Hello, my name is Jeremy Rush from San Antonio, Texas, and I'll be discussing pediatric orthopedics. I have no relevant financial disclosures. This review is not intended to be a complete review of every topic pertaining to pediatric orthopedics, rather a review of the most commonly tested subjects that you're likely to see on the examination.
Hopefully, I'll provide you a basic understanding of a broad range of topics. We'll begin with the discussion of trauma as well as specific fractures. Non-accidental trauma or child abuse is an incredibly important aspect of pediatric orthopedics.
All states have laws mandating physician reporting of suspected child abuse or non-accidental trauma. NAT are non-accidental traumas most common in patients under the age of three. There are certainly typical fracture patterns that are very suspicious for non-accidental trauma.
These include spiral humerus fractures as well as femur fractures especially in non-ambulatory children. It was previously felt that spiral femur fractures were somewhat pathognomonic for NAT. However, recent studies have demonstrated that transverse femur fractures are actually more common in non-accidental trauma.
However, one must remember that the most common presentation of child abuse are actually skin lesions such as bruising and burns. There are other fracture patterns which are also highly suspicious for NAT and which often show up on the test. These include the so-called metaphyseal corner fracture as well as distal humeral transphyseal fractures which we'll see here in a moment. Additionally, rib fractures especially in the non ambulatory child are very suspicious and posterior rib fractures are almost pathognomonic for NAT.
Additionally, a skeletal survey may reveal fractures in various stages of healing. Moving on to elbow fractures, supracondylar humerus fractures are incredibly common. and in fact are the most common fracture in children requiring surgical treatment.
These are classified based upon the direction of the fracture as flexion type or extension type with extension type accounting for approximately 95 percent of fractures. Additionally the Gartland classification is based upon the amount of displacement and also helps guide our treatment. Type 1 fractures are essentially non-displaced fractures and are treated with long arm casting for three to four weeks. Type 2 fractures are those which are hinged frequently with an intact posterior hinge and are angulated. The characteristic finding is the anterior humeral line will not bisect the capitellum on your lateral x-ray.
These fractures are typically treated with a closed reduction and percutaneous pinning. However, closed reduction and casting is an option. Type 3 and 4 injuries represent completely displaced fractures, with the type 4 fracture being unstable. in both flexion as well as extension. The mainstay of treatment is closed reduction in percutaneous pinning with open reduction indicated for un-reducible fractures.
Between 10 and 20 percent of supracondylar humerus fractures will present with a nerve injury and the AIN is the most common injury. However, the ulnar nerve is more commonly seen with flexion type injuries as well as after placement of a medial pin. Vascular injury is also a concern. and a complete vascular examination on presentation is mandatory. Cubitus varus represents a malunion or a malreduction.
Previous thinking was that this was primarily a cosmetic deformity. However, some recent studies have shown that it may increase the risk for subsequent fracture. A very highly testable concept is that of the pink pulseless supercondylar humerus fracture.
Between 10 and 20 percent of type 3 injuries will present without a pulse. However, a lot of these will be perfused or so-called pink pulseless. This represents a fracture without a palpable pulse but with a well-perfused hand. And this can be demonstrated by checking capillary refill, skin turgor, and skin temperature. If the hand is perfused, then the next step in treatment is closed reduction and percutaneous pinning on an urgent basis.
If anatomic reduction can be obtained, and this is critical, if anatomic reduction can be obtained, then the fracture is pinned. and the child is admitted for close monitoring for 24 hours to ensure they don't develop a compartment syndrome or lose perfusion to their hand. However, if on presentation the hand is non-perfused or under-perfused, then treatment is on an emergent basis.
An attempt at closed reduction can be made and if perfusion returns and you have anatomic reduction of the fracture, then you can proceed as above. However, if the hand remains non-perfused or under-perfused, Then the next step in treatment would be an open exploration and open reduction. There's no need for an arteriogram as a... site of injury is known. Lateral condyle fractures are the second most common elbow injury.
These are frequently the result of a fall on an outstretched hand and the key concept here is that often your standard AP and lateral x-ray may underestimate the amount of displacement. For that reason, internal oblique x-rays are recommended. This is the exact same child but the internal oblique x-ray very clearly demonstrates the fracture line and the true amount of displacement.
These fractures are classified utilizing the MILCH classification. which is based upon the fracture morphology. However, the Jacob or Jacob classification is based upon the amount of displacement and helps guide our treatment.
Non-displaced injuries are treated with long arm casting for four to six weeks and you'll notice that this is slightly more than a supercondylar humerus fracture. That's because these injuries frequently take longer to heal and close follow-up in the first two weeks is absolutely necessary because late displacement is a potential complication. Displaced injuries are treated with internal fixation. Now the fracture that is hinged or presents with an intact articular surface can be treated with arthrogram and closed reduction percutaneous pinning.
However, the widely displaced fracture is treated with open reduction and internal fixation. Now this again is different from a supraconolar humerus fracture. This fracture is interarticular and one of the primary goals is to obtain a congruent articular reduction.
Fixation can occur either with pins or with a screw. For example, the anterior part of the anterior part of the anterior part of the anterior part of the anterior Potential complications include nonunion, and again, this requires longer immobilization, as well as a risk for cubitus valgus and a subsequent tardy ulnar nerve palsy. Another very commonly tested concept is the blood supply to the capitellum, which arises posteriorly.
