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Xamse Cayuun
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About 1 or 2 in every 1,000 babies have DDH that needs to be treated.

You'll be encouraged to allow your baby to move freely when the harness is off. Swimming is often recommended.

Ortolani test is done with the baby on their back with the hips and knees flexed. Palms are placed on the baby’s
knees with thumbs on the inner thigh and four fingers on the outer thigh. Gentle pressure is used to abduct the
hips and apply pressure behind the legs with the fingers to see if the hips will dislocate anteriorly.

Barlow test is done with the baby on their back with the hips adducted and flexed at 90 degrees and knees bent at
90 degrees. Gentle downward pressure is placed on knees through femur to see if the femoral head will dislocate
posteriorly.

PAVLICK = Keeps legs…This harness keeps the baby’s hips flexed and
abducted.

Surgery
Surgery may be needed if your baby is diagnosed with DDH after they're 6 months old, or if the Pavlik harness has not helped.
The most common surgery is called reduction. This involves placing the femoral head back into the hip socket.

Reduction surgery is done under general anaesthetic and may be done as either:
•closed reduction – the femoral head is placed in the hip socket without making any large cuts
•open reduction – a cut is made in the groin to allow the surgeon to place the femoral head into the hip socket

Your child may need to wear a cast for at least 12 weeks after the operation.

Their hip will be checked under general anaesthetic again after 6 weeks, to make sure it's stable and healing well.

After this investigation, your child will probably wear a cast for at least another 6 weeks to allow their hip to fully stabilise.

Some children may also require bone surgery (osteotomy) during an open reduction, or at a later date, to correct any bone
deformities.
RFs for Perthes:
The exact cause of Perthes disease is unknown but there are some risk factors associated with it, including:

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•Age 4-10
•Male
•FHX
•Caucasian

Examination findings
•Limp (can be painless)
•Hip stiffness- loss of internal rotation and abduction
•Pain
•Antalgic gait
•Muscle spasms
•Leg length discrepancy (late finding)

There will be no history of trauma. If the pain is

triggered by minor trauma, think about slipped upper
femoral epiphysis, particularly in older children.

Investigations
The initial investigation of choice in Perthes disease is
an xray, however this can be normal.
Other investigations that can be helpful in establishing
the diagnosis are:
•Blood tests are typically normal, particularly
inflammatory markers that are used to exclude other
causes
•Technetium bone scan
•MRI scan

TREATMENT OF PERTHES:

Treatment in younger + less severe disease is

conservative. The aim of management to maintain a
healthy position and alignment in the joint and reduce
the risk of damage or deformity to the femoral head. This
is with:
•Bed rest
•Traction; Traction helps to reduce pain by resting the hip joint. It is applied using bandages and light weights.
•Crutches
•Analgesia; NSAIDS
•MDT; paeds, orthopaedics
•SUPPORT; Perthes association

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Physiotherapy

Regular xrays are used to assess healing.

Surgery may be used in severe cases, older children or those that are not healing. The aim is to improve the alignment and function of the femoral head and hip. (osteotomy) is
considered by the orthopaedic surgeon, based upon the patient’s age, radiographic findings and clinical features. The following would increase the likelihood of the need for surgical
intervention:9
• >8y/o
• >50% femoral head damaged
• Nonsurgical management has been unsuccessful

Surgery may be considered to improve the position or function of the hip joint. Options include:
• Soft tissue release: an operation to improve movement in the affected hip by releasing certain tight muscles in the groin.

• Shelf acetabuloplasty: an operation to enlarge the socket of the hip, using a bone graft, so that the ball-shaped head of the femur fits, to improve the cover of the femoral head.

• Pelvic osteotomy: an operation to alter the position of the hip socket.

• Femoral osteotomy: an operation to alter the position of the femoral head within the socket.

Complications of Perthes
• Osteoarthritis
• General joint stiffness and immobility
• Premature physeal arrest, degenerative arthritis
• Acetabular dysplasia
• Unequal, shortened limb length

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Presentation
The typical exam presentation is an
adolescent, obese male undergoing
a growth spurt. There may be a
history of minor trauma that triggers
the onset of symptoms. Suspect
SUFE if the pain is disproportionate
to the severity of the trauma.


Presenting symptoms can be vague.

These can be:
•Hip, groin, thigh or knee pain
•Restricted range of hip movement
•Painful limp
•Restricted movement in the hip
When examining the patient, they will
prefer to keep the hip in external
rotation. They will have limited
movement of the hip, particularly
restricted internal rotation.

RFs for SUFE:

- unknown but there are some risk factors
associated with it, including:
•Male
•Obesity- increases stress on physis
•Puberty/Endocrine disorders- hormones weaken
physis, making it more prone to displacement
•Previous radiotherapy

Diagnosis
The initial investigation of choice in SUFE is xray.
Other investigations that can be helpful in establishing the
diagnosis are:
•Blood tests are normal, particularly inflammatory
markers used to exclude other causes of joint pain
•Technetium bone scan
•CT scan
•MRI scan
TREATMENT IN SUFE:

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Management
Always surgical
• In situ fixation of epiphysis with screw. ( crutches for 12 weeks
after, wearing boot in bed)
• Bone graft epiphysiodesis
• Spica cast
• In situ fixation with multiple pins
• Follow up X-rays with orthopaedics

Complications 
• Chondrolysis
• Late deformity
• SCFE in the contralateral hip
• Osteonecrosis
• Infection
• Chronic pain
• Degenerative arthritis
• Pin associated fracture

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Children with transient synovitis typically do not have a fever.

