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UL & LL Deform

Torticollis
Patho = SCM fibrosis, fail to elongated (become more obvious as child grow)
Classify = 1) Congenital = Maybe due to in-utero ischemia / labour difficulty
2) Acquired = Common = Acute disc prolapsed
= Vertebral infection, Inflamed neck gland, Cervical injury, Trauma, Atlanto-axial subluxation
= Ocular disease (CN 234 also involved in innervating SCM)
= Middle ear infection
= Grisel’s syndrome
Grisel’s syndrome = Torticolis developed 10d after URTI episodes
= Viral infection cause ligament laxity => A-A subluxation => Torticollis
PE = Chin tilt away from the affected side (as SCM shorten / fail to elongate)
= aw Neck lump
= Check EOM
= Check ENT
Tx = Reassure, might spon resolve before 1yo
= Daily manipulation / msg = Stretch the neck, Turn the face back
= Op, if persist > 1yo, worry about Plagiocephaly (Mis-shaped of the head) as child tend to sleep on one side, Irreversible up to 3-4yo
Facial asymmetry
= Divide contracted muscle, usually at lower end, but sometime upper end / both ends
+ Orthosis & Stretching exercise
= Refer to Ortho & Physio

UL Angulatory deform (N = 5-15’ valgus, measured with Goniometer, compare both sides)
Cubitus Varus / Gun-stock deform
- 2’ Malunion of Supracondylar #
medial sides of cancellous bone collapse & compressed
- Tx = Reassure & Monitor for functionability
= Corrective Wedge Osteotomy (Cutting the bone & Realign)
= Early op, Deform can recur as child grow
Cubitus Valgus
- 2’ Non-union of Lat Condylar #
medial sides continue to grow but lateral side stop growing after #
- Tardy Ulnar N Palsy = Hand clawing 2’ Valgus deformity
- Tx = Transfer Ulnar N to the front of medial condylar

Radial Dysplasia
- Congenital deformity
- aw VACERAL, Holt-Oram syndrome, Fanconi Anaemia, TAR Thrombocytopenia-absent radial
- Tx = Reassure & Monitor for function
= Corrective Op, may recur, may lose function after op

Trigger finger
Trigger thumb in children
-Patho = Pulley holding the tendon fibrosed, tendon snap at the enterance
A1 – A5 pulley for Thumb, 2nd, middle, ring, little finger
Thumb has C1-C3 pulley
= Congenital in children
2’ to repeated trauma / DM (poor blood supply => fibrosis)
- PC = Suddenly cannot extend the finger, after flexion
= Finger snap on Forced extension
= Intermittent
= may be able to palpate a Nodule / Lump on MCP jt
- Trigger thumb involve = A1 pulley involved (less important)
- Tx = Spon recover
= Msg to release fibrosis, promote circulation
= Splinting (wear at night tume, stretch to extend thumb)
= Op to prevent contracture, if persist too long

LL Torsion / Rotationary deform


In-toeing – Femoral anterversion = Hip Ex/Int rotation => Sitting in W position Child present with abno walking gait
- Internal Tibial torsion = Medial malleolus @ same level as Lat malleolus (Sitting at bed side)
PE = Expose LL, wear shorts
= Normal = Med malleolus @ front than Lat malleolus
= Walking gait
- Metatarsus adductus = Mid heel => 3rd web space (Child lying on bed, look at the sole)
=> Rotationary / Angulatory deform
= Normal = Mid heel => 2nd web space
= Stand straight & Measure
Out-toeing – Femoral retroversion
- External tibial torsion
Out-toeing is more pathological
Tx = Conservative (90% in-toeing spon resolve)
LL Angulatory deform
Genu varus / Bow-leggedness
- Stand straight, measure between 2 femur medial epicondyle = >6m (patho)
- Physiological bowing in child up till 2yo = Normal, No need Xray
- Patho cause of Genu Varum  Blount’s disease
 Healed Rickets
 Trauma to upper tibial epiphysis
 Upper tibial epiphysis slipped in pt Obese / Endocrine disorder
Blount’s disease = Medial condyle of Tibial erosion & collapsed (Idiopathic) => Progressive bowing BL (may aw rotational elements)
= in Early-walker / Obese child (effect on growth plate)
= Xray = Abno flattening / slopping of medial half of epiphysos
= Tx = Rarely resolve spon
= Growth modulation, for mild deform (Stapling guided growth, stop growth & hemi eiphysodesis = fuse the growth plate)
= Corrective wedge osteotomy (always recur, might need multiple op)
Metaphyseo-diaphyseal angle, perpendicular line along tibia

