PEDIATRIC ORTHOPEDICS

Scoliosis: •Lateral spinal curvature with a Cobb angle of >? degrees

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the normal bony outgrowths that arise from separate ossification centers and eventually fuse with the bone in time

Apophysis

painful inflammation of a bony outgrowth and in an area of active Growth at the end of a bone

Apophysitis

•Progressive deformity •Usually unilateral •Early walking, obesity, •Family history •Lateral Thrust during gait •If a child >2 y/o still has Genu Varum → refer Pathologic Genu Varum

Blount's Disease

•Type of incomplete fracture •Typically occurs at metaphyseal-diaphyseal junction •FOOSH •Very stable fracture •Tend to heal more quickly than •greenstick fractures

Buckle (Torus) Fracture

Pathology •Equinus (the inability of the ankle joint to dorsiflex) , Adductus, Varus, and medial rotation •Differentiate from metatarsus varus by seeing the Equinus in club foot •Dx should prompt search for other MSK problems Treatment options •Serial casting •Casting 3-6 weeks, heel cord lengthening, shoes with brace full time for thee months, then nights and naps till 4 years old. •PT guided daily stretching, taping -surgery (heel cord lengthening) Goal of Treatment •Flexible, "shoe-able" foot •Foot, leg never looks entirely normal in true congenital clubfoot deformity

Club Foot

Common pediatric orthopedic condition •Focus of newborn evaluation Diagnosed with spectrum of anatomic abnormalities including: •Hip that is dislocated and irreducible •Unstable (dislocatable and reducible) •Dysplastic, but within acetabulum Risk Factors •First Born - girl - POS FAM HX

Developmental Dysplasia of hip (DDH)

Newborn •Birth order, position, weight •Family History Infant/Child •Toe walking- can be unilateral •Limb length inequality •Waddling Gait •Hyperlordosis (Swayback) Exam (Barlow/Ortolani) •Relaxed, quiet child- use pacifier •Completely undressed •Caregiver at bedside •Delicate/gentle •Don't forget neck, feet and spine exam to evaluate for associated diagnoses

Developmental Dysplasia of hip (DDH)

Treatment •Pavlik Harness **US post application to verify good position in harness If all conservative measures fail or >6months of age at diagnosis: •Closed reduction 1st option •Open reduction if closed reduction fails •Spica cast to hold hip/hips in reduced position

Developmental Dysplasia of hip (DDH)

•Fracture of distal radius + •Dislocation of distal radioulnar joint (DRUJ) •Intact ulna •Primarily encountered in children •Peak incidence of 9-12 years of age •In adults, accounts for ~7% forearm fractures •Typically occur following FOOSH with a flexed elbow

Galeazzi Fracture Dislocation

Incomplete fracture of long bone produced on convex cortex, while concave cortex bends •Usually occurs in forearm of young child •Results from bending force applied perpendicular to shaft •FOOSH

Greenstick Fracture

•Tends to be habitual or familial •Almost always bilateral •Presents when toddler begins to walk +/-Limits ankle dorsiflexion •Improves later spontaneously with maturity and weight •Clinical Exam: •+/-Reduction of ankle dorsiflexion •Normal neurologic exam Treatment: •PT: Heel-cord stretching •Serial casting •Surgical: Heel-cord lengthening Diagnosis of exclusion, R/O: •Neuromuscular disorder •Cerebral Palsy •Autism •Due to increase in vestibular stimulation

Idiopathic Toe Walking

Outcome •Self-healing in 2-4 years •Problem: Not all end up with a spherical head •Can produce permanent femoral head deformity and early arthritis in adulthood •Poorer outcome in older patients >8 years of age

Legg-Calve Perthes Disease (LCP)

Presentation • > male •Small for age •Very active or hyperactive •Pain may be non-specific •Anterior hip, thigh or knee •Insidious onset (maybe weeksmonths) •Mild limp •Usually no history of trauma Exam •Limp •Limited motion: abduction and internal rotation •Depends on stage of disease •Guarding with leg rolling •Atrophy of quad muscle secondary to disuse •Leg length inequality due to collapse of femoral head AP Pelvis and Frog Lateral •Compare to contralateralside •Early changes: smaller epiphysis, radiodense (sclerosis) •Crescent sign or mild flattening •Metaphyseal radiolucency (if nothing seen, f/u and repeat xray)

