1. pediatric orthopaedic (2)

8/11/2019 1. Pediatric Orthopaedic (2)

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Pediatric Orthopaedics

SMF BEDAH ORTHOPAEDI

RSUD ULIN BANJARMASIN/

FK UNLAM

dr. Andreas Siagian SpOT


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COMMON CHILDHOOD

MUSCULOSKELETAL CONDITIONS


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GENERALPRINCIPLESOFFRACTURESAND

DISLOCATIONSINCHILDREN

Childrens bones bend more before fracture than do

adults bones (childrens bones are more ductile)

The periosteum in children is thicker and more highly

developed and often remains intact on the concave sideof a fracture

Childrens fractures heal more rapidly and, therefore,

require shorter immobilization time than do adults

fractures


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PHYSEALGROWTHFRACTURE


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Physeal (growth plate) fractures- Classically occur through the zone of hypertrophyof the growth plate but can involve other zones

- Usually caused by a torsion (not tension) at thegrowth plate

- Complications of physeal fractures include* Limb length discrepancies

* Malunions

* Physeal bars (leading to angular or longitudinal

deformities)-Most common sites for physeal fractures are thedistal radius and distal tibia


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Growth plate arrest (Fig.5-2)

- Physeal bars (bridges) arise as a result of a growthplate injury that leads to an arrest of growth of aportion of the physis: an uninjured portion of thephysis may continue to grow

- Centrally located bars within the physis lead toarrest of longitudinal growth with resultant shorteningof the extremity

- Peripheral bars lead to angular deformities

- Treatment options include operative resection ofthe bar or ipsilateral completion of a growth arrest inconjunction with an epiphysiodesis to thecontralateral extremity (to equalize the growthdisturbance in both extremities)


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Torus (buckle) fracture

occurs in children at the

metaphyseal diaphyseal

junction of long bone (most

commonly distal radius) asa result of an axial load

Torus #


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Greenstick #

Greenstick fracture

fractures in children

commonly are incomplete

and leave a hinge of intact

bone and soft tissues similarto the manner in which a

green stick from a tree

branch breaks


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Childs abuse (battered child syndrome)

- A high index of suspicion is needed to make thediagnosis

- Most common in children younger than 3 years ofage

- Unusual histories are a tip-off

- Physical exam may show multiple healing skinbruises, burns, etc.

- The most common locations for fractures in childabuse are the humerus, tibia, and femur

- Skull fractures are common- Skeletal survey (x-rays of the skull, thoracolumbarspine, chest and ribs, pelvis, femur, knees, tibias,fibulas, ankles, wrists, and hands)


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Talipes Equinovarus(congenital clubfoot)


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I. Etiology

Unknown, possibly multiple factors, including

polygenic inheritance, persistence of fetal positioning,

primary germ plasma defect, and neuromuscular

factors

II. Incidence

A. In whites, 1.2/1000. male > female (2:1);

50% bilateral


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III. Embryology

1. Embryonic position: 30 mm embryo with equinovarus foot

2. Fetal position:50 mm embryo with mild adducted

equinovarus foot secondary to tibialgrowth


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IV. Pathology

A. Histologic abnormalities in muscle, tendon, and

ligament in addition to contracture

B. Equinus, hindfoot varus, and foot varus (talonavicular)C. Calcaneus rotates through subtalar joint in a medial

direction and inverts (varus tilting or supination)

D. Body of talus may be directed laterally and neck of

talus is directed medially (lateral rotation of the talus)


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E. Navicula is displaced medially

F. Cuboid is often subluxated medially

G.Plantar fascia is tight


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V. X-Rays Findings

1. Increased lateral calcalcaneotibial angle (>125 )secondary to ankle equinus

2. Decreased lateral talocalcaneal angle (


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Pathol

o

gy

N

or

mal


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VI. Prognosis

A. Condition worse if :1. Teratogenic (eg, arthrogryposis,

myelodysplasia)

2. Short, far, rigid foot with severe mid footcrease

3. Boat-shaped heel, severe, adductus varus,

atavistic short first toe

4. Delayed treatment and failure to respond


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VII. Treatment

A. Postnatal: corrective manipulation and(correct adduction,heel varus, and then equinus) every 1-2 weeks for 3

months, then holding cast or brace until surgery (50 %

effective)

B. Surgery

1. One-stage posteromedial release of tight structures

2. Ideally, 4-8 months but up to 6 years of age

3. Turco posteromedial or extensive subtalar

release by Mckay or Simon techniques

T li E i ( it l l bf t)


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Talipes Equinovarus (congenital clubfoot)

Serial cast

Dennis brown shoes


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DEVELOPMENTALDYSPLASIA

OFTHEHIP(DDH)


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EPIDEMIOLOGY

0.7 to 35 per 1000 live births

Depends on geography

Depends on type of studyRetrospective studies tend to report

lower incidence

Screening programmes tend to report

higher incidence


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PREDISPOSINGFACTORS

Female

Breech delivery

First born

Family history

Oligohydramnions

Other congenital abnormalities


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CLINICALSCREENING

Baby must be relaxedExaminer must not use excessive force

Asymmetric abduction


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2. BARLOWS SIGN:

CLUNK OF

DISLOCATIONPROVOCATIVE TEST

3. Ortolani Sign: Clunk

of EntryReduc t ion maneuver


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4. GALEAZZI SIGN


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HIPULTRASONOGRAPHY

Graf (1980)

Harcke and Grissom (1990)

dynamic US


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IMAGING

AP Pelvis Useful after 6-8 months

Monitoring hip/acetabular development

Detection of complications


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1-6 months

Pavlik harness for 3-4 weeks.

