PAEDIATRIC ORTHOPAEDICS

Paediatric Orthopaedic conditions are relatively common. In most cases the observed abnormalities are simply variations of normal development and with growth these deformities undergo spontaneous correction (physiological deformity). No treatment is therefore required for these cases. On the other hand, in a minority of cases the deformities are due to sinister conditions and treatment may be necessary (pathological deformity).

When faced with a child with a limb deformity, the question that needs to be answered is whether the deformity is physiological or pathological. As mentioned earlier physiological deformities require no treatment other than reassurance. On the other hand, pathological deformities may require intervention.

The Rule of 5 Ss is a useful tool to distinguish between physiological and pathological deformities in paediatric practice and consists of the following:

Symptoms
Symmetry
Stiffness
Systemic Disorders
Syndromes

A child with a physiological deformity would generally be asymptomatic, have symmetrical deformities, exhibit no stiffness in the affected joints and has no underlying systemic disorders or syndromes. In contrast, a child with a pathological deformity is often symptomatic (pain) and the deformity maybe asymmetrical with stiffness in the affected joints. There may also be associated systemic disorders or syndromes.

In most cases this information could easily be obtained by taking a history and clinical examination. Occasionally additional investigations such as plain radiographs, blood tests or scans are needed to complete the assessment.

The clinical features and the management of following common paediatric orthopaedic conditions are discussed below:

• Developmental Dysplasia of the Hip (DDH)
• Intoe Gait
• Knock Knees & Bow Legs
• Flat Foot
• Calcaneovalgus Foot
• Club Foot
• Irritable Hip
• Perthes' Disease
• Slipped Upper Femoral Epiphysis
• Apophysitis
• Growing Pains

DEVELOPMENTAL HIP DYSPLASIA (DDH)

This paediatric hip condition was previously known as congenital dislocation of the hip (CDH). Recently the name was changed to DDH as it was recognised that in this condition the hip may exhibit a spectrum abnormalities, which only in a minority of cases it presents as a dislocated hip at birth (<25%). In most cases the hip shows various degrees of dysplasia or subluxation (partial dislocation). In a small number of cases the hip may actually be normal at birth, but become abnormal later in life.

The incidence of this condition is about 2-4 cases per 1000 live births. Females are more frequently affected than males by 4:1. It may be bilateral in 25% of cases.

The Natural History. If this condition is left untreated, it would lead to serious complications such as a severe limp, limb shortening, scoliosis or early onset of osteoarthritis in the hip as an adult. Following subgroup of children are particularly at risk of DDH:

• Breech presentation.
• Positive family history.
• Babies with lower limb abnormalities at birth.
• Babies with spinal deformities at birth.
• Syndromic children.

If this condition is detected early within the first few months of life, it could easily be treated with a short period of bracing with successful outcome in over 95% of cases.

Late presentation for example in a walking child is associated with a much worse prognosis. Treatment in the walking age group is generally more complex and prolonged, often requiring open surgical procedures. Early detection and treatment is therefore paramount to ensure a successful outcome and to avoid the need for major surgery.

Screening for this condition In United Kingdom is mandatory and is carried out at birth, 6 weeks and 8 months of age. Most cases are therefore detected at an early age and treated appropriately.

Clinical Features of DDH are:

• Limitation of abduction in flexion (all age groups).
• Hip or thigh asymmetry (all age groups).
• Extra deep crease around the back of the thigh.
• Positive Barlow or Ortolani Tests (<2 months of age).
• Short leg or limping (walking age group).

It is important to note that these physical signs are more obvious in unilateral cases due to limb asymmetry. In bilateral cases
these signs could easily be overlooked. Limited abduction (<60°) in both hips should raise the suspicion that both hips may be abnormal.

In difficult cases or high risk groups further investigations is recommended. For a child younger than 5 months ultrasound examination is indicated and for over 5 months plain radiographs.

Treatment. The basic principals for treatment are:
• Reduce the dislocation or subluxation.
• Hold the reduction until hip stabilises.
• Careful follow-up until skeletal maturity.

In a child less than 6 months of age the reduction can easily be achieved by flexing and abducting the hips (frog position). The reduction is usually maintained using a brace such as a Pavlik harness for a period of 2-3 months.

