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Paediatrics for FRCS (Tr & Orth)
Paediatric orthopaedics covers the three hip conditions of childhood — developmental dysplasia, Perthes disease and slipped upper femoral epiphysis — the foot, rotational and angular deformity and limb-length discrepancy, cerebral palsy and the neuromuscular conditions, children’s fractures and physeal injury, bone and joint infection, and the skeletal dysplasias, syndromes and congenital limb differences. Age is the organising principle: the same limp has a different differential at two, six and thirteen, and the same hip condition is treated differently at each age.
Topics in this domain
- The paediatric hip50
- Foot, lower limb deformity & neuromuscular50
- Paediatric trauma25
- Infection, syndromes & congenital conditions25
What the paper tends to test
- Hip questions give an age and a presentation, and ask for the diagnosis or the age-appropriate treatment: harness, closed or open reduction, containment, or fixation in situ.
- Clubfoot questions test the Ponseti method: the order of correction, the role of Achilles tenotomy and the importance of bracing.
- Fracture questions use the Salter–Harris and Gartland classifications and ask for the nerve most likely to be injured or the complication to expect.
- The limping child is tested through the distinction between septic arthritis and transient synovitis.
- Deformity questions ask which appearances are physiological for the child’s age and which need investigation.
- Neuromuscular questions centre on hip surveillance in cerebral palsy and the Gross Motor Function Classification System.
Classic traps and discriminators
- A slipped upper femoral epiphysis is classified as stable or unstable by whether the child can bear weight, with or without crutches — not by the duration of symptoms — and the unstable slip carries a much higher risk of avascular necrosis. Knee pain may be the only complaint.
- In the Ponseti method the cavus is corrected first, by elevating the first ray; pronating the forefoot makes the deformity worse. Equinus is corrected last, usually with a percutaneous Achilles tenotomy.
- In an extension-type supracondylar fracture the anterior interosseous nerve is the one most often injured; the ulnar nerve is the one at risk from a medial wire.
- A pink, pulseless hand after a supracondylar fracture is treated by urgent reduction and fixation and then observed; a white, pulseless hand that stays poorly perfused after reduction needs exploration.
- Bow legs are physiological until about the age of two and knock knees peak at around three to four; deformity that is unilateral, progressive or outside those ages needs investigation for causes such as Blount’s disease or rickets.
Free revision notes
Paediatrics questions, answered
What are the Kocher criteria for septic arthritis of the hip?
Four predictors that distinguish septic arthritis from transient synovitis in a child with an irritable hip: inability to bear weight, a temperature above 38.5 °C, an erythrocyte sedimentation rate above 40 mm/h and a white cell count above 12 × 10⁹/L. The probability of septic arthritis rises with each one present; a raised C-reactive protein was later shown to be an additional independent predictor.
How is developmental dysplasia of the hip treated at different ages?
In broad terms: a Pavlik harness in the first six months for a reducible hip, with ultrasound monitoring; examination under anaesthesia, arthrogram and closed reduction in a hip spica from about six to eighteen months, or when a harness has failed; and open reduction, with femoral or pelvic osteotomy as needed, in the older child. Avascular necrosis of the femoral head is the complication every stage tries to avoid.
Which nerve is most often injured in a supracondylar fracture?
In the common extension-type fracture, the anterior interosseous branch of the median nerve: the child cannot flex the interphalangeal joint of the thumb or the distal interphalangeal joint of the index finger, and there is no sensory loss. Most are neurapraxias that recover.
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