Genu Valgus / Knock-knee


- Normal degree of Valgus = 5-7’
- Stand straight, btw 2 Med malleous >8cm
- Patho cause of Genu Valgum
 Rickets
 Obesity
 Down syndrome
 Hereditary multiple exostoses
 Neurofibromatosis
TRO Trauma (Growth plate injury)
Infection
Rickets (Nutritional Rickets / Renal Rickets, check Ca & P)
Skeletal dysplasia
Ligament injury
Degenerative (OA = Varum / RA = Valgus)
Skeletal dysplasia (Dwardism)
Tx = Reassure &6m monitor , bowing below 2yo is normal, resolve spon
= Operative correction if persist >10yo

Limb length discrepancy


PC = Limping child
PE = Lying & Limb measurement
Aetio = Congenital
Trauma / Infection / Tumour
Neurovascular
Genetic
Degenerative
Cx = Discrepancy > 2.5cm => Early OA of CL Hip & Spine
Tx = Shoe-raise
= Growth manipulation = Arresting growth plate @ femur / tibiral (Femur more useful than tibial, better put for both)
= Insert temporary staples / screw
= >5cm (2’ to OM / Congenital)
= Bone transport / Lengthening = Cut bone into 2, Pull / Distract 1cm / day, grow by 1mm /day
= Use Ilizarov method)
= 1m distraction, continue wearing Ilizarov for 2m, as protection, to prevent fragile bone / caltical bone
= Cannot extend >20% of length, soft tissue / vessels cannot catch up
= Cx = Pin-tract infection
= Distraction osteoporosis
= Severe discrepancy 15-20cm => Amputation
Paeds Ortho
Epiphysis = Rounded end of long bone, Articular cartilage & Subchondral bone
= Red bone marrow, produce RBC
1) Pressure epiphysis (head of femur, head of humerus) = Transmitting body weight
2) Traction epiphysis (tubercles, trochanters) = Not involved in jt, next to Pressure E, ossify later than PE
3) Atacistic epiphysis (Coracoid process) = Fused bone
4) Aberrant epiphysis (epiphysis @ head of 1st metacarpal) = not always present
= Patho = AVN, Osteochondritis dissecans OCD (involving subchondral bone)
= Malig = Chondroblastoma, Giant-cell tumour
Metaphysis = Epiphyseal plate / growth plate (chrondogenesis & osteogenesis)
= Childhood, growth plate contain connecting cartilage, enable bone growth
= Adulthood, 18-25, growth plate stop growing, complete ossify
metaphysic function to transfer wg bearing to diaphysis
= Due to rich blood supply & vascular stasis => Metaphysis prone to haematogenous spread of OM (child)
= Osteosarcoma, Chondrosarcoma, Fibrosarcoma, Osteoblastoma, Enchrondroma, Fibrous dysplasia
Simple bone cyst, Aneurysmal bone cyst, Non-ossifying fibroma, Osteoid osteoma
= Rickets = Cupping & Fraying @ metaphysic, on Xray
Diaphysis = Contain of Cortical bone, BM, Adipose tisse
= Primary ossification
= Ewing’s sarcoma

Hip Pain in Paeds +/- Limp = DDH, Transient synovitis, Perthes, SA, SCFE, Tumour
- Transient synovitis 4-8yo = Self-limited inflammatory condition, with effusion of hip jt
= Limited movement in all direction, esp Abd & IR

