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Chapter45: Orthopaedics in the Teenager 277

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hip x-ray is not done. Delay in diagnosis may result in continued slipping and a much worse prognosis. Such delays in diagnosis frequently lead to litigation.

Both types of slip require immediate operation. Chronic (stable) slips are pinned in situ to prevent progression and have a good outcome if the degree of slip is not severe. The management of acute (unstable) slips ismore controversial and the outcome is uncertain. Amajor operation to openly reduce the severe unstable slip as soon as the slip is recognised is increasingly widely used but only available in specialist centres. Open reduction certainly improves the shape of the proximal femur but unfortunately does not abolish the risk of avascular necrosis.

Anterior knee pain

Knee pain is very common in adolescents and there are many causes. Most knee disorders are self-limiting and are managed by advice and reassurance. However, knee pain may be the presenting symptom of a limb- and lifethreatening condition, such as an osteosarcoma. Not every patient with knee pain should have a bone scan or MRI, as the history and examination are the primary tools to distinguish the serious from the trivial.

Anterior knee pain is a common clinical syndrome in adolescents, especially girls, with up to 30% affected. Pain is usually intermittent, is located around or behind the patella and is made worse by exercise and relieved by rest and simple analgesics. It is often bilateral, but one side may be more symptomatic than the other.

Examination is usually unremarkable apart from patellar tenderness and crepitus. X-rays are normal but are done to exclude more serious pathology. Arthroscopic examination of the knee may reveal changes in the retropatellar cartilage, which are sometimes called chondromalacia. However, the relationship of these changes to pain is not clear. Some of the most painful knees are normal on arthroscopic examination, and the changes of chondromalacia may be present without pain. Anterior knee pain can be considered tobe an overuse syndrome affecting the immature retropatellar cartilage, which is ultimately benign and self-limiting. It does not lead to arthritis or any other sequelae in later life.

Management is conservative: explanation, education and simple measures to control symptoms, including

analgesics, restricting activities which provoke symptoms, hamstring stretching and quadriceps strengthening. Neither arthroscopic examination nor surgery should be advised routinely.

The differential diagnosis includes osteochondritis dissecans of the tibial tuberosity (Osgood–Schlatter’s disease), bipartite patella, meniscal tears, plica syndrome, patellar instability and referred pain from the hip.

Bone tumours

The principal symptoms of a bone tumour are pain and the presence of a mass or lump. Slow-growing bone tumours often present as a mass, with pain as a less prominent feature. The most common bone tumour is the benign osteocartilaginous exostosis, usually abbreviated to ‘exostosis’ [Fig.45.3]. Exostoses are benign bone tumours which are usually solitary and are found near

Figure 45.3 X-ray of exostosis of the distal femur.

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Figure 45.4 Solitary bone cyst of the humerus. Note the

fractures of the thinned cortex.

the ends of long bones because they originate from aberrant cartilage cells from the growth plate. Some children have multiple exostoses, and this may be inherited as anautosomal-dominant condition, ‘hereditary multiple exostoses’. The bony lumps are noticed incidentally or after minor trauma. They grow slowly until skeletal maturity or a little later. Clinically and radiologically they are benign in behaviour, although incomplete excision may lead to local recurrence. Excision is advised if the lumps are symptomatic or the diagnosis is in doubt.

A solitary bone cyst usually presents as a pathological fracture of the proximal humerus or femur [Fig. 45.4]. Often the fracture stimulates healing of this benign lesion.

Painful benign bone tumours include osteoid osteoma and osteoblastoma. These are small tumours which present with night pain, characteristically relieved by aspirin. Diagnosis may be delayed because the tumours are small and are not always easily demonstrated on x-ray. Excision is usually performed by CT guidance using a trocar passed percutaneously into the nidus.

Figure 45.5 Ewing’s sarcoma involving the proximal half of the

diaphysis of the femur, with layers of new bone and fusiform swelling of the soft tissue.

Malignant bone tumours usually present with welllocalised pain, which is progressive, disturbs sleep and is not easily or fully relieved by rest or analgesics. The rapidly growing ends of long bones are most likely to be affected, including around the knee (the distal femur and proximal tibia) and the proximal femur and the proximal humerus. The two most common primary malignancies of bone, osteosarcoma and Ewing’s sarcoma [Fig.45.5], are most common in childhood and adolescence.

Diagnosis and staging is achieved by imaging studies that may include plain x-rays, technetium bone scans, computed tomography (CT), MRI scans and positron emission tomography scans (PET scans) followed by biopsy, in all cases. Although there are features which suggest malignancy on x-ray (e.g. bone destruction by the lesion, a large soft tissue mass and a marked periosteal reaction), these features can be mimicked by benign bone tumours, bone dysplasias and infection.

The prognosis for saving both life and limb in adolescents with primary bone tumours has improved

Chapter45: Orthopaedics in the Teenager 279

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dramatically with limb salvage surgery and chemotherapy. The tumour must be completely excised with a margin of healthy tissue, and the limb reconstructed, whenever possible, using a variety of techniques including bone grafts (autografts and allografts) and endoprosthetic replacement. Chemotherapy is usually commenced after the diagnosis has been established by biopsy but before the tumour excision surgery.

