viva Hands and Paediatric Orthopaedics
Hands and Paediatric Orthopaedics
Section 1 Hands
Viva 1
What is the likely diagnosis?
What are the risk factors for this condition?
What are the two main components seen in the histology of mature tissue from this condition?
What are the management options?
What are the risks of surgical treatment?
What is the likely diagnosis?
T he clinical photograph shows fl exion of the right little fi nger metacarpophalangeal (MCP) joint, suggestive of Dupuytren’s contracture.
What are the risk factors for this condition?
The risk factors associated with Dupuytren’s disease include: positive family history; liver disease; high alcohol intake; diabetes mellitus, and epilepsy.
What are the two main components seen in the histology of mature tissue from this condition?
C lassic histological appearance is the presence of myofi broblast cells (probably derived from fi broblasts) and thick collagen fi bres.
What are the management options?
The management options are non-operative measures and operative procedures.
Non-operative options include observation (and possibly splintage, especially at night).
Some authors have reported that steroid injections to early palmar nodules may reduce local tenderness. Although promising short-term results have been reported with collagenase injection, no longterm results are available.
Surgical options include: z Percutaneous fasciotomy, especially for mild contractures affecting MCP joint contractures z Segmental/palmar fasciectomy zRegional fasciectomy (and Z-plasty closure or skin grafting) z Dermo-fasciectomy and skin grafting z Proximal interphalangeal (PIP) joint arthrodesis (for severe or recurrent disease) z Occasionally, amputation of the digit (for severe or recurrent disease)
What are the risks of surgical treatment?
Specifi c surgical risks include:
z Delayed wound healing, infection z Tendon, nerve, and vessel injury zTemporary or permanent numbness z Necrosis of the digit and amputation zIncomplete correction z Recurrence and re-operation z Joint stiffness
z Reduced flexion/extension especially at the PIP joint z Pain, swelling, and tenderness; occasionally chronic regional pain syndrome
Viva 2
Reproduced from C. Bulstrode et al., Oxford Textbook of Trauma and Orthopaedics
second edition, 2011, fi gure 6.13.2, page 512, with permission from Oxford University Press.
What is the likely diagnosis of the cystic, soft-tissue lump shown in the photograph? From what structure does it commonly arise?
What clinical test, outpatient procedure, and simple imaging investigation can be performed to confirm the diagnosis?
Give a histological definition of this condition.
What are the other sites for these cystic swellings in the wrist and hand?
How would you manage this condition in a 26-year-old woman who works as a secretary and presents to you for the first time?
What is the risk of recurrence post-excision?
What is the likely diagnosis of the cystic, soft-tissue lump shown in the photograph? From what structure does it commonly arise?
The appearance of the lump at the wrist is suggestive of a ganglion cyst. Approximately two-thirds of such cysts originate in the radiocarpal joint. The remaining third arise from the scapho-trapezoid joint.
What clinical test, outpatient procedure, and simple imaging investigation can be performed to confi rm the diagnosis?
Clinical test = compressible lump which trans-illuminates
Outpatient procedure = aspiration of the ganglion under local anaesthetic
Simple imaging investigation = ultrasound scan
Give a histological defi nition of this condition.
A ganglion cyst is a fl uid-fi lled cavity lined by compressed collagen and a few cells.
What are the other sites for these cystic swellings in the wrist and hand?
1. Ganglia in the hand are commonly seen over the dorsum of the wrist where they commonly arise from scapholunate ligament
2. Cysts arising from the distal interphalangeal (DIP) joint present as dorsal cysts and are called dorsal distal ganglia, mucoid, or mucous cysts
3. Smaller, firmer cysts may be found in relation to the flexor tendon sheath in the region of the A2 pulley. These are called palmar digital ganglia, flexor sheath ganglia, or pearl ganglia Interosseous ganglia are uncommon, but when present are often in the lunate bone.
How would you manage this condition in a 26-year-old woman who works as a secretary and presents to you for the fi rst time?
I would explain:
1. That a ganglion is a common benign cyst
2 . That during the natural history of a ganglion it can often fluctuate in size periodically and may resolve spontaneously if simply observed
3. Treatment options and their potential risks include: z Simple observation (few if any risks) z Aspiration of the cyst (small risks of haematoma or infection, radial artery damage, and recurrence)
z Surgical excision of the ganglion, open or arthroscopic (risks of anaesthesia and surgery including nerve, vessel, and tendon injury, haematoma and infection, pain, swelling, tenderness, stiffness, and recurrence)
What is the risk of recurrence post-excision?
The risk of recurrence in some published series is similar for all three treatment options above, so observation is the safe course of action.
Viva 3
Describe the picture.
How would you grade the thumb condition radiologically?
Why does subluxation occur in this condition?
How could you explain the hyperextension deformity of the MCP joint?
What are the management options?
How would you treat this patient who has unremitting carpo-metacarpal (CMC) joint pain despite full non-operative treatment and who is fit for surgery?
What are the advantages and disadvantages and surgical risks with simple excision arthroplasty?
Describe the picture
This is a clinical photo of the dorsal aspect of the hands showing a symmetrical, deforming, polyarthropathy consistent with rheumatoid arthritis. There are bilateral Z-shaped thumbs, swan-necking of the right middle fi nger, and marked ulnar deviation of all fi ngers at the MCP joints.
How would you grade the thumb condition radiologically?
I would use the Eaton and Littler system to stage this condition.
z Stage I — joint space widening, normal articular contours z Stage II— u p to one-third subluxation (on stress radiographs, thumbs resting on plate and pushing against each other): osteophytes < 2 mm, scapho-trapezio-trapezoidal (STT) joint is normal
z Stage III — marked narrowing of joint space, more than one-third subluxation: osteophytes
> 2 mm z Stage IV — pan-trapezial arthritis
Why does subluxation occur in this condition?
