Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children

Tachdjian’s Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children
Title Volume One
Title Volume Two
Copyright
Contributors
PREFACE
PREFACE
1 - Growth and Development
Normal Growth and Development
Disorders of Normal Growth and Development
Evolution of Proportionate Body Size
Physical Growth
Developmental Milestones
References
2 - The Orthopaedic History
3 - The Orthopaedic Examination: A Comprehensive Overview
4 - The Orthopaedic Examination: Clinical Application
5 - Gait Analysis
6 - The Limping Child
7 - Back Pain
8 - Disorders of the Neck
Overview
Developmental Anatomy
Atlas
Axis
Subaxial Cervical Spine
Unique Characteristics
Cervical Deformity: Torticollis
Deformity Without Pain—Congenital Torticollis
Congenital Muscular Torticollis
Nonsurgical. Excellent results with massage and a stretching program can be achieved in approximately 90% of patients.11,14,21,2...
Surgical. Most authors favor surgery, when indicated, by 6 years of age.95,117 Others have extended this period upward to age 12...
Congenital Osseous Torticollis/Klippel-­Feil Syndrome
Clinical Features
Radiographic Findings
Treatment
Halo Fixation. Deformity management involving head tilt or rotation frequently requires the use of a halo vest to obtain and mai...
Indications. A strong indication for surgical treatment in KFS or other cervical anomalies is progression of head tilt or rotati...
Techniques for Occipitocervical Fusion. Because of limited motion and craniofacial abnormalities, airway management in patients ...
Techniques for Atlantoaxial Fusion. Atlantoaxial internal fixation, for instability/hypermobility or deformity management (see b...
Deformity With Pain
Radiographic Finding. As with any torticollis, radiographs of the cervical spine and occipitocervical junction are often difficu...
Neurogenic Torticollis
Inflammatory and Septic Causes
Pharyngeal or Lymphatic Abscess
Vertebral Osteomyelitis and Diskitis
Tumor-­Like Conditions
Intervertebral Disk Calcification
Juvenile Arthritis
Sandifer Syndrome
Ocular Torticollis (Lateral Gaze Palsy)
Cervical Deformity: Kyphosis
Congenital or Developmental Kyphosis
Clinical Features
Radiographic Findings
Treatment
Orthotic Management. Orthotic management of cervical kyphosis may be appropriate as a delaying tactic. There is no evidence that...
Surgical Stabilization: Posterior Versus Anterior Cervical Fusion. Surgical stabilization for kyphosis is indicated when dural e...
Acquired Postlaminectomy Kyphosis
Treatment
Cervical Hyperlordosis
Cervical Instability
Os Odontoideum
Down Syndrome
Atlantooccipital Anomalies
Odontoid Anomalies and Ligamentous Instability in Skeletal Dysplasia
Nontraumatic Atlantooccipital Instability
Subaxial Instability
9 - Scoliosis
Definition
Classification of Scoliotic Curves
Idiopathic Scoliosis
Adolescent Idiopathic Scoliosis
Prevalence
Natural History
Natural History Before Skeletal Maturity
Gender
Remaining Growth
Curve Magnitude
Prognostic Testing
Natural History After Skeletal Maturity
Scoliosis Screening
Screening Programs
Screening Methods
Etiology
Neurologic Dysfunction
Connective Tissue Abnormalities
Genetic Factors
Pathophysiology
Clinical Features
Initial Signs and Symptoms
Physical Examination
Neurologic Examination
Patient Maturity
Radiographic Findings
Plain Radiography
Measurement of Curve Magnitude
Measurement of Vertebral Rotation
Measurement of Spinal Balance
Measurement of Kyphosis and Lordosis on Lateral Radiographs
Surface Imaging
Magnetic Resonance Imaging
Computed Tomography
Treatment
Observation
Nonsurgical Treatment
Orthotic (Brace) Treatment
Indications for Brace Treatment
Contraindications to Brace Treatment
Comparison of Orthoses
Boston Brace
Wilmington Brace
Providence Brace
Charleston Brace
Spine-­Cor Brace
Milwaukee Brace
Brace Treatment Protocols
Electrical Stimulation
Physical Therapy and Biofeedback
Surgical Treatment
Indications for Surgery
Preoperative Planning
Curve Patterns
Lenke Classification System
Construct Selection
Preoperative Curve Flexibility
Neurologic Status
Rib Deformities
Future Growth Potential
Transfusion Requirements
Bone Grafting
Spinal Cord Monitoring
Postoperative Pain Management
Antibiotic Prophylaxis for Dental Procedures
Posterior Spinal Instrumentation
Multiple-­Hook Segmental Instrumentation
Pedicle Screws
Freehand Technique
Image-­Guided Techniques
Other Methods of Assessing Screw Placement
Clinical Outcome
Posterior Mobilization Techniques
Anterior Mobilization Techniques
Correction Techniques
Complications of Posterior Instrumentation and Fusion for Adolescent Idiopathic Scoliosis
Anterior Spinal Instrumentation
Anterior Approach to Thoracolumbar and Lumbar Curves
Solid-­Rod Anterior Instrumentation
Juvenile Idiopathic Scoliosis
Predicting Curve Progression
Neural Axis Abnormalities
Congenital Spinal Deformities
Etiology
Associated Abnormalities
Congenital Scoliosis
Classification
Defects of Formation
Defects of Segmentation
Natural History
Radiographic Findings
Nonoperative Treatment
Operative Treatment
Anterior and Posterior Fusion
Posterior Spinal Fusion
Hemivertebra Excision
Osteotomy of the Spine
Congenital Kyphosis
Classification
Defects of Formation (Type I)
Defects of Segmentation (Type II)
Natural History
Clinical Features
Radiographic Findings
Treatment
Type I Kyphosis
