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Orthopedic Problems in Children
Orthopedic Problems 1n Children JACOB F. KATZ, M.D., F.A.C.S. Assistant Attending Surgeon and Chairman, Orthopedic Clinic, Outpatient Department, The Mount Sinai Hospital, New York, N.Y.
THE orthopedic problems of childhood represent diverse derangements of musculoskeletal structure and function. Some abnormal states exist at birth and include various limb and vertebral deformities and defects such as congenital hip dislocation and absent or malformed limbs. Others, such as slipped femoral capital epiphysis and scoliosis, appear later in childhood and early adolescence but are distinctive in that they occur only in these age groups. Finally there are those conditions which occur in children in greater or lesser frequency but may also occur in adults, such as fractures, bone infections and bone tumors. This presentation does not presume to include all problems of orthopedic interest in childhood. Examples in the several categories referred to above will be given and some of the more common problems will be dealt with in considerable detail. CONGENITAL AND NEONATAL DEFORMITIES
Torticollis12 There are several types of congenital torticollis or wryneck. In the first variety, the etiological factor is a vertebral deformity usually of hemivertebrae, which is evident upon radiographic examination. In the second category, there is a congenitally short sternomastoid muscle which is evident at birth. The third variety, by far the commonest one, is the sternomastoid contracture. Here, at birth or within days afterwards, a hard, localized thickening is palpable and visible in the sternomastoid muscle. This gradually disappears, leaving an apparent state of normalcy. Fibrosis sets in and torticollis, because of relative shortness of the muscle, then develops months to years later. Treatment in the milder cases of torticollis is usually manipulation and stretching of the neck carried out by the mother. In the more resistant cases, especially where there is associated facial asymmetry,
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treatment consists of tenotomy of the sternomastoid muscle at its clavicular ends and severance of its fascia. A bandage swathe form of light collar may be prescribed for several months postoperatively. What is most important, however, is continuation of manipulative stretching of the neck in the after-surgical period for about four to six months. Relief is satisfactory and facial asymmetry gradually lessens with additional growth and remodeling. Congenital Anomalies of the Hand1
According to Barsky, SYNDACTYLY (webbed fingers) is the most common congenital deformity of the hand. Syndactyly may be unilateral or bilateral, symmetrical or asymmetrical. The middle and ring fingers are most frequently involved. It may be shallow in some instances, while in others the web may extend the entire length of the joined digits. It may be complicated by fusion of the bones and occasionally of tendons and nerves. Before any operation, study should include x-rays to assay the bone status. If growth and development are deemed to be in jeopardy, operation to separate the digits should be performed early, usually at two or three years of age, when the digits have grown to sufficient practical length. Repair is accomplished either by flap formation or use of free skin graft. Barsky favors a combined procedure dividing the web and skin-grafting the raw areas so produced. POLYDACTYLY (supernumerary fingers) ranges from doubling of a simple phalanx to complete duplication of a limb. Polydactyly tends to be inherited and may also be associated with other anomalies such as syndactyly. Although the extra digit may be completely developed with its own accessory structures, it is commonly rudimentary. There is a tendency for the supernumerary digit to be marginal, either to the radial or ulnar side of the hand. Surgical operation is the treatment of choice. When an extra digit with bifurcation of the metacarpal is present, it is recommended that the bifurcation elements of the bony components of the several digits as well as the tendon and nerve supply be removed so that the proper digit is retained. Other defects are BRACHYDACTYLY (short fingers), BRACHYSYNDACTYLY, SYMPHALANGISM (end-to-end fusion of phalanges), ANNULAR GROOVES Or BANDS, ECTRODACTYLY (absence of one or more digits), MACRODACTYLY (hypertrophy of the digits) and CLINODACTYLY (bent or deviated finger). Some of these conditions do not require therapy. Macrodactyly may require shortening of the phalanx; ectrodactyly may require shifting of fingers particularly where the absence is of the thumb. Other congenital defects include CLUB HAND in which the distal portion of the limb is defective causing deviation in position of the hand. There may be asymmetrical growth or absence of a forearm bone producing a
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similar deviation. Treatment is difficult because of the problem of disturbance of growth and usually combines conservative manipulation with splinting followed by graft stabilization. The results are not predictably satisfactory. Finally, there are cases of ABSENCE OF ARM OR LEG with retention of hand or foot. This usually remains an orthopedic enigma for which little can be done beyond rehabilitation of existing structures or the provision of a prosthesis. Congenital Anomalies of the Legs and Feet12
In the lower extremities, similar congenital defects occur such as syndactylism and accessory digits. For syndactyly, treatment is rarely required. Supernumerary toes are usually removed, especially if they create abnormal widening of the foot. CoNGENITAL HALLUX VARUS with prominent inward displacement of the great toe requires surgical realignment to avoid difficulties from shoe pressure. CALCANEONAVICULAR FUSION may be symptomatic and produce a rigid flat foot. Occasionally the bridge between calcaneus and navicular is incomplete on x-ray but functionally a similar symptomatic picture may result. The foot is held in rigid valgus and is painful. Treatment may be conservative in the form of plaster cast immobilization and later prescription of metallic arch supports. For persisting discomfort, stabilization of the hind foot with triple arthrodesis usually affords relief. METATARSUS VARUS is a condition in which the heel and posterior part of the foot are normal in their relation to the leg but the metatarsals swing inwardly and therefore produce a concavity of the inner border of the foot. There is considerable variation in severity of this condition. Treatment consists in remolding the foot in plaster casts or using outflare shoes for a similar purpose. 'Vith additional growth under such corrective pressure, the foot gradually assumes a normal form. TALIPES CALCANEOVALGUS is usually a malleable flexible deformity in which the foot is held in prominent calcaneus and some valgus. Treatment is not necessary for milder degrees of this deformity. Bandaging or holding the feet in corrected attitude by utilizing a Denis-Browne splint usually suffices for the severer cases. CoNGENITAL FLAT FOOT or vertical talus is manifested by an equinus position of the talus and a marked valgus of the remainder of the foot resulting in convexity of the inner border of the foot. Attempts are made to mold the foot into a calcaneocavus position and retain in correction in plaster. This may not be adequate for permanent restoration of form, and surgical fusion has to be considered. TALIPES EQUINOVARUS is a foot deformity identified by plantar flexion
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of the talus, inversion of the calcaneus and adduction of the forefoot. The severity at times is such that the adduction and inversion cause the sole of the foot to face backward. With persistence of the deformity there is further contracture of the soft tissues on the medial and plantar aspects of the foot. In the inverted attitude the Achilles tendon further aggravates this malposition. Classically, correction here is more difficult to obtain and maintain than in the other forms of congenital deviations. Treatment in the newborn consists in molding the foot into an overcorrected attitude. In the first days of life this may be in the form of a bandage but soon thereafter is changed to gradual correction and maintenance in plaster casts. Changes are made on a regular basis every week or two depending on the rapidity of growth. There is usually an orderly progression of corrective force application beginning with correction of the forefoot adduction, then the hind foot inversion and finally the equinus. The correction should be maintained until the child walks and thereafter splints should be worn at night for several years. If vigilance is relaxed after initial correction is attained, recurrence must be accepted. Even under most meticulous treatment and supervision, a tendency to recur must at times be thwarted by permanent foot stabilization in later childhood. Where adequate correction of the condition has not taken place despite a good conservative program of progressive corrections in plaster and later in Denis-Browne splint, surgical procedures are carried out. For persistent equinus, heel cord lengthening and posterior ankle capsulotomy usually suffice to effect a corrected functional status. For persistent varus of the heel and forefoot in a child not yet old enough (usually three to five years) to undergo definitive bone stabilization and wedge resection, soft tissue release is done. 11 This includes tendon lengthenings as well as capsular strippings and ligamentous excisions over the medial border of the foot, extensive enough to allow swinging out of the foot under the talus and improving the alignment between the talus and the navicular head. In the older children (over eight years) with relapsed deformity or incomplete correction of club foot, definitive bone surgery utilizing wedge resections and triple arthrodeses gives good results. CONGENITAL ANGULATION OR BOWING OF THE TIBIA 7 is a relatively rare orthopedic condition. In one variety there is a forward and lateral tibial angulation, and pseudarthrosis eventually develops. The bone is usually small and sclerotic and the medullary canal is diminished. It is variously ascribed to neurofibromatosis, fibrocystic lesion or some form of congenital insufficiency. Healing of the pseudarthrosis by any of the conventional bone grafting techniques is notoriously difficult to achieve.
