Paediatric Orthopaedics😊

NOTE: Different Fanconis

ㅤ	ㅤ
Fanconi disease/syndrome	• Proximal tubular reabsorption problem → Type 2 RTA • Glycosuria, aminoaciduria
Fanconi anemia (Not syndrome)	• Pancytopenia + radial ray
Fanconi Bickel syndrome	• Mutation in GLUT-2   • Bickel → Bi → 2 (GLUT 2) Defect in glucose sensing → ↓ insulin release • Postprandial Hyperglycemia. • Fasting Hypoglycemia • Glycogen accumulation disorder

Stranger things characters

• Dustin (Cleido cranial dysplasia)

• Robin (Cock robin position)

• Ray (Radial Ray) Hopper (Holt Oram ASD)

Paediatric Orthopaedics

NOTE:

• NAI/Child abuse
• Bucket handle # → Metaphyseal corner #

 

• M/c # in children
• Distal forearm (radius) bones

• M/c # during birth
• Clavicle #

• Most common elbow fracture:
• Supracondylar humerus fracture

Characteristics of Paediatric Bones

• More Water Content:
• Flexible and resilient to stress.
• Bends rather than breaks.

• Thicker Periosteum: Offers greater stability.

Effects of Applying Force to the Bone

• Force within physiological limits:
• Outer surface is convex.
• Causes distractive/tension force.

• Force beyond physiological limits:
• Outer cortex breaks.
• Results in a Greenstick/Unicortical fracture

Common Paediatric Fractures

• Most Common Fracture (m/c) in Children:
• Greenstick fracture.
• Forearm: Radius > Ulna (more common in radius).

• Most Common Fracture (m/c) at Birth:
• Clavicle fracture.

• Most Common Fracture (m/c) in Child after Fall on Outstretched Hand (FOOSH):
• Supracondylar humerus fracture.

• Note: Most common fracture (m/c) in humans overall is a Clavicle fracture.

Osteochondrosis

• Due to
• Idiopathic.
• Most Common Cause (m/c)
• primary vascular event
• repetitive trauma.

• Self-limiting abnormality of bone growth.

• Affects ossification centers in the epiphysis.

• Begins in childhood as a necrotic condition.

Specific Osteochondrosis and Affected Bones:

Perthes Disease (AKA Coxa plana/Legg-Calve-Perthes disease)

• Etiology: Idiopathic, spontaneous osteonecrosis.

• Age: 4–9 years

• Sex: Boys > girls

• Site: Femoral epiphysis.

• Risk Factors
• Low birth weight
• Passive smoking
• Positive family history
• Low socioeconomic status
• ADHD

• A/w
• Thrombophilia, Protein C & S deficiency

• Pathogenesis
• Disruption of blood supply to femoral head
• Involved vessel: Lateral epiphyseal artery
• Leads to:
• Osteonecrosis
• Cessation of bone growth
• Healing phase:
• Neovascularization
• Removal of necrotic bone
• Loss of bone mass
• Weakening of femoral head

• Clinical Features:
• Pain at the hip.
• Limping gait after activity.

• Management:
• < 8 years
• Rest allows vascularity to recover → improve symptoms
• Bisphosphonates
• Surgery: Proximal femur varus osteotomy
• > 8 years
• Pelvic osteotomy

Miscellaneous Paediatric Orthopaedic Pathologies

Klippel Feil Syndrome

• Definition: 
• Segmentation defect of cervical spine.
• Fused C Spine

• Clinical Features (Triad):
1. Short webbed neck.
2. Low set hairline.
3. Restriction of neck movement.

• Associations:
• Scoliosis (most common).
• Kyphosis
• Cervical rib
• Sprengel shoulder.
• Genito-urinary anomalies.
• Ocular/auditory/cardiac defects.
• Diastematomyelia
• congenitally split spinal cord

Sprengel's Deformity

• Congenital undescended hypoplastic scapula.

• Impact: Limits shoulder mobility.

• Associations: 
• M/c associated with Klippel Feil syndrome.

Slipped Capital Femoral Epiphysis (SCFE)

• AKA: Sub-capital neck of femur fracture.
• A split fracture at the growth plate of the capital femoral epiphysis.

• Type: Classified as Type I Salter Harris fracture.

• Mechanism: 
• Femoral head remains within the acetabulum
• Neck → slips relative to the head.

• Left hip >Right hip

Causes of SCFE

• Most Common: 
• Idiopathic.

• Associations with Endocrinopathies:
• Hypothyroidism (most common).
• Hypogonadism.
• Increased growth hormone.

Clinical Features of SCFE

• Usual Age: Around puberty.
• Males: 13 to 17 years.
• Females: 11 to 14 years.

• Associated with Hypogonadism:
• High-pitched voice in boys.
• Gynecomastia in boys.

• Coxa Vara Presentation:
• Gradual/sudden pain at the hip.
• Restricted abduction and internal rotation (earliest sign)
• Decreased flexion
• The affected limb is externally rotated.
• Axis deviation test:
• Knee-axilla sign positive
• Knee points to ipsilateral shoulder on hip flexion
• normally points towards contralateral shoulder
• Trendelenburg gait.
• Extension is not much affected

• Observation: 
• Externally rotated toe.

• Risk Factors:
• Males > females.
• Increased weight for age in children.

Investigation of SCFE

• Investigation of Choice (IOC): 
• MRI.

• X-ray Findings:
• Trethowan’s sign: 



• Klein’s line does not intersect with the head of the femur.
• Klein’s line: 
• Line drawn at the lateral aspect of the neck of femur
• Mnemonic: Cleaner Steffi → runaway with Trethowan

Developmental Dysplasia of the Hip (DDH)

• Definition: 
• Idiopathic spontaneous subluxation of the femoral head.

