Pads VIII Flashcards

Question

NICE recommend that a child aged between 3-9 years with a working diagnosis of transient synovitis can be managed in primary care if: [3]

Answer 1

They are **afebrile**, **mobile** but **limping** and symptoms have been **present for < 48 hours**

Answer 2

**Conservative** * It is important to explain to parents the natural history of the condition and to provide adequate safety netting * For example - **we would expect the symptoms to resolve within 1 week with rest and simple pain relief. We would not expect the symptoms to worsen or the child to become systemically unwell (fever, lethargy, irritability).** If this does happen then you should take the child to the emergency department immediately as this could be a sign of a more serious pathology. * **Arrange a follow-up appointment after 48-hours to ensure symptoms are resolving** **Medical** - Simple analgesia using paracetamol or ibuprofen ## Footnote Typically there is a significant improvement in symptoms after 24 – 48 hours. Symptoms fully resolve within 1 – 2 weeks without any lasting problems. Transient synovitis may recur in around 20% of patients.

Answer 3

Perthes disease present with a slow onset of: * **Pain in the hip or groin** * **5-8 years old** * **Limp** * **Restricted hip movements** * There may be **referred pain to the knee** There will be NO history of trauma. If the pain is triggered by minor trauma, think about slipped upper femoral epiphysis, particularly in older children.

Answer 4

**PM**: * If less than **6 years: observation** * Older: **surgical management with moderate results** * **Operate on severe deformities** **Conservative management:** - This includes **activity modification** - **Pain** **management** with analgesics or anti-inflammatory medications - **physical therapy** to maintain range of motion and muscle strength. - **Orthotic device**s, such as casts or braces, may be used to provide containment of the femoral head within the acetabulum. **Surgical management:** * Procedures include **femoral or pelvic osteotomies to improve hip joint congruence** * **arthrodiastasis** to decompress the hip joint * in severe cases, **hip arthroplasty.**

Answer 5

Indications for surgery include **persistent pain, progressive deformity, or failed conservative management.**

Answer 6

**Chondromalacia patella** **Similarities**: - knee pain presenting in sporty teenagers, managed conservatively **Differences**: - typically presents with pain on anterior or inner side of the knee ## Footnote Chondromalacia patellae is a condition where there is damaged cartilage behind the patella (kneecap). It is like a softening or wear and tear of the cartilage.

Answer 7

**Osteochondritis dissecans** **Similarities**: - activity-related knee pain with localised bony tenderness **Differences**: - presents with mechanical features as knee intermittently locks and gives way. Effusion and joint crepitus present on examination

Answer 8

**Osteochondritis dissecans (OCD)** is a **pathological process affecting the subchondral bone** (most often in the knee joint) **with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions.**

Answer 9

**Joint effusion** **Full range of movement** in the joint without signs of ligamentous instability **External tibial rotation when walking** - if medial femoral involvement **Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed** **Wilson's sign** for detecting medial condyle lesion - with the knee at 90Â° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30Â°, external rotation of the tibia at this point relieves the pain

Answer 10

**X-ray** (anteroposterior, lateral and tunnel views) - may show the **subchondral crescent sign or loose bodies** **MRI** - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion **CT** - may be used in preoperative planning and in cases where MRI is not available or contraindicated **Scintigraphy** - may be used to guide treatment as it may show increased uptake in the fragments - a sign of osteoblastic activity

Answer 11

**hypothyroidism, growth hormone supplementation and renal osteodystrophy**

Answer 12

The **Southwick angle** can also be used to quantify the degree of slippage in SCFE. It compares the angle between a line parallel to the physis and a line perpendicular to the shaft of the femur in both normal and affected hips. A greater angle indicates increased severity.

Answer 13

The typical exam presentation is an **adolescent, obese male undergoing a growth spurt.** There may be a history of **minor** **trauma** that **triggers the onset of symptoms**. Suspect SUFE if the **pain is disproportionate to the severity of the trauma.** Presenting symptoms can be vague. These can be: * **Hip, groin, thigh or knee pain** * **Restricted range of movement in the hip** * **Painful limp** * **11/12 year old** * When examining the patient, they will **prefer to keep the hip in external rotation.** **They will have limited movement of the hip, particularly restricted internal rotation.**

Answer 14

There may be restriction in hip movements, especially **internal rotation, abduction and flexion**. Forced passive internal rotation often exacerbates the pain.

Answer 15

The management of slipped capital femoral epiphysis (SCFE) is primarily surgical, aiming to stabilise the epiphysis and prevent further slippage. The specific management steps are as follows: **In Situ Pinning:** - This is the most common treatment for stable SCFE. A single screw or pin is inserted percutaneously into the femoral head to secure it in place. In unstable SCFE, multiple screws may be used. **Open Reduction and Internal Fixation (ORIF):** - In severe cases or when closed methods fail, open reduction followed by internal fixation can be performed. This involves surgically exposing the hip joint, realigning the displaced femoral head under direct vision and then securing it with screws. **Osteotomy**: - If there is significant deformity or chronic SCFE, an osteotomy may be required. This procedure involves cutting and realigning the bone to correct its position and orientation.

