Pediatric Orthopaedics

dr. Andreas Siagian SpOT

SMF BEDAH ORTHOPAEDI
/RSUD ULIN BANJARMASIN
FK UNLAM

COMMON CHILDHOOD
MUSCULOSKELETAL CONDITIONS

GENERAL PRINCIPLES OF FRACTURES

AND DISLOCATIONS IN CHILDREN
Childrens bones bend more before fracture than do
adults bones (childrens bones are more ductile)
The periosteum in children is thicker and more highly
developed and often remains intact on the concave side
of a fracture
Childrens fractures heal more rapidly and, therefore,
require shorter immobilization time than do adults
fractures

Stiffness across joints after immobilization is less of

a problem in children than in adults
Childrens bones remodel to a greater extent than
adults do and, therefore, a greater amount of
angulation and displacement is acceptable in children
than in adults except intra-articular fractures

PHYSEAL GROWTH FRACTURE

Physeal (growth plate) fractures

- Classically occur through the zone of hypertrophy of
the growth plate but can involve other zones
- Usually caused by a torsion (not tension) at the
growth plate
- Complications of physeal fractures include
* Limb length discrepancies
* Malunions
* Physeal bars (leading to angular or longitudinal
deformities)
-Most common sites for physeal fractures are the
distal radius and distal tibia

Growth plate arrest (Fig.5-2)

- Physeal bars (bridges) arise as a result of a growth plate
injury that leads to an arrest of growth of a portion of the
physis: an uninjured portion of the physis may continue
to grow
- Centrally located bars within the physis lead to arrest of
longitudinal growth with resultant shortening of the
extremity
- Peripheral bars lead to angular deformities
- Treatment options include operative resection of the bar
or ipsilateral completion of a growth arrest in conjunction
with an epiphysiodesis to the contralateral extremity (to
equalize the growth disturbance in both extremities)

Torus (buckle) fracture

occurs in children at the
metaphyseal diaphyseal
junction of long bone
(most commonly distal
radius) as a result of an
axial load

#Torus

Greenstick fracture
fractures in children
commonly are incomplete
and leave a hinge of intact
bone and soft tissues
similar to the manner in
which a green stick from a
tree branch breaks

#Greenstick

Childs abuse (battered child syndrome)

- A high index of suspicion is needed to make the
diagnosis
- Most common in children younger than 3 years of
age
- Unusual histories are a tip-off
- Physical exam may show multiple healing skin
bruises, burns, etc.
- The most common locations for fractures in child
abuse are the humerus, tibia, and femur
- Skull fractures are common
- Skeletal survey (x-rays of the skull,
thoracolumbar spine, chest and ribs, pelvis, femur,
knees, tibias, fibulas, ankles, wrists, and hands)

Talipes Equinovarus
(congenital clubfoot)

I. Etiology
Unknown, possibly multiple factors, including
polygenic inheritance, persistence of fetal
positioning, primary germ plasma defect, and
neuromuscular factors
II. Incidence
A. In whites, 1.2/1000. male > female (2:1);
50% bilateral

III. Embryology
1. Embryonic position: 30 mm embryo with equinovarus
foot
2. Fetal position:50 mm embryo with mild adducted
equinovarus foot secondary to tibialgrowth

IV. Pathology
A.
Histologic abnormalities in muscle, tendon, and
ligament in addition to contracture
B.
Equinus, hindfoot varus, and foot varus
(talonavicular)
C.
Calcaneus rotates through subtalar joint in a medial
direction and inverts (varus tilting or supination)
D.
Body of talus may be directed laterally and neck of
talus is directed medially (lateral rotation of the
talus)

E. Navicula is displaced medially

F. Cuboid is often subluxated medially
G.Plantar fascia is tight

V. X-Rays Findings
1.

Increased lateral calcalcaneotibial angle (>125 )

secondary to ankle equinus

2.

Decreased lateral talocalcaneal angle

(<35 , 3550 normal) and anteroposterior (AP) talocalcaneal
angle (<20, 20-40 normal) secondary to hindfoot
varus)

3.

Abnormal AP talo-first metatarsal angle (zero is

normal) secondary to talonavicular subluxation

P
a
t
h
o
l
o
g
y

N
o
r
m
a
l

VI. Prognosis
A. Condition worse if :
1.
Teratogenic (eg, arthrogryposis,
myelodysplasia)
2. Short, far, rigid foot with severe mid foot
crease
3. Boat-shaped heel, severe, adductus varus,
atavistic short first toe
4. Delayed treatment and failure to respond

VII. Treatment
A. Postnatal:

corrective manipulation and(correct

adduction, heel varus, and then equinus) every 1-2

weeks for 3 months, then holding cast or brace until
surgery (50 % effective)
B. Surgery
1.

One-stage posteromedial release of tight structures

2.

Ideally, 4-8 months but up to 6 years of age

3.

Turco posteromedial or extensive subtalar

release by Mckay or Simon techniques

Talipes Equinovarus (congenital clubfoot)

Serial cast

Dennis brown shoes

DEVELOPMENTAL
DYSPLASIA OF THE
HIP (DDH)

EPIDEMIOLOGY
0.7

to 35 per 1000 live births

Depends on geography
Depends on type of study
Retrospective studies tend to report
lower incidence
Screening programmes tend to report
higher incidence

PREDISPOSING FACTORS
Female
Breech delivery
First born
Family history
Oligohydramnions
Other congenital abnormalities

CLINICAL SCREENING
Baby

must be relaxed
Examiner must not use excessive force

Asymmetric abduction

2. BARLOWS SIGN:
CLUNK OF
DISLOCATION
PROVOCATIVE TEST

Ortolani Sign: Clunk. 3

of Entry
Reduction maneuver

4. GALEAZZI SIGN

HIP ULTRASONOGRAPHY
Graf

(1980)
Harcke and Grissom (1990)
dynamic

US

IMAGING
AP Pelvis
Useful after 6-8 months
Monitoring hip/acetabular development
Detection of complications

Management Protocol

1-6 months
Pavlik

harness for 3-4 weeks.

