Pediatric Orthopedics

Pediatric Orthopedics

•An avascular necrosis of the femoral head •Should be considered in any limping child 4 – 12 years of age

Risk factors/ etiology •Cause is unknown •Femoral head has a tenuous vascular supply, which, when interrupted, can lead to necrosis •Risk factors are trauma, transient synovitis, venous congestion, hyperviscosity, and coagulation abnormalities •Boys predominate 4 – 5:1; 20% of cases bilateral •Other associations include poverty, low birth weight, and undescended testes

Risk factors of Legg-Calve’-Perthes (LCP) disease

Presentation: •Limping the hallmark of Legg-Calve’-Perthes •At first it is painless, but it can proceed to pain that is worsened by activity and relieved by rest •Pain reported in the groin, hip, thigh or knee Diagnostic tests •Radiographs show a wide articular space, then necrosis •Follow-up films during reconstitution reveal a flattened femoral head; later it become spherical

Treatment: •A self-healing process •Goal of therapy is to maintain joint mobility, done through the concept of containment – maintaining the hip in the acetabulum •Accomplished by close observation, bracing with orthoses, or surgically with osteotomies Complications: •Osteoarthritis

Legg-Calve’-Perthes (LCP)

Differential diagnosis Acute trauma Developmental dysplasia of the hip (DDH): (Formerly Congenital Hip Dislocation) •Newborn up to 3 years of age •20% of cases have a positive family history, ligamentous laxity, maternal estrogens, breech position, and torticollis •Barlow (provocative), Ortolani (reduction), and Galeazzzi signs useful in diagnosing DDH

DDH (contd…): Galeazzi sign: knees flexed, feet flat on table. DDH: knee is lower on affected side Barlow’s sign: hip is in joint. Thumb is on adductor muscles medially, and 3rd and 4th fingers are on greater trochanter. Move the hip laterally: normal hips will not dislocate, abnormal hips will. If dislocate: + Barlow’s sign Ortolani sign: hip is out of joint; by pushing on greater trochanter, femoral head is reduced into the hip socket as the hip is abducted. hip “clunks” back into socket. This can be palpable, visible, and even audible. Ortolani sign found only in neonates several weeks of age.

Galeazzi sign

Ortolani sign

Barlow’s sign

DDH (contd…): •Ultrasound the best test in newborns, •later, frog lateral radiographs of the pelvis useful in older infants and children Treatment •Varies with extent of disease •Containment is the key and achieved by harnesses, casting, osteotomies •DDH can lead to avascular necrosis of the femoral head

Radiograph (x-ray) of a 1-month-old child showing a dislocated right hip:

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH:

Slipped capital femoral epiphysis (SCFE) •Seen in adolescents •A displacement of the femoral head from the femoral neck because of a stress fracture through the femoral capital epiphyseal plate •Patients are obese with delayed skeletal maturation or tall and thin with a recent growth spurt

Chronic SCFE •Associated with obesity, deficient gonadal development, and hypothyroidism •Manifestations depend on the degree of slippage and its classification (preslip, acute, acute on chronic, chronic) •Presents with groin pain referred to anteromedial knee and thigh, limp, and accentuated external rotation

Chronic SCFE (contd…) Radiographs show medial displacement of the epiphysis, a bare upper portion of the femoral neck, and a wide growth plate, Treatment Pinning, external fixation, bone grafts and casting

•An abnormal curvature of the spine caused by misalignment in the frontal plane Risk factors/ etiology •Most are idiopathic •Congenital, neuromuscular, and compensatory scoliosis •M:F fairly equal; girls tend to have a higher risk of progression that requires treatment

Presentation •Idiopathic scoliosis usually painless, diagnosed on routine physical exam •Asymmetry on standing, a prominent shoulder blade, and spinal curvature seen •The curve progresses during periods of rapid growth Diagnostic tests •Forward bending (Adams test) the best way to screen for scoliosis •Radiographs of the spine the gold standard for evaluating suspected scoliosis

Forward bending (Adams test) the best way to screen for scoliosis

Treatment •Mild curves need no therapy •Bracing recommended to slow down progression of curves •Surgery (fusion, fixation rods) considered on curves greater than 45 degrees •Exercise and electrical stimulation have no effect Complications Idiopathic scoliosis: Degenerative joint disease, cardiorespiratoy disease, and poor self- esteem

