Paediatrics Orthopaedics Flashcards
(124 cards)
1
Q
Where are epipheseal growth plates?
A
Found in bones of children but not adults
Made from hyaline cartilage and divide the epiphysis and the metaphysis (epithysis and metaphysis fuse and growth plates become the epiphyseal lines)
2
Q
Label this:
A
3
Q
What types of bone are in children and adults respectively?
A
Children = more cancellous bone spongy, highly vascular in centre of bones (more flexible but less strong)
Adults = more cortical bone which is compact, hard bones around the outside
4
Q
What type of fractures are children more prone to?
A
Greenstick fractures - one side of bone breaks and other stays intact
5
Q
Why is bone healing in children better?
A
Good blood supply (less long term deformity than compared with adults)
6
Q
Childrens bones are less resistant to compression, what is the result?
A
Buckle fracture (or torus fracture)
7
Q
What is bone remodelling?
A
Process where bone tissue is taken from areas of low tension and deposited in areas of high tension (bone changes to optimum shape for function)
8
Q
Why is bone remodelling useful in children?
A
Even if set at incorrect angle - remodels over time to return to correct shape
9
Q
Label the following fractures:
A
10
Q
What classification system is used for growth plate fractures?
A
Salter-Harris classification
11
Q
What mnemonic is used for fractures through the growth plate?
A
SALTR mnemonic
Type 1: Straight across
Type 2: Above
Type 3: BeLow
Type 4: Through
Type 5: CRush
12
Q
Label the following salter harris fractures?
A
13
Q
What is the management of fractures in children?
A
Safeguarding is important
Firstly achieve mechanical alignment of the fracture:
- Closed reduction via manipulation of the joint
- Open reduction via surgery
Secondly provide relative stability to allow healing
14
Q
How can bones be fixed in position?
A
External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plates and screws
15
Q
What is the WHO pain ladder for children?
A
Step 1: paracetamol or ibuprofen
Step 2: morphine
16
Q
What pain relief is not used in children and why?
A
Codeine and tramadol (unpredicatability in their metabolism - effects vary too greatly)
17
Q
Why is aspirin contraindicated in children?
A
Risk of Reye’s syndrome(except in certain circumstances e.g.Kawasaki disease)
18
Q
How may a child present with hip pain?
A
Limp
Refusal to use affected leg
Refusal to weight bear
Inability to walk
Pain
Swollen or tender joint
19
Q
What are the differential diagnoses for hip pain in 0-4 year olds?
A
Septic arthritis
Developmental dysplasia of the hip (DDH)
Transient sinovitis
20
Q
What are the differential diagnoses of hip pain in 5-10 year olds?
A
Septic arthritis
Transient sinovitis
Perthes disease
21
Q
What are some differentials for hip pain in 10-16 year olds?
A
Septic arthritis
Slipped upper femoral epiphysis (SUFE)
Juvenile idiopathic arthritis
22
Q
What are some ref flags for hip pain?
A
Child under 3 years old
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen / red joint
23
Q
When is urgent referral for assessment in a limping child?
A
Child under 3 years
Older than 9 with a restricted or painful hip
Not able to weight bear
Evidence of neurovascular compromise
Severe pain / agitation
Suspicion of abuse
24
Q
What investiagtion for hip pain in children?
A
Blood tests including inflammatory markers (CRP and ESR) for JIA and septic arthritis
Xrays to diagnose fractures, SUFE and other boney pathology
Ultrasound to establish an effusion (fluid) in the joint
Joint aspiration to diagnose or exclude septic arthritis
MRI to diagnose osteomyelitis
25
What age is **septic arthritis** most common at?
**Children under 4 years** (mortality 10%)
26
Why is **septic arthritis** an emergency?
**Destroys the joint**
Causes **serious systemic illness**
27
What percent of **joint replacement surgery** does spetic arthritis occur in?
**1%** (higher in revision surgery)
28
How does **septic arthritis present**?
**Hot, red**, swollen, painful joint
**Refusing to weight bear**
**Stiffness** and reduced range of motion
Systemic symptoms = fever, lethargy and sepsis
29
What is the **most common bacteria** causing **septic arthritis?**
**Staphylococcus aureus**
Neisseria gonorrhoea (gonococcus)
Group A streptococcus (strep pyogenes)
Haemophilus influenza
Escherichia coli (E. Coli)
30
What are some **differential diagnoses** for **septic arthritis**?
Transient **sinovitis**
**Perthes** disease
**Slipped** upper femoral **epiphysis**
**Juvenile idiopathic arthritis**
31
What is the **management of septic arthritis**?
