Pediatric Orthopedics

Pediatric Orthopedics

Jan Douwes Visser Pediatric Orthopedics Symptoms, Differential Diagnosis, Supplementary Assessment and Treatment

Jan Douwes Visser Groningen The Netherlands Word processing: Hendrika Schotanus and Yvonne Werink. Translation: Prof. Peter H. Robinson, MD., Ph.D. Drawings: Douwe Buiter ISBN 978-3-319-40176-8 DOI 10.1007/978-3-319-40178-2 ISBN 978-3-319-40178-2 (ebook) Library of Congress Control Number: 2016960534 Springer International Publishing 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface In practice, we do not tend to think in terms of differential diagnosis. We often consider the most probable diagnosis based on the patient s complaints. Only when the most probable diagnosis is not supported by physical examination and/or supplementary tests, do we further consider the other possibilities. In this book, Pediatric Orthopedics: Symptoms, Differential Diagnosis, Supplementary Assessment and Treatment, we are working towards a system for differential diagnosis based on the principal complaints and findings. In some cases there are more than one different kinds of complaint. As an example, in Osgood-Schlatter, there are complaints of pain and swelling. In those cases we consider the most preveland complaint which in Osgood- Schlatter is pain. In other cases, for instance a meniscal tear, there may be several individual complaints or a combination of these such as pain medially or laterally combined with limited extension and/or swelling. A torn meniscus appears in several differential diagnoses. A system has been established for every diagnosis as described here: (a) explanatory notes, (b) advice on supplementary tests, (c) advice as to which problems can be treated in primary care, (d) when to refer for secondary care treatment, and (e) what the options are for secondary care treatment. Generalized neurological disorders and neuromuscular disorders such as in spasticity, spina bifida, and acute traumatic lesions have been left out. There are many diverse treatment possibilities available. However, many pediatric orthopedic treatments are not evidence based or sometimes have a low or extremely low value from the literature. The author, advisers, and the publisher are not responsible for faults, omissions, or other implications as a result of the information given in this book. Application of the information given in this publication remains the responsibility of the clinician involved. Groningen, The Netherlands Jan Douwes Visser v

Acknowledgments Advisory Board Minne Heeg, M.D., Ph.D. Pediatric orthopedic surgeon Wilhelmina Hospital Assen, The Netherlands Sjoerd K. Bulstra, M.D., Ph.D. Professor and chairman Department of Orthopedic Surgery University Medical Center Groningen, The Netherlands Peter H. Robinson, M.D., Ph.D. Emeritus Professor of Plastic, Hand and Reconstructive Surgery University Medical Center Groningen, The Netherlands vii

Abbreviations ANF Antinuclear factor C Cervical CRP C-reactive protein CT Computed tomography ESR Erythrocyte sedimentation rate Hb Hemoglobin HLA Human leukocyte antigen Ht Hematocrit L Lumbar MRA Magnetic resonance arthrography MRI Magnetic resonance imaging n. Nerve NSAID Non-steroidal anti-inflammatory drugs S Sacral T Thoracal WBC count White blood cell count ix

Contents 1 Chest Wall........................................... 1 Chest Wall Deformity................................... 1 Chest Wall Pain........................................ 3 2 Neck................................................ 7 Neck Deformity....................................... 7 Neck Flexion Deformity............................... 7 Short Neck......................................... 7 Wry Neck.......................................... 9 Neck Pain............................................ 12 Acute Onset of a Painful Stiff and Possibly Wry Neck....... 12 Slow Onset Painful Stiff and Possibly Wry Neck............ 16 Painful Stiff and Possibly Wry Neck with Neurological Symptoms.......................................... 17 3 Back................................................ 21 Back Misalignment..................................... 21 Lateral Curvature(s) of the Back......................... 21 Abnormal Rounded Back.............................. 34 Abnormal Hollow Back............................... 41 Combined Curvatures................................. 45 Back Pain............................................ 45 Back Pain.......................................... 45 Back Pain Accompanied by Noctural Sweating............. 51 Back Pain with Neurological Symptoms.................. 52 4 Pelvis................................................ 57 Pelvic Pain........................................... 57 5 Shoulder............................................. 61 Shoulder Anomalies.................................... 61 Absent Collarbone................................... 61 Elevated Shoulder Blade............................... 61 Repeated Non Traumatic Shoulder Subluxation/ Dislocation......................................... 64 Repeated Traumatic Shoulder Subluxation/Dislocation....... 66 xi

