Paediatric Orthopaedic Problems.www.1aim.net

Common Paediatric Orthopaedic Problems

Introduction What does the word orthopaedics mean? “Orthos”: Greek → for straight.

“Paedos”: → Greek for child.

Injuries unique to the skeletally immature individual Physeal injuries: 

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Green stick fractures:

Physeal injuries Salter & Harris classification:

Physeal injuries

Physeal injuries Treatment: 

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Immediate, anatomic reduction. Closed / open. Each delay makes reduction more difficult.

Physeal injuries Incomplete reduction results in deformity.

Physeal injuries Prognosis:  

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Age. Anatomic site  Growth contribution.  Remodelling capacity. Severity of injury.

Physeal injuries Complications: Premature growth arrest (physeal arrest).

Physeal injuries

Physeal arrest:

Complete: → Shortening ( LLD ) no angular deformity

Physeal injuries Physeal arrest

Partial: due to a bone bridge 

Peripheral → angulation & deformity.

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Central → metaphyseal cupping & LLD.

Physeal injuries Bone bars may not develop till years after the injury, so follow up till skeletal maturity is imperative.

Green stick Fractures

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Single intact cortex. Two perpendicular views.

Green stick Fractures In very young children “plastic deformation” may occur which should be recognised & reduced.

Elbow Injuries In Children 

Much more common in the skeletally immature.

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2nd most common area of injury (distal radius most common).

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More common in boys.

Elbow Injuries In Children

At birth some areas remain Unossified: •

Most common site: distal humerus (86.5%)  70% supracondylar region.  17% lat condyle.  13% med epicondyle.

Supracondylar Fracture Humerus

Shaft condylar angle: Normally 40°. Anterior humeral line: Thru middle 1/3 of capitellum.

Supracondylar Fracture Humerus 

Types:  Extension type.  Flexion type.

Supracondylar Fracture Humerus Type I: Undisplaced. May be missed on AP&lat views Rely on fat pad sign & oblique views

Supracondylar Fracture Humerus Type II: Angulated.

Supracondylar Fracture Humerus

Type III: Completely displaced with angulation & rotation.

Supracondylar Fracture Humerus Grade I  Back slab. Grade II  CRUGA + PC fixation. Grade III  CRUGA + PC fixation / ORIF.

Supracondylar Fracture Humerus Complications: Compartment syndrome:    

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High index of suspicion. Pain out of proportion to #. Pain on passive extension of fingers. It is mainly a vascular outflow problem, so urgent # reduction & elbow immobilisation without excessive flexion restores outflow from the compartment & normalises the pressure. If not treated promptly by immediate & extensive fasciotomy; Volkmann’s ischaemic contracture develops.

Supracondylar Fracture Humerus

Volkmann’s ischaemic contracture is an extremely disabling condition that is very difficult to treat. The shortened, fibrotic flexor muscles prevent extension of wrist & fingers together.

Supracondylar Fracture Humerus Displaced supracondylar # with vascular compromise:

The radial pulse is unreliable as a danger signal. It’s absence is not an indication for exploration. Its presence a guarantee that ischaemia will not develop.

Supracondylar Fracture Humerus

Diagnosis of vascular damage is clinical : 

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Static signs as peripheral pulse, capillary circulation & pulse oximetry are not reliable. Dynamic signs as pain at rest / passive finger extension out of proportion to # pain, inability to actively contract forearm muscles are much more reliable.

Supracondylar Fracture Humerus Angular deformities Angular deformities

(cubitus varus, rarely valgus): Management:  Conservative in most cases as little functional deficit.  Supracondylar osteotomy.

Supracondylar Fracture Humerus Neurological:   

Incidence: 7%. Usually neuropraxia (resolve with time). Radial & anterior interosseous most common.

Loss of mobility:  

Loss of flexion : Malunited # (Remodelling of posterior angulation is limited). Loss of extension: May occur even with undisplaced / anatomically reduced #.

Supracondylar Fracture Humerus Myossitis Ossificans:

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Heterotopic deposition of Ca in surrounding muscles. Caused by aggressive passive exercise. Treat by rest, then at later date remove deposits.