In a child in the age group of 6-18 months this condition is associated with major soft tissue contractures. To achieve reduction a period of traction for 1 week is usually necessary. This is then followed by an attempt of closed reduction under general anaesthesia. The reduction would require confirmation using an arthrogram (injection of dye into the hip joint under X-ray control). In the cases that there is resistance to reduction, additional surgical procedures such as tenotomy (tendon release) or limited open reduction of the hip may be necessary. Following this procedure the reduction is maintained using a frog plaster for a period of at least 4 months.

In a walking age child (>18 months) major surgery is often required to reduce and stabilise the hip. this could be in the form of an open reduction of the hip +/- pelvic or femoral osteotomy. Postoperatively a period of casting in a hip spica is necessary for 10 weeks.

Prognosis for this condition is directly related to the age of the child at the time of presentation and the severity of the hip dysplasia.

In children less than 6 months of age 98% success rate is generally expected. This is reduced to 95% if the child is within the age group of 6-24 months and 85-90% if the child is over the age of 2 years at the time of treatment.

Careful follow-up
until skeletal maturity (age 16 years) is needed to confirm satisfactory progress and to identify complications such as recurrent dysplasia or avascular necrosis (loss of blood supply to femoral head) at an early stage.


Limited Abduction & Extra Thigh Crease



Barlow & Ortolani Tests



Ultrasound & Radiographs



Pavlik Harness - Frog Plaster



Gallows' Traction & Arthrogram



Open Reduction with Femoral or Pelvic Osteotomy


 

INTOE GAIT

Intoe gait (pigeon toed) is a common childhood problem. It is estimated to occur in 10% of children between ages of 2-5 years. In most cases this is an entirely benign condition and is a feature of normal variation of growth pattern.

Lack of any symptoms such as pain, symmetrical deformities, absence of any stiffness in the affected joints and no associated systemic disorders or syndromes indicates a benign condition with excellent long-term outcome.

Most children with this deformity spontaneously stop intoeing before the age of 9 years. No treatment is therefore required in the majority of cases.

There are 3 main causes of intoe gait:

• Persistent femoral anteversion
• Internal tibial torsion
• Forefoot adductus

Persistent Femoral Anteversion (PFA). PFA is excessive anterior rotation within the upper femur. Normally in adults the upper femur is anteriorly rotated in relation to the lower femur (femoral condyles) by 15°. In young children this angle is about 30°, but this steadily reduces to adult angles by the onset of adolescent growth spurt.

On examination of the hips in children with PFA, the most striking feature is excessive range of internal rotation, but limited external rotation.

As previously mentioned in most cases this is an entirely benign condition and requires no treatment.

Internal Tibial Torsion (ITT). Tibia is normally rotated externally in relation to the femur by 20°. This is best measured by comparing the intermalleolar axis to the intercondylar axis. Another simple way of assessing this relationship is to measure the thigh-foot angle with the child in prone position and knees flexed to 90°.

In ITT the tibia is found to be internally by more than 10°-20°
. This phenomenon is extremely common at birth and rapidly remodels to normal levels within the first few years of life. However, in a minority of cases ITT may persist until onset of adolescent growth spurt. This condition is unlikely to persist into adult life and rarely creates problems severe enough to require treatment or correction.

Forefoot Adductus is another important cause of intoe gait. In this condition the foot has a curved lateral border rather than straight. The forefoot therefore appears to be turned in (bean shaped). This condition could easily be distinguished from club foot as there are no fixed deformities within the hind foot.

This condition has a tendency for spontaneous correction with age. Long-term prognosis is usually very good and treatment is not required in most cases.

For severe cases, especially when it is unilateral, application of serial corrective casts could be very effective. Surgical correction is rarely needed .

 

Normal - - - - - - - Intoe Gait

 

Causes of Intoe Gait

Femoral Anteversion



Internal Tibial Rotation




Thigh Foot Angle



Forefoot Adductus


 

KNOCK KNEES & BOW LEGS

Angular deformities of the lower limbs are common during childhood. In most cases this is an entirely benign condition and represent a variation in the normal growth pattern.