KEY POINTS

• Scoliosis is common (4%) in both sexes, but is often more severe in girls.

• Structural scoliosis persists when ‘touching the toes’ (forward bend test).

• ‘Knee pain’ in adolescents is commonly referred from the hip (e.g. slipped upper femoral epiphysis).

• Pain around the patella is common in girls from overuse affecting immature retropatellar cartilage.

• A mass (+pain) in the limb needs urgent investigation for bone tumour.

Further reading

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-DDHeducational-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.

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.

JChild 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. JBone 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

fractures. In: Beaty JH, Kasser JR (eds) Rockwood and Wilkins’ Fractures in Children, 7th Edn. Lippincott Williams & Wilkins, Philadelphia, pp. 18–44.

CHAPTER46

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The Hand

CASE 1

A 3-year-old has a xed exion deformity at the interphalangeal joint of the thumb.

Q 1.1

What is the diagnosis? Is splinting indicated?

Q 1.2 Q 1.3

Is surgery required?

Reconstructive surgery of the hand in a child has a better prognosis than for similar conditions in adults. Injuries should be repaired immediately, while malformations are often corrected in the first year of life or at least prior to starting school. The stiffness that adults experience after upper limb surgery is seldom a problem. The hand needs to be protected, immobilised and maintained in an elevated position until sufficient healing has taken place to allow the child to play and use the hand without restriction. A plaster slab or cast must be applied in such a way that the child cannot easily remove it. It must be comfortable and immobilise the hand, the wrist and often the elbow in a safe position. In most cases, the tips of the digits should be able to be inspected to ensure that vascular compromise does not occur. Elevating the arm in a well-designed sling under the clothing is the best way of ensuring that the limb is protected. In a child, a plaster should be maintained for 2 weeks after simple suturing, 3 weeks after skin grafting (e.g. syndactyly release) and almost 4 weeks following tendon surgery. Ongoing protective splinting may then be required.

CASE 2

A 4-month-old child of a diabetic mother has weakness of the right arm. Hand movement has recovered following a difcult vaginal delivery. However, elbow exion and shoulder control have not yet appeared. Q 2.1 What are the diagnosis, cause (aetiology, pathology and

anatomy) and treatment?

Congenital anomalies

These are common and varied. A classification based on embryological aberrations is useful in describing and recording malformations [Box 46.1]. Unfortunately, many unrelated conditions, such as trigger thumb, syndactyly, clinodactyly and so on, are classified as a failure of differentiation. Anomalies may be confined to the hand or be a local manifestation of a generalised condition, such as arthrogryposis multiplex congenita. Some deformities, for example, certain forms of syndactyly, are strongly familial; others are sporadic, with no known cause. Other associated congenital conditions should be looked for. Some are potentially lethal, such as when radial club hand coexists with cardiac and haemopoietic abnormalities.

Management

A child with a hand anomaly (congenital difference) may have functional and/or cosmetic impairment. They will, however, learn to use it with dexterity, provided certain basic anatomical elements are present that provide

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.

280

BOX 46.1 Classification of malformations of the hand

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Failure of formation

• Transverse congenital amputations

• Phocomelia

• Radial club hand

• Cleft hand

Failure of differentiation

• Syndactyly

• Clinodactyly

• Camptodactyly

• Clasp thumb

Duplication

• Polydactyly

• Triphalangeal thumb

Overgrowth

• Giantism

• Macrodactyly

Undergrowth

• Hypoplasia

• Brachydactyly

• Symbrachydactyly

Constriction ring syndrome

• Intrauterine amputations

• Congenital constriction bands

• Acrosyndactyly

Congenital

• Skeletal abnormalities (achondroplasia)

rudimentary pinch and/or grasp. The psychological effects on the parents need to be managed.

Syndactyly

This affects 1 in 2000 births and may be incomplete or complete (to the fingertip) and simple or complex (fused bones). It may be part of a syndrome, such as the Poland or Apert syndrome. Family history is positive in up to 40% of cases; inheritance is dominant but there is reduced expression and penetrance. Early surgery (in the first 6 months) is indicated when border digits, particularly the thumb, are involved, leading to growth disturbance in digits of unequal length [Fig46.1].

Clasp thumb

This may be due to a congenital trigger thumb caused by a swelling within the flexor pollicis longus tendon impinging on the fibrous flexor sheath. Alternatively, it may represent a weakness in the extensor muscles, which can be improved by splinting initiated in the first month of life. A deficiency of skin on the palmer surface may be improved by splinting but may need correction using skin flaps or grafts.

Chapter46: The Hand 281

Figure 46.1 Syndactyly, complete and complex (fused) distal

phalanges between ring and middle fingers, with simple and almost complete syndactyly between the ring and little fingers.

