PART COMMON ORTHOPAEDIC PROBLEMS

Transcription

1 PART 8 COMMON ORTHOPAEDIC PROBLEMS Ch008-F10280.indd 247 7/27/2007 5:34:31 PM

2 Ch008-F10280.indd 248 7/27/2007 5:34:31 PM

3 Common paediatric orthopaedic problems and fractures P. Cundy 8.1 Skeletal variations during growth Adult posture should not be used as a criterion for the proper posture in infancy and childhood. During development in childhood a number of different limb shapes (or postures) may be noted and these can cause parental anxiety. These transitory postures can be due to: intrauterine posture, sometimes described as packaging developmental variants i.e. not present at birth, but may appear during growth and then disappear spontaneously. These include the common conditions of bow legs, knock knees, flat feet and in-toeing. These conditions seldom require active treatment but parents do need informed reassurance, which must be based on accurate knowledge of the natural history of the variations of posture in infants and children. Intrauterine posture The position of the child before birth is normally one of flexion. The spine is flexed so that it forms a long curve with a concavity forward, the arms and legs are flexed, and the feet may assume a variety of postures. In the newborn the intrauterine posture can be readily reconstructed by folding the baby into his or her most comfortable position, and this may indicate any postural abnormality present. Two common foot postures are seen in newborns. Talipes calcaneovalgus Many babies are born with the foot turned upwards at the ankle so that the toes lie close to the front of the shin: this is known as talipes calcaneovalgus (Fig ). This posture can be corrected passively so that the foot can be brought down to a plantigrade position or even into equinus. The condition has a strong tendency to correct itself spontaneously over a period of 2 3 months. Postural talipes equinovarus Some babies are born with one or both feet in a position of plantar flexion at the ankles, and inversion of the remainder of the foot, so that the sole of the foot faces the opposite foot. This is postural talipes equinovarus and may be distinguished from true talipes equinovarus by the fact that the former condition is easily correctable, either actively by the baby s movement or passively by the attendant. The foot can be readily held in normal alignment to the leg or even in a position of calcaneovalgus, whereas in true congenital talipes equinovarus (club foot) the deformity is rigid. The fixed deformities of a true club foot require treatment by serial casting and usually surgery in the first 6 months of life. Developmental variants Many developmental variants are seen in early and later childhood and often cause concern for parents. Bow legs Bow legs (Fig ) are common up to 2 years of age: the parents will often be concerned that the legs are bowed and the feet turn in. The condition is not caused by bulky nappies, because the bowing is in the tibiae. It is a normal developmental process and does not require treatment apart from parental reassurance. If the bowing is in one leg only, you should investigate with plain X-rays to exclude pathological causes such as a bone dysplasia or growth abnormality. Knock knees A large proportion of the population between the ages of 2 and 7 years have knock knees (Fig ). This condition has a very strong tendency to correct itself by the age of 7 years and as a rule the only management necessary is parental reassurance that improvement will occur. There is a rare form of 249 Ch008-F10280.indd 249 7/27/2007 5:34:31 PM

4 8.1 COMMON ORTHOPAEDIC PROBLEMS Fig Calcaneovalgus foot in a newborn this will correct spontaneously. Fig A 5-year-old child with pronounced knock knees. is due to physiological joint laxity and requires no treatment. The clinician can show the parents how the hind foot straightens when the child stands up on high tiptoes. This is the tiptoe test, which also demonstrates development of the medial longitudinal arch (Fig ). 250 Fig Bow legs in a toddler: a normal phenomenon. knock knees that presents in obese children over the age of 12 years and which does require treatment. Rolling in of ankles Parents will frequently mention this, especially after it has been noticed by a concerned grandparent or shoe fitter. The rolling of the hind foot into valgus Flat feet Flat feet in children are a frequent cause for parental concern. Usually this concern is unwarranted and the child s foot is normal for age (Fig ). Often parents notice that their child s foot appears flat. Sometimes the attendant fitter at the shoe shop may comment on the shape of the child s foot. Children usually have low arches because they are loosejointed and flexible. The arch flattens when they are standing. However, the arch can be better seen when the feet are hanging free or the child stands on tiptoes (the tiptoe test, Fig ). When a child first learns to walk, the stance is usually wide to assist balance, and the feet roll. As the child grows and ankle muscles strengthen, the foot gradually develops its mature shape with some medial arch. Flat feet are common in preschoolers Ch008-F10280.indd 250 7/27/2007 5:34:31 PM

