocation, an abnormal gait and early degenerative changes
60
when should degenerative dysplasia of the hip be diagnosed ?
First degree family history Breech presentation from 36 weeks onwards Breech presentation at birth if 28 weeks onwards Multiple pregnancy
61
What are the 2 special tests to check for degenerative dysplasia of the hip ?
Ortolani test Barlow test
62
How is the ortolani test performed ?
Baby on their back with the hips and knees flexed. Palms are placed on the baby’s knees with thumbs on the inner thigh and four fingers on the outer thigh. Gentle pressure is used to abduct the hips and apply pressure behind the legs with the fingers to see if the hips will dislocate anteriorly.
63
What is the Barlow test ?
Baby on their back with hips adducted and flexed at 90 degrees and knees bent at 90 degrees. Gentle downward pressure is placed on knees through femur to see if the femoral head will dislocate posteriorly.
64
What is clicking ?
Common examination finding and is usually due to soft tissue moving over bone. USS is needed
65
What sounds during a hip exam would indicate developmental dysplasia of the hips ?
Clunking
66
How is a diagnosis of developmental dysplasia of the hip ?
USS of the hips X-rays
67
What is the management of developmental dysplasia of the hip ?
Pavlik harness if the baby presents at less than 6 months of age. The harness keeps the babys hips flexed and abducted. Surgery if harness fails
68
What is rickets ?
A condition affecting children where there is defective bone mineralisation causing soft and deformed bones.
69
what are some causes of rickets ?
A deficiency in vitamin D or calcium. Genetic causes - hereditary hypophosphataemic rickets.
70
What is the pathophysiology of rickets ?
Vitamin D is hormone created in response to UV radiation. Vitamin D is essential in calcium and phosphate absorption from the intestines and kidneys. Inadequate vitamin D leads to a lack of calcium and phosphate.
71
What are some potential symptoms of rickets ( not bone deformities ) ?
Lethargy Bone pain Swollen wrists Poor growth Dental problems Muscle weakness
72
What are some bone deformities that can occur in rickets ?
Bowing of the legs Knock knees - legs curve inwards Rachitic rosary Craniotabes - soft skull with delayed closure of the sutures and frontal bossing Delayed teeth
73
What are some investigations for rickets ?
Serum 25-hydroxyvitamin D X ray Serum calcium Serum phosphate Serum ALP Parathyroid hormone
74
What is the management of rickets ?
Prevention is most important Breast fed babies are at a higher risk Vitamin D deficiency can be treated with ergocalciferol Vitamin D and calcium supplementation
75
What is achondroplasia ?
The most common cause of disproportionate short stature. It is a type of skeletal dysplasia.
76
What are the genetics behind achondroplasia ?
The achondroplasia gene, fibroblast growth factor receptor 3 is on chromosome 4. Sporadic mutation or inheritance of an abnormal copy of this gene. The condition is inherited in autosomal dominant pattern. Homozygous gene mutations is fatal
77
What does a mutation in the FGFR gene cause ?
Causes abnormal function of the epiphyseal plates. This restricts the bone growth in length leading to short bones and short stature.
78
What are some features of achondroplasia ?
Disproportionate short stature ( average - 4ft ) Short digits Bow legs Disproportionate skull Foramen magnum stenosis
79
What are some associations of achondroplasia ?
Recurrent otitis media Kyphoscoliosis Spinal stenosis Obstructive sleep apnoea Obesity Foramen magnum stenosis which can lead to cervical cord compression and hydrocephalus
80
What is the management of achondroplasia ?
No cure Can have leg lengthening surgery can add height
81
What is osgood-schlatter disease ?
Caused by inflammation at the tibial tuberosity where the patella ligament inserts. Anterior knee pain Unilateral
82
What is the pathophysiology of osgood-schlatters disease ?
The patella tendon inserts into the tibial tuberosity. Stress from running, jumping and other movements at the same time as growth result in inflammation on the tibial epiphyseal plate. There are multiple small avulsion fractures, where the patella ligament pulls away tiny pieces of the bone.
83
How does osgood-schlatters disease present ?
Gradual onset - Visible or palpable hard and tender lump at the tibial tuberosity Pain in the anterior aspect of the knee Pain exacerbated by physical activity, kneeling and on extension of the knee.
84
What is the management of osgood-schlatter disease ?
Reducing physical activity Ice NSAIDs Physiotherapy
85
What is a rare complication of osgood-schlatter disease ?
Full avulsion fracture
86
What is osteogenesis imperfecta ?
A genetic condition that results in brittle bones that are prone to fractures. Caused by a range of genetic mutations that affect the formation of collagen
87
How does osteogenesis imperfecta present ?
Hypermobility Blue/grey sclera Triangular face Short stature Deafness Dental problems Bone deformities - bowed legs or scoliosis Joint and bone pain
88
What is the management of osteogenesis imperfecta ?
Bisphosphonates Vitamin D supplements Physiotherapy
89
What are some investigations for osteogenesis imperfecta ?
Clinical diagnosis X-rays Genetic testing

Y4 Paeds (14 decks)

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