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Chapter: Orthopaedics

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Pediatric Orthopaedics

1. Fractures in Children 2. Stress Fractures 3. Evaluation of the Limping Child 4. Epiphyseal Injury 5. Slipped Capital Femoral Epiphysis (SCFE) 6. Developmental Dysplasia of the Hip (DOH) 7. Legg-Calve-Perthes Disease (Coxa Plana) 8. Osgood-Schlatter Disease 9. Congenital Talipes Equinovarus (Club Foot) 10. Scoliosis

Pediatric Orthopaedics

 

Fractures in Children

 

·                 type of fracture

o       usually greenstick or buckle because periosteum is thicker and stronger

o       adults fracture through both cortices

·                 epiphyseal growth plate

o       plate often mistaken for fracture and vice versa

o       x-ray opposite limb for comparison

o       mechanism which causes ligamentous injury in adults causes growth plate injury in children

o       intra-articular fractures have worse consequences in children because they usually involve the growth plate

·                 anatomic reduction

o       gold standard with adults

o       may cause limb length discrepancy in children (overgrowth)

o       accept greater angular deformity in clilldren {remodeling minimizes deformity)

·                 time to heal

o       shorter in children

·                 always be aware of the possibility of child abuse

o       make sure mechanism compatible with injury

o       high index of suspicion. look for other signs, including x-ray evidence of healing fractures at other sites

 

Stress Fractures

 

Mechanism

·                 insufficiency fracture

o       stress applied to a weak or structurally deficient bone

·                 fatigue fracture

o       repetitive. excessive force applied to normal bone

·                 most common in adolescent athletes

·                 tibia is most common site

 

Diagnosis and Treatment

·                 localized pain and tenderness aver. the involved bone

·                 plain films may not show fracture for 2 weeks

·                 bone scan +ve in 12-15 days

·                 treatment is rest from strenuous activities to allow remodeling (can take several months)

 

Epiphyseal Injury


 

Slipped Capital Femoral Epiphysis (SCFE)

·                 type I Salter-Harris epiphyseal injury

·                 most common adolescent hip disorder, peak at pubertal growth spurt

·                 risk factors: male, obese, hypothyroid

 

Etiology

·                 multifactorial

o       genetic: autosomal dominant, blacks > caucasians

o       cartilaginous physis thickens rapidly under growth honnone (GH) effects

o       sex honnone secretion, which stabilizes physis, has not yet begun

o       overweight: mechanical stress

o       trauma: causes acute slip

 

Clinical Features

·                 acute: sudden, severe pain with limp

·                 chronic: limp with medial knee or anterior thigh pain

·                 tender over joint capsule

·                 restricted internal rotation, abduction, flexion

Whitman's sign: with flexion there is an obligate external rotation of the hip

·                 pain at extremes of ROM

 

Investigations

·                 x-rays: AP, frog-leg, lateral radiographs

 • posterior and medial slip

 • if mild slip, AP view may be normal or show slightly widened growth plate compared with opposite side

 

Treatment and Complications

·                 mild/moderate slip: stabilize physis with pins in current position

·                 severe slip: ORIF or pin physis without reduction and osteotomy after epiphyseal fusion

·                 complications: AVN (most common), chondrolysis, pin penetration, premature OA, loss of ROM

 

Developmental Dysplasia of the Hip (DOH)

·                 formerly called congenital dysplasia of the hip (CDH)

·                 due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular roof

·                 spectrum of conditions that lead to hip subluxation and dislocation

o       dislocated femoral head completely out of acetabulum

o       dislocatable head in socket

o       head subluxates out of joint when provoked

o       dysplastic acetabulum, more shallow and more vertical than normal

·                 painless (if painful suspect septic dislocation)

 

Physical Examination

·                 diagnosis is clinical

o       limited abduction of the flexed hip ( <50-600)

o       affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum

o       Barlow's test (for dislocatable hip)

o       –flex hips and knees to 90° and grasp thigh

o       –fully adduct hips, push posteriorly to try to dislocate hips

·                 Ortolani's test (for dislocated hip)

o       initial position as above but try to reduce hip with fingertips during abduction

o       positive test: palpable clunk is felt (not heard) ifhip is reduced

·                 Galeazzi's Sign

o       knees at unequal heights when hips and knees flexed

o       dislocated hip on side oflower knee

o       difficult test ifchild <1 year

·                 false positive if congenital short femur

o       Trendelenburg test and gait useful ifolder (>2 years)

 

Investigations

·                 U/S in first few months to view cartilage

·                 follow up radiograph after 3 months

 

Treatment and Complications

·                 0-6 months: reduce hip using Pavlik harness to maintain abduction and flexion