Type II Kyphosis
Type III Kyphosis
Early-­Onset Scoliosis
Effect on Respiratory Function
Intrinsic Alveolar Hypoplasia
Extrinsic Disturbance of Chest Wall Function
Treatment
Nonoperative Delaying Tactics
Bracing
Casting
Traction
Operative Treatment
Instrumentation Without Fusion (Traditional Growing Rods, TGR)
Instrumentation Without Fusion: Current Technique, “Final” Fusion
Outcome—Traditional Growing Rods
Magnetic Controlled Growing Rod
Results—Magnetic Controlled Growing Rods
Hybrid Technique
Expansion Thoracoplasty With VEPTR
Growth Guidance Constructs
Summary
Other Causes of Scoliosis
Neurofibromatosis
Nondystrophic Scoliosis
Dystrophic Scoliosis
Marfan Syndrome
Congenital Heart Disease
Thoracotomy
Laminectomy
Irradiation
Hysterical Scoliosis
10 - Kyphosis
Posture
Causes of Hyperkyphosis
Postural Kyphosis
Scheuermann Kyphosis
Clinical Features
Radiographic Findings
Radiographic Findings for Lumbar Scheuermann Disease
Operative Treatment
Determining Fusion Levels
Summary
Progressive Noninfectious Anterior Fusion
Postlaminectomy or PostirradiationKyphosis
Postlaminectomy Kyphosis
Postirradiation Kyphosis
Surgical Treatment
Miscellaneous Causes of Kyphosis
Achondroplasia
Pseudoachondroplasia
Spondyloepiphyseal Dysplasia/Mucopolysaccharidosis
Marfan Syndrome
11 - Other Anatomic Disorders of the Spine
12 - Disorders of the Upper Extremity
Introduction
Embryology
History and Examination
Pertinent History
Physical Examination
Timing of Surgical Procedures
The Parent
Denial
Anger
Distress
The Child’s Maturity
The Surgeon
The Hand
The Anesthesiologist
Suggested Surgical Milestones
Principles of Dressings and Splinting
Dressings
Wound Closure
Primary Dressing
Gentle Compression Components
Padding and Skin Protection
Rigid Outer Shell
Hand Therapy
Activities of Daily Living
Splinting
Materials
Securing Splints
Children Not Suitable for Splinting
Static Splinting
Dynamic Splinting
Serial Casting or Serial Static Splinting
Static-­Progressive Splinting
Custom Splints
Prefabricated Splints
Combination Custom/Prefabricated Splints
Thumbs
Wrist.The most common wrist splints used in pediatrics are the wrist cock-­up splint, the dorsal-­blocking splint, and the long ...
Forearm.The tone and positioning (TAP) splint is a pronation/supination splint that is effective for lack of range caused by wea...
Elbow.Splinting the elbow is a challenge in pediatrics because all elbow splints restrict motion. When moderate support is neede...
Writing a Prescription for Hand Therapists
Scar Management
Principles of Acute Care
General Principles
Tendon Injury
Nerve Injury
Skin Injury
Bone Injury
Vascular Injury
Principles of Reconstruction
Architecture and Hand Physiology
Nerve Function: Sensibility and Power
Architecture of the Hand
Planning Reconstruction
Evaluation of the Child for Reconstruction
Congenital Anomalies
Classification
Diagnosing Associated Anomalies
Radial Longitudinal Deficiency
Prevalence and Epidemiology
Etiology
Clinical Features
Prevalence
Laterality
Upper Limb
Associated Anomalies
Holt-­Oram Syndrome
Fanconi Anemia
Thrombocytopenia–Absent Radius Syndrome
VACTERL Association
Clinical Evaluation
Classification
Anatomic and Surgical Pathology
Imaging
Pollicization
Adolescence
Radialization.Radialization was developed by Buck-­Gramcko in the 1980s as another modification of centralization in an attempt ...
Ilizarov Correction.Ilizarov correction can be used to lengthen the ulna through osteotomies in conjunction with realignment pro...
Vascularized Epiphyseal Transfer.This technique, developed by Vilkki in the 1990s, aims to replace the missing radial strut with...
Contraindications to Surgery
Congenital High Scapula (Sprengel Deformity)(Video 12.1)
Pseudarthrosis of the Clavicle (Video 12.2)
Ulnar Longitudinal Deficiency
History
Etiology
Clinical Features
Classification
Pathology
Imaging
Nonoperative Treatment
Hand.Although forearm and wrist surgeries are best done during the first year of life, hand operations should be done later. Syn...
Forearm.Creation of a one-­bone forearm should be reserved for older children with type II dysplasia and is indicated only when ...
Elbow.In selected type IV cases, osteotomy of the elbow synostosis may be useful, especially when the elbow deformity positions ...
Phocomelia (Proximal Longitudinal Dysplasias)
Classification
Synostosis of the Radius and Ulna
Etiology
Clinical Features
Imaging
Treatment
Results
Preferred Treatment at the Texas Scottish Rite Hospital for Children
Arthrogryposis in the Upper Limb
Principles and Goals
Treatment
Shoulder
Elbow
Posterior Release With Tricepsplasty.Posterior elbow release with tricepsplasty is done through a posterior curvilinear incision...
Procedures to Achieve Active Elbow Flexion.The ideal tissue to gain active elbow flexion would be an expendable muscle, synergis...
Bipolar Pectoralis Major Transfer.The entire pectoralis major muscle can be transferred by mobilizing it on its neurovascular pe...
Bipolar Latissimus Transfer.For this transfer the entire latissimus dorsi is mobilized on its pedicle and moved anteriorly throu...
Transfer of the Long Head of the Triceps.This transfer is feasible because the long head of the triceps has a separate neurovasc...
Steindler Flexorplasty.Transfer of the flexor pronator muscle origin to the anterior aspect of the humerus to flex the elbow wor...