Low threshold for treating (caution with **immunosuppressed** patients)
Admission to hospital under **orthopaedic team**
**Aspirate joint** before abx (send for **gram staining, crystal microscopy, culture** and **antibiotic sensitivities**)
If **severe** then may require surgical **drainage** and **washout** of the joint
32
Which **antibiotics** are used in **septic arthritis**?
**Empirical IV antibiotics** given until **sensitivities** are known (usually continues for 3 to 6 weeks when septic arthritis is confirmed)
33
What is **transient synovitis**? When is it seen?
**Temporary** irritation and inflammation in the **synovial membrane** of the joint
**Most common cause of hip pain** in **children aged 3-10 years**
34
What is **transient synovitis** associated with?
**Viral upper respiratory tract infection**
35
How does **transient synovitis** present?
Acute / gradual onset:
- Limp
- Refusal to weight bear
- Groin or hip pain
- Mild low grade temperature
**Otherwise well**
36
What is the **management** of **transient synovitis**?
**Symptomatic** - simple analgesia
Must **exclude septic arthritis**
Aged 3-9 years: managed in **primary care** if limp **present for less than 48 hours** and otherwise well - give **clear safety net advice** to attend A&E immediately if **symptoms worsen** or develop **fever**
37
How long should patients with **transient synovitis** be followed up for?
**48 hours** and **1 week** to ensure symptoms are **improving** and then **fully resolve**
38
What is the **prognosis** of **transient synovitis**?
Significant improvement after **24-48 hours**
Symptoms **fully resolve** within **1-2 weeks** without any lasting problems (may **recur** in **20% of patients**)
39
What happens in **Perthes disease**?
Disruption of **blood flow** to the **femoral head** causing **avascular necrosis** of the bone
40
What is the **full name** of **Perthes disease**?
**Legg-Calvé-Perthes disease**
41
When does Perthes disease most commonly occur?
**Boys** aged between 5-8 years
42
What **causes** **Perthes disease**?
**Idiopathic** - no clear cause or trigger for the avascular necrosis (theorised that its due to **repeated mechanical stress** to the epiphysis)
43
How does **Perthes disease** progress?
**Revascularisation** or **neovascularisation** and healing of femoral head
44
What is the **main complication** of **Perthes disease**?
**Soft and deformed** femoral head, leading to **early hip osteoarthritis**
THR (5% of patients)
45
How does **Perthes** disease **present**?
Pain in hip / groin
Limp
Restricted hip movements
Referred pain to knee
If **triggered by minor trauma =** slipped upper femoral epiphysis
46
What is the **investigation** in **Perthes** disease?
**X-ray** (can be normal)
**Blood tests** (inflammatory markers used to exclude other causes)
**Technetium bone scan**
**MRI scan**
47
What is the **management** of **Perthes disease**?
Younger + less severe disease = conservative
Maintain **healthy position** and **alignment** to reduce risk of deformity to femoral head:
* Bed rest
* Traction
* Crutches
* Analgesia
**Physio** to retain range of movement
**Regular x-rays** to assess healing
**Surgery** in severe cases, older children or **those that are not healing**
48
What is a **slipped upper femoral epiphysis** (SUFE) also known as?
Slipped capital femoral epiphysis (SCFE)
49
What is a slipped upper femoral epiphysis?
**Head of femur** displaces along the **growth plate**
50
In which children is **SUFE** more common?
Boys aged 8-15
More common in **obese** children
51
How does **SUFE present**?
Adolescent, obese male undergoing a **growth spurt** may be a history of **minor trauma** that triggers the onset of symptoms
**SUFE** is **pain is disproportionate** to the trauma
* Hip, groin, thigh or knee pain
* Restricted ROM
* Limp
**Restricted internal rotation**
52
How to **diagnose** SUFE?
**X-ray**
Blood tests are normal **particularly inflammatory markers** (excluding other causes)
**Technetium bone scan**
**CT scan**
**MRI scan**
53
What is the **management** in **SUFE**?
**Surgery** to return the femoral head to correct position and **fix**
54
What is **osteomyelitis**?
Infection in the **bone** and **bone marrow** (typically in the **meetaphysis** of long bones)
55
What is the **most common bacteria** in **osteomyelitis**?
**Staphylococcus aureus**
56
What is the development of osteomyelitis?
May be **acute** / **chronic**
57
How may **infection reach the bones**?
**Open fracture**
Travelled **through blood** (entering through skin/gums)
58
Who is **osteomyelitis** most **common in**?
**Boys and children under 10**
59
What are the **risk factors** for **osteomyelitis**?