5 COMMON PAEDIATRIC ORTHOPAEDIC PROBLEMS AND FRACTURES 8.1 Fig If the arch appears when standing on tiptoe then the feet are fl exible. The fl at arch is of no signifi cance and requires no treatment apart from explanation. 1 year 5 years 10 years 40 years Fig Flexible fl at feet are normal in infants and children. The arch develops whether the child wears shoes or goes barefoot. but are present in fewer than 10% of teenagers. The final shape of the foot may also be influenced genetically, in that one or both parents may have low arches. When children start walking they do so on feet that appear flat, partly because there is true flatness of the medial longitudinal arch and partly because the arch is filled in by a fat pad. Between the ages of 2 and 8 years, parents are often concerned because a second ankle bone appears on the medial aspect of the foot. They are referring to prominence of the navicular bone, which is present in most children who have flat feet. Unless the prominence of this bone is causing symptoms, it can be ignored. Sometimes an accessory navicular bone (ossicle) can be seen on X-ray and this requires no treatment unless painful. If painful, the wearing of a soft off the shelf arch support for a year usually helps. Children with flat feet generally have some valgus deformity of the heel: when viewed from behind the heels do not point straight up and down, but tend to slope outwards and downwards. The heels will correct and even swing into varus during the tiptoe test. This seldom persists into adult life. During the first 7 or 8 years of life the majority of children develop a medial longitudinal arch but approximately 15% do not. Clearly, the results of any form of treatment for flat feet are going to be excellent, as some 85% will get better whether or not they are treated. Sometimes treatment with shoe inserts (orthotics) or other forms of arch supports/shoe modifications are recommended by therapists. These may satisfy concerned parents but do little, if anything, to correct the flat foot and certainly do not make an arch where one is not present. Most of the time orthotics such as these are not necessary for children. Other treatments, such as splints, massage or special shoes may be offered but there is little evidence that these interventions alter the foot for the better. Shoes The only essential is that children s shoes should be roomy enough. Shoes themselves are not necessary to promote normal foot growth and development; they are only worn for protection and need not be worn until activities demand this protection. Boots are no better than shoes, although parents may prefer boots for toddlers in that they are less likely to fall off or be taken off. It is not harmful to use hand down shoes in good condition from older children in the family provided they are roomy enough. There is no evidence that sandals, thongs or sneakers have any harmful influence on the feet. While wedging of the soles and heels has long been employed for in toeing and out toeing, such footwear modifications have no influence either on the gait itself or on the natural history. Thomas heels are of little or no value in the management of flat feet. If the child has excessive wear on the inner side of the sole of the shoes, advise parents to look for shoes that have a stiffer heel area. Some children with flexible flat feet are rather hard on their shoes and this can be dealt with by selecting shoes of stronger construction. This is usually much less expensive than elaborate and unnecessary orthotics. Accessory navicular bone The child with a prominent accessory navicular may have some temporary discomfort, which may be relieved by wearing arch supports for a period of a year or two. Frequently the ossicle either unites with the main navicular bone or just becomes asymptomatic. Excision of the accessory navicular bone is required only rarely. 251 Ch008-F10280.indd 251 7/27/2007 5:34:32 PM

6 8.1 COMMON ORTHOPAEDIC PROBLEMS Fig W sitting is easy for the child with inset hips. Fig Curly middle toes fl exor tenotomy is sometimes needed for severe cases. Curly middle toe Sometimes the third toe curls inwards under the second toe so that the second toe tends to lie above the level of the first and third toes. Parents generally notice the abnormal posture of the second toe, but it is the third toe that is the cause of the problem. This can be safely ignored until the child is at least 2 years old. Occasionally a flexor tenotomy is required and provides excellent correction (Fig ). 252 In-toe gait (pigeon toeing) In-toeing in childhood is common. It may appear worse when the child is running or tired. It does not cause arthritis or back problems later in life. It can be due to one or more of the following: inset hips internal torsion of the tibia metatarsus adductus. Inset hips (persistent femoral neck anteversion) have internal rotation in excess of the range of external rotation. It is more common in girls and the feet seem to fly out sideways when running. The pathology lies in the top of the femur where there is a normal twist of 30 at birth, which unwinds gradually by the age of 7 years. In severe cases, when there is a major cosmetic problem unresolved by about 10 years, derotation femoral osteotomy can be performed but this is rarely required. Children with inset hips commonly sit between their feet with their hips in full internal rotation, the knees flexed and the legs splayed outwards (the W position) (Fig ). This is the only way they can sit comfortably as they cannot externally rotate their hips sufficiently to sit in a cross-legged fashion. There Fig A 3-year-old child with metatarsus adductus. Note the metatarsals and toes curving inwards. is no evidence that this sitting posture should be discouraged in children and it is worthwhile remembering that it is almost unknown for an adult to present with a complaint of in-toeing. Internal tibial torsion (a twist in the shin bone) is usually due to intrauterine pressure and can persist up to the age of 3 years and then spontaneously corrects. Metatarsus adductus (Fig ) is a condition in which the feet are banana-shaped, with the convexity Practical points Bow legs and knock knees are common normal variants Flexible fl at feet are normal and need no treatment Examine the child with in-toe gait to decide cause Provide brochure information to reassure (see website links) Ch008-F10280.indd 252 7/27/2007 5:34:32 PM