Free Gracilis Transfers.Theoretically, the gracilis can serve as a free muscle donor to the anterior aspect of the arm to flex t...
Wrist
Dorsal Closing Wedge Osteotomy of the Midcarpus and Tendon Transfers.Release of the tight volar structures is accomplished throu...
Proximal Row Carpectomy.Proximal row carpectomy was used in the past, but because the capitate and radial articulations are gros...
Wrist Fusion.Wrist fusion should be avoided because all motion is lost at the wrist of an arthrogrypotic child. It can be reserv...
Hand
Thenar Release.The skin incision is planned to provide maximal increase in the web. Either a four-­flap Z-­plasty or a local rot...
Madelung Deformity
Etiology
Pathology
Clinical Features
Imaging
Treatment
Epiphysiolysis
Ligamentous Release and Dome Osteotomy
Results
Complications
Polydactyly
Etiology
Pathology
Incidence
Associated Conditions.Triphalangeal thumbs are associated not only with thumb duplications but also with duplications of the gre...
Classifications.The Wassel classification (based on his analysis of Flatt’s cases) is frequently used for the radial polydactyli...
Surgical Challenges.Surgical repair of radial polydactyly is usually more involved than the surgical repair of ulnar duplication...
Central Polydactyly
Associated Conditions.Central polydactyly, syndactyly, and cleft hand not infrequently occur together. Polydactylous elements ma...
Classification.The classification system most commonly used for central polydactyly is a modification of the previously outlined...
Ulnar Polydactyly
Mirror Hand
Imaging
Treatment
Radial Polydactyly
Wassel Type I and II Thumbs.In these patients the distal phalanx is bifid, but a common joint is shared. When one thumb is much ...
Wassel Type III Thumbs.When one thumb is smaller, it is best deleted, but when the condition represents a truly bifid thumb, the...
Wassel Type IV Thumbs.In this most common variety (Fig. 12.103), reconstruction of ligaments and tendons is especially critical....
Wassel Type V and VI Duplications.These rare and complex duplications require reattachment of the abductor tendons and reconstru...
Triphalangeal Thumbs
Central Polydactyly
Ulnar Polydactyly
Mirror Hand
Central Polydactyly
Ulnar Polydactyly
Syndactyly
Etiology
Pathology
Clinical Features
Incidence
Associated Syndromes
Imaging
Cutaneous (Simple) Syndactyly
Preparation.All syndactyly reconstructions should be carried out under general anesthesia. A tourniquet must be used to ensure a...
Design of the Incisions.It has been said, with some justification, that after the incisions have been drawn in a syndactyly, the...
Separation of the Digits.We usually begin with incision and elevation of the dorsal flap distally and carry the dissection down ...
Flap Closure.The flaps are rotated into position and meticulously closed with fine (6-­0) absorbable suture (Fig. 12.123). Using...
Skin Graft Patterns.The defects requiring grafting are now carefully measured by making a precise paper pattern of the defect. P...
Graft Harvest and Donor Site Closure.There have been many donor sites outlined for the harvesting of full thickness skin graft—g...
Attaching Grafts to the Digital Skin Defects.We use fine (6-­0) absorbable suture and first anchor the corners and then complete...
Tip Reconstruction.If the syndactyly is incomplete at the tip, the flaps and grafts described previously suffice to reconstruct ...
The Composite Graft.A composite graft of skin and fat can be useful to resurface the raw bone surface associated with a complex ...
Buck-­Gramcko “Stiletto Flap” Reconstruction.This method is useful when more skin is available. The flaps are so long and attenu...
Dressing Application.The goal of syndactyly surgery is to achieve complete and primary healing of all wounds and skin grafts. An...
Aftercare.The wound is left undisturbed under the cast for 3 weeks unless fever, increasing pain, or an unusual odor is noticed....
Syndactyly of the First (Thumb–Index) Web.Of all the operations performed to treat congenital hand problems, none reward the sur...
Complications and Outcomes
Thumb Abnormalities
Tight Thumbs (Thumb-­in-­Palm Deformity)
Etiology.Trigger thumb is not a congenital deformity. An examination of 1116 newborns in Japan did not identify trigger thumb in...
Pathology.A thickening within the tendon forms a nodule at the region of the first annular pulley of the flexor sheath mechanism...
Imaging. Radiographs are not usually necessary but should be obtained if trauma is suspected
Treatment.Although one report on the natural history of 71 Korean trigger thumbs found that the flexion deformity resolved in 63...
Complications.Complications of treatment include infection, damage to digital neurovascular structures, and excessive release of...
Etiology.Spasticity is the end pathway for the upper motoneuron dysfunction that may result from an antenatal infarct, cerebral ...
Imaging. Imaging studies are not usually necessary unless bone procedures are being contemplated
Treatment.Initially, manipulation and perhaps splinting may help bring the thumb out of the palm. Any splint applied must be car...
Results.The results of both surgical and nonsurgical treatment can be encouraging if the goals are selected carefully and normal...
Clinical Features.A clasped thumb cannot be passively extended at the CMC, MCP, or IP joint. The skin on the palmar aspect of th...
Imaging.Imaging studies demonstrate the abnormal posture of the thumb but show no deficiencies in the bony anatomy. Later, joint...
Treatment.Treatment consists of passive stretching and splinting until no further change in position can be achieved. Surgical t...
Results.Nonoperative treatment of a type I clasped thumb can be successful in a patient younger than 1 year. However, nonoperati...
