Orthopaedics Unit 3

Question 1

what are the average age for child to sit independently, stand and walk

Answer 1

sit - 9 months

stand - 12 months

walk - 20 months

[however is a lot of variation, not always a problem if child does not reach the milestone at this point]

Question 2

what is the medical term for knock knees

Answer 2

genu valgum

Question 3

what is the medical term for bow legs

Answer 3

genu varum

Question 4

what is the normal alignment of the knee

Answer 4

in valgus

when child stands to attention, normally a gap of 4cm between the FEET

Question 5

how does the gap change between the feet in varus and valgus

Answer 5

varus - gap decreases

valgus - gap increases

Question 6

what is important to note in relation to genu varum and genu valgum in children

Answer 6

almost all children by the age of 7 with this condition will have normal knee alignment t

Question 7

what is in-toeing and how can you spot it

Answer 7

children stand with their feet pointing inwards “pigeon-toed”

often exaggerated when they run and causes clumsiness

shoes tend to wear down at the heels

Question 8

what are causes of in-toeing

Answer 8

femoral neck angle variation

tibial torsion

abnormal forefeet

Question 9

how does femoral neck angle variation develop

Answer 9

During later stages of the normal development of foetus, the leg rotates on the pelvis so that the acetabulum points almost backwards and the femoral head on the neck is orientated forwards

sometimes this process is not completed by birth and the femoral neck is more anteriorly orientated (i.e. anteverted)

Question 10

what can children who are born with femoral neck angle variation do more than other children

Answer 10

internally rotate their femur a lot and externally rotate it only a little
- causes the in-toeing posture

Question 11

when is femoral neck angle variation often corrected by

Answer 11

10 y/o

surgery rarely needed

Question 12

what is tibial torsion

Answer 12

bone is warped along vertical axis

is normal variation and can be ignored

Question 13

what is abnormal forefeet

Answer 13

hooked (adducted) forefoot

vast majority correct spontaneously

Question 14

what is important to remember about flat foot

Answer 14

it is normal variation which rarely causes functional abnormalities

all children’s feet are flat at birth, normal arch may not form until child is 7

Question 15

what are the 2 types of flat foot

Answer 15

rigid

• rare
• implies bony abnormality
• sometimes seen in RA

mobile

• vast majority
• no issue

Question 16

what is curly toes

Answer 16

minor overlapping, commonly of the 5th toe

most correct spontaneously and should be left alone

Question 17

when would surgery on curly toes be required

Answer 17

if the overlapping toes becomes fixed or if people are getting discomfort from shoes

Question 18

when is pain around the knee most common in girls

Answer 18

as they develop secondary sexual characteristics.

Question 19

what is Osgood Schlatter’s disease

Answer 19

inflammation of the attachment of the patellar tendon to the growing tibial epiphysis, caused by excess traction by the quads

Question 20

Sx of Osgood Schlatter’s disease

Answer 20

tenderness, discomfort worse after exercise

swelling

Question 21

what are features of the Osgood Schlatter’s disease

Answer 21

thought to be overuse injury, seen most common in active children

episodic
Tx w/ rest

Question 22

when will children cease to have Osgood Schlatter’s disease

Answer 22

in middle adolescence when the epiphysis fuses

Question 23

what is features of adolescent knee pain

Answer 23

most common in girls

not the same as dislocation of patella

most girls grow out of the condition

if Sx persist, arthroscopy may be necessary

Question 24

what is chondromalacia patellae

Answer 24

erosion of an area of patella cartilage

Question 25

what is the rate of Congenital Dislocation of the Hip (CDH) [or congenital hip dysplasia CHD]

Answer 25

occurs in 1 or 2 births per thousand

Question 26

epidemiology of CHD

Answer 26

girls > boys | significant number of children, condition is bilateral

Question 27

what is the screening program for CHD

Answer 27

screened at birth, 3 months, 6 months and 12 months

Question 28

what are the two screening tests for CHD and what are they doing

Answer 28

Barlow maneuver - adduct the hip, apply light pressure - if hip dislocates = +ve test Ortolani test - try to relocate the hip - if you hear a click or a clunk = +ve test

Question 29

what are the Sx of CHD if it is not discovered till later life

Answer 29

shortening of the limb asymmetrical skin creases limited abduction limp

Question 30

what should be the next stages if a "click" is heard in CHD

Answer 30

re-examined by specialist at 3 months radiograph

Question 31

Mx of CHD

Answer 31

Tx from birth - Pavlik harness Tx if discovered late but before weight bearing - period of gentle traction followed by open or closed manipulation - then splinted in plaster for 3 months Tx if discovered late and is weight bearing - major surgery to deepen the undeveloped acetabulum and re-angulate the femoral neck to stabilise the hip

Question 32

why is it important to Tx CHD from birth

Answer 32

If the femoral head is relocated and maintained in the acetabulum using splintage then the vast majority will settle with no further development issue

Question 33

what is the issue with the Tx of CHD if discovered late and child is weight bearing

Answer 33

results are at best moderate, Secondary OA is highly likely.