Differential diagnosis Idiopathic scoliosis divided into three types: •Infantile (0 – years) •Juvenile (4 – 10 years) •Adolescent (>11 years)

Congenital scoliosis •Caused by vertebral anomalies such as a hemivertebera •Associated with genitourinary anomalies (renal agenesis horseshoe kidneys, obstructive uropathy), congenital heart disease, and spinal dysraphism •Early surgical treatment indicated because of the underlying pathophysiology (hemivertebra)

•Many neuromuscular disorders (eg, cerebral palsy) course with scoliosis Syndromes associated with scoliosis: •Neurofibromatosis, •Marfan •VACTERL [V - vertebral A - anal atresia C - cardiac T - TE fistula E - esophageal atresia R - renal abnormalities L - limb anomalies]

•Goldenhar (malar/maxillary hypoplasia, microtia, hemivertebrae)

Talipes equinovarus (clubfoot): A deformity of the foot and lower leg Risk factors/ etiology •Causes unknown •Can be related to in utero displacement and malalignment •Inheritance plays a part (probably a neruomuscular basis) •Half of all cases are bilateral

Talipes equinovarus (clubfoot)

Talipes equinovarus (clubfoot) (contd…) Associated disorders include •developmental hip dysplasia, •amniotic bands, •spina bifida., and •arthrogryposis Clubfoot more common in boys Treatment: Serial casting and surgery

Differential diagnosis Metatarsus adductus (metatarsus varus) •Forefoot adducted, but the hind foot is normal •Forefoot can be brought to the neutral position •Observation, passive range of motion, and casting may treat this condition

Differential diagnosis Tibial torsion •Usually secondary to in utero positioning •Treatment not necessary because this condition resolves on its own Femoral anteversion •More common in children older than 2 years •More frequent in girls •Affected by sitting position Treatment •Usually an attempt to correct sitting position

Femoral anteversion

Tibial torsion

•Usually seen during periods of rapid bone growth •More common during adolescence Osteosarcoma: most common Ewing sarcoma: more common in the second decade of life

Osteosarcoma •Retinoblastoma has higher association •Can also be induced by exposure to radiation •Most common in the long bones at the metaphysis (eg, distal femur, proximal humerus, proximal tibia) •Usually presents with pain at the tumor site

Osteosarcoma (contd…) •Limitation of motion and palpable, visible tumor •Deep bone pain awakening an adolescent at night •Radiographs show a typical “sunburns” appearance •Definite diagnosis is made by biopsy •Lung and bone are common sites of metastasis

Osteosarcoma (contd…) Treatment •Surgery and chemotherapy •Up to 75%of patients with nonmetastatic osteosarcomas are cured •Pelvic tumors present a worse prognosis

Ewing sarcoma •Presents similarly to osteosarcoma •Radiographic presentation is that of “onion skin” periosteal elevation •Metastais to the lung and bone •Definitive diagnosis by biopsy Treatment •Surgery, radiation, and chemotherapy •Prognosis worse if the primary tumor in the pelvis or with metastatic disease at the time of diagnosis

Other: Pes planus (flat feet) •Occurs when there is no longitudinal arch of the foot •A variation of normal feet •Usually seen in children older than 6 years of age, •Usually asymptomatic •Requires no treatment •Occasionally associated with heel cord contractures and cerebral palsy

Popliteal cyst (Baker cyst) •Arises from the capsule or tendon sheaths •Appears as a painless nonpulsatile swelling on the posterior aspect of the knee •Becomes more prominent on knee extension Treatment •Usually not necessary because it resolves spontaneously •Excision recommended for large, painful lesions D/D includes lipoma, aneurysm, neuroma, and rarely tumors

Osgood Schlatter disease •A traction apophysitis of the tibial tubercle caused by overuse •More common in physically active boys around puberty •Patients present with localized tenderness and swelling over the tibial tubercle •Pain exacerbated by running and jumping and relieved by rest •Radiographs show soft tissue swelling over the tubercle •NSAIDs usually do not help •Resolution occurs over 12- 24 months

Radial head subluxation (nursemaid’s elbow) •Occurs after sudden traction on the arm, usually in children younger than 4 years •Child cries immediately and won’t move the arm •Arm is held partially flexed at the elbow and supinated •Radiographs not needed but are normal Treatment •Reduction by gentle supination with pressure over the radial head; a click may be heard

Radial head subluxation : reduction