Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

@xirurgi_2025 - 1281 - файл

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

3 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 4950 / 5050

CHAPTER 12 Paediatric surgery

452

Solid tumours of childhood

Neuroblastoma

• Commonest solid abdominal tumour of childhood.

• Spectrum of tumours derived from neuroblasts found in the adrenal

gland, along the sympathetic chain, or extra-adrenal sympathetic tissues.

• Aggressive tumour with early spread to lymph glands, liver, bone

(cortex or marrow), orbits, and skin.

• Presents as painless large, abdominal mass in children <2y.

• May present as weight loss, hypertension, or metastatic disease.

• Urinary HMMA, HVA elevated.

• CT scan. Optimal investigation for suspected neuroblastoma.

• Treatment by combination of chemotherapy, surgery, and

radiotherapy.

• Survival of between 30 and 90%, depending on the site and stage

at presentation.

Nephroblastoma (Wilms’ tumour) of kidney

• Fast-growing tumour of the kidney.

• Ranges from benign mesoblastic nephroma of infancy to poorly

differentiated, malignant nephroblastoma in the older child.

• Malignant tumours frequently metastasize to regional lymph nodes,

liver, and lungs.

• Usually presents as a large, relatively painless abdominal mass in an

otherwise well child.

• Treatment by combination of chemotherapy, surgery, and radiotherapy

according to histology and spread at diagnosis.

• 5y survival:

Early stage, 90%.• Disseminated disease, 30%.•

Rhabdomyosarcoma

• Tumour of striated muscle origin from the bladder, vagina, prostate,

parameningeal tissue, and limbs.

• Haematuria, vaginal bleeding, and the appearance of grape-like cysts

(sarcoma botryoides) at the vaginal introitus.

• Variable histology (embryonal is most favourable), which determines

the prognosis.

• Survival of up to 70% from surgery and chemotherapy.

Hepatoblastoma

• This presents as a right hypochondrial mass extending across the

midline.

• Chemotherapy may render initially inoperable tumours resectable.

• Depending on staging, size, and histology, survival of up to 70% is

possible.

This page intentionally left blank

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

CHAPTER 12 Paediatric surgery

454

Neck swellings

Key facts

• Childhood neck lumps may be due to embryological abnormalities as

well as the same spectrum of conditions in adults (b pp. 222–226).

• Embryological abnormalities may relate to:

Descent of the thyroid from the foramen caecum of the tongue • l thyroglossal cysts (b p. 222). Formation of 2nd, 3rd, and 4th branchial arches and clefts • l branchial cysts (b p. 224). Formation of lymphatic vessels and veins • l cystic hygroma and cavernous haemangiomata.

• 2 Lymphadenopathy is very common in children, but typically ‘waxes

and wanes’.

• 3 If lymphadenopathy persists for longer than 2 months and

measures >2cm diameter, it should be biopsied.

Causes and clinicopathological features

Thyroglossal cyst (b p. 222). Branchial cysts (b p. 224).

Lymphadenopathy

• The neck contains large numbers of lymph glands draining areas of

potential infection in the mouth, nose, fauces, and ears.

• Common causes of lymphadenopathy include upper respiratory tract

infection, middle ear infections, tonsillitis, parotitis, dental abscess, atypical mycobacterial infection.

• Malignant lymphadenopathy is much less common.

May be primary lymphoma.• Secondary deposits, e.g. from neuroblastoma.•

Salivary gland swellings

• May be due to duct obstruction (stones or duct stenosis), infection

(mumps), autoimmune disorders (recurrent parotitis), neoplasia (adenoma).

• Commonest in the submandibular, sublingual, and parotid glands.

Skin lesions

• Dermoid cysts. Usually in the midline above the hyoid bone and are

rarely infected.

• Sebaceous cysts. Epidermal origin with a small central punctum; may

occur anywhere, but most commonly on the scalp or back of the neck.

Lymphovascular lesions

• Haemangiomas. Can be mixed capillary or cavernous haemangiomas or

haemangioendotheliomas within the neck and parotid area; may grow rapidly in size and lead to high output cardiac failure or even carotid steal syndrome.

• Cystic hygroma (lymphangioma). Commonly in the posterior triangle of

the neck.

NECK SWELLINGS

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Treatment

• Excision of dermoid cysts, sebaceous cysts, thyroglossal cysts, thyroid

neoplasms, salivary gland enlargements, lymph gland enlargements (biopsy).

