Paeds Ortho

Question 1

What are the specific differentials for limp in a toddlers 0-4?

Answer 1

Toddlers fracture (most specific to age)
- 9months to 3 years
- Fibula intact

Transient hip synovitis
- May have preceding viral illness
- Painful but still able to mobilise

Acute Myositis
- Can be benign (BACM)
- Associated with viral illness
- Can be associated with rhabdomyolysis

Developmental dysplasia of the hip

Question 2

What are the specific differentials for limp in a toddlers 5-10?

Answer 2

Perthes disease (most specific to age)
- idiopathic avascular necrosis prox femoral epiphysis
- Male 5:1, usually 3-11yrs
- Pain on aBduction and internal rotation

Transient hip synovitis

Acute Myositis

Developmental dysplasia of the hip

Question 3

What are the specific differentials for limp in a toddlers >10?

Answer 3

SUFE (most specific to age)
- Pain on internal/external rotation
- Obligatory external rotation when the hip is flexed
- obesity, adolescence

Osgood Schlatter
- traction apophysitis of the proximal tibia
- Most common knee pain 10-15yrs
- Tender tibial tubercle
- Physical activity/growth spurts

Sever’s Disease
- Calcaneal apophysitis
- Common in active growing adolescents

Stress fractures and sprains

Question 4

What are the general differentials for limp in all age groups?

Answer 4

Septic arthritis
- Often severe pain on any movement, rapid onset
- Non weight bearing
- ESR >40, CRP >20, Leukocytosis >12
- Fever >38.5

Trauma with a lower body fracture
NAI
Osteomyelitis
Discitis/epidural abscess
Malignancy
Haem (sickle cell, haemophilia)
Abdominal (ovarian or testicular torsion, appendicits)
Functional limp
Auto immune (HSP, post infectious arthritis, juvenile RA etc)

Question 5

How are supracondylar fractures graded?

Answer 5

Gartland Classification
Type I- Undisplaced fracture of distal humerus
- Above elbow backslab and fracture clinic as outpatient

Type II- Displaced but posterior cortex intact
- Orthopaedics referral, gentle reduction and above elbow back slab, early follow up vs surgery

Type III- Distal fragment displaced posteriorly with no cortical contact
- Always needs urgent surgery +/- ED reduction

Question 6

What are the potential complications of a supracondylar fracture? What are the indications for open surgery?

Answer 6

Complications
- Brachial artery injury
- Compartment syndrome leading to Volkmanns contracture
- Radial nerve injury
- Ulnar nerve injury
- Median nerve (especially anterior interosseous branch) injury is most common

Indications for open surgery
- Open dislocation
- Significant joint instability
- Failure of closed reduction
- Incarcerated avulsed fracture

Question 7

What are the ways of testing the nerves quickly in a supraconydlar injury?

Answer 7

Question 8

What are the ref flags for a child with a limp?

Answer 8

Question 9

What are Kochers criteria for the clinical diagnosis of septic arthritis?

Answer 9

Question 10

What are the potential complications of Slipped Upper femoral Epiphysis? What is the treatment?

Answer 10

• Needs urgent Ortho referral for inpatient management

Question 11

What is a Tillaux fracture and what is its treatment?

Answer 11

• A Salter-Harris type 3 fracture through the anterolateral aspect of the distal tibial epiphysis
• Occurs in older children and adolescents before the growth plate is fully fused
• Caused by Abduction-external rotation mechanism
• Often requires operative intervention depending on degree of displacement, may need a CT scan

Question 12

What is the history and treatment for a pulled elbow?

Answer 12

Hx
- Age usually 1-4
- 50% have no pull, often very minor trauma
- Otherwise well and no deformity