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a Textbook of Paediatric Orthopaedics
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Transcript of a Textbook of Paediatric Orthopaedics
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Nigel S. Broughton
A Textbook Of Pediatric Orthopaedics
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Contents
Contributors VllForeword IXPreface XlAcknowledgements xii
- Chapter 1 Orthopaedic assessmentD Robert V Dickens and Nigel S Broughton
Chapter 2 General approach to paediatric orthopaedics 13Malcolm B Menelaus
Chapter 3 Normal and pathological gait 21H Kerr Graham and Donnchadha G Gallagher
Chapter 4 Lower limb deficiencies 27Ian P Torode
Chapter 5 Skeletal dysplasias 39Virginia J Saxton and Mark D O'Sullivan
Chapter 6 Metabolic bone disease 65Mark D O'Sullivan and Virginia J Saxton
Chapter 7 Bone and soft tissue tumours 75Mark D O'Sullivan and Virginia J Saxton
Chapter 8 The orthopaedic management of cerebral palsy 101H Kerr Graham
Chapter 9 Spina bifida 115Malcolm B Menelaus
t:'
Chapter 10 Neuromuscular disorders of childhood 131Gary R Nattrass
Chapter 11 Bone and joint infection 149Virginia J Saxton and Mark D O'Sullivan
Chapter 12 Juvenile chronic arthritis 165Susan M Randle
Chapter 13 Osteochondritic conditions 175D Robert V Dickens
.- Chapter 14 Normal variants: intoeing, bow legs and flat feet 183H Kerr Graham
Chapter 15 The upper limb 193Andrew J Herbert and Nigel S Broughton
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vi Paediatric Orthopaedics
Chapter 16 Developmental dysplasia of the hip 203Nigel S Broughton
Chapter 17 Perthes disease 219Malcolm B Menelaus
Chapter 18 Slipped upper femoral epiphysis 229Gary R Nattrass
Chapter 19 The knee 239Nigel S Broughton
Chapter 20 The foot 251D Robert V Dickens
Chapter 21 The spine 267D Robert V Dickens
-Chapter 22 Upper limb trauma 283H Kerr Graham
Chapter 23 Lower limb trauma 299Mark D O'Sullivan
Chapter 24 Limb length inequality 313Ian P Torode
Index 327
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Developmental Dysplasia of the Hip 207
a b
Figure 16.4 a Radiograph showing left-sided unilateral DDH in an 18-month-old child. b Radiograph showingbilateral DDH in a 15-month-old child.
months that radiographs are the imaging techniqueof choice (Figure 16.4).
The pelvic radiograph is a static examination, butin the young child allows a useful assessment of therelationship between the metaphysis of the femurand the acetabulum. The pelvis is X-rayed with thelegs in neutral. If the ossific nucleus of the femoralbead has formed, it should be below a projection ofth Hilgenreiner line and the major part medial toth Perkin line, in th inferomedial quadrant. Thedislocated hip shows the ossific nucleus in thesuperolateral quadrant. If there is no ossifi nucleusthe metaphyseal edge (ME) angle, which assesses therelative position of the medial edge of the metaphy-sis to the edge of the bony acetabulum can be useful.The hip is probably dislocated if the medial edge ofthe upper femoral metaphysis lie lateral to thout r edge of the acetabulum. Von Rosen viewscan also be helpful if th re are no ossific nuclei. Thelegs are abducted to 45 and a line is drawn alongthe axis of the femoral shaft. This should project
through the centre of the acetabulum. Disruption ofthe Shenton line should be sought. The acelabularindex has some value in the interpretation of acet-abular dysplasia; however, it is subject to markedinterobserver error (Figure 16.5).
In the older child assessment of any ongoingacetabular dysplasia is carried out by examining aseries of pelvic radiographs and looking at the shapeof the acetabulum, which may involve measuring theacetabular ind x. he centr dge (CE) angle,Shenton line and Moses concentric rings are alsou eful in the older child.
ArthrographyIn the young child in whom there is only a smallossific nucleus and much of the hip is cartilage,arthrography is useful for defining the relationshipbetween the femoral head and the acetabulum. Thisrequires a general anaesth tic. It can defin an hour-glas constriction of the capsule, and the invertedlimbus may show up as the 'rose thorn' sign.
tV = 2.AJ - 2...rI ~N ~!J==l
Perkin line
Hilgenreiner lineI
Head-teardropdistance
~AcetabularIndex/.
a
Fig 16.5 a Diagram showing the acetabular index, Hilgenreiner line and Perkin line. b The centre-edge angle.This becomes useful at about eight years of age.
