title: "Week 7: Orthopaedics, Rheumatology, Emergency & Adolescent Health"
Week 7: Orthopaedics, Rheumatology, Emergency & Adolescent Health
1. Orthopaedics
Common Orthopaedic Findings
| Condition | Age | Notes |
|---|---|---|
| Flat feet (pes planus) | All ages | Typically resolves 4-8 years. Reassure. |
| In-toeing | 1st year | Various causes. Usually resolves spontaneously. |
| Bow legs (genu varum) | 1-2 years | Increased intercondylar distance. Resolves by 4-5. |
| Knock knees (genu valgum) | 3-4 years | Increased intermalleolar distance. Resolves spontaneously. |
Trendelenburg gait: Unilateral hip abductor weakness. The sound side "sags" and torso swings toward the affected side.
The Limping Child
Most limping children don't need investigations. However, acute inability to weight-bear is a red flag. Always consider septic arthritis in severe localised joint pain with fever.
Red Flags:
- Duration >7 days
- Severe localised joint pain (septic?)
- Complete inability to weight-bear
- Nocturnal symptoms
- Systemic symptoms
- Fever + petechiae
Normal X-ray cannot exclude septic arthritis or early osteomyelitis!
Developmental Dysplasia of the Hip (DDH)
Spectrum from subluxable to fully dislocated hip. Incidence 4 in 1000. F:M 6:1 (only hip condition with female preponderance).
- Female
- Firstborn
- Family history
- Feet down (breech)
- Fluid low (oligohydramnios)
Clinical Tests:
- Barlow's test: Provocation - hip dislocates posteriorly
- Ortolani test: Abduct and apply inward pressure - hip relocates
- Galeazzi sign: Different knee heights when hips/knees flexed to 90°
Imaging:
- <6 months: Ultrasound (hip is cartilaginous)
- >6 months: X-ray
Treatment: Pavlik harness (infants), abduction brace (older children)
Hip Pain by Age
| Age | Condition | Key Features |
|---|---|---|
| 2-6 years | Transient synovitis | Acute hip pain, decreased ROM, preceding URTI, well child |
| 4-10 years | Perthes disease | Progressive hip pain/limp, AVN of femoral head, positive Trendelenburg |
| 10-14 years | SCFE | Overweight male, externally rotated hip, surgical emergency |
Transient Synovitis
Preschool child with sudden onset hip/knee pain, limp, and morning stiffness. Often follows viral URTI. Benign course, child is constitutionally well. Resolves in 2 weeks with rest and NSAIDs.
Perthes Disease (Legg-Calve-Perthes)
AVN of femoral head in boys aged 4-10. Idiopathic interruption of blood supply. Progressive hip pain, limp, positive Trendelenburg, decreased ROM.
- X-ray: Fragmentation and collapse of femoral head
- Younger = better prognosis (<8 years)
- Usually conservative treatment, self-resolving over 4-5 years
- 50% need hip replacement by age 50
Hip pain may refer to the knee! Always examine the hip in any child with knee pain.
Slipped Capital Femoral Epiphysis (SCFE)
Surgical emergency! Typically overweight peripubescent male (10-14 years). Femoral head "slips" off neck through growth plate.
Features:
- Hip/knee/thigh pain
- External rotation deformity
- Out-toeing gait
- "Knee pain" is a red herring
Investigation: X-ray AP + frog lateral view (AP alone can miss early slips)
Management: Screw fixation, often prophylactic contralateral fixation
Paediatric Fractures
Paediatric bones differ from adults:
- Thicker periosteum (heals faster)
- Physis is weak point (fractures > dislocations)
- More porous (bend before break)
Unique Paediatric Fracture Patterns:
- Greenstick: Incomplete fracture, cortex intact on one side
- Buckle/Torus: Compression failure at metaphysis
- Plastic bowing: Bone bends but doesn't break
- Physeal (growth plate) fractures: Risk of growth disturbance
SALTER = Same (I), Above (II), beLow (III), Through (IV), crUshed (V)
- I: Through physis only
- II: Above (metaphysis + physis) - most common
- III: Below (epiphysis + physis)
- IV: Through all (metaphysis + physis + epiphysis)
- V: Crushed physis (worst prognosis)
Non-accidental injury fractures: Multiple fractures at different healing stages, metaphyseal corner fractures, rib fractures without trauma, femur fractures in non-ambulatory children.
2. Rheumatology
pGALS Musculoskeletal Screen
Screening questions:
- Any pain or stiffness in joints, muscles, or back?
- Any difficulty dressing without help?
