Paediatric Orthopaedics - Dr. Ken Kontio

7/30/2019 Paediatric Orthopaedics - Dr. Ken Kontio

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MCCQE 1 Preparation

Paediatric Orthopaedics

Dr. Ken Kontio


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Outline

Exam content mainly

Common / bread n`butter topics

Meat and potatoes

Questions?


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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 withleft shorter than right

What do you think is going on?


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Options

A. X-rays legs to find site of shortening

B. U/S hips to diagnosis possible DDH

(dislocation)

C. Xray hips to confirm dislocation hip

D. Give shoe lift for better posturing

E. Pavlik harness for obvious hip dislocation

clinically


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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 (


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DDH

Treatment Dislocated - reduction, confirmation, pavlik

Dislocatable - immediate post birth, repeat later

- later, pavlik

Pavlik continues until normal U/S or Xray (AI


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DDH


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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?


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Options

A. Give tensor for sore knee

B. Xray knee to rule out fracture

C. Examine hips for source of problem

D. MRI knee to rule out meniscal pathology

E. Tap knee for possible infection


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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)


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Perthes


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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


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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


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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


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Spine Curvature

12 year old female presents with parents toclinic regarding a concern about a newcurvature of the spine

Noticed in dance class by teacher

6 months post menarch

Right convex thoracic curve

X-ray shows curve with Cobb angle 20degrees

What would you do?


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Spine Curvaturewhat to do?

A. Put into brace for the next two years

B. Follow-up in 4 months and re-Xray

C. Offer her surgery for her deformity

D. Do nothing as she is essentially skeletally

mature (no follow-up)

E. Prescribe physiotherapy for curve

containment


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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


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Scoliosis

Juvenile and Adolescent curves

(AIS)

Right thoracic and left lumbar

curve directions

Risk of progression 1 maturity

related

Presentation

Painless, if painful consider spinal

pathology


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Scoliosis- AIS

Treatment

0-25(30) observe

25(30)-45(50) brace

50 or more considersurgery

Brace used until maturity Surgery to correct and prevent

progression


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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(femur)

Parents wonder if they should be concerned?


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What would be the expected

discrepancy at maturity?

A. 1cm

B. 1.5 cm

C. 2.5 cm

D. 5cm

E. 10cm


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LLD - How would you mange this

child?A. Tell them that we need to do an operation

immediately to shorten the right leg

B. Tell them that it will stay that way and not be

an issueC. The child will need a lengthening procedurelater in life when done growing

D. Tell them that it will increase but will be

acceptableE. Tell them to get a shoe lift when patient

complains of pain with walking.


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LLD

Common presentation

Main issue is LLD at maturity

Most proportional

If 10% less at a certain age, will be samepercentage at later age (ie. 10% shorter in 15 cm

femur is 1.5 cm, but same child at maturity with

40 cm femur its a 4 cm LLD)

Causes include: hemihypertrophy, fibularhemimelia

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


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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)


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LLD - Treatment

General rules:

Discrepancy atmaturity mainconcern

Length andangulation (bothplanes) clinicallyrelevant

If growing considerusing growth arrest

If done growingconsider lengtheningor 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


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Cases

4 year old boy presents with pain in his hipand 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), CRP 40 (0-8)

What is your plan of management?


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Options

A. Give him NSAID and follow up in 1 week

B. U/S hip, aspiration/ arthrotomy , then start

antibiotics

C. Start Abx and admit for observation

D. Start Abx and admit for hip arthrotomy /

washout

E. Admit for bone scan and start antibiotics


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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


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Inflammatory

Presents as benign picture

Little systemic evidence of infection

Recent illness common (URTI)

Tx

Watch for worsening

Workup to rule out other problemsArrange close follow-up


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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


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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 Txbefore getting bone scan

Weird things such as salmonella common insickle cell disease, but Staph Aureus still

most common in this population


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Fractures


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Fractures

SalterHarris

classification

II most common

III-IV intra-articular

requiring anatomic

reduction

V diagnosed afterarrest seen


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Fractures

If displaced and healing

Accept up to 20-30 degrees angulation in

plane of joint in young child (


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General Principles

A/B/C

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

allergies

PE

deformity, bleeding, open wounds, bruising, distalpulse, neurological motor and sensory (2-ptdiscrimination) exam

immobilization the unstable fracture needs immobilization before

imaging (any fracture really)

analgesia oral/sc/IV

General Principles


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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 scaphoidfractures

CT

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

MRIs role continues to expand

delineates surrounding tissue injuries e.g. spinal

cord compression

General Principles


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General Principles

Orthopedic Consultation

general indications

open, unacceptably displaced, neurovascularcompromise, significant joint or growth plate

involvement

specific indications

non-avulsion pelvic fractures, femur fractures,

dislocation of major joints (not shoulder),

spinal fractures

Special Considerations


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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


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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 roomhoping separation would settle things

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

EXAM: obvious instability mid femur,

Fractured on xray

What to do now?



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Child Abuse

features strongly suggestive of abuse

fractures inconsistent with the history

fractures inconsistent with the childs 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: cornerfractures bucket handle fractures

Skeletal survey required in suspected cases

C


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CornerFractures

2-month-old female

to ER for decreasedmovement of the left leg

according to the mother, theinfant cries a lot when she isdressed

the step-father told her that

while he was cleaning thehouse, he tripped over theinfant's brother andaccidentally stepped on thebaby


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Bucket HandleFracture

9 m.o. is to ER when itwas noted somethingis wrong with the

infant's arm after a toywas pulled away fromhim

infant was in the careof the baby-sitter atthat time.


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Abuse

Any case you suspect it or think about it as a

real possibility, you obligated to contact

authorities.

CAS (legislation) Social worker first line

Abuse team at any childrens hospital

Police if above not available

Document accurately concerns and discrepancies

if anystories change over time.


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Questions?

R b b l i b t!! (R l


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Remember balance is best!! (Relax

and take the time for yourself and

family)


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Remember:

The big quiz is just a bump in the winding and exciting road ahead.

Keep your chin up!

Paediatric Orthopaedics - Dr. Ken Kontio

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