The palmar oblique ligament (also known as the ‘beak’ ligament) is a very strong ligament extending from the trapezium to the base of the fi rst metacarpal. Degenerative attenuation and rupture of this ligament results in dorsal subluxation of the fi rst metacarpal.
How could you explain the hyperextension deformity of the MCP joint?
Dorsal subluxation of the CMC joint causes metacarpal adduction, a thumb in the palm deformity, and reduction in thumb span. This leads to a secondary compensatory hyperextension at the MCP joint in an eff ort to increase the thumb span.
What are the management options?
N on-operative options include: oral analgesia; activity modifi cation; use of splints; physiotherapy; and intra-articular steroid injection which could be performed in the outpatient clinic or under fl uoroscopic guidance.
Operative options include:
1 . Excision of the trapezium offers satisfactory pain relief in most cases and preserves movement. Results are reliable. However, pinch grip may be weakened
2. The addition of a suspension procedure and tendon interposition has been shown to offer no extra benefit
3. Implant arthroplasty has failed to offer good long-term results and early implant failure has made this procedure less popular
4. Rarely, CMC arthrodesis is performed in young adult manual workers as this procedure offers a stable thumb with good pinch grip. However, the manoeuvrability of the thumb is affected
5. First metacarpal-basal osteotomy may be considered, especially in earlier stages of the disease
How would you treat this patient who has unremitting CMC joint pain despite full non-operative treatment and who is fi t for surgery?
I would off er this patient excision of the trapezium and fusion of the MCP joint under general anaesthetic (GA)/regional block. I would perform the procedure as a day-case.
What are the advantages and disadvantages and surgical risks with simple excision arthroplasty?
T rapezium excision results in good pain relief and consequently improved function, but slight shortening of the thumb can cause reduced power of pinch. Risks specifi c to the procedure include painful scar, infection, nerve damage (superfi cial branch of the radial nerve), blood vessel damage (radial artery), incomplete relief of symptoms (especially if adjacent joints are aff ected by osteoarthritis), a relatively slow recovery of function and attainment of maximal pain relief, and instability of the carpus.
Viva 4
A 20-year-old man presents 48 h after he was involved in a fight with another person, when he sustained a punching injury shown in the photograph below.
What is the likely nature of this injury?
How would you assess this patient?
How would you treat this injury?
Which organisms commonly cause infection with this type of injury?
Which antibiotics would you use to cover these organisms?
What is the likely nature of this injury?
There is a ‘fi ght-bite’ puncture wound over the right ring fi nger MCP joint that may have been caused by a penetrating human tooth and may extend into the joint causing cartilage injury, bony fracture, and associated joint infection ± osteomyelitis.
How would you assess this patient?
I would take a full history including the circumstances of the injury, past medical history, and tetanus immunization status. I would look for systemic signs such as fever and tachycardia. On local examination, I would look for signs of cellulitis, tendon sheath infection, tendon rupture, and septic arthritis. I would request plain radiographs to exclude the presence of a foreign body and a fracture. I would also request baseline blood tests [full blood count (FBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)].
How would you treat this injury?
M y initial treatment would be to provide tetanus prophylaxis if indicated and apply sterile dressing to cover the wound. I would withhold antibiotics, if systemically well, until tissue samples are obtained.
I would take the patient to theatre for urgent debridement under GA with a tourniquet around the arm. During surgery, I would obtain pus swab and tissue samples for histology and microbiological examination. I would extend the wound and look for tendon damage (re-create fi st by fl exing the MCP joint). If the tendon is ruptured, I would tag the tendon ends and not attempt primary repair. I would inspect the joint. I would then wash the wound with copious amounts of fl uid. I would leave the wound open and apply a splint over non-adhesive dressing. I would commence broad-spectrum antibiotics, pending culture results and arrange for a further look after 48 h.
Which organism commonly causes infection with this type of injury?
Although Eikenella corrodens is peculiar to this injury, Staphylococcus aureus is the commonest organism; anaerobic bacteria may also be implicated.
Which antibiotics would you use to cover these organisms?
I would prescribe broad-spectrum antibiotics according to local microbiological protocols such as co-amoxiclav, cephalosporin, and metronidazole.
Viva 5
A 24-year-old male cyclist has been knocked off his bicycle sustaining an isolated injury to his left wrist.
Describe the appearances of these radiographs.
How would you classify this injury?
How would you assess this patient’s isolated injury?
How would you manage this injury initially and definitively?
Describe the appearances of these radiographs
Postero-anterior (PA) and lateral radiographs of the left wrist showing a perilunate dislocation.
PA view shows:
1 . Disruption of the ‘Gilula’s’ smooth carpal lines that join the proximal joint surfaces of the proximal row of carpal bones at the radiocarpal joint and the distal joint surfaces of the proximal row of carpal bones and the proximal joint surfaces of the distal row of carpal bones (at the mid-carpal joint). The Capitate appears to overlap the lunate
2. Hyperflexion of the scaphoid (scaphoid signet ring sign)
3. Abnormal triangular appearance of the lunate, but lunate located in the lunate fossa of the radius
4. Overlapping of the lunate and triquetrum [unable to visualize lunotriquetral (LT) joint] 5. No obvious fractures of radial styloid, scaphiod, capitate, triquetrum, hamate, or ulnar styloid.
Lateral view shows:
1. Dorsal dislocation of the capitate head from its articulation with the lunate at the mid carpal joint and dorsal translation of distal carpal row and metacarpals relative to the long axis of the radius.
How would you classify this injury?