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Repeated surgical intervention is the rule with its protracted invalidism and inevitable limb shortening, atrophy and contractural deformities. In late cases so much shortening and deformity may have developed that the unfortunate choice of amputation puug tting with a prosthesis remains if rehabilitation and return of the child to a useful existence are to take place. When healing following operation does take place, prolonged observation is required to determine the maintenance of such continuity, for on occasion re-fracture occurs and new pseudarthrosis may develop. In a second variety, congenital angulations of the tibia are characterized by anterior bowing associated with a shortening of the calf muscles. There is also concomitant resistant talipes equinus. Here spontaneous fracture and pseudarthrosis are not the rule. However, the condition may be further complicated by other anomalies such as absence of portions of the foot, absent fibula and congenital hip dislocation. There is usually marked shortening of the entire lower extremity. In a third group the congenital angulation of the tibia is backward and medial bowing is usually present at the middle and lower thirds of the tibia and fibula. There is associated severe talipes calcaneus, tightness of the anterior leg muscles, weakness of the calf and shortening of the leg. There is no unusual tendency to fracture. Treatment along conservative lines utilizing braces and physical therapy often yields surprisingly good late correction and function. TIBIAL TORSION 13 has been accepted as a designation of a twist or rotation of the tibia on its longitudinal axis. This results in a change of alignment of the planes of motion of the proximal (knee) and distal (ankle) articulations. In its most benign manifestation this distortion produces varying degrees of toeing-in or toeing-out gait patterns. It has been noted that some correlation exists between static forces in a growing child and the subsequent development of tibial torsion. Children in the habit of sleeping upon the abdomen with the feet turned inward and the lower extremities flexed at the hip and knee have been noted to develop internal tibial torsion. Children who sit on their legs habitually with the knees flexed and the feet externally rotated may develop external tibial torsion. Extreme degrees of external torsion are occasionally found in paralytic extremities in which outward rotation results from gravitational effects (paraplegia) or need for stability with only minimal hip external rotators still functional (poliomyelitis). Severe internal torsion often accompanies club feet and metatarsus varus. From a practical clinical consideration, however, the majority of children with torsion who are brought for treatment have internal tibial torsion. Some of the patients undergo spontaneous correction in the milder variety of torsion and in them a short period of observation is
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warranted. Nevertheless, it has been found that correction in very young children is readily obtained by the use of Denis-Browne splints, to which shoes are attached and adjusted to maintain the extremities in outward rotation. In the neglected child who is older (three years or more), derotation tibial osteotomy is done, as use of a splint is no longer practical. Healing is usually prompt and reliable and the ensuing disability only of short duration. Congenital Dysplasia of the Hip Joint 6
The etiology of congenital dysplasia of the hip joint is not known with certainty. The actual or potential primary malformation is an inadequate acetabulum with an insufficient roof or buttress for stability of the head of the femur. There is an associated lag in endochondral ossification of the superior border of this acetabular rim. In the newborn infant congenital dislocation of the hip exists (or may exist) usually as a potential rather than an actual dislocation of the hip. During the early months of life, it frequently is only a persistence of the hip structures in the fetal cartilaginous state, a delayed ossification of either the femoral head or the acetabulum or both. Early recognition is extremely important as treatment, to be most effective, must be started before the cartilaginous structures become malformed through the pressures applied on them by muscle pull and weight bearing. CLINICAL FINDINGS
Abduction of the flexed hip joint is practically always limited in subluxation by contracture of the adductor group of muscles. In a normal relaxed infant with the knees and hips flexed 90 degrees, the knees may be spread apart and the hips abducted about 80 degrees. Shortening from the pelvis to the knee is frequently demonstrated by comparing the knee levels with knees and hips flexed 90 degrees. This is not frequently positive early since complete displacement is not common during infancy. Ortolani' s test for the "sign of the jerk" is extremely valuable. The jerk or snap occurs as the fovea of the femoral head suddenly meets and rides over the acetabulum ridge. There may be a "click of entry" or "click of exit" as the femoral head makes its entrance or its exit from the socket. Telescoping may be possible when the hip is flexed because the acetabular defect is more posterior and inferior than superior. Other common clinical findings are extra skin folds and creases along the adductor aspect of the thigh, and deeper and more cephalad in·
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guinal and gluteal creases. However, skin fold deviations are also frequently observed in normal children. RoENTGEN FEATURES
Roentgen findings of congenital dysplasia with subluxation of the femoral head are definite and positive after the appearance of the ossification center for the head of the femur. During the first two or three months of life the ossification center of the femoral head is usually absent. X-ray interpretations are difficult and measurements permit considerable chance of error. A push-pull technique may add valuable information to the x-ray, demonstrating instability due to capsular relaxation, plasticity of the cartilaginous acetabular roof and femoral head displacement. Various measurements can be made on the x-ray to assist in the diagnosis. The acetabular index is measured by the angle formed by the junction of a line transversely drawn at the depth of the sockets with one through the lateral border of the socket. Kleinberg and Lieberman regarded 30 degrees or over to be abnormal. Caffey denies this and believes that the range is greater. Shenton's line in a normal hip is an even arc formed by the medial border of the neck of the femur and superior border of the obturator foramen. This line is broken and eccentric with femoral head displacement in a child with congenital dislocation when proper attention to positioning on the x-ray table is taken. TREATMENT
Treatment should be instituted as early as possible and preferably before weight bearing has started. For dysplasia without displacement, an abduction pillow splint devised by Frejka still enjoys a considerable popularity. It permits active functional immobilization. It gradually overcomes the adduction contracture and permits better seating of the femoral head in the socket. Certain disadvantages in diaper hygiene have prompted the development of substitute measures for obtaining similar gradual abduction. These have been metallic bars with thigh cuffs. By gradually bending the bar into greater abduction the relaxation of the adductor tightness has been similarly obtained. The advantage here is of ease in diapering the infant since the buttock and perineal areas are exposed. Where the femoral head is displaced (Fig. 1), simple abduction splints cannot be used until after reduction has been accomplished. The essence of modern therapy is gentleness of reduction. Violent manipulative methods have caused later secondary head changes which compromised the final smooth functions of the hip. The recommendation for slow,
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Fig. 1. Congenital dislocation of the hip with prominent upward displacement of the femoral head. Note the shallow acetabular roof and the smaller ossific nucleus of the femoral head on the involved side.
controlled reduction by the employment of traction preliminary to immobilization is almost universally endorsed. Where reduction cannot be effected by the routine mentioned above because of the severity of secondary deforming adaptive changes, open reduction is done. Results vary with the promptness, simplicity and gentleness of the treatment. Although good results have been obtained, they tend to be less reliable. Surgery may assume the form of simple replacement of the femoral head into its socket with immobilization thereafter in a plaster splint. If stability and adequate concentric positioning of the femoral head is not assured, acetabular shelf construction and derotation osteotomy may be added either simultaneously or serially in the course of the convalescence.
