Pediatric Orthopedics Potpourri - Healthcare Professionals

Pediatric Orthopaedics
When to send…
CHRIS SOUDER, MD
BAYLOR SCOTT & WHITE HEALTH
MCLANE CHILDREN’S HOSPITAL
Orthopaedics
 Specialty originated in the diagnosis and treatment
of conditions of children

Ortho

To straighten or correct
Paed
Child, children
Orthopaedics
 Trauma


Fractures
Ligament & joint injuries
 Infections


Osteomyelitis
Septic Arthritis
 Spine



Scoliosis
Kyphosis
Spondylolysis
 Foot & Ankle




Clubfoot
Congenital vertical talus
Tarsal Coalitions
Cavus & Pes planus (flatfoot)
 Hip



Developmental dysplasia
(DDH)
SCFE
Perthes
 Sports Medicine



ACL, meniscus tears
Patellofemoral instability
Femoroacetabular
impingement
 Upper Extremity


Syndactyly, polydactyly
Congenital deformities
 Neuromuscular


Cerebral Palsy
Spina bifida
 And more…
Orthopaedics
 Trauma


Fractures
Ligament & joint injuries
 Infections


Osteomyelitis
Septic Arthritis
 Spine



Scoliosis
Kyphosis
Spondylolysis
 Foot & Ankle




Clubfoot
Congenital vertical talus
Tarsal Coalitions
Cavus & Pes planus (flatfoot)
 Hip



Developmental dysplasia
(DDH)
SCFE
Perthes
 Sports Medicine



ACL, meniscus tears
Patellofemoral instability
Femoroacetabular
impingement
 Upper Extremity


Syndactyly, polydactyly
Congenital deformities
 Neuromuscular


Cerebral Palsy
Spina bifida
 And more…
Most Common Things I See
(and don’t operate on)
 Anterior knee pain
 In-toeing
 Knock-knees/Bowlegs
 Flatfeet
Anterior Knee Pain
 Chondromalacia Patella

Pain in the knee due to increased pressure from the
patella
 Commonly occurs without injury to the knee
 Pain is diffuse about the knee

I tend to see kids draw it out superiorly and lateral
to the patella
 Described as achy

May worsen with prolonged sitting or with activities
 May have catching or giving out episodes
 Minimal or no swelling present
Anterior Knee Pain
 Physical Exam
 Pain with compression or manipulation of the patella




Diffuse TTP
No significant effusion
NO pain with ROM of hip
Tight hamstrings and quads

Decreased popliteal angles (straight leg raise) and prone
knee flexion
 Treatment
 NSAIDs



I typically ask them to take these as a scheduled Rx for
2-3 wks
Ice/heat
Stretching & Strengthening
Anterior Knee Pain
Hamstring Stretches
Quadricep Stretches
In-toeing
 Metatarsus Adductus
 Internal Tibial Torsion
 Femoral Anteversion
In-toeing
 Metatarsus Adductus
 Most common in infants/toddlers
 Typically resolves spontaneously
 Stretching may or may not help
 Rarely are corrective shoes required
 Surgery performed only in severe and persistent
cases
Requires osteotomies
 Child typically > 4 y/o

In-toeing
 Internal Tibial Torsion
 Inward twist of the tibia
 Most common cause in 3-4 y/o
 Most cases slowly improve over time without
treatment
Infants are born with medially rotated feet that
laterally rotate as they age
 No treatment needed


Identified by a decreased thigh foot axis (TFA) or
decreased transmalleolar axis
In-toeing
 Femoral Anteversion


Infants are born with femoral anteversion of ~40° that typically
decreases to ~15° by adulthood
Lower extremity internally rotates to compensate for increase
anteversion





Patella rotated inwards and in-toeing present in stance phase of gait
Commonly seen in children 5-6 y/o
Typically improves by 10 y/o
Recommend improve sitting
Surgery rarely needed for symptomatic
patients 11-12 y/o

Requires femoral osteotomy
Knock-knees / Bowlegs
 Knock-knees
 Genu valgum
 Bowlegs
 Genu Varum
 Children naturally progress from varus to valgus during
development
 Concern arises if:
 Significant varus past 2 y/o
 Unilateral
 Severe
 Familial
Flatfeet
 Pes Planovalgus
 One of the most common “deformities”
evaluated by pediatric orthopaedists




Normal variation of childhood
Normal in children as arch slowly develops over time
Frequently associated with ligamentous laxity
Deformity corrects with heel rise