Perilunate injuries often follow a typical pattern as described by Mayfi eld. Assuming there are indeed no fractures, this is a ‘lesser arc’ ligament-rupturing perilunate dislocation. ‘Greater arc’ injuries also include one or more fractures, typically of the radial styloid, scaphoid, capitate, hamate, triquetrum (± ulnar styloid). A typical lesser arc perilunate injury follows the ‘Mayfi eld sequence’ of ligament failures in sequential defi ned stages:
Check:
Stage I: failure of the radiocarpal ligament
Stage II: failure of the scapholunate ligament
Stage III: failure of the LT ligament and dorsal mid-carpal dislocation
Stage IV: palmar dislocation of lunate at the radiocarpal joint
Therefore this patient’s injury is a Mayfi eld stage III lesser arc perilunate dislocation.
How would you assess this patient’s isolated injury?
I would take a detailed history including handedness, occupation, mechanism of injury, co-morbidities, and time since last meal. I would examine carefully for abnormal wrist contour, pain and swelling, and signs of median nerve compression, and document median nerve function, sensory, and motor function.
How would you manage this injury initially and defi nitively?
Initial management
z Exclude another injury. Provide analgesia. Regular neurovascular observations z Keep nil-by-mouth [ ± intravenous (IV) hydration if necessary] z Splintage [e.g. padded plaster of Paris (POP) slap + loose bandage] z High elevation (Bradford sling or Chinese finger traps) z Explain severity of injury to patient z Prepare and consent patient for urgent theatre z Minimum initial intervention requires closed (± open) reduction of the dislocation using image intensifier control ( ± carpal tunnel decompression) + POP slab stabilization
Defi nitive intervention (± specialist hand surgery advice)
z Would include closed but anatomical restoration of carpal alignment using joystick k-wires (arthroscopically and image intensifier controlled) + buried k-wire stabilization of scapholunate, LT, and mid-carpal joints
z OR open dorsal anatomical carpal reduction, buried k-wire stabilization, and repair of scapholunate, LT, dorsal and palmar radiocarpal, ligaments
z Post-operatively: high elevation and careful neurovascular observation. Full POP for 2 weeks.
Removal of wires at 8 weeks and mobilization zRisks of post-traumatic carpal instability or stiffness ± osteoarthritis
Viva 6
Reproduced from C. Bulstrode et al., Oxford Textbook of Trauma and Orthopaedics second edition, 2011, fi gure 1.10.2, p. 75, with permission from Oxford University Press.
Describe these radiographs and explain the diagnosis.
What are the indications for internal fixation of scaphoid fractures?
Should acute non-displaced fractures be fixed?
What are the complications of this injury?
How would you plan the management of an established non-union of a scaphoid fracture?
Describe these radiographs and explain the diagnosis
T he standard PA radiograph of the wrist does not show any obvious fractures; however, there is a subtle, non-displaced fracture of the scaphoid visible on the scaphoid view. This view is obtained by putting the hand and wrist in ulnar deviation, along with 15 ° of cephalad angulation of the X-ray tube.
What are the indications for internal fi xation of scaphoid fractures?
Indications for internal fi xation of a scaphoid fracture are:
1. If the displacement is more than 1 mm
2. Or the scapholunate angle > 60 °
3. Lunocapitate angle > 15 °
4. Intrascaphoid angle > 20 ° (dorsal humpback)
5. Proximal pole fractures, fractures associated with a peri-lunate dislocation
6. Delayed union
Should acute non-displaced fractures be fi xed?
The overall rate of non-union scaphoid fractures treated in POP is 10 % .
N ot all acute non-displaced fractures need fi xation, although there are some advantages. Studies have shown better early outcome scores, grip strength, and range of motion (ROM) with fi xation but no diff erence after 12–16 weeks. The rate of delayed union has been shown to be less with early fi xation. Patients should be advised to avoid cigarette smoking to optimize their potential for bone healing.
What are the complications of this injury?
T he two major complications related to this injury are avascular necrosis (AVN)of the proximal pole and non-union.
How would you plan the management of an established non union of a scaphoid fracture?
I f arthritic changes are not present on the radiographs, fi xation with bone graft should be attempted in an eff ort to get the fracture to unite. Zaidemberg and colleagues have reported excellent (100% union in 11 patients) results with a vascularized distal radial bone graft based on the 1,2 intermetacarpal branch of the radial artery. More recent studies have reported a success rate of around 70 % . If arthritic changes are present and patient is symptomatic, salvage procedures such as radial styloidectomy, proximal row carpectomy, scaphoid excision, and four-corner fusion and arthrodesis of the wrist should be considered.
Viva 7
This adolescent man comes to your clinic complaining of non-specific wrist pain and a magnetic resonance imaging (MRI) scan he has obtained privately.
Reproduced from C. Bulstrode et al., Oxford Textbook of Trauma and Orthopaedics second edition, 2011, fi gure 13.23.7, p. 1617, with permission from Oxford University Press.
Describe what you see in the image.
What is the cause of this condition?
What is the staging system for this condition?
What else should you look for on the radiographs?
What are the management options?
Describe what you see in the image
This T1 magnetic resonance image shows low signal density in the lunate, suggestive of Keinbock’s disease.
What is the cause of this condition?
Kienbock’s disease is AVN of the lunate bone in the wrist.
What is the staging system for this condition?
The Lichtmann classifi cation, which recognizes four stages:
Stage I: normal radiographs, possible stress fractures
Stage II: sclerosis of the lunate, no collapse
Stage IIIA: fragmentation and early collapse
Stage IIIB: IIIA + scapholanate dissociation and fixed rotation of the scaphoid
Stage IV: IIIB + degenerative changes in the wrist joint
What else should you look for on the radiographs?
I would look for negative ulnar variance on antero-posterior (AP) radiographs taken with the forearm in mid-prone position.
What are the management options?
T he condition can be managed non-operatively with analgesia and splintage. Operative options include joint levelling procedures (radius shortening), wrist denervation, partial or total wrist fusion, and proximal row carpectomy. Choice of treatment depends on the stage of the disease, degree of symptoms, and patient factors.
