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FRCS CBD Course Paediatrics Nicola A Evans FRCSCase 1 • 2 year old boy presents with a painless deformity of his right leg. • Describe the deformity • What types do you know of and their associations? • Management?Case 2: 9y female with leg pain after a fall • Red flag symptoms and signs? • Differential diagnosis? • Management?Case 3 • Diagnosis? • Associations? • Management?Case 4 • Diagnosis • Associations • Management?Case 5: • Describe the Radiograph • What do you understand by “hip surveillance”? • Principles of management?Paediatrics CBD AnswersCase 1 • 2 year old boy presents with a painless deformity of his right leg. • Describe the deformity • What types do you know of and their associations? • Management?Case 1: Anterolateral bowing Tibia • This is an AP and lateral radiograph of the right lower leg in a skeletally immature patient. • There is Anterolateral bowing of the tibia. Typeust mention MDTCauseoach Treatment Posteromedial Physiological causes LLDn, rarely Anteromedial Fibula hemimelia Reconstruction v Amputation for severe deformities Anterolateral Congenital Total contact cast, Pseuedoarthrosis IMN, Ex-Fix, 50% NF (Only 10% NFAmputation have this disorder)Case 2: 13y female with leg pain after a fall • Red flag symptoms and signs? • Differential diagnosis? • Management?Case 2: 13y leg pain after a fall • Red Flag Symptoms and signs • Night pain • Weight loss • Ewings • T(11:22) translocation • Adolescents • Identified with PCR • Periosteal reaction– Onion-skinning or codman’striangle • Moth-eaten appearance • Diaphysis of long and flat bones • Mets to lungsCase 2: Differential diagnosis • Concern is a malignanttumour – Ewings/ Osteosarcoma • Infection • Fibrous dysplasiaCase 2: management • MDT • Principles of Biopsy –small round blue cells • Local and systemic staging • Neo adjuvant Chemotherapy • Radiotherapy • Prognosis • 60 - 70% long term survival with isolated extremity disease • 40% with pelvis lesions • 15% if mets • Limb salvage vs amputationCase 3 • Diagnosis? • Associations? • Management?Case 3: Bilateral Clubfoot • Bilateral congenital talipes Equino-varus (CTEV, Clubfoot) • Birth defect • Not a packaging disorder • Bilateral 50%Case 3: associations • Positive family history • Sibling of an affected child 20-30 times increased • Parent and child affected subsequent risk is 1 in 4 • Polynesians • Spina bifida • Arthrogryposis • Diastrophic dwarfism • AmniocentesisCase 3: Management • Multidisciplinary approach • Aim is to achieve a painless, functional plantigrade foot • Ponsetticasting technique (p227 CON)– need to be able to describe thisCase 4 • Diagnosis • Associations • Management?Case 4: Congenital dislocation of the knee • Hyperextended knee at birth • Types: •spontaneouslynded knee resolves • II: Anterior subluxation of the tibia • III: Anterior dislocation of the tibia • Page 224 CONCase 4:Associations • Myelomenigingocele • Arthrogryposis • Larsen’s Syndrome • DDH (screen for it) • Clubfoot • Metatarsus adductusCase 4: Treatment • MUA and long leg cast • Stretching (Physiotherapy) • Surgical soft tissue release – Failure to gain 30 degrees of flexion after 3 months • Quads lengthening (V-Y or Z-plasty) • Anterior joint capsule release • Posteriorcapsulorrhaphy • Hamstring tendon posterior transposition • Collateral ligament mobilization • If both hips and knee dislocated – treat knee first so can get Pawlick harness on (Need knee flexion)Case 5: • Describe the Radiograph • What do you understand by “hip surveillance”? • Principles of management?Case 5: • AP pelvis radiograph skeletally immature • Dislocated left hip • Hilgenreiners • Acetabular index • Perkins • Proximal femur appears anteverted and in valgus – consider CPCase 5: Hip Surveillance • Identify Hip “at risk”, “subluxed” or “dislocated” • NICE guidelines • posture or pain, LLD, Increased hip tone or reduced ROM (restrictediculty with abduction) • If Reimer migration Index > 30% - Hip XR 6 monthly • GMFCS > 3 – annual hip XRFRCS CBD Paeds Set 2 Q’sCase 1 • 13year old boy with injury to his left hand after playing cricket at school • Describe the clinical photograph • Assessment?Case 1 • Concerns? • Management?Case 1: Seymour fracture • History and Examination • Tetanus and IVAB’s • Recognisethe injuryCase 2: • 12y male a limpts with following a rugby tackleCase: SUFE Risk factors pathophysiology • Obesity • physisical forces acting on a susceptible • Male > Female (2:1.4) • Endocrine disorders • Hypertrophic zone of the physis • Hypothyroidism • Metaphysis translates anteriorly and • Reanlosteodystrophy externally rotates • GH deficiency • Epiphysis remains in acetabulum • Panhypopituitarism • Periosteum– remains intact in chronic, • Ethnicity– pacific islanders, African may tear in acute americans, latinos • Period of rapid growth (1016y) • Acetabular retroversion and femoral retroversion (? Increased shearing forces)Case 2: SUFE - Classification Timing Stability - Loder • Acute < 3 weeks • Stable = Able to weight bear +/- • Chronic > 3 weeks crutches • Unstable = unable to weight • Acute on Chronic bear • May be a delayed presentation with non- specific thigh or KNEE • Loder’s series pain • Stable 0% AVN • Unstable 47% AVNCase 2: SUFECase 2: SUFESUFE: Treatment • MDT Approach • Contact local Orthopaediatric Specialist centre for ?Open reduction • Modifiable risk factors • Treat metabolic/endocrine disorders – paediatrician • ?contralateral