xii Contents Shoulder Swelling...................................... 69 Collarbone Swelling in Newborns....................... 69 Swelling of the Shoulder Blade or Collarbone or Upper Arm....................................... 70 Shoulder Movement Limitations in Newborns................ 71 Paralysis of the Arm at Birth............................ 71 Shoulder Pain......................................... 74 Vague Shoulder Pain.................................. 74 Shoulder Pain After a Trivial Trauma..................... 75 Shoulder Pain in Overhead Athletes...................... 76 Painful Shoulder Movement Trajectory................... 76 Extremely Painful Immobile Shoulder.................... 77 6 Elbow and Forearm................................... 79 Elbow Misalignment.................................... 79 Crooked Elbow After a Fracture......................... 79 Repeated Elbow Subluxation/Dislocation................. 80 Elbow Swelling........................................ 81 Elbow Swelling on the Back or Front or Outer Side......... 81 Elbow and Forearm Movement Limitations.................. 82 Limited Extension and/or Flexion in the Elbow After a Fracture...................................... 82 Forearm Movement Limitation.......................... 83 Elbow Pain........................................... 84 Pain in the Outer Side of the Elbow After Arm Traction...... 84 Pain in the Outer Side of the Elbow...................... 86 Pain in the Inner Side of the Elbow...................... 87 Extremely Painful Immobile Elbow...................... 87 7 Wrist................................................ 91 Wrist Misalignment.................................... 91 Crooked Wrist....................................... 91 Wrist Swelling........................................ 92 Hard Swelling on the Back of the Wrist................... 92 Soft Swelling on the Back or Front of the Wrist............. 93 Wrist Pain............................................ 94 Pain on the Back of the Wrist........................... 94 Wrist Pain After a Trauma............................. 95 Severely Painful Immobile Wrist........................ 96 8 Hand................................................ 99 Thumb and Finger Abnormalities.......................... 99 Extra Thumb or Finger(s).............................. 99 Gigant Growth of Thumb and/or Finger(s)................. 102 Finger Misalignment.................................. 104 Short Finger........................................ 106 Fused Fingers and/or Thumb........................... 106 Thumb Misalignment................................. 107 Long Thumb........................................ 110 Short Thumb........................................ 111 Hand Swelling......................................... 114

Contents xiii 9 Hip................................................. 117 Hip Movement Limitations in Babies and Infants............. 117 Hip Movement Limitation Away from the Midline of the Body............................... 117 The Legs Can Not Be Approximated or with Pelvic Obliquity............................... 140 Waddling Gait......................................... 141 Snapping Hip......................................... 143 Hip Pain............................................. 146 Vague Pain Around Groin or Pelvis or Upper Leg........... 146 Hip Pain and Limited Internal Rotation................... 147 Hip Pain and Movement Limitation in All Directions........ 163 Hip Pain After a Trivial Trauma........................... 165 Extremely Painful Immobile Hip........................ 167 10 Knee................................................ 171 Knee Misalignment..................................... 171 Bowleg............................................ 171 Knock Knee........................................ 179 Overstretched Knee Deformity.......................... 186 Bent Knee Deformity................................. 192 Repeated Kneecap Subluxation/Dislocation................ 193 Knee Swelling......................................... 198 Swelling Just Above and/or Below the Knee............... 198 Swelling at the Back of the Knee........................ 199 Knee Movement Limitations............................. 200 Knee Stretch Limitation............................... 200 Knee Bending Limitation.............................. 206 Knee Effusion......................................... 206 Knee Effusion Within a Few Hours After Trauma........... 206 Knee Effusion Within 24 h After Trauma.................. 215 Knee Effusion Without a Preceding Trauma................ 216 Knee Effusion Skipping to Other Joints................... 220 Knee Effusion Accompanied by Nocturnal Sweating......... 221 Knee Pain............................................ 223 Vague Pain Just Above or Below the Knee................. 223 Pain in the Inner or Outer Side of the Knee................ 229 Pain at the Front of the Knee........................... 229 Thigh and Knee Pain.................................. 234 Extremely Painful Immobile Knee....................... 235 11 Lower Leg........................................... 237 Lower Leg Misalignment................................ 237 Forwards and Outwards Lower Leg Bowing............... 237 Backwards and Inwards Lower Leg Bowing............... 240 Lower Leg Pain........................................ 243 Severe Lower Leg Pain................................ 243 Pain in the Outer Side of the Lower Leg................... 244 Pain in the Inner Side of the Lower Leg................... 246