Epidemiology of DDH

• Female child

• First-born

• Faulty intrauterine position
• Frank breech with extended knees.

• Family history.

• Caucasians > Asians.

• Incidence: 1 in 1000 live births.

Etiology of DDH

• Most Common: Idiopathic.

Pathology of DDH

• Developmental anomaly leading to lack of concavity of the acetabulum
• flat/shallow/concave

• Result:
• Femoral head slips out.

Clinical Features of DDH

1. Short limb: 
• Asymmetrical thigh
• gluteal folds.

2. Vascular sign of Narath: 
1. Femoral pulsations absent on the affected side
• due to displaced femoral head,
• palpation is not possible

Clinical Diagnosis of DDH

Child < 3 months old:

• Barlow’s test: 
• Performed to dislocate a dislocatable hip.
• Mnemonic: Bahar valikkunath
• BADD (Barlow → adduct)

• Ortolani’s test: 
• Performed to reduce a dislocated hip.
• Mnemonic: ottayil kuthi keettunath
• Ortolani → abduct

Child > 3 months old:

• Allis/Galeazzi sign: 
• One knee is higher than the other on knee flexion,
• → leg length discrepancy.

• Trendelenburg gait/Waddling gait: 
• Abnormal gait due to gluteal muscle weakness or hip instability.

NOTE

Investigations for DDH

• Screening IOC: 
• < 6 months
• Ultrasonography (USG).
• Graf classfication → vowels dont stick together
• Alpha angle: ↓↓
• Beta angle: ↑↑
• Ultrasonography
• To screen for DDH (developmental dysplasia of hip)
• To look for joint effusion
• > 6 months
• X-ray.

• Confirmation Test: 
• X-ray.
• MRI is an additional investigation if needed.

X-ray Lines for Diagnosis:

• Hilgenreiner’s line (H): 
• A line passing through the centers of both triradiate cartilages.
• Epiphysis N in Inferomedial quadrant
• If elsewhere → abn

• Perkins line (P): 
• A line perpendicular to Hilgenreiner’s line,
• passing through the lateral edge of the acetabulum.
• Normal: 
• Head of femur lies in the inner, lower quadrant.
• DDH: 
• Head of femur displaces to the upper, outer quadrant.

Treatment for DDH

Bilateral Knee Deformity

Congenital Talipes Equinus Varus (CTEV)

• Most Common (m/c) Anomaly of Foot: 
• Clubfoot.

Epidemiology of CTEV

• 50% cases are bilateral.

• Males > Females.

• Common in first-born children.

• Associated with breech presentation and oligohydramnios
• (not typically twin pregnancy).

Causes of CTEV

• Most Common: Idiopathic.

• Spina bifida.

• Arthrogryposis multiplex congenita.

• Polio doesn't cause

Pathology of CTEV

• C A V E Mnemonic (referring to the deformities):
• Cavus: Exaggeration of medial longitudinal arch.
• Adduction: At talonavicular/mid tarsal joint.
• Varus: At talocalcaneal/subtalar joint.
• Equinus: At ankle joint (plantar flexion).

• Internal rotation of tibia (a component but not part of CAVE).

Investigations for CTEV

• X-ray: Kite’s angle (Talocalcaneal angle).



• Normal: 20 to 40 degrees.
• Clubfoot: Decreased angle.

• Screening: 
• Dorsiflexion test:
• If dorsiflexion causes the tip of the toe to touch the shin,
• it indicates good flexibility and is normal
• If doesnt touch skin → CTEV

Treatment for CTEV

Initial: 

• Manipulation of foot to correct deformity,

• followed by POP cast
• serial casting for 8-9 weeks

Ponseti Method:

• Fulcrum of correction: Talar head

• Order of Manipulation (CAVE Mnemonic):
• Cavus.
• Adduction.
• Varus.
• Equinus.

• Method: 
• Start as early as possible
• Apply POP cast (above knee) for 21 weeks
• then remove and manipulate again.

Maintenance:

Before child starts walking (<1 years): 

• Dennis Brown splint (used at night/rest periods).



• Till the baby learns to walk,
• Mechanism : As baby moves the leg, deformity gets corrected,

Once child starts walking (>1 year):

• Day: CTEV shoe.

• Night: Dennis Brown splint.

CTEV Shoes (for correcting residual deformities):

• Straight inner border: To correct adduction.

• Outer raise: To correct inversion & varus.

• Absence of heel: To correct equinus.

• Should be worn at least 3 hrs/day

Triple Arthrodesis:

• Indication: Presentation at >10 years of age.

• Procedure: Joint fusion surgery.

• Most important joint: Talonavicular joint.

Joshi’s External Stabilization System (JESS):

• Used for CTEV resistant to treatment.

Achondroplasia

• Most Common Cause (m/c) of: 
• Disproportionate dwarfism.

• Cause: 
• FGFR3 gene mutation
• Chromosome 4 (Autosomal dominant or sporadic).

• Pathology:
• Endochondral ossification defect
• affects growth plate development
• Intramembranous ossification is normal
• skull and clavicle formation are unaffected by this process

Clinical Features of Achondroplasia

Note: Differential Diagnosis for Limping Child (DDx)

• Chevron’s sign
• Femur length = Tibia length
• Dont confuse with scurvy/rickets
• Rhizomelic dwarfism
• Rhizomelic shortening of femur
• Metaphyseal dyplasia

Other signs

• Trident/ Starfish hand:
• Increased gap between middle and ring fingers.

• Champagne glass pelvis

• Tombstone appearance of iliac blades

• Flat acetabulum

• Mnemonic: Achondroplasia → Tyrion lannister → carries a trident → drinks champagne → acetabulum got flat due to repeated sex → died in tombstone