7 COMMON PAEDIATRIC ORTHOPAEDIC PROBLEMS AND FRACTURES 8.1 of the banana outwards and the toes directed towards each other. This may be due to intrauterine pressure; however, if it persists it is called metatarsus adductus. It is passively correctable and slowly rights itself, especially after walking commences. Very rarely, manipulation and plaster immobilization is necessary. A Congenital abnormalities Developmental dysplasia of the hip This condition was previously called congenital dislocation of the hip (CDH); however, developmental dysplasia of the hip (DDH) is now the preferred term as it implies that some of these hip problems may develop after birth. DDH is the most common musculoskeletal abnormality in neonates. The incidence of this condition in Australia and North America is 7 per 1000 live births. In some regions of Europe it is more common. Clinical classifi cation DDH can be classified clinically as follows: stable subluxable dislocatable dislocated, reducible dislocated, irreducible teratological. Main risk factors Some of the important risk factors for DDH (with the degree of increased risk) are: breech presentation (10 ) female baby (4 ) oligohydramnios (4 ) big baby >4 kg (2 ) firstborn baby (2 ) family history. When diagnosed and treated from birth, it is possible to produce a normal hip joint after a few months treatment in an abduction splint. However, if the diagnosis is not made until after the child begins to walk, the treatment is long and tedious and often ends with an imperfect joint. Diagnosis in the newborn The Barlow and Ortolani tests are used for diagnosis (Fig ). Every baby should be examined for hip dislocation during the first day of life and again at discharge from the maternity ward, and at ages 6 weeks, B Fig A The Barlow test is positive if the hip can be manually dislocated. B The Ortolani test is positive if the hip is lying in a dislocated position and is manually reducible. 3 months, 6 months and 1 year. The baby must be relaxed for the examination to be meaningful. If the baby is crying, a bottle or pacifier is offered or the baby is examined later when relaxed. With the legs extended, any asymmetry of the legs or adductor creases is noted. The examiner then holds the leg to be examined (using the opposite hand to the side of the hip to be examined). With the knee flexed, the thumb is placed over the lesser trochanter and the middle finger over the greater trochanter. The pelvis is steadied by the other hand and the flexed thigh is abducted and adducted and any clunk or jerk is noted. It is very important to note that frequently a fine click can be felt in the hip joint without any laxity or abnormal movement. Sometimes the click comes from the knee joint. This is very common and is of no significance. Also, it is common in the first 2 or 3 days of life for the hip to be felt to subluxate smoothly without any clunk. This is especially felt in premature babies and requires repeated examination; frequently the hip becomes normal without treatment but it must be carefully followed. Radiography has no place in the diagnosis of developmental dysplasia of the hip in the neonatal period (Ch. 7.1). Ultrasound examination of the hips gives the clinician useful information as to the relationship of the femoral head to the acetabulum and the existence of any acetabular dysplasia during the first 6 months of life. Ultrasound has a high falsepositive rate in babies under 6 weeks of age and scans should only be performed under 6 weeks either to check whether a hip is in joint while in a splint or 253 Ch008-F10280.indd 253 7/27/2007 5:34:33 PM

