Pediatric orthopedic conditions

Question 1

What are the risk factors for developmental dysplasia of the hip (DDH) during the perinatal period?

Answer 1

DDH risk factors include congenital issues, poor positioning after birth, higher incidence in females, breech births, family history of DDH, oligohydramnios, being the firstborn, having a moulded baby (e.g., twins), high birth weight (>4kg), and multiple pregnancies.
Tight lower extremity swaddling

Question 2

What are the clinical signs and symptoms of DDH in infants?

Answer 2

Signs of DDH include asymmetrical hip creases, uneven thigh or gluteal folds, limited hip movement (reduced abduction), apparent leg length differences, and positive findings on Barlow’s and Ortolani’s tests.

Question 3

How does untreated DDH impact a child’s mobility and gait?

Answer 3

Untreated DDH can lead to severe arthritis due to reduced contact area in the hip joint, severely affecting a child’s gait and overall mobility.

Question 4

What methods are used to diagnose DDH in routine infant screenings?

Answer 4

Diagnosis methods involve neonatal baby checks, selective ultrasound screenings for specific risk factors, general practitioner (GP) checks at 6-8 weeks, and late presentations usually when the child starts to walk (12-18 months).

Question 5

What are the potential outcomes of untreated developmental dysplasia of the hip?

Answer 5

If untreated, DDH can result in a shallow acetabulum, formation of a false acetabulum in severe cases, leading to a shortened lower limb, increased risk of severe arthritis at a young age, and significant impairment in gait and mobility.

Question 6

What imaging modalities are used in the diagnosis of developmental dysplasia of the hip (DDH), and why is each preferred or limited at certain ages?

Answer 6

Ultrasound (USS) is preferred, particularly in early infancy, but becomes less helpful after three months as ossification begins. X-rays are the preferred choice after ossification starts at around 4-6 months of age.

Question 7

What are the primary management approaches for early and late developmental dysplasia of the hip (DDH)?

Answer 7

Early DDH is commonly managed with a Pavlik harness, used for up to 12 weeks until USS shows normal hip positioning, with a 95% success rate. Late DDH often requires surgical interventions such as closed reduction (CR) or open reduction (OR) spica. OR becomes more likely for persistent dislocation in children over 18 months, often needing corrective procedures on the femur or acetabulum.

Question 8

How is DDH managed in its early stages, and what is the primary device used for treatment?

Answer 8

Early DDH is managed primarily using a Pavlik harness, worn for a specific duration with the hip abducted and flexed. Night splints might follow the harness treatment for a few weeks.

Question 9

What surgical interventions are considered for late-stage DDH, and under what circumstances are these procedures typically required?

Answer 9

Late-stage DDH may necessitate closed reduction (CR) spica or open reduction (OR) spica surgery. OR is more probable for children over 18 months with persistent dislocation, often requiring corrective procedures on the femur or acetabulum due to shallow acetabulum development.

Question 10

What are the prognostic outcomes for persistent or undiagnosed DDH in later stages, and what percentage of cases might necessitate further surgery?

Answer 10

Persistent or undiagnosed DDH in later stages often results in a poorer prognosis, making it challenging to reconstruct a normal hip. Approximately 30% of such cases might need further surgical intervention.

Question 11

What defines Developmental Dysplasia of the Hip (DDH) and what potential complications can arise in adulthood due to this condition?

Answer 11

DDH is a condition resulting from a structural abnormality in the hip due to irregular fetal bone development, potentially leading to instability, subluxation, or dislocation. If untreated, it may persist into adulthood, causing weakness, recurrent subluxation or dislocation, abnormal gait, and early degenerative changes.

Question 12

How is DDH usually detected, and at what stages can it become apparent in a child’s life?

Answer 12

DDH might be detected during newborn examinations or later when a child presents with hip asymmetry, limited hip movement, or a limp.

Question 13

What are the risk factors associated with DDH as mentioned in the notes?

