Paediatric Orthopaedics - Normal Growth and Development Flashcards
Describe the normal development of leg alignment
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)
Characteristics of truly abnormal deformities?
ASYMMETRICAL
When is a childhood deformity significant?
Only significant if it is likely to persist and cause physical or mental health problems later in life
How do bones grow?
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
Which physes contribute to growth most in the upper and lower limbs?
Upper limbs - wrist and shoulder contribute most
Lower limbs - knee contributes most
Factors affecting the growth plate?
Nutrition, sunshine, vitamins (Vit D & A)
Injury
Illness
Hormones (GH)
Assessing a child with short stature?
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
Normal stages of development for children?
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
What are “abnormal” features (variations of normal) in children than usually correct with age?
Genu varum/valgum
In-toeing
Curly toes
Flat feet
When is genu varum physiological?
Normal <2 years
Persisting mild genu varum can run in families - REASSURE
Signs that genu varum is pathological?
Unilateral (asymmetry >5 degrees)
If it is severe (>16 degrees from mean)
If the child has a short stature
Painful
Causes of pathological genu varum?
Skeletal dysplasia
Rickets
Tumous, e.g: enchondroma
Blount’s disease - growth arrest of medial tibial physis of unknown aetiology
Trauma (physeal injury)
X-ray sign of Blount’s disease?
Typical beak-like protrusion
ADD BLOUNT’S PICTURE
Pathological causes of genu varum?
Tumours – enchondroma, osteochondroma
Rickets
Neurofibromatosis
Idiopathic
What is intoeing?
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
What is femoral neck anteversion?
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
What is internal tibial torsion?
Inward twisting of the tibia that is usually seen at 1-3 years, with most resolving by 6 years
Surgery only for severe cases
What is metatarsus adductus?
Forefoot is malaligned and faces medially; it is common, benign and tends to resolve
If not passively correctable, serial casting can help
Occurrence of flat feet?
Common in adults and normal in babies; medial arch is developed on walking (as the tibialis posterior is strengthened)
Usually asymptomatic
How to assess flat feet?
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
What is hypermobility?
Joints that easily move beyond the normal range expected; assess using Beighton score
Treatment of rigid flat feet?
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
Describe curly toes
Common in children, usually 3rd/4th toes
Most resolve by 6 years and splinting/taping is ineffective
Rarely, if persistent, consider flexor tenotomy
Describe anterior knee pain
More common in FEMALES than males, esp. adolescents
There is localised patellar tenderness, often worse on climbing stairs/squatting
Ix and treatment of anterior knee pain?
Use radiography and check the hips
Use physiotherapy and most resolve