For this reason, you want to limit your dissection posteriorly to avoid the risk of avascular necrosis. Fysial growth arrest is also a potential complication. Medial epicondyle fractures are commonly associated with an elbow dislocation. Again, a frequent scenario which shows up on the test is an elbow dislocation that either spontaneously reduces or is reduced in the emergency department, and the medial epicondyle becomes entrapped within the joint.
For this reason, you always want to look for the medial epicondyle on your post-reduction radiographs. The treatment is somewhat controversial. Previous teaching was that open reduction internal fixation was reserved for elite throwing athletes.
However, some newer studies have questioned that. General treatment recommendations for medial epicondyle fracture ORF, general indications include open fractures, entrapped fragments, neurovascular injury, as well as a significant amount of displacement. This is because the UCL attaches to your medial epicondylar fragment, and there is a risk of late valgus instability with widely displaced fractures.
Transfacial distal humerus fractures again have a strong association or non-accidental trauma. These are often confused with elbow dislocations because the distal aspect of the humerus is not yet ossified. However, this actually represents a fracture, typically a Salter-Harris 1 or Salter-Harris 2 fracture through the distal humerus. The treatment is very similar to supracondylar humerus fractures with long arm casting for non-displaced injuries and closed reduction versus open reduction and pinning for significantly displaced fractures. Physical complications include cubitus varus as well as the risk of medial condyle avascular necrosis.
A montasia fracture refers to a fracture of the ulna with a concomitant radiocapitellar dislocation. The ulna fracture can actually be quite subtle as in this case and can present with a subtle plastic deformation, but it's critical to evaluate the radiocapitellar alignment on your x-rays because these injuries are very difficult to treat if they are missed. This is the same child who presented two and a half years later with a radio with with a montasia with persistent radiocapitellar dislocation.
The treatment in the acute setting is reduction of the ulna, and that's critical. You can obtain reduction through closed means and place the child in a long-arm cast. However, you must clearly demonstrate a reduced radiocapitellar joint. Otherwise, treatment can be with an IM nail or a plate, and it's critical to restore your ulnar length and maintain reduction of your ulna.
Forearm fractures are very common in children and the vast majority of these can be treated with closed methods. However, maintaining a straight ulnar border in your cast is very critical because if you don't do this, you can have sagging of the ulnar fracture. The amount of displacement depends upon the age of the child and the growth remaining in the time for remodeling. Bayonet apposition is acceptable as long as you have adequate angular reduction and no significant... an angulation.
Moving on to femur fractures. Again, femur fractures, you must always think about NAT. And one of the only grade A recommendations on the Academy Clinical Practice Guideline is consideration of NAT when examining a child with a femur fracture.
Your treatment is based upon the age of the child. Up to six months of age the mainstay of treatment is with a Pavlik harness. Between six months and five years of age the mainstay of treatment is closed reduction and spica cast placement. Now this can be a single leg or a dual leg spica cast.
A single leg spica cast is effectively a long arm cast with a pelvic band. Recent studies have shown that the single leg spica cast may be just as effective but may improve the ability of the parent or the caregiver to take care of the child with the example of a better ability to place them in a car seat. You can allow up to two centimeters of shortening. This is because femur fractures typically have happen to have between one half and two centimeters of overgrowth. after healing.
And you should have a lot of caution with the so-called 90-90 cast or a cast with the hip and knee in 90 degrees of flexion because there are reports of vascular injury. In the child older than five there are multiple options for treatment. Certainly external fixation is an option especially in a child who has soft tissue injury or multiple fractures.
However, there is a risk of refracture, knee stiffness, as well as the risk of pen site infection. In addition, The additional option is submuscular plating, and this is an option that's seen an increase in popularity recently. This is best used for fractures with a good deal of comminution, as well as the so-called length unstable fracture. This implies a fracture pattern that is either a long oblique fracture or a spiral fracture.
Now there is difficulty with plate removal, but plate removal is recommended because there is an associated risk of genu valgum after healing of the fracture. Intramedullary nails, specifically flexible intramedullary nails, are also an option in this patient population. However, studies have shown that if you use a flexible nail in a child older than 11 or greater than 45 kilograms, especially if you're using tight nails, nails there may be an increased risk of complications. In these older or heavier patients you need to think about either using a stainless steel elastic nail or using an alternative method of treatment. Rigid intramedullary nails are an option option in the older adolescent or teenager, however one must remember the blood supply to the femoral head, which are branches of the medial femoral circumflex artery.
For this reason you want to avoid a piriformis start and instead use a lateral entry or a trochanteric start. Moving on to fractures about the knee. Distal femoral fractures, specifically distal femoral fissile fractures, are often the result of high energy.
However, you can see these injuries after relatively low energy mechanisms, such as athletic injuries or falls off of bicycles. You should always exercise a great amount of caution if you hear a scenario of a young patient with an MCL or an LCL sprain. These patients will have tenderness over their fissus, and their injury is actually a fissile injury, not a collateral ligament injury. There's an up to 60% chance of a patient with an MCL or an 60% incidence of premature Fysial closure and treatment is with closed reduction and casting for non-displaced fractures or minimally displaced fractures or closed reduction and internal fixation versus open reduction and internal fixation for significantly displaced fractures.
