WCS34 Children's Orthopaedics And Deformities Flashcards
Epiphyseal growth and Ossification centres
Different growth platelets contribute different growth proportion / rate
—> Body proportion changes throughout growth
Ossification centres:
- Gradually ↑ in size and Model into adult form
- Shape into joints
Children vs Adult
Children:
- Remodeling potential
Growth is different in everyone
- Normal variance Hypophosphataemic rickets
- Normal distribution curve
Growth is a process
- Body proportion changes
- Individual variation
- Normal variation may be considered “abnormal”
—> Short stature
—> **Limb length discrepancy
—> **Intoeing
—> **Knock knees / Bowlegs
—> **Flatfoot
Approach to Various problems
Short stature?
- Percentile?
- Height of parents?
- Proportion of body?
- ***Syndromal features?
- ***Skeletal dysplasia?
Bowlegs? Knocked knees? Limb length discrepancy?
- Age?
- Unilateral?
- History of injury?
- Infection?
Intoeing gait?
- Symmetrical?
- Which level?
- ***Neuromuscular problem?
- ***Gait pattern?
Flatfoot?
1. Flexible / ***Rigid?
Evaluation
- Multidisciplinary approach
- Paediatricians, Endocrinologists, Orthopaedic surgeons - History + PE
- Family history
- **Medication affecting Ca absorption (glucocorticoid, anti-epileptics), diet etc.
- Body height
- **Limb deformities
- ***Growth chart (Skeletal maturity: male: 16, female: 14) - Lab exam
- Vit D, Ca, ALP, growth hormone, thyroid hormone, PTH
- Genetic studies - Radiological exam
- X-ray
Evaluation of Short stature
Proportional:
- Familial
- Endocrine
Disproportional:
- ***Achondroplasia
- ***Fibular hemimelia (shortening / absence of fibula)
Evaluation of limb length discrepancy
Is the condition
- Congenital?
- Infection?
- Tumour?
- Trauma?
Limb length discrepancy is NOT uncommon
- 20-30% normal subjects have LLD ***0.5-2cm
- usually compensated well ***<2.5cm, treatment not needed
Causes:
- Congenital
- Proximal femoral focal deficiency
- ***Fibular hemimelia
- Hemihypertrophy - Developmental
- ***Physeal injury / infection
- Ollier’s disease
- Poliomyelitis
Investigations:
1. Gait
Treatment:
- ***Shoe raise
- Limb length equalisation surgery
- **Epiphysiodesis (Stop growth of longer bone)
- **Lengthening (Lengthen shorter bone)
Limb malalignment
- Bowlegs
- Knock knees
- Intoeing
Symptoms:
- Joint pain
Normal lower limb alignment
- normal adults: hip (centre of femoral head), knee, ankle in straight line (***Mechanical axis)
- Anatomical axis: shaft of femur + shaft of tibia (angle ~70o)
- significant deviation —> malalignment
**Normal growth changes:
- Varus till **2 yo (~15o varus)
—> Valgus till ***4 yo (~15o valgus)
—> Normal onwards ~7 yo (~7o valgus) (angle of anatomical axis, NOT mechanical axis) (7歲7度)
Management:
- ***Guided growth control
- Acute surgical correction (if already mature)
Intoeing gait
Walking with excessive inward foot-progression angle
- Very common in children
- 3-10 yo
- 80-95% of increased femoral anteversion will resolve spontaneously by 10 yo
- Part of growth
Causes:
- ***Excessive femoral anteversion (body compensate by excessive internal rotation of femur)
- Increased ***internal tibial torsion (knee normal position but foot intoe)
- ***Metatarsus adductus
Problem:
- foot hit each other —> trip over
Evaluation:
- Distinguish where the deformity is (the ***level of deformity)
Treatment:
- Braces / Shoe modification has ***NO effect in speeding up modeling
- If no symptoms —> no need to treat
Flatfoot
Normal
Standing: Ankle: Valgus
Tiptoe: Ankle becomes Varus (rotation of talus and tarsal bones around calcaneus)
Growth:
- Flatfoot common in young children
- Longitudinal arch develops spontaneously in ***1st decade of life
Causes:
- Loss of normal medial longitudinal arch (∵ ***ligamentous laxity, not fully developed muscle, excessive fat pad in foot)
- ***Forefoot abduction (~ eversion of ankle)
- ***Excessive hindfoot valgus (~ eversion of ankle)
Evaluation:
- Flexible vs Rigid
Treatment:
Rigid: Surgery
Flexible: Orthosis if cannot modify foot arch