Viva 8
Reproduced from C. Bulstrode et al., Oxford Textbook of Trauma and Orthopaedics second edition, 2011, fi gure 6.4.9, p. 440, with permission from Oxford University Press.
Describe what you see on this radiograph of a 22-year-old with ulnar-sided wrist pain.
Which soft tissue structure would you expect to be involved?
Can you simplify the anatomy of this complex structure?
What are the management options for this condition?
Describe what you see on this radiograph of a 22-year-old with ulnar-sided wrist pain
T his AP radiograph of the wrist shows ulnar positive variance. This appearance is typical of ulnar abutment syndrome.
Which soft tissue structure would you expect to be involved?
T riangular fi brocartilage complex (TFCC) tears are frequently associated with this condition (Class 2 lesion).
Can you simplify the anatomy of this complex structure?
T he TFCC is a pyramid-shaped fi brocartilagenous ligamentous structure found at the distal aspect of the ulna.
It comprises a fi brocartilagenous disc (a meniscus-like structure) and a sling of ligaments and acts as a key stabilizer of the distal radioulnar (DRU) joint and the ulnocarpal joint.
What are the management options for this condition?
Non-operative measures are splint, analgesia, and avoidance of aggravating activities. Operative options include arthroscopic wafer resection of ulna, or open ulnar shortening osteotomy.
Viva 9
Tell me about the dorsal compartments at the wrist joint.
What is de Quervain’s syndrome?
What are the clinical signs of de Quervain’s syndrome?
What are the management options for de Quervain’s syndrome?
What are the adverse effects of local steroid injection?
What are the pitfalls of surgery?
Tell me about the dorsal compartments at the wrist joint
There are six compartments in which the extensor tendons traverse the dorsum of the wrist
1. APL, EPB (abductor pollicis longus, extensor pollicis brevis)
2. ECRL, ECRB (extensor carpi radialis longus, extensor carpi radialis brevis)
3. EPL (extensor pollicis longus)
4. EI, EDC (extensor indicis, extensor digitorum communis)
5. EDM (extensor digiti minimi)
6. ECU (extensor carpi ulnaris)
What is de Quervain’s syndrome?
I t is a painful condition aff ecting the fi rst compartment tendons of the wrist joint. It is commoner in females, especially post-partum.
What are the clinical signs of de Quervain’s syndrome?
There is localized tenderness and/or swelling along the radial aspect of the wrist over APL/EPB. The Finkelstein test is considered positive if pain is elicited on holding the thumb and quickly ulnardeviating the wrist. Pain may also be elicited on ulnar-deviating the wrist with fi ngers fl exed over the thumb held in the palm.
What are the management options for de Quervain’s syndrome?
N on-operative options are splintage, analgesia, and local steroid injection. If non-operative measures fail, surgical release could be considered. The procedure is done under GA or regional anaesthetic and with a upper arm tourniquet. Release may be achieved thorough a longitudinal or transverse skin incision.
What are the adverse eff ects of local steroid injection?
Adverse eff ects of local steroid injection are infection, skin atrophy and depigmentation, subcutaneous fat atrophy at the site of injection, injury to the superfi cial branch of radial nerve (painful neuroma), and tendon rupture.
What are the pitfalls of surgery?
Failure to recognize anatomical variation (EPB may lie in a separate compartment) may lead to incomplete relief of symptoms. Injury to the sensory branch of the radial nerve could result in a painful neuroma.
Viva 10
Reproduced from C. Bulstrode et al., Oxford Textbook of Trauma and Orthopaedics second edition, 2011, fi gure 14.7.1, p. 1675, with permission from Oxford University Press.
How would you manage this crush injury?
What would you explain to the patient?
How would you manage this crush injury?
I would take a relevant history, including: handedness; occupation; mechanism of injury; and comorbidities. I will provide tetanus prophylaxis (if indicated) and antiseptic (betadine) dressing.
I would obtain radiographs to exclude an underlying fracture.
As defi nitive management, I would explore and repair the nail bed under local anaesthesia (digital block) and digital tourniquet.
The salient steps of the procedure are:
1. Remove the nail plate carefully
2. Inspect the nail bed and wash thoroughly
3. Copious lavage of any underlying fracture
4. Reduce fracture if present and stabilize (axial k-wire; remove after 3–4 weeks) if necessary
5. Repair nail bed with a 6-0 absorbable suture (VICRYL Rapide)
6. Wash and replace nail plate. Figure-of-eight stitch (or equivalent) to hold the nail plate in place
What would you explain to the patient?
I would explain that the nail plate will fall off and be gradually replaced by a new one, which may initially appear disfi gured. There is a risk of some long-term nail deformity and discomfort in the region of the nail bed and some distal interphalangeal joint stiff ness.
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Viva Table 1
Hands and Paediatric Orthopaedics Section 2 Paediatric Orthopaedics
Viva 11
This 21/2-year-old girl is referred to your clinic with a limp.
Describe the radiographic findings.
How would you proceed in your management from here?
What open operative approaches would you use to reduce this hip?
Describe the radiographic fi ndings.
This is an AP pelvic radiograph showing a dislocated left hip and dysplastic acetabulum. Shenton’s line is broken and the femoral head lies lateral and superior to the inferiomedial quadrant (made by the intersection of Perkin’s and Hilgenreiner’s lines).
How would you proceed in you management from here?
I would take a full history and examine the child. There may be risk factors for developmental dysplasia of the hip (DDH) including positive family history and/or decreased intrauterine space [fi rst born, breech, oligohydramnios (associated packaging problems)].
M ore importantly I would be looking to see if there were any underlying neuromuscular conditions such as spina bifi da, arthrogryphosis, or cerebral palsy. Examination may reveal a Trendelenberg gait, leg length discrepancy, fi xed fl exion deformity as well as reduced abduction of the left hip, which is the most consistent and reliable clinical sign of this condition.
