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CHAPTER44
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Orthopaedics in the Child
CASE 1
Mary, a 4 year old, was brought to see her general practitioner
(GP) because of in-toeing. Examination revealed that she walked
with both feet and knees facing inwards by 20°. Her mother
commented that she had been described as ‘double jointed’ as a
child. Both had signs of generalised joint laxity.
Q 1.1
What is the diagnosis?
CASE 2
Jacky, a 5 year old, was brought to see an orthopaedic surgeon
because of knock-knees. Examination revealed symmetric genu
valgum with 6
Q 2.1
cm between the ankles in the standing position.
Is treatment required?
As children become older, parental anxiety about the
appearance of their feet, legs and walking continues.
As in the younger age groups, the majority of these
children are also normal, but a different spectrum of
problems are seen from those seen in the toddler. It may
be rare to see developmental dysplasia of the hip or
cerebral palsy presenting for the first time in the child,
but irritable hip, Perthes’ disease [Fig.44.1], osteomyelitis and septic arthritis are all seen.
As children become more adventurous in play and
participate in sport, an increasing number and variety of
fractures and epiphyseal injuries are seen.
Internal femoral torsion (inset hips)
This is frequently seen in children between the ages
of 3 and 10 years. The in-toeing is symmetrical.
Parents complain that their children look awkward
CASE 3
Sara, a 6 year old, was a keen gymnast and was noted to have
‘at feet’. Expensive orthotics were prescribed.
Q 3.1
Are these necessary?
CASE 4
A 7-year-old boy falls out of a tree on to his outstretched hand.
He presents shortly after with a very swollen, painful elbow and
decreased radial pulse.
Q 4.1 Why is this important?
and tripfrequently, but the degree of disability is not
great. The child often has signs of generalised joint
laxity and may have associated features, such as flexible
flat feet.
Examination reveals a characteristic shift of the arc
of hip rotation inwards, hence the synonym ‘inset
hips’. A typical finding would be internal rotation of
80–90° and external rotation of 0–10°. This is the
reason why the children can sit comfortably in the ‘W’
position [Fig.44.2]. It is doubtful if sitting in this position causes the condition, but there is some evidence
that habitually sitting in this posture slows down the
natural tendency to spontaneous recovery.
In some children, correction of the in-toeing is accomplished by a compensatory tibial torsion. In these children, the feet no longer turn in, but in standing and
walking the patellae are facing inwards or ‘squinting’.
This combination of deformities can look unattractive
and gives the appearance of bowlegs.
Jones’ Clinical Paediatric Surgery, Seventh Edition. Edited by John M. Hutson, Michael O’Brien, Spencer W. Beasley,
Warwick J. Teague and Sebastian K. King.
© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.
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Figure 44.1 Typical x-ray appearance of Perthes’ disease.
IMS
Figure 44.2 Internal femoral torsion (inset hips): the child can
sit on the floor in the ‘W’ position.
Management
The natural history of the condition is for spontaneous
resolution during the growing years. There is no evidence that any form of exercises or orthotic devices
influences the resolution. The condition can be treated
Figure 44.3
separation).
Knock-knees (genu valgum). (IMS: intermalleolar
surgically by means of external rotation osteotomy of
the femur, but the vast majority of children improve
spontaneously and do not require intervention.
Knock knees
Physiological genu valgum, or knock-knee deformity, is
often seen in children between the ages of 3 and 8 years
[Fig.44.3]. The majority of children straighten spontaneously. The deformity is symmetrical, not excessive
(e.g. gap between ankles on standing <10 cm) and
improves with time. Pathological genu valgum is usually
more severe, asymmetrical and increases with time.
Causes include trauma (proximal metaphyseal greenstick fracture of the tibia or growth plate injury) rickets,
skeletal dysplasias and congenital limb deficiencies.
Management
There is no evidence that the natural history of the
condition is affected by exercises, shoe inserts or night
splints.
