Paediatric Orthopaedic Surgery Flashcards
(99 cards)
1
Q
What presentations in orthopaedics do we need to be able to form differentials for?
A
Limp
Swollen joint
2
Q
A child comes in with a limp.
Which structures do we need to think about?
A
Hip
Knee
Ankle/Foot
Neurological
3
Q
What hip related differentials could you have for a limp?
A
SUFE Perthes disease Septic arthritis of hip Transient synovitis Trauma Osteomyelitis DDH Juvenile idiopathic arthritis
4
Q
What knee related differentials could you have for a limp?
A
Septic arthritis Transient synovitis Trauma Osteomyelitis Juvenile idiopathic arthritis
5
Q
What neurological problems could be included in the differentials for a limp?
A
Cerebral palsy
Muscular dystrophy
6
Q
What else might cause a child to limp (other than medical/surgical differentials)?
A
Non-accidental injury
7
Q
What is DDH?
A
Developmental dysplasia of the hip is an abnormality of the neonatal hip joint, with a spectrum of severity
8
Q
How many newborns need treating for DDH?
A
1-2 in every 1000
Although it may affect 1 in every 100, but they don’t need treatment
9
Q
Which hip is DDH more common in?
A
The left hip
10
Q
How many cases of DDH are bilateral?
A
Around 20%
11
Q
What are the main risk factors that we use for screening for DDH?
A
Breech presentation
Family Hx of DDH
12
Q
What are the other potential risk factors for DDH (aside from breech presentation and FHx)?
A
- Oligohydramnios
- First-borns
- Female sex
- Race (Native Americans)
- Very high birth weight (over 5kg)
13
Q
What % of DDH cases are females?
A
80%
14
Q
When do we screen for DDH?
A
Initially in the NIPE
15
Q
How do we screen for DDH?
A
Using visual insepction and the Barlow test and Ortolani test
16
Q
What is the Barlow test?
A
Attempt to dislocate an articulated femoral head by:
1 - adducting and pushing posteriorly on the hip joint
2- Feel for a clunk that indicates dislocation
17
Q
What is the Ortolani test?
A
Attemp to relocate a dislocated femoral head by:
1 - Elevation and abduction of hip while flexed at 90 degrees.
2 - Feel for palpable clunk of relocation of femoral head
18
Q
If DDH is suspected, what should we do?
A
Refer them for USS for diagnosis
19
Q
How is DDH managed?
A
Most spontaneously stabilise by 3-6 weeks of life, so nothing until then.
Pavlik harness between 6 weeks and 4-5 months.
Older children may need surgical intervention.
20
Q
What position does a Pavlik harness hold a child’s hips in?
A
Flexion and abduction
21
Q
What sign might we see on visual inspection of a neonate with DDH?
A
Leg length discrepancy when knees are flexed by comparing knee height.
22
Q
What is the main complication of untreated DDH?
A
Early onset arthritis
23
Q
What is osteomyelitis?
A
An infection of the bone, usually caused by Staph. aureus.
24
Q
What are the risk factors for osteomyelitis?
A
- Diabetes
- Sickle cell anaemia
- IV drug use
- Immunosuppression
- Alcohol excess
25
How should we investigate osteomyelitis?
MRI scan
26
Which part of the bone is most commonly affected in children?
The metaphysis
27
A child presents to A&E with acute inset illness (possibly septic), and a very very painful left femur.
What is your top differential?
Osteomyelitis -> Sepsis
28
What will the affected area be like on examination of suspected osteomyelitis?
- Very painful, but with preserved range of movement
- If no movement, may have spread to joint capsule
-Pyrexia over painful area
29
How should suspected osteomyelitis be investigated?
- Blood cultures
- Bloods (FBC and CRP)
-X-rays are not useful initially as they show nothing, but >2 weeks later will show loss of density
30
How should osteomyelitis be managed?
- Sepsis protocol if sepsis suspected
- Rest
- IV abx for 4-6 weeks
- Surgical intervention if abscess present, and to remove pieces of dead bone.
31
What are some acute complications associated with osteomyelitis?
- Sepsis
- Acute pyogenic arthritis
- Septic arthritis
32
What are some chronic complications associated with osteomyelitis?
- Growth retardation
- Chronic osteomyelitis
- Increased risk of fractures
33
Which antibiotics are used for osteomyelitis?