xiv Contents 12 Ankle............................................... 249 Ankle Misalignment.................................... 249 The Heel Progressively Deviates Outwards (Valgus Deformity)................................... 249 The Heel Progressively Deviates Inwards (Varus Deformity).................................... 252 Ankle Pain............................................ 253 Pain at the Front of the Ankle........................... 253 Pain at the Back of the Ankle........................... 255 Extremely Painful Immobile Ankle...................... 256 Ankle Sprain.......................................... 256 13 Foot................................................. 261 Foot Deformities....................................... 261 Foot Deformities Present at Birth........................ 261 Toe Walking........................................ 276 Flattened Longitudinal Medial Foot Arch.................. 279 Abnormal High Longitudinal Medial Foot Arch............ 285 Foot Pain............................................. 291 Pain in the Outer Side of the Hindfoot.................... 291 Heel Pain........................................... 292 Pain in the Inner Side of the Midfoot..................... 294 Painful Swelling on the Upper Outer Side of the Heel........ 295 Painful Swelling on the Inner Side of the Midfoot........... 295 Painless Bilateral Swelling on the Medial Side of the Footsole.................................. 296 14 Toes................................................. 299 Abnormal Toe......................................... 299 Extra Toe........................................... 299 Giant Toe Growth.................................... 300 Bent Toe Deformity.................................. 301 Overlapping Toe..................................... 303 Short Toes.......................................... 304 Fused Toes.......................................... 304 The Big Toe Deviates Medially......................... 306 The Big Toe Deviates Laterally......................... 306 The Little Toe Is Deviated Medially...................... 312 Painful Toes........................................... 314 Painful Stiff Big Toe.................................. 314 Pain at the Level of the Head of the Second Metatarsal (or Third or Fourth or Fifth)................... 315 Toenail Pain......................................... 315 15 Leg Length Inequality................................. 319 One Leg is Shorter or Longer than the Other................. 319 One Leg is Shorter than the Other....................... 319 One Leg is Longer than the Other........................ 324

Contents xv 16 Abnormal Gait....................................... 333 Introduction........................................... 333 Gait Disorders......................................... 333 Limping............................................ 333 Waddling Gait....................................... 333 Toe Walking........................................ 337 Out-Toeing......................................... 337 Intoeing............................................ 338 Unburdening Hip Gait................................. 344 Gaits with a Shortened Standing Phase................... 345 17 Limb and Back Reduction Deficiency Present at Birth....... 347 Limb General......................................... 347 Classification........................................ 347 Frequency.......................................... 349 Upper Limb........................................... 349 Absence of the Whole or Part of the Arm.................. 349 Absence of the Whole Arm or Upper Arm or Forearm Between the Trunk and the Hand in Which Case the Elbow Joint Is Always Absent........................ 354 Abnormal Forearm and/or Hand......................... 355 Lower Limb........................................... 365 Absence of the Whole or Part of the Leg.................. 365 Absence of the Whole Leg or Thigh or Lower Leg Between the Trunk and the Foot, in Which Case the Knee Joint Is Always Absent......................... 366 Short Upper Leg, the Knee Joint Is Always Present.......... 368 Abnormal Lower Leg and/or Foot....................... 376 Back................................................ 389 Buddhist Posture..................................... 389 18 Bone and Joint Infections............................... 393 Extremely Painful Immobile Extremity..................... 393 Incidence........................................... 394 Pathogenesis of Acute Osteomyelitis..................... 394 Pathogenesis of Septic Arthritis......................... 395 Localization......................................... 396 More Locations...................................... 396 Pathogens.......................................... 397 Late Complications................................... 400 Caffey Disease...................................... 402 Addendum............................................... 407 Appendix................................................ 409 Literature................................................ 425 Index... 431