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IndexNote: page numbers in bold indicate tables and numbers in italics indicate illustrations
Abscessesacute osteomyelitis 152-3Brodie 157-8
Acetabulardysplasia 214-16
persistent 214, 217fractures, 301index 207salvage 216
Achilles tendonfiat feet, associated with tight 258lengthening 106-7
Achondroplasia 40-1Acoustic neuromas,
neurofibromatosis 57Acromioclavicular dislocations 284Acute
osteomyelitis 149-54calcaneum 151complications 153distal tibial metaphysis 152epiphyseal 153humerus 151investigations 150-2management 152-3neonatal 153
patellar dislocation 241polyradiculoneuritis 146
Adolescenthip dysplasia 214-16idiopathic scoliosis see Scoliosis:
adolescent idiopathicAggressive fibromatosis 95--6Aitken's radiological classification,
femoral focal deficiencies 27Aldolase 134Alpha-fetoprotein, prenatal diagnosis
117Amniocentesis, prenatal dignosis 117Amputation
congenital pseudoarthrosis of tibia35
osteosarcoma 89and prostheses, limb length
inequality 31 7Syme 30,317tibial dysplasia-deficiency 33
Amyoplasia see ArthrogryposisAnaesthesia, JCA, difficulties 173
Aneurysmal bone cyst 85, 86Ankle
congenital deficiencies of fibuladisarticulation 31-2stabilization with bone 32
and foot, assessment 9-11spastic diplegia, cerebral palsy
110and subtalar valgus 124valgus deformity 123, 124
Ankle-foot orthoses (AFOs) 104-5,121
Ankylosing spondylitis 168Antalgic gait 3Anterior
knee pain 243-7vertebral body beak, causes 42, 51
Anterolateral reduction, DDH 210-11, 213
combined with Salter osteotomy211
and femoral osteotomy 211Antibiotics
acute osteomyelitis 152septic arthritis 155
Apprehension testpatella 9, 242shoulder 11
Arachnodactyly see Marfansyndrome
Arterial injury, supracondylarfracture 285, 287-8
Arthritis see Juvenile chronic arthritis(JCA); Septic arthritis
Arthrography, DDH 207Arthrogryposis 142--4, 194
multiplex congenita 142Arthroscopy 241,245,247Asphyxiating thoracic dysplasia 43Astereognosis 108, 109Asymmetrical spastic diplegia 110Athetoid cerebral palsy 102Avascular necrosis
causes 222DDH 209, 211-12hip fractures 302limb length inequalities 313, 316Perthes disease 219, 221SUFE 231-2,233,235--6
Avulsion fracturespelvis 299-300
ischial tuberosity 300tibial tubercle 306upper femur 302-3
Baker procedure 107Barlow test, DDH 204, 210Baunlann angle 289Becker muscular dystrophy 135, 136,
137Below-knee amputees, prosthetics 26Benign tumours
bone-forming 78-80cartilaginous 80-3differentiation from malignant 76-7fat 97fibrous 83--4, 95--6neural 96soft tissue, miscellaneous 98synovial 97-8vascular 94-5
Bennett fracture 297Bipartate patella 245Birth
fractures, shaft of femur 194, 303palsies, upper limb 193-5
Bladder paralysis, spina bifida 116Block test
of Coleman see Coleman block testleg length inequality 5
Blount disease 248-9Bone
cystaneurysmal 85,86metaphyseal, Perthes disease 255simple 84-5, 311
decreased density see Osteogenesisimperfecta; Osteoporosis
fragility, spina bifida 119increased density 39, 49-50scan 77
acute osteomyelitis 150-1adolescent idopathic scoliosis 270Perthes disease 221-2septic arthritis 155
tumours 75benign 78-80, 84-8
-
328 Paediatric Orthopaedics
Bone (continued)tumours (continued)
malignant 88-92metastatic 92-4
see also Metabolic bone diseaseBoston underarm brace 270, 271Botulinum toxin, cerebral palsy 105,
109Bow legs 187-8Brachial
artery, supracondylar fracture 287plexus, obstetric injuries 193-5
Bracingadolescent idiopathic scoliosis
270-1poliomyelitis 145-6
Brodie abscess 157-8Broomstick cast
DDH 210Perthes disease 225-6
Buck-Gramcko procedure 200Buckle fractures, forearm 294
Caesarean section, spina bifida 11 7Cafe au lait spots 4,57Caffey disease 161Calcaneal exostoses 263Calcaneocavovalgus deformity 123Calcaneonavicular bar 259-60Calcaneus 122Calcitonin 66Calve disease 87Camptodactyly 202Carpal injuries 297Carrying angle 11, 12, 288Cartilaginous tumours, benign 80-3Catterall classification, Perthes disease
224Cavovalgus deformity 122, 123Cavovarus feet 133, 260-1
commonest causes 261Friedreich ataxia 142peripheral neuropathies 137-8
Cavus deformity 122, 260Cells, bone 65Central core disease, congenital
myopathy 138Cerebral palsy 101-13
aetiology 101classification 101, 102clinical features 102gait analysis 25, 105-6management 102-6
hemiplegic lower limb 106-8hemiplegic upper limb 108-9spastic diplegia 107-9spastic quadriplegia 109-10
pathology 102recurrent hip dislocation 216
scoliosis 273-4stiff knee gait 22
Cheilectomy 227, 234Chemotherapy
Ewing sarconla 92osteosarcoma 89tuberculosis 161
Chiari osteotomy 216, 227Chondroblastoma 81, 82Chondrodiatasis, limb lengthening
322Chondroectodermal dysplasia 43Chondrolysis 232, 234-5Chondromalacia patellae 9Chondromyxoid fibroma 81, 82Chondrosarcoma 60, 92, 93Christmas disease 173Chromosomal abnormalities 62-3Chronic osteomyelitis 156-9
multifocal, recurrent 157Cincinnati incision 254, 257Clavicle
congenital pseudoarthrosis 11,195-6
injuries 284Cleidocranial dysplasia 54, 56Clinodactyly 202Cloacae 149, 156, 157Club feet see Congenital talipes
equinovarusCobb angle, scoliosis 270, 272Codman triangle, osteosarcoma 89Coleman block test 10, 11, 140, 261Compartment syndrome,
supracondylar fracture,humerus 285, 288