Presence of symmetrical deformities and absence of symptoms, joint stiffness, systemic disorders or syndromes indicates a benign condition with excellent long-term outcome. In contrast deformities which are asymmetrical and associated with pain, joint stiffness, systemic disorders or syndromes may indicate a serious underlying cause and require treatment.

The most common deformities that would be discussed here are Bow Legs (Genu Varum) and Knock Knees (Genu Valgum).

The Natural History. It is important to note that a newborn initially presents with bow legs. With normal growth, knees gradually become straight by the age 18 months. With further normal development knees gradually drift into valgus (knock knee). This knock knee deformity is maximal at around age 3-4 years. By the age 7 years knee angle (tibiofemoral angle) return to normal adult values of 5°-7°.

This is well illustrated by the opposite graph (Salenius 1975). The shaded area in light green indicates the 2 standard deviations (SD) from the average. Tibiofemoral angles within this range are considered to be within normal limits.

Treatment is not required for physiological deformities. i.e. deformities within 2 standard deviation or deformities that are not associated sinister features such as pain, asymmetry, stiffness, systemic disorders or syndromes.

Treatment for pathological deformities depends on the underlying disorder and the severity of the deformity.

Metabolic deformities such as rickets could simply be corrected with medical treatment i.e. calcium and vitamin D supplements.

Prior to skeletal maturity (<14 years in females and 16 years in males) deformities could be corrected slowly using partial growth plate arrest (hemiepiphysiodesis). For severe deformities or after skeletal maturity corrective osteotomy or may be needed.

Tibiofemoral Angle





Salenius 1975




Rickets



Hemiepiphysiodesis -- Osteotomy
   

FLAT FOOT

Flat foot is a common finding in childhood. This is broadly divided into 2 groups i.e. flexible or rigid flat foot.

Flexible Flat Foot is the more common variety (95%). It is generally observed in the younger child and is frequently associated with generalised joint laxity. This condition is rarely symptomatic or limits the level of activity.

A classical finding in flexible flat foot is that the foot arch develops normally when the child stands on tip toes. whilst standing normally the flat foot deformity recurs.

In vast majority of cases flexible flat foot is a benign condition and requires no treatment. Recent long-term studies have shown that old methods of treatment such as insoles or surgical shoes have no beneficial effect on the ultimate outcome.


Rigid Flat Foot on the other hand is a sinister finding and often associated with serious conditions such as tarsal coalition or congenital vertical talus.

Unlike flexible flat foot, rigid flat foot is frequently a painful disorder. In this condition when the child stands on tip toes, the medial foot arch does not develop normally. On examination the foot is found to be stiff, lacking normal range of movement in the subtalar joint.

Congenital vertical talus (CVT) is a rare but serious foot deformity. It generally presents at birth and rarely responds to conservative treatment. 50% of cases are associated with underlying neuromuscular conditions or syndromes. Surgical intervention is frequently required as this is a painful condition as an adult. surgical correction is generally carried out at age 1 year.

Tarsal coalition is a relatively common condition (1-2% of population). Most cases are relatively asymptomatic and do not come to the attention of the medical profession.

Tarsal coalition is usually asymptomatic in the younger child and only becomes painful during the adolescent growth spurt. There 2 main varieties of tarsal coalition are: Talo-calcaneal coalition and Calcaneo-navicular coalition. Both varieties present with pain and stiffness in the foot.

Treatment for tarsal coalition is controversial. My preference for early cases is to excise the coalition and insert a fat graft into the gap to stop the coalition from reforming. Other methods of treatment are: short period of casting in a walking plaster or subtalar fusion.

Normal ------Flat Foot

 

Flexible Flat Foot


Standing-----On Tip Toe

Insoles & Shoe Inserts



Congenital Vertical Talus



Tarsal Coalition


Talo-calcaneal ---Calcaneo-navicular
 

CALCANEOVALGUS FOOT

This is the most common paediatric foot deformity. As the name implies, in this condition the hindfoot is in excessive calcaneus (dorsiflexed) and valgus position. In a walking child, on weight-bearing the foot has an excessively everted and pronated appearance.

This is an entirely benign condition in majority of cases. It is usually secondary to joint laxity and immature muscle pattern as seen in the newborn or a young child.

This condition is rarely associated with hip dysplasia (DDH) and screening for this condition is required.

