Paediatric Orthopaedics

» Orthopaedic

Osteochondroses

Osteochondroses is a condition that affects the epiphysis of bones. Pathology consists of localised area of ischaemic bone necrosis and oedema of adjacent soft tissue.

Remember Osteochondroses result in avascular necrosis of the epiphyseal bone, similar to Perthes disease, but less common. In general osteochondroses is more troublesome than serious.

Age effects usually 10-15 +/-

Clinical Feature Ache and muscle spasm +/- pain

Diagnosis Clinical + X-ray

Management Usually self-resolving (except slipped capital femoral epiphysis). Manage with streatching and NSAIDs

TYPES OF OSTEOCONDRITIDES
Osteochonroses	Features	Treatment
Scheuermann's Condition	Increased kyphoses and mid/low thoracic back pain	Observe, reassurance, encourage exercise and standing straight. Physiotherapy can help.
Chondromalacia patellae	Pain in the knee or distal thigh and a limp	Resolves within 1-2 years. Quadricep stretch recommended
Osgood Sclatter condition	Pain and swelling over tibial tuberosity exacerbated by jumping or diret pressure (kneeling)	Resolves within 1-1.5 years. Quadricep stretch recommended
Sever Condition	Posterior heel pain with activity and shoe wear	Resolves 1 year. Calf stretch recommended

Bow Legs vs. Knock knees

Normal development

Varus (birth-24 months)

Neutral (18-24 months)

Valgus (4-7 years)

Neutral/Slight Vulgus (7- adults)

	Knock Knees (Venu Valrum)	Bow Legs (Genu Varum)
Feature	Angular deformity at the knee where the apex of the deformity points toward the midline	Angular deformity at the knee where the apex of the deformity points away from the midline
Physiologic normal	Between ages 2-7 yo	<2 y0
Investigate	<2years or >7years. Unilateral an/or symptomatic	> 2 years. Unilateral, gait abnormalities
Pathological	Fractures especially physeal fractures, rickets, skeletal dysplasia, neoplasms	Blount disease (cartilage disorder), rickets, skeletal dysplasia, trauma, infection, neoplasm
Treatment	Surgery usually required or treatment for systemic conditions	Surgery usually required or treatment for systemic conditions

Painful/Problamtic Hips

Overview Hip pain and problems are common in children and are caused by a variety of things. Children may present with knee pain, but actually hip problem in origin. This is due to referred pain from the hip to the knee, which is common.

COMMON CAUES OF HIP PAIN IN CHILDREN
Condition	Features	Treatment
Transient synovitis of the hip	Cheif cause of hip pain in children. It is usually diagnosed by exclusion.	Observation, rest and analgesia
Perthes' disesae	3-11 yo. Osteochondritis of the femoral head, secondary to avascular necrosis of the developing femoral head. More common in males (4:1), bilateral 15%.	Monitor, early arthritis. Surgery is inevitable
Slipped capital femoral epiphysis	10-16 yo. Limp, usually in an overweight child (50%), commonly in males (3:1), bilateral 20%. The affected limb will be shorter and lies in external rotation. abduction is limited when hip is flexed and internally rotated	Surgery with screw fixation across the physis to prevent furtehr slip
Tubercular arthritis	2-5yo and the elderly. Rare condition. All hip movements cause pain and hip spasm	Rest. Anti-tuberculosis drugs. +/- Arthrodesis

Developmental Hip Dysplasia

More info on Congenital Hip Dysplasia

Idopathic scoliosis

Definition
Scoliosis: lateral curvature of the spine (>10º of curvature). Typically accompanied by a degree of spinal column rotation.
Idiopathic scoliosis: scoliosis with no definite etiology unlike neuromuscular, congenital, or syndromic types.

Overview 80-85% of cases occur in adolescents (children over 10 years of age)

Investigations

PA standing spine radiograph

Assess cobb angle (measure magnitude)
Assess skeletal maturity
Evaluate etiology: congenital, neuromuscular, idiopathic

Management depends on degree of severity

Observation: for patient with a Cobb angle of less than 20º
- Clinical examination and plain x-ray until skeletal maturity is reach or curve progresses to require bracing
Bracing: for curvature greater than 20º but less than 50º
- Generally a thoraco-lumbar- sacral orthosis is used for 13-18 hours each day
- If brace is worn less 13 - less successful outcome
Surgery: spinal fusion for curvature greater then 50º

Fractures

More to come

Remember Rules of 2's for fracture: 2 views: AP and lateral, 2 joints: above and below- exclude dislocation, 2 times: ensure fracture not shifted after 1 week, 2 sides: contralateral side for comparison