This is an injury that you probably want to obtain a reduction under skeletal relaxation. You do not want to make multiple attempts at reduction and you want to use so-called Fysial kind techniques including hardware fixation that does not cross the physis. Tibial tubercle fractures are very common in adolescents and teenagers, especially those involved with jumping or running sports such as soccer or basketball. There is a reported incidence of compartment syndrome.
Frequently these injuries have a great deal of soft tissue injury. X-ray often underestimates the amount of injury. The board question is the blood supply which is disrupted and can cause a compartment syndrome and that's the recurrent branch of the anterior tibial artery.
It's critical that you look for interarticular extension. and if there is interarticular extension, the meniscus can become entrapped in the fracture site and prevent reduction. This is an example of such a case treated with open reduction internal fixation, which is the mainstay of treatment. One of the primary complications of this treatment is prominent hardware, which frequently requires hardware removal after healing of the fracture. Tibial spine fractures are the so-called pediatric ACL.
However, it should be noted that a true ACL injury can occur in a skeletally immature patient. These have a similar mechanism, similar presentation, and a similar exam compared to an ACL injury. They're classified based upon the amount of displacement with type 1 injuries being non-displaced, type 2 being hinged anteriorly, and type 3 and 4 being completely displaced and rotated respectively.
Treatment of type 1 injuries is with long leg casting, and type 2 injuries, frequently you can obtain a reduction with extension at the knee. Type 3 and 4 injuries are treated with internal fixation and reduction. Reduction and internal fixation. Your reduction can occur either through a mini-arthrotomy or it can be obtained arthroscopically.
And fixation can occur utilizing a suture construct or a screw as well. Similar to tibial tuberosity fractures, you have to ensure that the meniscus is not entrapped at the fracture site or the intrameniscal ligament, which can also become entrapped at the fracture site. This will prevent your reduction. Complications include stiffness, especially with prolonged immobilization, as well as the risk of late anterior instability. Patellar sleeve fractures present similar to adult patella fractures or adult patellar tendon ruptures.
These are difficult to diagnose as the bony fragment is actually quite small. You will often see patella alta on your lateral x-ray though. Treatment is with open reduction and either a suture repair or a tension band technique. Proximal metaphyseal tibia fractures are called Kozen's fractures.
These are often the result of of low energy and they heal rapidly with application of a long leg cast. However, there is a risk of late valgus deformity which can be quite disconcerting to the parents. This is because this usually appears five to six months after the injury after the child has returned to full activity. The etiology is unknown but the valgus deformity typically corrects over 12 to 24 months.
However, the key point here is that you have to counsel the parents or caregivers at every opportunity regarding this potential complication. Transitional fractures of the ankle occur in adolescents between the age of 12 and 16. This is because of the anatomy of the distal tibial growth plate. The distal tibial growth plate doesn't close overnight, but closes in a very orderly fashion.
Initially, centrally, followed by medially, and finally, anterolaterally. The tallow fracture... Frequently occurs in children, boys between 14 and 16, and girls between 12 and 14, and it's a fracture of the anterior lateral aspect of the distal tibia occurring through the only portion of the growth plate that's still open.
The triplane fracture refers to a fracture which occurs in all three planes, and this fracture occurs in slightly younger children where there's more of the growth plate remaining open. On the lateral x-ray, this will frequently look like a Salter-Harris 2 injury, whereas on the AP, AP. It looks like either a Salter-Hirsch 3 or a Salter-Hirsch 4 injury. Treatment for non-displaced injuries is with immobilization. However, CT is often recommended because frequently the amount of displacement is underestimated on your initial x-rays.
Displacement of greater than 2 to 3 millimeters is not acceptable, and this may increase the risk of arthrosis. Minimally displaced injuries can be treated with attempted closed reduction with casting. or with percutaneous internal fixation, whereas widely displaced injuries are treated with closed reduction or open reduction internal fixation. This is an example of a triplane fracture treated with closed reduction and percutaneous fixation and an example of a triplane fracture treated with ORIF. Moving on to infection, osteomyelitis is very common in children and is commonly spread through a hematogenous route.
This is most commonly located in the metaphyseis of the long bones and this is because of the very specific anatomy of the metaphyseis, specifically the metaphyseal blood vessels. These blood vessels take a very circuitous route and the blood flow through this area often becomes sluggish, allowing bacteria to dislodge and propagate. Staph aureus is the most common organism, with community acquired MRSA becoming more and more common. Group B strep is commonly seen in neonates and the test question involves a premature infant or a preterm infant who's had poor prenatal care presenting with osteomyelitis.
Kingella has also seen some attention recently. Kingella is a fastidious organism which requires blood culture media for growth. Frequently these have less acute symptoms than a staph aureus infection and a delayed presentation is very common. The classic clinical picture includes a child with a warm tender swollen limb.
Frequently there's a history of trauma. A common scenario is a child who falls off their bicycle or has an athletic injury, has pain which resolves over a day or two, but five to seven days later the pain returns and progresses. Children will also frequently have a limp and fever. Inflammatory markers will be elevated and the CRP is important because it tends to peak faster and also normalizes quicker than your ESR after appropriate treatment. X-rays are frequently normal early, but an MRI may be useful in localizing the site of infection and also investigating for a subperiosteal abscess.
There are two important concepts, the involucrum and the sequestrum. The involucrum is periosteal new bone formation occurring around chronic osteo whereas the sequestrum is necrotic bone which has become isolated from its blood supply. This is important because this can be a nidus for either persistent or refractory infection. Treatment of osteomyelitis without a subperiosteal abscess or without pus involves IV antibiotics with the transition to oral antibiotics after appropriate response.
