Short Stature

Short stature - clinical features and growth

Growth assessment and physeal contribution to limb length in the short child.

15 questions 3 source pages

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Q1Describe the clinical photo of obstetric brachial plexus injury.▸

Q2What risk factors would you identify for obstetric brachial plexus injury in this infant?▸

Q3What is the Narakas classification and how is progress monitored?▸

Narakas: C5,6 / C5,6,7 / C5-T1 / C5-T1 + Horner's
Mallet score to monitor progress: 1 active abduction, 2 external rotation, 3 hand to head, 4 hand to back, 5 hand to mouth
MRI to look for meningocele

Q4What are the favourable and unfavourable prognostic factors in obstetric brachial plexus injury?▸

In general 90% spontaneous resolve
Favourable: Erb's palsy; +ve twitching (M1) over bicep and deltoid at 2mth old
Unfavourable: M0 at 3mth old; preganglionic injuries (Horner, dorsoscapular and phrenic nerve involvement)
Unfavourable: lower nerve root involvement (C5-7, Klumpke)

Q5What is the treatment of obstetric brachial plexus injury?▸

Daily stretching to maintain good ROM
If no antigravity biceps function return by 2 months (max 3 mth) --> OT
Primary reconstruction: root avulsion - nerve transfer; lower lesion - nerve repair or nerve graft
Secondary reconstruction: posterior dislocation (capsulorrhaphy or humeral derotation osteotomy); IR (subscapularis release, LD and teres major transfer to GT, or derotation osteotomy)

Q6What is the pathoanatomy of Erb's and Klumpke's palsy?▸

Erb's: upper trunk C5,6 injury from excessive abduction of head away from shoulder -> traction on plexus
Associated with glenoid retroversion and flattened, posteriorly subluxed humeral head (persistent shoulder IR), elbow contracture
C5 deficiency: axillary (deltoid, teres minor), suprascapular (supraspinatus, infraspinatus), musculocutaneous (biceps); C6: radial (brachioradialis, supinator); sensory loss lateral arm/forearm
Klumpke: lower trunk C8,T1; intrinsic minus, weak wrist and finger flexion, sensory loss medial hand/forearm

Q7What do the knee X-rays show and what do they suggest?▸

Left X-ray: corner fracture of distal femur
Right X-ray: bucket handle fracture of proximal tibia
Bucket handle = corner fracture viewed from a different plane
In a skeletally immature patient these are very suggestive of non-accidental injury

Q8What are the red flag signs of non-accidental injury?▸

Multiple bruises (most common symptom is skin lesion); multiple fractures in various stages of healing
Long bone fractures in an infant not yet walking
Metaphyseal fractures: corner (primary spongiosa), bucket handle; transphyseal separation of the distal humerus
Posterior rib fractures, scapular fracture, sternal fracture; ruptured frenulum

Q9List the high and moderate specificity fractures for non-accidental injury.▸

High specificity: metaphyseal fractures/bucket handle lesion, scapular fracture, posterior rib fracture, spinous process fracture, sternal fracture
Moderate specificity: fracture of different ages, multiple fractures especially bilateral, epiphyseal separation
Moderate specificity: vertebral fracture or subluxation, complex skull fracture, multiple digital fractures

Q10What history, examination and investigations are needed in suspected non-accidental injury?▸

Hx: inconsistent history, fails to explain injury, delayed presentation, multiple fractures
P/E: systemic - growth, failure to thrive, bruises, burn marks; local - fractures
Ix: skeletal survey (=8 months of background radiation) +/- bone scan in <5 years
ADMIT + multidisciplinary approach + child protection service + social worker (remove abuser from environment); mandatory to report

Q11Why must non-accidental injury be diagnosed?▸

Q12What is the overall growth rate of the leg and which physis contributes most?▸

Q13What is the annual growth contribution of each physis of the femur and tibia?▸

Q14At what age does a child achieve 1/2 of adult leg length?▸

Q15What proportion of longitudinal growth comes from the proximal humerus and distal radius?▸

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