I would organize an examination under anaesthesia (EUA) and arthrogram to delineate the anatomy of the acetabulum, soft tissues, and proximal femur. It would be unlikely that this hip would reduce closed. Blocks to reduction would include: an inverted limbus; elongated ligamentum teres; hour-glass constriction of the capsule; psoas tendon and pulvinar. Indications for open reduction include: failure of closed reduction; an unstable reducible hip, or soft tissue interposition preventing a congruent reduction.
What open operative approaches would you use to reduce this hip?
I would use a modifi ed anterior (ilio-femoral) approach to the hip. I would place my skin incision parallel and distal to the iliac crest, passing 2 cm distal to the anterior superior iliac spine (ASIS) and extending medially within the groin skin crease.
I would identify and protect the lateral cutaneous nerve of the thigh and then distally I would develop the internervous plane between tensor fascia lata (superior gluteal nerve) and sartorius (femoral nerve). Splitting the iliac crest apophysis I would elevate the muscles en masse on both sides of the pelvis down to the sciatic notch and the superior border of the acetabulum. I would divide the straight head of rectus femoris and then make a T-shaped capsular incision to enter the hip joint and clear the acetabulum of pulvinar and redundant ligamentum teres (not the labrum). Any inverted labrum will require to be everted and one or more radial cuts may be necessary to allow this. The inferior capsule may also require release, with care not to damage the blood supply to the femoral head. It is likely there would be tightness in the iliopsoas and its tendon will need releasing to be able to reduce the hip.
I would then assess the need for: (1) a shortening femoral osteotomy and/or (2) pelvic osteotomy (e.g. Salter) to give more cover.
I would then perform a double-breasted capsular repair, close in layers and apply a hip spica cast with the hip in approximately 30 ° of abduction and internal rotation. The spica would need changing at 6 weeks for a total of 3 months. Post-operatively I would watch carefully for spica syndrome and organize an MRI scan to check that the hip remains enlocated.
The patient would require long-term follow-up to check that the hip develops normally.
Viva 12
This is a photograph of a 7-year-old girl sitting in a comfortable position. Her mother is concerned because she walks with her feet turned in.
Photograph courtesy of Paul Thornton-Bott FRCS (Tr&Orth).
How would you proceed with your assessment?
You find on your examination that the child has extremely lax ligaments and increased internal rotation of both hips.
How do you grade ligamentous laxity in children?
The mother has asked about surgical treatment for this condition. What would you offer her?
How would you proceed with your assessment?
This clinical photograph shows a child sitting in the ‘W’ position.
I mportant questions in the history would include enquiry about the pregnancy and birth, developmental milestones, family history, and any signifi cant past medical history. I would ask the child and the parents about current symptoms and concerns. The common causes of an in-toeing gait include metatarsus adductus, internal tibial torsion, and persistent femoral anteversion.
I n the examination it is important to rule out asymmetry in the lower legs or any neurological signs, which could indicate an underlying spinal abnormality or neurological problem.
I would examine the gait (with shoes on and barefoot), looking specifi cally at the foot progression angle (negative in this case: normal is –5 ° to + 20 ° )
With the child lying prone I would assess the torsional profi le, looking for:
z Metatarsus adductus: foot shape in relation to heel bisector line z Tibial torsion: thigh–foot angle (normal range 0–20 ° ) if foot shape is normal or transmalleolar axis (normal range 0–45° ) if foot is abnormal. Tibial torsion is defined as the angle between the transcondylar axis of the proximal tibia and the bi-malleolar axis (normal range 10–25 ° external)
z Femoral anteversion: range of motion, internal rotation (IR) > 60 ° (normal range 20–60 ° ) > external rotation (ER) < 20 ° (normal range 30–60 ° ); Ruwe’s method, measure angle from vertical [finger on greater trochanter (GT), most lateral point; normal is about 8–14 ° ]
I would also examine the spine and lower limb neurology as well as assess the degree of ligamentous laxity.
How do you grade ligamentous laxity in children?
I would use the Beighton score (out of 9):
Increased finger hyperextension — 2 points
Increased thumb hyperextension — 2 points
Increased elbow hyperextension — 2 points (1 point for each side)
Increased knee hyperextension — 2 points
Ability to place palms on floor with legs straight — 1 point
The mother has asked about surgical treatment for this condition. What would you off er her?
T his child’s in-toeing gait is most likely due to persistent femoral anteversion which is a common cause in children older than 3 years.
I would reassure the mother that her daughter is physiologically normal but just at one end of the normal spectrum for children of her age. She may be interested to learn that the only eff ective treatment is to cut the femora, rotate them, and then fi x them, which is a major surgical procedure, with risks, for essentially a cosmetic problem.
I would also explain the natural history of the condition that it tends to improve over the fi rst decade but she may well be left in-toeing as an adult. As muscle balance improves into adulthood it rarely presents a functional problem.
Viva 13
This 13-year-old boy presented with pain in his right knee.
Describe the radiograph.
How do you classify this condition?
What is your management plan now with the right hip?
What is your management plan now with the left hip?
Describe the radiograph.
This is an AP radiograph of the pelvis in a skeletally immature child. There is a mild slip of the right upper femoral epiphysis (SUFE) with a positive Trethowan’s sign. This is shown by drawing Klein’s line up the lateral border of the femoral neck and noting it does not intersect the epiphysis.
How do you classify this condition?
I would use Loder’s classifi cation which divides SUFEs into stable and unstable based on the patient’s ability to bear weight secondary to pain, and is important for predicting the risk of AVN. Other classifi cations grade the slip into mild (<33% ) , moderate (33–50% ) , or severe (> 5 0% ) the degree of which corresponds to the slip angle; this is useful when working out which are pinnable or not in situ .
What is your management plan now with the right hip?
I would take a full history for the patient and parents and examine the child. I am looking for any underlying cause for this SUFE such as endocrinopathy.