Other than gentle stretching exercises no other treatment is generally required and long-term prognosis is excellent.

Calcaneovalgus Foot

At Birth



Walking Age
   

CLUB FOOT (Congenital Talipes Equinovarus)

Club foot is the second most frequent paediatric foot condition. It affects 2 per 1000 live births and could be bilateral in 25% of cases. Males are more frequently affected than females by 2:1.

The deformities in club foot are complex and involves the whole foot, ankle and leg. In the hind foot the ankle joint is flexed (equinus deformity) and the heel is turned in (varus deformity). In the forefoot there is a high medial arch (cavus deformity) and the foot has a bean shaped and curled outer border (forefoot adductus deformity). The whole leg, foot including calf muscles are smaller on the affected side.

In 30% of cases this deformity is flexible and rapidly resolves after birth. In the remaining 70% the deformity is stiff and if left untreated it would lead to severe painful deformities in the long-term and the affected child could end up walking on the outer aspect of the foot.

Most cases of club foot are idiopathic (unknown cause) in nature and the child is otherwise entirely normal. In minority of cases (<5%) this deformity is secondary to other conditions such as neuromuscular disease or syndromes. There is also an increased risk of developmental dysplasia of the hip (DDH) in children with club foot and screening for this condition is therefore mandatory.

Treatment for flexible club foot is stretching exercises under the supervision of a physiotherapist. Rapid resolution of the deformity is generally expected within weeks and it is unlikely other methods of treatment would be necessary.

For rigid or inflexible deformities my preference is to use Ponseti's method of treatment. This is currently gathering increasing popularity and recent comparative studies have shown results equivalent or even superior to traditional methods of treatment such as surgical soft tissue releases.

Ponseti Treatment in my experience this is best suited for infants and young babies (< 6 months age).

Treatment starts initially by stretching the deformity to its maximal position of correction and applying an above knee cast using plaster of Paris or Softcast. This is repeated on a weekly basis for 6 weeks and a new cast is applied on each occasion.

In 20% of the cases complete correction of the deformities is observed within this 6 week period of stretching and casting. However, in 80% of cases the hind foot equinus deformity may persist. In these cases the complete correction of the deformity is achieved at week 7 by performing a small operation to release the tendo-Achilles (percutaneous tendo-Achilles release).

When complete correction of the deformities has been achieved an above knee cast is applied for another 6 weeks. At 12 weeks following start of treatment, all casting is discontinued.

To avoid recurrence of deformity use of a Denis Browne splint at night time is recommended until age 2 years. Note splinting is not required during day time.


The success rate of Ponseti treatment is about 85-90%. For failed cases or children with severe recurrent deformity, surgery may be required at a later date. In general the procedures necessary to treat failed Ponseti cases are lesser in magnitude as compared with traditional operative procedures for correction of club foot deformity. Most cases with recurrent deformity after Ponseti treatment need a simple tendon transfer at the age 3-4 years (tibialis anterior tendon transfer).

Prognosis With appropriate treatment we expect most children (>95%) with clubfoot deformity to lead a normal life into adult hood and even take part in strenuous physical activities.


N.B. in a small number of cases club foot deformity may not respond to stretching or Ponseti's treatment. These cases would require surgical soft tissue release at around age 1 year.

 

Deformities in Club Foot






Thin Calf Muscles & Smaller Foot


Ponseti Treatment
Stretching & Application of Serial Corrective Casts








Denis Browne Splint
 

IRRITABLE HIP
This is the commonest cause of hip pain or limping in a young child. The peak age group is 3-8 years. Although this is a hip condition, in about 30% of cases the pain may initially be felt in the knee or the thigh.

The underlying pathology in this condition is formation of fluid under tension (effusion) within the hip joint. The exact cause of this effusion is unknown, but viral infections, minor trauma or allergy have been implicated.

Diagnosis is usually made on clinical grounds. The affected hip is generally irritable on movement but relatively comfortable when the hip is kept in the position of flexion and abduction. Signs of sepsis such as high temperature, rapid pulse, flushing, limb swelling or erythaema are notably absent.

Best method of investigation is ultrasound of the hip to confirmed the presence of the effusion and blood tests to rule out rise in inflammatory markers. Plain radiographs of the hips is also taken to exclude rare associations such as Perthes' disease. Radiographs may occasionally confirm presence of an effusion by showing a subtle medial joint space widening.

