Paediatric Orthopaedics - Normal Growth and Development

Question 1

Describe the normal development of leg alignment

Answer 1

Newborn - bow-legged (physiologic genu varum)

Once the child begins walking (1 1/2 to 2 years), the legs straighten

Eventually progresses to being knock-kneed and then straightens again to 6 degrees of knock-kneed (normal)

Question 2

Characteristics of truly abnormal deformities?

Answer 2

ASYMMETRICAL

Question 3

When is a childhood deformity significant?

Answer 3

Only significant if it is likely to persist and cause physical or mental health problems later in life

Question 4

How do bones grow?

Answer 4

Begin as a cartilage model that is replaced with bone, i.e: in newborns, most bone is still cartilage

There is:
• Longitudinal growth from the growth plate (physis) by enchondral ossification

• Circumferential growth from the periosteum by appositional growth

Question 5

Which physes contribute to growth most in the upper and lower limbs?

Answer 5

Upper limbs - wrist and shoulder contribute most

Lower limbs - knee contributes most

Question 6

Factors affecting the growth plate?

Answer 6

Nutrition, sunshine, vitamins (Vit D & A)
Injury
Illness
Hormones (GH)

Question 7

Assessing a child with short stature?

Answer 7

Few children with a below average height have a pathological reason for it, like low GH

Consider the parent’s height

Look for other dysmorphic features, e.g: a flat forehead, that increase the chance of an underlying genetic/endocrine disorder

Question 8

Normal stages of development for children?

Answer 8

6-9 months - sits alone and crawls
8-12 months – stands
14-17 months - walks
24 months - jumps
3 years - manages stairs alone

1-6 months - loss of primitive reflexes (moro, grasp , stepping, fencing)
2 months - head control
9-12 months - few words
14 months - feeds self, uses spoon
18 months - stacks 4 blocks and understands 200 words
3 years - potty trained

Question 9

What are “abnormal” features (variations of normal) in children than usually correct with age?

Answer 9

Genu varum/valgum

In-toeing

Curly toes

Flat feet

Question 10

When is genu varum physiological?

Answer 10

Normal <2 years

Persisting mild genu varum can run in families - REASSURE

Question 11

Signs that genu varum is pathological?

Answer 11

Unilateral (asymmetry >5 degrees)

If it is severe (>16 degrees from mean)

If the child has a short stature

Painful

Question 12

Causes of pathological genu varum?

Answer 12

Skeletal dysplasia

Rickets

Tumous, e.g: enchondroma

Blount’s disease - growth arrest of medial tibial physis of unknown aetiology

Trauma (physeal injury)

Question 13

X-ray sign of Blount’s disease?

Answer 13

Typical beak-like protrusion

ADD BLOUNT’S PICTURE

Question 14

Pathological causes of genu varum?

Answer 14

Tumours – enchondroma, osteochondroma

Rickets

Neurofibromatosis

Idiopathic

Question 15

What is intoeing?

Answer 15

Child walks with toes pointing in (AKA pigeon-toed); often accentuated when running

May be related to femoral neck anteversion, internal tibial torsion, metatarsus adductus or combination

Question 16

What is femoral neck anteversion?

Answer 16

Femoral neck normally points anteriorly

They tend to sit in a “W” position and there is increased internal rotation of the hip

Usually of no consequence but it can predispose to patellofemoral problems; surgery is only indicated for severe deformity

Question 17

What is internal tibial torsion?

Answer 17

Inward twisting of the tibia that is usually seen at 1-3 years, with most resolving by 6 years

Surgery only for severe cases

Question 18

What is metatarsus adductus?

Answer 18

Forefoot is malaligned and faces medially; it is common, benign and tends to resolve

If not passively correctable, serial casting can help

Question 19

Occurrence of flat feet?

Answer 19

Common in adults and normal in babies; medial arch is developed on walking (as the tibialis posterior is strengthened)

Usually asymptomatic

Question 20

How to assess flat feet?

Answer 20

Determine if flexible (e.g: due to generalised ligamentous laxity or tightness of the gastrocsoleus complex) OR fixed

Most resolve and, even if they do not, there are no proven consequences

Use CALF TIGHTNESS ASSESSMENT

Question 21

What is hypermobility?

Answer 21

Joints that easily move beyond the normal range expected; assess using Beighton score

Question 22

Treatment of rigid flat feet?

Answer 22

When the medial longitudinal arch (MLA) is absent or nonfunctional in both the seated and standing positions; sometimes, they may have an underlying bony connection, known as a tarsal coalition

If painful, consider surgery

Question 23

Describe curly toes

Answer 23

Common in children, usually 3rd/4th toes

Most resolve by 6 years and splinting/taping is ineffective

Rarely, if persistent, consider flexor tenotomy

Question 24

Describe anterior knee pain

Answer 24

More common in FEMALES than males, esp. adolescents

There is localised patellar tenderness, often worse on climbing stairs/squatting

Question 25

Ix and treatment of anterior knee pain?

Answer 25

Use radiography and check the hips

Use physiotherapy and most resolve