Answer 13

Risk factors for DDH include a first-degree family history, breech presentation from 36 weeks onwards, breech presentation at birth from 28 weeks onwards, and multiple pregnancies.

Question 14

What elements are examined during DDH screenings, and what findings might indicate the possibility of DDH?

Answer 14

During DDH screenings, symmetry in hips, leg length, skin folds, and hip movements are examined. Findings indicating DDH include different leg lengths, restricted hip abduction, bilateral restriction in abduction, and variations in knee level when hips are flexed.

Question 15

What are the specific tests used to check for DDH, and how are they performed?

Answer 15

The two tests used for DDH are the Ortolani test, checking for anterior hip dislocation, and the Barlow test, assessing posterior femoral head dislocation.

Question 16

What distinguishes “clicking” from “clunking” during a physical examination in the context of DDH, and what further steps might be necessary based on these findings?

Answer 16

“Clicking” during an examination is generally due to soft tissue moving over bone, while “clunking” is more indicative of DDH and requires an ultrasound for confirmation.

Question 17

What diagnostic methods are employed to confirm DDH in suspected cases, and when is each method particularly useful?

Answer 17

Ultrasound is the preferred method for diagnosing DDH in suspected cases, particularly in children with risk factors or suggestive examination findings. X-rays can be useful, especially in older infants.

Question 18

What constitutes the primary treatment approach for DDH in infants below six months, and how does it function?

Answer 18

The primary treatment for infants under six months involves a Pavlik harness, which aims to maintain the femoral head in the correct position for normal acetabular development.

Question 19

When is surgery considered in the management of DDH, and what is the subsequent post-surgery immobilization method utilized?

Answer 19

Surgery becomes necessary when the Pavlik harness fails or when the diagnosis is made after six months, with subsequent post-surgery immobilization using a hip spica cast for an extended period.

Question 20

What are the typical ages and gender predilection for idiopathic osteochondritis of the femoral head?

Answer 20

Idiopathic osteochondritis typically occurs between the ages of 4 to 9 and is more common in boys, particularly very active boys of short stature (around 5:1 ratio).

Question 21

What happens during the pathophysiology of idiopathic osteochondritis, leading to potential outcomes?

Answer 21

This condition occurs due to a transient loss of blood supply to the femoral head, resulting in necrosis and subsequent abnormal growth. It may lead to femoral head fracture and collapse, with remodelling that depends on age of onset and the amount of collapse. An incongruent joint might lead to early-onset arthritis and may necessitate hip replacement in severe cases.

Question 22

What clinical symptoms characterize children affected by idiopathic osteochondritis of the femoral head?

Answer 22

Affected children present with pain and a limp, mostly unilateral. Bilateral cases may indicate an underlying skeletal dysplasia or thrombophilia.

Question 23

What signs are observed during a clinical examination of children with this condition?

Answer 23

Clinical signs include initial loss of internal rotation, followed by loss of abduction, and a positive Trendellenburg test due to gluteal weakness.

Question 24

What imaging modalities are used for diagnosing idiopathic osteochondritis of the femoral head, and what is their efficacy?

Answer 24

Imaging, primarily X-rays, may sometimes appear normal. MRI or bone scans can be used to identify pathology more clearly.

Question 25

What are the general management approaches for this condition, and what proportion of cases tend to show positive outcomes?

Answer 25

There is no specific treatment except for regular X-ray observation and avoiding physical activity. Around 50% of cases have positive outcomes, but in severe instances, the femoral head might become aspherical, leading to muscular weakness. In rare cases, femoral head subluxation may require osteotomy of the femur or acetabulum.

Question 26

What potential complications might arise in severe cases of idiopathic osteochondritis, and what interventions could be required?

Answer 26

Severe cases might lead to femoral head deformation, resulting in muscular weakness (positive Trendellenburg), or even femoral head subluxation necessitating surgical intervention like osteotomy of the femur or acetabulum.

