This article is an introduction to Paediatric Orthopaedics. It covers some of the commonest conditions that one will come across at undergraduate level. It is important for one to appreciate the difference in terms of managing a child with an orthopaedic problem from an adult with the same orthopaedic problem.

Growth plate fractures

Anatomy: several differences exist between a child’s bone and an adult’s bone:

1) presence of growth plates (physes) --> they are located at both ends of the long bones and are responsible for the longitudinal bone growth à good remodeling power

2) thicker periosteum --> responsible for growth in thickness à provides stability to a # which improves healing process

3) characteristics of the bone --> less dense, more porous and vascular --> less force is needed for # to occur but the healing time is shorter

 



Salter Harris classification of epiphyseal injury

Background: growth plate fractures only occur in growing children and adolescents. These fractures occur in the physis which is the area responsible for growth. The majority of these fractures heal without any significant growth impairment.

 

In some untreated or severe cases, the epiphyseal circulation may be impaired which will inhibit the physeal growth which will ultimately lead to shortening and angulation of the affected limb. The prognosis depends on the site of the fracture. We use the Salter Harris classification to classify these fractures.

 

Salter – SALTR

I – S – Straight across

II – A – Above

III – L – Lower

IV – T – Through

V – R – Rammed (crushed)

Take home message:            

if physis is not damaged --> good remodeling potential

if physis is damaged --> risk of growth retardation

 

# of the physis

# above the physis

# below the physis in the epiphysis

# through the epiphysis, metaphysis & physis

Crush # of the physis

 

Developmental dysplasia of the hip (DDH)

Background: was formerly known as congenital dislocation of the hip, now it is known as the developmental dysplasia of the hip as this term reflects the condition is an ongoing developmental process. It includes a wide spectrum of severity ranging from a stable hip with mild acetabular dysplasia to hip instability with severe dysplasia. Screening for DDH is part of the routine physical examination of newborn and 6 weeks old baby check. DDH is a differential diagnosis of developmental delay.

 

Epidemiology: affects approximately 1 to 3 in every 100 births, with the left hip more likely to be dislocated than the right; 20% of all cases are bilateral

 

Risk factors:

1) breech

2) female

3) first-born

4) multiple pregnancy

5) oligohydramnios

6) positive family history

7) prematurity

 

Clinical Presentation:

1) asymmetry of groin skin crease

2) reduced hip abduction

3) wadding gait

4) short limb

 

Special Tests:

1) Ortolani’s test

- abduction of the hip, attempting to move a posteriorly dislocated femoral head forwards into the acetabulum

- positive if a ‘click’ could be felt

- checking for REDUCIBILITY

2) Barlow’s test

- apply backward pressure in adducted hip- positive if displacement

- checking for DISLOCATILIBITY (note: increasing difficulty in performing both the aboved tests after neonatal period)

3) Galeazzi sign

- examine the child in supine position with the hips and knees flex to 90 degrees

- compare the height of each knee

- positive if 1 leg appears shorter than the other

 

 



Please see the following link for a video demonstration on how the Barlow’s and Ortolani’s tests are performed.http://www.youtube.com/watch?v=uPPkrS8ktp8

 

Investigations:

1) Ultrasound – used to assess the stability of the hip and acetabular development

2) Pelvic XR – more useful in older children

 

Management:

1) Non- operative:

Pavlik harness

- keeps the hip in an abducted and flexed position, allowing the hip joint to remodel

- worn for 8 weeks until hip is stable

- size and compliance are key 

- risks: temporary femoral nerve palsy, avascular necrosis

- CI: in children older than 6 months

 

2) Operative:

- indications: those do not respond to early splint/harness treatment, those are not suitable for splint or harness treatment

- closed reduction ± adductor/psoas tenotomy

 - hip will be manipulated under anaesthetic and a special cast will be used to keep the hip in the correct position

- CT/MRI to correct position

- 3-4 months in a plaster cast

- open reduction ± femoral osteotomy

- might be required in patients over 18 months

- loosening the tendons around the hip joint + part of the femur is excised in order to correct any anterversion/valgus deformity

- risks:  

--> avascular necrosis of capital femoral epiphysis           

--> blood loss             

--> redislocation           

--> stiffness

 

Perthes' disease

Background: also known as Legg-Calve-Perthes disease, a condition which affects the femoral head due to inadequate blood supply to the epiphysis. This leads to necrosis of the affected area (osteonecrosis). The blood vessels will soon regrow and blood supply will return to the previously affected area (revascularization). New bone will be laid down and the femoral head will regrow (reossification). This is a similar process to how bone reforms and remodels after a fracture. However, the process is longer in Perthes disease.

 

Key concept:

 osteonecrosis --> revascularization --> reossification (deformity can occur in the last stage)

 

Epidemiology:

affecting 1 in 1000 children, with children between 4 and 8 years old being the most commonly affected; 10% of all cases are bilateral

 

Risk factors:

1) boys (3-5x more likely than girls)

2) low socioeconomic groups

3) child with low birth weight

4) presence of inguinal hernia/genitourinary tract anomaly

 

Clinical Presentation:

1) hip/groin pain

2) wasting of the quadriceps

3) leg shortening

4) leg stiffness

 

Investigations:

1) serial XR hip – ‘flattened’ femoral head when it should be round

2) bone scan

3) MRI scan – joint space widening (early); patchy density & reduced femoral head size (late)

 

Management:

- main aim: ensure femoral head remains well seated in the hip socket and promotes the healing process

 - watchful review --> >50% resolve spontaneously

- lifestyle advice: encourage swimming, avoid running or jumping

- bed rest &/or crutches – may be needed initially

- plaster cast/special brace – for more severe cases

- femoral osteotomy – for more severe cases

Prognosis:

- the younger the patient, the better the prognosis

 

Clubfoot (Talipes Equinovarus)

Background: a congenital condition in which the affected foot is inverted. It is not a painful condition but can lead to significant disability if left untreated. The etiology is unknown though genetic predisposition is thought to be a factor.