If there is a subperiosteal abscess or pus on aspiration, then treatment is with surgical debridement and irrigation followed by IV antibiotics. Chronic osteo including that involving an involucrum or sequestrum is treated with surgical debridement and excision and antibiotics. Septic joints are also commonly seen in children and frequently occur in joints with interarticular Metaphyses including the hip shoulder elbow and ankle.
Dr. Coker had described four criteria for helping for help differentiating a septic hip from transient synovitis of the hip and these include an elevated temperature elevated ESR Elevated white count and refusal to bear weight. Additionally an elevated CRP has also been added treatment is with debridement irrigation and antibiotic treatment. Moving on to spine, adolescent idiopathic scoliosis refers to scoliosis with a Cobb angle or a curve greater than 10 degrees in the coronal plane. Idiopathic refers to a scoliosis without another identifiable cause, such as a neuromuscular cause or a congenital abnormality. There's certainly a female predominance, especially in cases requiring treatment.
A common test question is when should you obtain an MRI. Routine MRI is not necessary, but you should strongly consider an MRI with atypical curve patterns, such as especially sharp curves or a left thoracic curve. Additionally, a rapidly progressing curve that was previously stable and neurologic abnormalities on examination should also prompt an MRI. Treatment is based upon the curve magnitude as well as the amount of growth remaining or physiologic maturity. Now, physiologic maturity can be measured or estimated using several different methods, including bone age.
This is the Risser sign, which is ossification of the iliac crest apophysis. Additionally, you can use ossification of the calcaneal or of the olecranon apophysis. Treatment for curves that are over 45 to 50 degrees is with instrumentation and fusion. This is because large natural history studies out of Iowa have demonstrated that curves greater than 45 to 50 degrees of skeletal maturity tend to progress during adulthood.
Treatment for curves greater than 25 degrees in a skeletally immature child includes bracing. Now this slide a few years ago may have said bracing is controversial. However, there have been recent studies which do demonstrate the efficacy of bracing. This is an example of one such trial, which was the BRACED trial, which was recently published in the New England Journal of Medicine. Certainly the effect of bracing is dose dependent and authors have recommended different amounts of time per day including 12 hours, 16 hours, and 23 hours.
However, what is known is the more you wear the brace the more efficient it is. Dr. Carroll and her colleagues in Scottish Rite at Scottish Rite demonstrated that bracing may be less effective in boys. This is an example of the most commonly used brace which is a Boston type custom molded TLSO brace.
Again, surgery is indicated for curves that are greater than 45 to 50 degrees. Your surgical goals are to prevent complications, prevent progression, and obtain a solid fusion, and also to restore sagittal and coronal balance and correct rotation. You also want to spare as many motion segments as you can while including structural curves in your fusion construct.
A previously tested concept was that of the anterior approach and when you go anteriorly. Previous thinking was an anterior approach was necessary with open triradiate cartilages or especially a young age. However, recent studies have demonstrated that with pedicle screw fixation this may not be necessary. However, an anterior approach can improve the flexibility in particularly large or or stiff curves.
Spondylolisis represents a stress fracture at the pars interarticularis. This is frequently seen in athletes who do a lot of repetitive hyperextension, including gymnasts, football linemen, and wrestlers. These patients will present with pain with hyperextension. frequently they'll have hamstring tightness on examination as well.
Oblique views of the lumbar spine very clearly demonstrate the spondylolisis. However, recent studies have demonstrated that these views may not add additional info. compared to your AP and lateral x-rays and come at the cost of increased radiation exposure.
An MRI, however, can be very useful, especially if you have a child who you have a strong clinical suspicion for spondylolisis but may have negative x-rays. The MRI will frequently show increased signal on your fluid-sensitive images in either the pars interarticularis or in the pedicle. The mainstay of treatment is rest and activity modification. Physical therapy Therapy for core strengthening is also utilized, and operative intervention is reserved for failure of extensive medical management and non-operative treatment.
Spondylolisthesis refers to a forward slippage of one vertebra on the other, and in children and adolescents this is most commonly seen at L5 as S1. And isthmic spondylolisthesis refers to a slip in spondylolisis due to repetitive hypertension. extension and a fracture.
Dysplastic spondylolisthesis refers to a congenital deformity of the pars or congenital elongation of the pars. The Myreddin classification of spondylolisthesis is based upon the amount of forward slippage of one vertebra on the other. Grade 1 is between 0 and 25, grade 2 up to 50%, and so on and so forth up to a grade 5, which is complete spondyloptosis of the cranial vertebra on the caudal vertebra. The slip angle is also an important concept. A slip angle greater than 45 to 50 degrees increases the risk for progression as well as nonunion.
Pelvic incidence has also been tested recently. Pelvic incidence is an angle which is independent of patient positioning. The angle is drawn first by drawing a line from the center of S1 to the femoral heads, as well as a line from the center of S1 perpendicular to the S1 end plate.
Normal is 50 degrees, and an increased pelvic incidence may predispose to progression of slip or to pseudoarthrosis after surgical treatment. The presentation of spondylolisthesis is very similar to that of lysis. However, high-grade slips can present with fixed knee and hip flexion contractures, a quinas gait, a sacral prominence, as well as very prominent hyperlordosis.