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ORTHOPEDIC PROBLEMS APPEARING LATER IN CHILDHOOD
Structural Scoliosis9
Scoliosis refers to lateral curvature of the spine. Normally the spinal column is straight and does not present lateral curves. Scoliosis is said to be structural if there is fixed vertebral rotation. On examination of a patient with structural scoliosis a lateral curve can be identified with compensatory curves above and below the main or primary curve. The function of the compensatory curves is to maintain body balance and to keep the head centered over the pelvis. Where such balance is successfully achieved despite the asymmetry of the trunk, the scoliosis is said to be compensated whereas if trunk balance is not attained, the scoliosis is described as uncompensated. Scoliosis has been classified according to its causes, of which there are many. The largest group still remains the so-called idiopathic scoliosis for which no reliable cause has yet been found. Its prognosis is linked to the site of the primary curve as well as the age at which it commences. Scoliosis increases in its severity as skeletal growth takes place. When skeletal growth is completed the progression of lateral curvature usually ceases. A useful indicator of the skeletal maturity of the vertebral column is the growth of the iliac apophysis which starts anteriorly and extends posteriorly. As it reaches the posterior superior iliac spine one can assume that vertebral maturity has been attained. In order to record a given curvature status it is necessary to measure the angle of curvature. The uppermost and the lowermost vertebrae of a primary curve show no rotation of the spinous process and the discs are not asymmetrically compressed in a wedge deformity at these extremities. Transverse lines are drawn at the borders of these vertebrae at the end of the curve and perpendiculars are erected to them. The angle at which they intersect represents the angular equivalent of the deformity. 1. Idiopathic scoliosis can theoretically occur at any portion of the vertebral column. It is most common, however, at the thoracic and lumbar areas as isolated regional deformity or combinations over several zones. 2. Congenital Scoliosis. This form of vertebral curvature is associated with anomalies. The latter may be manifest as hemivertebrae, absent ribs, vertebral body coalition or other varieties of deformities. Although generally the extent of cosmetic defect is mild and slowly progressive, there are occasional exceptions, particularly in the thoracic area. 3. Paralytic Scoliosis. Just as in the other varieties of scoliosis, any portion of the vertebral column may be involved. Prognosis in this group
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is related to the degree of paralysis and resultant trunk imbalance as well as the age of onset of the paralytic disease. 4. A miscellaneous group of scolioses of less common incidence includes that in neurofibromatosis, where the curve tends to be severe and rigid; neuropathic and myopathic as in Friedreich's ataxia, syringomyelia, arthrogryposis, muscular dystrophy, etc.; thoracogenic, as after empyema and thoracoplasty. The last is now fortunately rare. TREATMENT
Conservative treatment traditionally included varieties of exercises in combination with some modality of spinal support as cast, brace or corset. Since these were disappointing in prevention of progression in specific instances, other varieties of control were devised and tried. Periods of bed rest with and without traction offered temporary deterrents especially in idiopathic scoliosis, where relief from the gravitational element appeared beneficial. This was less reliable in the paralytic group where muscle imbalances continued to operate even in recumbency. Another more recent device in this direction has been the Milwaukee brace with its principle of gravity-distracting turnbuckles exerting head and neck support against a base on the pelvis. Usually, however, the problem is concerned with identification of the scoliosis and a study of its pattern of change with growth. Surgery is usually necessary where curves progress rapidly causing severe deformity or threatening to produce it. Surgical stabilization after some form of plaster cast correction remains the procedure of choice. There is still some question about the best age for surgical treatment of progressive scoliosis. At skeletal maturity, dealing with the curvature affords the reassuring prospect of avoiding recurrence of deformity through additional years of growth. However, should the curvature by that time have developed such rigidity and rib rotation fixity that correction can at best be slight or inadequate, a valuable opportunity has been missed (Fig. 2, A, B). On the basis of previous studies of curve patterns, especially in idiopathic scoliosis, thoracic curvatures of rapid progression should be anticipated by fusion at ages earlier than maturity and probably at age 10 to 12 years. In paralytic scoliosis, surgical stabilization is required more frequently than in the idiopathic or other varieties. Because of the associated physical handicaps and the rapid progression of the curve, surgery is required at ages somewhat younger than in the idiopathic group.
Slipped Capital Femoral Epiphysisto, ta A child in early adolescence who limps or complains of pain in the region of the hip, anterior part of the thigh or the knee, or all, should be
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Fig. 2. A, Idiopathic thoracic scoliosis in a 5 year old child. B, Progression and worsening of the curvature after prolonged conservative management 7 years later.
suspected of having a slipped capital femoral epiphysis (Fig. 3). The average age is 13 years in boys and 12 years in girls, and it occurs somewhat more frequently in males. During examination of the suspected hip, in the course of flexion, the limb tends to go into external rotation even where the limitation iri internal rotation is slight. The diagnosis is confirmed by roentgenograms made in the anteroposterior and lateral projections in which the femoral head is identified as either posterior or medial relative to the neck. As a result of slipping of the femoral head, the anterolateral portion of the femoral neck adjacent to the epiphysis becomes devoid of head contact and an angular contour is presented. This subsequently becomes rounded off as adaptive changes supervene. In addition, periosteal proliferation proceeds at the posteromedial portion of the femoral neck,
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Fig. 3. Acute slip of the femoral capital epiphysis. This followed trauma, and the lack of periosteal reaction or remodeling confirmed the short duration of the process.
adding to the deformity. The deformity arises as a result of the weakening of the bond between the epiphysis and the neck of the femur. The resulting displacement seems to be the effect of the normal shearing strains on this site. The predisposing element having been established, the displacement may be precipitated by a single minor injury, or may gradually develop over a period of weeks or months. There are several categories of femoral head slipping: 1. That associated with a history of recent trauma and acute disability in an otherwise previously normal hip joint. Here adaptive changes are usually absent or slight and cautious reduction may be accomplished by skeletal traction applied over a period of time and followed by nailing of the epiphysis through a lateral thigh approach. If slipping is minimal, reduction need not be attempted and nailing can be instituted promptly, using the same technique as in femoral neck fractures through a lateral incision. Wilson defined minimal slip as one which in the anteroposterior view showed the upper border of the epiphysis to be above the upper surface of the neck and in the lateral view to be displaced posteriorly not more than one-third of the diameter of the neck. 2. That with history of gradual onset of increasing and persisting disability of the hip. In this group, prompt nailing is also the procedure of choice lest the usually mild slip be complicated by further slipping.
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3. That with history of recurrent periods of disability alternating with periods of quiescence and presenting physical findings consistent with the diagnosis. In this group, a pronounced slip, for which open surgery is apt to be recommended, is likely to be present. In recent years osteotomy through or close to the epiphyseal plate and accurate replacement of the epiphysis on the femoral neck were proposed. Stability was added by a Smith-Petersen nail or multiple threaded wires such as the Telson. Because of the threat as well as the significant incidence of avascular necrosis of the femoral head following such correction, there has developed a cautious attitude and reluctance to favor this operative procedure. Rather, the position of altered head-neck displacement has been accepted and a compromise procedure utilizing trochanteric or subtrochanteric osteotomy for correction of the coxa vara has been substituted. In the minimal slip category following Smith-Petersen nailing and stabilization, the leg is placed in Buck's extension for mild traction until the postoperative reaction has subsided, usually about one week. Active motion is then gradually permitted and, after several weeks, partial weight bearing on crutches is commenced since muscle spasm has probably then disappeared. Thereafter, free weight bearing may be permitted. In the severe chronic epiphyseal slip where the surgery involved is osteotomy for correction, the length of time for protection varies with evidence of sound bone healing and requires three or more months. ORTHOPEDIC CONDITIONS OF CHILDREN WHICH ALSO AFFECT ADULTS
Acute Osteomyelitis1
Hematogenous osteomyelitis is a disease which may occur at any age but is most common in childhood. The primary focus is often a skin infection which may appear innocuous. Early treatment of such minor conditions today prevents disseminating sepsis and distant localizations. Blood gets to long bones via the nutrient artery and the smaller vessels which enter the metaphysis. It is accepted generally that. the bone focus arises in the vicinity of the end arteries of the metaphysis. Such local infection results in thrombosis with secondary death of the adjacent bone. As the infection spreads toward the medulla and along the vascular channels to the subperiosteal area there is stripping of the periosteum leading to death of the underlying cortex. Osteomyelitis resulting from blood stream infection may show signs only of septicemia at first. As the disease progresses there is local tender-
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ness, heat and swelling of the bone and often effusion into the neighboring joint. Radiography is of little value initially except as a basis for comparison. As bone decalcification or periosteal bone formation takes place, x-ray changes reflect these processes but several days are needed to identify them. TREATMENT
Treatment must be prompt. Aspiration over the point of greatest tenderness may yield pus which is diagnostic and affords informatiou both as to drug sensitivity and offending organism. Since many such infections are caused by staphylococci which are likely to be sensitive to penicillin, this drug is given promptly and in large doses (1 million units or more daily); lest the initially unidentified organism be penicillin-resistant, other drugs may be given simultaneously (Chloromycetin or achromycin) until the laboratory data on drug sensitivity are obtained. After laboratory data confirm the organism and its sensitivity to specific antibiotics, the adjustment is then made as necessary. Treatment is usually continued for about a month if x-ray changes are slight to absent and for several months if there is evidence of bone necrosis. In case of subperiosteal abscess formation, evacuation of the pus with drilling and saucerization followed by primary closure may be done where adequate organism sensitivity has been demonstrated to the antibiotic. Proper support of the involved limb by judicious plaster splinting adds to the patient's comfort. Repeated blood counts and erythrocyte sedimentation rate determinations permit following of the patient's systemic response to the infection and assist in the assay of healing and subsidence of the inflammatory processes. Fractures in Children 3
Fractures in children pose certain problems beyond those common to comparable skeletal injuries in adults. The diagnosis by x-ray is confused by epiphyseal lines, nutrient blood vascular channels, dense growth lines, congenital fractures and absent ossific centers at ends of long bones at certain ages. End results are more predictable in adults. The growth factor in children introduces an additional element of uncertainty because of possible late deformity. In case of crushing epiphyseal injuries, retardation in growth can be expected. The principles of treatment are usually simple and usually conservative. Fractures in children can heal with indifferent treatment but on occasion less than meticulous reduction and care may produce disastrous
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results. This is particularly so in fractures of the lower humerus and elbow. In therapy, alignment is most important. Gross angulation awl rotation should be corrected. Slight angulation is usually compatible with perfect end results. Advantage may be taken of the tendency to spontaneous correction of angulation in fractures under certain conditions. The younger the child and the nearer the fracture to the end of the bone, the more angulation can be accepted. The most complete spontaneous correction of angular deformity occurs when the angulation is in the plane of motion of a neighboring hinge joint. Rotational deformities tend to persist. The femoral neck fracture in children, though rare, requires restoration of the angle of the neck. Coxa vara, if present following fracture, tends to persist if uncorrected. Apposition (end-to-end contact) and moderate shortening are not as significant in children as in adults. Long bones may be permitted to heal with side-to-side apposition in youngsters as old as ten years with assurance that remodeling will result in normalcy by the time growth is terminated. In very young children, side-to-side union is even desirable since there is a stimulus to accelerated growth. Except for specific fractures about the elbow and occasional articular fractures, treatment should be conservative, employing traction or manipulation as necessary followed by plaster cast immobilization. Bone Tumors4
SIMPLE CYsT (Fig. 4). Simple or "unicameral" cyst of bone is of unknown cause. Although not a bone tumor by definition, it is included here since it must be considered diagnostically as a lytic lesion. It is relatively common and usually becomes manifest during the first two decades of life. In most cases it occurs in the upper part of the diaphysis of the humerus, the diaphysis of the femur and the proximal part of the diaphysis of the tibia, in that order of frequency. Clinically, the patient with a simple cyst may have local pain but in most cases the cyst comes to attention only after pathologic fracture has occurred. Treatment consists of curettage of the wall of the cyst with complete evacuation of its contents. Bone chips are ordinarily used to fill the defect. There is a 50 per cent recurrence rate if the patient is less than ten years of age, in which cases the cyst is usually juxta-epiphyseal in location. The chance for permanent cure is better in patients who are more than ten years of age, for in them the cyst has been left behind by the growing epiphyseal line. OsTEOCHONDROMA (Exostosis). This is the most common of the benign bone tumors. The bony mass is produced by progressive en-
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Fig. 4. A, Bone cyst in the upper femoral shaft. This was discovered because of pain associated with an incomplete fracture which healed spontaneously. B, Status 4 months after curettage and packing with bone chips. C, Status 2~ years later showing practically complete obliteration of the cyst and incorporation of the bone chip grafts. ·
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Fig. 5. Osteoid osteoma in the lower third of the femur of a 6 year old child. The characteristic central zone surrounded by reactive sclerosis is well demonstrated.