Treatment. Irritable hip is a benign and self-limiting condition. In most cases it spontaneously resolves within 48-72 hours. During the painful episode rest is advisable and this could be done at home. Other than anti-inflammatory drugs no other treatment is usually required.

If symptoms fail to resolve within the 48-72 hours or there is deterioration of general condition, urgent specialist review is necessary.

Joint Space Widening




Effusion In Affected Hip

   

PERTHES' DISEASE 

Perthes' disease is avascular necrosis of the femoral head of unknown aetiology. The interruption of the blood supply to the femoral head results in collapse, fragmentation and progressive deformity of the hip joint. It affects the age groups 4-10 years. Males are more frequently affected than females by 4:1 and it is bilateral in 25% of cases.

A child suffering from this condition usually presents with hip pain or a limp. However, in 30% of cases the pain may initially be referred to the thigh or the knee. This could on occasions result in missed or delayed diagnosis, especially if the hips are not radiographed routinely in a child with knee or thigh pain.

Perthes' disease is recognised to undergo a number of well defined radiological stages i.e. necrosis, fragmentation, healing and remodelling stages.

The Natural History of untreated Perthes' disease is eventual healing and revascularisation of the necrotic femoral head within 2-3 years. In 75% of the cases the healing process results in a round congruent hip joint with good to excellent outcome in the long-term. In these cases no treatment other than careful follow-up is necessary.

In contrast in 25% of untreated cases this condition results in severe deformity of the hip joint. In these cases operative intervention may be required to improve the outcome.

It is important to note that from onset of Perthes’ disease i.e. necrosis stage until the lesion heals (healing stage) it may take up to 2-3 years. Regardless of the prognosis, the affected child is expected to experience intermittent pain and limping during this period until healing stage is reached.

Treatment is not required for children with good prognosis. Good prognosis is indicated by the following clinical features:
• Age less than 6 years at the onset of symptoms.
• Less than 50% of head involvement.
• No stiffness or shortening on examination.

On the other hand bad prognosis is indicated by the following clinical findings:
• Age more than 7 years at the onset of symptoms.
• More than 50% of head involvement.
• Significant stiffness or shortening on examination.

In poor prognosis group operative intervention could improve the outcome. In general there are 2 class of operations available to treat Perthes's disease: i) Containment, ii) Corrective Osteotomy.

Containment is most suitable for cases within the necrosis or fragmentation stages. During these early stages the femoral head remains malleable and the aim is to contain the femoral head deep within the acetabulum until healing occurs. The acetabulum which is hemispherical in shape helps to remodel the femoral head into a spherical shape. Varus femoral or pelvic osteotomy are the operations generally done for containment.

Corrective osteotomy is more suitable for cases that have entered the healing or remodelling stages. in these stages the femoral head deformity is unlikely to remodel by containment . Corrective osteotomy aims to address residual problems such limb shortening or limited abduction in the hip. the most popular type of osteotomy in this situation is a valgus lengthening osteotomy.

Progression of Perthes' Disease

 
Necrosis - Fragmentation - Healing - Remodelling


Natural History of Untreated Perthes' Disease



Less than 50% Head Involvement


More than 50% Head Involvement

Containment

Valgus Lengthening Osteotomy

 

SLIPPED UPPER FEMORAL EPIPHYSIS

This is the commonest cause of hip pain in the adolescent age group (10-15 years). Males are more frequently affected than females by 2:1. It may be bilateral in 30% of cases. Positive family history, obesity and hormonal abnormalities such as hypogonadism, hypothyroidism and hypopituitarism are well known associations.

The pathology is a stress fracture through the upper femoral growth plate resulting in a progressive slip of the femoral head over the femoral neck. The affected limb shortens and externally rotates as the deformity increases with time.

The Natural History. If this condition is left untreated it may result in severe limb shortening, fixed external rotation and stiffness of the hip. This may then be followed by early onset of osteoarthritis in adulthood. In a small number of cases sudden catastrophic failure of the growth plate may occur, resulting in severe deformity and loss of blood supply to the femoral head (avascular necrosis) with serious long-term sequelae.