Fracture Lateral condyle Humerus Compared to supracondylar #: 

Diagnosis is less obvious clinically & radiologically.

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# line extends into articular surface so higher incidence of functional loss of motion.

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Complications may not be evident till months or years later.

Fracture Lateral condyle Humerus 

One of the few # of childhood that almost always should be treated by internal fixation.

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The only exception is an undisplaced #; in which case X-rays every 3 days in the 1st 10 days are imperative.

Fracture Lateral condyle Humerus

Complications: Non-union: 

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One of the few paediatric # that may fail to unite. Non united # → cubitus valgus, (fragment migrates proximally & laterally). It is not only a cosmetic problem as it can lead to tardy ulnar nerve palsy.

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Fracture Shaft Femur Neonate: Tongue depressor.

< 1 yr:  > 1yr: 

Gallows traction. Thomas splint for 3 wks then hip spica for 3 wks.

Common Paediatric Orthopaedic Problems

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Acute Haematogenous Osteomyelitis History of preceding direct trauma to limb (most common tibia).

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Within 12-24 hours child develops fever & is tender all over the limb.

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Acute phase reactants: + ve.

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X ray: normal.

No X ray change before 10-14 d.

Acute Haematogenous Osteomyelitis

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US & MRI can detect a sub periosteal abscess (determines the need for surgical drainage). IV antibiotics on an empirical basis (anti-staph) are to be started ASAP after blood cultures.

Acute Haematogenous Early &Osteomyelitis correct ttt (medical or surgical) cures the condition & prevents development of chronic osteomyelitis which is almost a life time problem.

Chronic Osteomyelitis

Septic Arthritis 

Sudden onset of pain, swelling of a joint (knee, hip, shoulder, elbow, ankle, wrist).

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Cardinal sign is complete loss of joint movement.

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Aspiration of the joint is diagnostic.

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Surgical emergency; once diagnosed joint needs to be drained (arthrotomy) and washed.

Septic Arthritis

Early & correct ttt (medical or surgical) cures the condition & prevents development of septic epiphysitis which is almost a life time problem.

Congenital Talipes Equinovarus

What does the word talipes mean?

The term talipes is derived from a contraction of the Latin words for ankle (talus) & foot (pes). The term refers to the gait of severely affected patients, who walked on their ankles.

Congenital Talipes Equinovarus 

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Incidence:1/1000 live births. (higher if +ve FH). M:F = 2:1. Bilateral in 50%. Components of the deformity:  Equinus.  Varus.  Adduction.  Supination.  Cavus & depressed 1st MT.

Congenital Talipes Equinovarus

Best results are achieved with early manipulation (as early as first week of life) and serial casting (changed every week).

Congenital Talipes Equinovarus

Wearing Of DB splints for 3 months day & night & one yr at night is imperative to avoid recurrence.

Congenital Talipes Equinovarus

Good results may be achieved if previous technique is applied.

Developmental Because DDH encompasses frank dislocation, subluxation or radiographic abnormalities as shallow Dysplasia of Hip acetabulum: Because many of these findings may not be present at birth:

The terms "developmental" & “dysplasia” are more accurate than the terms "congenital“ & “dislocation”.

Developmental Dysplasia of Hip 

Incidence : 1 per 1000.

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Shortening / limitation of hip abduction can be detected in unilateral cases with established dislocation.

Developmental Dysplasia of Hip Clinical screening for DDH: Ortolani & Barlow tests.

ble clunks and not audible clicks are cons

Developmental Dysplasia of Hip At risk babies who should be screened for DDH by US:  ♀.  First born child.  + ve FH.  Breech presentation.

Developmental Dysplasia of Hip US examination:

Developmental Dysplasia of Hip Treatment in 1st 6 months: Dynamic hip splints (Pavlik Harness): 

Active ROM→spontaneous reduction.

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Less incidence of AVN.

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Less restricting & more convenient.

Developmental Dysplasia of Hip Treatment after age 6 mo:     

Open reduction of hip. Capsulorrhaphy. Pelvic osteotomy. Femoral osteotomy Immobilization in hip spica for 6-12 wks.

