Pediatric Orthopaedics
Fractures in Children
· type of fracture
o usually greenstick or buckle because periosteum is thicker and stronger
o adults fracture through both cortices
· epiphyseal growth plate
o plate often mistaken for fracture and vice versa
o x-ray opposite limb for comparison
o mechanism which causes ligamentous injury in adults causes growth plate injury in children
o intra-articular fractures have worse consequences in children because they usually involve the growth plate
· anatomic reduction
o gold standard with adults
o may cause limb length discrepancy in children (overgrowth)
o accept greater angular deformity in clilldren {remodeling minimizes deformity)
· time to heal
o shorter in children
· always be aware of the possibility of child abuse
o make sure mechanism compatible with injury
o high index of suspicion. look for other signs, including x-ray evidence of healing fractures at other sites
Stress Fractures
Mechanism
· insufficiency fracture
o stress applied to a weak or structurally deficient bone
· fatigue fracture
o repetitive. excessive force applied to normal bone
· most common in adolescent athletes
· tibia is most common site
Diagnosis and Treatment
· localized pain and tenderness aver. the involved bone
· plain films may not show fracture for 2 weeks
· bone scan +ve in 12-15 days
· treatment is rest from strenuous activities to allow remodeling (can take several months)
Epiphyseal Injury
Slipped Capital Femoral Epiphysis (SCFE)
· type I Salter-Harris epiphyseal injury
· most common adolescent hip disorder, peak at pubertal growth spurt
· risk factors: male, obese, hypothyroid
Etiology
· multifactorial
o genetic: autosomal dominant, blacks > caucasians
o cartilaginous physis thickens rapidly under growth honnone (GH) effects
o sex honnone secretion, which stabilizes physis, has not yet begun
o overweight: mechanical stress
o trauma: causes acute slip
Clinical Features
· acute: sudden, severe pain with limp
· chronic: limp with medial knee or anterior thigh pain
· tender over joint capsule
· restricted internal rotation, abduction, flexion
Whitman's sign: with flexion there is an obligate external rotation of the hip
· pain at extremes of ROM
Investigations
· x-rays: AP, frog-leg, lateral radiographs
• posterior and medial slip
• if mild slip, AP view may be normal or show slightly widened growth plate compared with opposite side
Treatment and Complications
· mild/moderate slip: stabilize physis with pins in current position
· severe slip: ORIF or pin physis without reduction and osteotomy after epiphyseal fusion
· complications: AVN (most common), chondrolysis, pin penetration, premature OA, loss of ROM
Developmental Dysplasia of the Hip (DOH)
· formerly called congenital dysplasia of the hip (CDH)
· due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular roof
· spectrum of conditions that lead to hip subluxation and dislocation
o dislocated femoral head completely out of acetabulum
o dislocatable head in socket
o head subluxates out of joint when provoked
o dysplastic acetabulum, more shallow and more vertical than normal
· painless (if painful suspect septic dislocation)
Physical Examination
· diagnosis is clinical
o limited abduction of the flexed hip ( <50-600)
o affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum
o Barlow's test (for dislocatable hip)
o –flex hips and knees to 90° and grasp thigh
o –fully adduct hips, push posteriorly to try to dislocate hips
· Ortolani's test (for dislocated hip)
o initial position as above but try to reduce hip with fingertips during abduction
o positive test: palpable clunk is felt (not heard) ifhip is reduced
· Galeazzi's Sign
o knees at unequal heights when hips and knees flexed
o dislocated hip on side oflower knee
o difficult test ifchild <1 year
· false positive if congenital short femur
o Trendelenburg test and gait useful ifolder (>2 years)
Investigations
· U/S in first few months to view cartilage
· follow up radiograph after 3 months
Treatment and Complications
· 0-6 months: reduce hip using Pavlik harness to maintain abduction and flexion
· 6-18 months: reduction under GA, hip spica cast x 2-3 months (if Pavlik harness fails)
· >18 months: open reduction; pelvic and/or femoral osteotomy
· complications
o redislocation, inadequate reduction, stiffness
o AVN of femoral head
Legg-Calva-Perthes Disease (Coxa Plana)
· self-limited AVN of femoral head. presents at 4-10 years of age
· etiology unknown, 20% bilateral, males> females, 1/10,000
· associations
o family history
o low birth weight
o abnormal pregnancy/delivery
o history of trauma to affected hip
· key features
o AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodelling of regenerated bone
Clinical Features
· child with hip pain and limp
· tender over anterior thigh
· flexion contracture: decreased internal rotation, abduction of hip
Investigations
· x-rays
o may be negative early
o eventually, characteristic collapse of femoral head (diagnostic)
· subchondral fracture
· metaphyseal cyst
Treatment
· goal is to preserve ROM and preserve femoral head in acetabulum
· PT: