Paed Ortho

Question 1

Order of Elbow ossification centre development

Answer 1

CRITOL - occurring from 6m to 12y
Capitellum
Radial head
Internal (medial) epicondyle
Trochlea
Olecranon
Lateral epicondyle

Question 2

History to ask when assessing child with abnormal gait

Answer 2

Milestones/development
Birth history - e.g. breech
Family history
trauma/infection/tumour history

Question 3

Rotational variations in gait

Answer 3

in-toeing - more common in toddlers
out-toeing - more common in older kids
both are common

Question 4

What constitutes the rotational profile?

Answer 4

Foot progression angle (angle of foot compared with axis)
Foot shape (lateral border should be straight)
Thigh-foot angle (line from 2nd toe-heel-thigh)
Femoral rotation (internal and external)

Question 5

Abnormal foot shape in rotational profile

Answer 5

Lateral border usually straight, adduction of the front of the foot present in metatarsus adductus

Question 6

Thigh-foot angle: what is normal, what causes it to be abnormal

Answer 6

2nd toe-heel-thigh
Normally 25 degree external angle
Internal tibial torsion causes internal angle

Question 7

Normal femoral rotation and rotational abnormality if abnormal

Answer 7

internal rotation usually 50 deg - increased in inset hips

External rotation normally 40 deg, reduced in inset hips

Question 8

When to refer for rotational variations in gait

Answer 8

not resolving over time
asymmetrical rotation
functional difficulties (e.g. frequent falling)
neuromuscular concerns
outside normal age parameters for particular cause

Question 9

By what age does metatarsus adductus usually resolve spontaneoulsy

Answer 9

4 years

Question 10

Angular variations

Answer 10

bow legs (genu varum)
knock knees (genu valgum)

Question 11

Alignment changes of legs with growth

Answer 11

Birth: bow-legged

18m: straight legs
3y: somewhat valgus
7y: normal adult alignment (minorly valgus)

Question 12

Causes of bow legs/varus deformities

Answer 12

physiological (99%)
Pathological:
Rickets - if develops at time that child is physiological bow-legged
Blounts disease (failure of knee growth plate due to obesity)
Skeletal dysplasias

Question 13

Causes of knock knee deformities

Answer 13

Physiological (98%)
Pathological:
Metabolic bone disease e.g. Rickets (if develops at age where physiologically knock-kneed)
Post-traumatic valgus (injury - growth plate arrest)
Skeletal dysplasias
Asymmetric femoral growth

Question 14

When to refer to ortho for angular variations (bow legs or knock knees)

Answer 14

Severe deformity
Asymmetric deformity
Associated conditions
>2y for varus, >8y for valgus

Question 15

Normal development of arch of foot

Answer 15

Flat in infants/toddlers due to low tone, lax ligaments, poor muscle strength and fat in arch of foot
Arch develops by 6 years

Question 16

Causes of painless flat feet

Answer 16

Physiological
Ligamentous laxity
Calf tightness
Paralytic foot

Question 17

Causes of painful flat feet

Answer 17

Tarsal coalition
Accessory navicular
Subtalar irritability

Question 18

Assessment for physiological flat foot

Answer 18

Painless
Flexible: i.e. have child stand with hands against couch/wall, when rise onto tip-toes, heels swing inwards and reconstitution of arch due to tibialis posterior muscle
NO TREATMENT REQ

Question 19

When to refer flat feet

Answer 19

Inflexible (does not correct on tip-toes)
Painful
Congenital vertical talus (i.e. rocker bottom foot)

Question 20

Curly toes

Answer 20

Usually affects 3rd or 4th toe (never 2nd) but may present with pain in 2nd toe due to being pushed up by curly toe beneath
Often +ve family history
No Inx,
Refer if symptomatic >4y (treatment rarely req, lengthening of toe flexor tendons)

Question 21

Risk factors of SCFE

Answer 21

Male gender
Obesity
Polynesian ancestry
Adolescent

Question 22

Patho-anatomy of SCFE

Answer 22

Femoral head stays in position

Femoral neck slides externally and superiorly leads to turning out of foot

Question 23

Presentation of SCFE

Answer 23

Pain in hip, groin, thigh or knee: non-radiating, dull, aching, increased by physical activity, acute or chronic or intermittent
+/- leg length discrepancy