Question 27

What characterizes Perthes disease in terms of its effect on the femoral head and the primary age group affected by this condition?

Answer 27

Perthes disease involves disruption of blood flow to the femoral head, causing avascular necrosis and mainly affects children aged 4 to 12 years, more commonly between 5 and 8 years, and is more prevalent in boys.

Question 28

Describe the pathophysiology of Perthes disease, specifically the process of avascular necrosis and subsequent healing.

Answer 28

The disease involves avascular necrosis of the femoral head’s epiphysis, leading to subsequent revascularization and healing, with potential remodelling of the bone. Complications often include a deformed femoral head, potentially causing early hip osteoarthritis and necessitating total hip replacement in around 5% of patients.

Question 29

What are the key clinical presentations associated with Perthes disease? How is it differentiated from other similar conditions?

Answer 29

Presentations typically include a slow onset of hip or groin pain, limping, restricted hip movements, and possible referred knee pain. Notably, there is no history of trauma associated with the condition, distinguishing it from other conditions like slipped upper femoral epiphysis.

Question 30

What are the primary investigations used to diagnose Perthes disease, and why are these particular tests chosen?

Answer 30

Initial investigations include X-rays, which might be normal, along with blood tests (often with normal inflammatory markers), technetium bone scans, and MRI scans, which can help confirm the diagnosis.

Question 31

How is Perthes disease managed initially, especially in younger patients with less severe conditions?

Answer 31

Initial management involves conservative approaches such as bed rest, traction, crutches, and analgesia, particularly for younger patients with less severe disease. The goal is to maintain a healthy position and alignment in the joint to minimize damage or deformity to the femoral head.

Question 32

What is the role of physiotherapy in managing Perthes disease?

Answer 32

Physiotherapy is employed to preserve muscle and joint movement without adding excessive stress to the bone.

Question 33

When is surgery considered in the management of Perthes disease, and what is its aim in treatment?

Answer 33

Surgery might be considered in severe or non-healing cases, especially in older children, aiming to improve the alignment and function of the femoral head and hip.

Question 34

What demographic is primarily affected by Slipped Upper Femoral Epiphysis (SUFE), in terms of age, gender, and predisposing factors?

Answer 34

Slipped Upper Femoral Epiphysis (SUFE) primarily affects overweight pre-pubertal adolescent boys aged between 8-18 years, with a higher incidence in males (80% of cases). Racial disparities are observed, notably in Afro-Caribbean and Hispanic populations. Endocrine or metabolic conditions like hypothyroidism or renal disease may predispose individuals to SUFE.

Question 35

What is the primary pathophysiological reason for the occurrence of SUFE, particularly in overweight pre-pubertal adolescent boys?

Answer 35

The femoral epiphysis slips inferiorly concerning the femoral neck due to the weight strain; the growth plate (physis) is insufficient to support body weight, primarily during the pubertal growth spurt.

Question 36

What are the varied clinical presentations of SUFE in terms of onset and potential symptoms experienced by affected individuals?

Answer 36

Cases of SUFE can be acute, chronic, or acute-on-chronic in nature.

Question 37

What specific symptoms and signs are often observed in patients with SUFE?

Answer 37

Symptoms might include hip, groin, thigh, or knee pain with a limp, occasionally presenting purely as knee pain due to the obturator nerve’s joint supply. Signs may involve an antalgic gait and loss of internal rotation of the hip. Approximately one-third of cases are bilateral.

Question 38

What imaging technique is essential for diagnosing SUFE, and why is a particular view crucial in detecting milder instances?

Answer 38

X-rays are crucial for diagnosis, particularly obtaining a lateral view to detect even mild slips of the femoral head.

Question 39

What is the urgent management approach for SUFE, especially concerning surgical interventions?

Answer 39

Urgent surgical intervention is essential to prevent further slippage, usually involving pinning of the femoral head. However, in severe acute cases, gentle manipulation may be attempted, although this carries the risk of avascular necrosis.