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A small number of children with physiological genu
valgum do not correct completely. The reasons to consider surgery are discomfort from ‘knee-swishing’ while
running, concern about the appearance and progression
of the deformity in the pathological cases. In order to
assess the degree and site of deformity, a standing x-ray of
the lower limb should be obtained. Correction can be
achieved by restricting growth in the distal femoral or
proximal tibial growth plates on the medial side of the
knee using staples or screws. New, safer devices for
growth plate surgery are now widely available, minimally
invasive and very successful for the correction of angular
deformities in children. However, by definition the children must be ‘growing’ and must be referred in time!
When the growth plates have already fused, unfortunately osteotomy of the distal femur or proximal tibia
may be required.
Flat feet
Almost all infants have ‘flat feet’, and in the majority an
arch will develop by the age of 6 years. The clinical findings of a flexible flat foot include absence of the medial
longitudinal arch and a variable degree of hind foot
valgus. When the child stands ‘at ease’, the only support
to the medial arch is the interosseus ligaments and
intrinsic muscles of the foot, which are not continuously
active. When the child stands on tiptoe, the long flexor
and extensor muscles are recruited into continuous
activity. In the correctable flat foot, the medial
longitudinal arch usually appears and the heel tilts into
neutral or varus. This ‘tiptoe test’ can be used to explain
the nature of the condition to parents and to reassure
them that the internal structure of the foot is normal. In
the flexible flat foot, the medial arch is also reformed on
weight bearing when the hallux is passively dorsiflexed.
This is referred to as the ‘toe-raising test of Jack’.
Pathological causes of flat foot include hypermobility
syndromes and cerebral palsy.
dence that orthotics may prolong the life of the shoe by
decreasing deformation and wear. If excessive shoe wear
and cost of replacements are important to the parents, or
pain is a problem, the Helfet or UCBL heel cup or a
simple medial arch support may be helpful. Expensive,
custom-made orthotics are rarely, if ever, required.
In children with normal flexible flat foot, surgery is
very rarely required.
Growing pains and night cramps
About 15% of children go through a period where they
waken at night, crying because of pains in their legs.
The child goes to sleep after an energetic day only to
waken in pain and misery, but the following day all is
well. Presentation is often delayed until there have been
many disturbed nights.
Clinical features
The child has no daytime pain and no limp. The pain at
night is relieved by rubbing, heat and simple analgesics.
Examination reveals no abnormalities.
Differential diagnosis
Night pains are a feature of osteoid osteoma, but this is
always unilateral and often reasonably well localised.
One cause of bilateral leg pains is leukaemia, which can
be excluded in most children by a full-blood count.
There are usually other features in leukaemia or an
atypical story, so investigation is not necessary in all
children with bilateral nocturnal leg pain.
Management
Full history-taking and thorough examination excludes
pathological causes and allays parental anxiety.
Reassurance is very important, and fortunately, most
parents can accept the situation. There may be a role for
a programme of stretching exercises.
Management
Most of the enthusiasm for ‘treating’ flat foot has probably been based on the observation that with use of any
of the popular forms of treatment, the majority of children are noted to get ‘better’.
Although shoe modifications and inserts do not change
the shape of the foot in the long term, there is some evi-
Fractures and epiphyseal injuries
inthe child
As the child becomes more adventurous in play, and
then active in organised sport, the incidence of musculoskeletal injuries increases dramatically. The weak link in
the child’s skeleton is the growth plate or physis. In
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Figure 44.4 An x-ray image of valgus injury to the knee. In an
adult, a tear of themedial ligament would be likely, whereas
in this child theresult is a Harris–Salter type 2 separation of
the distal femoral plate.
children, epiphyseal separations are common, as are
fractures of the long bones.
Specific soft tissue injuries, such as collateral ligament
tears, are rare and the diagnosis of a ‘sprain’ in the child
is frequently incorrect. A valgus force at the knee, which
would result in a tear of the medial collateral ligament
Figure 44.5 Children’s bones may bend and buckle, as in this
fracture of the distal tibia and fistula.
Figure 44.6 (a) X-ray of open fracture of the femur as a result of a fall from a tree. Note the gross displacement and shortening. (b)
X-ray after wound care, reduction and traction, the fracture is healing in good position. Up to 1 cm of overlap is acceptable because
of anticipated overgrowth.
