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

• 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)