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
TB
60
What are the **symptoms** of osteomyelitis?
Refusing to weight bear
Pain
Swelling
Tenderness
Afebrile (**low grade fever -** if **high fever** then may have spread to become **septic arthritis**)
61
What are the **investigations** of **osteomyelitis**?
**X-ray** (can be normal)
**MRI** best imaging for **diagnosis**
**Bone scan** (alternative)
**Blood tests** show **raised inflammatory markers** (CRP and ESR) and raised **white blood cells** in response to infection
**Blood culture** for **causative organism**
**Bone marrow aspiration** / **bone biopsy** with histology and culture
62
What is the **management** of **osteomyelitis**?
**Extensive** and **prolonged** antibiotic therapy
**Surgery** = drainage and debridement of the infected bone
63
What is **osteosarcoma**?
Type of **bone cancer** (normally in 10-20 year olds)
64
What **bones** are **commonly affected** in osteosarcoma?
**Femur**
Tibia
Humerus
65
How does **osteosarcoma** present?
**Persistent bone pain** (particularly worse at night)
Bone **swelling**
Palpable **mass**
**Restricted** joint movements
66
How to **diagnose** **osteosarcoma**?
**X-ray** (urgent direct access xray within 48 hours - for unexplained bone pain / swelling)
**If possible sarcoma** urgent **specialist assessment** within **48 hours**
**Blood test** may show **raised ALP** (alkaline phosphatase)
67
What will an **x-ray** show for **osteosarcoma**?
**Poorly defined lesion** on the bone
"**Fluffy**" appearance
**Periosteal reaction** - irritation of the lining of the bone (**sun-burst** appearance)
68
What **further investigations** to **better define the lesion**?
**CT** scan
**MRI** scan
**Bone** scan
**PET** scan
**Bone biopsy**
69
What is the management of osteosarcoma?
**Surgical resection** of the lesion (often with **limb amputation**)
**Adjuvant chemo** to improve outcomes
70
Who is involved in the **MDT** for osteosarcoma?
**Paediatric oncologists** and surgeons
Specialist **nurses**
**Physio**
**OT**
**Psychology**
Dietician
**Prostetics** and **orthotics**
Social services
71
What are the **main complications** of **osteosarcoma**?
**Pathological bone fractures**
**Metastasis**
72
What is **talipes**?
**Fixed abnormal ankle position** which **presents at birth**
Also known as **clubfoot**
73
What is the position of **talipes equinovarus**?
Ankle in **plantar flexion** and **supination**
74
What is the **position** of **talipes calcaneovalgus**?
Ankle in **dorsiflexion** and **pronation**
75
What is **talipes** treated with?
**Ponseti method** (good results) - surgery if ponseti method fails
76
What is the **ponseti method**?
Foot is **manipulated** to a normal position and a cast applied - repeated **over and over** until the foot is in the correct position (started from birth)
**Achilles tenotomy** is required to release tension in the tendon
After **treatment with cast finished** then **brace is used** to hold feet in position when not walking until **child is around 4 years old**
77
What is **positional talipes**?
Resting position of the ankle is in **plantar flexion** and **supination** - not fixed and **no structural boney issue**
**Muscles are tight** - requires **referral to physio** (resolves with time)
78
What is **developmental dysplasia of the hip**?
Condition where there is **structural abnormality** in the hip caused by **abnormal development of the fetal bones**
79
What is the **result** of **developmental dysplasia of the hip**?
Instability - **subluxation** or **dislocation**
Can persist into adulthood = recurrent dislocation, abnormal gait, early degenerative changes
80
When is **developmental dysplasia** **of the hip** (DDH) found?
**Newborn examination** or later with **hip asymmetry**, reduced **ROM in hips** / limp
81
What are some **risk factors** for **developmental dysplasia** of the hip?
- First degree **FH**
- **Breech** presentation from **36 weeks onwards**
- **Breech** presentation at birth if 28 weeks onwards
- **Multiple pregnancy**
82
When is **DDH screened for**?
**Neonatal examination** at birth and 6-8 weeks old
83
What **findings** may be suggestive of **DDH**?
**Different** leg **lengths**
**Restricted** hip **abduction** (on one side)
**Bilateral restriction** in abduction
Difference in **knee level** when **hips are flexed**
**Clunking** of hips on **special tests**
84
What two **special tests** are used for **DDH**?
