Pediatric Orthopaedics

When to send

CHRIS SOUDER, MD

BAYLOR SCOTT & WHITE HEALTH

MCLANE CHILDRENS HOSPITAL
 Orthopaedics

Specialty originated in the diagnosis and treatment

of conditions of children

Ortho-
To straighten or correct

Paed-
Child, children
 Orthopaedics
Trauma Hip
Fractures Developmental dysplasia
Ligament & joint injuries (DDH)
Infections SCFE
Osteomyelitis Perthes
Septic Arthritis Sports Medicine
Spine ACL, meniscus tears
Scoliosis Patellofemoral instability
Kyphosis Femoroacetabular
impingement
Spondylolysis
Upper Extremity
Foot & Ankle
Syndactyly, polydactyly
Clubfoot
Congenital deformities
Congenital vertical talus
Neuromuscular
Tarsal Coalitions
Cavus & Pes planus (flatfoot) Cerebral Palsy
Spina bifida
And more
 Orthopaedics
Trauma Hip
Fractures Developmental dysplasia
Ligament & joint injuries (DDH)
Infections SCFE
Osteomyelitis Perthes
Septic Arthritis Sports Medicine
Spine ACL, meniscus tears
Scoliosis Patellofemoral instability
Kyphosis Femoroacetabular
impingement
Spondylolysis
Upper Extremity
Foot & Ankle
Syndactyly, polydactyly
Clubfoot
Congenital deformities
Congenital vertical talus
Neuromuscular
Tarsal Coalitions
Cavus & Pes planus (flatfoot) Cerebral Palsy
Spina bifida
And more
 Most Common Things I See
(and dont 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 Greenstick Buckle (Torus)

deformation fracture 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 Supracondylar Humerus

Fracture 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
Least sensitive
ESR
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 > 38.5C

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
Stress fracture of the pars inter-articularis
Tends to occur in adolescent athletes
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
Strengthen core and abdominal musculature
Bracing
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
Infancysubluxatable, dislocatable,
dislocated
Childhooddysplasia, dislocated hip
Adolescentdysplasia
 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
Positive family history in 12-33% of cases
Breech position (Feet first)
17-23% of DDH patients were breech
Female gender
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
Adductor longus becomes contracted secondary to hip
subluxation/dislocation
Difficult to detect if bilateral dislocations are present
Limb length discrepancy
Galeazzi sign reveals apparent femoral shortening
Asymmetric gluteal folds
More specific than thigh folds
Klisic sign
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%
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