chrondral ossification of its growing cartilaginous cap. Growth of the tumor usually parallels that of the patient and often it becomes quiescent when the epiphyses have closed. A great number are asymptomatic and may never be discovered. Osteochondromas may occur on any bone that develops by enchondral ossification. They usually occur in the metaphysial region of the long bones of the limbs, more commonly the femur and humerus. Palpable mass is usually the only finding. Symptoms may arise from secondary effects of the tumor's impingement on adjacent structures. If symptoms are troublesome or there is an abnormal increase in size, complete excision commonly results in cure. OsTEOID OsTEOMA (Fig. 5). This distinctive benign osteoblastic lesion consists of a small oval or round mass associated with a surrounding zone of sclerotic bone. This tumor has a predilection for the younger age group. It commonly affects the lower extremities. The most important complaint is pain of gradually progressive severity. There may be localized tenderness and adjacent joint dysfunction. The treatment is surgical removal of the nidus. For complete removal, a small margin of adjacent bone should be removed and whenever pos-
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Fig. 6. Fibroma in the lower third of the tibia accidentally discovered following pathologic fracture. Its ec<'entric location, loculation and slight cortical bulge are common features.
sible the lesion should be removed en bloc. Complete removal results in cure. FIBROMA (Fig. 6). This is a rarefying lesion ordinarily affecting a metaphysis of a long bone. It is benign and often asymptomatic. It may be discovered accidentally or in investigation of a fracture. It is almost always eccentrically located in the metaphysis and sometimes produces a bulging of one cortex. The tumor is readily eradicated by curettage and filling with bone chips, if any treatment is elected. Smaller lesions may be left alone if their identity can be established confidently from x-ray, otherwise diagnosis and therapy can be combined through surgical attack. OsTEOGENIC SARCOMA. This highly malignant tumor has its peak incidence in the second decade of life, although children in their preteens have been affected as well. The metaphysial portion of the long
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bones represents the site of greatest predilection. Pain and swelling are the major symptoms. A painful mass in the involved area is often found. Histologically, there is great variation in its morphology but the stroma is frankly sarcomatous and somewhere in the tumor mass osteoid or bone can be found. It is radioresistant and the treatment is usually amputation when that is feasible. Five-year survival rates of 15 to 20 per cent have been reported. EWING's TuMOR. This has been branded the most lethal of bone tumors. It is a small, round cell sarcoma whose parent tissue has been a subject of controversy. It is generally believed to arise from undifferentiated mesenchyme. Its incidence in the young age group is well established. Many of the tumors are found in the extremities but any bone may be involved. Any portion of a long bone may show this localization. Pain and swelling are again the commonest symptoms. Palpable, tender mass may be found on examination. Sometimes an associated elevated temperature may make the differential diagnosis from osteomyelitis a necessary one. The lesion usually is more extensive than the x-ray changes suggest. These changes are a combination of lytic destruction and secondary new bone formation. The latter may take the form of subperiosteal bone producing the so-called "onion skin" appearance of Ewing's tumor. Treatment is discouraging in its effects. Five-year survival rates have been reported ranging from zero to 12 per cent with amputation, x-ray therapy or a combination of both. OTHER PROBLEMS
Orthopedic conditions not included in this presentation are not to be construed as of lesser importance or significance. Poliomyelitis carries in its wake a host of complicated reconstruction problems involving tendon transfers and joint stabilizations. 1 Cerebral palsy in its great variety of forms often poses decisions carrying grave consequences in rehabilitation or in aggravation of disability, and requires the expert services of ancillary rehabilitation personnel. Arthrogryposis multiplex congenita with its joint contractures causing upper and lower extremity dysfunction may require the best techniques of orthopedic surgery for restoration of useful limb functions. Bone and joint tuberculosis, though of lesser frequency in our modern American society through suitable public health as well as chemotherapeutic measures, cannot be denied as a vital and recurring challenge demanding vigilance for its detection. Its ravages of limbs and spine have been mollified by prompt, effective drug therapy and appropriate surgery where indicated. Metabolic and endocrinologic changes in bones are important associa-
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tions of more generalized disturbances of the body economy and are handled in conjunction with other specific medical disciplines. SUMMARY
Highlights of childhood orthopedic problems have been presented and their therapy briefly indicated. A gross categorization was attempted using the incidence of pathologic states in certain age groups as a base. This was practical for some conditions but not for others which occurred in all age ranges. Some conditions have been emphasized because of their frequency and seriousness, others because of the complexity of the problem of therapy. REFERENCES 1. Barsky, A. J.: Congenital Anomalies of Hand and Their Surgical Treatment. Springfield, Ill., Charles C Thomas, 1958. 2. Blount, W. P.: Fractures in Children. Baltimore, Williams & Wilkins Co., 1957. 3. Dahlin, D. C.: Bone Tumors. Springfield, Ill., Charles C Thomas, 1957. 4. Ellis, V. H.: Modern Trends in Orthopedics. 1st Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1950. 5. Forrester-Brown, M.: Modern Trends in Orthopedics. 1st Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1950. 6. Hart, V. L.: Congenital Dysplasia of Hip Joint and Sequelae. Springfield, Ill., Charles C Thomas, 1952. 7. Heyman, C. H. and Herndon, C. H.: Congenital Posterior Angulation of Tibia. J. Bone & Joint Surg. 31-A: 571-580, 1949. 8. Hutter, C. G. and Scott, W.: Tibial Torsion. J. Bone & Joint Surg. 31-A: 511518,1949. 9. James, J. I. P.: Modern Trends in Diseases of the Vertebral Column. Edited by Reginald Nassim and H. Jackson Burrows. New York, Paul B. Hoeber, 1959. 10. Klein, A., Joplin, R. J., Reidy, J. A. and Hanelin, J.: Slipped Capital Femoral Epiphysis. Springfield, Ill., Charles C Thomas, 1953. 11. Mcqauley, J. C. Jr.: Surgical Treatment of Club Foot. S. CLIN. NoRTH AMERICA 31: 561-574 (April) 1951. 12. McFarland, Bryan: Modern Trends in Orthopedics. 1st Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1950. 13. Scott, J. C.: Modern Trends in Orthopedics. 2nd Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1956. 30 East 60th Street New York 22, N.Y.