Legg-Calve Perthes Disease (LCP)

•Idiopathic osteonecrosis of capital femoral epiphysis •Vascular interruption to subchondral bone •Peri-articular cartilage not affected •Epiphyseal changes due to subchondral Fx • Ages 2-14 (mostly 5-8 years of age) • Boys 5x > Girls

Legg-Calve Perthes Disease (LCP)

•Fracture of ulna shaft •Dislocation of radial head •Displaced and overlapped fracture of the ulnar shaft is present •Radial head is dislocated anteriorly •Usu. secondary to FOOSH •ORIF is standard of care

Monteggia Fracture Dislocation

Treatment: •Rest •Avoidance •Out of sports •Timeline depends on severity •Ice •NSAIDs •Knee immobilizer for a few days to quiet symptoms •Reassurance

Osgood-Schlatter's Syndrome

•Traction apophysitisin adolescents •Boys > girls but girls younger than boys (10-11 vs 13-14) •Pain over tibial tuberosity relieved with rest •Can be bilateral •Prominent tibial tubercle •± swelling, redness •Think '4-sport' per year •During a growth spurt

Osgood-Schlatter's Syndrome

•Traction at insertion of patella tendon into tibial tuberosity •Boys > girls but girls younger than boys (10-11 vs 13-14) •Pain often relieved with rest; bilat 25% •Prominent tibial tubercle; ± swelling, redness

Osgood-Schlatter's Syndrome

Pathologic genu varum •Short Stature •Enlargement of elbow, wrists, knee, and ankles

Rickets

•Grades skeletal maturity based on level of ossification of iliac crest apophyses - useful method of bone age determination for scoliosis

Risser classification:

Salter-Harris Fracture Classification? fracture through growth plate only

Salter Type I

•Transverse fracture through the physis •Cannot occur if the growth plate is fused •Good prognosis, growth disturbance is unusual

Salter Type I

Salter-Harris Fracture Classification? fracture through metaphysis and growth plate

Salter Type II

•~ 75% (most common) •Fracture through portion of physis and metaphysis •Fracture passes across most of growth plate and up through metaphysis •Good prognosis

Salter Type II

Fracture through portion of physis and epiphysis into joint •Poorer prognosis because of intra- articular component and because of disruption of growing or hypertrophic zone of the physis • 7-10% •Fracture plane passes through epiphysis and growth plate

Salter Type III

Salter-Harris Fracture Classification? - fracture through epiphysis and growth plate

Salter Type III

Salter-Harris Fracture Classification? fracture through metaphysis and epiphysis

Salter Type IV

• Fracture through metaphysis, physis, and epiphysis •high risk of complication • 10% • Poor prognosis aka triplane fracture

Salter Type IV

Salter-Harris Fracture Classification? Crushed through growth plate

Salter Type V

•Uncommon < 1% •Crush injury of the physis •Crushing type injury does not displace growth plate but damages it by direct compression Worst prognosis - Subsequent growth arrest of this area confirms presence of SalterHarris type V injury •Complete obliteration or diminished physeal distance of the affected extremity confirms the diagnosis

Salter Type V

gold standard when talking about pedi fractures •Epiphyseal plate(growth plate) fractures ( Can result in premature closure and limb shortening)

Salter-Harris Fracture Classification

•Allows for prognostic information regarding premature closure of growth plate and functional outcomes Higher number grade, more likely complications Common sites: •Distal radius •Distal tibia •Distal fibula

Salter-Harris Fracture Classification

Cobb angle most widely used measurement to quantify the magnitude of spinal deformities 3 Types: •Idiopathic- 90% F, +/- fam. hx, adolescent growth spurt •Congenital- vertebral abnormality •Neuromuscular- underlying d/o •*Most common pediatric back deformity •*Not usually painful