Complete injury, obstetric brachialplexus injury 194
Computerized tomographyacute osteomyelitis 152adolescent idiopathic scoliosis
270bone tumours 77DDH208limb length inequalities 316SUFE233
Condylar injuries, humerus 290-2Congenital
deficienciesfemur 27-31fibula 31-2radius 199-201tibia 27, 32-3
dislocationship see Developmental dysplasia
of the hip (DDH)knee 239patella 239-41radial head 198shoulder 197
flat feet see Congenital: verticaltalus
generalized fibromatosis 96glenoid hypoplasia 197limb length inequality 313muscular dystrophy 137myopathy 137-8myotonic dystrophy 138pseudoarthrosis
clavicle 11, 195-6tibia 33, 35ulna 57
recurvatum, knee 239scoliosis 272-3sensory neuropathies 146talipes calcaneovalgus 256vertical talus 256-7see also Hereditary
Congenital talipes equinovarus(CTEV) 185, 251-65
aetiology 251clinical features 252complications 255-6incidence 251management 253-5pathology 251-2radiology 252-3
Connective tissue disorders 53-4Conradi-Hiinermann syndrome 45Consultation 14-16Cord, tethering 121Coronal plane deformities 187-90Coronoid fractures 292-3Cortical destruction, tumour
diagnostic factor 77Corticosteroids 66, 170, 171
intra-articular 171, 172osteoporotic changes 170
Cotrel-Dubousset system 272Coventry and Johnson classification,
congenital deficiencies, fibula31
Coxa vara, infantile 35, 36-7Creatinine phosphokinase (CPK) 133Curly toes 263-4Cutaneous lesions see SkinCyclosporin 171Cyst
boneaneurysmal 85, 86metaphyseal, Perthes disease 225simple 84-5, 311
popliteal 248Cytomegalovirus 161
Deficiencies see Congenital:deficiencies
Delivery fractures 194, 303Denis Browne splint 208-9, 253, 254
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Dermatomyositis 98, 138, 169Developmental delay 1, 2Developmental dysplasia of the hip
(DDH) 3-4, 8, 203-17diagnosis 204examination 204-5
under anaesthetic 209incidence 203management 208-11
(}-3 months 208-96-12 months 209-101-3 years 21(}-11over 3 years 211complications of treatment 211-
12, 313operative procedures 212-14
pathology 203--4radiology 205-8see also Hip: dysplasia, adolescents
withDial osteotomy 216Diaphyseal
aclasia see Heriditary multipleexostoses
dysplasia 50fractures
forearm 294-5limb length inequalities 313
Diastematomyelia 129Diastrophic dysplasia 43Dillwyn Evans procedure, CTEV 256Discitis 161-2Discoid lateral meniscus 247-8Distraction, limb lengthening 319-21DNA diagnosis, neuromuscular
disorders 134Down syndrome see Trisomy 21Duchenne muscular dystrophy 135-7,
275-6Dynamic contractures, cerebral palsy
102, 105Dyschondrosteosis 59, 134Dysplastic form, spondylolisthesis 278Dystrophin testing, neuromuscular
disorders 134
Edwards syndrome 63Ehlers-Danlos syndrome 39, 53Elbow
assessment 11-12dislocation 290, 291flexion deformity, cerebral palsy
108floating 288, 289fractures 289-93
Electromyographygait analysis 22neuromuscular disorders 134
Ellis-van Creveld syndrome 43
Elmslie technique 244Emery-Dreifuss muscular dystrophy
137Enchondroma 8(}-1Enchondromatosis 6(}-1, 314
with haemangiomas 60,61,95Energy studies, gait analysis 22-5Engelmann disease 39, 50Enneking classification, bone and soft
tissue tumours 78Enthesopathy 169Eosinophilic granuloma 86, 87Epiphyseal
disorders 43--4dysplasia, multiple 43, 44, 222injuries
classification 283, 284, 290, 294,305
forearm 294humerus 290limb length inequalities 313
lesions, lytic 82osteomyelitis 153
Epiphyseodesis 29,233,318Epiphyseolysis, partial growth plate
arrest 324-5Equinocavovarus deformity,
Duchenne muscular dystrophy136
Equinovarus deformitycerebral palsy 108spina bifida 121-2
Equinus 4, 122Erb-Duchenne type paralysis 194Erb palsy, right arm 193Erlenmeyer flask deformity 53Ewing sarcoma 90,91,92,93, 152Examination 16-17
assessment 2-12normal variants 183--4
Exquisitely tender lesions 99External rotation
hip, torsional profile 184osteotomies, bilateral femoral 110tibia 124
Eye involvement, pauciarticular JCA166
Fairbank triangle, infantile coxa vara35-6
Falling fragment sign 84Familial
hypertrophic osteoarthropathy 50hypophosphataemic rickets 67,
68-9Family history 2Fanconi syndrome 67, 199Fascioscapulohumeral muscular
dystrophy 137
Index 329
Fat tumours, benign 97Femoral
deficiencies 27-31,313with abscence of fibula 31
dysplasia, upper 216-17fractures
fracture-separation, distal physes304-5
shaft 303-4SUFE, in situ pinning 236supracondylar, spina bifida 119upper, avulsion 302-3
head, Perthes diseasefragmentation and displacement
220uncovering at presentation
223-4osteotomy
and anterolateral reduction,DDH 211
Perthes disease 227partial growth plate arrest 323rotation
external osteotomies, spasticdiplegia 110, III
range 7shortening 318, 319
Fibrocartilaginous dysplasia 62, 83-4Fibrodysplasia ossificans progressiva
58Fibroma
non-ossifying 83, 311of Reye, recurring digital 96
Fibromatoses 95-6Fibrosarcoma 92Fibrous
cortical defect and non-ossifyingfibroma 83
dysplasia 61-2, 83, 314hamartoma of infancy 95tumours, benign 83-4, 95-6
Fibulacongenital deficiencies 31-2
associated with short femur 28,29
see also Tibia and fibulaFibular grafts, vascularized 35Fifth toe, overriding 264Flail
hips 125shoulder 144undeformed knee 124-5
Flat feet 10, 189-90, 257-60Flexion supracondylar fracture,
humerus 287Floating elbow 288, 289Floor reaction orthoses 105, 121Floppy baby 131Foot 251-64