Treatment for grade 1 and grade 2 slips is very similar to spondylolisis and includes rest, activity modification, occasionally a brace, and surgical treatment reserved for failure of extensive medical management. The treatment for high-grade slips, including grade 3, grade 4, and grade 5, is somewhat controversial. However, surgical treatment is generally recommended given the risk of progression.
However, which surgical approach you take is very controversial. A reduction can be performed and likely decreases your risk of pseudoarthrosis and increases the risk of obtaining a good solid fusion. However, it comes at the risk of increased neurologic injury.
Moving on to specific anatomic pathology. Developmental dysplasia of the hip has certain risk factors including breach presentation, female sex, a first born child as well as a strong family history. These risk factors are frequently tested on the examination. The examination in the newborn. consists of the Barlow and the Ortolani maneuvers.
The Barlow maneuver is essentially taking a hip which is reduced and subluxing subluxating it or dislocating it. The Ortolani on the other hand is taking a hip which is subluxed or dislocated and returning it to a reduced position. These maneuvers tend to go away in the older child and in the older child physical examination findings include limited hip abduction, a positive Galeazzi sign or asymmetric thigh links.
well as asymmetric thigh folds. Ultrasound is very useful in these patients in both making the diagnosis as well as gauging the results of your treatment. This is because the femoral head ossification center appears between four and six months of age.
This is an example of what you will see which is a coronal image rotated 90 degrees. I think it's very important to know some of these structures as this may show up on the examination. In this particular example number one represents the tri-radiate cartilage. Number two represents your abductors. Number three represents your represents the bony ilium, number four the femoral head, and number five the bony acetabulum.
In this particular case the femoral head is slightly less than 50% covered. Another important concept is that of the alpha angle. Normal is greater than 60 degrees and this angle is drawn first by drawing a line along the bony acetabulum and another line along the bony ilium. X-rays are useful after the appearance of the femoral head ossification center, and there are some important lines and arcs on the radiographs which are important.
These include Shenton's line as well as Perkins'line, which is a longitudinal line drawn at the edge of the bony acetabulum. The femoral head ossification center should be medial to that line. This is an example of bilateral high hip dislocations, showing that the femoral head ossification center is in fact lateral to Perkins'line. and shenton's arc or shenton's line is not intact the treatment of hip dysplasia in essence is to get the hip in keep it in and avoid complications in the child between birth and six months of age the mainstay of treatment is the padlock harness however it's critical that reduction be obtained by three weeks in the harness if the harness is continued with the dislocated hip It can lead to so-called Pavlik harness disease or erosion of the posterior acetabulum. If the hip is not reduced by this point, you can consider rigid abduction bracing or closed reduction in casting.
It's important that in the Pavlik harness you not overly flex the hips as too much flexion can lead to ephemeral nerve palsy. And if this occurs, you should stop the brace until quadriceps function returns. Additionally, too much abduction can create an environment where you can have avascular necrosis.
And for that reason, your posterior straps, which limit adduction, should not be tight. They should not be tight to the point that you are forcing abduction. However, they act as a check rein to prevent adduction and dislocation of the hip.
In children between 6 and 18 months of age, the mainstay of treatment is a closed reduction, often with an adductor tenotomy and spica casting. In a child older than 18 months of age, the treatment is with open reduction, Usually a pelvic osteotomy, most typically a salter osteotomy, and a femoral shortening osteotomy is used in children older than three years of age. This is because of the risk of AVN, and you want to take pressure off of the immature ossification center. In the older child, you treat residual bony dysplasia with a pelvic osteotomy.
A commonly tested concept are the blocks to reduction at the time of open reduction of the hip. These include the iliopsoas tendon, which is often constricted and needs to be lengthened, as well as the transverse acetabular ligament, an inverted labrum, constricted or hourglass capsule, as well as the pulvinar or the fibro fatty tissue at the bottom of the acetabulum. Again, you have to address all of these blocks reduction to obtain and maintain a reduction in your cast.
Slip capital femoral epiphysis refers to a slip through the hypertrophic zone of the physis. Risk factors include obesity as well as endocrine disorders like hypothyroidism and growth hormone deficiency. Additionally, a risk factor includes renal osteodystrophy.
A very common test scenario is a child who's had persistent knee pain, especially an overweight child, and knee pain, concomitant knee pain, is often seen with a SCFI. Examination will show obligate external rotation with hip flexion. The loader classification is based upon whether the child can bear weight, or is unable to bear weight, with stable injuries being those where the child is able to bear weight, unstable being unable to bear weight even with crutches. This is important because it's a prognostic classification system. Dr. Loader demonstrated that unstable injuries have an up to 47% risk of avascular necrosis, whereas stable injuries, that risk approaches zero.
The mainstay of treatment is pinning in situ. Now an important concept. is the location of your start point for your screw. Since the epiphysis itself is posterior, frequently your screw has to start anteriorly so you can cross the physis at 90 degrees and have good purchase into the epiphysis. This is an example of a in situ pinning.
An incidental reduction of the SCIFI often occurs when positioning. However, you want to avoid a forceful reduction as this may increase your risk of AVN. Some authors add a capsulotomy as well. to decrease intracapsular pressure. A very common question is when do you prophylactically pin the other hip?
Certainly if you have contralateral symptoms, you would pin the other hip. But other indications for prophylactic pinning include an endocrinopathy, age younger than 10, especially open tri-radiate cartilage. Also, if you have a child who may have poor follow-up, you may consider prophylactic pinning.