Trigger thumb

Trigger thumb is a common and often bilateral abnormality. It is sometimes identified at birth but is usually found in children up to 5 years of age. There may be a family history of this condition. The primary lesion is thickening in the flexor tendon of the thumb associated with narrowing of the tendon sheath at the metacarpophalyngeal joint [Fig 46.2]. Once the affected digit is flexed, extension is restricted by impingement of the thickened tendon proximal to the narrowing. Usually, children present with fixed flexion deformities of the interphalangeal joint. Clinically, the thickening in the tendon can be palpated at the level of the metacarpal head in the palm. Treatment involves longitudinal incision of the tendon sheath to allow full excursion of the thickened tendon through the area of narrowing. Splinting is not effective.

Distal arthrogryposis

This condition, which may be inherited, is associated with skin deficiency, underdeveloped flexure creases and weakness associated with underdevelopment of the musculature. The thumbs may be clasped and the digits ulnar deviated. An intense programme of splintage, initiated in the neonatal period, produces quite dramatic improvements.

Camptodactyly

This condition affects 1 in 100 hands and causes a flexion contracture, particularly of the proximal interphalangeal joint of the little finger, and is due to an

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Figure 46.2 Right trigger thumb presenting as a fixed flexion

deformity.

thumbs is triphalangeal in which situation the condition is often bilateral and is inherited as an autosomal dominant condition. Ulnar (post-axial) polydactyly occurs in 1 in 300 in Africans, and in 1 in 3000 in Caucasians. This condition is often bilateral and inherited in an autosomal recessive pattern and may be part of a syndrome.

Symbrachydactyly

This is a sporadic unilateral condition with hypoplasia of the digits that are short and stiff (aplasia of bones and joints). In several cases, the digits are represented by soft tissue nubbins. Microsurgical transfer of toes can significantly improve function in some patients. Others may benefit from free grafting of toe proximal phalanges into redundant soft tissues in the first 2 years of life.

Obstetric brachial plexus palsy

This is due to a traction injury associated with a difficult delivery frequently in babies weighing in excess of 4 Injuries to the upper (C5, C6 upper (+middle) trunk of the brachial plexus are known as Erb’s palsy. These improve in 90% of cases. If there is no recovery after 3 months, particularly if all nerve roots are involved, then exploration and reconstruction with nerve grafts should be contemplated within the first year of life. The results of reconstruction are far better than those achieved in adults with brachial plexus trauma.

+ 7) nerve roots or the

kg.

imbalance of anomalous muscles, tendons and fascial structures. In severe cases, the joint becomes deformed. The results of surgery are frequently disappointing, but early aggressive splinting can be effective.

Clinodactyly

This condition affects 1 in 100 hands. Radial deviation, particularly of the little finger, is often due to a deltashaped middle phalanx associated with an anomalous C-shaped cartilage growth plate. Resection during childhood of the abnormal cartilage bridging the radial border of the phalanx can allow the finger to grow almost normally.

Polydactyly

Radial (preaxial) polydactyly involving the thumb occurs in 1 in 1000 births, particularly in Asia. This condition is sporadic and unilateral, except when one of the duplicated

Injuries to the hand

The repair of injuries to the hand differs little from that in adults, except that the results are generally better. Absorbable skin sutures should be used. Restoration of function is more rapid and more complete, and prolonged hand therapy is rarely necessary.

Failure to diagnose the extent of the injury when the child is first seen leads to unsatisfactory results and the need for later reconstruction. Subjective tests for nerve injuries are of little value, and cooperation during a detailed examination is unlikely. Injuries to tendons and nerves may be overlooked until loss of function is noted by parents, weeks or months later.

Awareness of the likelihood of these injuries associated with lacerations of the hand is essential. Abnormal posture of the fingers with the hand at rest suggests possible

Figure 46.3 Finger crushed in a door.

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tendon injury. Most injuries are cuts or crushing injuries. Any wound in a child that cannot be adequately examined, particularly if it overlies an important structure, must be explored under general anaesthesia. Any damage to tendons and nerves can be repaired primarily under ideal conditions. No matter how minor the injury is, a full plaster and sling should be used to promote uncomplicated healing.

Chapter46: The Hand 283

possible, a portion of the fingertip should be left exposed so that the circulation can be observed in the early postoperative period.

In slicing injuries with skin loss, some form of primary closure with a skin graft or local flap may be indicated. In younger children, the cross-sectional area of the fingertip is small, healing is rapid, and the results of healing by second intention can be excellent. Amputations at the level of the mid-distal phalanx can often be microsurgically replanted by anastomosis of preferably two blood vessels. More distal amputations or unreplantable crushed or avulsed parts may be, after defatting, replaced as a graft with moderate success.

KEY POINTS

• Congenital hand anomalies may be complex and require sophisticated reconstruction, but prognosis for function is good.

• A toddler with a xed exion deformity of the thumb has trigger thumb, needing surgery.

• Injuries to the hand need absorbable sutures and plaster immobilisation.

• Lacerations may need exploration under general anaesthetic (GA) to exclude tendon, nerve or vessel injury.

Injuries to fingertips

Crushing and slicing injuries with loss of a part of the fingertip are common in childhood [Fig.46.3]. In most crush injuries, the tissue remaining after judicious debridement and thorough lavage is viable. Any associated fracture of the distal phalanx should be reduced and in some cases pinned with a fine Kirschner wire. If