and ankle assessment 9-11
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330 Paediatric Orthopaedics
Foot (continued)deformities
arthrogryposis 144cerebral palsy 107-8peripheral neuropathies 139, 140spina bifida 121--4spinal dysraphism 129-30
fractures and dislocations 310progression angle (FPA) 6, 184-thigh angle (FTA) 6-7
Forearmfractures 293--4
diaphyseal, middle and upperthirds 294-5
distal third 294Galeazzi fracture dislocation 297Monteggia fracture dislocation
292,296hemiplegia, cerebral palsy 108radial club hand 199-201radial head, dislocation 198-9radio-ulnar synostosis 199ulna, congenital pseudoarthrosis 57
Freiberg disease 10, 179Freijka pillow 208Friedrich ataxia 141-2Functional disorders 17-18
Gage sign 224Gait 3--4, 21--6
cerebral palsy 105--6cycle 21Trendelenburg 3--4, 22, 210see also Intoe gait; Limp
Galeazzifracture dislocation 297test, limb length inequality 5, 315
Galveston technique 274, 275Gartland classification, supracondylar
fractures, 285grade 111287
Gaucher syndrome 52-3Genetic counselling, spina bifida 11 7Genu valgunl 188-9Giant cell tumour 85--6, 87Glenohumeral dislocation 284Gold 170-1Gowers sign 3, 131, 132Gradual distraction, limb lengthening
319-22Grars DDH ultrasound classification
206Grafts, vascularized fibular 35Green and Anderson, limb length
inequality assessment 317Green procedure, Sprengel shoulder
197Greenstick fractures, forearm 294Grice procedure 108, 111
Ground reaction AFO 105Growing pains 191Growth plate
arrest, limb shortening 318disorders 40-3premature arrest 322-5vascularized transfer 325
Gruca procedure 32Guhl arthroscopic classification,
osteochondritis dissecans 247Guillian-Barre syndrome 146
Habitual dislocationpatellar 240-1shoulder 197-8
Haemangioma 88, 94Haemophilia 173,315Haemophilus 154Haemophilus influenzae type b (HIB)
150Haemostatic disorders 173Hallux
rigidus 263valgus 261-3
Handassessment 12camptodactyly 202clinodactyly 202dislocations 297hemiplegia, cerebral palsy 109Kirner deformity 202trigger thumb 201-2and wrist injuries 297
Hand-Shuller-ehristian disease 87Harrington system 272Heel bumps 263Hemiatrophy syndromes 314-15Hemihypertrophy syndromes 314-15Henlimelica epiphyseal dysplasia 45,
46Hemiplegia
lower limb 106-8upper limb 108-9
Hereditarymotor and sensory neuropathies
138--40multiple exostoses 11, 59--60spinal cerebellar ataxia 141-2see also Congenital
Herndon-Heyman procedure 234Heterotopic ossification, spina bifida
119Hilgenreiner
epiphyseal angle, infantile coxa vara36
line 207Hinged AFO 105Hip
adductors, spasticity 111
arthrogryposis 143--4arthrotomy 155assessment 8dislocation 125
causes 203secondary to septic arthritis 155spina bifida 126, 127traumatic 301
dysplasiaadolescent with 214-16developmental see
Developmental dysplasia of thehip (DDH)
neuropathies 140spinal muscular atrophy 141
fixedadduction contracture 6flexion deformity 8
fractures 301-2irritability 8rotation 7spastic diplegia, cerebral palsy 109spina bifida 125-6surgery
reconstructive and salvage 112-13
soft tissue release, cerebral palsy111-12
transient synovitis of 162--4tuberculosis 160, 222see also Perthes disease
Histiocytosis X 86-7, 88History taking 1-2, 14-16Hitch-hiker's thumb 43HLA B27-positive JeA 168, 169,
170Hoke triple cut technique, Achilles
tendon 107Holt-Dram syndrome 199Homocystinuria 72-3Hospitals and children 18Humeral fractures
diaphyseal 285distal 11-12, 285--92epiphyseal, distal 290proximal 284T and Y condylar 292
Hunter syndrome 50, 51Hurler syndrome 51Hydroxychloroquine 17025-hydroxylation, deficiencies 66I-hydroxylation, deficiencies 66Hyperparathyroidism 70Hypertrophic callus formation 120Hypertrophy syndromes and vascular
malformations 94-5Hypocalcaemia, effects 66Hypochondroplasia 42Hypophosphatasia 73Hypothyroidism 71
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Idiopathicjuvenile osteoporosis 72, 73scoliosis 267
adolescent 267, 268, 269-72infantile 267, 268
toe walkers 190Iliofemoral fusion, proximal focal
femoral deficiency 30Ilizarov
frame 256, 320, 321ring fixators 35
Immunosuppressants 171Implantable intramedullary
distractors 322In situ pinning, SUFE 231,232-3,
236further slipping 236
Indolent toe ulcers 146Infantile
cortical hyperostosis 161coxa vara 35, 36-7idiopathic scoliosis 267, 268
Infection, bone and jointdiscitis 161-2limb length inequalities 313-14osteomyelitis see Osteomyelitisperiosteal reaction 161pin tract 321septic arthritis see Septic arthritissyphilis, bone 161transient synovitis, hip 162-4tuberculosis 159--61viral osteopathy 161
Inflammatory myopathies 138Injured child 18Innominate osteotomy 28
Perthes disease 223,226-7Internal rotation
femoral 186-7hip 184tibial 124, 186, 188, 256
Intoe gait 184-7assessing 7-8congenital talipes equinovarus
256Intramedullary
nail, distraction over, limblengthening 322
rodding and bone grafting, tibialpseudarthrosis 34
Intrapelvic shortening 318-19Involucrum 149, 156,157Iritis, pauciarticular JCA 166Irritable hip see Transient synovitis of
the hipIsthmic form, spondylolisthesis 278
Jansen type metaphysealchondrodysplasia 46
Jeune syndrome 43Joint
contractures, arthrogryposis 142replacement, JCA 172-3
Juvenile chronic arthritis (JCA) 165-73