(b)(a)
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in an adult, is more likely to cause a separation of
the distal femoral epiphysis in the child [Fig. 44.4].
Theequivalent of an anterior cruciate tear in a child is
avulsion of the tibial spine.
Non-specific, minor soft tissue injury is common in
the child, including abrasions and bruising.
Fractures in children
Fractures are caused by forces applied to the skeleton
which result in failure of the bone under the applied load.
Because children’s bones have different biomechanical
qualities from adult bones, the patterns of failure are different. Children’s bones may bend and buckle rather than
breaking cleanly [Fig. 44.5]. Plastic bowing, buckle
fractures and greenstick fractures are all incomplete
fractures frequently seen in children but not in adults.
Children’s fractures heal more quickly than adult fractures,
and recovery of function is also faster and
complete. Children’s fractures are subject to a process of
remodelling during further growth by which residual
deformity may correct and function improve. Remodelling
is faster and more complete in younger children and for
fractures close to an active growth plate. Hence, residual
angulation or displacement of distal radial fractures in
younger children is well tolerated and there are few poor
results in the long term. Fractures of the femur in children
aged between 4 and 10 years are subject to ‘overgrowth’.
During the remodelling phase, which may last for more
than 12 months, the hyperaemia results in faster growth
of the injured limb compared with the uninjured limb.
During the first year after fracture, this may amount to
between 0.5 and 1.5 cm. With this in mind, femoral
fractures in this age group may be allowed to heal with up
to 1 cm of overlap or shortening, in the expectation that
overgrowth will tend to make up the deficit and equalise
the length of the lower limbs [Fig.44.6].
In children, most fractures are isolated injuries caused
by indirect forces:
• In the upper limb, a fall on the outstretched hand
• In the lower limb, a twisting injury, for example, roller
skating
These are usually closed injuries, with a good prognosis.
A small percentage of injuries are caused by direct violence, usually road trauma. These injuries are more likely to
be multiple, severely displaced, open or compound, and
have associated injuries to the head, spinal cord or abdomen.
Fractures in children are treated in many ways,
including cast immobilisation [Fig. 44.7], traction,
generally more
internal
management is based on an understanding of the risks
and benefits of each type of treatment, with safety, efficacy and convenience being the most important factors.
fixation and external fixation. The choice of
Upper limb fractures
Fractures occur most frequently at the ends of the long
bones but may be seen in the midshaft. The area next to
the growth plate, the metaphysis, is especially vulnerable. In the upper limb, the most common injuries are
fractures of the distal radial metaphysis, the diaphyses of
the radius and ulna, and fractures around the elbow.
Most fractures of the radius and ulna are managed by
closed reduction and cast immobilisation for about 6
weeks.
Elbow fractures in children are common; there are
many types, and a variety of management strategies are
required. An accurate diagnosis is required which in
turn requires good quality anterior-posterior (AP) and
Figure 44.7 X-ray of cast immobilisation of a femoral fracture,
with acceptable overlap in good position.
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(a)
BOX 44.1 Features of arterial ischaemia in fractured limbs
1 Pain, severe and unremitting
2 Pallor of the digits with lack of capillary return
3 Paralysis with inability to move the digits
if full passive mobility produces pain, suspect ischaemia
4
Altered sensation
lateral x-rays, and a knowledge of the normal growth
patterns of the elbow.
The most common of the more serious injuries is the
supracondylar fracture of the distal humerus. This is a
transverse fracture of the distal humerus, just above
the growth plate, and is usually displaced backwards as
the result of a fall on the outstretched hand [Fig.44.8a].
The fracture displacement or subsequent swelling may
result in vascular problems in the forearm and hand
and Volkermann’s ischaemia. Nerve palsies are also
common. In the past, these fractures were usually
managed by reduction and casting with the elbow
flexed, but this increases the risk of Volkermann’s
ischaemia. The preferred management for displaced
supracondylar fractures is now closed reduction and
percutaneous fixation with Kirschner wires [Fig.44.8b,
Box44.1].
Displaced fractures of the lateral condylar physis are
Harris–Salter type 4 injuries and require open reduction
and internal fixation. Fractures of the radial neck can
usually be managed by closed reduction or an indirect
percutaneous reduction with a Kirschner wire.