Children with joint pain and a fever need urgent management for septic
arthritis.

Examination findings
•Hip presents in flexion, abduction and external rotation
•Limited range of motion- most commonly, hip abduction
•Limp
•Pain
•Muscle spasms

General management of transient synovitis is symptomatic, with simple analgesia to help ease the
discomfort. The challenge is to establish the correct diagnosis and exclude other significant
pathology, particularly septic arthritis.

Children aged 3 – 9 years with symptoms suggestive of transient synovitis may be managed in
primary care if the limp is present for less than 48 hours and they are otherwise well, however they
need clear safety net advice to attend A&E immediately if the symptoms worsen or they develop a
fever.
They should also be followed up at 48 hours and 1 week to ensure symptoms are improving and then
fully resolve.

TX:
- bed rest, - activity modification. - AVOID ASPIRIN for pain relief. - safety net for fever + lack of
resolution of Sxs

SEPTIC ARTHRITIS REFER TO NOTES ON

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AVOID ASPIRIN IN PAIN RELIEF

A rare complication is a full avulsion fracture, where the tibial tuberosity is

separated from the rest of the tibia. This usually requires surgical intervention.

Symptoms will fully resolve over time. The patient is usually left with a hard boney
lump on their knee.

Initial management focuses on reducing the pain and inflammation.

•Reduction in physical activity
•Ice
•NSAIDS (ibuprofen) for symptomatic relief

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What else could it be, and what are the alarming symptoms?
• Bone tumours or infection:progressive constant pain, night pain, rest pain, systemic features, pain
at other sites
• Juvenile idiopathic arthritis:joint swelling and erythema, lymphadenopathy, hepatosplenomegaly
• Referred hip pain: Slipped Upper Femoral Epiphysis (SUFE), reactive arthritis, Perthes
• Trauma
• Osteochondtitis dissecans:mechanical symptoms (intermittent locking and giving way)
• Vitamin D deficiency

Management will focus on identifying the underlying cause. Investigations that can be useful include:
• Blood tests including inflammatory markers (CRP and ESR) for JIA and septic arthritis
• Xrays are used to diagnose fractures, SUFE and other boney pathology
• Ultrasound can establish an effusion (fluid) in the joint
• Joint aspiration is used to diagnose or exclude septic arthritis
• MRI is used to diagnose osteomyelitis
 

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IX:
DEXA

Management
Osteogenesis imperfecta is a clinical diagnosis. Xrays can be helpful in diagnosing fractures and bone deformities.
Genetic testing is possible but not always done routinely.
The underlying genetic condition cannot be cured. Medical treatments include:
•Bisphosphates to increase bone density
•Vitamin D supplementation to prevent deficiency

Management is done by the multidisciplinary team, with:

•Physiotherapy and occupational therapy to maximise strength and function
•Paediatricians for medial treatment and follow up
•Orthopaedic surgeons to manage fractures
•Specialist nurses for advice and support
•Social workers for social and financial support

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OSTEOSARCOMA

Osteosarcoma is a type of bone cancer. This usually presents in adolescents and

younger adults aged 10 – 20 years. The most common bone to be affected is the
femur. Other common sites are the tibia and humerus.
 
Presentation
The main presenting feature is persistent bone pain, particularly worse at night
time. This may disturb or wake them from sleep.
Other symptoms that may be present include bone swelling, a palpable mass and
restricted joint movements.
 
Diagnosis
NICE guidelines recommend a very urgent direct access xray within 48 hours
for children presenting with unexplained bone pain or swelling. If the xray suggests
a possible sarcoma they need very urgent specialist assessment within 48
hours.

Xrays show a poorly defined lesion in the bone, with destruction of the normal
bone and a “fluffy” appearance. There will be a periosteal reaction (irritation of the
lining of the bone) that is classically described as a “sun-burst” appearance. There
can an associated soft tissue mass.

Blood tests may show a raised alkaline phosphatase (ALP).

Further investigations is used to better define the lesion and stage the cancer:
• CT scan
• MRI scan
• Bone scan
• PET scan
• Bone biopsy
 
Management
Management involves surgical resection of the lesion, often with a limb amputation. Adjuvant chemotherapy is used alongside surgery to improve outcomes.

They will require support and input from the multidisciplinary team in addition to treatment of the tumour:
• Paediatric oncologists and surgeons
• Specialist nurses
• Physiotherapy
• Occupational therapy
• Psychology
• Dietician
• Prosthetics and orthotics
• Social services

The main complications are pathological bone fractures and metastasis.

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