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MCCQE 1 Preparation. Paediatric Orthopaedics Dr. Ken Kontio. Outline. Exam content mainly Common / bread n`butter topics Meat and potatoes Questions?. Case. 7 month old presenting with leg concern Mother noticed left leg shorter to finger assisted standing

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mccqe 1 preparation

MCCQE 1 Preparation

Paediatric Orthopaedics

Dr. Ken Kontio

  • Exam content mainly
    • Common / bread n`butter topics
    • Meat and potatoes
  • Questions?
  • 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?
  • 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
  • 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 (<3mo)
      • Ossification femoral epiphysis 3-6 mo
      • Xray later due to void defect from ossification
  • Treatment
      • Dislocated - reduction, confirmation, pavlik
      • Dislocatable - immediate post birth, repeat later

- later, pavlik

Pavlik continues until normal U/S or Xray (AI<22º)

  • 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)
  • 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?
  • 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
  • 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)
  • X-Ray
    • Unilateral or mixed stage bilateral
    • Epiphyseal ossification abnormalities
  • Tx
    • Maintain ROM
    • Coverage issues
    • Self limiting
    • Head sphericity key to long term outcome
  • 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
  • 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
  • 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
  • Juvinile and adolescent curves
    • Right thoracic and left lumbar curve directions
    • Risk of progression 1º maturity related
  • Presentation
    • Painless, if painful consider spinal pathology
  • 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
  • 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?
  • 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
  • U/S hip, aspiration/ arthrotomy , start antibiotics
infection vs inflammation
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
  • 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
  • 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
  • If near joint can mimic septic arthritis (Especially acetabular infection)
  • 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
  • Salter –Harris classification
    • II most common
    • III-IV intra-articular requiring anatomic reduction
    • V diagnosed after arrest seen
  • If displaced and healing
    • Accept up to 20-30 degrees angulation in plane of joint in young child (<10yrs)
    • 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
general principles
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
general principles1
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
    • MRI’s role continues to expand
      • delineates surrounding tissue injuries e.g. spinal cord compression
general principles2
General Principles
  • Fracture Description
    • clinical:
      • age, sex, mechanism, anatomy, NV status, associated injuries
    • radiographic:
      • anatomy
      • pattern (longitudinal, transverse, oblique, spiral, impacted, comminuted, bowing, greenstick, torus)
      • Displacement (angulation and translation)
      • shortening
      • joint or growth plate involvement
general principles3
General Principles
  • Orthopedic Consultation
    • general indications
      • open, unacceptably displaced, neurovascular compromise, significant joint or growth plate


    • specific indications
      • non-avulsion pelvic fractures, femur fractures,
      • dislocation of major joints (not shoulder),

spinal fractures

special considerations
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
special considerations1
Special Considerations
  • Child Abuse
    • features strongly suggestive of abuse
      • fractures inconsistent with the history
      • fractures inconsistent with the child’s 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:
        • corner fractures
        • bucket handle fractures
    • Skeletal survey required in suspected cases
corner fractures
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
bucket handle fracture
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.


Good Luck…Relax!!