Feet that do not correct need to be seen by an
orthopaedic surgeon
Treatment is conservative



Studies have proven no benefit with corrective shoes or
arch supports
Symptomatic tx can consist of well-structured athletic
shoes or off-the-shelf arch supports
Surgery needed only in severe cases (>8 y/o)
Trauma
 25% of children sustain a injury every year
 10-25% of injuries are fractures
 Largest share of all children injuries
 Radius is most common long bone fracture
 23% of all fractures
 21.7% of fractures involve the physis
Trauma
 Most children factures can be treated with
nonoperative methods
 Trends toward more operative treatment
 Improvement in technology
 Rapid healing allows for minimal internal fixation
 Modern parents expect the perfect outcome
Trauma
 Unique aspects

Anatomical regions of a growing bone

Different fracture patterns

Physeal fractures

Remodeling
Children Fractures
 Aids in
communication &
description of fx

Classifications
 Guides treatment


Acceptable criteria
Length of
immobilizatoin
 Provides prognosis


Potential for
remodeling
Possible
complications
Children Fractures
Plastic
deformation
Greenstick
fracture
Buckle (Torus)
fracture
Physeal Fractures
 20-30% of all children fractures
 Salter-Harris Classification
 Guides treatment
 Provides prognosis
 Reduction is primarily traction
 Physeal disturbance
 Harris growth arrest lines
 Need re-evaluated at 6 & 12 mc
Remodeling
 Bone and cartilage remodel in response to
normal stresses of body



Body weight
Muscle action
Joint reactive forces
 Greater potential

Younger
Closer to physis
In plane of joint motion

Rotational deformities do not reliably remodel


Common Injuries
Distal Radial Buckle
Fracture
Supracondylar Humerus
Fracture
Unique Injuries
 Occult elbow fracture


Posterior fat pad sign with history of trauma to
the elbow
No radiographic evidence of fx
 Tx is long arm splint or cast for 3 weeks
 76% have evidence of fx




53% SCH
26% proximal ulna
12% lateral condyle
9% radial neck
Unique Injuries
 Radiocapitellar dislocation
 Monteggia Fracture-dislocation
Unique Injuries
Tillaux Fracture
Triplane Fracture
Key Points
 Fractures near physis heal rapidly
 Remodeling potential allows for ‘acceptable
deformity’
 Rare stiffness seen with immobilization
 Physeal arrest can lead to deformity
 Must remember the possibility of child abuse
Compartment Syndrome
 3 As

Increased Anxiety

Increased Analgesic requirements

Increased Agitiation
Acute Hematogenous Osteomyelitis (AHO)
 Most commonly occurs in the
metaphysis

75% of cases involve long bones

Lower extremities more frequent than
upper
 Most common pathogen is Staph




Aureus
Commonly seen after minor
trauma
Typically present with pain and
decreased use of extremity
Fever is commonly seen
Skin changes can be present
Acute Hematogenous Osteomyelitis (AHO)
 Labs
 WBC


ESR


Least sensitive
Becomes elevated after 48h
CRP
Serum levels rise after 6h
 Elevated in 98% of osteomyelitis


Blood cultures

Yield organisms 30-60%
Acute Hematogenous Osteomyelitis (AHO)
 Imaging
 Radiographs
Soft-tissue swelling & loss of tissue planes seen within 3 days
 Evaluate for associated effusion
 Bony changes present after 7-10days


MRI
Sensitivity 88-100%
 Specificity 75-100%
 IV contrast
 Allows evaluation for soft-tissue and subperiosteal abscess
formation

Acute Hematogenous Osteomyelitis (AHO)
 Treatment
 PO abx
 IV abx
 Needle aspiration
 Open biopsy
 Curettage
Septic Arthritis
 Most commonly a result hematogenous seeding of the
synovium
 Staph Aureus is most common pathogen
 Child is typically more ill appearing than in osteomyelitis