- SA = Very painful, unable to walk


= Limited movement in all directions
= Normal Xray, Need US

- Tumour = Osteosarcoma, Ewing Sarcoma, Osteoid Osteoma


DDH
- Development dysplasia of hip
Underdeveloped femoral head dislocated Post & Superiorly
- Spectrum of disorder = 1) Complete dislocation
2) Subluxation
3) Acetabular dysplasia (shallow acetabullum) without displacement
- Mech = Instability => Imperfect seating of femoral head, affect acetabulum development
= Primary acetabular dusplasia => Instability
- Pathogenesis = Hip unstable @ birth, with normal shape / redundant capsule
= Primary acetabular dysplasia, w Catilaginuous socket shallow & anteverted
= Femoral head dislocated Post& Superiorly, Bony nucleus delay to ossify
= Fibrocartilagenous of acetabulum, obstruct the reduction
= When Capsule & Ligament elongated, Femoral head pressure induce false socket
- RF = FFFF = Females, Hormonal, Mechanical, Primary actabular dysplasia
- Aetiology
Genetic  Generalised jt laxity (dominant trait)
 Shallow acetabulum (girls)
Hormonal change in late preg  High Oestrogen (+ Progesteron, Relaxin)
prevent collagen maturity, aggravate ligamentous laxity
Breech  Footling, with extended leg
* 17x increased risk, if via SVD
 UL DDH, as UL next to mother’s sacrum
Oligohydramnio  Crowding in womb, limited to move about
Intrauterine crowding cause package
=> Plagiocephaly, Cong Torticollis, Postual foot deformities
First preg  Tighter uterus, less elastic, baby has less room to move
Post natal  Swaddle baby, Carry baby with full extension of hip & knee
* better to Astride baby at the back, with legs widely abducted

0-4yo Girls, L>R, UL / BL


=> Limp / Late walking => UL w Trendelenberg gait, BL w Waddling gait (can be mistaken for normal toddling)
Limited Abduction (Perineal gap is abno wide in BL DDH, hard to apply napkin)
+ Excessive lumbar lordosis (BL), Prominent GT
PE INSP = Assym skin crease (inguinal, gluteal, thigh, popliteal, apparent shortening of femur)
Galeazzi sign = Lying supine, Hip & Knee flex 90, Compare height of each knee => One leg shorter, Discrepancy
= False Neg if Pelvis not level, BL DDH
Barlow test dislocating unstable hip = Flex, Add, Force posteriorly => Click
Ortolani test reduce dislocated hip = Flex, Press anteriorly GT, Abd (Reconfirmed with US)

Inv = US (Dynamic assess Shape of cartilaginous socket & femoral head position)
= Invisible acetabulum & femoral head
= Xray after 6m yo = 4 quadrants = Normal hip w ossification center of femoral hip @ lower medial quadrant
= Normal = Acetabular roof angle <30’, angle decrease w age, Should be <20’ by 2yo
= Perkins line & Hilgenreiners line intersecting
Horizontal Hilgenreiner = Btw upper ends of Tri-radiate cartilage of acetabulum
Vertical Perkin = Perpendicular thru Hilgenreiner, through point at lateral margin of acetabulum
= Acetabular index = Angle from Tri-radiate cartilage to Lateral margin of Acetabulum
= Shenton line (from medial femoral neck to inferior border of pubic rami) should be smooth arc, disrupted suggest subluxation
= Von Rosen’s line = Hip abd 45’, the Femoral shaft should point to acetabula
= For <6m, hard to order xray
= Comment on Xray = L Hip dislocated, Femoral head under-developed
Acetabular roof slopes upward steepily, Acetabular angle exceed 30’
Van Rosen line abno, not pointing towards acetabulum
= CT, MRI