Frequently, SCIFIs have a resultant deformity which may contribute to femoroacetabular impingement. And there are emerging techniques like open surgical dislocation with a modified Dunn osteotomy. However, the mainstay of treatment for the examination purposes is still going to be in situ pinning. LCP or Perthes disease is AVN of the femoral head.
It's due to a vascular insult of unknown origin, but it's most commonly seen in skinny children, especially hyperactive boys between the ages of four and eight. Now if you see bilateral Perthes disease, especially of the same stage, you should think about multiple epiphyseal dysplasia. Waldenstrom described four stages.
Initial, which is characterized by pain as well as sclerosis on the x-ray, followed by fragmentation. reossification, and finally remodeling. Additionally, the lateral pillar classification relies on the amount of bone remaining in the lateral pillar of the femoral head.
Poor prognosis is portended by an age greater than six, female sex, a lateral pillar C classification, as well as decreased range of motion on presentation. The goals of treatment include maintaining a range of motion, controlling pain, and containing the hip within the acetabulum. There are multiple treatment modalities with authors recommending all sorts of different algorithms but treatment includes non-steroidals, physical therapy, and limited weight bearing along with crutches to control pain and also help maintain range of motion. Additionally, some authors recommend either Petri casting or abduction bracing, again to contain the hip and control pain. Finally, surgical strategies for containment include a proximal femoral osteotomy as well as acetabular osteotomy.
and it has been shown that surgery improves the radiographic outcomes for patients older than 8 with lateral pillar B or BC disease. Limb link discrepancies are due to a host of reasons. However, the most testable etiologies include proximal focal femoral deficiency, fibular deficiency, as well as post-infectious or post-traumatic growth arrest. Your treatment relies on the amount of growth remaining as well as the projected limb length discrepancy at skeletal maturity.
There's a couple different ways to calculate the leg length discrepancy at maturity. One method is the arithmetic method. This method is a little bit more complicated. This method relies on the fact that the distal femoral growth plate grows at approximately nine millimeters per year, with the proximal tibial growth plate growing at approximately six millimeters per year. Boys grow generally until the age of 16, with girls growing until the age of 14. Additionally, the Moseley straight line graph is another method.
However, this necessitates multiple measurements with bone ages taken over time. Dr. Paley also developed the Paley multiplier method, which is useful because you can perform this with only one point in time. Again your treatment depends upon the discrepancy at maturity. Discrepancy less than two centimeters is treated with observation or a shoe lift. Discrepancy between two and five centimeters is frequently treated with epiphysiodesis or shortening of the long limb.
Now this can be done utilizing a bone block which is somewhat of a permanent solution or it can be done with screws or plates. Discrepancies greater than five centimeters are more challenging to treat. and frequently these require some combination of shortening and lengthening and often require multiple surgical interventions.
Lower extremity rotation problems are frequently disconcerting to families, and this is a common reason for presentation to a pediatric orthopedic clinic. End-toeing can be caused by metatarsus seductus, internal tibial torsion, which is very common between three and six years of age. as well as increased femoral an aversion now non-operative interventions such as twister cables braces orthotics and physical therapy have not been shown to affect the natural history of internal tibial torsion or femoral an aversion and the treatment is reassured counseling and surgical intervention if you have a persistent deformity past the age of eight to ten that is disabling and is interfering with the child's ability to perform athletic athletic activities or activities of daily living out towing similarly can be caused by external tibial torsion but in toddlers it's frequently due to external rotation contractures of the abductors however if you ever see a child especially an obese child with unilateral out towing you you should think about SCFI.
Osgood-Schlatter disease represents tibial tubercle apophysitis. This is a traction-induced phenomenon. And it's more common in boys than girls, especially boys involved in basketball and soccer. On examination, these patients will have pain over their tubercle.
The tubercle will be enlarged, swollen, and sometimes erythematous, and they'll have pain with resisted extension, and frequently they have quadriceps or hamstring tightness. Radiographs will reveal fragmentation of the tibial tubercle apophysis, and sometimes these patients will be referred for a fracture. However, there's no inciting traumatic event.
and they have an intact straight leg raise. The treatment is reassurance, activity limitation, stretching, which is very important, as well as the judicious use of non-steroidal anti-inflammatories. Osteochondritis desiccans is very common in children between the age of 12 and 15 and is seen commonly in the knees, ankle, and elbow.
This can lead to separation of the fragmented bone from the surrounding bone, and there's multiple theories on etiology, but most of these theories rely on overuse and it's felt to be likely some form of avascular necrosis. In the knee, the lateral portion of the medial femoral condyle is the most common location and this is readily identified on your tunnel or notch view. Additionally, MRI is useful in looking for stability and also looking for fluid signal behind the lesion which may portend poorly for healing. Treatment is based upon the age of the patient as well as the duration of symptoms.
Non-operative treatment is indicated initially with bracing and restricted weight-bearing, and the chance of healing is very good, especially in younger children with open growth plates. Operative treatment, including drilling, is indicated after failure of medical management, and displaced fragments or fragments with fluid behind them are often treated with fixation, with or without bone grafting. This is an example of a 14-year-old male who had a displaced OCD treated with a limited arthrotomy, internal fixation, and subsequent hardware removal three months later.