classification 165forms, summary of features 166incidence 165limb length inequalities 315pauciarticular 166polyarticular 166, 167-9systenlic 166, 169-73
management 17~2orthopaedic management 172-3
Juvenile subcutaneous fibromatosis95
Juxtacorticalchondroma 81-2osteosarconla 89, 90
Kalamchi and McEwen classification,late effects of avascularnecrosis, DDH 212
Kinematics, gait analysis 22cerebral palsy 25normal and severe asymmetric
spastic diplegia 23Kinetics, gait analysis 22Kirner deformity 202Klippel-Feil syndrome 58-9, 196-7Klippel-Trenaunay syndrome 93Klippel-Trenaunay-Webber
syndrome 314Klumpke paralysis 194Knee 239-49
anterior pain 243-7arthrogryposis 144assessment 8-9congenital
dislocation 239recurvatum 239
in congenital short femur 28fractures and dislocations 304-6fusion, proximal focal femoral
deficiency 30knock 188-9monoarthritis 167recurvatum 125, 177, 239spastic diplegia, cerebral palsy 109-
10spina bifida 124-5
Knee-ankle-foot orthoses (KAFOs)118
Knock knees 188-9Kohler disease 177-8Kyphosis
Scheuermann 277spina bifida 126, 127
Index 331
Lachman test, knee 9Langenskoild classification, Blount
disease 249Langerhans cell histiocytosis 86-7, 88Larsen syndrome 53, 55, 239Larsen-Johannson disease 177Lateral
condylar fracture, elbow 291epicondyle, elbow, fractures 290and medial condylar physes, injuries
290-2pillar ossification, Perthes disease
223Lead poisoning 71Leaf spring AFO 104Leg length discrepancy see Limb
length inequalitiesLeontiasis ossea 62Leri-Weill disease 201Letterer-Siwe disease 87Leukaemia 93,94, 191Ligamentous laxity, normal 2-3Limb length inequalities 5-6, 27, 313-
25aetiology 313-15assessment 315-16clinical features 315growth plate arrest 322-5lengthening 27, 28, 319-22management 317-22poliomyelitis 145, 314prognosis 316-17radiology 315-16shortening 317-18spina bifida, hip dislocation 125
Limb-girdle muscular dystrophy 137Limb-salvage resection, osteosarcoma
89Limp 3-4
Perthes disease 220see also Trendelenburg gait
Lipoma 97Liposarcoma 99Looser zones 67, 68Lordosis 277-8
spina bifida 126Low-flow vascular malformations 94,
95Lower limb
arthrogryposis 143-4assessment 5-11contractures, Duchenne muscular
dystrophy 136deficiencies 27-37hemiplegic 106-8JCA 167osteochondritic conditions 176-81trauma 299-312
Lower motor neurone lesions 132Lumbar lesions, spina bifida 118
-
332 Paediatric Orthopaedics
Lung metastases, osteosarcoma 89Luque system 272, 274, 275Lymphoma 93
McCune-Albright syndrome 62McKusick type metaphyseal
chondrodysplasia 46Madelung deformity 59, 60, 63, 201Mafucci syndrome 60, 61, 95Magnetic resonance imaging (MRI)
acute osteomyelitis 152adolescent idopathic scolios'is 270bone tumours 77-8DDH208Perthes disease 221, 222
Malabsorption 66Malalignment, lower limb deficiencies
33Malignant bone and soft tissue
tumours 88-92, 98-9,314differentiation from benign 76-7
Malignant changesenchondromatosis 61fibrous dysplasia 62hereditary multiple exostoses 60
Malunion, supracondylar fractures,humerus 11-12,286,288
Marfan syndrome 12, 39, 53, 54,276
Massive osteolysis 87Matrix, bone 65Medial
condylar injuries, elbow 290-2epicondyle, elbow, fractures 290femoral torsion and lateral tibial
torsion 187open reduction, DDH 210, 212-
13Median nerve palsy, supracondylar
fracture 287Melbourne modification, Coleman
test 10, 11Melorheostosis 61Menelaus and Westh technique, limb
length inequality assessment317
Menelaus-Batten syndronle 177Meningococcal septicaemia 154Meningocoele 115, 116Meniscal tear 246Meryon 'fall through' sign 132Metabolic bone disease 65-73Metabolism, bone 65Metacarpal injuries 297Metaphyseal
chondroplasia 45-7cyst, Perthes disease 225disorders 45-7dysplasia 47
Metastasesgiant cell tumour 85leukaemia 93, 94neuroblastoma 93, 94osteosarcoma 89
Metastatic bone tumours 92, 93, 94Metatarsus
adductus 185varus 186
Metatrophic dysplasia 42, 43Methotrexate 171Milwaukee brace 270, 271Monoarthritis, knee 167Monteggia fracture dislocation 292,
296Morquio syndrome 39, 44,52Moseley graph technique, limb length
inequality assessment 317Mucopolysaccharidoses 50-2Multidisciplinary team, spina bifida
116-17Multiple
disabilities 14epiphyseal dysplasia 43, 44, 222exostoses, lirrlb length inequalities
314Muscle
biopsy, neuromuscular disorders134, 135
contractures, cerebral palsy 102,105
imbalance, spina bifida 120-1strength, MRC grading 3
Muscular dystrophies 3, 134-7, 275-6Mycobacterium tuberculosis 159Myelocoele 115, 116Myelomeningocele see Spina bifidaMyeloschisis 115, 116Myotonic syndromes 138
Nail-patella syndrome 54, 55, 56,198
Navicular, osteochondritis 177-8Nemaline (rod-body) myopathy 138Neonatal
osteomyelitis 153, 194rickets 70
Nerve conduction studies 134Nerve palsy
fractures of humerus 285, 287, 288limb lengthening 322upper limb birth palsies 193-5
Neural tube defects 115see also Spina bifida
Neural tumours, benign 96Neurilemmoma 96Neuroblastoma 93, 94Neurofibroma 96
multiple 54
Neurofibromatosis 4,55-7, 96, 276,313
Neurogenic bowel 116-17Neurological assessment 3Neuromuscular disorders
diagnosis 131-4disorders
arthrogryposis 142-4, 194congenital myopathy 137-8Friedreich ataxia 141-3hereditary 138--40inflammatory myopathies 138muscular dystrophies 134-7,
275--6myotonic syndromes 138spinal nluscular atrophy 135,
140-1examination 131history 131-3limb length inequalities 314
