Overview of Pediatric Orthopedics Topics

Aug 14, 2024

Pediatric Orthopedics Lecture Notes

Introduction

  • Speaker: Jeremy Rush, San Antonio, Texas
  • Topic: Pediatric Orthopedics
  • No financial disclosures
  • Focus on commonly tested subjects in pediatric orthopedics

Trauma and Specific Fractures

Non-Accidental Trauma (NAT) / Child Abuse

  • Importance: Physician reporting is mandatory.
  • Common Patterns:
    • Spiral humerus fractures
    • Femur fractures in non-ambulatory children
    • Rib fractures, especially posterior rib fractures
  • Typical Presentations:
    • Skin lesions (bruising and burns)
    • Metaphyseal corner fracture
    • Distal humeral transphyseal fractures
  • Diagnosis: Skeletal surveys for fractures in various healing stages.

Elbow Fractures

Supracondylar Humerus Fractures

  • Most common fracture requiring surgery in children.
  • Classification: Flexion type or extension type (95%).
  • Gartland Classification: Guides treatment based on displacement.
    • Type 1: Non-displaced, treat with casting.
    • Type 2: Hinged, treat with closed reduction/pinning or casting.
    • Type 3 & 4: Displaced, treat with reduction and pinning.
  • Complications:
    • Nerve injury (AIN and ulnar nerve)
    • Vascular injury
    • Cubitus varus
    • Pink pulseless fracture: urgent closed reduction and pinning.

Lateral Condyle Fractures

  • Second most common elbow injury.
  • Recommended X-rays: Internal oblique x-rays for better displacement view.
  • Jacob Classification: Guides treatment based on displacement.
    • Non-displaced: Long arm casting.
    • Displaced: Internal fixation.
  • Complications: Nonunion, cubitus valgus, and tardy ulnar nerve palsy.

Other Fractures

  • Medial Epicondyle Fractures: Associated with elbow dislocation.
    • Treatment controversy: Open reduction internal fixation for specific cases.
  • Transfacial Distal Humerus Fractures: Associated with NAT.
    • Treatment similar to supracondylar humerus fractures.
  • Montasia Fractures: Ulna fracture with radiocapitellar dislocation.
    • Treatment: Reduction of ulna and demonstrate reduced radiocapitellar joint.
  • Forearm Fractures: Common in children, treated mostly with closed methods.
  • Femur Fractures: Consideration of NAT; treatment varies by age.

Femur Fracture Treatment by Age

  • Up to 6 months: Pavlik harness.
  • 6 months to 5 years: Closed reduction and spica casting.
  • Older than 5 years: External fixation, submuscular plating, or intramedullary nails.

Knee Fractures

  • Distal Femoral Fractures: High energy, caution with MCL/LCL sprain scenarios.
  • Tibial Tubercle Fractures: Common in adolescents, risk of compartment syndrome.
  • Tibial Spine Fractures: Pediatric ACL equivalent, treatment based on displacement.
  • Patellar Sleeve Fractures: Difficult to diagnose, treated with open reduction.
  • Proximal Metaphyseal Tibia Fractures: Risk of late valgus deformity.

Ankle Fractures

  • Transitional Fractures: Occurs in ages 12-16 due to growth plate anatomy.
    • Types: Tillaux and triplane fractures.
    • Treatment: Based on displacement.

Infection

Osteomyelitis

  • Common Presentation: Child with warm, tender, swollen limb, often post-trauma.
  • Common Organisms: Staph aureus, MRSA, Group B strep, Kingella.
  • Diagnosis: Elevated inflammatory markers, MRI for infection site.
  • Treatment: IV antibiotics, possible surgical debridement.

Septic Joints

  • Common Joints: Hip, shoulder, elbow, ankle.
  • Diagnosis Criteria: Coker criteria (temperature, ESR, WBC, refusal to bear weight).
  • Treatment: Debridement, irrigation, antibiotics.

Spine Conditions

Adolescent Idiopathic Scoliosis

  • Definition: Curvature > 10 degrees, female predominance.
  • Indications for MRI: Atypical curve patterns, rapid progression, neurologic issues.
  • Treatment: Based on curve magnitude and growth remaining.
  • Brace Efficacy: Dose-dependent.

Spondylolisis and Spondylolisthesis

  • Spondylolisis: Stress fracture at pars interarticularis, common in athletes.
  • Spondylolisthesis: Forward slippage, common at L5-S1.
    • Classification: Myreddin classification based on slippage.
    • Treatment: Based on grade of slip.

Hip Conditions

Developmental Dysplasia of the Hip (DDH)

  • Risk Factors: Breach presentation, female sex, first born, family history.
  • Diagnosis: Barlow and Ortolani maneuvers, ultrasound, x-rays.
  • Treatment: Pavlik harness, spica casting, open reduction depending on age.

Slip Capital Femoral Epiphysis (SCFE)

  • Risk Factors: Obesity, endocrine disorders.
  • Classification: Loader classification (stable/unstable).
  • Treatment: Pinning in situ.

Legg-Calvé-Perthes Disease

  • Characteristics: AVN of femoral head, common in boys 4-8 years.
  • Stages: Initial, fragmentation, reossification, remodeling.
  • Treatment: Maintain range of motion, control pain.

Limb Length Discrepancies

  • Causes: Proximal focal femoral deficiency, fibular deficiency, growth arrest.
  • Methods of Calculation: Arithmetic method, Moseley graph, Paley multiplier.
  • Treatment: Based on discrepancy at maturity.

Lower Extremity Rotation Problems

  • Causes of Intoeing: Metatarsus seductus, internal tibial torsion, femoral anteversion.
  • Treatment: Reassurance and counseling.

Specific Conditions

  • Osgood-Schlatter Disease: Tibial tubercle apophysitis, common in boys in sports.
  • Osteochondritis Desiccans: Common in ages 12-15, affects knees, ankle, elbow.
  • Lower Extremity Alignment Issues: Genuvarum and genuvalgum, normal patterns and treatment.
  • Blount's Disease: Pathologic tibia vera, treatment varies by stage.

Foot and Ankle Conditions

  • Tibial Bowing: Associated with calcaneovalgus foot or congenital pseudoarthrosis.
  • Clubfoot: Genetic component, treated with Ponseti casting.
  • Tarsal Coalitions: Fusion of tarsal bones, treatment based on involvement.

Dysplasias and Diseases

  • Charcot-Marie Tooth: Disorder of myelin, muscle imbalance.
  • Muscular Dystrophy: Inherited, progressive muscle weakness.
  • Marfan Syndrome: Defect in fibrillin 1, associated with aortic dilation.
  • Myelodysplasia/Spina Bifida: Incomplete spinal cord closure.
  • Cerebral Palsy: Neuromuscular condition, characterized by muscle contractures.
  • Rickets: Characterized by short stature, varus angulation.
  • Achondroplasia: Short limb dwarfism, most common form.
  • Diastrophic Dysplasia: Autosomal recessive, deficiency in sulfate transport protein.

These notes cover the breadth of pediatric orthopedics topics as discussed in the lecture, providing a comprehensive overview of key concepts, common conditions, and treatment strategies.