Pain experienced with gentle ROM
 Same work up as for osteomyelitis


Labs (ESR, CRP, WBC, BCx)
Plain radiographs

If concern for septic hip, obtain ultrasound to evaluate for an effusion
 Aspiration provides final diagnosis
 Treatment is URGENT joint lavage
Transient Synovitis of the Hip
 One of the most common causes of hip pain
 Must be differentiated from septic arthritis
 Accurate diagnosis required to avoid joint
destruction
 Clinical Predictors
 Refusal to bear weight
 Temp > 38.5°C
 WBC > 12,000
 ESR > 40 mm/h
 CRP > 20.0 mg/L
Scoliosis
 Curvature of the spine > 10° in the coronal plane
 Idiopathic
 Infantile <4 y/o
 Juvenile 4-10 y/o
 Adolescent 11 y/o & older
 Congenital
 Secondary to a bony abnormality
 Neuromuscular
 CP, syndromic, spina bifida, etc
Adolescent Idiopathic Scoliosis (AIS)
 Larger curves requiring treatment are much more
common in females
 Family history is associated with presence, not
progression, of a curve

Strongest relationship is a daughter of male with scoliosis
 Etiology is not completely understood
AIS
 Curve progression associated with curve magnitude
and growth remaining

Seen during rapid growth phases

Predicted based on
 Skeletal age
• Risser sign, bone age

Maturity
• Onset of menses
 Indicates deceleration of growth
AIS
 Screening
 Recommended to be performed 2x for
females 10-12 y/o


1x for males 13-14 y/o
Appearance
Shoulder asymmetry
 Scapular prominence
 Waist asymmetry


Scoliometer

Rib or lumbar prominence on Adam
Forward Bend Test
 7° angle of trunk rotation (ATR)
referred to Orthopaedics
AIS
 Treatment
 Observation
<25° with significant growth remaining (Risser 0-2)
 <45-50° with minimal growth remaining (Risser 3-5)


Bracing


>25° with significant growth remaining (Risser 0-2)
Surgery

>45-50°
 Most commonly posterior spinal instrumentation
and fusion
Key Points
 Goals of treatment

Limit magnitude of curve/deformity present at skeletal maturity


Curves <45-50° at maturity have a low likelihood of progression in
adulthood
Bracing is used to halt or slow progression

Does not improve curve
 Patient expectations


Braces are worn 12-23h/day for avg 12-18m
Some deformity remains after surgical correction
 Patient Education

http://www.settingscoliosisstraight.org/
Spondylolysis
 Spondylolysis

Most commonly a result of a pars defect


Tends to occur in adolescent athletes


Stress fracture of the pars inter-articularis
Associated with repetitive hyperextension
 Gymnasts, down linemen
Produces dull low back pain
Can radiate to buttocks or posterior thighs
 Worse with back extension
 Rare radicular complaints
 Often associated with hamstring tightness

 Spondylolisthesis

Slippage of the vertebra secondary to
spondylolysis
Spondylolysis
 Mechanical back pain warrants radiographs


Especially in patients at risk (gymnast, etc)
Spot lateral of lumbosacral junction
 Treatment




Avoid painful activities
NSAIDs
Ice/heat
Stretches/strengthening


Bracing


Strengthen core and abdominal musculature
If failed PT
Surgery

Last resort after months of conservative treatment
Clubfoot
 Congenital talipes equinocavovarus
 One of the most common birth defects
 1 in 400 babies in US
 Males 2x more frequent than females
 Can be unilateral or bilateral
 Etiology unknown
 Occasionally associated with other orthopaedic conditions
 DDH
Clubfoot
 Congenital deformity of the foot
consisting of




Cavus of the midfoot
Adductus of the of the forefoot
(metatarsus adductus)
Varus of the hindfoot
Equinus of the hindfoot

C-A-V-E
 Foot is twisted downward and
inward
 Severity ranges from mild to
severe
 Requires vigorous orthopaedic
treatment
Clubfoot
 Gold standard in treatment is corrective
casting described by Dr. Ignacio Ponseti

Allows soft-tissue relaxation and atraumatic
remodeling of joint surfaces
 The earlier the treatment begun, higher
likelihood of success

<1 month of age
 Surgical correction rarely required

Severe deformities and neglected feet


<5%
Associated with poorer outcomes

Scarring, stiffness
Ponseti Casting




Consists of serial manipulations of the clubfoot to stretch
the contracted tissues
Casts are then applied to hold the correction
Cast changes and manipulations occur weekly until foot is
corrected
Occasional Achilles tenotomy is needed to obtain
correction of equinus

Day surgery vs procedure room
Clubfoot
 Bracing is required after casting
for successful treatment


Prevent recurrence
Allow for remodeling of joints in
corrected position
Worn full time for several months
 Worn for nighttime and naps until 3-4 y/o