Neuromuscular scoliosis 273-fJNeuropathies
congenital sensory 146heriditary motor and sensory 138-
40Night cramps 191Non-accidental injury 311-12Non-ossifying fibroma 311Non-steroidal anti-inflammatory
drugs (NSAIDS) 170Non-structural scoliosis 267Normal
gait 21-2variants 183-91
NutrItional rickets 66, 68
Observational gait analysis 22Obstetric injuries see Birth injuriesOccupational therapy 171Oestrogen 66Olecranon fractures 292OIlier disease 60-1, 314Open epiphyseodesis see
EpiphyseodesisOrthofix system, limb lengthening 320Orthotics and prosthetics
ankle-foot orthoses 104-5, 121below-knee amputees 26cerebral palsy 104-5, 274flat feet 189-90floor reaction 105, 121gait analysis 25--6knee-ankle-foot orthoses 118limb length inequality 317reciprocal gait orthoses 25, 118, 121scoliosis 270, 271, 274, 275spina bifida 121, 275
Ortolani test, DDH 204-5, 210Osgood-Schlatter disease 9, 176-7
-
Osteo-onychodysplasia 54, 55, 56Osteoarthritis
knee, following Hauser technique244
secondary toDDH212Perthes disease 220, 222SUFE236
Osteoarthropathy, familialhypertrophic 50
Osteoblastoma 80Osteochondritic conditions 175-81
lower limb 245-6, 176-81upper limb 175-6
Osteochondritis dissecansfifth metatarsal 179hip 180-1, 222, 227knee 246-7navicular 177-8talus 180
Osteochondroma 80Osteochondromatosis 11, 59-60
synovial 97-8Osteofibrous dysplasia 87, 88Osteogenesis imperfecta 39, 47-9
classification 48fractures 47, 48, 49, 311scoliosis 276-7
Osteoid osteoma 78-80, 191femur 79spine 79
Osteolysis, massive 87Osteomyelitis
acute 149-54chronic 1556-9
recurrent multifocal158, 159epiphyseal 153limb length inequalities 313-14neonatal 153, 194
Osteopathia striata 61Osteopathy, viral 161Osteopetrosis 39, 49-50, 311Osteopoikilosis 61Osteoporosis 7, 39, 72
causes 72idiopathic juvenile 72, 73pathological fractures 311vertebral
collapse 170crush fracture 169
Osteosarcoma 88-9, 90, 93humerus 91juxtacortical 89, 90limb length inequalities 320, 325tibia 90
OsteotomiesBlount disease 247DDH 211distal first metatarsal 262-3femoral 28
innominate 28, 223,226-7lCA 172os calcis 124Pauwel36primary 233--4rotational, femur 110-11, 113scapular 197supramalleolar, tibia 123
Overriding fifth toe 264Oxygen rate and cost, gait analysis
22-5
Pachydermoperiostosis 50Palmar fibromatosis 96Panner disease 175-6Paralytic
convex pes valgus 124flat feet 258
Parathyroid hormone (PTH) 65-6Parkes-Weber syndrome 95Partial growth plate arrest 322-5Patella baja and early osteoarthritis
244Patellar
apprehension test 9, 242dislocation 239--43fractures 306-7squinting 187
Pathologicalbow legs 187fractures 117,310--12spondylolisthesis 279
Pauciarticular lCA 166Pauwels osteotomy, infantile coxa
vara 36Pavlik harness 208, 209Pelvic fractures 299-301
acetabular 301classification 299, 300injuries associated 299pelvic ring, breaks
double 301single 300without 299-300
Pelvic obliquity, fixed 5Pemberton
acetabuloplasty, DDH 214osteotomy 215
Percutaneous K wire fixation 295Periosteal
chondroma 82-3osteosarcoma 89, 90reaction 161
acute osteomyelitis 150general and focal causes 150tumour diagnostic factor 76, 77
Periostitis, tumour diagnostic factor76
Perkin line 207
Index 333
Peronealmuscular atrophy 10
causing pes cavus 260spasmodic flat feet 258
Perthes disease 163--4,219-27aetiology 219clinical features 220differential diagnosis 222incidence 219management 224-7
conservative 225-6surgical 226-7
pathology 219-20prognosis 222--4
factors affecting 223radiology 221-2
Pes cavus see Cavovarus feetPes planus 257-60Phalanges, injuries to 297Phemister technique, growth plate
arrest 318Phosphate deficiency 67Physiological
bow legs 187cost index (PCI) 22, 24flat feet 258
Physiology of bone 65-6Physiotherapy
cerebral palsy 104lCA 171
Pigmented villonodular synovitis 97Planovalgus deformity, foot, lCA
172Plantar
fibromatosis 96response 3
Platyspondyly in childhood 43Plica syndrome 245Pneumococcus 150Poliomyelitis 103, 144-6
limb length inequalities 145, 314Polyarticular lCA 166, 167-9Polymyositis 138Polyostotic fibrous dysplasia 62Popliteal cyst 248Posterior interosseous nerve palsy,
supracondylar fracture 287Posterolateral release, congenital
deficiencies, fibula 32Posteromedial bowing, tibia 35, 36Posture
posturallumbar lordosis 278scoliosis 5
spina bifida 118, 121Premature growth plate arrest 322-5Proportional short stature 39Prosthetics, gait analysis 25-6
see also Orthotics and prostheticsProteus syndrome 315
-
334 Paediatric Orthopaedics
Proximalfemoral osteotomy 28, 110, 111focal femoral deficiency 29-31interphalangeal joint flexion
contractures 168muscle weakness 131-2realignment, recurrent acute
patellar dislocation 243Pseudarthrosis, congenital
proximal focal femoral deficiency29-30
tibia 34-5ulna, neurofibromatosis 57
Pseudoachondroplasia 42Pseudohypertrophy, calf muscle,
muscular dystrophy 135Pseudoporphyria 170Psoriatic arthritis 168PTH-related peptide 66Pulmonary function, Duchenne
muscular dystrophy 136-7,275
Punctate epiphyseal dysplasia 45, 46Pyknodysostosis 50Pyle disease 47
Quadriplegia 111-13
Radialclub hand 199-201head, dislocation 198-9
Radio-ulnar synostosis 199Radiotherapy, limb length inequalities
315Radius
deficiencies of see Radial: club handfractures
neck 293see also Forearm: fractures
