Common

Paediatric
Orthopaedic
Problems
 Introduction
What does the word orthopaedics mean?

“Orthos”: Greek
→ for straight.

Greek for child.

“Paedos”: →
Injuries unique to
the skeletally
immature

individual
Physeal injuries:

 Green stick fractures:

 Physeal injuries
Salter & Harris classification:
Physeal injuries
 Physeal injuries
Treatment:
 Immediate, anatomic reduction.

 Closed / open.

 Each delay makes reduction more

difficult.
 Physeal injuries
Incomplete reduction results in deformity.
 Physeal injuries
Prognosis:
 Age.
 Anatomic site
 Growth contribution.

 Remodelling capacity.

 Severity of injury.
 Physeal injuries
Complications:

Premature growth arrest (physeal arrest).

 Physeal injuries
Physeal arrest:

Complete: → Shortening ( LLD )

no angular deformity
 Physeal injuries
Physeal arrest
Partial: due to a bone bridge

 Peripheral → angulation &

deformity.

 Central → metaphyseal
cupping & LLD.
 Physeal injuries

Bone bars may not develop till years

after the injury, so follow up till
skeletal maturity is imperative.
 Green stick
Fractures

 Single intact cortex.

 Two perpendicular views.
 Green stick
Fractures
In very young children “plastic deformation”
may occur which should be recognised &
reduced.
 Elbow Injuries In
Children
 Much more common in the skeletally immature.

 2nd most common area of injury

(distal radius most common).

 More common in boys.

 Elbow Injuries In
Children
At birth some areas remain
•

Unossified:

Most common site: distal humerus (86.5%)

 70% supracondylar region.
 17% lat condyle.
 13% med epicondyle.
 Supracondylar
Fracture Humerus

Shaft condylar angle: Normally 40°.

Anterior humeral line: Thru middle 1/3 of capitellum.

 Supracondylar
Fracture Humerus
 Types:
 Extension type.

 Flexion type.
 Supracondylar
Fracture Humerus
Type I: Undisplaced.

May be missed on AP&lat views

Rely on fat pad sign &

oblique views
 Supracondylar
Fracture Humerus
Type II: Angulated.
 Supracondylar
Fracture Humerus
Type III: Completely displaced with angulation &
rotation.
 Supracondylar
Fracture Humerus
Grade I  Back slab.
Grade II  CRUGA + PC fixation.
Grade III  CRUGA + PC fixation / ORIF.
 Supracondylar
Fracture Humerus
Complications:
Compartment syndrome:
 High index of suspicion.
 Pain out of proportion to #.
 Pain on passive extension of fingers.
 It is mainly a vascular outflow problem, so urgent #
reduction & elbow immobilisation without excessive
flexion restores outflow from the compartment &
normalises the pressure.
 If not treated promptly by immediate & extensive
fasciotomy; Volkmann’s ischaemic contracture
develops.
 Supracondylar
Fracture Humerus
Volkmann’s ischaemic contracture is an extremely disabling
condition that is very difficult to treat.

The shortened, fibrotic flexor muscles prevent extension of

wrist & fingers together.
 Supracondylar
Fracture Humerus
Displaced supracondylar # with vascular compromise:

The radial pulse is unreliable as a danger signal.

It’s absence is not an indication for exploration.

Its presence a guarantee that ischaemia will not

develop.
 Supracondylar
Fracture Humerus
Diagnosis of vascular damage is clinical :

 Static signs as peripheral pulse, capillary

circulation & pulse oximetry are not reliable.

 Dynamic signs as pain at rest / passive finger

extension out of proportion to # pain, inability to
actively contract forearm muscles are much more
reliable.
 Supracondylar
Fracture Humerus
Angular deformities
Angular deformities

(cubitus varus, rarely valgus):

Management:
 Conservative in most cases
as little functional deficit.
 Supracondylar osteotomy.
 Supracondylar
Fracture Humerus
Neurological:
 Incidence: 7%.
 Usually neuropraxia (resolve with time).
 Radial & anterior interosseous most common.

Loss of mobility:
 Loss of flexion : Malunited # (Remodelling of
posterior angulation is limited).
 Loss of extension: May occur even with undisplaced /
anatomically reduced #.
 Supracondylar
Fracture Humerus
Myossitis Ossificans:

 Heterotopic deposition of Ca
in surrounding muscles.
 Caused by aggressive passive
exercise.
 Treat by rest, then at later
date remove deposits.
 Fracture Lateral
condyle Humerus
Compared to supracondylar #:
 Diagnosis is less obvious
clinically & radiologically.