Examination fi ndings would reveal classically a hip that externally rotates and abducts with fl exion.
My management plan would consist of pinning this slip in situ with a single cannulated screw — use of more than one screw increases complications including AVN and chondrolysis.
I would perform this under GA on a fracture table, but would not use a forced reduction manoeuvre or traction which could increase the risk of AVN. I would use a triangulation technique to defi ne the appropriate location for the skin incision. The thread of the screw should be in the centre of the epiphysis passing through perpendicular to the physis (this avoids perforating the femoral head). As the slip is usually postero-medial this technique usually requires an anterior femoral neck entry point. A minimum of two to three screw threads should pass into the epiphysis, depending on the size of the child and the instrumentation used.
What is your management plan now with the left hip?
Contralateral prophylactic screw fi xation to prevent slip in the future remains a controversial topic. Options are to treat every case with contralateral fi xation, versus pinning only those children thought to be at higher risk of contralateral slip or signifi cant leg length discrepancy (less than 10 years old, underlying endocrinopathy).
Viva 14
This 8-month-old baby was brought to casualty with the above injury.
What are your thoughts?
Tell me about non-accidental injury and what you would do if you suspected it?
How would you treat this fracture?
What are your thoughts?
T his is a AP view radiograph of a child's lower pelvis and femurs showing an oblique fracture at the left subtrochanteric level. I would like to take a detailed history from the parents or carer, as a fracture of the femur in a non-ambulant child could be a non-accidental injury (NAI). You must pick this possibility up— it is reasonable for this to be a pass/fail type question.
Tell me about non-accidental injury and what you would do if you suspected it.
N on-accidental injury is an injury deliberately infl icted by a parent or a caregiver. It may be diffi cult to suspect a parent or carer of abuse but we have a duty of care as professionals to ensure care and protection of children.
Child abuse itself can take diff erent forms (physical, neglect, sexual, emotional, Munchausen’s by proxy — rare): most are in combination. It is the second most common cause of death in young children (after trauma). Risk factors include fi rst born, premature babies, stepchildren, family history of abuse, and parental IV drug abuse.
Firstly it is important to get the child into a safe environment and treat the traumatic injuries appropriately in the same way as for an accidental injury, according to Advanced Trauma Life Support (ATLS) guidelines and being mindful that there may be other more life-threatening injuries (subdural haematoma and ‘shaken baby’ syndrome). Having taken a detailed history from the parents and examined the child fully (with a chaperone), I would document my fi ndings carefully in the notes. Clues suggesting NAI in the clinical assessment include a history that doesn’t fi t the injury, inconsistent explanations and delayed presentation, bruising patterns on the child, and retinal haemorrhages. I would inform the paediatricians of my concern about a possible NAI and make arrangements for the child to be admitted.
R adiographic clues for NAI include metaphyseal bucket handle corner fractures (virtually pathognomonic), rib fractures, and fractures of varying ages evidenced by diff erent stages of healing.
How would you treat this fracture?
I would treat this fracture in gallows traction with a radiograph at 2–3 w eeks, to show callus formation, and then gentle mobilization as comfort allows. A hip spica is sometimes used.
Viva 15
A 3-year-old child is referred from casualty with a 24-h history of fever, malaise, and reluctance to bear weight on his right leg.
What is your approach to this patient?
The casualty officer has sent some routine bloods and organized an ultrasound scan (USS) of his right hip which is shown above.
How would you assess the child and what is your management now based on the hip scan?
What is your approach to this patient?
I would want to assess the child to exclude an infectious cause for his symptoms such as a septic arthritis or osteomyelitis.
How would you assess the child and what is your management now based on the hip scan?
My clinical assessment would start with a detailed history from the parents.
On examination I would make an assessment of whether the child was well or unwell, and request a temperature measurement. I would assess the resting posture and range of motion of the hips. I may fi nd the hip to be in a position of most comfort (fl exed, abducted and externally rotated). I would also examine the whole lower limb, chest, abdomen, and spine.
The ultrasound shows an eff usion around the hip which has been measured as 7 mm.
I would review the blood investigations taken.
I would organize AP and lateral radiographs of any aff ected part to rule out any underlying structural abnormality or fracture.
Four predictive markers of hip septic arthritis include:
1. Temperature > 38.5 ° C
2. White blood cells (WBC) > 12,000 cells/mm 3
3. ESR > 40
4. Non-weight bearing
T he chance of there being a septic arthritis increases with the number of positive factors present [ × 1= 3 % , × 2= 40 % (treat as septic arthritis), × 3= 93 % , / × 4= 99.6 % ].
I would arrange an aspirate of the hip joint
If the aspirate revealed pus I would organize an open washout of the hip as soon as possible (urgent case < 6 h)
I would approach the hip through an anterior approach and remove an ellipse of capsule to allow free drainage after taking some deep tissue samples to send to microbiology and a copious washout with normal saline. I don’t routinely use a hip spica post-operatively but recognize the risk of secondary subluxation and dysplasia that may develop in this condition. I would discuss appropriate antibiotics with the microbiologist, usually starting with broad spectrum and then adjusting, guided by the culture and sensitivities.
The child would require daily clinical and serial biochemical (infl ammatory markers) review to make sure they improved. A prolonged course of antibiotics is advised. The child would also require longerterm follow-up to check the development and the growth of the hip joint.
Viva 16
You are asked to go and assess a newborn chid on the maternity ward.
Describe the clinical photograph and the components of this deformity.
How do you classify the severity of this condition?
Describe the clinical photograph and the components of this deformity.
T his is a clinical photograph of a newborn child with a clubfoot deformity (congenital talipes equinovarus). This is a complex three-dimensional deformity seen at birth with cavus and adductus of the midfoot and forefoot and varus and equinus of the hindfoot.
How do you classify the severity of this condition?