(b)
Figure 44.8 (a) Supracondylar fracture of the humerus with
gross displacement: the neurovascular structures are at risk.
(b) The appearance after closed reduction and Kirschner
wirefixation.
The Harris–Salter classification
ofgrowth plate injuries
There are many classifications of growth plate injuries,
but that by Harris and Salter is the most popular and
useful [Fig.44.9]. The line of separation of the growth
plate is identified on good quality AP and lateral x-rays,
looking for both horizontal and vertical components.
Most injuries can be readily classified in one of the five
groups. Some complex injuries require further imaging
including CT scans or MRI.
Type 1 and 2 injuries are the most common and are
usually managed by closed reduction and cast immobilisation. Epiphyseal injuries heal very quickly and in
type1 and 2 injuries, the prognosis is usually good. In
type 3 and 4 injuries, the growth cartilage and articular
Chapter44: Orthopaedics in the Child 273
45
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1
Figure 44.9 The types of growth-plate injury, as classified by Salter and Harris.
23
cartilage are both disrupted. Precise reduction is
required (this usually means an open reduction) but
growth disturbance is still a possibility. Partial growth
arrest may cause a progressive angular deformity in
the limb; a complete arrest results in progressive
shortening.
Lower limb fractures
KEY POINTS
• In-toeing needs no treatment if symmetrical.
• Knock-knee deformity is common between 3 and 8 years
and usually needs no treatment.
• Custom-made orthotics are unnecessary in at foot.
• Night pains in legs need full history and physical examination
to exclude rare serious pathology and reassure parents.
• Fractures and epiphyseal injuries are much more common
than ‘sprains’ or ligamentous injuries.
Fractures of the femur and tibia are common and are
usually classified according to the position of the fracture in the diaphysis; for example, the upper, lower or
Further reading
middle third. Femoral fractures can be managed by a
wide variety of methods including traction, hip spica
casts, internal fixation and external fixation [Fig.44.6].
The method is chosen according to the age of the child,
the fracture type and displacement, and the experience and preference of the surgeon. Younger children
tolerate traction and casts very well. Open fractures
and those associated with head injuries, tibial fractures
and multiple injuries are better managed by internal
fixation. Flexible intramedullary nails are the most
widely used fixation devices. The time to healing is
closely related to age: 2–3 weeks in the first year of
life, 6–8 weeks in children and 8–12 weeks in teenagers. Remodelling and overgrowth have been referred
to earlier.
Tibial fractures are very common but are usuallymore
easily managed than femoral fractures. The majority are
treated by closed reduction and cast immobilisation for
6–10 weeks. Displaced diaphyseal fractures carry a risk
of compartment syndrome, and neurovascular monitoring is important for 48
h after injury. Tibial and
femoral fractures cause a prolonged period of limping in
most children because of weakness, stiffness and loss of
confidence. Time and reassurance of parents is of more
help than physiotherapy.
Baxter A, Dulberg C (1988) Growing pains in children. J Pediatr
Orthop 8: 402–406.
Beaty JH, Kasser JR (2010) The elbow: physeal fractures,
apophyseal injuries of the distal humeus, avascular necrosis
of the trochlea, and T-condylar fractures. In: Beaty JH, Kasser
JR (eds) Rockwood and Wilkins’ Fractures in Children, 7th Edn..
Lippincott Williams & Wilkins, Philadelphia, pp. 533–593.
Benson M, Fixsen J. Macnicol M, Parsch K (eds) (2009)
Children’s Orthopaedics and Fractures, 3rd Edn. Springer-Verlag,
London.
Charles YP, Diméglio A, Canavese F, Daures JP (2007) Skeletal
age assessment from the olecranon for idiopathic scoliosis at
Risser Grade 0. J Bone Joint Surg 89-Am: 2737–2744.
Developmental Dysplasia of the Hip. www.rch.org.au/ortho/
education-training/developmental-dysplasia-of-the-hip-DDH-
educational-resource/
Fracture module. www.rch.org.au/fracture-education/
Fracture guidelines. www.rch.org.au/clinicalguide/fractures/
Glasgow JFT, Graham HK (1997) Management of Injuries in
Children. BMJ Publishing Group, London.