• Haemangioma. Supportive measures (intubation, steroids, interferon,

and emergency surgical intervention).

• Cystic hygroma. Sclerosant injection (OK 432—streptococcal

derivative), effective in lymphangiomas with few large cysts.

Differential diagnosis of neck lump

Neck lumps may be lateral or midline.

Lateral

• Lymph node

• Branchial sinuses and cyst

• Cystic hygroma

• Sternomastoid tumour

Midline

• Submental lymph nodes

• Thyroglossal cyst

• Thyroid swelling

• Dermoid cyst

• Haemangioma

• Lymphangioma

• Submandibular gland

• Parotid gland

• Neoplasm

Neck swellings by cause

Congenital

• Thyroglossal cysts

• Branchial cyst

• Cystic hygroma

Acquired

• Reactive lymphadenopathy

• Infective lymphadenopathy

• Secondary tumour deposits

• Haemangioma

• Dermoid cyst

455

Anatomy related to neck lump surgery

• Incisions should be parallel with skin creases (Langer’s lines).

• Subcutaneous closure should be meticulous (e.g. removable 4/0,

5/0, or 6/0 continuous subcuticular monoﬁ lament).

• Facial nerve. Passes between the two lobes of parotid gland.

• Lingual nerve. Swerves around submandibular duct.

• Thoracic duct. Enters junction of left subclavian and jugular veins.

This page intentionally left blank

Chapter 13

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Paediatric orthopaedic

Developmental dysplasia of the hip (DDH) 458 Slipped upper femoral epiphysis (SUFE) 460 The limping child 462 The child with a fracture 464 Non-accidental injury (NAI) 466 Legg–Calvé–Perthes disease 468 Motor development 470 Club foot or congenital talipes equinovarus (CTEV) 471 Flat feet (pes planus) 472 The osteochondritides 474

457

CHAPTER 13 Paediatric orthopaedic

458

Developmental dysplasia of the hip (DDH)

DDH covers a spectrum of abnormalities from a mildly underdeveloped stable hip to well-established dislocation and/or acetabular dysplasia in the older child. The incidence is 1–2 per 1000 newborns in the UK. It is bilateral in 20%. It was previously called congenital dysplasia of the hip (CDH), but as it may also be acquired after birth, the term was changed. Early detection is important.

Risk factors

• Family history. First-degree relative.

• Breech presentation at or after 36 weeks of gestation.

• Foot abnormalities. Congenital talipes calcaneovalgus and metatarsus

adductus.

• Oligohydramnios.

• Children with syndromes.

• Torticollis.

Clinical features

• Barlow test (dislocatable hip). It tests if a hip is unstable. Take the baby’s

leg between your thumb and index ﬁ nger and place your other ﬁ ngers onto the buttock. Flex and adduct the hip. Posterior-directed force is applied in line with the shaft of the femur. In case of instability, the femoral head then subluxes or dislocates which you can palpate in the buttock.

• Ortolani Sign (dislocated hip). Now abduct the leg. If the hip is

dislocated and reducible, you will feel the femoral head moving into the joint. This often does not produce a palpable clunk.

• Irreducible hip.

Shortened leg.• Limited hip abduction.• Asymmetry of skin creases can be present; many children with • normal hips have asymmetry of thigh and buttock skin creases.

Abnormal ﬁ ndings can prove easy to miss if the dislocations are bilateral.

Screening

All children with risk factors and an abnormal neonatal clinical hip examination have a hip ultrasound. The majority of hips are fully developed at full term plus 6 weeks. Therefore, the ultrasounds of those children with risk factors, but normal clinical ﬁ ndings, are done at that point. Those children with obvious clinical abnormalities on hip examination have the ultrasound done earlier.

Paton RW et al. reported in 2009 that there is no association between

postural and ﬁ xed talipes equinovarus and DDH. for non-paediatric orthopaedic surgeons to differentiate the different foot abnormalities, it is continued to scan the hips of children with club feet. Evidence shows that there is no advantage of universal baby hip screening over selective at risk screening.

Since it can be difﬁ cult

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Radiology

• Ultrasound is the investigation of choice. Baby hip ultrasound

was pioneered by Dr Graf from Austria. It is more accurate than radiographs. It visualizes the cartilage and allows dynamic testing of the hip joint. A Graf alpha angle of t60° is classed as normal.

