Paediatric Orthopaedics

Question 1

Characteristics of Paediatrics bone

Answer 1

1. More water content:
   > Flexible and resilient to stress
   > Bends > breaks
2. Thicker periosteum

Question 2

M/C # in children

Answer 2

Green stick
Forearm: Radius > Ulna

Question 3

M/C # at birth

Answer 3

Clavicle

Question 4

M/C # in child following fall on outstretched hand

Answer 4

Supracondylar humerus #

Question 5

When force beyond physiological limits is given on bone, then

Answer 5

Outer cortex breaks: Greenstick/unicortical #

Question 6

What is Osteochondrosis?

Answer 6

Self-limiting abnormality of bone growth

Question 7

General features of Osteochondrosis

Answer 7

1. Involves ossification centres in epiphysis
2. Begins in childhood as necrotic condition
3. D/t primary vascular event or repetitive trauma
4. M/C cause: Idiopathic

Question 8

What is Perthe’s disease?

Answer 8

AKA Coxa plana/Legg-Calve-Perthes disease
Idiopathic, spontaneous osteonecrosis

Question 9

Site of Perthe’s disease

Answer 9

Femoral epiphysis

Question 10

C/F of Perthe’s disease

Answer 10

1. Pain at the hip
2. Limping gait after activity

Question 11

Management of Perthe’s disease

Answer 11

Rest (Vascularity recovers -> Symptoms improve)

Question 12

What is Sprengel’s deformity?

Answer 12

Congenital undescended hypoplastic scapula
Limits shoulder mobility
Association: Klippel Feil syndrome (M/C)

Question 13

What is Klippel Feil syndrome?

Answer 13

Segmentation defect of cervical spine:
1. Short webbed neck
2. Low set hairline
3. Restriction of neck movement

Question 14

Associations of Klippel Feil syndrome

Answer 14

1. Scoliosis (M/C)
2. Sprengel shoulder
3. Genito-urinary anomalies
4. Ocular/auditory/cardiac defects

Question 15

What is Slipped capital femoral epiphysis?

Answer 15

AKA sub-capital neck of femur #
Splint # at growth plate of capital femoral epiphysis
Type 1 Salter Harris
Femur:
1. Head: Within acetabulum
2. Neck: Slips

Question 16

Causes of SCFE

Answer 16

1. Idiopathic
2. A/w endocrinopathies: Hypothyroidism (M/C), hypogonadism, Inc in growth hormone

Question 17

C/F of SCFE

Answer 17

1. Usual age:
   > Males: 13-17 years
   > Females: 11-14 years
2. Associated hypogonadism, high pitched voice and gynaecomastia in males
3. Coxa vara
4. Externally rotated toe

Question 18

Coxa vara in SCFE

Answer 18

1. Gradual/sudden pain at hip
2. Restricted abduction and internal rotation
3. Axis deviation: Knee points to I/L shoulder on hip flexion (Normally towards C/L shoulder)
4. Trendelenburg gait

Question 19

Investigation of SCFE

Answer 19

IOC: MRI
X ray: Trethowan’s sign

Question 20

What is Trethowan’s sign?

Answer 20

Line drawn on lateral aspect of neck of femur (Klein’s line) does not intersect with head of femur

Question 21

What is Developmental Dysplasia of Hip (DDH)?

Answer 21

Idiopathic spontaneous subluxation of femoral head

Question 22

Epidemiology of DDH

Answer 22

1. Usually seen in 1st born female child with fetal malpresentation (M/C breech: Frank breech with extended knees)
2. Strong family history
3. 1:1000 live births

Question 23

Pathology of DDH

Answer 23

Developmental anomaly of acetabulum -> Lack of concavity -> Femoral head slips out

Question 24

C/F of DDH

Answer 24

1. Short limb: Asymmetrical thigh and gluteal folds
2. Vascular sign of Narath: Femoral pulsations -ve

Question 25

What is Vascular sign of Narath?

Answer 25

Femoral pulsations -ve (Displaced femoral head -> Palpation not possible)

Question 26

Clinical diagnosis of DDH

Answer 26

1. <3 months old child: > Barlow’s test > Ortolani’s test 2. >3 months old child: > Allis/Galeazzi sign > Trendelenburg gait/Waddling gait

Question 27

What is Allis/Galeazzi sign?