Lower extremity alignment issues like genuvarum or genuvalgum are also a frequently tested concept and also a frequent reason for a visit to a pediatric orthopedic or to an orthopedic surgeon in general. Genuvarum or physiologic varum is normal up to the age of two, with most children assuming a neutral position between 18 months and two years of age. After this, you have progressive valgus angulation, which again is normal. This peaks at age 3 with improvement to a normal valgus appearance at adulthood. You should consider treatment for valgus greater than 10 to 15 degrees when the child is older than 10. Infantile blounts disease, on the other hand, represents a pathologic tibia vera.
This is frequently seen in children less than 4 years of age. Frequently, these are obese children, and it is associated with early walking. And often they have internal tibial torsion on examination as well. One difficulty is differentiating a mild blounts disease from physiologic tibia vera.
One angle that can be utilized is the metaphyseal-diaphyseal angle of Drennan, and studies have shown that an angle greater than 16 degrees predicts progression to infantile blounts disease. Additionally, Langen-Skjold classified these based upon the physiologic changes to the metaphysis. and the physis.
This is important because stage 4, 5, and 6 effectively represent a medial physial growth arrest. Treatment is based upon the age as well as a stage of the lesion. Bracing is indicated for children younger than 3 with stage 1 and 2 lesions. Stage 2 and 3 lesions in older children are treated with proximal osteotomy and realignment.
Stage 4, 5, and 6 lesions are much, much more complex because effectively these have a medial fascial growth arrest and often require multiple procedures. Adolescent blouse disease, on the other hand, presents in the older adolescent or teenager. It is frequently unilateral, but it does occur in obese patients. A characteristic radiographic finding is widening of the proximal medial fasces.
Bracing is not effective, and treatment includes hemipiphysiodesis and mild deformity. as well as osteotomy and significant deformity. Now your osteotomy can be done with an acute correction and plating or external fixation with gradual correction. Tibial bowing is very commonly tested. Posterior medial bowing is associated with a calcaneovalgus foot.
And the test question is that this will resolve over time. However, these patients are frequently left with a limb-link discrepancy which persists into adulthood. Anterior lateral bowing on the other hand is associated with congenital pseudoarthrosis of the tibia and is commonly seen in patients with neurofibromatosis.
Approximately 50% of patients with CPT will have a neurofibromatosis. have neurofibromatosis, but only about 10% of patients with NF have CPT. The initial treatment is bracing to prevent fracture.
This is important because once fracture occurs, it's very difficult to obtain and maintain osteosynthesis. Surgical treatment at this point is with resection of the hamartomus tissue, bone grafting, and internal fixation. Clubfoot is a congenital deformity characterized by forefoot adduction, supination, and hindfoot aquinas and varus. There is a genetic component certainly to this and one recent culprit has been identified which is the PITX1-TBX4 transcriptional pathway.
Additionally, these patients will have a deficient tibialis anterior artery which makes preserving the posterior blood supply, especially if you're doing a posterior medial release, very important. Frequently you see parallelism on the x-rays which is a parallel appearance of the talus and calcaneus. And the mainstay of treatment is with Ponseti casting, which is a series of casts applied usually once a week for between three and seven weeks.
The order of correction is often tested, and this can be remembered using the mnemonic CAVE. CAVUS followed by ADDUCTUS, VERUS, and finally AQUINUS. And often these patients require a TAL or tendo-achilles lengthening at the conclusion of casting.
Recurrence is associated with brace non-compliance following casting. About 10% of these patients will also have residual dynamic supination, which is treated with transfer of the tibant. Tarsal coalitions are failure of mesenchymal segmentation, resulting in fusion of individual tarsal bones. The two most common are talocalcaneal and calcaneonavicular. These patients will present with decreased subtalar motion, as well as a spastic flat foot.
There is an association with FGFR. related craniosynostosis syndromes, and familial cases with an autosomal dominant inheritance pattern have been identified. Talocalcaneal coalitions are treated with resection and fat interposition if less than 50% of the joint is involved, or with fusion if greater than 50% of the joint is involved.
Calcaneonavicular coalitions are treated with resection and fat interposition. This is an example of a talocalcaneal coalition on a 3D reconstruction. as well as a calcaneonavicular. Pest planus or flat foot deformity is flexible, frequently bilateral, and frequently runs in families. Oftentimes these patients have external tibial torsion and may have ligamentous laxity as well.
The mainstay of non-operative treatment for symptomatic patients is inserts, braces, or athletic shoes with a good arch support. However, it's important to note that these modalities do not actually change the shape of the arch. Surgical treatment is indicated for failure of non-operative modalities with persistent symptoms and can be either a calcaneal lengthening osteotomy as described by Evans or with a 3C osteotomy or an osteotomy of the calcaneus, a lengthening through the cuboid, and a shortening through your medial cuneiform.
Moving on to a discussion of some dysplasias and diseases which often show up on the examination. Hereditary motor and sensory Neuropathy number one, or Charcot-Marie tooth, is a very common tested subject. It's a disorder of myelin degeneration and is autosomal dominant.
This is due to a deficiency of peripheral myelin protein 22, which is found on chromosome 17. It's the most common cause of pes cavus. Now, a fundamental aspect of this disease is a muscle imbalance, and it's important to know which muscles are weak and which muscles are relatively strong. The tibialis anterior and the peroneus brevis are most severely affected, and a relatively strong peroneus longus leads to a plantar flexed first ray, which seems to drive the deformity. A relatively strong tibialis posterior leads to varus deformity at the hind foot.