• Radiographs are taken in children who present late, usually after the

age of 6 months.

Treatment

• 0–6 months of age. A Pavlik harness is applied. This is a soft harness

which ﬂ exes the hips and knees and directs the legs away from the body midline, thereby directing the femoral heads towards the hip joints. It allows limited hip movements. It is used until the hips normalize, which can take several months; it works 90% of times.

• 6–18 months. If the harness is unsuccessful or if a child is older than

6 months, they need a closed or open reduction of the hip joint and hip spica cast immobilization. Some children need a hip adductor tendon release in the groin and occasionally, a femoral osteotomy. A removable hip abduction brace is used after spica removal.

• t18 months. These children usually need an open reduction of the hip

joint, a hip adductor release, and a femoral ± pelvic osteotomy and hip spica immobilization. A hip abduction brace is normally not necessary after hip spica removal because of the improved bone alignment.

Reference

1 Paton RW, Srinivasan MS, Shah B, et al. (1999). Ultrasound screening for hips at risk in develop-

mental dysplasia: is it worth it? J Bone Joint Surg Br. 81: 255–8.

459

CHAPTER 13 Paediatric orthopaedic

460

Slipped upper femoral epiphysis (SUFE)

This is reported to have an incidence of 4–7 per 100 000 population. It is caused by the displacement of the femoral epiphysis (growth plate) in relation to the femoral neck. It is the commonest cause of a limp in a boy aged 12–14 or girl aged 11–13 (growth spurt at puberty). In this age group, it must be actively excluded in a limping child.

Risk factors

• Obesity. Classic is the limping, obese, 13y-old boy with knee pain.

• Rapid growth.

• Hormone disturbances. Hypothyroidism, renal rickets, pituitary

deﬁ ciency, growth hormone deﬁ ciency, and treatment with it).

• Male—♂:♀, 3:1.

• Side affected. Left > right.

Classiﬁ cation

This is usually classiﬁ ed by the ability to weight bear on presentation.

• ‘Unstable’ slips cannot walk due to pain and present like a fracture.

• Diagnosis is easy.

• ‘Stable’ slips can weight bear, though usually with a limp.

• Presentation is usually late, i.e. after 2–3 weeks of limping.

• Fifty per cent will have no pain; pain is commonly referred to the knee.

2 Any child with knee pain must have there hip examined.

A summary of presentation and prognosis can be seen below.

Clinical features

• There will be an obvious limp, usually in an overweight child,

commonly male.

• The affected limb will be shorter and lies in external rotation.

• Abduction is limited; when the hip is ﬂ exed, it will rotate externally—

this sign is almost diagnostic of the condition.

Radiology

Anteroposterior and lateral views of BOTH hips should be insisted on. The slip is often easier to see on the lateral view. The slip is in an inferior and posterior direction (down and backwards). Widening of the physis may be a sign of impending slip (i.e. ‘pre-slip’).

• Klein’s line giving Trethowan’s sign. If you draw a line on the superior

aspect of the femoral neck (called), it should cut through the femoral head; if it does not, it is diagnostic of a SUFE (see Fig. 13.1).

Management

The acute slip (i.e. <3 weeks history) can be managed by gentle manipulation and cannulated screw ﬁ xation in the reduced position. This is controversial, however, as any manipulation may damage the already damaged epiphysis and possibly cause avascular necrosis.

Standard treatment is stopping the slip from worsening and the slip is

usually pinned in situ (where it is with no manipulation) with one cannulated screw percutaneously.

SLIPPED UPPER FEMORAL EPIPHYSIS (SUFE)

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 13.1 Normal (left) and Abnormal, i.e. SUFE (right) Klein’s lines.

Deformed epiphysis can remodel by up to 60*. Residual deformity can

be corrected via an osteotomy once the epiphysis has fused if there is a functional deﬁ cit.

The condition can be bilateral in some cases. This is much more likely if

there is an underlying endocrine disorder. Some surgeons advocate prophylactic pinning of the unaffected side, but this is controversial.

Complications

• Avascular necrosis of femoral head.

• Chondrolysis. Rapid progressive loss of cartilage; joint space narrowing

is seen on X-ray.

• Subtrochanteric fracture. If pins entry point placed too low.

• Late osteoarthritis. Estimated 10%.