Pathology
Imaging
Treatment
Complications
Macrodactyly
History
Etiology
Clinical Features
Imaging
Treatment
Complications
Congenital Band Syndrome
History and Etiology
Pathology
Clinical Features
Classification
Imaging
Reconstruction
Results
Complications
Apert Syndrome
Clinical Features
Treatment
Juvenile Arthritis and Other Noninfectious Inflammatory Conditions
General Principles
Education of the Patient and Parents
Appropriate Therapy and Splinting
Intraarticular Corticosteroid Injection
Wrist Involvement
Wrist Joint Synovitis
Tendon Synovitis (Tenosynovitis)
Treatment of Synovitis and Tenosynovitis
Splints
Heat
Intraarticular Corticosteroids
Exercises
Synovectomy.Synovectomy of the multiple tiny joints in the wrist is rarely useful in children with juvenile arthritis. In most c...
Technique.When significant deformity is present, we tend to use small-­plate fixation to ensure maintenance of alignment. Usuall...
Technique.The surgeon should take care to resect a minimal amount of the distal end of the ulna (only just enough to allow rotat...
Hand Involvement
Finger Synovitis and Deformity.The typical deformity in the hands of children with juvenile idiopathic arthritis is yet another ...
Thumb Synovitis and Deformity.As in adults, deformities of the thumb in children are varied and include adduction contracture, a...
Tenosynovitis in the Digits.Triggering is rarely seen as a result of tenosynovitis at the wrist, but it is quite commonly associ...
Treatment of Digital Involvement
Splinting
Injections
Synovectomy
Metacarpophalangeal Joints.MCP joint deformities in the fingers of patients with juvenile arthritis rarely require surgical trea...
Thumb Deformities.One of the most functionally limiting deformities in these children is a fixed flexion deformity of the MCP jo...
Other Noninfectious Inflammatory Conditions
Infections
Paronychia
Felon
Herpetic Whitlow
Pyogenic Tenosynovitis
Deep-­Space Infections
Bite Wounds
Human Bite Wounds
Animal Bite Wounds
Septic Arthritis
Osteomyelitis
Other Infections
Human Papillomavirus (Common Warts)
Atypical Mycobacterial Infections
Conditions Mimicking Infection4
Neonatal Brachial Plexus Palsy
Etiology
Classification
Clinical Features
Prognosis and Natural History
Differential Diagnosis
Treatment
Initial Management
Assessment
Later Treatment
Residual Deformities
Shoulder
Contractures
Flaccid Paralysis
Elbow
Wrist
Hand
Management of Residual Deformities
Management.A variety of tendon transfers have been described for the treatment of shoulder contracture (Table 12. 11)
Abduction and External Rotation Contracture
Abduction Contracture
Elbow and Forearm
Hand
Tumors of the Upper Limb
Nonneoplastic Masses
Synovial Cysts (Ganglions, Retinacular Cysts)
Epidermoid Inclusion Cysts
Foreign Bodies or Reactions
Aneurysm and Pseudoaneurysm
Malformations
Vascular Malformations
Hamartoma of the Nerve
Neoplasms
Giant Cell Tumor of the Tendon Sheath
Glomus Tumors
Pyogenic Granuloma
Lipomas
Fibrous Tumors
Aponeurotic Fibroma.Aponeurotic fibromas are unusual lesions that involve the palmar aponeurosis. They tend to occur in preteens...
Infantile Digital Fibroma.Infantile digital fibromas occur in young children. The lesions are often multiple and appear as hard,...
Simple Fibromas.Simple fibromas are unusual but may occur. These well-­defined lesions are hard masses, typically on the dorsum ...
Neurofibromas.Neurofibromas are seen in association with neurofibromatosis and often occur as multiple lesions. Treatment is res...
Malignant Soft Tissue Tumors
Malignant Schwannomas and Nerve Sheath Tumors
Subungual Melanoma
Other Malignant Tumors
Benign Bone Tumors
Solitary Enchondroma
Enchondromatosis (Ollier Disease)
Osteochondromatosis
Microsurgery
Replantation (Attachment of Severed Parts)
Preoperative Care
Indications and Contraindications
Revascularization
Free Tissue Transfer
Disadvantages of a Pedicle Flap
Inherent Advantages of Free Tissue Transfer
Free Motorized Muscle Transfer
Free Toe Transfer
Free Vascularized Bone Transfers
Free Joint Transfer for Radial Clubhand
13 - Developmental Dysplasia of the Hip
Definition
Incidence
Etiology
Ligamentous Laxity
Prenatal Positioning
Postnatal Positioning
Racial Predilection
Associated Conditions
Pathophysiology
Normal Hip Development
Natural History
Neonatal Hip Instability
Clinical Features
Neonate
Infant (Video 13.1)
Walking Child
Radiographic Findings
Ultrasonography
Graf Technique
The Harcke Method
The Terjesen Method
Treatment Implications
Radiography
Arthrography
Magnetic Resonance Imaging
Screening Criteria
Treatment
Treatment of the Neonate
Pavlik Harness
Treatment of the Young Child (2 to 6 Months Old)
Other Splints and Braces
Frejka Pillow and Triple Diapers
Treatment of the Child (6 Months to 2 Years Old)
General Guidelines
Traction
Closed Reduction (Video 13.5)
Open Reduction
Medial Approach
Anterior Open Reduction
Open Reduction With Femoral Shortening (Videos 13.7 and 13.8)
Open Reduction With Innominate Osteotomy
Complications and Pitfalls
Avascular Necrosis
Etiology
Diagnosis
Classification
Other Manifestations of Avascular Necrosis
Interventions to Alter the Effects of Avascular Necrosis
Trochanteric Epiphysiodesis
Trochanteric Advancement
Intertrochanteric Double Osteotomy
Lateral Closing Wedge Valgus Osteotomy With Trochanteric Advancement
Inadequate Reduction and Redislocation
Residual Acetabular Dysplasia
Acetabular Dysplasia Presenting Late
Reconstructive Procedures for Dysplasia
Simple Pelvic Osteotomies That Reposition the Acetabulum
Pemberton Osteotomy (Video 13.9)
Salter Innominate Osteotomy (Video 13.10)
Dega Osteotomy