There are diff erent scoring systems described to grade the severity of the deformity. In my institution we use the Pirani scoring system. It comprises two main scores, the midfoot contracture score and the hindfoot contracture score, which are combined to give a possible maximum total score of 6. (A high score correlates to a more deformed foot.) Each of these scores is made up of three separate components which are graded as 0, 0.5, or 1. The individual components of the deformity assessed are: severity of medial crease, coverage of the lateral head of talus, and curvature of the lateral border used in the midfoot score and rigidity of equinus, severity of the posterior crease, and degree of emptiness of heel for the hindfoot score.
How would you take your management from here?
I would manage this patient by taking a good history from the parents and examining the child to make sure they did not have any associated congenital anomalies or features which may suggest that this is a 'syndromic' club foot as opposed to an idiopathic clubfoot. I would then explain and start the Ponseti treatment programme, which is now recognized worldwide as an appropriate mainly non-operative approach to club foot treatment.
It starts with manipulation and serial casting.
T he fi rst key manoeuvre is to reduce the cavus deformity by dorsifl exing the fi rst ray and unlocking the forefoot and midfoot. Elevation of the fi rst ray produces supination so I warn the parents the foot may look worse after the fi rst cast. The second important manoeuvre is to abduct the forefoot at midfoot level using the uncovered head of the talus laterally as a fulcrum.
A bove-knee casts (with the knee at 90° ) are applied with moulding into the corrected position and then each week the old cast is removed, the foot is scored and then subsequent casts are applied. The midfoot usually corrects well after four or fi ve casts. If there is residual equinus (or less than 20 ° of dorsifl exion) of the hindfoot then this can be addressed by performing an Achilles tenotomy under a local or general anaesthetic. A fi nal cast is applied for a further 3 weeks while the tenotomy heals.
Babies then go into Denis Browne boots with a bar (23 h a day for 3 months then just at night and naptime until the age of 5 years). This holds the aff ected foot externally rotated at about 70 ° . The vast majority of patients do very well and avoid the need for extensive surgical release. However, approximately 25% will require a tibialis anterior transfer laterally for residual deformity or inversion in swing after the age of about 4–5 years.
Viva 17
Here is a child with cerebral palsy.
What is cerebral palsy and what different types do you know?
What is spasticity?
In what different ways do we manage spasticity?
Often ambulant children with cerebral palsy are assessed by gait analysis. What does that involve?
What is cerebral palsy and what diff erent types do you know?
Cerebral palsy is a neuromuscular disorder caused by a non-progressive lesion to the immature developing brain (before the age of 2 years). Although the neurological injury is non-progressive, the musculoskeletal features evolve as the child grows.
Types of cerebral palsy are:
Anatomical — hemiplegia (40 % )/diplegia (30 % )/total body involvement (30 % )
Physiological — spastic (60 % )/dystonic (20 % )/ataxic (10 % )/hypotonic (10 % ) Functional — classified by the Gross Motor Function Classification System (GMFCS)
What is spasticity?
Spasticity is the velocity-dependent increase in the tone of muscles (represents an increased response to stretch refl ex).
In what diff erent ways do we manage spasticity?
Principles include a multidisciplinary approach involving family and patient in goal planning, decisions about treatments, and exploring expectations.
Non-operative treatment is based around a physiotherapist who often acts as the main link between specialists. Adjuncts can be used to control spasticity including: botulinum toxin injections or baclofen (tablets or intrathecal pump).
z Botulinum toxin A (derived from Clostridium botulinum ) is injected locally (dose is weight dependent) into spastic muscles. It works by preventing release of acetylcholine at the neuromuscular junction of those tight muscles and is effective for 3–6 m onths. It is often used in combination with plasters and targeted physiotherapy and/or orthotics to maintain an improved stretch
z Baclofen is a gamma-aminobutyric acid (GABA) agonist (an inhibitory neurotransmitter) which acts both centrally and peripherally to decrease spasticity. If administered intrathecally, via an infusion pump it allows an increased local dose with decreased systemic side-effects
Surgery is often needed, and appropriate planning and timing is crucial when performing multilevel surgery to avoid ‘birthday syndrome’. Options can include bony surgery as well as soft tissue lengthening (without weakening) of tight muscles, as well as transfers of muscles to augment weak muscles.
Often ambulant children with cerebral palsy are assessed by gait analysis. What does that involve?
G ait analysis is the systematic description, assessment, and measurement of the quantities that characterize human locomotion. It involves the study of kinematics (the movements of the individual parts of the body) and kinetics (the forces and how they interact to produce those movements) as well as electromyography and energy consumption.
T here is no defi ned standard; however, most gait laboratories will have two-dimensional video analysis and three-dimensional computer analysis, using specialized markers stuck onto specifi c bony landmarks. The computer program then breaks down the individual movements of anatomical parts into graphic form. Further detailed analysis involves the use of force plates, measuring ground reaction force, and electromyography, looking at muscle fi ring patterns.
I t is important that the results of gait analysis are looked at in conjunction with a static detailed physical examination.
Viva 18
Can you describe this radiograph? What do you think the diagnosis is?
This patient presents with new-onset pain in the upper thigh. What do you think has happened?
How would you manage this patient now?
You treat expectantly, but unfortunately the lesion remains. How would you proceed now?
Can you describe the radiograph? What do you think the diagnosis is?
This is an AP radiograph showing a multiloculated lytic lesion in the proximal metaphysis of an immature individual. The zone of transition is sharp indicating this is likely to be a benign lesion with no associated periosteal reaction. Top of my diagnosis would be a loculated simple bone cyst, but an aneurysmal bone cyst is also a possibility.
This patient presents with new-onset pain in the upper thigh. What do you think has happened?
A lot of these lesions are found incidentally on radiographs taken for another reason, but new-onset pain in that area would suggest a pathological fracture through the weakened bone. A fallen fragment sign (cortex that has fallen into the cystic cavity) is pathognomonic of this.