8 8.1 COMMON ORTHOPAEDIC PROBLEMS to check a doubtful hip when the Barlow or Ortolani tests are equivocal. Over the age of 4 months the degree of ossification of the upper femur and acetabulum enables X-rays to be of value. If the dislocatable or dislocated hip is held in a flexed and abducted position for 8 12 weeks, it will usually develop normally. The Pavlik harness or Denis Browne splint is used to maintain this position. Subluxable hips can be observed with a later ultrasound after 6 weeks or radiograph at 4 months. The use of double nappies is not recommended. All abnormal or treated hips require follow-up until normal hip morphology is ascertained. Teratological hip If there is considerable restriction of abduction in flexion and the clunk sign cannot be elicited, it usually means that the hips are dislocated and irreducible. These hips require paediatric orthopaedic surgical assessment and probably operative reduction at a later date. Diagnosis in the older infant The Barlow and Ortolani tests become more difficult to elicit after 3 months of age. In the abnormal hip, a new sign of limited abduction appears due to tightness of the adductor tendons. This sign is not diagnostic but an X-ray is indicated when there is asymmetry in the range of the abduction of the hips or when the range of abduction of both hips is inappropriate for the age of the child. In the first year of life the range of abduction in flexion is usually ; this arc normally lessens with age. The physical signs of late presenting dislocation include: higher greater trochanter wide perineum asymmetric gluteal buttock crease short leg abnormal gait. If a dislocation presents after walking age, an open reduction operation is usually required and these hips are rarely normal, with an increased risk of early hip osteoarthritis. Hence early diagnosis and treatment of DDH is the best way to prevent hip arthritis. Congenital talipes equinovarus (congenital club foot) Congenital talipes equinovarus is the commonest congenital abnormality of the foot, occurring in about 1 per 1000 live births. The male:female ratio is 2:1. The condition is bilateral in 40% of cases and there is a 2% chance of a subsequent child being affected if there is a positive family history. The deformity is a combination of: equinus of the hind foot varus of the hind foot adductus of the midfoot cavus of the medial arch. The degree of each deformity is variable but all are rigid and are incapable of being fully corrected manually (Fig ). This is distinct from the postural club foot, which is due to intrauterine pressure and is fully passively correctable and resolves without treatment, as described above. Club feet should start treatment in the first week of life. Treatment involves serial plaster casting for 6 12 weeks, and surgical intervention is usually required at 3 6 months of age, with a posterior or posteromedial release of tendons and joints. Congenital muscular torticollis Torticollis usually presents in the first few months of life when some tilt of the head and limited lateral flexion is noted. Sometimes it can remain undetected for 1 2 years. The head is held with a lateral flexion toward the shoulder and with rotation of the face towards the opposite side. The face on that side is smaller and the eye is lower on the side of the tight sternomastoid. Most patients will have presented Practical points 254 All babies should be assumed to have dislocated hips until proven otherwise Re-examine babies hips at every well-baby check If in doubt, do an ultrasound when 6 weeks of age Ensure that the sonographer is experienced in babies hips Fig Club foot deformity is rigid and cannot be passively corrected. Ch008-F10280.indd 254 7/27/2007 5:34:33 PM

9 COMMON PAEDIATRIC ORTHOPAEDIC PROBLEMS AND FRACTURES 8.1 in the first few months of life with a sternomastoid tumour; that is, a palpable lump in the middle of the sternomastoid muscle. The cause of this condition is unknown. Treatment in the first 6 months of life with a stretching programme supervised by a physiotherapist is usually effective, with full resolution. If the condition does not resolve then surgical correction at 2 4 years of age is required. At operation, the muscle is divided transversely and the corrected position maintained by the use of a collar. Alexander the Great (354 BC) is reported to have had this condition, with statues showing a persistent head tilt. Trigger thumb This presents with the parents suddenly noticing that their 1 3-year-old child has a bent thumb. At this age children start to handle objects and the thumb deformity becomes obvious. The thumb is bent about 30 at the interphalangeal joint and cannot be passively straightened. It is due to a constriction in the flexor tendon sheath and a nodule on the tendon itself. The cause is unknown and the treatment is surgical release of the tendon sheath under general anaesthesia. Surgery should be performed around the age of 2 years to prevent permanent joint changes. Congenital: vertebral anomalies are responsible for the curvature. Usually the deformity is minor and may be present at birth or develop during growth. In only 5% is the deformity progressive Neuromuscular: such as Duchenne muscular dystrophy, cerebral palsy or spina bifida Idiopathic: this is usually seen as adolescent idiopathic scoliosis. Idiopathic scoliosis can be seen in younger children as: infantile idiopathic scoliosis: most commonly seen in males and may be seen in association with congenital dislocation of the hip and other congenital anomalies. The natural history is for the curve to resolve in a high proportion of cases juvenile idiopathic scoliosis: a curve in children between the age of 3 years and the onset of puberty; it is uncommon. Adolescent idiopathic scoliosis Some 90% of cases occur in girls and the scoliosis progresses during the rapid growth spurt years. For diagnosis, the child must remove all clothing above the waist and stand with the back facing the examiner (Fig ). In all but very minor curves the deformity will be readily apparent. Signs to look for are: Scoliosis Scoliosis (lateral curvature of the spine) is most commonly seen in its adolescent idiopathic form (Fig ). However, there are other forms of scoliosis. The common ones are: T4 L1 Fig Adolescent idiopathic scoliosis; the curve is usually convex to the right side. Fig Adolescent scoliosis in a male; 90% occur in females. 255 Ch008-F10280.indd 255 7/27/2007 5:34:33 PM