·                 6-18 months: reduction under GA, hip spica cast x 2-3 months (if Pavlik harness fails)

·                 >18 months: open reduction; pelvic and/or femoral osteotomy

·                 complications

o       redislocation, inadequate reduction, stiffness

o       AVN of femoral head

 

Legg-Calva-Perthes Disease (Coxa Plana)

 

·                 self-limited AVN of femoral head. presents at 4-10 years of age

·                 etiology unknown, 20% bilateral, males> females, 1/10,000

·                 associations

o       family history

o       low birth weight

o       abnormal pregnancy/delivery

o       history of trauma to affected hip

·                 key features

o       AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodelling of regenerated bone

 

Clinical Features

·                 child with hip pain and limp

·                 tender over anterior thigh

·                 flexion contracture: decreased internal rotation, abduction of hip

 

Investigations

·                 x-rays

o       may be negative early

o       eventually, characteristic collapse of femoral head (diagnostic)

·                 subchondral fracture

·                 metaphyseal cyst

 

Treatment

·                 goal is to preserve ROM and preserve femoral head in acetabulum

·                 PT: ROM exercises

·                 brace in flexion and abduction x 2-3 years

·                 femoral or pelvic osteotomy

·                 prognosis better in

o       males <5 years old. <50% of femoral head involved, abduction >30°

·                 50% of involved hips do well with conservative treatment

·                 complicated by early onset osteoarthritis and decreased ROM

 

Osgood-Schlatter Disease

 

Mechanism

·                 repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causes minor avulsion at the site and subsequent inflammatory reaction (tibial tubercle apophysitis)

·                 most common in adolescent athletes, especially jumping sports

 

Clinical Features

·                 tender lump over tibial tuberosity

·                 pain on resisted leg extension

·                 anterior knee pain exacerbated by jumping or kneeling, relieved by rest

 

Investigations

·                 x-rays: fragmentation of the tibial tubercle, ± ossicles in patellar tendon

 

Treatment

·                 benign, self-limited condition

·                 may restrict activities such as basketball or cycling

·                 flexibility, strengthening exercises

 

Congenital Talipes Equinovarus (Club Foot)

 

·                 fixed deformity

·                 3 partB to defonnity

o       talipes: talus is inverted and internally rotated

o       equinus: ankle is plantar flexed

o       varus: heel and forefoot are in varus (supinated)

·                 may be idiopathic, neurogenic, or syndrome-associated

·                 1-2/1,000 newborns, 50% bilateral, occurrence M>P, severity P>M

 

Physical Examination

·                 examine hips fur associated DDH

·                 examine knees for deformity

·                 examine back for dysrapbiam (unfused vertebral bodies)

 

Treatment

·                 correct deformities in the following order (Ponseti Technique):

o       furefoot adduction, ankle inversion, equinus

o       –––change strapping/C81it ql-2 weeks

·                 surgical release in refractory case (50%)

o       –––delayed until 3-4 months of age

·                 3 year recurrence rate = S-10%

·                 mild recurrence common; affected foot is permanently smaller/stiffer than normal foot with calf muscle atrophy

 

Scoliosis

 

Definition

·                 lateral curvature of spine with vertebral rotation

 

Epidemiology

·                 age: 10-14 years

·                 more frequent and more severe in females

 

Etiology

·                 idiopathic: most common (90%)

·                 congenital: vertebrae fail to form or segment

·                 neuromuscular: UMN or LMN lesion, myopathy

·                 other: osteochondrodystrophies, neoplastic, traumatic

·                 portural: leg length discrepancy, muscle spum

 

Clinical Features

·                 ± back. pain

·                 1° where several vertebrae affected

·                 2° above and below fixed 1o to try and maintain normal position of head and pelvis

·                 asymmetric shoulder height when bent forward

·                 • Adam's test: rib hump when bent forward

·                 prominent scapulae, creased flank, asymmetric pelvis

·                 aaaociated posterior midline skin lesions in non-idiopathic scolioses

o       cafe-au-lait spots, dimples, neuro1ibromas

o       axillary freckling. hemangiomas, hair patches

·                 associated pes cavus or leg atrophy

·                 apparent leg length discrepancy

 

X-Raya

·                 3-foot standing

·                 measure curvature - Cobb Angle (Figure 52)

·                 may have associated kyphoala

 

Treatment

·                 based on degree of curvature

o       <20°: observe for changes

o       >20° or progressive: bracing (many types) that halt/slow curve progression but do NOT reverse deformity

o       >40°, cosmetically unacceptable or respiratory problems: surgical correction (spinal fusion)

 

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