THE orthopedic problems of childhood represent diverse derangements of musculoskeletal structure and function. Some abnormal states exist at birth and include various limb and vertebral deformities and defects such as congenital hip dislocation and absent or malformed limbs. Others, such as slipped femoral capital epiphysis and scoliosis, appear later in childhood and early adolescence but are distinctive in that they occur only in these age groups. Finally there are those conditions which occur in children in greater or lesser frequency but may also occur in adults, such as fractures, bone infections and bone tumors. This presentation does not presume to include all problems of orthopedic interest in childhood. Examples in the several categories referred to above will be given and some of the more common problems will be dealt with in considerable detail. CONGENITAL AND NEONATAL DEFORMITIES
Torticollis12 There are several types of congenital torticollis or wryneck. In the first variety, the etiological factor is a vertebral deformity usually of hemivertebrae, which is evident upon radiographic examination. In the second category, there is a congenitally short sternomastoid muscle which is evident at birth. The third variety, by far the commonest one, is the sternomastoid contracture. Here, at birth or within days afterwards, a hard, localized thickening is palpable and visible in the sternomastoid muscle. This gradually disappears, leaving an apparent state of normalcy. Fibrosis sets in and torticollis, because of relative shortness of the muscle, then develops months to years later. Treatment in the milder cases of torticollis is usually manipulation and stretching of the neck carried out by the mother. In the more resistant cases, especially where there is associated facial asymmetry,
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treatment consists of tenotomy of the sternomastoid muscle at its clavicular ends and severance of its fascia. A bandage swathe form of light collar may be prescribed for several months postoperatively. What is most important, however, is continuation of manipulative stretching of the neck in the after-surgical period for about four to six months. Relief is satisfactory and facial asymmetry gradually lessens with additional growth and remodeling. Congenital Anomalies of the Hand1
According to Barsky, SYNDACTYLY (webbed fingers) is the most common congenital deformity of the hand. Syndactyly may be unilateral or bilateral, symmetrical or asymmetrical. The middle and ring fingers are most frequently involved. It may be shallow in some instances, while in others the web may extend the entire length of the joined digits. It may be complicated by fusion of the bones and occasionally of tendons and nerves. Before any operation, study should include x-rays to assay the bone status. If growth and development are deemed to be in jeopardy, operation to separate the digits should be performed early, usually at two or three years of age, when the digits have grown to sufficient practical length. Repair is accomplished either by flap formation or use of free skin graft. Barsky favors a combined procedure dividing the web and skin-grafting the raw areas so produced. POLYDACTYLY (supernumerary fingers) ranges from doubling of a simple phalanx to complete duplication of a limb. Polydactyly tends to be inherited and may also be associated with other anomalies such as syndactyly. Although the extra digit may be completely developed with its own accessory structures, it is commonly rudimentary. There is a tendency for the supernumerary digit to be marginal, either to the radial or ulnar side of the hand. Surgical operation is the treatment of choice. When an extra digit with bifurcation of the metacarpal is present, it is recommended that the bifurcation elements of the bony components of the several digits as well as the tendon and nerve supply be removed so that the proper digit is retained. Other defects are BRACHYDACTYLY (short fingers), BRACHYSYNDACTYLY, SYMPHALANGISM (end-to-end fusion of phalanges), ANNULAR GROOVES Or BANDS, ECTRODACTYLY (absence of one or more digits), MACRODACTYLY (hypertrophy of the digits) and CLINODACTYLY (bent or deviated finger). Some of these conditions do not require therapy. Macrodactyly may require shortening of the phalanx; ectrodactyly may require shifting of fingers particularly where the absence is of the thumb. Other congenital defects include CLUB HAND in which the distal portion of the limb is defective causing deviation in position of the hand. There may be asymmetrical growth or absence of a forearm bone producing a
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similar deviation. Treatment is difficult because of the problem of disturbance of growth and usually combines conservative manipulation with splinting followed by graft stabilization. The results are not predictably satisfactory. Finally, there are cases of ABSENCE OF ARM OR LEG with retention of hand or foot. This usually remains an orthopedic enigma for which little can be done beyond rehabilitation of existing structures or the provision of a prosthesis. Congenital Anomalies of the Legs and Feet12
In the lower extremities, similar congenital defects occur such as syndactylism and accessory digits. For syndactyly, treatment is rarely required. Supernumerary toes are usually removed, especially if they create abnormal widening of the foot. CoNGENITAL HALLUX VARUS with prominent inward displacement of the great toe requires surgical realignment to avoid difficulties from shoe pressure. CALCANEONAVICULAR FUSION may be symptomatic and produce a rigid flat foot. Occasionally the bridge between calcaneus and navicular is incomplete on x-ray but functionally a similar symptomatic picture may result. The foot is held in rigid valgus and is painful. Treatment may be conservative in the form of plaster cast immobilization and later prescription of metallic arch supports. For persisting discomfort, stabilization of the hind foot with triple arthrodesis usually affords relief. METATARSUS VARUS is a condition in which the heel and posterior part of the foot are normal in their relation to the leg but the metatarsals swing inwardly and therefore produce a concavity of the inner border of the foot. There is considerable variation in severity of this condition. Treatment consists in remolding the foot in plaster casts or using outflare shoes for a similar purpose. 'Vith additional growth under such corrective pressure, the foot gradually assumes a normal form. TALIPES CALCANEOVALGUS is usually a malleable flexible deformity in which the foot is held in prominent calcaneus and some valgus. Treatment is not necessary for milder degrees of this deformity. Bandaging or holding the feet in corrected attitude by utilizing a Denis-Browne splint usually suffices for the severer cases. CoNGENITAL FLAT FOOT or vertical talus is manifested by an equinus position of the talus and a marked valgus of the remainder of the foot resulting in convexity of the inner border of the foot. Attempts are made to mold the foot into a calcaneocavus position and retain in correction in plaster. This may not be adequate for permanent restoration of form, and surgical fusion has to be considered. TALIPES EQUINOVARUS is a foot deformity identified by plantar flexion
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of the talus, inversion of the calcaneus and adduction of the forefoot. The severity at times is such that the adduction and inversion cause the sole of the foot to face backward. With persistence of the deformity there is further contracture of the soft tissues on the medial and plantar aspects of the foot. In the inverted attitude the Achilles tendon further aggravates this malposition. Classically, correction here is more difficult to obtain and maintain than in the other forms of congenital deviations. Treatment in the newborn consists in molding the foot into an overcorrected attitude. In the first days of life this may be in the form of a bandage but soon thereafter is changed to gradual correction and maintenance in plaster casts. Changes are made on a regular basis every week or two depending on the rapidity of growth. There is usually an orderly progression of corrective force application beginning with correction of the forefoot adduction, then the hind foot inversion and finally the equinus. The correction should be maintained until the child walks and thereafter splints should be worn at night for several years. If vigilance is relaxed after initial correction is attained, recurrence must be accepted. Even under most meticulous treatment and supervision, a tendency to recur must at times be thwarted by permanent foot stabilization in later childhood. Where adequate correction of the condition has not taken place despite a good conservative program of progressive corrections in plaster and later in Denis-Browne splint, surgical procedures are carried out. For persistent equinus, heel cord lengthening and posterior ankle capsulotomy usually suffice to effect a corrected functional status. For persistent varus of the heel and forefoot in a child not yet old enough (usually three to five years) to undergo definitive bone stabilization and wedge resection, soft tissue release is done. 11 This includes tendon lengthenings as well as capsular strippings and ligamentous excisions over the medial border of the foot, extensive enough to allow swinging out of the foot under the talus and improving the alignment between the talus and the navicular head. In the older children (over eight years) with relapsed deformity or incomplete correction of club foot, definitive bone surgery utilizing wedge resections and triple arthrodeses gives good results. CONGENITAL ANGULATION OR BOWING OF THE TIBIA 7 is a relatively rare orthopedic condition. In one variety there is a forward and lateral tibial angulation, and pseudarthrosis eventually develops. The bone is usually small and sclerotic and the medullary canal is diminished. It is variously ascribed to neurofibromatosis, fibrocystic lesion or some form of congenital insufficiency. Healing of the pseudarthrosis by any of the conventional bone grafting techniques is notoriously difficult to achieve.
