paediatric orthopaedics - dr. ken kontio
TRANSCRIPT
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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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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
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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?
Special Considerations
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Special Considerations
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!