Importance of brace cannot be
overemphasized

Poor compliance is #1 cause of
recurrence
Clubfoot
 Approximately 1/3 have partial recurrence
 Repeat casting can be performed if young
 Limited surgical correction can be performed
 30% display a dynamic swing phase supination
deformity as a young child

Tendon transfer can prevent further deformity
Clubfoot
Tarsal Coalitions
 Abnormal connection between bones of the feet
 Most commonly between the calcaneus and navicular

2nd most common is talocalcaneal (subtalar)
 Usually become symptomatic in adolescence when
the region begins to ossify and stiffen
 Pain is most common complaint

Exacerbated with activities



Worse with running on uneven surfaces
Can be associated with recurrent ankle sprains
Patient may note decrease ROM or deformity

Flatfoot deformity
Tarsal Coalition
 Physical Exam
 Rigid, uncorrectable flatfoot deformity
 Decreased subtalar ROM and ankle plantarflexion
 Peroneal spasms
 50-60% have bilateral coalitions
 Radiographs can usually provide diagnosis
 AP, lateral, oblique, Harris view
 MRI or CT used if suspicion high and XRAYs neg
Tarsal Coalition
 Initial trial of conservative treatment indicated for
symptomatic coalitions

Limit subtalar ROM for 4-6wks
Short leg cast
 UCBL orthotic

 Surgery indicated for refractory cases
 Excision of coalition with interposition of muscle or fat
 Fusion occasionally needed for large coalitions
Flatfeet
 Discussed earlier
Developmental Dysplasia of the Hip (DDH)
 Formerly known as Congenital Dislocation of the Hip
 Spectrum of structural abnormalities about the hip
presenting from birth to skeletal maturity
 Commonly due to excessive laxity of the hip with resultant
instability of the femoral head within the acetabulum

Leads to inadequate acetabular and/or proximal femoral development
 Typically begins with normal structures during
embryogenesis
 Abnormalities then evolve overtime
 Infancy—subluxatable, dislocatable,
dislocated
 Childhood—dysplasia, dislocated hip
 Adolescent—dysplasia
DDH
 Incidence ranges from 1:1,000 to 3.4:100 live births



Dislocation 1.4:1,000
Clinical findings 2.3:100
Ultrasound abnormality 8:100
 Risk factors
 Family history


Breech position (Feet first)



17-23% of DDH patients were breech
Female gender


Positive family history in 12-33% of cases
80% of cases are females
First-born child
Oligohydraminos


Limited fetal movement
Association with other intrauterine molding abnormalities
• Torticollis and metatarsus adductus
• Crowding phenomenon
DDH
 Physical Exam

Early Findings

Ortolani sign

palpable sensation of the femoral head
reducing into the acetabulum
• Trochanter is elevated as hip is abducted
• Palpable clunk compared to audible click
• Originally described as the femoral head gliding
in and out of the acetabulum over the neolimbus

Barlow sign

palpable sensation of the femoral head
dislocating from the acetabulum
• Provocative maneuver with the femur adducted
and flexed

Newborn screenings suggest 1:100
newborns have some degree of instability
(positive Ortolani or Barlow)
DDH
 Physical Exam

Late Findings
Instability is absent due to adaptive changes
 Limited abduction is the most common, reliable finding




Limb length discrepancy


More specific than thigh folds
Klisic sign


Galeazzi sign reveals apparent femoral shortening
Asymmetric gluteal folds


Adductor longus becomes contracted secondary to hip
subluxation/dislocation
Difficult to detect if bilateral dislocations are present
A line from GT to ASIS passes inferior to the umbilicus
Waddling gait or hyperlordosis in ambulatory patients
Courtesy of D. Wenger
DDH
 Imaging
 Ultrasound used until ~6 m/o (until femoral head ossifies)
 X-RAYs utilized after 6 m/o
 Currently ultrasound screening of all infants for DDH is
not being performed


Expensive
False positives
 Ultrasounds are performed on children with
abnormalities on physical exam or at increase risk
based on risk factors
 Dysplasia can still occur despite normal initial
ultrasound
DDH
 Goal of tx is to center the femoral head in the acetabulum
to allow appropriate acetabular development

Pavlik harness
Typically used in 0-6 m/o
 Worn for 2-4 months
 95% success if began in 1st month, 85% after 1st month


Abduction orthosis


Useful in dysplasia or subluxtion in 6-24m
Operative tx used if >18-24 m/o or if bracing fails
Closed reduction and casting
 Open reduction
 + pelvic and/or femoral osteotomies