**Ortolani test** = baby on back, hip and knees flexed. Palms on baby's knees with thumbs on inner thigh and four fingers on **outer** thigh. Gently abduct hip apply pressurebehind leg and see if hip **dislocates anteriorly**
**Barlow test** = baby on back, hip adducted, knee and hip flexed, downward pressure to see if hip **dislocated posteriorly**
85
What is the **examination finding on the 'special tests'** what is the next step?
**Clicking** due to **soft tissue moving over bone** (if isolated then doesn't require further tests)
**Clunking** indicated **DDH** and requires an **ultrasound**
86
How is the **diagnosis** of **DDH** made?
**Ultrasound** of the hip to establish diagnosis
**X-rays** are also helpful, particularly in older infants
87
What is the **management** of **DDH**?
**Pavlik harness** (if presenting less than 6 months of age)
**Holds femoral head** in correct position to allow **acetabulum** to develop a normal shape - keeps hip **flexed and abducted** (can be removed when more stability usually after 6-8 weeks)
**Surgery** if harness fails or **diagnosis** made **after 6 months** - after surgery **hip spica cast** is used to **immobilise** the hip
88
What is **rickets**?
Condition in **older children** with **defective bone mineralisation** causing "soft" and deformed bones - leads to **osteomalacia**
89
What are some **causes of Rickets**?
**Vit D** / **calcium deficiency**
Genetic defect resulting in **low phosphate** (**hereditary hypophosphataemic rickets**)
90
Where do vitamin D and calcium come from?
**Vitamin D** = produced in **body** in response to sunlight / from food (eggs, oily fish, nutritional supplements)
**Calcium** = dairy products and green vegetables
91
What is the **mode of inheritance** of **hereditary hypophosphataemic rickets**?
**X-linked dominant** (has other forms of inheritance)
92
What is **vitamin D**?
A **hormones** (not technically a vitamin) created from **cholesterol** by the skin in response to **UV radiation**
93
Who are **more likely to have vitamin D deficiency**?
**Darker** skin (require more vit D)
**Malabsorption disorders** (e.g. **inflammatory bowel disease**)
**Chronic kidney disease** (kidneys are essential in metabolising vitamin D to active form)
94
What can **low vitamin D** result in?
**Low calcium and phosphate** (as vit D is needed to absorb from intestines and kidneys)
**Low calcium** causes **secondary hyperparathyroidism** - stimulates **increased reabsorption** of calcium from bones (causing **further problems with bone mineralisation**)
95
What are some **potential symptoms** of **vitamin D deficiency**?
**Lethary**
Bone **pain**
**Swollen wrists**
Bone **deformity**
**Poor growth**
**Dental** problems
**Muscle weakness**
Pathological / abnormal fractures
96
What **bone deformities** can occur in rickets?
**Bowing of the legs**
**Knock knees** (knees bow inwards)
**Rachitic rosary** (ends of ribs **expand** at the **costochondral junctions** causing **lumps along chest**)
**Craniotabes** (soft skull with **delayed closure of the sutures** and **frontal bossing**)
**Delayed teeth** with under-development of the enamel
97
What is the diagnostic **lab investigation** for **vit D deficiency**?
**Serum 25-hydroxyvitamin D** (result of less than 25 nmol/L)
98
What **imaging** is used to **diagnose rickets**?
**X-ray** (may show **osteopenia** - more **radiolucent** bones)
99
What may **other investigations** reveal in **vitamin D deficiency**?
**Serum calcium** is low
**Serum phosphate** is low
**Serum alkaline phosphatase** may be high
**Parathyroid hormone** may be high
100
What **other pathology** may explain symptoms of vit D deficiency?
**Full blood count** and **ferritin**, for iron deficiency anaemia
**ESR** and **CRP** for inflammatory conditions
**Kidney function tests**, for kidney disease
**Liver function tests**, for liver pathology
**Thyroid function tests**, for hypothyroidism
**a****nti-TTG antibodies**, for coeliac disease
**Autoimmune and rheumatoid tests**, for inflammatory autoimmune conditions
101
What is the **management** of **r****ickets**?
**Preventio****n**:
* **Breastfed babies** are more at risk of vit D deficiency (formula is fortified with vit D) mothers **take vit D supplement** (10 micrograms per day)
* **Children** with deficiency take **ergocalciferol** (vitamin D)
**Rickets**:
* Referral to **paediatrician**
* Vit D and calcium supplements
102
What is **achondroplasia**?
Most common cause of **disproportionate short stature** (dwarfism) - type of **skeletal dysplasia**
103
Where is the **achondroplasia** gene?
The **fibroblast growth factor receptor 3** (FGFR3) is on **chromosome 4**
104
What is the **genetic cause** of achondroplasia?