head, dislocation 198-9Realignment procedures
anterior knee pain 245recurrent acute patellar dislocation
243Reciprocal gait orthosis (RGO) 25,
118, 121Recurrent acute patellar dislocation
241-3Recurring digital fibroma of Reye 96Recurvatum, knee
congenital 239with limited flexion 125, 177
Redislocation, DDH 211Reflex sympathetic dystrophy 173Remodelling
fracture 299SUFE deformity 234
Renal osteodystrophy 69-70
Respiratory function, Duchennemuscular dystrophy 136-7, 275
Retinoblastoma 93Reye, digital fibroma of 96Rhabdomyosarcoma 93, 98-9Rheumatoid factor-positive JeA 168Rhizotomy, selective posterior 105Ribs, asymmetrical 4, 5Rickets 66-8
neonatal 70radiological appearance 67-8vitimin D-resistant rickets 67-8
Rifampicin 161Rotation osteotomies, cerebral palsy
110-11Rotational profile, leg 6-7
see also External rotation; Internalrotation
Roux-Goldthwaite technique 240,241,243,244
Rubella 161Russel-Silver syndrome 314-15
Sacralfractures 300lesions, spina bifida 118
Salter innominate osteotomy, DDH213-14,215,216
Salter sign 224avascular necrosis 212Perthes disease 221, 224
Salter-Harris classification,epiphyseal injuries 283, 290,294,305
Scapularfractures 284osteotomy 197
Scheuermann kyphosis 277Schmid type metaphyseal
chondrodysplasia 45-6Scleroderma 169Sclerosing osteomyelitis of Garre 158Scoliosis 6, 267-77
adolescent idiopathic 266, 268, 269-72
aetiology 269clinical features 269-70management 270-2radiology 270
arthrogryposis 144assessment 4cerebral palsy 273-4congenital 272-3Duchenrie muscular dystrophy 136-
7,275-6Friedreich ataxia 141-2infantile idiopathic 267, 268Marfan syndrome 276neurofibromatosis 276
neuropathies 140osteogenesis imperfecta 276-7poliomyelitis 146postural 5spina bifida 126, 127-8, 274-5spinal muscular atrophy 141
Scottish Rite brace, Perthes disease226
Scurvy 70-1Selective posterior rhizotomy 105Septic arthritis 152, 154-6, 163
limb length inequalities 313shoulder 194
Septicaemia, meningococcal 154Sequestrum 149, 156, 157Seronegative enthesopathy and
arthritis (SEA) syndrome169
Serpentine (z-shaped) foot 186Sever osteochondritis of the os calcis
10, 178Shelf procedure, acetabular salvage
216,217Shepherd's crook deformity 62Short limb gait 3Short-limbed short stature 37Shoulder
apprehension test 11assessment 11dislocation 197-8girdle injuries 284late deformity, obstetric brachial
plexus injury 195Sprengel 11, 196-7
Sickle cell crisis 152Silverskiold test 106Simmonds-Menelaus operation,
hallux valgus 263Simple bone cyst 84-5, 311Site, tumour diagnostic feature 76Skeletal dysplasias 39-63, 198
diagnosis 39disorders
chromasomal abnormalities 62-3connective tissue disorders 53-4diaphyseal disorders 47-50epiphyseal 43-5growth plate 40--3metaphyseal 45-6miscellaneous 54-62storage 50-3
radiology 39Skin
anaesthesia, spina bifida 119lesions
cafe au lait spots 4, 57spinal area 4, 128
necrosis, congenital talipesequinovarus 255
Skull, neurofibromatosis 57
-
Slipped upper femoral epiphysis(SUFE) 229-36, 246
aetiology 229classification 230clinical features 230complications 230incidence 229management 231--4pathology 229radiology 23(}-1
Slow-acting antirheumatic drugs(SAARDS) 17(}-1
Soft tissuechanges, neurofibromatosis 57release
equinovarus deformity 122JCA 172preventative hip surgery, cerebral
palsy 111-12tumours 75
benign 95--6, 98malignant 98-9
Solid AFO 105Spastic
diplegia 109-11quadriplegia 111-13
Spina bifida 115-30aetiology 115clinical features 116embryonal origin and resultant
condition 129foot 121--4gait analysis, oxygen rate and cost
24-5hip 125-8incidence 115knee 124-5i1mb length inequalities 314lumbar level 22management, general 116-17,128
goals and outcomes 118neurosegmentallevel assessment
118-19occulta 115, 116paralytic flat feet 258pathology 115-16prevention 117problems 119-21reciprocal gait orthosis 25recurrence risk 117-21scoliosis 274-5spine 126-8
deformity, classification 126, 127tibia, torsional deformities 124
Spinalcord, tethering 121dysraphism 4-5, 128-30
cavovarus foot 261embryonal origin and resultant
condition 129
muscular atrophy 135, 140-1tuberculosis 160
Spineanterior vertebral body beaking,
causes 51arthrogryposis 144assessment 4-5kyphosis 126, 127, 277lordosis 126, 277-8neurofibromatosis 4, 56, 276normal curvature, comparison with
scoliosis 4see also Scoliosis; Spina bifida
Spondyloepiphyseal dysplasia (SED)43,44-5
Spondylolisthesis 5classification 279spina bifida 126
Spondylolysis/spondylolisthesis 278-81
Spondylometaphyseal dysplasia 47Sprengel shoulder 11, 19fr-7Squinting patellas 187Stable hips, DOH, management 208Staging, bone and soft tissue tumours
78Staphylococcus aureus 149-50, 154,
156Staphylococcus epidermis 156Staples, growth arrest by 318Stature, skeletal dysplasias 39Steel osteotomy 215Steinert disease 138Sternoclavicular dislocations 284Stiff knee gait, cerebral palsy 22Still's disease see Juvenile chronic
arthritis (JCA): systemicStorage disorders 5(}-3Streptococcus 153, 154, 156Streptomycin 161Stress fractures, tibial shaft 308Structural scoliosis 267Subluxation, lilnb lengthening 321-2Subtalar valgus 124Sulphasalazine 170Supracondylar femoral osteotomy
111Supracondylar fractures, humerus
285-9assessing child 287associated injuries 288classification 285complications 285-6malunion 11-12, 286management 28fr-9