Answer 16

Treatment typically **involves a Pavlik harness** if the baby **presents at less than 6 months of age** - The Pavlik harness is **fitted and kept on permanently**, adjusting for the growth of the baby. - The aim is to **hold the femoral head in the correct position** to allow the hip socket (**acetabulum**) to **develop a normal shape**. - This harness keeps the **baby’s hips flexed and abducted**. - The child is regularly reviewed and the harness is removed when their hips are more stable, usually after 6 – 8 weeks. **Surgery** - is required when the harness fails or the diagnosis is **made after 6 months of age.** - After surgery is performed, an **hip spica cast** is used to immobilises the hip for a prolonged period. - **Open reduction:** **For children older than two years**, or when closed reduction is unsuccessful, surgical intervention in the form of an open reduction may be required. Additional procedures, such as femoral or pelvic osteotomies, may be needed to achieve optimal hip stability and congruity.

Answer 17

**Pavlik harness:** - Under 6 months **Closed reduction and spica casting:** - In infants aged six months to two years - or when Pavlik harness treatment fails **Open reduction**: - For children older than two years, or when closed reduction is unsuccessful

Answer 18

**Early Complications:** **Osteonecrosis**: - This is one of the most severe early complications. It involves death of bone tissues due to limited blood flow, leading to femoral head deformity and growth disturbance. **Residual dysplasia**: - Despite adequate treatment, some patients may still exhibit residual dysplasia. This refers to persistent abnormality in the shape or position of the hip joint, predisposing it to premature degenerative changes. **Subluxation or dislocation:** - If not adequately treated or managed, DDH can result in subluxation (partial dislocation) or complete dislocation of the hip joint. **Late Complications:** **Osteoarthritis**: - Untreated or poorly managed DDH often leads to early onset osteoarthritis. This degenerative disease results from wear and tear on the hip joint over time, causing pain, stiffness and reduced mobility. **Gait abnormalities**: - These are common in individuals with untreated DDH. Abnormalities such as limping or waddling gait can affect mobility and quality of life. **Hip impingement:** - Also known as Femoroacetabular Impingement (FAI), this condition occurs when there's an abnormal contact between the femoral head and acetabulum. It can cause pain and limit movement in the hip joint.

Answer 19

is the **commonest** **cause** of **heel** **pain** in children and adolescents . It is an **overuse injury caused by micro-fractures of the calcaneal apophysis** at the **site of attachment of the Achilles tendon.**

Answer 20

It presents with **gradual onset heel pain** which may be **worse on standing and with activity**. It is typically **relieved by rest**. It can be **unilateral** but is often **bilateral** (60% of cases) Medial and lateral compression of the heel i.e '**squeezing**' causes **pain**. Pain on **ankle dorsiflexion**, especially on active toe raise **Mild heel swelling** **Calcaneal enlargement** * Only if chronic which is rare

Answer 21

Red flag features suggestive of an alternative diagnosis include **significant rest pain, night pain or large swelling.**

Answer 22

**Talipes** is a fixed abnormal ankle position that presents at birth. It is also known as **clubfoot**. It can occur spontaneously or be associated with other syndromes. It is usually identified at birth or during the newborn examination. **Talipes equinovarus** describes the **ankle in plantar flexion and supination.** **Talipes calcaneovalgus** describes the **ankle in dorsiflexion and pronation.**

Answer 23

Talipes is treated with the “**Ponseti method”** with good results. Surgery may be required if the Ponseti method fails or cannot be used.

Answer 24

The Ponseti method is a way of treating talipes without surgery. It is usually very successful. **Treatment is started almost immediately after birth**. It is performed by a properly trained therapist. 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, often in clinic**. **After treatment with the cast is finished a brace is used to hold the feet in the correct position when not walking until the child is around 4 years old.** This brace is sometimes referred to as “boots and bars”.

Answer 25

**Positional talipes** is a common condition where the **resting position of the ankle is in plantar flexion and supination**, however it is **not fixed in this position** and there is no structural boney issue in the ankle. - The muscles are **slightly tight around the ankle but the bones are unaffected**. This requires **referral** to a **physiotherapist** for some simple exercises to **help the foot return to a normal position**. Positional talipes will resolve with time.

Answer 26

**BITE** **B**ones fracture **I**(eye) blue sclera **T**eeth imperfections **E**ar hearing loss

Answer 27

The underlying genetic condition cannot be cured. Medical treatments include: **Bisphosphates** to increase bone density **Vitamin D** supplementation to prevent deficiency **Management is done by the multidisciplinary team, with:** * Physiotherapy and occupational therapy to maximise strength and function * Paediatricians for medial treatment and follow up * Orthopaedic surgeons to manage fractures * Specialist nurses for advice and support * Social workers for social and financial support

Answer 28

The achondroplasia gene, **fibroblast growth factor receptor 3 (FGFR3)**, is on chromosome 4. - This results in **abnormal cartilage** **Presentation**: * **short** **limbs** (rhizomelia) with **shortened** **fingers** (brachydactyly) * **large head with frontal bossing and narrow foramen magnum** * **midface hypoplasia with a flattened nasal bridge** * **'trident' hands** * **lumbar lordosis** * **Bow legs** (genu varum)

Answer 29

**Different areas** of the **skull grow by different methods**, some of which are affected more than others. The **skull base grows and fuses via endochondral ossification**, which is affected by **achondroplasia** and leads to a **flattened mid-face and nasal bridge and foramen magnum stenosis**. The **cranial vault grows** and **fuses via membranous ossification**, which is **unaffected** by **achondroplasia** and leads to a **normal sized vault and frontal bossing** (prominent forehead).

Answer 30

**Recurrent otitis media**, due to cranial abnormalities Kyphoscoliosis Spinal stenosis Obstructive sleep apnoea Obesity Foramen magnum stenosis can lead to **cervical cord compression and hydrocephalus**

Pads VIII Flashcards

(55 cards)