Question 40

What factors influence the prognosis of SUFE, and what might severe cases require in terms of long-term management?

Answer 40

The prognosis in SUFE is influenced by the degree of slip, with more severe cases potentially necessitating hip replacement in adolescence or early adulthood. Chronic severe slips may require an osteotomy for long-term management.

Question 41

What are the alternative names for Slipped Upper Femoral Epiphysis (SUFE), and what anatomical part of the femur is affected in this condition?

Answer 41

Slipped Upper Femoral Epiphysis (SUFE) is also known as Slipped Capital Femoral Epiphysis (SCFE), and it involves the displacement of the head of the femur along the growth plate.

Question 42

Who are the primary demographics affected by SUFE in terms of age, gender, and predisposing factors such as weight?

Answer 42

SUFE is more common in boys aged 8-15 years, with an average age of 12, and slightly earlier in females, with an average age of 11. It is more prevalent in obese children.

Question 43

What are the common symptoms and exam findings observed in a patient suspected of having SUFE?

Answer 43

Symptoms of SUFE include hip, groin, thigh, or knee pain, a painful limp, restricted hip movement, and a preference to keep the hip in external rotation. Exam findings often include limited movement, particularly restricted internal rotation of the hip.

Question 44

What is the initial investigative method of choice in diagnosing SUFE, and what additional tests might aid in confirming the diagnosis?

Answer 44

X-ray is the initial investigation for diagnosing SUFE. Additional tests such as blood tests (normal inflammatory markers), technetium bone scans, CT scans, and MRI scans can aid in confirming the diagnosis.

Question 45

What treatment approach is typically required for SUFE management?

Answer 45

Management typically involves surgery to reposition the femoral head correctly and fix it in place to prevent further slippage.

Question 46

What joint is commonly affected by self-limiting inflammation of the synovium in children, and what is the typical age range for this condition?

Answer 46

Self-limiting inflammation of the synovium commonly affects the hip joint, primarily occurring between the ages of 2 and 10.

Question 47

What are the primary causes or triggers of this condition, and how does it typically manifest clinically?

Answer 47

This condition commonly occurs shortly after an upper respiratory tract infection, usually of viral origin, although sometimes no specific cause is found. It is considered the commonest cause of hip pain in childhood, with a slight predilection for boys over girls.

Question 48

What key clinical features are often observed in a child affected by this condition?

Answer 48

Common clinical features include a limp or reluctance to weight bear on the affected side, along with potential restricted range of motion. In some cases, there might be a low-grade fever, but the child generally doesn’t appear systemically unwell.

Question 49

Which imaging techniques are employed in diagnosing this condition, and what other investigations can be utilized to differentiate it from potential similar conditions?

Answer 49

Diagnostic imaging such as X-rays is used to exclude Perthes disease, while MRI is employed to rule out osteomyelitis of the proximal femur. Blood tests, particularly C-reactive protein (CRP), can assist in differentiating septic arthritis if the levels are normal or near-normal. If uncertainty remains between transient synovitis and septic arthritis, hip aspiration or open surgical drainage may be performed.

Question 50

What management approaches are generally recommended for this condition?

Answer 50

Management involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and rest. Pain typically resolves within a few weeks, but if there’s no improvement, further investigation for alternative causes of hip pain is warranted.

Question 51

What is another term used for Transient Synovitis, and what is the primary cause of this condition?

Answer 51

Transient Synovitis is also known as “irritable hip” and is caused by temporary irritation and inflammation in the synovial membrane of the joint.

Question 52

What age group is commonly affected by Transient Synovitis, and what is it typically associated with?

Answer 52

It is the most common cause of hip pain in children aged 3-10 years and is often associated with a recent viral upper respiratory tract infection.

Question 53

How can Transient Synovitis be differentiated from a more serious condition like septic arthritis, especially concerning the presence of fever?

Answer 53

Children with Transient Synovitis typically do not have a fever, while those with joint pain and fever require urgent management for septic arthritis.