Perthes’ Disease Most common in boys 4-8 yrs. Self limiting disease characterised by AVN of femoral head. Complete revascularization of epiphysis occurs without any ttt,but may take 3 yrs. Deformation of epiphysis occurs during revascularization in some patients. This may lead to degenerative arthritis in young adult life.

Perthes’ Disease Aim of treatment is to prevent deformation of femoral head by ensuring that epiphysis is contained within acetabulum. Containment can be achieved by:  Abduction plasters / splints.  Surgery;  Femoral osteotomy.  Pelvic osteotomy.

Slipped Upper Femoral Epiphysis

Common in boys 10-17 yrs.  Bilateral in 1/3 of pts.  Possible underlying endocrine disease eg hypothyroidism.  Pt may present with knee pain. AP view:  Line tangent to superior border of neck normally cuts through epiphysis. 

Common pitfalls In a child with a painful knee always examine the hip as referred pain is very common.

The Limping child Causes of limp in childhood:       

Pain (antalgic). Short leg. Instability of joints. Stiffness of joints. Muscle spasticity or incoordination. Proprioceptive disturbances. Hysteria.

Irritable Hip       

Most common cause of acute limp (trauma excluded). 3% of children will have at least one episode. Peak age: 3-8yrs. 70%: preceding/concomitant URTI. 20%: preceding local trauma. 70% have effusion on US Synovial biopsy: synovial hypertrophy due to non specific, non pyogenic inflammation.

Irritable Hip Diagnosis:  Pain (hip/thigh/knee) & antalgic gait.  No other joint involvement.  Not systemically unwell.  Hip held in flexion, Abd & ER. DD:  Septic arthritis of hip.  Osteomyelitis upper femur.  Perthes’ disease.  SUFE.  Trauma.  Osteoid osteoma.

Irritable Hip Investigations: FBC, ESR, CRP.  X-ray AP & frog lateral views.  US. Treatment:  Reassurance. parents should be warned about association with early stages of Perthes’ disease & 10% chance of recurrence.  Bed rest & analgesics / NSAID. too early return to activities will prolong symptoms & may be associated with increased risk of recurrence. 

Rickets 

Nutritional rickets is the most common cause.

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Very common in Egypt regardless of socio- economic status.

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↓/N Ca, N P, markedly ↑AP.

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Children with active rickets need vit. D (either inactive D3, eg Devarol, or active form eg one alpha).

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Beware of giving vit D if Ca levels are low as this may cause tetany.

Rickets Developmental knee alignment: Normal knee alignment progresses from 10-15° varus at birth to maximum valgus angulation of 10-15° at age 3-3.5 yrs. Gradual decrease of valgus occurs to reach adult value of 6° by age 7yrs. Physiologic genu varum (bow legs):  Usually presents at 14 - 24 mo.  Bilateral & symmetrical. Physiologic genu valgum (knock knees):  Usually presents at 3 yrs.  Bilateral & symmetrical.

Rickets

Rickets may cause genu varum/valgum: In cases of genu valgum exclude renal rickets: 

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Renal functions are normal as this is a tubular disorder. The key laboratory finding is low phosphorous level.

Scoliosis

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Idiopathic scoliosis accounts for most spinal curvatures. Scoliosis is, surprisingly, quite common. 3-4 / 1000 children of the general population will need specialist supervision & about 1 / 1000 will need ttt. 80% arises in girls, & 80% have rib prominence on the Rt. The best screening test is the “bending forward test”.

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Obstetric brachial palsy History plexus of difficult labour is not always present. Sometimes even baby delivered by Caesarian section. Baby does not move limb & classic deformity is internal rotation of shoulder, extended elbow & pronated forearm. DD: Pseudo-paralysis:  # clavicle / proximal humerus / slipped epiphysis.  Septic arthritis shoulder.  Osteomyelitis upper end humerus.

Chronic obstetric brachial plexus palsy Disability in childhood & adolescence:

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Osgood Schlatter’s An example ofDisease apophysitis. Common in adolescent boys. No treatment in most cases (apart from reassurance, exercise modification, occasionally short periods in cast).

Osteogenesis Imperfecta Characterised by: Repeated fractures of multiple bones. Pencil-like cortex & deformed bones. IV bisphosphonates may be helpful.

Pathologic Fractues

Simple bone cyst: