MCCQE 1 Preparation

Paediatric Orthopaedics

Dr. Ken Kontio

Outline

Exam content mainly Common / bread n`butter topics Meat and potatoes

Questions?

Case

7 month old presenting with leg concern

Mother noticed left leg shorter to finger assisted standing

Exam shows Ortilani/Barlow tests neg, mildly decreased Abduction left hip, mild LLD with left shorter than right What do you think is going on?

Options

Xrays legs to find site of shortening U/S hips to diagnosis possible DDH

(dislocation) Xray hips to confirm dislocation hip Give shoe lift for better posturing Pavlik harness for obvious hip dislocation

clinically

DDH

Commonest paediatric hip problem early on Presentation may be very benign

Decreased abduction most sensitive after 3-6mo

Exam : Ortolani + for dislocated hip

Barlow + for dislocatable hip

Workup U/S early (<3mo) Ossification femoral epiphysis 3-6 mo Xray later due to void defect from ossification

DDH

Treatment Dislocated - reduction, confirmation, pavlik Dislocatable - immediate post birth, repeat later

- later, pavlikPavlik continues until normal U/S or Xray (AI<22º)

Late may need CR (spika) older than 6 mo Later may need surgery, older than 1 year

(painless limp-todler or less) Long term follow for normal acetabular

development (surgery if no AI in 18mo)

DDH

Case

6 year old boy with pain in the Rt knee Limps at end of day, no complaints of pain

Exam shows mild limp, Knee exam normal

What to Do?

Options

Give tensor for sore knee Xray knee to rule out fracture Examine hips for source of problem MRI knee to rule out meniscal pathology Tap knee for possible infection

Perthes

Hip concern in child 4-8 years Commonly knee pain as presenting complaint

If leg pain always think about hip pathology Presentation

Painless limp Decreased ROM (esp. Abd, IR)

Perthes

Perthes

X-Ray Unilateral or mixed stage bilateral Epiphyseal ossification abnormalities

Tx Maintain ROM Coverage issues Self limiting Head sphericity key to long term outcome

SCFE

Most common cause of hip problems in adolescents

Some able (stable) and some not able (unstable) to walk

Obligatory ER hip with flexion If not teen consider outliers (endocrine

disorders, renal disease)

Xray needed to make diagnosis

SCFE

Workup Xrays show slipped

neck-head interface

Tx All need protection All need treatment Pin(s) across slip Closure about 6-12

months Watch for avn

Scoliosis

Congenital types need progress documented to prove progressive nature Rule our renal (U/S) or cardiac

(Echo) involvement

Infantile AIS, more boys, left convex thoracic curves Many resolve on their own

Scoliosis

Juvinile and adolescent curves Right thoracic and left lumbar

curve directions Risk of progression 1º maturity

related

Presentation Painless, if painful consider spinal

pathology

Scoliosis

Treatment 0-25(30) observe 25(30)-45(50) brace 50 or more consider

surgery

Brace used until maturity Surgery to correct and prevent

progression

Cases

A 6 year old child is brought to your office for assessment of a “longer” leg on one side.

Exam shows that this child has about 1 cm difference, the right longer than the left

Parents wonder if they should be concerned?

What would be the expected discrepancy at maturity?A. 1cm

B. 1.5 cm

C. 2.5 cm

D. 5cm

E. 10cm

LLD - How would you mange this child?A. Tell them that we need to do an operation

immediately to shorten the right legB. Tell them that it will stay that way and not be

an issueC. The child will need a lengthening procedure

later in life when done growingD. Tell them that it will increase but will be

acceptableE. Tell them to get a shoe lift when patient

complains of pain with walking.

LLD

Common presentation Main issue is LLD at maturity Most proportional

If 10% less at a certain age, will be same percentage at later age (ie. 10% shorter in 15 cm femur is 1.5 cm, but same child at maturity with 40 cm femur it’s a 4 cm LLD)

Causes include: hemihypertrophy, fibular hemimelia

Half deformity present at 3yrs (girls), 4yrs (boys)

LLD

Some are dynamic Growth arrest after trauma Will change quickly with time Growth femur

20% proximal 80% distal (9-10 mm/year)

Growth tibia 40% distal 60% proxiaml (6 mm/yeal)

Example: 10yr old boy (16yrs mature) with distal femur arrest will get (6 yrs growth x 10 mm/yr = 6 cm LLD)

LLD - Treatment

General rules: Discrepancy at

maturity main concern

Length and angulation (both planes) clinically relevant

If growing consider using growth arrest

If done growing consider lengthening or shortenting

0-2 cm nothing 2-5 cm lift 5-7 cm shortening or

lenghtening or epiphysiodesis

7-15 lengthening >15cm amputation

and / or prosthetics

Cases

4 year old boy presents with pain in his hip and a low grade fever.