Complex Osteotomies That Reposition the Acetabulum
Steel Osteotomy
Tönnis Osteotomy
Ganz Osteotomy
Spherical Acetabular Osteotomy
Osteotomies That Augment the Acetabulum
Chiari Osteotomy
Shelf Procedures
Teratologic Dislocation of the Hip
14 - Legg-­Calvé-­Perthes Disease
Definition
Incidence
History
Etiology
Pathology and Pathophysiology
Hip Synovitis
Histopathology of the Epiphysis
Pathogenesis of Femoral Head Deformity
Metaphyseal Changes
Clinical Features
Symptoms
Signs
Clinical Course
Natural History of the Disease
Radiographic Findings
Radiographic Staging of Disease Evolution
Initial Stage
Fragmentation Stage
Reossification (Healing) Stage
Healed (Residual) Stage
Other Radiographic Findings
Changes in the Metaphysis
Changes in the Physis
Changes in the Acetabulum
Limited Radiographic Changes of Meyer Dysplasia
Bilateral Changes
Magnetic Resonance Imaging
Scintigraphy
Arthrography
Ultrasonography
Computed Tomography
Radiographic Classification Systems for Prognostication
Catterall Classification
Salter-­Thompson Classification
Lateral Pillar Classification
Classification of End Results
Mose Classification
Stulberg Classification
Deformity Index
Quantitative Measures of Femoral Head Sphericity and Congruency
Prognostic Risk Factors
Differential Diagnosis
Treatment
Concept of Containment Treatment
Symptomatic Therapy
Surgical Containment
Femoral Varus Osteotomy
Salter Innominate Osteotomy
Triple Innominate Osteotomy
Combined Femoral and Innominate Osteotomy
Shelf Arthroplasty
Other Surgical Treatments
Femoral Valgus Osteotomy
Hip Joint Distraction
Chiari Osteotomy
Age at Onset Before 6 Years
Age at Onset 8 to 11 Years
Age at Onset After 11 Years
Age at Onset 6 to 8 Years
Long-­Term Prognosis
15 - Slipped Capital Femoral Epiphysis
Incidence and Epidemiology
Classification
Functional Classification
Classification Based on Onset of Symptoms
Morphologic Classification
Etiology
Mechanical Factors
Thinning of the Perichondral Ring Complex
Relative or Absolute Femoral Retroversion
Change in Inclination of the Adolescent Proximal Femoral Physis Relative to the Femoral Neck and Shaft
Associated Conditions With a Mechanical Etiology
Endocrine Factors
Pathology
Clinical Features
Stable, Chronic Slipped Capital Femoral Epiphysis
Unstable Acute or Acute-­on-­Chronic Slipped Capital Femoral Epiphysis
Chondrolysis Complicating Slipped Capital Femoral Epiphysis
Radiographic Findings
Plain Radiography
Computed Tomography
Technetium-­99 Bone Scan
Ultrasonography
Magnetic Resonance Imaging
Treatment
Initial Management
Definitive Treatment
Postoperative Management.We allow protected partial weight bearing with crutches as soon as the patient is comfortable, usually ...
Percutaneous In Situ Fixation Using a Radiolucent Tabletop.This technique may be used instead of the fracture table technique at...
Cannulated Screw, Design and Positioning.A number of well-­designed, partially threaded cannulated screw systems are available, ...
Screw-­Related Complications.Complications directly re­lat­ed to the use of screws include perforation into the joint space by t...
Routine Removal of Screws.In the past, fixation devices were routinely removed after physeal fusion in patients with SCFE. Reaso...
Summary of In Situ Pinning.We believe that in situ pinning with a single cannulated screw inserted either percutaneously or thro...
Bone Graft Epiphysiodesis
Spica Cast
Unstable Slipped Capital Femoral Epiphysis
Closed Versus Open Reduction
Timing of Reduction.The importance of the time interval between the onset of symptoms and reduction has been addressed in severa...
Primary Open Reduction of the Slipped Epiphysis
Operative Technique.The hip is approached through a standard surgical dislocation approach. The epiphysis can be partially visua...
Results.Ziebarth, Ganz, and others reported an initial series of 40 patients with a variety of slips, followed after reduction v...
Other Open Reduction Techniques
Screw Fixation With Minimal Reduction.Screw fixation with minimal reduction remains the gold standard for internal fixation of u...
Aftercare.Most surgeons recommend restricted weight bearing with support (crutches or walker) for 6 or more weeks postoperativel...
Complications.Whether AVN is due to damage to the blood supply of the capital epiphysis caused by its acute displacement or by i...
Summary.In summary, we believe that the classification of SCFE into stable and unstable is clinically meaningful and should be p...
Residual Deformity After Primary Treatment
Proximal Femoral Osteotomy
Base-­of-­Neck Osteotomy (Kramer and Barmada Procedures)
Intertrochanteric Osteotomy (Imhauser/Southwick Procedure)
Operative Technique.Preoperative assessment involves calculating the amount of deformity from AP and lateral radiographs. Based ...
Anterior and Valgus Slips
Prophylactic Treatment of the Contralateral Hip
Complications
Avascular Necrosis
Epidemiology
Radiographic Findings and Clinical Features
Natural History
Treatment
Chondrolysis
Epidemiology
Etiology
Pathology
Natural History
Treatment
Prognosis
Remodeling After Epiphyseal Stabilization
Summary of Natural History and Prognosis
16 - Congenital Coxa Vara
17 - Disorders of the Femur
Femoral Anteversion
Definition
Clinical Features
Differential Diagnosis
Prognosis and Natural History
Association With Other Conditions
Measurement
Treatment
Snapping Iliotibial Band Syndrome
18 - Disorders of the Leg
Congenital Hyperextension and Dislocation of the Knee
Classification
Etiology
Clinical Features
Surgical
Preoperative Planning. Preoperative planning begins with an assessment of all concomitant lower extremity deformities. The use o...