Epidemiology: affects approximately 1 in every 1000 births, with boys being more likely to be affected; increased risk with positive family history; 50% bilateral

Classification:

 1) congenital/idiopathic – most common

2) postural – more successful with non-operative treatment

3) neurological – i.e. cerebral palsy

4) syndromal (teratologic) – i.e. arthrogryposis multiplex congenita

 

 

http://www.orthopediatrics.com/docs/Guides/clubfoot.html

Symptoms:

1) inversion of the affected foot

2) the affected side appears to be shorter

 

Investigations:

1) Ultrasound

2) X-Rays: Anteroposterior view + lateral standing view

 

Management:

1) Non operative:

 Ponseti method + brace

--> involves stretching and casting, the aim is to stretch the foot back to the correct position --> brace is then used at night for 2 years to maintain the position

 2) Operative:

 done at 9 to 12 months of age

--> surgeons’ recommendation: foot around three inches long --> gives the infant enough time to heal before walking

--> involving soft tissue release of the medial, posterior and lateral structures of the foot, the Achilles tendon is almost always excised

--> complications: infection; blood vessels injury; up to 50% require one further surgery

 

Prognosis:

with treatment, the affected foot will still be 1 size smaller and less mobile than the normal side

 

Osgood Schlatter disease

Background: a condition which mainly affects the knee joint due to overusing the patellar tendon which leads to inflammation and knee pain, commonly seen in sporty teenagers. Overuse of the quadriceps muscle is thought to be the most common cause for this condition. No investigations are necessary as diagnosis is often clear from the presenting symptoms.

Overusing the patellar tendon and quadriceps mucle can lead to mutople small avulsion fractures within the tibial tuberosity. The tibial tubercle will grow as a result of healing and remodelling process occuring at the avulsed fragments.

Symptoms:

1) localized tenderness (below the patella)

2) knee pain (exacerbated during/after activity; relieved by rest)

3) swelling

Investigations:

1) generally none; X-Ray if suspicious of other injuries

Management:

1) reassurance and rest

2) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Prognosis:

1) most symptoms will resolve spontaneously after the completion of the adolescent growth spurt (boys around 16 years old and girls around 14 years old)

 

Left: showing the patellar tendon attaching to the distal femur superiorly and tibial tubercle infer

Slipped Upper Femoral Epiphysis (SUFE)

Background: a condition in which there is displacement of the femoral neck and shaft against a stationery femoral head. The femoral neck is displaced anteriorly whereas the head is displaced posteriorly. It is the most common hip disorder seen in adolescents.

Patients with this condition are usually present in one of the following 4 ways: 

- pre-slip: no slippage but with wide epiphyseal line on X-Ray

- acute: sudden spontaneous slippage

- acute-on-chronic: sudden slippage occuring in an already known chronic slip

- chronic: ongoing progressive slippage

Risk factors:

1) mechanical causes: obesity and local trauma

2) previous exposure to radiation

3) inflammatory causes: untreated septic arthritis

4) others: hypothyroidism; hypopituitarism, growth hormone deficiency

Symptoms:

1) hip, groin, knee pain

2) antalgic gait

3) out-toeing

4) obligatory external rotation with flexion

 

Classification:

 - according to the Southwick angle - (Definition: http://www.enotes.com/topic/Southwick_angle)

--> measured from a lateral radiograph

--> mild - <30 degrees

--> moderate - 30-50 degrees

--> severe - >50 degrees

 

http://www.orthopaedia.com/download/attachments/30507338/Epiphyseal+Shaft+Angle.jpg

Investigations:

1) Anteroposterior and lateral X-Rays of the hip

- may show femoral head displacement or widening of the epiphyseal line

Management:

1) in-situ fixation

2) spica cast

 

Prognosis:

 --> stable hip - 96% satisfactory result

--> unstable hip - 47% satisfactory result

 

Complications:

- chondrolysis

- AVN

- early osteoarthritis in patient with severe slip angle

 

References

http://pediatric-orthopedics.com/Treatments/Skeletal/Fractures/fractures.html

http://orthopedics.about.com/od/fracturesinchildren/p/typesgrowthplate.htm

http://www.wheelessonline.com/ortho/salter_harris_classification_of_growth_plate_fractures

http://www.patient.co.uk/doctor/Developmental-Dysplasia-of-the-Hip.htm

http://www.perthes.org.uk/what-is-perthes-disease/

http://orthoinfo.aaos.org/topic.cfm?topic=A00255&return_link=0

http://orthoinfo.aaos.org/topic.cfm?topic=A00411&return_link=0

http://www.orthopediatrics.com/docs/Guides/clubfoot.html

http://www.sydneyorthopaedic.com.au/paediatric-orthopaedics.html

Oxford Handbook of Clinical Specialties; 8th Edition

http://www.patient.co.uk/doctor/Slipped-Upper-Femoral-Epiphysis.htm

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