pinning – Obese males < 10 years, endocrine disorder • Close follow upCase 3 9y female gamepain after a hockeyCase 3Case 3Case 3: EwingsSarcoma • Small round cell tumour of • MDT unknown origin • Local and systemic staging – skip • 11:22 translocation lesions and pulmonary • 5 – 25 years metastasis • Biopsy – Principles • Fever +/- elevated WCC/Inflammatory markers / • Treatment LDH • Chemo + surgery • Diaphyseal with a large soft • Radiotherapy tissue mass • Prognosis • Expendable bone – resecteg ribsCase 4: 8y female, fall from a swing • Examination? • Management? • OutcomesCase 4: supracondylar fractureBoast – Updated October 2020 • A documented assessment of the limb must be performed on presentation and immediately before surgical treatment. It should include the status of radial pulse, digital capillary refill time and the individual function of the radial, median (including anterior interosseous) and ulnar nerves. • documented.nagement should be carried out on the day of injury. Nighttime operating is not necessary unless there are indicatio s for urgent surgery which should be • Surgical management should be provided urgently when there is an absent radial pulse, clinical signs of impaired perfusion of the hand and digits, open injury or evidence of threatened skin viability. • The majority of vascular impairments associated with supracondylar fractures resolve with fracture reduction. A limb without clinical signs of ischaemia does not require brachial artery exploration whether or not the radial pulse is present. • Surgical stabilisation should be with at least two K wires that engage in the cortex proximal to the fracture. Crossed wires re associated with a lower risk of loss of fracture reduction, whereas divergent lateral wires reduce the risk of injury to the ulnar nerve. • When a medial wire is used, techniques to avoid ulnar nerve injury should be employed and recorded on the operation note. • 2mm diameter wires should be used, where possible, to achieve stability. Intraoperative assessment of satisfactory stability and clinical alignment should be performed and documented. • If the limb remains ischaemic after fracture reduction then exploration of the brachial artery is required with a surgeon competent to perform a small vessel vascular repair. • Monitoring of neurovascular status as described in 1 should continue postoperatively until the treating surgeon is confident there is no risk of vascular compromise or compartment syndrome. When there is concern over iatrogenic nerve injury then a documented assessment with consultant inputs required for consideration of nerve exploration before discharge. • Suspicion of compartment syndrome or deterioration of perfusion should prompt immediate vascular reassessment and interventio if required. • The operating surgeon should determine and document the need for post-operative radiographs and anticipated time of wire remova. • Routine long-term follow up is not usually required. Any indications for further review should be documented.Case 5: Child – crying, not moving right armDistal Humeral Physeal Separation Distal humeral epiphysis is cartilage anlage until second• Operativeation occurs Fracture occurs in young children, typically < 3 y • Distinguish from lateral condyle Mechanism Fall on outstretched hand fracture – Fluroscopy, arthrogram Rotational forces • CRPP Birth injury Child abuse • Open reduction rarely necessary – Evaluation lateral approach a. History of trauma-suspect abuse b. b. Exam • Complications Elbow swelling, deformity • Cubitus varus Crepitus • Missed diagnosis Neurovascular exam-usually normal Imaging • Growth disturbance (vascular vs Radiographs of upper extremity damage to chondroepiphysis) Ultrasound MRI for equivocalCase 6: 5y old child with a limp Emergency Department •  If concerns of NAI (non-accidental Injury) suspected –  Check if child is on a Child Protection Plan –  Red flag / Starburst on Computer Medical Records –  Named Social Worker –  Contact Safeguarding Team –  Child MUST Not de discharged without full Multi-agency discussion or agreement of social worker in charge of the case and –  Consultant Paediatrician –  Detailed records of discussions/telephone discussions and any advice. –  Responsibility of ALL STAFFRisk Factors for Non-accidental Injury Child-Related Caregiver related Environmental Boys > Girls Substance abuse Poverty Twins Depression/other mental illness Living with an unrelated adult Prematurity Low self esteem Social isolation Chronic Illness Unemployment Single parent Physical or developmental Parent has a history of abuse as a Non-biologically related male disabilities child living in home Unwanted Child Young maternal or paternal ageIntimate partner violence Unplanned Pregnancy Poor knowledge of child development Negative perception of normal child behaviourThe role of the orthopaedic surgeon • Fractures are second most common injury caused by NAI after bruises •for victims of NAIons at frontlines for providing care • High index of suspicion • Accidental trauma more common that abuse but up to 20% of fractures in children under 3 years are misdiagnosed or attributed to other causes rather than NAI • Failure to recognize may contribute to further injury or death to a child • Safeguarding training compulsoryExam tips • PaedsHips – DDH/Perthes/SUFE/Coxa Vara/septic arthritis • Skeletal dysplasia – achondroplasia • Scoliosis • BOAST • NAI • Clubfoot • Tumours • Infection