Closed

surgical reduction if harness fails.

Problem:
Extreme position
Avascular necrosis
Tight shoulder straps
Nerve palsies
Femoral nerve palsy
extreme flexion
Uncomfortable
Inferior dislocation

DDH

Closed reduction

Traction

Adductor tenotomy

Closed reduction and spica

Arthrogram is helpful in visualizing reduction

months casting, change at 6 weeks 3

Night hip abduction brace for 6 months

TREATMENT

6-18 months.

Closed

or open surgical reduction

Hip spica cast
Some time we combined with
pinning for maintain reduction +
hip spica cast

OPEN REDUCTION
Indications
Failed closed after trial of casting
Interposition of soft tissue on arthrogram
Limbus shape on arthrogram
Age over 1 year without concentric reduction

TREATMENT

18 months - 8 years
Open

reduction with femoral osteotomy or /and pelvic

osteotomy

PELVIC OSTEOTOMIES

Salters

innominate
Pemberton
Osteotomies to free the
acetabulum - Steel & Dega
Chiari displacement
osteotomy

COMPLICATIONS
The most common complication of treatment of
DDH is osteonecrosis of the femoral head
Growth disturbance of proximal femoral physis
Gait abnormality

LEGG CALVE PERTHES DISEASE

.Joseph Donnelly, M.D

December 10, 2001

HISTORY
Late 19th century: hip infections that resolved
without surgery
First described in 1910
Early path studies: cartilaginous islands in the
epiphysis

EPIDEMIOLOGY
Disorder of the hip in young children
Usually ages 4-8yo
As early as 2yo, as late as teens
Boys:Girls= 4-5:1
Bilateral 10-12%
No evidence of inheritance

ETIOLOGY
Unknown
Past theories: infection, inflammation, trauma,
congenital
Most current theories involve vascular
compromise

Sanches

1973: second infarction theory

PRESENTATION
Often insidious onset of a limp
C/O pain in groin, thigh, knee
17% relate trauma hx
Can have an acute onset

PHYSICAL EXAM
Decreased ROM, especially abduction and
internal rotation
Trendelenburg test often positive
Adductor contracture
Muscular atrophy of thigh/buttock/calf
Limb length discrepency

IMAGING
AP

pelvis
Frog leg lateral
Key= view films
sequentially over
course of dz
Arthrography
MRI role undefined

DIFFERENTIAL DIAGNOSIS
Important to rule out infectious etiology (septic
arthritis, toxic synovitis)
Others:

Chondrolysis
JRA

Osteomyelitis
Lymphoma

-Neoplasm
-Sickle Cell
-Traumatic AVN
-Medication

RADIOGRAPHIC CLASSIFICATIONS
Describe extent of epiphyseal disease
Catterall classification= most commonly used

groups based on amount of femoral head

involvement
Also presence of sequestrum, metaphyseal reaction,
subchondral #

GROUP I

GROUP II

GROUP III

GROUP IV

PROGNOSIS
60% of kids do well without tx
AGE is key prognostic factor:

<6yo=

good outcome regardless of tx

6-8yo= not always good results with just containment
>9yo= containment option is questionable, poorer
prognosis, significant residual defect

PROGNOSIS
Flat femoral head incongruent with acetabulum=
worst prognosis
Do not treat in reossification stage (>15mos)

NON-OPERATIVE TX
Improve ROM 1st
Bracing:

Removable

abduction orthosis
Pietrie casts
Hips abducted and internally rotated

Wean from brace when improved x-ray healing

signs

BRACING

NON-OPERATIVE TX

Check serial radiographs

Q3-4

mos with ROM testing

Continue bracing until:

Lateral

column ossifies
Sclerotic areas in epiphysis gone

Cast/brace uninvolved side

OPERATIVE TX
If non-op tx cannot maintain containment
Surgically ideal pt:

6-9yo

Catterral

II-III
Good ROM
<12mos sx
In collapsing phase

LATE EFFECTS OF LCP

Coxa magna
Physeal arrest patterns
Irregular head formation
Osteochondritis dessicans

SLIPPED CAPITAL FEMORAL

EPIPHYSIS

SLIPPED CAPITAL FEMORAL

EPIPHYSIS: PRESENTATION

Who?
7

14 yo
Growing FAST (or about
to)
Obese or active more
likely

?What c/o
ANY hip/thigh/knee pain
Limp
Sits/runs/walks funny

SLIPPED CAPITAL FEMORAL

EPIPHYSIS:
Kleins Line on AP
DIAGNOSIS

Exam

Limited/painful

IR Hip
Obligate IR with flexion

You KNOW when:

Kleins

line
Radiologist frantic page

What Next?

Normal

Abnormal

Frog Leg

SLIPPED CAPITAL FEMORAL

EPIPHYSIS:
FINAL THOUGHTS
Treatment:
Non-weight

Bearing!
Ortho Consult within 72
hours
This can be bad!

Watch Out for:

Legg-Calve-Perthes
Septic/Toxic

Synovitis