 # line extends into articular

surface so higher incidence of
functional loss of motion.

 Complications may not be

evident till months or years
later.
 Fracture Lateral
condyle Humerus
 One of the few # of childhood that
almost always should be treated by
internal fixation.

 The only exception is an undisplaced #;

in which case X-rays every 3 days in
the 1st 10 days are imperative.
 Fracture Lateral
condyle Humerus
Complications:
Non-union:
 One of the few paediatric # that may
fail to unite.
 Non united # → cubitus valgus,
(fragment migrates proximally &
laterally).

 It is not only a cosmetic problem as it

can lead to tardy ulnar nerve palsy.
 Fracture Shaft
 Femur
Neonate: Tongue depressor.
 < 1 yr: Gallows traction.
 > 1yr: Thomas splint for 3 wks
then hip spica for 3 wks.
 Common
Paediatric
Orthopaedic
Problems
 Acute
Haematogenous

Osteomyelitis
History of preceding direct trauma
to limb (most common tibia).

 Within 12-24 hours child develops

fever & is tender all over the limb.

 Acute phase reactants: + ve.

No X ray change
before 10-14 d.
 X ray: normal.
 Acute
Haematogenous
Osteomyelitis
 US & MRI can detect a sub periosteal abscess
(determines the need for surgical drainage).

 IV antibiotics on an empirical basis (anti-staph)

are to be started ASAP after blood cultures.
 Acute
Haematogenous
Early &Osteomyelitis
correct ttt (medical or
surgical) cures the condition &
prevents development of chronic
osteomyelitis which is almost a
life time problem.
 Chronic
Osteomyelitis
 Septic Arthritis
 Sudden onset of pain, swelling of a joint (knee, hip,
shoulder, elbow, ankle, wrist).

 Cardinal sign is complete loss of joint movement.

 Aspiration of the joint is diagnostic.

 Surgical emergency; once diagnosed joint needs to

be drained (arthrotomy) and washed.
 Septic Arthritis
Early & correct ttt
(medical or surgical)
cures the condition &
prevents development
of septic epiphysitis
which is almost a life
time problem.
 Congenital Talipes
Equinovarus
What does the word talipes mean?
The term talipes is derived from a contraction
of the Latin words for ankle (talus) & foot
(pes).

The term refers to the gait of severely affected

patients, who walked on their ankles.
 Congenital Talipes
Equinovarus
 Incidence:1/1000 live births.
(higher if +ve FH).
 M:F = 2:1.
 Bilateral in 50%.
 Components of the deformity:
 Equinus.

 Varus.

 Adduction.

 Supination.

 Cavus & depressed 1st MT.

 Congenital Talipes
Equinovarus
Best results are achieved with early manipulation
(as early as first week of life) and serial casting
(changed every week).
 Congenital Talipes
Equinovarus
Wearing Of DB splints for 3 months day & night &
one yr at night is imperative to avoid recurrence.
 Congenital Talipes
Equinovarus
Good results may be achieved if previous technique
is applied.
 Developmental
Because DDH encompasses frank dislocation,
Dysplasia
subluxation
acetabulum:
of Hip
or radiographic abnormalities as shallow

Because many of these findings may not be present at

birth:
The terms "developmental" & “dysplasia” are more
accurate than the terms "congenital“ &
“dislocation”.
 Developmental
Dysplasia of Hip
 Incidence : 1 per 1000.

 Shortening / limitation of
hip abduction can be
detected in unilateral cases
with established dislocation.
 Developmental
Dysplasia
Clinical screening for DDH:
of Hip
Ortolani & Barlow tests.

ble clunks and not audible clicks are cons

 Developmental
Dysplasia of Hip
At risk babies who should be screened for DDH by
US:
 ♀.
 First born child.
 + ve FH.
 Breech presentation.
 Developmental
Dysplasia of Hip
US examination:
 Developmental
Dysplasia of Hip
Treatment in 1st 6 months:

Dynamic hip splints (Pavlik Harness):

 Active ROM→spontaneous reduction.
 Less incidence of AVN.
 Less restricting & more convenient.
 Developmental
Dysplasia of Hip
Treatment after age 6 mo:

 Open reduction of hip.

 Capsulorrhaphy.
 Pelvic osteotomy.
 Femoral osteotomy
 Immobilization in hip
spica for 6-12 wks.
 Perthes’ Disease
Most common in boys 4-8 yrs.
Self limiting disease
characterised by AVN of
femoral head.
Complete revascularization of
epiphysis occurs without any
ttt,but may take 3 yrs.
Deformation of epiphysis
occurs during revascularization
in some patients.
This may lead to degenerative
arthritis in young adult life.
 Perthes’ Disease
Aim of treatment is to prevent
deformation of femoral head by
ensuring that epiphysis is
contained within acetabulum.