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Repeated surgical intervention is the rule with its protracted invalidism and inevitable limb shortening, atrophy and contractural deformities. In late cases so much shortening and deformity may have developed that the unfortunate choice of amputation puug tting with a prosthesis remains if rehabilitation and return of the child to a useful existence are to take place. When healing following operation does take place, prolonged observation is required to determine the maintenance of such continuity, for on occasion re-fracture occurs and new pseudarthrosis may develop. In a second variety, congenital angulations of the tibia are characterized by anterior bowing associated with a shortening of the calf muscles. There is also concomitant resistant talipes equinus. Here spontaneous fracture and pseudarthrosis are not the rule. However, the condition may be further complicated by other anomalies such as absence of portions of the foot, absent fibula and congenital hip dislocation. There is usually marked shortening of the entire lower extremity. In a third group the congenital angulation of the tibia is backward and medial bowing is usually present at the middle and lower thirds of the tibia and fibula. There is associated severe talipes calcaneus, tightness of the anterior leg muscles, weakness of the calf and shortening of the leg. There is no unusual tendency to fracture. Treatment along conservative lines utilizing braces and physical therapy often yields surprisingly good late correction and function. TIBIAL TORSION 13 has been accepted as a designation of a twist or rotation of the tibia on its longitudinal axis. This results in a change of alignment of the planes of motion of the proximal (knee) and distal (ankle) articulations. In its most benign manifestation this distortion produces varying degrees of toeing-in or toeing-out gait patterns. It has been noted that some correlation exists between static forces in a growing child and the subsequent development of tibial torsion. Children in the habit of sleeping upon the abdomen with the feet turned inward and the lower extremities flexed at the hip and knee have been noted to develop internal tibial torsion. Children who sit on their legs habitually with the knees flexed and the feet externally rotated may develop external tibial torsion. Extreme degrees of external torsion are occasionally found in paralytic extremities in which outward rotation results from gravitational effects (paraplegia) or need for stability with only minimal hip external rotators still functional (poliomyelitis). Severe internal torsion often accompanies club feet and metatarsus varus. From a practical clinical consideration, however, the majority of children with torsion who are brought for treatment have internal tibial torsion. Some of the patients undergo spontaneous correction in the milder variety of torsion and in them a short period of observation is
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warranted. Nevertheless, it has been found that correction in very young children is readily obtained by the use of Denis-Browne splints, to which shoes are attached and adjusted to maintain the extremities in outward rotation. In the neglected child who is older (three years or more), derotation tibial osteotomy is done, as use of a splint is no longer practical. Healing is usually prompt and reliable and the ensuing disability only of short duration. Congenital Dysplasia of the Hip Joint 6
The etiology of congenital dysplasia of the hip joint is not known with certainty. The actual or potential primary malformation is an inadequate acetabulum with an insufficient roof or buttress for stability of the head of the femur. There is an associated lag in endochondral ossification of the superior border of this acetabular rim. In the newborn infant congenital dislocation of the hip exists (or may exist) usually as a potential rather than an actual dislocation of the hip. During the early months of life, it frequently is only a persistence of the hip structures in the fetal cartilaginous state, a delayed ossification of either the femoral head or the acetabulum or both. Early recognition is extremely important as treatment, to be most effective, must be started before the cartilaginous structures become malformed through the pressures applied on them by muscle pull and weight bearing. CLINICAL FINDINGS
Abduction of the flexed hip joint is practically always limited in subluxation by contracture of the adductor group of muscles. In a normal relaxed infant with the knees and hips flexed 90 degrees, the knees may be spread apart and the hips abducted about 80 degrees. Shortening from the pelvis to the knee is frequently demonstrated by comparing the knee levels with knees and hips flexed 90 degrees. This is not frequently positive early since complete displacement is not common during infancy. Ortolani' s test for the "sign of the jerk" is extremely valuable. The jerk or snap occurs as the fovea of the femoral head suddenly meets and rides over the acetabulum ridge. There may be a "click of entry" or "click of exit" as the femoral head makes its entrance or its exit from the socket. Telescoping may be possible when the hip is flexed because the acetabular defect is more posterior and inferior than superior. Other common clinical findings are extra skin folds and creases along the adductor aspect of the thigh, and deeper and more cephalad in·
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guinal and gluteal creases. However, skin fold deviations are also frequently observed in normal children. RoENTGEN FEATURES
Roentgen findings of congenital dysplasia with subluxation of the femoral head are definite and positive after the appearance of the ossification center for the head of the femur. During the first two or three months of life the ossification center of the femoral head is usually absent. X-ray interpretations are difficult and measurements permit considerable chance of error. A push-pull technique may add valuable information to the x-ray, demonstrating instability due to capsular relaxation, plasticity of the cartilaginous acetabular roof and femoral head displacement. Various measurements can be made on the x-ray to assist in the diagnosis. The acetabular index is measured by the angle formed by the junction of a line transversely drawn at the depth of the sockets with one through the lateral border of the socket. Kleinberg and Lieberman regarded 30 degrees or over to be abnormal. Caffey denies this and believes that the range is greater. Shenton's line in a normal hip is an even arc formed by the medial border of the neck of the femur and superior border of the obturator foramen. This line is broken and eccentric with femoral head displacement in a child with congenital dislocation when proper attention to positioning on the x-ray table is taken. TREATMENT
Treatment should be instituted as early as possible and preferably before weight bearing has started. For dysplasia without displacement, an abduction pillow splint devised by Frejka still enjoys a considerable popularity. It permits active functional immobilization. It gradually overcomes the adduction contracture and permits better seating of the femoral head in the socket. Certain disadvantages in diaper hygiene have prompted the development of substitute measures for obtaining similar gradual abduction. These have been metallic bars with thigh cuffs. By gradually bending the bar into greater abduction the relaxation of the adductor tightness has been similarly obtained. The advantage here is of ease in diapering the infant since the buttock and perineal areas are exposed. Where the femoral head is displaced (Fig. 1), simple abduction splints cannot be used until after reduction has been accomplished. The essence of modern therapy is gentleness of reduction. Violent manipulative methods have caused later secondary head changes which compromised the final smooth functions of the hip. The recommendation for slow,
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Fig. 1. Congenital dislocation of the hip with prominent upward displacement of the femoral head. Note the shallow acetabular roof and the smaller ossific nucleus of the femoral head on the involved side.
controlled reduction by the employment of traction preliminary to immobilization is almost universally endorsed. Where reduction cannot be effected by the routine mentioned above because of the severity of secondary deforming adaptive changes, open reduction is done. Results vary with the promptness, simplicity and gentleness of the treatment. Although good results have been obtained, they tend to be less reliable. Surgery may assume the form of simple replacement of the femoral head into its socket with immobilization thereafter in a plaster splint. If stability and adequate concentric positioning of the femoral head is not assured, acetabular shelf construction and derotation osteotomy may be added either simultaneously or serially in the course of the convalescence.