Treatment initially is with orthotic with a lateral post and depression for the first ray. However, surgical intervention is frequently needed because of progression. Surgical treatment is plantar fascia release.
with a dorsiflexion first metatarsal osteotomy and then depending upon the flexibility of the hind foot either a posterior tibialis transfer or a calcaneal osteotomy and you judge the flexibility of the hind foot utilizing the coleman block test now during the coleman block test you place the lateral portion of the hind foot on a block allowing the first ray to become plantar flexed and if you see the hind foot go into valgus you know that the hind foot is flexible And again, if the hind foot is flexible, you proceed with posterior tib transfer, otherwise a calcaneal osteotomy. Muscular dystrophy are inherited non-inflammatory conditions characterized by progressive proximal muscle weakness. Duchesne's muscular dystrophy is the most common and is due to a deficiency in the dystrophin protein.
It is X-linked recessive and frequently these patients will have elevated CK on examination. Becker muscular dystrophy, on the other hand, is also X-linked recessive but is less severe than Duchesne's. Again, the characteristic finding is progressive loss of motor strength.
Frequently these patients will also have lumbar lordosis and calf pseudohypertrophy. A very characteristic examination finding is the Gower sign. in which the child effectively has to triplane up when arising from a sitting or a supine position. Now, the treatment of scoliosis is different from that of AIS.
Posterior spinal fusion and instrumentation is indicated once the curve progresses past 20 to 25 degrees, which, again, is lower than an AIS. This is because once the scoliosis has progressed to this point, it usually progresses very rapidly. And with that progression, you see a worsening of pulmonary function.
which makes subsequent surgical intervention much more dangerous. Marfan syndrome is autosomal dominant and is a defect of fibrillin 1. Frequently these patients will have aortic dilation and other cardiac issues as well as superior lens dislocation. Now this mandates both a cardiology as well as an ophthalmology consultation. Orthopedic manifestations include long slender fingers, pectus deformities, and also scoliosis.
It's important to note that scoliosis is not treated with bracing as bracing has been found to be somewhat ineffective. Myelodysplasia or spina bifida is due to incomplete spinal cord closure or rupture of the developing cord. Frequently the mom will have an increased serum alpha-fetoprotein and risk factors include the use of certain anti-seizure medications like valproic acid and carbamazepine as well as a low folic acid.
In fact folate Supplementation has significantly reduced the incidence of spina bifida. The level is based upon the motor level that remains in the child, and this is important because an L4 level, which basically gives you quad function, is necessary for community ambulation. Most of these patients have a latex allergy, so it's critically important that if you take them to the operating room, you operate in a latex-free environment. Orthopedic problems include hip dislocations, knee flexion contractures, Foot disorders, especially clubfoot, as well as Aquinas deformity, tethered cord can present in a child who's had a stable neurologic examination and is now having worsening of either motor or sensory function, and that's a classic clinical scenario.
Another classically tested scenario are fractures in a child with spina bifida. Since the child may be insensate, frequently these fractures are not painful, but they'll present with a warm, swollen, erythematous limb. which can mimic infection.
However, radiographs will demonstrate the fracture, and these fractures usually heal with an abundance of callus. Cerebral palsy is another neuromuscular condition, which is often due to an injury to the immature brain. This can be classified either based upon the physiologic type, such as spastic, athetoid, or ataxic, with spastic being the most common. It can also be characterized by the location, either hemiplegic, diplegic, or quadriplegic, or total body.
Additionally, the gross motor functional classification system classifies these children on their ability to ambulate or mobilize using assistive devices. Muscle contractures are very common, and surgical treatment may include tendo-achilles lengthening, hamstring lengthening, or iliopsoas or hip flexor lengthening. Scoliosis is also very common, and surgical indications are similar to AIS. Surgery can be considered in curves greater than 45 to 50 degrees, but it should be noted There's a much higher complication rate compared to idiopathic scoliosis and this complication rate approaches 40 to 50 percent.
Hip subluxation dislocation is also very common. You want to be aggressive and treat the hip at risk with adductor releases but late hip subluxation or dislocation requires a bony reconstruction. Foot deformities are also very common including equinovalgus and equinovarus. Hallux valgus or a bunion is treated with fusion.
not with soft tissue releases as might be done in an adult patient. Rickets is characterized by short stature, varus angulation at the knees, as well as bone pain. On histology, you'll see an enlarged zone of hypertrophy and the characteristic radiographic findings include fissile cupping and widening of the physis. The treatment is aimed at the underlying disorder. Achondroplasia is the most common form of short limb dwarfism.
It's autosomal dominant. and is due to a defect in the FGFR3 protein. This is a failure of the proliferative zone of the physis, and orthopedic issues that cause disability include lumbar stenosis and excessive lordosis.
In comparison, pseudoachondroplasia is less severe and is due to a defect in the COMP protein. Diastrophic dysplasia has also been tested recently. This is an autosomal recessive condition.
It's characterized by a deficiency in the sulfate transport protein, and characteristic findings include a cleft palate, cauliflower ears, as demonstrated here, as well as hitchhiker thumb, and a very high incidence of club feet. And these club feet are often resistant to Ponseti treatment and have a high risk of recurrence. Additionally, cervical kyphosis can be a potential source of profound disability. Thank you.