Question 34

what is the medical name for club foot

Answer 34

Talipes Equino Varus

Question 35

what are the 2 types of club foot

Answer 35

``` postural form (mild) - seen after breech birth ``` fixed form - associated with development abnormalities of nerves and muscles of the leg both CAN BE bilateral (not always)

Question 36

Mx of mild talipes equino varus

Answer 36

initial Tx for both forms - gentle stretching in two phases - 1st phase = corrects hindfoot equinus - 2nd phase = corrects mid and forefoot varus = 6 weeks of stretching and strapping in a corrected or over-corrected position

Question 37

Mx of fixed talipes equino varus

Answer 37

6 weeks of stretching Reassessed - if correction is incomplete or cannot be maintained Surgery

Question 38

what is the follow up period for talipes equino varus

Answer 38

until feet stop growing - around age 14 [affected foot often significantly smaller than normal foot which causes difficulties in shoe fitting]

Question 39

what are the 2 types of spina bifida

Answer 39

spina bifida occulta spina bifida cystica

Question 40

what is spina bifida occulta

Answer 40

minor bony abnormality which affects 2% of the population - usually of no significance develop mechanical backache

Question 41

what is a possible consequence of spina bifida occulta

Answer 41

diastamatomyelia | - tethering of the spinal cord to the higher lumbar vertebrae

Question 42

what is spina bifida cystica

Answer 42

babies born with the neural plate tissues open with little or no skin or bony cover

Question 43

what is a meningocele

Answer 43

nerve tissue covered by a cyst

Question 44

what is meningomyelocele

Answer 44

nerve tissue may be incorporated in the cyst wall

Question 45

what are the consequences of spina bifida cystica

Answer 45

hydrocephalus > can lead to mental retardation paralysis growth deformities [due to muscle imbalance] incontinence joint contraction resulting in a fixed flexed position of their knees and dislocation of their hips

Question 46

Mx of spina bifida cystica

Answer 46

most babies die at, or soon after, birth some survive to undergo surgery - early surgery to feet to maintain functional shape - try to keep the children mobile

Question 47

what causes cerebral palsy

Answer 47

damage to the brain at birth

Question 48

what are the pathological features of cerebral palsy

Answer 48

spinal tissue develops normally > have uninhibited spinal reflexes > lack co-ordination and purpose of movement, normally controlled by the brain > causes SPASTIC PARALYSIS abnormal muscle and bone growth > due to some spastic muscle [muscles contracting strongly in uncoordinated way] > and due to some muscles being weak and flaccid secondary deformities of joints

Question 49

what are the patterns of cerebral palsy

Answer 49

Hemiparesis - 1 arm and 1 leg on the SAME side Paraparesis - 2 legs are affected Quadraparesis - all limbs affected

Question 50

what are other Sx of cerebral palsy

Answer 50

some are mentally retarded some are blind and/or deaf some are neither

Question 51

what is the management of patients with only minor degrees of spasticity

Answer 51

spasticity may only affect 1 muscle group - common sign is toe-walking in teens - often calf muscle spasticity Tx = tendo-achilles lengthening before growth ceases

Question 52

Mx of cerebral palsy

Answer 52

similar to spina bifida maintain mobility physiotherapy surgery to lengthen tight muscles or to denervate them to maintain posture and function

Question 53

what is scoliosis

Answer 53

Curvature of the spine with a rotatory abnormality of the vertebrae

Question 54

what causes the curve of the spine in scoliosis

Answer 54

abnormal lordosis of the spine, which leads to buckling and twisting of the vertebral column as a result of the action of muscles and gravity.

Question 55

what is the aetiology of scoliosis

Answer 55

most are idiopathic - seen in adolescence - girls more than boys - principal effects are cosmetic but cause great distress can be caused by congenital abnormalities of the vertebrae or by neuromuscular imbalance

Question 56

clinical presentation of scoliosis

Answer 56

usually complaints of twisting of the ribs which causes a hump on one side of the shoulder skirts hang crooked may be painful

Question 57

Mx of scoliosis

Answer 57

not all curves get worse if curve is progressive or causing distress Tx should be offered early - surgical correction of the ROTATORY element of the deformity

Question 58

what is the most likely cause of a limp at birth, between 4-10 and between 10-15

Answer 58

birth - CDH - infection of the hip between 4 and 10 - Perthe's disease between 10 and 15 - SUFE

Question 59

what is Perthe's disease

Answer 59

blood supply to the femoral head epiphysis becomes inadequate causes AVN of the femoral head

Question 60

aetiology of perthe's disease

Answer 60

more common in boys than girls 20% of cases are bilateral

Question 61

clinical presentation of perthe's disease

Answer 61

child has painful limp which is followed by a slow recovery

Question 62

radiological appearance of perthe's disease

Answer 62

femoral head may be normal on 1st presentation - month later it may show changes USS reveals fluid around hip joint

Question 63

Mx of Perthe's disease

Answer 63

maintain the head within the acetabulum until the natural process of the disease runs its course minor cases [up to half of femoral head involved] - need no Tx - good prognosis severe cases - splintage to achieve containment - Careful follow-up with periods of traction to alleviate symptoms of pain and limp

Question 64

what are children who have had Perthe's disease at an older age prone to

Answer 64

secondary OA

Question 65

what is SUFE

Answer 65

slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted.

Question 66

aetiology of SUFE

Answer 66

seen mostly in boys around 12 y/o who are sexually immature for their age and in girl who are little older and have recently undergone an adolescent growth spurt

Question 67

clinical presentation of SUFE

Answer 67

child has a limp may be pain radiating to the knee [due to the obturator nerve supplying both the hip and knee joint] ANY CHILD WITH KNEE PAIN HAS TO HAVE THEIR HIP EXAMINED loss of internal rotation of the hip is the predominant clinical sign

Question 68

what imagining must be obtained for SUFE and why

Answer 68

a lateral view or minor degrees of slippage may be missed

Question 69

if a child has hip pain, what is the working diagnosis

Answer 69

All young adolescents with a painful hip must be regarded as having SUFE until it is clinically and radiologically excluded

Question 70

Mx for SUFE

Answer 70

Tx is always surgery Minor slippage - hip should be pinned in its new deformed position Major slippage - gentle attempt to replace the head on the neck by manipulation - does carry risk of AVN Always observe the other hip for slippage using imaging - pinned if any slippage

Question 71

when are the pins from surgery removed in SUFE

Answer 71

removed after fusion of the epiphysis at around eighteen years of age.