10 8.1 COMMON ORTHOPAEDIC PROBLEMS age, the site of the lesion, its blood supply and perhaps the method of treatment. Any bone having a cartilaginous area at the site of either the primary or secondary centre of ossification may be affected. The aetiology is uncertain. The common osteochondroses are: Sever condition of the heel: years Osgood Schlatter condition of the tibial tubercle: years Chondromalacia patellae: years Slipped capital femoral epiphysis of the hip: years Scheuermann condition of the thoracic spine: years 256 Fig On fl exion, a rib hump becomes readily visible. uneven shoulders waist (flank) asymmetry a unilateral rib prominence when the child bends forward (Fig ). If the curve disappears completely when the child bends forward, it can be labelled postural and treatment is not required. Should a rib hump become visible (due to rotation of the vertebrae and consequent rib deformity; Fig ) the curve is labelled structural. There are three main treatment options: observation for curves less than 20 bracing for curves surgery for curves greater than 40. These are broad guidelines only. Larger curves may not be treated if proven to be non-progressive in a skeletally mature patient. Several studies have investigated the role of exercises in improving the curve or preventing progression but there is no evidence that exercises or physiotherapy/chiropractic treatments alter the natural history of the curve. Osteochondroses (osteochondritis) These conditions involve the epiphysis. The pathology consists of localized areas of ischaemic bone necrosis and sometimes oedema of adjacent soft tissues. The tendency is for healing to occur but this is dependent on a number of factors, which include Sever condition This is an apophysitis of the os calcis (heel) bone where the tendo achillis attaches. It is seen in children aged between 10 and 12 years. It resolves over 12 months and is best treated by reassurance, calf stretches and sometimes a simple rubber heel raise. Sport is allowed within the child s level of comfort. Osgood Schlatter condition This is an apophysitis of the tibial tubercle and presents with pain and swelling (Fig ). Children notice the pain and then an adult sees the swelling and can be concerned about a sinister cause such as malignancy. The common age of presentation is years and the natural history is resolution over a month period. Warn the parents that a lump will remain permanently but that it will be smaller than when first seen. Normal activities within the limits of the child s comfort are allowed. The tibial tubercle does not detach or pull off. Radiographs are not necessary for diagnosis. Simple measures such as quadriceps stretches and massage with a liniment can provide some symptomatic relief. Rarely, a small loose ossicle remains and can be excised after the child reaches 15 years. Chondromalacia patellae This condition has a number of other names, including: anterior knee pain lateral pressure syndrome maltracking of the patella. It is particularly common over the age of 10 years. It is characterized by pain in the knee after activities that involve flexing the knee and quadriceps contraction. The child complains of aching around the patella during or especially after exercise. Stairs pre- Ch008-F10280.indd 256 7/27/2007 5:34:33 PM