Griffin PP, Wheelhouse WW, Shiavi R, Bass W (1997) Habitual
toe walkers. A clinical and EMG gait analysis. J Bone Joint
Surgery 59-A: 97–101.
Hensinger RN (1986) Standards in Pediatric Orthopedics. Raven
Press, New York.
Jadodzinski NA, Kanwar R, Graham HK, Bache CE (2009)
Prospective evaluation of a shortened regimen of treatment
for acute osteomyelitis and septic arthritis in children. J Pediatr
Orthop 29: 518–525.
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Kling TF, Hensinger RN (1983) Angular and torsional defor-
mities of the limbs in children. Clin Orthop Relat Res 186:
136–142.
Mosca VS (2010) Flexible flatfoot in children and adolescents.
JChild Orthop 4: 107–121.
Oetgen ME, Peden S (2012) Idiopathic toe walking. J Am Acad
Orthop Surg 20: 292–300.
Pavone V, Lionetti E, Gargano V, Evola FR, Costarella L, Sessa G
(2011). Growing pains: a study of 30 cases and a review of
the literature. J Pediatr Orthop 31: 606–609.
Pirone AM, Graham HK, Krajbich JI (1988) The management
of displaced extension type supracondylar fractures of the
humerus in children. J Bone Joint Surg 70(A): 541–650.
Rang M, Wenger D (2005) The physis and skeletal injury. In:
Rang’s Children’s Fractures, 3rd Edn.. Lippincott, Williams &
Wilkins, Philadelphia, pp. 11–25.
Sass P, Hassan G (2003) Lower extremity abnormalities in chil-
dren. Am Fam Phys 68: 461–468.
Steele JA, Graham HK (1992) Angulated radial neck fractures
in children, a prospective study of percutaneous reduction.
JBone Joint Surg 74-B: 760–764.
Stevens P (2007) Guided growth for singular correction: a pre-
liminary series using a tension band plate. J Pediatr Orthop 27:
253–259.
Wenger D, Maudlin D, Speck G, Morgan D, Leiber R (1989)
Corrective shoes and inserts as treatment for flexible flat
feet in infants and children. J Bone Joint Surgery 71-A:
800–810.
Williams PF, Cole WG (eds) (1991) Orthopaedic Management in
Childhood, 2nd Edn. Chapman & Hall, London.
Xian CJ, Foster B (2010) The biologic aspects of children’s
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Fractures in Children, 7th Edn. Lippincott Williams & Wilkins,
Philadelphia, pp. 18–44.
CHAPTER45
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Orthopaedics in the Teenager
CASE 1
A 12-year-old girl was on holidays with her family. When she
was on the beach in her swimsuit, her mother noticed that her
shoulders were uneven and when she bent forwards the ribs on
the right side were prominent. Although she had no pain, she
agreed to go for an x-ray of her back.
Q 1.1
What is the diagnosis?
What did the x-ray show?
Q 1.2
Q 1.3
What is the management?
CASE 2
A 14-year-old boy attended the emergency department for
the third time in 6 weeks complaining of pain in his left knee,
associated with limping. Symptoms were worse after basketball
and relieved by rest. Blood tests and x-rays of the knee were normal
and a diagnosis of sprained knee ligaments had been made. He
had been prescribed anti-inammatory medication and a knee
brace. On this occasion, it was noted that his left hip lacked internal
rotation and that the hip went into external rotation during exion.
Q 2.1
What is the diagnosis?
What investigations are appropriate?
Q 2.2
What is the management?
Q 2.3
The teenage years encompass the final period of skeletal
growth leading to the closure of the growth plates. The
adolescent growth spurt is relatively short but intense, a
time of rapid growth in the length of long bones and
remodelling of the skeleton to meet the needs of the
young adult.
Evaluating musculoskeletal symptoms in teenagers
can be difficult. Pain may be referred to the lower
limbs from the back and hip pathology frequently
presents with knee pain. Teenagers may conceal symptoms and signs from parents. A scoliosis may reach an
advanced degree of deformity before being noticed by
parents.