- Flucloxacillin (with fusidic acid)
- Clindamycin (if pen-allergic)
- Vancomycin or teicoplanin if MRSA suspected
34
What organism should be suspected if a child with sickle cell anaemia gets osteomyelitis?
Salmonella species
35
What is rickets?
Decreased mineral content in growing bones
36
What is the most common cause of rickets?
Vitamin D deficiency
37
How do we become vitamin D deficient most commonly?
Lack of sunlight &/or insufficient dietary intake (usually a combination)
38
Aside from vitamin d deficiency due to intake, what other causes of riskets are there?
- Renal (leading to vit d def)
- Drug induced
- Genetic (Vit D resistant)
- Hypoparathyroidism
39
Which drugs are most commonly associated with rickets?
Anticonvulsants
40
A child comes to the GP with pain on walking and muscle aches all the time. His mother says he is unwell but can't put her finger on how exactly.
O/E you can feel bumps along his ribs.
What are these bumps and what do they make you suspect?
Rachitic rosary -> rickets.
41
How might rickets present in a toddler/baby?
Delayed walking/crawling/sitting.
42
A child comes to the GP with pain on walking and muscle aches all the time. His mother says he is unwell but can't put her finger on how exactly.
O/E you can feel bumps along his ribs.
What investigations should we do?
- Vitamin D
- ALP
- PTH
- Calcium
- Phosphate
- U&Es for renal function
X-ray
43
Which bones are mot commonly x-rayed in suspected rickets?
Radius and ulna
44
What changes might we see on an x-ray of a child with rickets?
- Ragged bone edges
- Increased apparent distance from bone ends to carpal bones
- Generalsied increased radiolucency of bone
45
How do we manage rickets first-line?
Adjusting diet and increasing sunlight exposure (safely).
Vitamin D supplements and calcium
46
How should vitamin D resistant rickets be managed?
Calciferol at a very high dose
47
How might a child with very extreme rickets look?
Knock-knee, bow legs.
48
What features might also be seen with extreme rickets?
Features of hypocalcaemia (tetany, numbness and tingling, confusion)
49
A child comes into A+E with a very painful left knee. She doesn't want to put her weight on it, and has a fever of 40 degrees.
What is the most pressing concern here?
That it may be septic arthritis.
50
What kinds of gait patterns might be observed in a child?
In-toeing and out-toeing, bow legs, knock knees, flat feet, limping, toe-walking
51
What does the gait of an up to 3 year old look like?
Wide-based stance with rapid cadence and short steps
52
When does a child develop an adult gait and posture?
Around age 8
53
Who is toe-walking common in?
Infants up to age 3.
54
What does an antalgic gait in a child look like?
Reduced weight-bearing on affected side, or unwillingness to weight-bear in a younger child.
55
Describe a circumduction gait.
Excessive hip abduction as the leg swings forward
56
When would a circumduction gait typically be seen?
In a child who has a leg legth discrepancy, joint stiffness, or unilateral spasticity e.g. with cerebral palsy
57
Describe a spastic gait.
Stiff, foot-dragging gait with foot inversion
58
Describe an ataxic gait.
Instability with alternating narrow-to-wide base
59
Describe a Trendelenberg gait.
While weightbearing on the ipsilateral side to hip abductor weakness/hip pain, the pelvis drops to the contralateral side rather than rising.
60
Describe a toe-walking gait.
Child walks on their toes.
61
When is toe walking seen?
In young children, but also children with cerebral palsy
62
When is a stepping gait observed in a child?
Weak ankle dorsiflexors e.g. in LMN neurological diseases and peripheral neuropathies
63
What kind of milestone development is always significant?
Milestone regression - indicates inflammatory conditions or neurodegenerative conditions
64
What metabolic conditions are associated with gait disturbance?
Osteomalacia, lysosomal storage disease
65
What specifics from the HPC of a limp do you want to know?
SQITARS, pain, limping, joint stiffness, tripping, falling, difficulty standing from sitting, how they usually sit, does it occur with fatigue, age of onset, possible unwitnessed trauma, activity level (overuse injuries), worse in morning or after rest (inflammatory)
66
What can a limp with joint pain relieved by NSAIDs indicate?
An inflammatory cause
67
What red flags with a limp should be checked for?
Systemic upset (chills, fever etc), anything suggesting non-accidental injury, marked limitation of activities.
68
What might preceed an irritable hip if reactive arthritis is suspected?
