Paediatric Orthopaedics E.E.Fogarty F.R.C.S.I, F.R.A.C.S

Socrates

HEMLOCK Hemlock was frequently administered to criminals Is sedative and antispasmodic Prescribed as a remedy in cases of undue nervous motor excitability Overdose produces paralysis

Limp Normal gait Causes of limp Investigations

Normal Gait Bipedal Rhythmic and effortless Depends On a number of reflexes Intact locomotor system

Gait Cycle

Walking Cruise before 1year Walk at 14-18months Develop a mature(adult) gait at 3years

Limp Is any disturbance of gait Is due to one or more of 3 general causes Pain Weakness Structural abnormalities

Types of Limp Antalgic Neuromuscular Trendelenberg Short leg gait

Causes of Limp Congenital Coxa vara, congenital short limb Inflammatory Juvenile chronic arthritis,transient synovitis Infectious Osteomyelitis,septic arthritis,discitis

Causes of Limp Developmental Scfe, Ddh, Perthes, acquired limb length discrepancy Neoplastic Benign Malignant Secondary tumours

Causes of Limp Traumatic Toddlers and stress fractures Neuromuscular Metabolic Haematological Referred Appendicitis

Stress Fracture Adolescent Upper Tibia Looks aggressive

Stress Fracture

Investigations Plain x-rays Scannogram plus wrist x-ray MRI,CT scan, Bone scan FBC,ESR

Hip Intoeing Transient synovitis Development dysplasia of the hip Perthes disease Slipped capital femoral epiphysis

Intoeing Common condition Large number of children May be simple or complex Femur Tibia Foot Familial tendency

Line of progression Foot progression angle

Transient Synovitis Inflammatory condition. Cause unknown. Peak incidence 3-6 years. Mild U.R.T.I. Pain and limp. Resolves in 48 hours. May need aspiration.

Ultrasound Femur Capsule Normal Effusion

Joint Pain

Joint Fluid Aspiration Normal JRA SA Color yellow yellow Blood stained Clarity clear cloudy turbid Viscosity very high low very low WBC count PMN 75% Gram’s stain-ve -ve+ve in 30-40% Culture-ve -ve+ve in 50-60%

Developmental Dysplasia of the Hip Incidence 0.1% 4 times commoner in girls Risk factors 1 st. Born Breech Oligohydramnios

Diagnosis Ortolani Barlow Asymmetrical folds Galeazzi sign Limp X-ray U/S

Ortolani Test Ortolani manoeuvre to determine if the hip is dislocated

Barlow’s Test the Barlow is a provocative test for a dislocatable hip

Asymmetrical Folds

Galeazzi Sign

Ultrasound The  angle, which is a measurement of the slope of the superior aspect of the bony acetabulum, and the  angle, which evaluates the cartilaginous component of the acetabulum

Ultrasound Indications for ultrasonography are not universally established Overdiagnosis above the expected incidence of DDH Not Cost–effective

Treatment 0-6 months Pavlik 6-18 months Traction and casting More than 18 months Open reduction Osteotomy

Thoracic band Shoulder straps Stirrups Ant. Post. Straps

Perthes Ischaemic necrosis Collapse and repair Peak incidence 4-9 yrs Limp no pain Classification Lat.Pillar Containment

Knee Genu varum Genu valgum

Genu Varum

Genu Valgum

Foot Flatfoot Metatarsus varus Talipes equino-varus Pes cavus

Flatfoot Mobile Infantile Postural Temporary Spastic Neuromuscular

Physiological Pes Planus

Metatarsus Varus Partly genetic Normal hindfoot Adducted forefoot Usually resolves May need stretching and casting

Talipes Equino-varus 1.2/1000 live births Stiff Smaller calf Deformities Equinus Inversion Adduction Stretching,strapping Surgery

Pes Cavus Neurological Pma Dysraphism Friedrich’s ataxia