How would you manage this patient now?
Having taken a thorough history and examined the patient, I would probably manage this expectantly as in a good percentage of patients the fracture actually stimulates new bone formation and with time the cyst fi lls in.
You treat expectantly but unfortunately the lesion remains. How would you proceed now?
I f an expectant non-operative approach failed I would, under image guidance, aspirate the cyst and inject some steroid or bone graft/marrow to try and stimulate new bone formation. If this failed, a repeated attempt is worthwhile; however, the defi nitive surgical treatment would involve curetting out the lining of the cyst through a small cortical window and stabilizing the bone to prevent fracture. I would use fl exible intramedullary nails across the lytic area. If the cavity is adjacent to the growth plate it is important not to damage it and risk growth arrest.
Viva 19
This 6-year-old child fell out of a tree onto their left arm.
Can you describe the radiograph?
How would you manage this child?
You reduce and pin the fracture under anaesthetic, but on post-operative review in recovery you are unable to feel a pulse. What would you do now?
Can you describe the radiograph?
There is an ‘off ended’ Gartland 3 supracondylar fracture of the distal humerus.
How would you manage this child?
A ssuming this was an isolated injury I would assess the child for the presence of an open injury, and also assess the distal neurovascular status (colour of hand, capillary refi ll of the fi ngertips, radial pulse, sensation in the specifi c dermatomes, and motor function of ulnar, radial, median, and anterior interosseus nerves).
I would organize for the child to have analgesia and a temporary backslab splint to stop the arm from moving and then mobilize my theatre team, as this child needs to go to theatre as soon as possible for closed reduction and percutaneous pinning.
I n theatre, the set-up of the image intensifi er and the help of a good assistant is key. The technique for reduction of these injuries is to apply good continuous traction (in 20° of fl exion ) for several minutes, then correct any valgus/varus and rotational deformity, before fl exing up and hooking the distal fragment back on to the shaft. The forearm can be pronated to lock the fragments. I would insert a lateral wire fi rst (1.6 mm), making sure I was through the far cortex. With that wire giving some stability, it is possible to extend the arm a little to plan a mini open approach to the medial side, allowing protection of the ulna nerve prior to inserting the cross wire. I would bend and cut the wires for ease of removal in the clinic in 3–4 weeks’ time. I would splint the arm in a backslab in near extension. I would reassess the perfusion of the hand and watch for compartment syndrome.
You reduce and pin the fracture under anaesthetic, but on post-operative review in recovery you are unable to feel a pulse. What would you do now?
If I found no pulse in my post-operative review of the patient, I would make an assessment of the rest of the vascularity of the hand in terms of its colour and warmth and also the capillary refi ll time. If the hand was pink and warm with adequate capillary refi ll of the fi ngertips, then I would monitor the situation with regular review. The artery is likely to be in spasm and the pulse can take a day or two to recover. If the hand was white and capillary refi ll reduced, I would release the backslab and allow the arm to extend to see if this improved the situation. If not I would contact the vascular/plastic surgeons for an urgent review as the artery may have been caught up in the fracture and has now been occluded by the reduction. If so this would now require open exploration, usually via an anterior approach.
Viva 20
This radiograph shows a post-operative view of a boy’s pelvis. What do you think the underlying diagnosis is and what procedure has he had?
What is the underlying disease and who gets it?
How do you classify this condition?
What are the principles of management?
This radiograph shows a post-operative view of a boy’s pelvis. What do you think the underlying diagnosis is and what procedure has he had?
This is an AP pelvic radiograph of a skeletally immature patient showing fl attening and deformity of both femoral heads in keeping with Perthes’ disease. (Legg–Calve–Perthes disease). On the left side this patient has had a shelf procedure, which is a salvage type of acetabular procedure. It is an operation that redistributes the weight-bearing load of the femoral head through a larger surface area of pelvic cover.
What is the underlying disease and who gets it ?
P erthes’ disease is idiopathic AVN of the proximal femoral epiphysis in childhood. It remains a controversial topic in orthopaedics because of its unknown aetiology and uncertain optimal treatment. It is more common in boys than girls by about 4:1 and it is bilateral in about 20 % of cases.
How do you classify this condition?
T here are many classifi cations used for Perthes’ disease. Waldenström classifi ed it into pathological stages:
1. Initial avascular event (crescent sign — representing a subchondral fracture)
2. Fragmentation (Herring’s pillar classification)
3. Resolution — re-ossification
4. Remodelling — healed
T he Herring classifi cation of severity is based on the lateral pillar height on an AP radiograph during the fragmentation stage:
z B — more than 50 % maintained z C — less than 50 % maintained
(A B/C border category was subsequently added.)
C atterall’s classifi cation contains four groups depending on the amount of femoral head involved on the lateral radiograph.
C atterall also added clinical and radiological ‘head at risk signs’ which he used to guide his management:
|
Clinical |
|
|
Obese |
Horizontal physis |
Progressive decreased ROM Lateral subluxation of epiphysis
Abduction contracture Lateral calcifi cation
ER with fl exion Diff use metaphyseal reaction
G age sign— i nverted V-shaped lucency in lateral metaphysis
ROM, range of motion; ER, external rotation.
S tulberg’s classifi cation assessed the shape of femoral head at skeletal maturity and is used to predict who will do poorly in terms of early onset degenerative change:
I — normal
II — head spherical (magna/breva) and fits in socket which is congruent
III— mushroom head congruent
IV — flat head and flat socket congruent
V— flat head incongruent
Hands and Paediatric Orthopaedics
What are the principles of management?
Goals of treatment are:
1. Symptomatic relief
2. Containment of the head and hence correct development
3. Restoration of ROM
T hese goals can be achieved by various non-operative and operative treatments which still are debated around the world.
E ach patient should be managed on an individual basis taking into account their age, clinical signs, and radiological appearances on X-ray.