Recent foreign travel -> GI infection, sore throat/chest infection, or URTI infection symptoms. In an older child, sexual history may be relevant if -> infection -> reactive arthritis.
69
A child presents with a limp and a rash which is well dermarcated, erythematous, and has a silver scale. What is your top differential?
Psoriatic arthritis with psoriasis patch.
70
A child with a limp and hx of eye problems comes to see you. What might the limp be due to, and what is the underlying genetic link between this and the eye condition? Also what is the eye condition?
Arthritis associated with HLA-B27 gene, and acute uveitis.
71
What are most limps caused by?
Pain due to a minor injury that will resolve spontaneously after a short time.
72
What is the most common organism responsible for septic arthritis?
Staph. Aureus
73
What are the risk factors for septic arthritis in children?
Diabetes mellitus, prior joint damage, joint surgery, immunodeficiency
74
How does a septic arthritis joint present?
Single swollen joint with pain on active or passive movement
75
What can septic arthritis in children be confused with?
Transient synovitis, trauma.
76
Which age group of children is septic arthritis most common in?
Preschool infants and toddlers
77
Which joints are the 2 most commonly affected in children with septic arthritis?
Hip and knee - they make up a third each.
78
How do children classically present with septic arthritis?
Fever, joint pain, limp or unwilling to move/use affected joint
79
How is septic arthritis diagnosed?
Synovial fluid aspiration and culture alongside FBC with raised WBCs
80
How is septic arthritis managed?
Abx, and as needed; joint drainage, splinting.
81
What is Osgood-Schlatter disease?
A painful condition in which there is injury to the tibial tuberosity where it joins with the patellar tendon, commonly seen in adolescents
82
What pattern on symptoms is seen in Osgood-Schlatter disease?
Resolves with rest and exacerbated by activity
83
Why does Osgood-Schlatter disease occur?
Increased quadricpes muscle strength, repeated starin, and bone immaturity all contribute to damage to the tibial tuberostiy.
84
What might be seen on an X-ray of the knee of a pt with Osgood-Schlatter disease?
Thickening over tibial insertion of patellar tendon, or if sever, defoprmity and fragmentation of patellar tendon.
85
What differentials are there for a painful knee in a teenager?
Traumatic knee injury (ligament injury/rupture, meniscal tear), hip pathology referred to knee (Perthe's disease, SUFE)
86
How is Osgood-Schlatter managed?
Rest, simple analgesia, and icepacks to help symptoms. Avoid aggravating activities while there is still pain. Stretching and strengthening exercises of surroudning muscles with physiotherapist can prevent flare-ups.
87
What is the prognosis of Osgood-Schlatter?
Good - virtually all cases resolve after puberty.
88
What is transient synovitis, and where does it normally affect children?
Inflammation of the synovium of the hip.
89
Other than transient synovitis, what other causes are there of a painful hip in children?
Septic arthritis, viral arthritis (reactive arthritis), juvenile arthritis.
90
Is transient synovitis more common in boys or girls?
Boys, M:F 2:1
91
How does transient synovitis present?
Pain in joint, child reluctant to weightbear but able to walk with difficulty. Usually 1-2 weeks after URTI, but afebrile and systemically well. Often sit or lie with least pressure on the hip.
92
How will a hip with transient synovitis present on examination?
Reduced ROM esp. internal rotation, but can weightbear with encouragement.
93
What investigations can be done with suspected transient synovitis?
Bloods to rule out spetic arthritis, X-ray is usually normal.
94
How should transient synovitis be managed?
Make sure it isn't septic arthritis first!!!!! NSAIDs, wait for resolution which usually takes a week.
95
https://almostadoctor.co.uk/encyclopedia/slipped-capital-femoral-epiphysis-scfe-sufe
https://almostadoctor.co.uk/encyclopedia/talipes-equinovarus-club-foot
96
https://almostadoctor.co.uk/encyclopedia/osteomalacia-and-rickets
https://almostadoctor.co.uk/encyclopedia/osteochondroma
97
https://almostadoctor.co.uk/encyclopedia/osteosarcoma
https://patient.info/doctor/juvenile-idiopathic-arthritis-pro
98
https://patient.info/doctor/scoliosis-and-kyphosis
https://patient.info/doctor/reactive-arthritis-pro
99
https://patient.info/doctor/perthes-disease-pro
https://patient.info/doctor/neck-pain-cervicalgia-and-torticollis