In most cases the condition presents with a limp and pain in the hip or groin. However, in 30% of cases the pain may initially be referred to the knee or the thigh creating diagnostic difficulties. To avoid a missed or late diagnosis, it is vital to take radiographs of the hips as well as the knees in any adolescent presenting with thigh or knee pain.

N.B. In this condition the hip radiographs should routinely include 2 views at right angles as in the early stages the classical AP view may appear to be normal . The lateral view usually reveals the slipped epiphysis (see the top radiographs).


Treatment of choice for this condition is insertion of a single cannulated screw percutaneously under X-ray control. With modern techniques this could be achieved using a small stab incision. Postoperative recovery is generally rapid, but a period of protected weigh-bearing with crutches for 6 weeks is recommended.

For severe slips additional procedures in form of open reduction or corrective osteotomies may be necessary. Fortunately this a rare occurrence, especially if this condition has been picked up early before severe deformities have developed.

Prophylactic Fixation of the unaffected hip is a common point of debate. It is recognised that in 30% of cases, slips may occur in both hips.

Onset of symptoms in the unaffected side indicates the need for prophylactic screw fixation. My current practice is also to fix the unaffected hip in cases associated with hormonal abnormalities.

Prognosis
of this condition is dependent on the severity and the stability of the slip.

A stable slip is defined as a slip were the individual is able to weight-bear on the affected limb. In unstable slips weight-bearing is not possible due to the severity of symptoms. In general stable slips with slip angles of less than 30° carry excellent long-term prognosis when treated appropriately.

Unstable slips or slips more than 50° carry a more guarded prognosis. Occasionally these cases are complicated by conditions such as avascular necrosis (loss of blood supply to the femoral head) or chondrolysis (loss of cartilage of the head of femur). These complications cause severe deformity or stiffness in the affected hip and result in early osteoarthritis.

 

Slipped Upper Femoral Epiphysis




Threthowan Sign



Clinical Features

 

Catastrophic Unstable Slip



Screw Stabilisation Under X-Ray Control





 

APOPHYSITIS
In a child or skeletally immature adolescent, tendons insert into bone through a specialised cartilaginous tissue called apophysis. This tissue ossifies and turns into bone when skeletal maturity is reached in the adolescence.

During growth spurt apophyses are vulnerable to traction injury (micro-avulsion). Clinically this may manifest itself as painful or prominent apophyses. Positive family history, obesity and strenuous activity are some of the predisposing factors.

The most frequent site for apophysitis is the tibial tubercle, which is also referred as Osgood-Schlatter's disease. Other common sites are the heel (Sever's disease) and medial aspect of the foot (navicular apophysitis). Rarely the hip may also be affected.

Treatment for this condition is generally conservative and nonsurgical. During the active phase, reduction in the level of activity and mild painkillers are recommended. During remission normal activities could be commenced with caution. Rarely for severe symptoms shoe inserts or casting could be tried.

Prognosis for most cases of apophysitis is excellent in the long-term. This condition spontaneously heals when skeletal growth ceases in the late adolescence. Unfortunately during the active phase of the disease which may last a number of years, intermittent symptoms are expected. In an active sporting child this could become a great nuisance and necessitate reduction in level of activity until resolution of symptoms occurs in late teens.


Osgood-Sclatter's Disease




 
 

GROWING PAINS

This is a common condition, especially in the age group of 3-10 years. Classically symptoms are worse at nights. Usually the child wakes up in the middle of the night complaining of pain in both legs or knees. After a short period of massage and rubbing the painful area, symptoms resolve and the child goes back to sleep. In the day time symptoms are uncommon.

The exact cause of growing pains is unknown. It has been postulated that skeletal growth which mainly takes part at night, increases the limb length and this increases the stress on the soft tissues which tend to lag behind in growth.

Growing pains is a diagnosis of exclusion. Mode of presentation, age of the child and bilateral nature of the symptoms are strongly suggestive. However, thorough clinical examination and plain radiographs are needed to exclude rare but serious conditions such as tumours or infection which could mimic growing pains.

Treatment for this condition is symptomatic. Regular stretching exercises and a short course of mild painkillers at night could be helpful. In the long-term this condition spontaneously resolves.

Stretching Exercises

   
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