Question 28

What is Allis/Galeazzi sign?

Answer 28

One knee higher than other on knee flexion

Question 29

Investigations of DDH

Answer 29

Screening IOC: USG Confirmation test: X ray (MRI: Additional investigation)

Question 30

What is Hilgenreiner’s line?

Answer 30

Line passing through centers of both triradiate cartilage (Horizontal line)

Question 31

What is Perkin’s line?

Answer 31

Line perpendicular to Hilgenreiner’s line Passes through lat edge of acetabulum Head of femur: Upper, outer quadrant

Question 32

Treatment of DDH in 0-6 months of age

Answer 32

Pavlik harness Von Rosen splint

Question 33

Treatment of DDH in 6-18 months of age

Answer 33

Reduction: Open/closed Smith Peterson approach

Question 34

Treatment of DDH in 18-36 months of age

Answer 34

Femoral osteotomy

Question 35

Treatment of DDH in >3 years of age

Answer 35

VDRO + Pelvic osteotomy (Salter,Pemberton)

Question 36

Treatment of DDH in >10 years of age

Answer 36

Total hip replacement after skeletal maturity

Question 37

M/C cause of B/L genu varum (Bow legs)

Answer 37

Children: Rickets > Idiopathic Adults: Osteoarthritis > RA

Question 38

M/C of B/L genu valgus

Answer 38

Children: Idiopathic > Rickets Adults: RA>Osteoarthritis

Question 39

M/C cause of Wind swept deformity

Answer 39

Children: Rickets Adults: RA

Question 40

Causes of CTEV

Answer 40

1. Idiopathic (M/C) 2. Spina bifida 3. Arthrogryposis multiplex congenita

Question 41

Pathology of CTEV

Answer 41

Cavus: Exaggeration of medial longitudinal arch Adduction: At talonavicular/mid tarsal joint Varus: At talocalcaneal/subtalar joint Equinus: At ankle joint Internal rotation of tibia

Question 42

Investigations of CTEV

Answer 42

X ray: Kite’s angle (Talocalcaneal angle) 1. Normal: 20 - 40 deg 2. Clubfoot Screening: Dorsiflexion test: Dorsiflexion -> Tip of toe touches shin

Question 43

Treatment of CTEV

Answer 43

Started within 2 weeks Manipulation of foot (To correct deformity) f/b POP cast: Done serially for 8-9 weeks

Question 44

What is Ponseti method?

Answer 44

Fulcrum of correction: Talar head Order of manipulation: CAVE Cavus -> Adduction and Varus -> Equinus Method: Apply POP cast (Above knee) -> After >=1 week, remove -> Manipulate

Question 45

Maintenance of CTEV

Answer 45

Before child starts walking (<1 year): Dennis Brown splint Once child starts walking (>1 year): 1. Day: CTEV shoe 2. Night: Dennis Brown splint

Question 46

What is Triple arthrodesis?

Answer 46

Presentation of >10 years Joint fusion surgery Most imp: Talonavicular joint

Question 47

What is Joshi’s external stabilization system used for?

Answer 47

For CTEV resistant to treatment

Question 48

M/C cause of disproportionate dwarfism

Answer 48

Achondroplasia

Question 49

Cause of Achondroplasia

Answer 49

FGFR3 gene mutation on Chr. 4 (Autosomal dominant > Sporadic)

Question 50

Pathology of CTEV

Answer 50

Endochondral ossification defect Intramembranous ossification: Normal

Question 51

C/F of CTEV

Answer 51

1. Proximal limb shortening (Rhizomelic shortening) 2. Trunk is usually normal 3. Pts have normal IQ and sexual development 4. Brachydactyly 5. Frontal bossing of skull 6. Starfish hand 7. Trident hand 8. Bullet nose vertebrae 9. Champagne glass pelvis 10. Saddle nose

Question 52

What is Brachydactyly?

Answer 52

Short, stubby fingers

Question 53

What is Starfish hand?

Answer 53

All fingers are of same length

Question 54

What is Trident hand?

Answer 54

Exaggerated gap b/w middle and ring finger

Question 55

Limping child D/D Just study

Answer 55

1. Septic arthritis: High grade fever, swelling at hip 2. Transient synovitis: Low grade fever, slightly inc in ESR, CRP 3. Perthe’s disease: No fever; no inc in ESR or CRP