Question 54

What are the typical symptoms associated with Transient Synovitis, and how do children with this condition generally present?

Answer 54

Symptoms of Transient Synovitis include a limp, refusal to weight bear, groin or hip pain, and occasionally a mild low-grade temperature. Children with this condition should be otherwise well, with normal pediatric observations and no signs of systemic illness.

Question 55

What is the management approach for Transient Synovitis, and what safety net advice should be given, particularly in primary care settings?

Answer 55

Management of Transient Synovitis is mainly symptomatic, utilizing simple analgesia to alleviate discomfort. In primary care, children aged 3-9 years with suggestive symptoms can be managed if the limp is present for less than 48 hours and they are otherwise well. Safety net advice should prompt immediate attendance at A&E if symptoms worsen or if they develop a fever. Additionally, they should have follow-up assessments at 48 hours and 1 week to ensure symptom improvement and resolution.

Question 56

How long does it typically take for symptoms to improve and resolve in Transient Synovitis, and what is the likelihood of recurrence?

Answer 56

Symptoms typically significantly improve within 24-48 hours and fully resolve within 1-2 weeks without any lasting issues. There’s a chance of recurrence in around 20% of patients.

Question 57

What is the primary mechanism behind the development of Osgood-Schlatter’s disease?

Answer 57

Osgood-Schlatter’s disease develops due to excessive pull by a large tendon, resulting in damage to the unfused apophysis to which it is attached.

Question 58

Where does Osgood-Schlatter’s disease typically occur and what is the affected structure?

Answer 58

Osgood-Schlatter’s disease usually occurs at the tibial tubercle, which is the insertion point of the patellar tendon into the tibial tuberosity.

Question 59

Who is commonly affected by this condition in terms of age group and gender?

Answer 59

This condition commonly occurs in active adolescent boys.

Question 60

What are the key clinical features observed in individuals with Osgood-Schlatter’s disease?

Answer 60

Clinical features include knee pain, swelling, and the development of a prominent bony lump.

Question 61

Besides the tibial tubercle, what are the other sites where this condition might occur?

Answer 61

Osgood-Schlatter’s disease can also occur at other sites such as the patella and the Achilles tendon insertion.

Question 62

What is the primary cause of Osgood-Schlatter disease, and where does the inflammation occur in the condition?

Answer 62

Osgood-Schlatter disease is primarily caused by inflammation at the tibial tuberosity, where the patellar ligament inserts.

Question 63

What age group is commonly affected by Osgood-Schlatter disease, and is it more prevalent in a specific gender?

Answer 63

The condition typically occurs in patients aged 10-15 years and is more common in males.

Question 64

Explain the pathophysiology of Osgood-Schlatter disease, focusing on the relationship between the patellar tendon and the tibial tuberosity.

Answer 64

Stress from physical activities during the epiphyseal plate’s growth leads to inflammation on the tibial epiphyseal plate. The patellar ligament causes multiple small avulsion fractures, resulting in the growth of the tibial tuberosity, leading to a visible lump below the knee.

Question 65

What are the typical symptoms associated with Osgood-Schlatter disease upon presentation?

Answer 65

Symptoms of Osgood-Schlatter disease include a visible or palpable hard and tender lump at the tibial tuberosity, anterior knee pain exacerbated by physical activity, kneeling, and knee extension.

Question 66

How is Osgood-Schlatter disease initially managed to reduce pain and inflammation?

Answer 66

Initial management includes reducing physical activity, applying ice, and using NSAIDs (such as ibuprofen) for symptomatic relief to alleviate pain and inflammation.

Question 67

What is the expected prognosis for Osgood-Schlatter disease, and what rare complication might occur, requiring surgical intervention?

Answer 67

The prognosis for Osgood-Schlatter disease involves symptoms fully resolving over time, leaving the patient with a hard bony lump on their knee. A rare complication involves a full avulsion fracture, requiring surgical intervention.