Tx = The earlier the better


= Careful f/up to ensure no re-dislocation & normal acetabulum development
= Non-sx = For <6m = US show dusplasia / hip instability = Splint in flex & Abd
= + Ortolani / Barlow = Double napkin / Abduction pillow for 6/52, observe 6/12
= If persistent, Abduction splintage 4/12
= Pavlik Harness (for larger infant, before 6m) Reduce hip, confirmed with US, Hip @ 100’ flexed & abd
= Von Rosen’s splint
= Rules = Properly reduce, Avoid extreme position, Hip able to move
= Sx = 6m - 6yo
= Close reduction using Arthrogram &Gradual traction & Adductor tenotomy
+ Plaster cast (SPICA POP) / Abduction braces for 3m
= Open reduction & Osteotomy (if close reduction failed)
= Acetabuloplasty for acetabular dysplasia, aka Pemberton surgery / Salter surgery
= Hip replacement (Severe disability)
= Op Cx = Failed reduction
= Risk of femoral head AVN, miinimised by gradual reduction
(traction on LL, Abd 3w, keep legs wide separated // avoid wg bear)
= Persistent dislocation (cause impairment, disability, need to corrected by total joint replacement)
= Corrective osteotomy
- Prog = Tx after 1yo = <50% Free of trouble
= Untreated => Progressive deform & disability

CTEV
= Congenital Talipes Equinovarus
= Equinus heel (Point downwards), Varus hindfoot, Midfoot & Foorefoot add & supinate
- 2 types = 1) True club foot (fixed deformity)
2) Postural talipes (easily corrected by gentle passive movement)
- Aetio = Idiopathic / Inntrauterine (Pressure / Position)
= Common, Genetic
= aw
= Secondary = Neuropathic = aw Spina bifida (Myelomeningocele), DDH, Arthrogrryposis (Multiple ht contracture)
= Postural / Positional
- PC => Boys, 1/3 BL
Deform @ birth, Foot twisted inwards, with sole facing posteromedial
Small, high heel
Deep creases appear posterior & medial
+/- High arch (Cavus)
+/- Thin calf + Muscle atrophy
- PE => Resistance on passive dorsiflexsion & evertion = Rigid (true clubfoot) // Easily corrected (positional)
=> aw Spina bifida (Back scar), DD, Arthrigryposis (syndromic features)
= Normal baby = Toes should be able to touch the shin
- Inv = Dunid Xray
- Tx = Postural / non-true club foot = Cast, recover in few weeks
= Early, D2 after birth
= Conservative = Ponseti method / Kite / French
= Manipulation & Adhesive strapping (teach parents how to manipulate)
= Serial casting of POP (weekly)
Manipulation = Thumb pressure over Talus head, Calcaneo-cuboid-vavicular complex is ER
= Op = For resistant cases
= Open surgical release = TAL Tendoachilles lengthening
= Complete release of joint tethers
= Lengthening of tendons
+ Post-op POP
Kirschner wirse insertion to augment hold
+ Customised ankle-foot orthosis / FAO Foot abduction orthosis (for older) up till few months
hobble boots (Dennis-Brown boots) (for infants) up till 3-4yo, prevent in-toeing
- Cx = Untreated = Severe limit on mobility
= Calluses, ulcers, infection, chronic pain, not able to wear normal shoes

Perthe’s Syndrome
- AVN of femoral head in child (4-7yo) Ligamentous teres is obliterated
- 3 Stages of pathological process = Ischemia
= Recoverry ……….
=> Recurrent Hip pain (Transient synovitis = Once)
intermittent fever
- MRI = Early Perthes, very oedematous (Early stage, very oedematous)
Catherall radiological classification
- Tx = Analgesia / Symptomatic relief = Containment
= Containment / Sx reconstruction

SCFE Slipped Capital Femoral Epiphysis


= Displaced proximal femoral epiphysis (not a sub-capital fracture)
- Aaetio = Hormonal (happen @ growth spurt age)
= Trauma
= Obesity
- PC => Refered pain from hip to knee
- Xray = Trethowan’s sign = Superior of NOF, point towards growth plate
= Capener’s sign
= Widening physis
- Grading = Pre-slip
= Acute
= Chronic (>3w)
= Acute on chronic
- Tx = Preserve blood supply, stabilise
= Sx stabilise by internal screw

