Orthopaedic Slides
Summary
This on-demand teaching session designed for medical professionals is a focused exploration and recap of paediatric orthopaedics. The session aims to present comprehensive information on conditions such as fractures, irritable hip, and arthritis. By attending this session, healthcare professionals can refine their investigative skills through reviewing bedside pain scores, FBC, U&E, CRP, Lactate, Bloods, CrossMatch, Coag, and imaging diagnosis. Additionally, the curriculum includes a thorough discussion of presentations such as pain, visible deformity, bruising, swelling and skin changes, patient demographics, and specific management pointers such as safeguarding, pain management, mechanical alignment, and stabilisation. The session includes scenario-based learning by posing questions in SBA style, challenging attendees' practical understanding of the topic. Furthermore, differential diagnoses for fracture and irritable hip are provided, offering a holistic viewpoint on the conditions. This session proves to be a rewarding opportunity for attendees to build their foundations in paediatric orthopaedics.
Learning objectives
- Understand the different types of pediatric orthopedic conditions such as fractures and arthritis, including their presentation, diagnosis, and management strategies.
- Differentiate between various conditions that mimic serious orthopedic diseases, such as Irritable Hip and Transient Synovitis, and identify the differential diagnoses.
- Learn the appropriate imaging techniques, like X-ray and MRI, and how to interpret them for diagnosing pediatric orthopedic conditions.
- Understand the importance and process of clinical documentation in managing pediatric orthopedic cases.
- Gain knowledge in completing SBA style questions related to pediatric orthopedic conditions, making appropriate clinical judgments, and applying the knowledge in clinical practice.
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Paedia tric Orthopaedics JaceCappleman Fracture Agenda IrritableHip Arthritis SBA StyleQuestions Investigations Bedside–painscores Fracture Bloods–FBC,U&E,CRP,Lactate,CrossMatch,Coag Imaging–XRofthejointfrom2anglesplusXRofjointabove andbelowthe Presentation injury Pain,visibledeformity,bruising,swelling,skin Management changes Considersafeguarding RF–highimpact mechanismofinjury,sports, Painmanagement(PCMorIBF thenmorphine),Aspirin,Codeineand Tramafolare problemswithbalance neverused Mechanicalalignmentviaclosedreduction(manipulationofthejoint) oropen reduction(surgery) Periodofstability(various ways e,g.Externalcasts,IMwires/nails,screws etc) Clinical Documenta tion 1 2 3 4 5 Patient demographics XR taken on day and time Comment if AP or lateral view XR Intepretation Impression (be specific) Date & time pain, obvious deformity. injury, penetration and exposure of film Plan XR Interpretation, Name, Role Comment if any previous XR for number and bleep numberGMC comparison XR Interpreta tion Asymmetry& Alignment Bones Cortex SoftTissue • Commentonthealignmentof • Whichbonesareinvolved • Fractureis astepinthe • Anyreactionsofttissue thebones andany andwhichpart ofthebone cortex ofthebone swelling subluxation/fractures • Anyjointinvolvement • Typeoffracturee.g.complete, • Calcification • Commentonjointspace– loss • Texture ofthe bone displaced,open/closed • Foreignbodies ofjointspace, subchondral • Perisotealreactions (sarcoma) sclerosis, osteophytes • AnyevidenceofosteopeniaBuckle Fracture • XRInterpretationforpatientdemographics. • XRtakenondate/timeduetofallonoutstretchedhandandvisible deformity,noprevious XRforcomparison.Adequatepenetrationand exposureoffilm • Incompletestepinthecortex ofthedistalradius indicatingafracture withsubtledisplacement(buckling) • Impression:leftdistalradius fracture(BuckleFracture) • Plan:discuss withorthopaedics formanagementandimmobilisation Differentials for Fracture Osgood-SchlatterDisease Growingpains Benignself-limitingdiseasesthat presentswithbilateralanterior Presentaround3-12yearswithbilateralshin/anklepain at theend kneepainandtendernessatthe tibialtuberosity ofthe day Malesmore commonlyaffected Nosystemicsymptoms,limp,effect onADL,normalmilestonesand physicalexamination Symptomswaxandwane