Orthopedic pediatrics

• Club Foot


  Complex deformity of foot, result of complicated inter-relationships between bones, ligaments and muscles
• Refer immediately to the orthopedic surgeon for club foot to be corrected earliest possible. This is because the bones are still growing and soft to be easily manipulated.

  
• Clubfoot or congenital talipes equinovarus (CTEV)


  Deformity involving malalignment of the calcaneotalar navicular complex

  
• Components of club foot deformity

  • Cavus, adductus, varus, equinus
• Causes of club foot

  • Irradiation (maternal)
  • Circulatory failure
  • Arrested fetal development
  • Uterine compression
  • Excessive pressure of amniotic fluid
  • Defective gene
  • Hereditary

  
• Classification of club foot

  • Talipus Equinovarus
  • Talipus Calcaneovagus
  • Talipus Varus
  • Talipus Vagus
  • Talipus Equinovalgus
  • Talipus Calcaneovarus
• Equinus


  Foot pointing down (like a horse's foot)
• Varus


  Deviated towards midline
• Club foot correction


  1. Stretching and casting (Ponseti method)

  2. Stretching and taping (French method)

  3. Dennis-Brown brace
• NSAIDs are used in the medical management of osteomyelitis
• Surgery is sometimes needed if non-operative treatments are unsuccessful or achieve incomplete correction of the club foot deformity

  
• Juvenile rheumatoid arthritis (JRA)/ Juvenile idiopathic arthritis


  Chronic systemic inflammatory disease involving connective tissue of one or more joint

  
• Systemic JIA ILAR Classification Criteria

  • Fever ≥ 2 weeks, a quotidien in pattern (≥39°C at least once a day and returns to ≤37°C), documented daily for ≥ 3 days
  • Arthritis in ≥ 1 joint ( for ≥ 6 weeks)
  • Evanescent erythematous rash
  • Generalized lymph node enlargement
  • Hepatomegaly and/or splenomegaly
  • Serositis
• The most important criteria for JRA is joint pain which lasts for at least 6 weeks. This is to rule out other causes such as infection, trauma, and other systemic diseases that could present as joint infection.
• Pathophysiology of JRA


  • Chronic inflammation of the synovium joint
  • Effusion erosion
  • Distortion and fibrosis of the articular cartilage
  • Fibrous ankylosis with subluxation and distortion of the affected joint
  • Granulation tissue becomes hard, tough and fibrous, and converted to scar tissue inhibition of joint movements
• Classification of JRA


  • Pauciarticular onset
  • Polyarticular Onset
  • Systemic Onset
• Clinical manifestations of JRA

  • Involvement of both small and large joints
  • Joints are tender, swollen and warm
  • Reduced mobility
  • Prolonged fever
  • Muscle aches
  • Weight loss
  • Subcutaneous nodules
  • Hepatosplenomegaly for systemic manifestation
  • Pericarditis, myocarditis
  • Pneumonia
• Medical management of JRA

  • NSAIDs
  • Methotrexate - cornerstone for rheumatologic treatment
  • Physiotherapy
• Hip displacement


  Condition in which the femoral head and the acetabulum are improperly aligned, with the ball of the femur outside the hip socket

  
• Types of hip displacement

  • Hip dislocation or preluxation or acetabular dysplasia
  • Instability of hip or subluxation partial contact between the femoral head and acetabulum
  • Dislocation or subluxation of hip refers to a hip with no contact between the articulating surfaces of the hip
• Clinical manifestations of hip displacement

  • Apparent shorter femur on affected side
  • Limited ROM
  • Asymmetry of gluteal fold
  • Laxity of ligaments
  • Waddling gait
  • Difference in length of limbs
  • Extra fold at thighs and groins
  • Variation in gait
• Management of hip displacement

  • Pavlik harness
  • Skin traction
  • Surgery and cast
• Fracture


  Break in the continuity of a bone
• Clinical features of bone fracture

  • Severe muscle rigidity
  • Deformity
  • Tenderness
  • Bruising
  • Generalized Swelling
  • Paralysis
  • Pallor
  • Pain
• Medical management of bone fractures

  • Closed reduction - manipulation of the fracture without cutting the skin
  • Open reduction - surgical
  • Traction - use of weights to straighten the fracture
• Osteomyelitis


  Bacterial infection of the bone involving the cortex and/ or the bone marrow
• Types of osteomyelitis


  • Chronic osteomyelitis
  • Acute osteomyelitis
• Staphylococcus aureus is the most common infecting organism in osteomyelitis among all age groups, including newborns
• Community-acquired methicillin-resistant S. aureus (CA-MRSA) isolates account for more than 50% of S. aureus isolates recovered from children with osteomyelitis in some reports
• Pathophysiology of osteomyelitis


  • Occur mostly at the metaphyseal region of long bones, especially femur and tibia
  • Bacteria enters through osseous circulation to metaphysis
  • Pus formation and medullary canal & cortex get affected
  • Necrosis and devascularization of the cortex
  • Necrosis and detachment chronic or acute osteomyelitis
• Osteomyelitis


  Bacterial infection of the bone involving the cortex and/or the bone marrow
• Osteomyelitis


  • Risk is greatest if the physis (the growth plate of bone) is damaged
  • Staphylococcus aureus is the most common infecting organism, including in newborns
  • Community-acquired methicillin-resistant S. aureus (CA-MRSA) isolates account for more than 50% of S. aureus isolates recovered from children with osteomyelitis in some reports
• Types of osteomyelitis


  • Chronic osteomyelitis
  • Acute osteomyelitis
• Causes of osteomyelitis


  • Exogenous sources
  • Endogenous sources
• Pathophysiology of osteomyelitis


  1. Bacteria enters through osseous circulation to metaphysis

  2. Pus formation and medullary canal & cortex get affected

  3. Necrosis and devascularization of the cortex

  4. Necrosis and detachment chronic or acute osteomyelitis
• Clinical manifestations of osteomyelitis

  • Neonates might exhibit pseudoparalysis or pain with movement of the affected extremity
  • Older infants and children are more likely to have pain, fever, and localizing signs such as edema, erythema, and warmth
  • Systemic symptoms: fever, limited ROM, erythema, tenderness, swelling, pain & lethargy
• Management of osteomyelitis


  • Home care: asepsis, skin assessment, wound care, regular blood check up
  • Immobilization: complete bed rest
  • Antibiotic therapy
• Kyphosis


  An enhanced angulation in the thoracic or thoraco-lumbar spine in the sagittal plane or a round back deformity
• Causes of kyphosis


  • Juvenile Rheumatoid Arthritis
  • Malignancy
  • Congenital or secondary to compression fracture
  • Rickets
  • Defective posture, common in big breast women
• Management of kyphosis


  • Psychological support
  • Pre and post operative care
  • Orthopaedic surgery
  • Orthotic devices
  • For children, their bags should not weigh more than 10% of their total body weight