- Any problems going up and down stairs?
Arthritis = joint swelling/effusion, OR 2+ of: tenderness, pain on movement, limited movement, increased warmth.
Septic Arthritis
Orthopaedic emergency! Acute joint pain, swelling, tenderness, inability to walk + fever.
- Usually Staph aureus via haematogenous spread
- Joint aspiration is definitive (WCC (White Cell Count) >50,000)
- Management: Antibiotics, arthroscopic washout
Osteomyelitis
Most common organism: Staph aureus. Less acute than septic arthritis. Pinpoint bone tenderness, serous effusion if near joint.
- X-rays may be normal early - use bone scan or MRI (Magnetic Resonance Imaging)
- Treatment: IV (Intravenous) antibiotics +/- surgery
Transient Synovitis vs Post-Infectious Arthritis
| Feature | Transient Synovitis | Post-Infectious Arthritis |
|---|---|---|
| Age | 2-5 years | Variable |
| Preceding illness | Viral URTI | Documented infection (bacterial/viral) |
| Joints | Unilateral hip | Oligoarthritis, lower limb |
| Systemic symptoms | Absent/mild | May have fever |
| Duration | 1-2 weeks | Weeks to months |
| Prognosis | Excellent | Usually good |
Juvenile Idiopathic Arthritis (JIA)
Arthritis ≥6 weeks, onset <16 years, exclusion of other causes. Most common chronic rheumatic disease in children.
Types:
- Oligoarticular (most common): ≤4 joints, high ANA, uveitis risk
- Polyarticular: ≥5 joints, RF+/RF-
- Systemic (Still's disease): Quotidian fever, salmon-pink rash, hepatosplenomegaly
All children with JIA need regular ophthalmology screening for uveitis - can be asymptomatic and cause vision loss.
Growing Pains
Age 3-10 years. Bilateral, at night, calf/thigh/shins. Normal examination. Requires massage and analgesia.
Red flag: Unilateral nocturnal pain - consider malignancy!
Apophysitis (Growth-Related Conditions)
| Condition | Location | Age |
|---|---|---|
| Osgood-Schlatter | Tibial tubercle | 10-14 years |
| Sinding-Larsen-Johansson | Inferior patella | 10-14 years |
| Sever's disease | Calcaneal apophysis | 8-12 years |
Apophysitis presents with mechanical pain (no early morning stiffness), activity-related, at sites of tendon insertion on growth centres.
IgA Vasculitis (Henoch-Schonlein Purpura)
Most common childhood vasculitis. Triad: palpable purpura (buttocks/lower limbs), arthritis, abdominal pain.
- May have renal involvement (nephritis)
- Usually self-limiting, supportive treatment
- Monitor for renal complications
3. Emergency Medicine
Recognising the Sick Child
Use Paediatric Assessment Triangle (PAT): Appearance, Work of breathing, Circulation. Abnormality in any = sick child.
Appearance: Tone, interactiveness, consolability, look/gaze, speech/cry
Red Flags:
- Altered consciousness
- Weak, high-pitched, or continuous cry
- Reduced skin turgor
- Mottled/pale/blue colour
- Non-blanching rash
Paediatric Fluid Management
Holliday-Segar formula for maintenance:
- First 10 kg: 100 mL/kg/day
- Second 10 kg: 50 mL/kg/day
- Each kg after: 20 mL/kg/day
Source: Holliday–Segar (4-2-1 rule).
Resuscitation bolus: 10-20 mL/kg 0.9% saline
Assess dehydration:
- Mild (3-5%): Dry mucous membranes, decreased urine
- Moderate (5-10%): Sunken eyes/fontanelle, decreased skin turgor
- Severe (>10%): Shock, altered consciousness
Source: Local paediatric dehydration assessment guideline (e.g., RCH CPG).
Anaphylaxis
First-line treatment: IM (Intramuscular) Adrenaline (1:1000)
- 0.01 mg/kg (max 0.5 mg) Repeat every 5 minutes if no improvement.
Source: ASCIA Guidelines.
Paediatric Basic Life Support
Compression to ventilation ratio:
- Single rescuer: 30:2
- Healthcare providers (2 rescuers): 15:2
Compression depth: 1/3 of chest depth
Foreign Body Aspiration
Choking in conscious child:
- Infant (<1 year): 5 back blows, 5 chest thrusts
- Child (>1 year): 5 back blows, 5 abdominal thrusts (Heimlich)
If unconscious: Begin CPR (Cardiopulmonary Resuscitation)
4. Adolescent Health
Main drivers of adolescent morbidity: mental health, injury, chronic illness, and risk-taking behaviours.
