Paediatric

FRCS Trauma and Orthopedic Exam

1. what are the X ray finding ?

deformity of the right femoral head
subchondral fracture with collapse of the articular surface
Lateral subluxation of the femoral head
break in shenton's line
leg in held in adduction

what is Perthes Disease ?

it is an idiophatic avascular necrosis of the femoral capital epiphysis. The cause in
unknown. It is thought to be multifactorial

Epidemiology
It occurs between about 18 months of age and skeletal maturity. Most children are between
5 and 10 years of age at the time of onset. It is bilateral in 10 to 12 % of children. Boys are
affected 4 to 5 time more frequently than girls. Girls have a worse prognosis.

Etiology
The cause is uncertain. It is probably multifactorial. Haematologic and clotting
abnormalities (e.g. deficiencies of protein C and S) have been suggested by some but have
not been confirmed by others.

The main arterial supply to the femoral head comes from the lateral ascending cervical
artery which is the terminal branch of the medial circumflex femoral artery and lies within
the hip joint capsule. The terminal branch runs through a narrow passage between the
greater trochanter and the capsule where it can become constricted. The blood supply can
be occuled by abducting and internally rotating the hip.

Most common symptom and signs ?

symptom are pain in the groin, around the hip and/or knee. Sign are:
-child walks with a limp
-limited range of the hip movements affecting generally abduction and internal rotation.

what is the lateral Pillar classification (Herring) ?

Group A
No involvement of the lateral pillar. No density change. No loss of height
Group B
Mild density change in the lateral pillar. Height >50% of original height. Cental pillar
colapse.
Group B/C

Very narrow lateral pillar (2-3 mm wide) with 50% of the original height that is depressed
relative to the central pillar.
Group C
Lateral pillar with <50% of the original height
It has superseded the classification and has become the most commonly used classification.

What is the Catterall classification ?

Group I : Only anterior portion of the epiphysis affected. up to 25% head involvement.
Group II : More of the anterior portion is involved and a central segment is present. Up to
50% head involvement.
Group III : Most of the epiphysis involved with the unaffected portions located medial and
lateral to the central segment. Up to 75% head involvement.
Group IV : Total head involvement.

According to Catterall, groups I and II have a benign prognosis.

Several interobserver studies have shown a low degree of reproducibility.

What are Catterall's Head at risk signs?

1. Gage sign (V shape lucency at lateral epiphysis)
2. Horizontal growth plate
3. Lateral classification
4. Subluxation
5. Metaphyseal cystic changes

What are the radiographic stages described by Waldenstorm?

1. Initial / ischaemic
2. Fragmentation/resorbtion
3. reossification/healing
4. residual / remodelling

Treatment
This is very controvesial with there being no national and no international agreement.
In the early onset group under the age of the 8 years, children are mostly managed nonoperatively.

Prognosis
This is related to the congruency of the hip joint and the spericity of the femoral head.

Congenital Taliped Equino Varus (CTEV)

What are the deformities ?
Deformities
1. Hindfoot equinus
2. Hindfoot varus
3. Midfoot/forefoot cavus
4. Forefoot adduction

CAVES : CavusAdductusVarusEquinus
The forefoot looks supinated but it is in a pronated position in relation to the midfoot. The
calf and foot are smaller which is obvious in the unilateral deformity.

What is the Pirani classification ?

This is a system to score to severity of a clubfoot deformity. It consist of A)a hindfoot
score, assesing the posterior heel/ankle crease, the position of the calcaneum in the heel and
the rigidity of the equinus and B) a midfoot score, assesing the medial crease, the lateral
curvature of the foot and the lateral coverage of the head of the talus by the navicular.

Each component scores 0,05 or 1 giving a maximum of 6 points for the most severe
deformity.