CASE 3
Sue, a 14-year-old girl, presents with painful knees. There has
been pain in the right knee, then the left and currently both are
sore. She has been seeing a physiotherapist for over a year with
similar symptoms, including pain, giving way and clicking. Many
sets of x-rays had been taken and were reported as normal.
Q 3.1
What is the diagnosis?
What investigations are appropriate?
Q 3.2
Q 3.3
What is the management?
CASE 4
Mary, a 13-year-old girl, complains of pain in her right knee for
the past 8 weeks. The pain has been mild and intermittent, but
has become more constant, keeping her awake at night. She had
physiotherapy for a pulled muscle with some temporary benet.
She agreed to her mother’s request to see her general practitioner
after she noted a lump on the inner aspect of her thigh, just
above the knee.
Q 4.1
What is the differential diagnosis?
What investigations are needed?
Q 4.2
What is the management?
Q 4.3
Scoliosis
Scoliosis means a lateral curvature of the spine and
may be classified as structural or non-structural. Nonstructural curves have a cause outside the spine, the most
common being a difference in leg lengths. Structural scoliosis is a complex, three-dimensional deformity of the
spine, in which a rotational deformity is an important
component [Fig.45.1]. Idiopathic adolescent scoliosis is
equally common in both sexes (minor curves are found
in up to 4% of the population), but far more girls than
boys come to surgery because their curves are more likely
to progress. There is often a family history and curves
Jones’ Clinical Paediatric Surgery, Seventh Edition. Edited by John M. Hutson, Michael O’Brien, Spencer W. Beasley,
Warwick J. Teague and Sebastian K. King.
© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.
275
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Figure 45.1 Scoliosis. There is a right thoracic scoliosis
producing prominence of the right scapula and ribs due to
rotation of the vertebral bodies. The left shoulder is lowered
and the left waist is increased. The deformity of the spine and
chest is more apparent on forward bending.
may progress rapidly during the adolescent growth spurt.
Scoliosis is recognised clinically by the ‘forward bend test’
and confirmed on x-ray. Curve progression should be
monitored clinically and by measuring directly from the
x-ray. Curves of less than 20° are unlikely to progress,
curves of between 20° and 40° may be controlled by bracing and curves of more than 40° may require surgical
correction by spinal instrumentation and fusion.
Slipped upper femoral epiphysis
Diagnoses such as ‘sprains’ and ‘pulled muscles’ can be
dangerous. They lack precision and are often incorrect,
a smokescreen for fuzzy thinking, wrong diagnoses and/
or incorrect treatment.
Figure 45.2 Slipped upper femoral epiphysis on x-ray.
There is only one growth plate which may fail under
normal physiological loads, the proximal femoral
growth plate. During the last 2 years of rapid growth
that lead up to the closure of the growth plate, the
upper femoral growth plate may slip, allowing posterior
displacement of the femoral head in relation to the shaft
[Fig.45.2]. This process may occur in normal teenagers,
but is more likely if the loads on the growth plate are
increased (e.g. in obesity) or the growth plate is weakened by endocrine disorders, radiation or renal disease.
The time frame of the slipping dictates the clinical
presentation. If the slip is acute (or unstable), the
adolescent will have severe pain in the hip, will be
unable to walk and all movements of the hip will be
grossly restricted. The x-ray appearances are usually
easily recognised and ultrasonography of the hip will
usually show a haemarthrosis, as well as the acute slip.
However, if the slipping occurs gradually over a period
of many weeks, the presentation can be much more
difficult to recognise. The pain, which may be mild and
intermittent, is often felt mainly or only in the knee.
The adolescent can walk, but there may be an intermittent limp. There is usually a good range of hip motion
except internal rotation, which is lost or restricted early
in the slipping process, and eventually there will be a
characteristic sign whereby the hip rolls into external
rotation when it is flexed. Early chronic slips are often
difficult to recognise on x-ray and the lateral view is the
most sensitive projection. Delay in diagnosis of chronic
slips is frequent because of failure to consider that knee
pain may be referred from the hip or because a lateral
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