11 COMMON PAEDIATRIC ORTHOPAEDIC PROBLEMS AND FRACTURES 8.1 Fig Slipped capital femoral epiphysis often presents with thigh or knee pain always exclude hip pathology when a child presents with knee/thigh pain. Fig Osgood Schlatter condition presents with painful enlarged tibial tubercles. cipitate discomfort, particularly walking downstairs. It is more common in adolescent females, both in those who enjoy sport and those who wish to avoid physical education lessons at school. Clinically there is little to find, although occasionally there is some patellofemoral crepitus and rarely an effusion in the knee. Ensure that the hips are normal and that the symptoms do not relate to a slipped hip. The diagnosis is based upon obtaining the relevant history. Some children are point tender at the inferior pole of patella (apophysis) and have a condition called jumper s knee. Treatment is massage with anti-inflammatory gels, quadriceps stretches and the expectation that symptoms will resolve over 18 months. Treatment involves education of the child and concerned parents (explain that the back of the knee cap is soft and will toughen up with time), some limitation of flexed knee/jumping activities, quadriceps stretches, elastic knee support and tincture of time. Frequently, children tolerate their symptoms and continue with their sport. The natural history suggests spontaneous resolution of symptoms over 1 2 years in 90% of patients. Slipped capital femoral epiphysis This is primarily a disorder of adolescents between the ages of 10 and 15 years. Approximately 40% of cases are bilateral. Its aetiology is unknown but recent reports suggest that hormonal factors may be of importance. Most cases present with pain and limp; pain is often referred to the knee and it is important to consider a hip radiograph when children present with distal thigh or knee pain. Types of slip: Acute: the child feels the hip collapse and is unable to walk. This is uncommon and needs urgent treatment Acute on chronic: the child has months of discomfort and then a worsening over a few weeks with a pronounced limp Chronic: many months of thigh ache and a mild limp. Examination reveals limited internal rotation of the hip compared with the other side and some joint irritability. The diagnosis is confirmed radiologically, especially with a frog lateral view (Fig ). All cases of slipped capital femoral epiphysis require surgery with screw fixation across the physis to prevent further slip. Practical points Knee/distal thigh pain often comes from the hip Always think of a slipped hip in adolescents with a limp Know the various apophysitis pains in children Anterior knee pain is common in teenagers 257 Ch008-F10280.indd 257 7/27/2007 5:34:34 PM

12 8.1 COMMON ORTHOPAEDIC PROBLEMS 258 Scheuermann condition The epiphyseal plates of the vertebral bodies are involved. Usually it is seen in the thoracic vertebrae but occasionally in the lumbar spine. Occurrences are almost always in the adolescent. Usually, children present in early adolescence because of pain or an increase in the normal thoracic kyphosis, so that the child appears round-shouldered. Most merely require observation, encouragement to exercise and stand straight and to be instructed in exercises by a physiotherapist. Some progress rapidly and require management in a brace. Rarely is surgery required. The condition is frequently overdiagnosed in radiology reports and causes anxiety in families, espe cially when the radiological changes are described as Scheuermann s disease. The term condition is preferred. Injuries in infancy and childhood Children are susceptible to injury because of their carefree play habits, and skeletal injuries are common. For practical purposes, sprains do not occur in children: children break bones and adults tear ligaments. Post-trauma pain, swelling and loss of function are nearly always the result of a fracture or growth plate separation; therefore X-rays are obligatory. Dislocations are rare in childhood, although shoulder and patella dislocations are seen in adolescents. The type of injury that may produce dislocation of an adult joint usually gives rise to a fracture or growth plate separation in a child. Fractures are the commonest type of skeletal injury in childhood; these generally unite in less than half the time the equivalent injury would take to heal in an adult, and non-union is almost unknown. Childhood fractures may unite in a position of deformity, with the deformity correcting itself spontaneously over the ensuing 6 12 months, especially if the fracture is near the ends of the bone where there is most growth. Some shortening of bones also can be expected to correct spontaneously following childhood fractures. Child abuse is an important cause of childhood injury; it is important because, if unrecognized, further abuse is likely to occur and might even be fatal. When assessing a child after trauma, ensure that you check the whole child, using the principles of emergency management of severe trauma (EMST), and look for hidden injuries. Clavicle fractures These are the most common fractures seen in children. The fracture is usually midshaft and of greenstick type. Complete fractures with overlap of the ends are seen in older children and unite well. It is important to warn the parents at the beginning that they must expect to see a large lump develop: this is healing callus, which will remodel over 6 12 months without any cosmetic or functional deficit. Treatment is with a triangular sling inside the clothes to support the elbow, regular analgesia and rest. The clavicle will start to join within a week and the sling can usually be discarded by 4 weeks. Forearm fractures Children s bones can break in several ways, namely: bend buckle greenstick complete, with/without displacement and overlap. Most forearm fractures are of the buckle or greenstick variety and if there is minimal tilt or deformity they can be treated in an above elbow cast for 5 weeks. It is important to do a check radiograph after 7 10 days to ensure that the fracture has not tilted more. If it has tilted to an unacceptable position, the fracture can still undergo a closed reduction before firm union occurs. Fractures with visible deformity or significant tilt/ displacement (Fig ) require closed reduction and a similar time of cast immobilization. Ensure that you complete and document a neurovascular examination of the limb initially. Provide the parents with written instructions for neurovascular observations at home and provide them with emergency contact details if excessive swelling or symptoms develop. Look for the five Ps: excessive Pain Paraesthesia (compression of the sensory nerves) Paleness of the fingers Plum-coloured (venous congestion) Pulseless. Approximately 30% of children s fractures involve the growth plate (physis). If the physis suffers permanent damage, the bone can end up: short (all physeal growth stops), or angulated (one side of the physis stops growing). The Salter Harris classification is used for growth plate fractures (Fig ). Type I is often seen in the distal fibula as the childhood equivalent of the adult ankle sprain. Type II is the commonest variety and frequent in the distal radius. Types III and IV have a much higher risk of growth disturbance and Ch008-F10280.indd 258 7/27/2007 5:34:34 PM