Question 24

Examination findings in SCFE

Answer 24

Obese child
Ipsilateral foot turned outwards
Flexion of affected hip and knee will lead to obligate external rotation in hip
Limited internal rotation

Question 25

X-ray findings in SCFE

Answer 25

will miss up to 10% AP pelvis and frog lateral of both hips (unless severe acute pain) mild widening, lucency and irregularity of the physis blurring of junction between metaphysis and growth plate Klein's line (along superior femoral neck) toes not transect the epiphysis

Question 26

Complications of SCFE

Answer 26

AVN in 10-15% Chondrolysis (10%) - acute cartilage necrosis Deformity Long term degenerative osteoarthritis 90% Limb length discrepancy

Question 27

Stats of DDH

Answer 27

1/1000 live births had DDH 1/100 babies will have some instability, majority will resolve in first 6 weeks of life Majority of DDH are left hip (position against spine in womb) 20% are bilateral

Question 28

Risk factors of DDH

Answer 28

Female gender (9:1) First born child (relative size of uterus is small) +ve family history Breech presentation Presence of other packaging disorders (esp. calcarnovalgus foot)

Question 29

Examination of DDH in a neonate

Answer 29

``` Barlow test (flex hip to 90 + slight adduction - apply axial pressure) +ve if feel lateralising of greater trochanter or feel some give of the femur Ortolani manoeuvre (abduction of the hip - dislocated femoral head CLUNKS back into joint) ```

Question 30

Examination findings of DDH in older infant

Answer 30

Barlow/Ortolani less sensitive as age limited hip abduction in affected hip leg length discrepancy (Galeazzi test)

Question 31

Imaging for DDH

Answer 31

Ultrasound up to 6m of age (at this age the capital femoral epiphysis begins to for and so cannot see acetabulum) - static and dynamic (what happens on Barlow and Ortolani) X-ray after 6m US recommended @ 6w for any infant with major risk factor (family history, breech etc)

Question 32

Treatment of DDH

Answer 32

In infants: Pavlik Harness (holds both hips in abduction to allow completion of hip development) Older patients; closed reduction Much older/unsuccessful closed reduction: open reduction

Question 33

Differentials for scoliosis

Answer 33

Adolescent Idiopathic Scoliosis: prominence of rib hump on forward bend test, no pain LIST: no rib hump on forward bend, associated with back pain Leg Length discrepancy: compensate for discrepancy with blocks or examine sitting down - loss of scoliosis

Question 34

When to refer a child with scoliosis

Answer 34

any recognisable curve, especially if associated with a rib hump leg length discrepancy neurological signs back pain Order a PA erect spine radiograph

Question 35

Which imaging to order in child with scoliosis

Answer 35

PA erect spine radiograph Commonly adolescent girls, and will often need serial x-rays, thus reduce radiation exposure to breast tissue

Question 36

Causes of limp in a child

Answer 36

``` Transient synovitis of the hip Infective (septic arthritis, osteomyelitis) Trauma (e.g. fractures) Bone deformities (SCFE, DDH) Osgood-Schlatter Tumours Neuromuscular ```

Question 37

Bone tumours in 0-5y age group

Answer 37

``` Osteomyelitis Neuroblastoma Leukaemia Histiocytosis Bone Cysts ```

Question 38

Bone Tumours in 6-18y age group

Answer 38

``` Osteomyelitis Bone Cysts Non-ossifying fibroma (NOF) Endochondroma Osteosarcoma Ewing's Sarcoma Chondroblastoma ```

Question 39

What is congenital talipes equinovarus?

Answer 39

Congenital club foot

Question 40

Epidemiology of club foot

Answer 40

Most common congenital abnormality of the foot 1/1000 live births Male:female ratio 2:1 Bilateral in 40% 2% risk of subsequent child being affected if positive family history

Question 41

Deformity in club foot

Answer 41

``` Combination of: - Equinus of hind foot - Varus of hind foot - Adductus of midfoot - Cavus of medial arch All of which are rigid, not able to be corrected manually ```

Question 42

Management of Club foot

Answer 42

``` Start treatment in first week of life Ponseti method (serial plaster casting for 6 weeks) Achilles tenotomy Cast for further 3 weeks "Boots and bars" until 4y ```