1. Common Pediatric Orthopedic Clinical Problems
Saunders Jones Jr. MD

2. Common Pediatric Orthopedic Problems
Metabolic
Developmental
Congenital
Traumatic
Infectious
Neoplastic
Neuromuscular

3. Radiological “hole in the bone”
Fibrous cortical defect
Aneurysmal Bone cyst
“bone island”
Giant cell tumor
Infection
Ewing’s Sarcoma
Enchondroma

4. Fibrous cortical defect (Fibroxanthoma)

5. Unicameral bone cyst Next to growth plate Active vs Inactive
Falling leaf sign

6. ABC
Aneurysmal bone cysts may occur in patients aged years, with a peak incidence in those aged 16 years.
About 75% of patients are younger than 20 years.
Four phases of pathogenesis are recognized, as follows:
Osteolytic initial phase
Active growth phase, which is characterized by rapid destruction of bone and a subperiosteal blow-out pattern
Mature stage, also known as stage of stabilization, which is manifested by formation of a distinct peripheral bony shell and internal bony septae and trabeculae that produce the classic soap-bubble appearance.
Healing phase with progressive calcification and ossification of the cyst and its eventual transformation into a dense bony mass with an irregular structure.

7. ABC

9. Ewing's Sarcoma

10. Incidence of Ewings

11. Ewings

12. Giant Cell tumor
Not ped age group

13. Osteochondromas or Multiple Exostoses
Cartilaginous cap covered by a bursa
Impinge on local structures
CT shows cap < 1cm in thickness
Can be excised due to structural problems
SMALL incidence (<1% per lesion) of transformation to Chondro sarcoma (or Osteogenic less common)

14. Multiple Exostoses Found in areas around growth plates
Can occur in multiple locations or singularly
Usually not Neoplastic
Bone with cartilaginous cap
Grows normally with growth of the rest of the skeleton

15. Osteochondromas B9
Cartilaginous cap
Impinges on local structures

16. Osteochondromas
Another view

17. Osteochondroma

18. Osteochondroma

19. Osteochondroma microscopic

20. Osteosarcoma

21. Osteosarcoma
Some bone
elements

22. Enchondroma

23. Non ossifying Fibroma

24. Metabolic Pediatric Category
Rickets
Osteogenesis Imperfecta

25. Rickets
Radiologic changes in the growth plate
Vitamin problem

26. Osteogenesis Imperfecta

28. Twisty Bendy Feet Most common is metatarsus adductus
FPS fetal packaging syndrome
Normal rotation of feet in utero
Should respond to gentle massage and SWN
Shoes could be worn in reverse (r-l l-r) if there is any “last” in the shoe

29. Metatarsus adductus/clubfoot (tell tale medial crease)

30. Twisty Bendy Feet Clubfeet “talipes equino-varus”
Metatarsus adductus, heel equinus and varus and talus adductus
Tell tale crease on lat underneath malleolus
Thinning and atrophy of lower leg
Needs attention based on severity of deformity, START TREATMENT AT BIRTH !!! Refer early

31. Club feet
Metatarsal
Talus
Hindfoot
Leg atrophy

32. Endstage Club feet

33. Clubfoot casting
In the nursery or soon as possible

34. Club foot Casting Must go above the knee to control rotation
Plaster is the best
Soak off night before
Manipulation and then maintenance of that correction

35. Limited clinic Tenotomy
New

36. Twisty Bendy legs

37. Twisty Bendy Legs Internal Tibial Torsion
Normal adult rotation is degrees external
Normal unwinding of child's lower legs
Not significantly affected by orthotics or treatment !!!
Sight along tibial crest and look at malleoli
Reassure (look for other conditions)

38. Twisty Bendy Legs Bendy knees/legs 2-4-6 years
Genu varus / genu valgus
Normal variants
Radiographs for Blount’s Disease
Vitamins
Orthotics (?)

39. Blount’s vs. Normal

40. Twisty Bendy Legs Femoral anteversion
Femur is turned in at the hip causing “pigeon towed gait”
Sit on their feet
SWN
Education
Twister cables!!?!?!?!?

41. Femoral anteversion

43. Pes Planus “flat feet”
Common in infants and up to about 8 years of age
Painful flat feet is different…tarsal coalition or other condition
Some pes planus is genetic or racial
Look at mom’s feet!!!