Monteggia #

Supracondylar #
= Commonest # in children (supracondylar is the thin area)
= 1) Undisplaced fracture => Soft tissue haematoma
2) Posterior displacement & tilt 95% = Hyperextension injury, FOOSH
Jagged edge might injury Brachial artery & Median N
3) Anterior displacement = Rare, can be caused by over-reduction of posterior displacement
PC => Elbow S-shaped deform + Pain + Swelling
=> Check Pulse & CRT for vascular cx (Brachial A)
=> Check wrist function, for Nerve injury
Xray = AP = Baumann’s angle = Vertical line of humerus axis, Line through coronal axis of capitellar physis (Normal <80’, increase with angulation)
= Compare both sides
Tx = Suspicion = Splint in 30’to prevent movement / NV injury
= Undisplaced injury = Immoblised 90’ flex, neutral position (5-7d later repeat Xray, to ensure no displacement)
= Splint 3w
= Displaced = Reduction under Xray guided, till satisfactory
= If unstable, might insert K wire
= Repeat Xray 1w, to ensure no replacement
Cx = 1) Vascular injury = Brachial A (Severe pain + Absent pulse / CRT / Pain on passive extension of finger)
2) N injury = temporary, expect recover in 3-4 m
3) Mal-union = Gun-stock deform, Varus (Correction osteotomy)
4) Elbow stiffness, esp extension, return in months,
but avoid passive / forced movement => Myositis ossificans (Bleed into tissue, inflame => Calcification)

Perthes disease
= Self-repairing ischemia necrosis of femoral head => Epiphysis collapse & remodelling
- 4-8 yo
=> Limp, Pain, Limited abd & int rotation
- Xray = Subchondral #, Dense head, Pebble stone epiphysis

SCFE
= Slipped capital femoral epiphysis
= Softening of epiphyseal cartilage during adolescence (10-15yo)
=> Limp, Pain, Limited IR
- Xray = Normal AP, Frog let view show slip

Fracture in Child

Erb’s palsy = Excessive traction on brachial plexus during childbirth


3 pattern = Upper root injury = Overwg baby w shoulder dystocia @ delivery (Usually L arm, d/t delivery posture) affect abductor / ER
= Klumpke’s palsy
= Lower root injury
- Upper root lesion, recover spon, return if biceps activity by 3m
+ Physio (mobilise jt, avoid contraction)
+ Nerve msg ??
- Sx = Neurotisation = Replace nerve gap by free Sural N
Accessory N joint to Musculocutaneous N (C5, C6) usually problematic in Erb’s
= Osteotomy of humerus
- aw = Horner’s syndrome = Best sign in baby = Miosis

Child abuse
- Shaken baby syndrome
- PE = Cutaneous, Skeletal, Cranial & Facial, Abdo injury
- Inv = ALT /AST (Abdo bleeding)
Bleeding disorder

Torus # (Buckle)
- D/t compression from one side, pressure & bone buckle out the opposite side
- FOOSH, Distal metaphysic of radius
- Xray = Buckle sign
- Tx = Immobilise by splint / cast 3-4w

Greenstick #
- Incomplete # of long bone, Periosteal is thick in children <10yo, remain intact during #
- FOOSH / Perpendicular force by direct blow
- Common @ Mid-diaphyseal, forearm / Lower leg
- PC => Pain, swelling. Deform in severe case
- Tx = Correct obvious angulation (Child dunid perfect angulation, they remodel well)
= Reduce & Immobilise

Physeal # (Salter-Harris classification)


- Growth plate, is the weakest part of immature bone & closest to jt, easily #
- PC => Localised jt pain following traumatic events
Swelling near jt & local tenderness over physis
Inability to bear wg, if injury LL
UL impair function
- 1) Straight cross (widening of physis space)
2) Above (Most commonest one)
3) Lower / below
4) Two / Through
5) ERausure of growth plate / Crush (In Xray, the physis is all gone, easily missed. Confirmed w soft tissue swelling)
- Tx = Undisplaced = 1 /2 = Casr 2-4w
= 3 / 4 = Repeat xray TRO late displacement
= Displaced = 1 / 2 = Closed reduction & splint
= 3 / 4 = Open reduction & internal fix w k wire
= 5 = Assess bony bridge across physis w CT /MRI