*20% residual dysplasia even with successful childhood tx
 Evaluation of the influence of straight-leg
swaddling on development of the hip
 112 rats divided into a control group and 3
“swaddled” groups
 Early swaddling (1st 5 days of life)
 Late swaddling (2nd 5 days of life)
 Prolonged swaddling (1st 10 days of life)
Swaddling
 No cases of dysplasia identified
in the control group
 Prolonged swaddling led to the
most detrimental outcomes

36 of 44 with dysplasia or dislocation
(82%)
 Early swaddling group revealed
21 of 44 hips with dysplasia
(48%)
Swaddling
 Increased severity of pathology
associated with increased swaddling
time and earlier initiation of swaddling



Prolonged swaddling: 33 dislocations, 3
subluxations
Early swaddling: 14 dislocations, 7
subluxations
Late swaddling: 1 dislocation, 8 subluxations
Swaddling
 Gross examination revealed a
deformed acetabular cartilage
complex in the prolonged swaddling
group



The iliac limb of the triradiate cartilage was
more vertical than control group
Acetabular wall slope and acetabular index
increased
Increased appositional cartilage growth
within the acetabulum prevented a
congruent hip joint
 All findings are similar to those seen
in human DDH
DDH
 International Hip Dysplasia Institute
 www.hipdysplasia.org

It is the recommendation of the
IHDI that infant hips should be
positioned in slight flexion and
abduction during swaddling
DDH
Slipped Capital Femoral Epiphysis (SCFE)
 Displacement of the proximal femoral epiphysis secondary to
weakness at the physis
 Typically occurs during rapid growth

Overweight, adolescent


Boys 13-15 y/o (avg 14), girls 11-13y/o (avg 12)
Males >> Females; L > R
 Bilateral involvement 20-25%
 ½ seen at initial presentation
 Stable SCFEs present with painless/mild limp, externally rotated
foot, decreased ROM


Need referal to ortho for surgical stabilization
*BEWARE OF KNEE PAIN in overweight adolescent male
 Unstable SCFEs present with severe pain, unable to bear weight
 Needs URGENT referral to orthopaedics
Legg-Calve-Perthes Disease (LCPD)
 Due to an unexplained, temporary loss of
blood flow to the femoral head
 Typically occurs in male children ages 3-10
y/o
 Patient presents with a limp

Can complain of pain and/or dec ROM


CAN PRESENT AS KNEE PAIN
Exacerbated by activity, relieved by rest
 Treatment ranges from PT to braces and
casting to aggressive surgical tx with
osteotomies

Based on age of child and degree of involvement
Anterior Cruciate Ligament Tears
 Recent dramatic increase in incidence


Increased athletic involvement
Increased recognition of the condition
 Frequently seen in noncontact activity


Twisting injury
“Heard/felt a pop”
 Typically associated with immediate, large effusion
 PE reveals increased translation with Lachmans test
 Non-op tx associated with further intra-articular injury
and accelerated degeneration
 Surgical reconstruction recommend if patient desires to
return to activities

Open physes require special thought/consideration
Meniscal Tears
 Isolated tears are not commonly seen
 Occur in 50% of ACL injuries
 Discoid meniscus are prone to tearing
 Presents with complaint of a loud snapping sensation
 PE reveals joint line TTP
 + effusion
 MRI confirms diagnosis
 Tx is surgical repair in most cases
Patellofemoral Instability
 Typically occurs without injury
 2:1 Female:Male ratio
 Can be secondary to quadricep weakness and/or bony
deformity



Genu valgum
Ligamentous laxity
2% of population has trochlear dysplasia

85% of instability patients have trochlear dysplasia
 Non-op tx for first time dislocators
 Immobilized x 3wks, patellar sleeve & PT x 4-6wks
 MRI if persistent effusion for 3 weeks
 50% chance of redislocation with non-op tx
 Discuss surgery if repeat dislocations occur
Femoroacetabular impingement
 Abnormal bony contact between the
proximal femur and acetabulum
 Slow onset intermittent groin pain that
may occur after minor trauma
 Pain is exacerbated by athletic activity and
prolonged walking.

May be associated with pain with prolonged sitting
or driving
 PE reveals positive ‘impingement sign’

Hip flexion, internal rotation, adduction
 Non-op Tx: activity modification, NSAIDs,
PT can be counterproductive
 Surgery can consistent of arthroscopic vs
open dislocation if pt fails non-op
Thank you