44. Heel Pain in Adolescent
Sever’s Disease
Calcaneal apophysitis
X rays show “fractionation”
Symptomatic tx with NSAIDs
Stretching
Limitation of activity ?

45. Sever’s Disease

46. Xray of the Calcaneal Apophysis

47. Stretch for Sever’s Disease

48. Knee Pain in Adolescent
Anterior tibial tubercle pain
Osgood-Schlatter’s disease
Tibial apophysitis
Rest stretching Ice Nsaids
Prominent tubercle
Hereditary tendencies
HIP PAIN MASQUERADES AS KNEE PAIN !!!!! Always xray same side hip!!!

49. Anterior Knee pain Adolescent Female
Increased valgus with tracking problems
Squatting and Indian style sitting
Quad sets and Nsaids
VMO?
Usually self limited
Make sure nothing else going on…..

50. OSDx and Ant knee pain

51. Osgood Schlatter's

52. Osgood Schlatter’s Disease

53. Hip Pain
SCFE
Transient synovitis
Hip pyarthrosis
LCP

54. Slipped Capital Femoral Epiphysis
SCFE
Endomorphic
Androgenital
Onset anterior thigh pain
Externally Rotated Gait
Can be bilat
Rx pin in situ

55. SCFE

56. SCFE

57. SCFE

58. LCP Perthe’s Disease
Avascular necrosis of the proximal femoral growth plate
Collapse
Maintain concentricity and “containment”
Multiple bouts of Transient synovitis

59. LCP initial and resorptive phases

60. LCP resorptive and remodeling

61. Congenital Dislocated Hip
Barlow's
Ortilani
Duration and treatment
Age of child at discovery
Pavlick harness
Closed reduction and casting
Open Reduction
Subtrochanteric osteotomy
Acetabular osteotomy

62. Congenital Dislocation

63. Congenital Hip Dislocation

64. Causes of Hip Pain in Children
CDH
0-2 years
1:4 m:f
20%bilat
LCP
4-8 years
5:1 m:f
10% bilat
SCFE
10-15 years
1.5:1 m:f
25-40%bilat

65. Idiopathic Adolescent Scoliosis
Not a painful condition
If there is pain…look for another cause!
OBJECTIVE OF TREATMENT:
To prevent deformity as adult
Skeletal maturity
Onset of menses, Risser sign
Criteria for referral relates to progression
BracesSurgery runs the gamut

67. Risser sign

68. Risser Sign

69. Nursemaids Elbow

70. Nursemaids Elbow

71. Falls from a Height common in Children

73. Epiphyseal Injuries: only in kids!!!
Salter classification
Joint involvement
Growth disturbance
Thick periosteum

74. Salter One

76. Salter 2

77. Salter 3

78. Salter 4

79. Salter 5

82. Supracondylar elbow fractures
Compartment syndrome because of vascular compromise
Characteristic fx due to the shape of the supracondlyar region of the humerus
“balancing two canoes”

87. Lines around the elbow

89. Supracondylar fx minimal displacement

90. Displaced Supracondylar fx

91. Medial Epicondyle fx

93. Lateral condyle Salter #?

94. Supracondylar fx

95. Radial Head fxs

96. Displaced Lateral condyle Salter #?

97. Radial Head Fx displaced epiphyseal….Salter# ?

98. Late Sequelae Cubitus varus

99. Fracture Tx in Kids Alignment has different criteria Overgrowth
Maintenance of overall alignment most important Rotation, etc

100. Fracture Tx in Younger Kids (growth potential)

101. Overall Alignment and Residual Growth

102. Fracture Tx in Older Kids

103. Fracture Tx in Even Older Kids

104. Neuromuscular Category
Cerebral Palsy
Spastic or Flaccid
Birth injury
Perinatal cerebral anoxia
Hyperactive stretch receptors
Contractures
Releases, Transfers, Braces etc.

105. Infections Joints Pyarthrosis Infants and young children
Endemic Otitis Media
No good lab test
X-rays normal
Patho-anatomy growth plate vasculature
Drain and decompress because of potential damage to cartilage
May lead to Osteomyelitis

106. ANY QUESTIONS???
Comments
Discussion

107. Thank you