Operative Technique. The knee is approached through a midline longitudinal incision that extends proximally and laterally to fac...
Congenital Dislocation of the Patella
Etiology
Clinical Features
Treatment
Disorders of the Legs Presenting After Infancy
Genu Varum (Bowlegs)
Physiologic Genu Varum
Tibia Vara
Infantile Tibia Vara (Blount Disease)
Etiology. Several authors have reported a familial occurrence of the condition,12,65,124,196,200 and one report of infantile tib...
Physiology. Histologic findings of the affected physis and corresponding metaphysis in infantile tibia vara have included (1) is...
Clinical Features. The typical child with infantile tibia vara may appear similar to a child with physiologic genu varum; howeve...
Radiographic Findings. A standing anteroposterior view of the lower extremities from hip to ankle should be obtained when initia...
Differential Diagnosis. The most common entity in the differential diagnosis in young children is physiologic genu varum, in whi...
Classification. In 1952, Langenskiöld classified infantile tibia vara according to the degree of metaphyseal-­epiphyseal changes...
Treatment. Untreated infantile tibia vara results in a nonresolving, progressive angular change, joint deformity, and growth ret...
Orthoses.Literature suggests that for children younger than 3 years old with early Langenskiöld stage I to II lesions, orthotic ...
Treatment of Langenskiöld Stage II Lesions.Surgical treatment in the early stages of the disease (stage I or II) is crucial to a...
Treatment of Langenskiöld Stage III Lesions.Stage III lesions can respond to corrective osteotomy alone in patients older than 4...
Treatment of Langenskiöld Stages IV/V Lesions.In stage IV and V lesions, simple mechanical realignment is rarely successful as a...
Treatment of Langenskiöld Stage VI Lesions.Treatment of stage VI lesions with established bony bridges is based upon the age of ...
Complications of Surgery.Complications of proximal tibial osteotomy in a growing child can be devastating. The osteotomy must be...
Summary.Early treatment aimed at curing infantile tibia vara, when discovered in its early stages, is more likely to produce a g...
Adolescent Tibia Vara
Etiology. No definitive cause for adolescent tibia vara has been established. Failure of the expected resolution of a physiologi...
Clinical Features. The typical patient with adolescent tibia vara is a male teenager, often African American, whose body weight ...
Radiographic Findings. Radiographically, the tibial epiphysis is relatively normal, without the depression and beaking of the me...
Treatment. Treatment is surgical. Orthotic management in heavier adolescent patients is impossible and ineffective. In the obese...
Osteotomy. High tibial osteotomy allows correction of adolescent tibia vara. Typically,31 a neutral mechanical axis is sufficien...
Realignment by External Fixation.External fixation with tibial and fibular osteotomies is another option for the treatment of ad...
Lateral Epiphysiodesis.Because of the potential complications associated with proximal tibial osteotomy and deformity correction...
Hemiepiphyseal Stapling.Lateral hemiepiphysiodesis of the proximal end of the tibia (and distal end of the femur) can also be pr...
Hemiepiphyseal Plating.The advent of extraperiosteal plate and screw systems introduced an alternative method to nonpermanent de...
Tibia Vara Secondary to Focal Fibrocartilaginous Dysplasia
Radiographic Findings.Radiographs of FFCD (Box 18.3) show a characteristic abrupt varus at the metaphyseal-­diaphyseal junction ...
Treatment.Tibia vara caused by FFCD may resolve spontaneously. Some 60 cases of tibia vara secondary to FFCD have now been repor...
Genu Valgum (Knock-­Knees)
?Idiopathic Genu Valgum (Video 18.1)
Genu Valgum Secondary to Previous Proximal Tibial Fracture
Genu Valgum Secondary to Miscellaneous Causes
Rickets
Spondyloepiphyseal and Metaphyseal Dysplasias
Tumor-­Like Conditions
Multiple Hereditary Exostoses
Tibial Torsion
Clinical Features
Treatment
Bowing of the Tibia
Anterolateral Bowing of the Tibia
Anterolateral Bowing With Congenital Dysplasia
Etiology and Pathology.The relationship of anterolateral bowing and neurofibromatosis (NF) has been known since 1937,59 and 5.7%...
Classification.Classification systems attempt to guide prognosis for achieving union based upon radiographic findings including4...
Clinical Features.Anterolateral bowing of the tibia is often seen at birth with an apical prominence laterally in the leg and wi...
Treatment.Except for the type I benign lesions,233 the natural history of tibial dysplasia (anterolateral bowing) is extremely u...
Intramedullary Fixation.Our procedure of choice to gain union and correct deformity requires resection of the pseudarthrosis (se...
Bone Morphogenetic Protein.Beginning in the early 2000s, the introduction of recombinant human BMPs for clinical use in fracture...
Bisphosphonates.A better understanding of the pathophysiology at the pseudarthrosis site has prompted investigations into the ef...
Vascularized Fibular Graft.Nonvascularized bone grafts have failed to achieve definite and lasting union of CPT. The first use o...
External Fixation and Distraction Osteogenesis.Distraction osteogenesis techniques (Ilizarov method) to improve tibial dysplasia...
Periosteal Grafting.A number of historical and recent studies propose that the periosteum plays an intricate role in the pathoge...
Electrical Stimulation.Bassett10,11 has demonstrated increased calcification of fibrocartilage, increased angiogenesis, and decr...
Late Fracture in Previously Undiagnosed Congenital Dysplasia.Occasionally, a child with no history of dysplasia sustains a tibia...