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ORTHOPEDIC PROBLEMS APPEARING LATER IN CHILDHOOD
Structural Scoliosis9
Scoliosis refers to lateral curvature of the spine. Normally the spinal column is straight and does not present lateral curves. Scoliosis is said to be structural if there is fixed vertebral rotation. On examination of a patient with structural scoliosis a lateral curve can be identified with compensatory curves above and below the main or primary curve. The function of the compensatory curves is to maintain body balance and to keep the head centered over the pelvis. Where such balance is successfully achieved despite the asymmetry of the trunk, the scoliosis is said to be compensated whereas if trunk balance is not attained, the scoliosis is described as uncompensated. Scoliosis has been classified according to its causes, of which there are many. The largest group still remains the so-called idiopathic scoliosis for which no reliable cause has yet been found. Its prognosis is linked to the site of the primary curve as well as the age at which it commences. Scoliosis increases in its severity as skeletal growth takes place. When skeletal growth is completed the progression of lateral curvature usually ceases. A useful indicator of the skeletal maturity of the vertebral column is the growth of the iliac apophysis which starts anteriorly and extends posteriorly. As it reaches the posterior superior iliac spine one can assume that vertebral maturity has been attained. In order to record a given curvature status it is necessary to measure the angle of curvature. The uppermost and the lowermost vertebrae of a primary curve show no rotation of the spinous process and the discs are not asymmetrically compressed in a wedge deformity at these extremities. Transverse lines are drawn at the borders of these vertebrae at the end of the curve and perpendiculars are erected to them. The angle at which they intersect represents the angular equivalent of the deformity. 1. Idiopathic scoliosis can theoretically occur at any portion of the vertebral column. It is most common, however, at the thoracic and lumbar areas as isolated regional deformity or combinations over several zones. 2. Congenital Scoliosis. This form of vertebral curvature is associated with anomalies. The latter may be manifest as hemivertebrae, absent ribs, vertebral body coalition or other varieties of deformities. Although generally the extent of cosmetic defect is mild and slowly progressive, there are occasional exceptions, particularly in the thoracic area. 3. Paralytic Scoliosis. Just as in the other varieties of scoliosis, any portion of the vertebral column may be involved. Prognosis in this group
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is related to the degree of paralysis and resultant trunk imbalance as well as the age of onset of the paralytic disease. 4. A miscellaneous group of scolioses of less common incidence includes that in neurofibromatosis, where the curve tends to be severe and rigid; neuropathic and myopathic as in Friedreich's ataxia, syringomyelia, arthrogryposis, muscular dystrophy, etc.; thoracogenic, as after empyema and thoracoplasty. The last is now fortunately rare. TREATMENT
Conservative treatment traditionally included varieties of exercises in combination with some modality of spinal support as cast, brace or corset. Since these were disappointing in prevention of progression in specific instances, other varieties of control were devised and tried. Periods of bed rest with and without traction offered temporary deterrents especially in idiopathic scoliosis, where relief from the gravitational element appeared beneficial. This was less reliable in the paralytic group where muscle imbalances continued to operate even in recumbency. Another more recent device in this direction has been the Milwaukee brace with its principle of gravity-distracting turnbuckles exerting head and neck support against a base on the pelvis. Usually, however, the problem is concerned with identification of the scoliosis and a study of its pattern of change with growth. Surgery is usually necessary where curves progress rapidly causing severe deformity or threatening to produce it. Surgical stabilization after some form of plaster cast correction remains the procedure of choice. There is still some question about the best age for surgical treatment of progressive scoliosis. At skeletal maturity, dealing with the curvature affords the reassuring prospect of avoiding recurrence of deformity through additional years of growth. However, should the curvature by that time have developed such rigidity and rib rotation fixity that correction can at best be slight or inadequate, a valuable opportunity has been missed (Fig. 2, A, B). On the basis of previous studies of curve patterns, especially in idiopathic scoliosis, thoracic curvatures of rapid progression should be anticipated by fusion at ages earlier than maturity and probably at age 10 to 12 years. In paralytic scoliosis, surgical stabilization is required more frequently than in the idiopathic or other varieties. Because of the associated physical handicaps and the rapid progression of the curve, surgery is required at ages somewhat younger than in the idiopathic group.
Slipped Capital Femoral Epiphysisto, ta A child in early adolescence who limps or complains of pain in the region of the hip, anterior part of the thigh or the knee, or all, should be
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Fig. 2. A, Idiopathic thoracic scoliosis in a 5 year old child. B, Progression and worsening of the curvature after prolonged conservative management 7 years later.
suspected of having a slipped capital femoral epiphysis (Fig. 3). The average age is 13 years in boys and 12 years in girls, and it occurs somewhat more frequently in males. During examination of the suspected hip, in the course of flexion, the limb tends to go into external rotation even where the limitation iri internal rotation is slight. The diagnosis is confirmed by roentgenograms made in the anteroposterior and lateral projections in which the femoral head is identified as either posterior or medial relative to the neck. As a result of slipping of the femoral head, the anterolateral portion of the femoral neck adjacent to the epiphysis becomes devoid of head contact and an angular contour is presented. This subsequently becomes rounded off as adaptive changes supervene. In addition, periosteal proliferation proceeds at the posteromedial portion of the femoral neck,
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Fig. 3. Acute slip of the femoral capital epiphysis. This followed trauma, and the lack of periosteal reaction or remodeling confirmed the short duration of the process.
adding to the deformity. The deformity arises as a result of the weakening of the bond between the epiphysis and the neck of the femur. The resulting displacement seems to be the effect of the normal shearing strains on this site. The predisposing element having been established, the displacement may be precipitated by a single minor injury, or may gradually develop over a period of weeks or months. There are several categories of femoral head slipping: 1. That associated with a history of recent trauma and acute disability in an otherwise previously normal hip joint. Here adaptive changes are usually absent or slight and cautious reduction may be accomplished by skeletal traction applied over a period of time and followed by nailing of the epiphysis through a lateral thigh approach. If slipping is minimal, reduction need not be attempted and nailing can be instituted promptly, using the same technique as in femoral neck fractures through a lateral incision. Wilson defined minimal slip as one which in the anteroposterior view showed the upper border of the epiphysis to be above the upper surface of the neck and in the lateral view to be displaced posteriorly not more than one-third of the diameter of the neck. 2. That with history of gradual onset of increasing and persisting disability of the hip. In this group, prompt nailing is also the procedure of choice lest the usually mild slip be complicated by further slipping.
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3. That with history of recurrent periods of disability alternating with periods of quiescence and presenting physical findings consistent with the diagnosis. In this group, a pronounced slip, for which open surgery is apt to be recommended, is likely to be present. In recent years osteotomy through or close to the epiphyseal plate and accurate replacement of the epiphysis on the femoral neck were proposed. Stability was added by a Smith-Petersen nail or multiple threaded wires such as the Telson. Because of the threat as well as the significant incidence of avascular necrosis of the femoral head following such correction, there has developed a cautious attitude and reluctance to favor this operative procedure. Rather, the position of altered head-neck displacement has been accepted and a compromise procedure utilizing trochanteric or subtrochanteric osteotomy for correction of the coxa vara has been substituted. In the minimal slip category following Smith-Petersen nailing and stabilization, the leg is placed in Buck's extension for mild traction until the postoperative reaction has subsided, usually about one week. Active motion is then gradually permitted and, after several weeks, partial weight bearing on crutches is commenced since muscle spasm has probably then disappeared. Thereafter, free weight bearing may be permitted. In the severe chronic epiphyseal slip where the surgery involved is osteotomy for correction, the length of time for protection varies with evidence of sound bone healing and requires three or more months. ORTHOPEDIC CONDITIONS OF CHILDREN WHICH ALSO AFFECT ADULTS
Acute Osteomyelitis1
Hematogenous osteomyelitis is a disease which may occur at any age but is most common in childhood. The primary focus is often a skin infection which may appear innocuous. Early treatment of such minor conditions today prevents disseminating sepsis and distant localizations. Blood gets to long bones via the nutrient artery and the smaller vessels which enter the metaphysis. It is accepted generally that. the bone focus arises in the vicinity of the end arteries of the metaphysis. Such local infection results in thrombosis with secondary death of the adjacent bone. As the infection spreads toward the medulla and along the vascular channels to the subperiosteal area there is stripping of the periosteum leading to death of the underlying cortex. Osteomyelitis resulting from blood stream infection may show signs only of septicemia at first. As the disease progresses there is local tender-
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ness, heat and swelling of the bone and often effusion into the neighboring joint. Radiography is of little value initially except as a basis for comparison. As bone decalcification or periosteal bone formation takes place, x-ray changes reflect these processes but several days are needed to identify them. TREATMENT
Treatment must be prompt. Aspiration over the point of greatest tenderness may yield pus which is diagnostic and affords informatiou both as to drug sensitivity and offending organism. Since many such infections are caused by staphylococci which are likely to be sensitive to penicillin, this drug is given promptly and in large doses (1 million units or more daily); lest the initially unidentified organism be penicillin-resistant, other drugs may be given simultaneously (Chloromycetin or achromycin) until the laboratory data on drug sensitivity are obtained. After laboratory data confirm the organism and its sensitivity to specific antibiotics, the adjustment is then made as necessary. Treatment is usually continued for about a month if x-ray changes are slight to absent and for several months if there is evidence of bone necrosis. In case of subperiosteal abscess formation, evacuation of the pus with drilling and saucerization followed by primary closure may be done where adequate organism sensitivity has been demonstrated to the antibiotic. Proper support of the involved limb by judicious plaster splinting adds to the patient's comfort. Repeated blood counts and erythrocyte sedimentation rate determinations permit following of the patient's systemic response to the infection and assist in the assay of healing and subsidence of the inflammatory processes. Fractures in Children 3
Fractures in children pose certain problems beyond those common to comparable skeletal injuries in adults. The diagnosis by x-ray is confused by epiphyseal lines, nutrient blood vascular channels, dense growth lines, congenital fractures and absent ossific centers at ends of long bones at certain ages. End results are more predictable in adults. The growth factor in children introduces an additional element of uncertainty because of possible late deformity. In case of crushing epiphyseal injuries, retardation in growth can be expected. The principles of treatment are usually simple and usually conservative. Fractures in children can heal with indifferent treatment but on occasion less than meticulous reduction and care may produce disastrous
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results. This is particularly so in fractures of the lower humerus and elbow. In therapy, alignment is most important. Gross angulation awl rotation should be corrected. Slight angulation is usually compatible with perfect end results. Advantage may be taken of the tendency to spontaneous correction of angulation in fractures under certain conditions. The younger the child and the nearer the fracture to the end of the bone, the more angulation can be accepted. The most complete spontaneous correction of angular deformity occurs when the angulation is in the plane of motion of a neighboring hinge joint. Rotational deformities tend to persist. The femoral neck fracture in children, though rare, requires restoration of the angle of the neck. Coxa vara, if present following fracture, tends to persist if uncorrected. Apposition (end-to-end contact) and moderate shortening are not as significant in children as in adults. Long bones may be permitted to heal with side-to-side apposition in youngsters as old as ten years with assurance that remodeling will result in normalcy by the time growth is terminated. In very young children, side-to-side union is even desirable since there is a stimulus to accelerated growth. Except for specific fractures about the elbow and occasional articular fractures, treatment should be conservative, employing traction or manipulation as necessary followed by plaster cast immobilization. Bone Tumors4
SIMPLE CYsT (Fig. 4). Simple or "unicameral" cyst of bone is of unknown cause. Although not a bone tumor by definition, it is included here since it must be considered diagnostically as a lytic lesion. It is relatively common and usually becomes manifest during the first two decades of life. In most cases it occurs in the upper part of the diaphysis of the humerus, the diaphysis of the femur and the proximal part of the diaphysis of the tibia, in that order of frequency. Clinically, the patient with a simple cyst may have local pain but in most cases the cyst comes to attention only after pathologic fracture has occurred. Treatment consists of curettage of the wall of the cyst with complete evacuation of its contents. Bone chips are ordinarily used to fill the defect. There is a 50 per cent recurrence rate if the patient is less than ten years of age, in which cases the cyst is usually juxta-epiphyseal in location. The chance for permanent cure is better in patients who are more than ten years of age, for in them the cyst has been left behind by the growing epiphyseal line. OsTEOCHONDROMA (Exostosis). This is the most common of the benign bone tumors. The bony mass is produced by progressive en-
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Fig. 4. A, Bone cyst in the upper femoral shaft. This was discovered because of pain associated with an incomplete fracture which healed spontaneously. B, Status 4 months after curettage and packing with bone chips. C, Status 2~ years later showing practically complete obliteration of the cyst and incorporation of the bone chip grafts. ·
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Fig. 5. Osteoid osteoma in the lower third of the femur of a 6 year old child. The characteristic central zone surrounded by reactive sclerosis is well demonstrated.
