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Flashcards in Paed Ortho Deck (42):
1

Order of Elbow ossification centre development

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

2

History to ask when assessing child with abnormal gait

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

3

Rotational variations in gait

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

4

What constitutes the rotational profile?

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)

5

Abnormal foot shape in rotational profile

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

6

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

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

7

Normal femoral rotation and rotational abnormality if abnormal

internal rotation usually 50 deg - increased in inset hips
External rotation normally 40 deg, reduced in inset hips

8

When to refer for rotational variations in gait

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

9

By what age does metatarsus adductus usually resolve spontaneoulsy

4 years

10

Angular variations

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

11

Alignment changes of legs with growth

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

12

Causes of bow legs/varus deformities

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

13

Causes of knock knee deformities

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

14

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

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

15

Normal development of arch of foot

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

16

Causes of painless flat feet

Physiological
Ligamentous laxity
Calf tightness
Paralytic foot

17

Causes of painful flat feet

Tarsal coalition
Accessory navicular
Subtalar irritability

18

Assessment for physiological flat foot

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

19

When to refer flat feet

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

20

Curly toes

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)

21

Risk factors of SCFE

Male gender
Obesity
Polynesian ancestry
Adolescent

22

Patho-anatomy of SCFE

Femoral head stays in position
Femoral neck slides externally and superiorly leads to turning out of foot

23

Presentation of SCFE

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

24

Examination findings in SCFE

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

25

X-ray findings in SCFE

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

26

Complications of SCFE

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

27

Stats of DDH

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

28

Risk factors of DDH

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)

29

Examination of DDH in a neonate

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)

30

Examination findings of DDH in older infant

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

31

Imaging for DDH

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)

32

Treatment of DDH

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

33

Differentials for scoliosis

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

34

When to refer a child with scoliosis

any recognisable curve, especially if associated with a rib hump
leg length discrepancy
neurological signs
back pain

Order a PA erect spine radiograph

35

Which imaging to order in child with scoliosis

PA erect spine radiograph

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

36

Causes of limp in a child

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

37

Bone tumours in 0-5y age group

Osteomyelitis
Neuroblastoma
Leukaemia
Histiocytosis
Bone Cysts

38

Bone Tumours in 6-18y age group

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

39

What is congenital talipes equinovarus?

Congenital club foot

40

Epidemiology of club foot

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

41

Deformity in club foot

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

42

Management of Club foot

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