HEEADSSS Assessment
- H - Home
- E - Education/Employment
- E - Eating
- A - Activities (peers, hobbies)
- D - Drugs/Alcohol
- S - Sexuality
- S - Suicide/Depression
- S - Safety (violence, abuse)
Consent and Confidentiality
Gillick competence: A minor can consent to medical treatment if they have sufficient understanding and intelligence to fully comprehend what is proposed.
Confidentiality limits:
- Risk of harm to self or others
- Mandatory reporting (child abuse)
- Notifiable diseases
Common Adolescent Issues
Mental Health:
- Depression and anxiety are common
- Self-harm is a major concern
- Always screen for suicidal ideation
Substance Use:
- Alcohol, cannabis, vaping most common
- Non-judgmental approach essential
Sexual Health:
- Contraception counselling
- STI screening
- Respectful, confidential discussions
One adult who cares is a key protective factor for adolescent resilience.
5. Paediatric Surgery Pearls
Acute Abdominal Pain
Surgical emergencies:
- Appendicitis (periumbilical to RIF, rebound, guarding)
- Intussusception (sausage-shaped mass, "redcurrant jelly" stool)
- Malrotation with volvulus (bilious vomiting in neonate)
- Incarcerated hernia
Intussusception
6 months - 2 years. Intermittent colicky pain, legs drawn up, "sausage-shaped mass" RUQ, "redcurrant jelly" stool (late sign).
- Diagnosis: Ultrasound ("target sign")
- Treatment: Air enema reduction (if stable), surgery if fails
Pyloric Stenosis
2-8 weeks old. Projectile non-bilious vomiting after feeds, hungry after vomiting, "olive-shaped mass" in epigastrium.
- Diagnosis: Ultrasound (pyloric muscle thickness >3mm)
- Bloods: Hypochloraemic, hypokalaemic metabolic alkalosis
- Treatment: Ramstedt pyloromyotomy (after rehydration and correction of electrolytes)
Burns
Rule of 9s (modified for children - head is larger proportion). Fluid resuscitation if >10% TBSA (Parkland formula).
Non-accidental injury patterns:
- Glove/stocking distribution
- Sharply demarcated burns
- Delay in presentation
- Story inconsistent with injury
6. Non-Accidental Injury (NAI)
Child abuse is common: approximately 1 in 4 children experience some form of maltreatment. Types: physical abuse, neglect (most common), emotional abuse, and sexual abuse. Health professionals are mandatory reporters in all Australian states and territories.
Indicators of Physical Abuse
High-suspicion injury patterns:
- Bruising in non-mobile infants (babies who are not yet cruising should not have bruises)
- Bruises on ears, neck, buttocks, or trunk (not typical play injuries)
- Multiple fractures at different stages of healing
- Metaphyseal corner fractures (classic for abuse - caused by shaking/pulling)
- Posterior rib fractures in infants (from squeezing)
- Femur fractures in non-ambulatory children
- Subdural haematomas in infants (shaken baby syndrome / abusive head trauma)
- Retinal haemorrhages
Bruises in these locations are concerning for abuse:
- T - Torso
- E - Ears
- N - Neck
- 4 - Any bruise in a child under 4 months old, OR any bruise in a child aged 4 years or under in the above locations
When documenting suspected NAI: use body maps, photograph injuries (with consent and ruler for scale), document the history verbatim from each caregiver separately, and note any inconsistencies between the history and the injury pattern.
Abusive Head Trauma (Shaken Baby)
Triad of abusive head trauma: Subdural haematoma, retinal haemorrhages, and encephalopathy. Peak age: under 1 year. Most common cause of death from child abuse.
Approach to Suspected NAI
- Ensure child safety - this is the priority
- Thorough history (mechanism, timing, who was present)
- Full examination (including genitalia, skin, fontanelle)
- Investigations: skeletal survey (under 2 years), CT head (if head injury suspected), bloods (FBC, coagulation, LFTs)
- Mandatory notification to child protection services
- Document meticulously
Always consider medical mimics before attributing injuries to NAI: bleeding disorders (haemophilia, ITP, von Willebrand), osteogenesis imperfecta, Mongolian blue spots, and cultural practices (cupping, coining).
Practice Questions
What is the most likely diagnosis?
What is the most important investigation?
What is the most likely diagnosis?
What is the most appropriate next step?
What is the most likely diagnosis?
What is the most appropriate immediate anti-epileptic treatment?