Amputation.Historically, amputation of an affected limb is considered a failure by the surgeon and the patient. Although amputat...
Benign Form of Anterolateral Bowing of the Tibia
Congenital Posteromedial Bowing of the Tibia
Etiology and Clinical Features
Treatment
Congenital Pseudarthrosis of the Fibula
Treatment
19 - Disorders of the Foot
Introduction
Normal Variations
Os Trigonum
Accessory Navicular
Etiology
Pathology
Clinical Features
Radiographic Findings
Treatment
Results and Complications
Osteochondroses
Köhler Disease
Etiology
Clinical Features
Radiographic Findings
Treatment
Outcomes
Freiberg Infraction
Etiology
Clinical Features
Radiographic Findings
Treatment
Congenital Deformities
Postural Deformities
Metatarsus Adductus
Etiology
Incidence
Pathology
Clinical Features
Radiographic Findings
Treatment
Talipes Calcaneovalgus
Etiology and Clinical Features
Treatment
Flexible Flatfoot (Pes Planovalgus)
Definition
Clinical Features
Natural History
Treatment
Conservative Treatment
Arthroereisis.Arthroereisis of the subtalar joint, using a metal, silicone, or Silastic implant, has been reported as an alterna...
Heel Cord Lengthening.An Achilles tendon contracture should always be considered and treated during any surgery for flatfoot. If...
Subtalar Fusion.Subtalar fusion as a primary procedure for hypermobile flatfoot should probably be condemned. While there is no ...
Lateral Column Lengthening.Lateral column lengthening by insertion of a bone graft into an osteotomy of the calcaneal neck is cu...
Imbrication of Talonaviculocuneiform Complex.Imbrication of the talonaviculocuneiform complex medially is performed in combinati...
Summary
Skewfoot
Incidence and Natural History
Radiographic Findings
Treatment
Congenital Talipes Equinovarus (Clubfoot)
Etiology
Pathologic Anatomy
Diagnostic Features and Differential Diagnosis
Nonoperative Treatment
Ponseti Method
Technique.The protocol consists of stretching and manipulating the foot and applying holding casts until the next session 5 to 7...
Results.The results of treatment with the Ponseti method depend both on the outcome parameter used to judge results and on the l...
French Physiotherapy (Functional) Method
Origin of the Procedure.The French method for nonoperative correction of clubfeet was conceived in the early 1970s by Masse131 a...
Current Procedure.The goal of this treatment is to reduce the talonavicular joint, stretch out the medial tissues, and then sequ...
Results.Most of the clubfoot improvement achieved with the functional method occurs during the first 3 months. After this period...
Surgical Treatment
Timing of the Procedure
Various Techniques
Suggested Operative Technique
Dorsal Subluxation of the Navicular.This condition, which produces a shortened cavovarus foot, has been reported frequently afte...
Valgus Overcorrection.A so-­called overcorrected foot, with excessive hindfoot valgus and usually forefoot abduction and pronati...
Dorsal Bunion.This deformity can be considered a complication of clubfoot surgery because the underlying muscle imbalance requir...
Revision and Secondary Procedures
Anterior Tibial Tendon Transfer (Video 19.7).Transfer of the tibialis anterior insertion—either the entire tendon or a split tra...
Transfer for Insufficient Triceps Surae (Calcaneus Gait).Overlengthening of the Achilles tendon or triceps insufficiency seconda...
Lateral Column Shortening (Video 19.8).“Recurrence” of clubfoot deformity after earlier surgical release requires analysis of th...
Calcaneal Osteotomy.In a foot with fixed heel varus, with or without other significant residual deformity, an opening or closing...
Supramalleolar Osteotomy.Persistence of a toe-­in gait is common in an otherwise plantigrade foot, regardless of the surgical te...
Triple Arthrodesis.After the age of 10 years, management of residual deformity requires bony stabilization, not only to correct ...
Correction Using the Ilizarov Technique.Because stretching plus elongation of contracted tissue is fundamental to the management...
Vertical Talus
Definition
Etiology
Clinical Features and Associated Conditions
Pathologic Anatomy
Radiographic Findings
Differential Diagnosis
Treatment
Results and Complications
Tarsal Coalition
Etiology
Clinical Features and Differential Diagnosis
Radiographic Findings
Treatment
Conservative Treatment
Surgical Treatment
Calcaneonavicular Coalition.A calcaneonavicular coalition is excised through a dorsolateral tarsal sinus incision (Video 19.11)....
Medial Talocalcaneal Coalition.Resection of a talocalcaneal coalition is more complex than excision of a calcaneonavicular bar. ...
Results and Complications
Cleft Foot
Etiology
Clinical Features
Treatment
Neurogenic Abnormalities
Cavus Foot
Etiology
Clinical Features
Radiographic Findings
Further Diagnostic Evaluation
Treatment
Conservative Treatment
Surgical Treatment
Plantar Release.Plantar release is always performed during surgery to correct a cavus foot. With mild flexible deformities in yo...
Peroneus Longus–to–Peroneus Brevis Transfer.One tendon transfer that has been commonly used as part of surgical reconstruction o...
Anterior Transfer of the Posterior Tibialis Tendon.Patients with cavovarus feet as a result of peripheral neuropathy or myopathi...
Transfer of the Toe Extensors to the Metatarsal Heads.Patients with pes cavus often have claw toes secondary to recruitment of t...
Calcaneal Osteotomy.A calcaneal osteotomy is indicated in children with inflexible hindfoot varus on the Coleman block test. The...
Satisfactory results have been reported in more than half of patients after a Dwyer osteotomy. Although incomplete correction or...
Midfoot Osteotomies.Several different osteotomies of the midfoot have been proposed for surgical reconstruction of a cavus foot....