for6-18 months Doesnot require furtherinvestigationsandmanagedwithrest, physiotherapyandNSAIDs Investigations Bedside–painscores,Barlow& OrtolaniTest Irritable hip Bloods–FBC,U&E,CRP,Lactate Imaging–XR(APandlateral),USS,jointaspiration,MRI Presentation DDx Limp,refusaltousetheaffectedlegor weight bear, inabilitytowalk,pain,swollen,ortenderjoint 0–4yearsold–SepticArthritis,DDH,Transientsynovitis 5–10yearsold–SepticArthritis,TransientSynovitis,PerthesDisease RedFlags–childunderthreeyears,old,fever,pain, 10–16yearsold–SepticArthritis,SUFE,JuvenileIdiopathicArthritis awakenatnight,weightloss,nightsweats,fatigue, persistentpaininmorning,stiffness,swollenredjoint Differentials for irritable hip • DDH–subluxationofthe hip.RiskfactorsincludeFH,breechpresentation,female,fixedfootdeformity,age0-4.Presentswithleglength discrepancyandlimitationinhip abduction.DiagnosedviaUSorXR(if>4.5months)andmanagedwithPavlikharnessorsurgerywithhip spicacast.Cancause transient femoralnerve palsyandvascularnecrosisofthe femoralhead • SepticArthritis–presentswithred,hot,swollenandpainfuljoint,inabilitytoweightbear,stiffness,reducedROM,feverandlethargy.Most commonlycausedbys.aureus(Neisseriainteens,salmonellainsicklecell).Managedwithjoint aspiration(samplesentforstaining, culture,microscopyandsensitivities),3-6weeksofantibioticsandmayrequiresurgicaldrainageandwashout • TransientSynovitis–inflammationofthesynovialmembrane,mostcommonlyassociatedwithrecentviralupperrespiratorytract infection.Presentswithlimpandrefusaltowaitbearbutotherwisesystemicallywell.Symptomatictreatmentandexclusionofother differentialse.g.septicarthritis.Symptomsfullyresolvedwithin1 to2weeks,butmayreoccur. Differentials for irritable hip • PerthesDisease–idiopathicavascularnecrosisoftheproximalfemoralepiphysis.Riskfactorsincludeage4-10,male,FHandCaucasian.XR showscoxa-plana,coxa-magnaandsaggingropesign.Treatedwithobservation,analgesiaandphysiotherapy(surgeryifover6and>50% headinvolvement).Complicationsinclude osteoarthritis • SUFE–displacementofthecapitalfemoralepiphysis.Riskfactorsinclude>10years,male,obesity,puberty,growthspurtandprevious radiotherapy.Presentswithpain,externalrotation,abnormalgait/limp,decreasedROM,weaknessandmuscle atrophy,mayfollowminor trauma.Diagnosedviabilateralfrog-legXR.Surgicalmanagementwithinternalfixation/DHS.Complicationsincludechondrolysis, osteonecrosis,infection,chronicpainandarthritis Investigations Bedside–painscores Arthritis Bloods–FBC,U&E,CRP,ESR,Anti-CCP,RhFactors Imaging–XRofthejointfrom2anglesplusXRofjointaboveandbelowthe injury,considerMRI Presentation Management Red,hot,swollen,joints,pain,stiffness,effecton ADL,Effectsonskin(psoriasis,rash,lupus,butterfly, Conservative –healthyeating,therapy,supplements rash),dryredskin,Uveitis RF– familyhistory,followingviralinfection Medical-analgesia,corticosteroidjointinjections,DMARDS(methotrexate), biologics(Etanercept,Infliximab,Adalimumab)SBA Style questions Question 1 Which of the following is •Painwakingthechildat night •A palpablemass not a red flag for a child •Unabletoweight bear •Noimprovement withparacetamol presenting with an acute monotherapy limp? •Unexplainedrashes or bruising 14 Question 2 •Foot deformity Which of the following is not a •Breech presentation •Femalesex risk factor for developmental dysplasia of the hip? •Being a twin •Polyhydramnios 15 Question 3 • Supracondylar humeral child comes to the A&E with an fracture acutely painful elbow after • Greenstickfracture of proximal ulna being lifted from the ground • Galeazzifracture • Radialhead subluxationfrom holding her hands only. What annuar ligament is the likely cause? • Ulnar head subluxation 16 Question 4 • Reduced internalrotation • Fever>38.5°C Which of the following is most • ESR>40 mm/hr consistent with transient • Historyofrecenttrauma synovitis of the hip? • Inabilityto weightbear 17 Question 5 • Transientsynovitis A 5 year old boy is brought to his GP by his • Perthes'Disease parents after noticing him w alk with an • Slipped UpperFemoral Epiphysis antalgic left sided limp for the last 3 • Septic Arthritis weeks, and he has been otherwise fit and well . What is the most likely diagnosis? • thehippmentalDysplasia of 18Thank you JaceCappleman J.e.cappleman1@ncl.ac.uk 19