13 COMMON PAEDIATRIC ORTHOPAEDIC PROBLEMS AND FRACTURES 8.1 usually require accurate reduction and internal fixation to minimize the risk of growth arrest. Supracondylar fracture of the humerus This fracture is often seen in children of 4 10 years after a fall from a height, such as from monkey bars, or when running. The mechanism is usually hyperextension of the elbow joint with the olecranon acting as a fulcrum lever to cause the fracture. Neuropraxia of the radial, median, ulnar nerve is common. Occasionally displaced fractures cause damage to the brachial artery. Again, neurovascular assessment is mandatory. Minimally tilted fractures can be treated in a collar and cuff under the clothes for the first 2 weeks, then outside the clothes for a further 2 weeks. Warn the parents to expect elbow stiffness, especially loss of elbow extension for several months. Displaced fractures require accurate reduction to avoid later deformity. Often the fracture will be held with K wires, which are removed at 4 weeks (Fig ). Fig Forearm fractures usually have dorsal tilt. E E I M M E E III M M IV II Toddler fracture of the tibia This distal shaft fracture may not be visible on initial radiographs and often perplexes clinicians faced with a toddler who refuses to walk for days after a seemingly minor trauma. The fracture can be diagnosed clinically by twisting the good leg first and then noting the cry or facial expression when twisting the affected side. Warn the parents what you are going to do first! Treat the fracture in an above knee cast and allow weight bearing as the child dictates. Most will walk after 1 week in the cast and the cast can be removed at 3 weeks. Warn the parents to expect a limp for 1 2 months: the limp will resolve spontaneously. Practical points Fig Salter Harris fracture: type I, the fracture passes directly through the physis; type II, a corner of the metaphysis (M) is broken off; type III, the fracture passes through the physis and the epiphysis (E); type IV, the fracture passes through the epiphysis and the metaphysis, causing a high risk of growth arrest. Rules of 2 for fractures 2 views (anteroposterior and lateral X-ray) 2 joints (X-ray the joint above and joint below to exclude dislocation) 2 joints (immobilize the joint above and below the fracture in a cast) 2 times (ensure the fracture has not shifted after 1 week) 2 sides (you can X-ray the contralateral side for comparison if needed) 259 Ch008-F10280.indd 259 7/27/2007 5:34:34 PM

14 8.1 COMMON ORTHOPAEDIC PROBLEMS A Fig A Supracondylar fracture of the humerus may have a nerve injury. B Displaced fractures require reduction and K-wire fi xa t i o n. B Pulled elbow The patient is usually a child aged 1 4 years who has been pulled along or up by the hand or treated to a whizzy. The child presents with pseudo-paralysis of the upper limb with the limb held by the side with the elbow extended and pronated. (Note that most elbow fractures present differently, with the elbow flexed and held across the body.) The history is typical in all cases. The pathology is believed to be a minor stretch of the annular ligament around the radial head. It is treated by forced full flexion and simultaneous full supination of the elbow. Sometimes a satisfying click can be felt. A collar and cuff sling in flexion is worn overnight with the expectation of ready return to full function. Warn parents that it can recur and that it is best to avoid pulling on the hand. 260 Ch008-F10280.indd 260 7/27/2007 5:34:35 PM