chrondral ossification of its growing cartilaginous cap. Growth of the tumor usually parallels that of the patient and often it becomes quiescent when the epiphyses have closed. A great number are asymptomatic and may never be discovered. Osteochondromas may occur on any bone that develops by enchondral ossification. They usually occur in the metaphysial region of the long bones of the limbs, more commonly the femur and humerus. Palpable mass is usually the only finding. Symptoms may arise from secondary effects of the tumor's impingement on adjacent structures. If symptoms are troublesome or there is an abnormal increase in size, complete excision commonly results in cure. OsTEOID OsTEOMA (Fig. 5). This distinctive benign osteoblastic lesion consists of a small oval or round mass associated with a surrounding zone of sclerotic bone. This tumor has a predilection for the younger age group. It commonly affects the lower extremities. The most important complaint is pain of gradually progressive severity. There may be localized tenderness and adjacent joint dysfunction. The treatment is surgical removal of the nidus. For complete removal, a small margin of adjacent bone should be removed and whenever pos-
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Fig. 6. Fibroma in the lower third of the tibia accidentally discovered following pathologic fracture. Its ec<'entric location, loculation and slight cortical bulge are common features.
sible the lesion should be removed en bloc. Complete removal results in cure. FIBROMA (Fig. 6). This is a rarefying lesion ordinarily affecting a metaphysis of a long bone. It is benign and often asymptomatic. It may be discovered accidentally or in investigation of a fracture. It is almost always eccentrically located in the metaphysis and sometimes produces a bulging of one cortex. The tumor is readily eradicated by curettage and filling with bone chips, if any treatment is elected. Smaller lesions may be left alone if their identity can be established confidently from x-ray, otherwise diagnosis and therapy can be combined through surgical attack. OsTEOGENIC SARCOMA. This highly malignant tumor has its peak incidence in the second decade of life, although children in their preteens have been affected as well. The metaphysial portion of the long
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bones represents the site of greatest predilection. Pain and swelling are the major symptoms. A painful mass in the involved area is often found. Histologically, there is great variation in its morphology but the stroma is frankly sarcomatous and somewhere in the tumor mass osteoid or bone can be found. It is radioresistant and the treatment is usually amputation when that is feasible. Five-year survival rates of 15 to 20 per cent have been reported. EWING's TuMOR. This has been branded the most lethal of bone tumors. It is a small, round cell sarcoma whose parent tissue has been a subject of controversy. It is generally believed to arise from undifferentiated mesenchyme. Its incidence in the young age group is well established. Many of the tumors are found in the extremities but any bone may be involved. Any portion of a long bone may show this localization. Pain and swelling are again the commonest symptoms. Palpable, tender mass may be found on examination. Sometimes an associated elevated temperature may make the differential diagnosis from osteomyelitis a necessary one. The lesion usually is more extensive than the x-ray changes suggest. These changes are a combination of lytic destruction and secondary new bone formation. The latter may take the form of subperiosteal bone producing the so-called "onion skin" appearance of Ewing's tumor. Treatment is discouraging in its effects. Five-year survival rates have been reported ranging from zero to 12 per cent with amputation, x-ray therapy or a combination of both. OTHER PROBLEMS
Orthopedic conditions not included in this presentation are not to be construed as of lesser importance or significance. Poliomyelitis carries in its wake a host of complicated reconstruction problems involving tendon transfers and joint stabilizations. 1 Cerebral palsy in its great variety of forms often poses decisions carrying grave consequences in rehabilitation or in aggravation of disability, and requires the expert services of ancillary rehabilitation personnel. Arthrogryposis multiplex congenita with its joint contractures causing upper and lower extremity dysfunction may require the best techniques of orthopedic surgery for restoration of useful limb functions. Bone and joint tuberculosis, though of lesser frequency in our modern American society through suitable public health as well as chemotherapeutic measures, cannot be denied as a vital and recurring challenge demanding vigilance for its detection. Its ravages of limbs and spine have been mollified by prompt, effective drug therapy and appropriate surgery where indicated. Metabolic and endocrinologic changes in bones are important associa-
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tions of more generalized disturbances of the body economy and are handled in conjunction with other specific medical disciplines. SUMMARY
Highlights of childhood orthopedic problems have been presented and their therapy briefly indicated. A gross categorization was attempted using the incidence of pathologic states in certain age groups as a base. This was practical for some conditions but not for others which occurred in all age ranges. Some conditions have been emphasized because of their frequency and seriousness, others because of the complexity of the problem of therapy. REFERENCES 1. Barsky, A. J.: Congenital Anomalies of Hand and Their Surgical Treatment. Springfield, Ill., Charles C Thomas, 1958. 2. Blount, W. P.: Fractures in Children. Baltimore, Williams & Wilkins Co., 1957. 3. Dahlin, D. C.: Bone Tumors. Springfield, Ill., Charles C Thomas, 1957. 4. Ellis, V. H.: Modern Trends in Orthopedics. 1st Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1950. 5. Forrester-Brown, M.: Modern Trends in Orthopedics. 1st Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1950. 6. Hart, V. L.: Congenital Dysplasia of Hip Joint and Sequelae. Springfield, Ill., Charles C Thomas, 1952. 7. Heyman, C. H. and Herndon, C. H.: Congenital Posterior Angulation of Tibia. J. Bone & Joint Surg. 31-A: 571-580, 1949. 8. Hutter, C. G. and Scott, W.: Tibial Torsion. J. Bone & Joint Surg. 31-A: 511518,1949. 9. James, J. I. P.: Modern Trends in Diseases of the Vertebral Column. Edited by Reginald Nassim and H. Jackson Burrows. New York, Paul B. Hoeber, 1959. 10. Klein, A., Joplin, R. J., Reidy, J. A. and Hanelin, J.: Slipped Capital Femoral Epiphysis. Springfield, Ill., Charles C Thomas, 1953. 11. Mcqauley, J. C. Jr.: Surgical Treatment of Club Foot. S. CLIN. NoRTH AMERICA 31: 561-574 (April) 1951. 12. McFarland, Bryan: Modern Trends in Orthopedics. 1st Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1950. 13. Scott, J. C.: Modern Trends in Orthopedics. 2nd Series. Edited by Sir Harry Platt. New York, Paul B. Hoeber, 1956. 30 East 60th Street New York 22, N.Y.