Containment can be achieved by:

 Abduction plasters / splints.
 Surgery;
 Femoral osteotomy.
 Pelvic osteotomy.
 Slipped Upper
Femoral Epiphysis
 Common in boys 10-17 yrs.
 Bilateral in 1/3 of pts.
 Possible underlying endocrine
disease eg hypothyroidism.
 Pt may present with knee
pain.
AP view:
 Line tangent to superior

border of neck normally

cuts through epiphysis.
 Common pitfalls
In a child with a painful knee always
examine the hip as referred pain is
very common.
 The Limping child
Causes of limp in childhood:
 Pain (antalgic).
 Short leg.
 Instability of joints.
 Stiffness of joints.
 Muscle spasticity or incoordination.
 Proprioceptive disturbances.
 Hysteria.
 Irritable Hip
 Most common cause of acute limp (trauma excluded).
 3% of children will have at least one episode.
 Peak age: 3-8yrs.
 70%: preceding/concomitant URTI.
 20%: preceding local trauma.
 70% have effusion on US
 Synovial biopsy: synovial hypertrophy due to non
specific, non pyogenic inflammation.
 Irritable Hip
Diagnosis:
 Pain (hip/thigh/knee) & antalgic gait.
 No other joint involvement.
 Not systemically unwell.
 Hip held in flexion, Abd & ER.

DD:
 Septic arthritis of hip.
 Osteomyelitis upper femur.
 Perthes’ disease.
 SUFE.
 Trauma.
 Osteoid osteoma.
 Irritable Hip
Investigations:
 FBC, ESR, CRP.
 X-ray AP & frog lateral views.

 US.

Treatment:
 Reassurance.

parents should be warned about association with early

stages of Perthes’ disease & 10% chance of recurrence.
 Bed rest & analgesics / NSAID.

too early return to activities will prolong symptoms & may

be associated with increased risk of recurrence.
 Rickets
 Nutritional rickets is the most
common cause.
 Very common in Egypt regardless
of socio- economic status.
 ↓/N Ca, N P, markedly ↑AP.
 Children with active rickets need
vit. D (either inactive D3, eg
Devarol, or active form eg one
alpha).
 Beware of giving vit D if Ca levels
are low as this may cause tetany.
 Rickets
Developmental knee alignment:

Normal knee alignment progresses from 10-15° varus

at birth to maximum valgus angulation of 10-15° at
age 3-3.5 yrs.

Gradual decrease of valgus occurs to reach

adult value of 6° by age 7yrs.

Physiologic genu varum (bow legs):

 Usually presents at 14 - 24 mo.
 Bilateral & symmetrical.

Physiologic genu valgum (knock knees):

 Usually presents at 3 yrs.
 Bilateral & symmetrical.
 Rickets
Rickets may cause genu
varum/valgum:

In cases of genu valgum

exclude renal rickets:

 Renal functions are normal as

this is a tubular disorder.

 The key laboratory finding is

low phosphorous level.
 Scoliosis
 Idiopathic scoliosis accounts for most spinal curvatures.
 Scoliosis is, surprisingly, quite common.
 3-4 / 1000 children of the general population will need
specialist supervision & about 1 / 1000 will need ttt.
 80% arises in girls, & 80% have rib prominence on the Rt.
 The best screening test is the “bending forward test”.
 Obstetric brachial
 History plexus palsy
of difficult labour is not always present.
 Sometimes even baby delivered by Caesarian section.
 Baby does not move limb & classic deformity is
internal rotation of shoulder, extended elbow &
pronated forearm.
 DD: Pseudo-paralysis:
 # clavicle / proximal humerus / slipped epiphysis.
 Septic arthritis shoulder.
 Osteomyelitis upper end humerus.
 Chronic obstetric
brachial plexus palsy
Disability in childhood & adolescence:
 Osgood
Schlatter’s
 An example ofDisease
apophysitis.
 Common in adolescent boys.
 No treatment in most cases (apart from reassurance,
exercise modification, occasionally short periods in cast).
 Osteogenesis
Imperfecta
Characterised by:

Repeated fractures of multiple bones.

Pencil-like cortex & deformed bones.

IV bisphosphonates may be helpful.

 Pathologic
Fractues
Simple bone cyst: