MCCQE 1 Preparation

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MCCQE 1 Preparation

• Paediatric Orthopaedics
• Dr. Ken Kontio

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Outline

• Exam content mainly
• Common / bread nbutter 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 with left
  shorter than right
• What do you think is going on?

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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

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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 (lt3mo)
• Ossification femoral epiphysis 3-6 mo
• Xray later due to void defect from ossification

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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
  (AIlt22º)
• 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)

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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

• 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

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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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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

• Juvinile and adolescent curves
• Right thoracic and left lumbar curve directions
• Risk of progression 1º maturity related
• Presentation
• Painless, if painful consider spinal pathology

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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

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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
• Parents wonder if they should be concerned?

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What would be the expected discrepancy at
maturity?

1. 1cm
2. 1.5 cm
3. 2.5 cm
4. 5cm
5. 10cm

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LLD - How would you mange this child?

1. Tell them that we need to do an operation
   immediately to shorten the right leg
2. Tell them that it will stay that way and not be
   an issue
3. The child will need a lengthening procedure later
   in life when done growing
4. Tell them that it will increase but will be
   acceptable
5. 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 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 its a 4 cm LLD)
• Causes include hemihypertrophy, fibular
  hemimelia
• 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 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
• gt15cm amputation and / or prosthetics

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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?

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Options

• U/S hip, aspiration/ arthrotomy , start
  antibiotics
• Give him NSAID and follow up in 1 week
• Start Abx and admit for observation
• Start Abx and admit for hip arthrotomy / washout
• U/S of hip and start antibiotics
• 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 problems
• Arrange 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 Tx before
  getting bone scan
• Weird things such as salmonella common in sickle
  cell disease, but Staph Aureus still most common
  in this population

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Fractures

• Salter Harris classification
• II most common
• III-IV intra-articular requiring anatomic
  reduction
• V diagnosed after arrest seen

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Fractures

• If displaced and healing
• Accept up to 20-30 degrees angulation in plane of
  joint in young child (lt10yrs)
• 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

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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

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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 scaphoid
  fractures
• CT
• helps define complex fractures e.g.
  intra-articular fratures, c-spine fractures (NOT
  instability)
• MRIs role continues to expand
• delineates surrounding tissue injuries e.g.
  spinal cord compression

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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

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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 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

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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

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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

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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.

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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 childrens hospital
• Police if above not available
• Document accurately concerns and discrepancies if
  anystories change over time.

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