Limp started two days earlier Progressive difficulty walking Temperature 37.6 (oral), ROM hip irritable Xray hip normal, WBC mildly increased, ESR

up about 35 (0-20)

What is your plan of management?

Options

1. U/S hip, aspiration/ arthrotomy , start antibiotics

2. Give him NSAID and follow up in 1 week

3. Start Abx and admit for observation

4. Start Abx and admit for hip arthrotomy / washout

5. U/S of hip and start antibiotics

6. Admit for bone scan and start antibiotics

Infection vs Inflammation

Often asked to differentiate between joint involvement (bacterial vs “viral”)

Spectrum of findings Walking painless limp to bedridden, painful Workup best to rule out options

Sensitive but not specific Labs, xrays, physical exam

Radiology U/S of joints, Bone scans of bones

Inflammatory

Presents as benign picture Little systemic evidence of infection Recent illness common (URTI)

Tx Watch for worsening Workup to rule out other problems Arrange close follow-up

Infective

Active picture clinically Workup suggestive but not localizing If joint fluid, obligated to sample If no fluid, bone scan to rule out osteo

Antibiotic therapy only after samples and treatment (if surgery) carried out

Deep infection needs deep treatment

Osteomyelitis

If near joint can mimic septic arthritis (Especially acetabular osteomyelitis)

Pain, fever, minor guarding if at all of joints Blood cultures, radiographs, then IV Tx

before getting bone scan

Weird things such as salmonella common in sickle cell disease, but Staph Aureus still most common in this population

Fractures

Salter –Harris classification II most common III-IV intra-articular

requiring anatomic reduction

V diagnosed after arrest seen

Fractures

If displaced and healing Accept up to 20-30 degrees angulation in

plane of joint in young child (<10yrs) Healing time same, remodelling time about 1

degree /month

If SH injury (I-II) After 7-10 days do not manipulate for risk of

iatrogenic injury to growth plate

General Principles A/B/C

Hx timing, mechanism, weight-bearing, last meal, allergies

PE deformity, bleeding, open wounds, bruising, distal

pulse, neurological motor and sensory (2-pt discrimination) exam

immobilization the unstable fracture needs immobilization before

imaging (any fracture really)

analgesia oral/sc/IV

General Principles

Investigation plain film:

2 views 90 degrees apart including joints above and below

oblique or additional views for certain body parts: cervical vertebrae, hand, ankle, foot, phalanges

Bone scan more sensitive in certain settings e.g scaphoid

fractures CT

helps define complex fractures e.g. intra-articular fratures, c-spine fractures (NOT instability)

MRI’s role continues to expand delineates surrounding tissue injuries e.g. spinal

cord compression

General Principles Orthopedic Consultation

general indications

open, unacceptably displaced, neurovascular compromise, significant joint or growth plate involvement

specific indications

non-avulsion pelvic fractures, femur fractures, dislocation of major joints (not shoulder),

spinal fractures

Special Considerations

Open fracture Td, IV Abx, never suture (tightly) overlying skin, ortho

consult

Compartment Syndrome need not be a significant fracture (or no fracture) pain with passive extension is the earliest sign

Pathologic Fracture tumors e.g. osteosarcoma hereditary diseases e.g. osteogenesis imperfecta metabolic diseases e.g. rickets neuromuscular diseases e.g. Muscular Dystrophy infectious diseases e.g. osteomyelitis

Case

9 month old brought in for clicking in thigh and pain with movement of right leg Mom noticed this 1 hour ago(diaper change) This morning after baby and twin would not

settle down (crying), dad took this (injured) twin to the other room hoping separation would settle things

Dad states he lay with child on bed and baby settled.

EXAM: obvious instability mid femur, Fractured on xray

Special Considerations Child Abuse

features strongly suggestive of abuse

fractures inconsistent with the history

fractures inconsistent with the child’s developmental age

multiple fractures, specially in various stages of healing

fractures in those less than 1 year-old

mid-diaphyseal periosteal elevation

epiphyseal or diaphyseal rib fractures

spiral fractures in non-ambulating children

epiphyseal-metaphyseal fractures: corner fractures bucket handle fractures

Skeletal survey required in suspected cases

Corner Fractures

2-month-old female

to ER for decreased movement of the left leg

according to the mother, the infant cries a lot when she is dressed

the step-father told her that while he was cleaning the house, he tripped over the infant's brother and accidentally stepped on the baby

Bucket Handle Fracture

9 m.o. is to ER when it was noted something is wrong with the infant's arm after a toy was pulled away from him

infant was in the care of the baby-sitter at that time.

Abuse

Any case you suspect it or think about it as a real possibility, you obligated to contact authorities.

Social worker first line Abuse team at any children’s hospital Police if above not available

Document accurately concerns and discrepancies if any…stories change over time.

Questions?

Remember balance is best!! (Relax and take the time for yourself and family)