Scoliosis

Exam •Pt should stand erect with feet slightly apart, knees straight, and arms hanging loosely at sides Observe for •One shoulder higher than the other •Larger space from arm to side of body(compare both sides) •Uneven waist creases •Uneven iliac crest levels •Forward Bend •Rib prominence Imaging •Full length Scoli X-ray series •Vertebral anomalies •Disc height Curve (Cobb measurement) To measure Cobb angle: •Determine which vertebrae are end vertebrae of the curve deformity (terminal vertebrae) •The vertebra whose endplates are most tilted towards each other •Lines then drawn along endplates, and angle between the two lines is measured

Scoliosis

•3 - O's in treatment: •Observe •Orthosis (brace) •Operation Infant and Juvenile (3-10 yo) •Observe to 25 degrees •Orthosis >25 degrees •Operate >40 degrees Adolescent •Observe to 30 degrees •Orthosis 30 to 40 degrees •Surgery > 40 degrees or rapidly progressing curves asking about periods can help determine how much longer a female will grow (grow 2-3yrs post menarche)

Scoliosis

Treatment •RICE •DC sports if symptoms moderate/severe •Gel heel pads if mild; ½" heel inserts if moderate or worse (wear in both shoes for symmetry) •NSAIDs •Stretching of Achilles'; •PT usually can be held as these are active kids anyway-just modify their activity •Excellent prognosis- if compliant, can require casting if not

Sever's Calcaneal Apophysitis

•Apophysitis at insertion of Achilles' tendon into calcaneus •Inflammatory condition of the growth plate in calcaneus

Sever's Calcaneal Apophysitis

•Common cause of heel pain in children •Occurs during adolescence; particularly during growth spurt •Girls peak incidence: 9-12 y/o; boys: 10- 13 •Repetitive stress (Running, jumping, etc.) on growth plate as foot strikes ground results in inflammation/pain •Often seen beginning of new season of sports c/o heel pain bad enough to cause a limp •Noticed initially after sports •Then during and after activity ends •As it progresses, pain without running/jumping •Pt. will often report "new cleats" or footwear

Sever's Calcaneal Apophysitis

Displacement of the capital Femoral epiphysis from the Femoral neck thru the physeal plate

Slipped Capital Femoral Epiphysis SCFE

Risk: - obese -male -fam hx Clinical Presentation •(+) limping •Intermittent groin/knee pain •Several weeks, months •Sudden onset of pain in groin/hip •Maybe after fall or trauma •Inability to walk/bear weight on affected leg •Shortened, externally rotated leg with significant slip/grade Imaging •Plain radiographs •AP Pelvis view + lateral (frog-leg)

Slipped Capital Femoral Epiphysis SCFE

Treatment Operative stabilization of the fracture/ 'slip' - Percutaneous Screw Fixation •1 single cannulated screw Goal: to stabilize the physis and prevent any further slippage...ultimately further complication

Slipped Capital Femoral Epiphysis SCFE

Subluxation of the Radial head

Subluxation of the Radial head

•Infants and small children Caused by being pulled/lifted by the hand - no falls •Radial head subluxes under Annular Ligament •Presents with pronated and painful elbow •Treatment by pressure on radial head and gentle supination while flexing the elbow (reduce)

Subluxation of the Radial head

Treatment Conservative •Long arm cast after initial splint •Analgesics •Serial radiographs (q 1-2 wks.) Reduction with Pin Fixation •Two lateral pin technique for stable fixation with a medial pin •Correct medial pin placement is critical

Supracondylar Elbow Fracture

•Extra-articular fracture of distal humerus at elbow •Typically occurs in children between 5-9 y/o •50% to 70% of all peds elbow fracture •Uncommon in adults •Almost always due to accidental trauma •FOOSH from a moderate height (bed/monkey-bars) •Typically (>90%) onto extended elbow Result in an extra-articular fracture line (joint not involved) •Posterior displacement of the distal component

Supracondylar Elbow Fracture

T or F More likely to require surgical fixation if: •Displaced epiphyseal fractures •Displaced intra-articular fractures •Fractures in child with multiple injuries •Open fractures •Unstable fractures Fracture Remodeling in kids • Periosteal resorption • New bone formation • No need perfect anatomic alignment • Younger patients have greater potential for fracture remodeling • Rotated fractures, and fracture deformity not in 'plane of motion' don't remodel as well