Sutherland osteotomy 215Syme amputation 30, 317Synovectomy
haemostatic disorders 173JCA 172
Index 335
Synovialbenign tumours 97-8osteochondromatosis 97sarconla 99
Syphilis of bone 161Systemic JCA see Juvenile chronic
arthritis (JCA): systemic
Talipescalcaneovalgus 257equinovarus 13, 122see also Congenital talipes
equinovarus (CTEV)Talocalcaneal
angle, congenital talipesequinovarus 252, 253
bar 258, 259, 260Tarsal coalition 258--60Thermal injuries, limb length
inequalities 315Thigh foot angle, torsional profile 184Thomas test 8 'Thomsen disease 138Thoracic lesions, spina bifida 118Thrombocytopenia absent radius
syndrome 199Tibia
congenitaldeficiencies 27, 32-3pseudarthrosi.s 33--4
distal tibial dysplasia-deficiency 33,35
fibrocartilagenous dysplasia 83--4fraeture-separation proximal physis
306fractures 306
avulsion, tubercle 306, 307intercondylar eminence 306, 307proximal metaphyses 308-9shaft 308-9triplanar 309, 310
posteromedial bowing 35, 36pseudarthrosis 34-5shortening 318, 319torsion fr-7, 124vara 248-9
Tibia and fibulafractures 307-10
distal physes 309-10shafts 308
limb length inequalities 313Tibial
hemimelia 27, 32-3osteotomy, Blount diesease 249
Tillaux fracture 309Toddler's fracture, tibial shaft 308Toe
deformities 10overriding fifth 264
-
336 Paed iatric Orthopaed ics
Toe (continued)recurring digital fibroma of Reye 96ulcers, congenital sensory
neuropathy 146walking 133, 190
differential diagnosis 133Tom Smith disease 313TORCH 101Torsional deformities see External
rotation; Internal rotationTorus fractures, forearm 294Total growth plate arrest 322Traction
DDH 210SUFE 232
Transient synovitis, hip 162-4Traumatic
causes, limb length inequality 313dislocation, shoulder 197spondylolisthesis 278-9
Trendelenburggait 3-4, 22, 210test 5
Trevor disease 45, 46Trichorhinophalangeal syndrome 60Trigger thumb 201-2Triplanar fractures, distal tibia 309,
310Triple
arthrodesis, congenital talipesequinovarus 256
osteotomy 215Trisomy 18: 63Trisomy 21: 62-3Trochanteric surgery, DDH 214True shortening, leg length inequality
5Tuberculosis 159-61
hip 160,222spinal 160
Tumoral calcinosis 98Tumours, bone and soft tissue 75-100
benign 78-88, 96, 98biopsy 78diagnosis 75malignant 88-92, 98-9metastatic 92, 93, 94radiology 7(r8
staging 78see also Malignant changes
Turner syndrome 63, 201
Ulnacongenital pseudarthrosis,
neurofibromatosis 57fractures see Forearm: fractures
Ulnar nerve palsy, supracondylarfracture 287, 290
Ultrasoundacute osteomyelitis 151DDH 204, 205-6prenatal diagnosis, spina bifida 117septic arthritis 155
Unicameral bone cyst 84-5,311Unilateral hemimelia 32-3Unstable hips, DDH, management
208Upper femoral dysplasia 21 (r17Upper limb 192-204
arthrogryposis 144assessment 11-12birth palsies 193-5hemiplegic, cerebral palsy 108-9osteochondritic conditions 175-6trauma 283-97
Upper motor neurone lesions 132Upper root injury, obstetric brachial
plexus injury 194
Valgus deformityankle 123, 124foot 108, 111, 121subtalar joint 124
Van Nes rotationplasty 30Vanishing bone disease 87Varus deformity, foot 107, 108
spina bifida 121Vascular
injuries, limb lengthening 322malformations 94,313tumours, benign 94
Vascularizedfibular grafts 35growth plate transfer 325
Vater syndrome 199Vertebra plana, causes 87Vertebral bodies
anterior beaking 42, 51scalloping 57
Vertical talus 124, 25(r7Viral osteopathy 161Vitamin A toxicity 71Vitamin D deficiencies 66, 67Vitamin D-resistant rickets 67, 68-9Volkmann ischaemic contracture 285-
6,288Voluntary dislocation, shoulder 198,
284Von Recklinghausen disease see
NeurofibromatosisVon Rosen splint 208, 209Von Willebrand disease 173
Wagner technique, limb lengthening319-20
Walk, ability tocerebral palsy 109poliomyelitis 145spina bifida 118
Watson-Jones classification, tibialtubercle avulsion 306
Wheelchairs 121White, slide technique, achilles tendon
lengthening 107Wi1m tumour 93Wilson sign 246Woodward procedure, Sprengel
shoulder 197Wormian bones, causes 49Wrist
assessment 12and hand
injuries 297Madelung deformity 59, 60, 63,
201hemiplegia, cerebral palsy 108-9
Z-lengthening, achilles tendon 107Zone of transition, tumour diagnostic
factor 76
-
Copyright 2010 Global HELP OrganizationOriginally published by the WB Saunders Company (Copyright 1997)
www.global-help.org
DeanTypewritten Text
DeanTypewritten TextThis book is designed to provide a text for orthopaedic surgeons in training to a depth required for Fellowship or Board examinations. Many of the contributors have been examiners at this level and give a valuable insight into the knowledge required.
DeanTypewritten TextIn using only contributors from the Orthopaedic Department at the Royal Children's Hospital, Melbourne, the book can provide the expertise in all areas and also combine in a consistency of philosophy and overall management. Appropriate editing has also produced a consistency of style and presentation so the facts can be easily understood and learned.
DeanTypewritten TextThe book should appeal not only to trainees about to take examinations, but also to general orthopaedic surgeons requiring an up-to-date overview of pediatric orthopaedics. Hopefully, it will inspire some young surgeons to pursue a career in an area in which all the contributors feel privileged to be involved.