Closed surgical reduction if harness fails.

Management Protocol


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Problem:

Extreme positionAvascular necrosis

Tight shoulder straps

Nerve palsies

Femoral nerve palsy

extreme flexion

Uncomfortable

Inferior dislocation


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DDH

Closed reduction

Traction

Adductor tenotomy

Closed reduction and spica

Arthrogram is helpful in visualizing reduction

3 months casting, change at 6 weeksNight hip abduction brace for 6 months


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TREATMENT

6-18 months.

Closed or open surgical reduction

Hip spica cast

Some time we combined withpinning for maintain reduction +

hip spica cast


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OPENREDUCTION

Indications

Failed closed after trial of casting

Interposition of soft tissue on arthrogram

Limbus shape on arthrogramAge over 1 year without concentric reduction


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TREATMENT

18 months - 8 years

Open reduction with femoral osteotomy or /and pelvic

osteotomy


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PELVIC OSTEOTOMIES

Salters innominate

Pemberton

Osteotomies to free the

acetabulum - Steel & Dega

Chiari displacementosteotomy


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COMPLICATIONS

The most common complication of treatment of

DDH is osteonecrosis of the femoral head

Growth disturbance of proximal femoral physis

Gait abnormality


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LEGGCALVEPERTHESDISEASE

Joseph Donnelly, M.D.December 10, 2001


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HISTORY

Late 19thcentury: hip infections that resolved

without surgery

First described in 1910

Early path studies: cartilaginous islands in the

epiphysis


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EPIDEMIOLOGY

Disorder of the hip in young children

Usually ages 4-8yo

As early as 2yo, as late as teens

Boys:Girls= 4-5:1 Bilateral 10-12%

No evidence of inheritance


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ETIOLOGY

Unknown

Past theories: infection, inflammation, trauma,

congenital

Most current theories involve vascular compromise

Sanches 1973: second infarction theory


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PRESENTATION

Often insidious onset of a limp

C/O pain in groin, thigh, knee

17% relate trauma hx

Can have an acute onset


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PHYSICALEXAM

Decreased ROM, especially abduction and internal

rotation

Trendelenburg test often positive

Adductor contracture

Muscular atrophy of thigh/buttock/calf

Limb length discrepency


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IMAGING

AP pelvis

Frog leg lateral

Key= view films

sequentially overcourse of dz

Arthrography

MRI role undefined


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DIFFERENTIALDIAGNOSIS

Important to rule out infectious etiology (septic

arthritis, toxic synovitis)

Others:

Chondrolysis -Neoplasm

JRA -Sickle Cell

Osteomyelitis -Traumatic AVN

Lymphoma -Medication


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RADIOGRAPHICCLASSIFICATIONS

Describe extent of epiphyseal disease

Catterall classification= most commonly used

4 groups based on amount of femoral head involvement

Also presence of sequestrum, metaphyseal reaction,

subchondral #


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GROUPI


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GROUPII


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GROUPIII


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GROUPIV


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PROGNOSIS

60% of kids do well without tx

AGEis key prognostic factor:

9yo= containment option is questionable, poorer

prognosis, significant residual defect


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PROGNOSIS

Flat femoral head incongruent with acetabulum=

worst prognosis

Do not treat in reossification stage (>15mos)


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NON-OPERATIVETX

Improve ROM 1st

Bracing:

Removable abduction orthosis

Pietrie casts

Hips abducted and internally rotated

Wean from brace when improved x-ray healing

signs


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BRACING


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NON-OPERATIVETX

Check serial radiographs

Q3-4 mos with ROM testing

Continue bracing until:

Lateral column ossifies

Sclerotic areas in epiphysis gone

Cast/brace uninvolved side


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OPERATIVETX

If non-op tx cannot maintain containment

Surgically ideal pt:

6-9yo

Catterral II-III

Good ROM


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LATEEFFECTSOFLCP

Coxa magna

Physeal arrest patterns

Irregular head formation

Osteochondritis dessicans


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SLIPPEDCAPITALFEMORALEPIPHYSIS


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SLIPPEDCAPITALFEMORALEPIPHYSIS:

PRESENTATION Who?

714 yo

Growing FAST (or aboutto)

Obese or active more likely

What c/o?ANY hip/thigh/knee pain

Limp

Sits/runs/walks funny

SLIPPED CAPITAL FEMORAL EPIPHYSIS:


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DIAGNOSIS

Exam

Limited/painful IR Hip

Obligate IR with flexion

You KNOW when:

Kleins line

Radiologist frantic page

What Next?

Kleins Line on AP

Frog Leg

Normal Abnormal


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Treatment:

Non-weight Bearing!

Ortho Consult within 72 hours

This can be bad!

Watch Out for:

Legg-Calve-Perthes

Septic/Toxic Synovitis


FINALTHOUGHTS


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