**Sporadic mutation** or inheritance of **abnormal copy** of gene (inherited in an **autosomal dominant** pattern)
**Homozygous gene mutation** is fatal in neonatal period
105
What is a **result** of **mutation** in the **FGFR3** gene?
Abnormal **function** of the **epiphyseal plates** (growth plates) restricting bone growth in length
106
What is the **average height** in **achondroplasia**?
Which bones are most affected?
4 feet
**Femur and humerus** (proximal limbs) are affected more than bones of forearm and lower leg
Spine length = less affected
107
Are intelligence or life expectancy affected by achondroplasia?
**No**
108
What are some **other features** of achondroplasia?
**Short digits**
**Bow legs** (genu varum)
**Disproportionate** skull
**Foramen magnum stenosis**
109
Why is there a **disproportionate skull** in **achondroplasia**?
Skull base = **endochondrial ossification** (affected = **flattened midface, nasal bridge** and **foramen magnum stenosis**)
Cranial vault = **membranous ossification** (unaffected = nomal sized vault and **frontal bossing** - prominent forehead)
110
Which conditions are **associated** with **achondroplasia**?
Recurrent **otitis media** dueo to cranial abnormalities
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Foramen magnum stenosis = **cervical cord compression** and **hydrocephalus**
111
Who is in the **MDT** for **achondroplasia**?
Pediatricians
Specialist nurses
Physios
OTs
Dieticians
Ortho surgeons
ENT surgeons
Geneticists
112
What **surgery** can be used to increase height in **achondroplasia**?
**Leg lengthening surgery** - cutting bone (osteotomy) and separating two parts = **gap between them** (distraction) and bone forms between creating a longre bone = **controversial** - leads to **significant problems** including **chronic pain** and **reduced function**
113
What is **Osgood-Schlatters disease** caused by?
**Inflammation** at the **tibial tuberosity** where the **patella ligament inserts** (common cause of anterior knee pain in adolescents)
Occurs in patients aged 10-15 years
Usually **unilateral** (can be bilateral)
114
How does **Osgood-Schlatters** disease occur?
**Patella tendon** inserts into **tibial tuberosity** (at the **epiphyseal plate**)
Stress from running / movements causes **inflammation** on the **tibial epiphyseal plate** causing **small avulsion fractures** where **patella ligament** pulls away **tiny pieces of the bone** leading to **growth of the tibial tuberosity** causing a visible lump below the knee - initially is **tender** but as bone heals it becomes **hard and non tender**
115
How does **osgood-schlatter disease** present?
**Gradual onset**:
- Visible lump at tibial tuberosity
- **Pain** in the **anterior** aspect of the knee
- Pain **exacerbated by physical activity**
116
What is the **management** of **Osgood-Schlatters** disease?
- **Reduce** physical acitivity
- **ICE**
- **NSAIDs** (ibuprofen) for symptomatic relief
Stretching and physio to strengthen the joint and improve function
117
What is the **prognosis** of **Osgood-Schlatters disease**?
Symptoms fully resolve over time (left with boney lumop)
118
What is a **rare complication** of **Osgood-Schlatters disease**?
**Avulsion fracture** (tibial tuberosity is separated from rest of the tibia) - usually required **surgical intervention**
119
What is **osteogenesis imperfecta**?
**Genetic condition** which results in **brittle bones** which are **prone to fractures** (also known as brittle bone syndrome)
120
What is **osteogenesis imperfecta** caused by?
Range of genetic mutations which **affect** the **formation of collagen** (essential in maintaining the **structure and function** of bone - and skin, tendons and other connective tissues)
**8 different types** (vary in severity)
121
How does **osteogenesis imperfecta** present?
**Hypermobility**
**Blue / grey sclera** (the "whites" of the eyes)
**Triangular** face
**Short stature**
**Deafness** from early adulthood
**Dental problems** (particularly with formation of teeth)
**Bone deformities** e.g. **bowed legs** and **scoliosis**
Joint and bone pain
122
How is **osteogenesis imperfecta** diagnosed?
**Clinical diagnosis**
X-ray = diagnose fractures and bone deformites
**Genetic testing** is possible but not always routine
123
What is the **medical treatment** of **osteogenesis imperfecta**?
**Bisphosphates** to increase bone density
**Vit D supplementation** to prevent deficiency
124
Who is involved in the **management** of **osteogenesis imperfecta**?
**Physio** and **OT** to maximise strength and function
**Paediatricians** for medical treatment and follow up
**Ortho surgeons** to manage fractures
**Specialist nurses** for advice and support
**Social workers** for social and financial support