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T or F Physiologic •Symmetric •Varus to Valgus to Straight pattern of resolution depending on age •Normal function and gait •Otherwise healthy child Pathologic •Asymmetric deformity, gait disturbance •Failure to resolve within normal age parameters • + Review of Systems or Family history •X-rays diagnostic

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T or F Physiologic Genu Valgus: - Symmetrical valgus, •Age: 3-5 years •Improves with growth •Normal growth plate on x-rays

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T or F Fracture Complications •Overgrowth •In long bones, result of increased blood flow associated with fracture healing •Femoral fractures in children <10 y/o can overgrow 1-3 cm •So end-to-end alignment for femur and long-bone fractures may not be indicated •After 10 y/o age, overgrowth less of a problem, end-to-end alignment is recommended Neurovascular Injury •Common locations: distal humerus and knee Compartment Syndrome

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T or F Legg-Calve Perthes Disease (LCP) Stages of Disease Necrosis: Initial period of ischemia/loss of blood supply to femoral head Fragmentation: Re-absorption of bone with femoral head collapse Re-ossification: New bone regrows to reshape the femoral head Remodeling: Femoral head reshapes itself into spherical shape

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T or F Pediatric Hip Blood supply to hip unique because blood vessels are extra-osseous and lie on surface of femoral neck, entering epiphysis peripherally Vulnerable to: •Trauma •Infection •Other causes that may increase intra- articular pressure Damage to blood supply can lead to avascular necrosis (AVN)

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T or F Physiologic Genu Varum •Symmetric Varus •Age: 0-2 years •Normal growth plate on x-ray Bowed legs to Knock knees to Neutral Bowlegs - generally benign and resolves without intervention Worrisome clinical features •Lateral thrust during gait •Short stature •Ligament laxity •Abnormal location of the deformity X-rays indicated if: •Asymmetry •Atypical age •Worsening deformity Pathological •Osteochondral dystrophy •Rickets •Tibia varum/Blount's

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T or F Toe Walking: Common complaint in early walkers •Eval any child >3 y/o who still toe walks •Most likely habit (idiopathic) : BUT, neuromuscular disorder should be considered: •Cerebral palsy •Tethered cord •Achilles tendon contracture •Leg-length discrepancy also possible

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T or F •Injuries to physis can result in premature closure •Partial closure may cause angular deformity •Complete closure may cause limb shortening •Most common locations: distal femur and distal/proximal tibia •Growth plate most susceptible to torsional and angular force

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*Presents limping and pain with WB, but minimal swelling and pain *Minimally/nondisplaced oblique fx of •*Tibia without fibula fx •*Often no trauma recalled •*Patients usu. 1-3 y/o NOTE: •Initial radiographs do not always show fracture •If symptoms persist, repeat x-ray in 7-10 days

Toddler's Fracture

Diagnostic Studies •**Diagnosis of exclusion •Labs: +/- mild elevation of WBC, ESR, CRP •X-ray: AP Pelvis/frog-leg lateral. Usu. normal, may show slight joint space widening •US: Evaluate effusion (negative Differential Diagnosis •Must exclude septic arthritis •Has more severe pain and marked limitation of hip motion •Due to +/- similar findings, hip aspiration recommended when ESR >20mm/hr •temperature > 99.5F (37.5)

Transient Synovitis of the Hip

NOTE: Seeing a patient often over the course of this presentation is appropriate until resolved! -re-exam/re-assess Treatment •Bed rest until symptoms and signs improve •Gradual increase of activity •NWB generally lasts 1-2 days •May have limp and decrease ROM up to two weeks •NSAIDs - wt. based •No Abx due to not infectious etiology •Resolution of symptoms and return of range of motion

Transient Synovitis of the Hip

•Most common cause of hip pain in children Self-limiting inflammatory condition of hip •Often undetermined etiology •Males 2-3X > females •Peak onset 4-10y/o, mean age 6 y/o •Occasionally follows URI. +/- low grade fever Clinical features: •Rapid onset of limping and subsequent refusal to walk/bear weight •ROM of hip limited by pain and spasm, hip held in flexion

Transient Synovitis of the Hip

shaft of bone

diaphysis

at ends of bones

epiphysis

between the diaphysis and epiphysis

metaphysis

growth plate

physis