Triple Arthrodesis.When the amount of deformity present in a foot with pes cavus cannot be corrected fully by soft tissue releas...
Toe Deformities
Hallux Valgus
Anatomy
Clinical Features
Radiographic Examination
Classification
Treatment
Distal Soft Tissue Realignment (McBride Procedure)
Distal Metatarsal Osteotomy
Mitchell Osteotomy.The Mitchell osteotomy is adequate for the treatment of mild to moderate hallux valgus. It is contraindicated...
Chevron Osteotomy.A second distal metatarsal osteotomy that has been popular for the treatment of hallux valgus is the chevron o...
Proximal First Metatarsal Osteotomy
Double Metatarsal Osteotomy
Diaphyseal Osteotomies
Metatarsal-­Cuneiform Fusion
Other Procedures
Recommended Treatment
Hallux Valgus Interphalangeus
Hallux Varus
Hallux Rigidus
Polydactyly
Syndactyly
Macrodactyly
Varus Fifth Toe
Curly Toe
Hammer Toe
Mallet Toe
Longitudinal Epiphyseal Bracket
Hair Tourniquet Syndrome
Subungual Exostosis
Glomus Tumor
20 - Limb Length Discrepancy
Leg Length Inequality
Etiology and Associated Conditions
Congenital and Developmental Conditions
Acquired Conditions
Impact of Inequality
Assessment of Inequality
Clinical
Radiographic
Orthoroentgenography.Orthoroentgenography is a radiographic technique described by Green and colleagues in 1946.168 The purpose ...
Scanography.The term scanography arose from an early technique called slit scanography, but it has come to be used for a techniq...
Computed Radiography
Computed Tomography
Ultrasonography
Prediction of Leg Length Inequality in the Skeletally Immature Child
Normal Skeletal Growth
Longitudinal Growth of Long Bones
Alterations of Growth
Functional Physeal Anatomy
Menelaus Method
Moseley Straight-­Line Graph
Paley Multiplier Method
Summary of Prediction Methods
Treatment
Psychological and Social Factors
Indications
Orthotic Management
Shortening of the Long Leg
Results.In Green and Anderson’s series (163) of 77 epiphysiodeses, there were 5 cases of angular deformity (4 requiring correcti...
Percutaneous Methods.Concern about the cosmetic appearance of two to four incisions around the knee has prompted interest in the...
Results.Green and Anderson, in the same publication describing the results of epiphysiodesis, evaluated 83 stapling procedures i...
Eight Plate and Tension Band Plating
Transphyseal Screws.Métaizeau and colleagues described a modification of epiphysiodesis using percutaneously inserted transphyse...
Acute Shortening
Results.Merle d’Aubigne and Dubousset reported one case of deep infection but no other complications in four patients treated by...
Complications.Significant biologic complications can occur with closed femoral shortening. These include the following: postoper...
Tibial Shortening.Shortening of the tibia is performed less frequently than is shortening of the femur for several technical rea...
Lengthening of the Short Leg
Stimulation of Growth in the Short Leg
Surgical Lengthening of the Short Leg
History.Codivilla89 is credited with the earliest description of limb lengthening.236,351 He stated that the “best results are o...
Indications.In 1958, after evaluating 40 patients who had undergone leg lengthening 20 or more years previously, Sofield and col...
Femoral and Tibial.In 1965 Merle d’Aubigne and Vaillant described in the French literature a technique of transverse osteotomy a...
Callotasis.A more acceptable method of leg lengthening is by gradual distraction (callotasis) of a fracture callus after low-­en...
Effects of Gradual Lengthening.Ilizarov deserves much credit for his studies on the effects of gradual distraction on bone and s...
Bone.After extensive studies in dogs, as well as an assessment of his clinical experience, Ilizarov concluded that the quality a...
Muscle.The effect of lengthening on the function of muscle and, correspondingly, the resistance to lengthening by muscle tissue ...
Peripheral Nerves.Ilizarov described histologic evidence of the development and growth of nerves, including axon elongation and ...
Joints and Articular Cartilage.The one tissue that appears to incur only deleterious effects from lengthening is articular carti...
Complications of Gradual Lengthening.The reported incidence of complications associated with gradual leg lengthening ranges from...
Nerve or Vessel Injury During Device Application.Acute nerve or vascular injury during application of an external fixator is an ...
Incomplete Osteotomy.When a low-­energy corticotomy is performed through a small incision in an effort to minimize soft tissue i...
Premature Consolidation.This complication is unique to the gradual distraction techniques of callotasis. On occasion, the rate o...
Poor Regenerate Bone Formation.The opposite of premature consolidation is poor regenerate bone formation. This may be a global p...
Joint Subluxation.One of the most serious complications of leg lengthening is joint subluxation or frank dislocation. Typically,...
Neurapraxia.In addition to acute nerve injury at the time of external fixation, neurapraxia can occur with lengthening.ff This m...
Pin Site Infection.Pin site infection is nearly universal in external fixation for leg lengthening because of a combination of t...
Sequestrum.Much less frequent than pin site infection is the development of a true ring sequestrum. The presumed mechanism is bo...
Regenerate Bone Fracture.A significant complication of lengthening is fracture or bending of regenerate bone after apparatus rem...
Subsequent Growth Disturbance of the Lengthened Limb.Many reports exist of significant deceleration of expected growth after leg...
Psychological Stress.The prolonged treatment protocol, the intensity of treatment of the extremity, and chronic pain, even if on...
Other Complications.In addition to the aforementioned well-­recognized complications, loss of joint motion, joint contracture, a...
Dynamic Axial Fixator.Aldegheri and co-1396983920workers11139705914013 and De Bastiani and colleagues1061397059140108 popularize...
Ilizarov Apparatus.Ilizarov began his work with external fixation for the management of fractures, deformity correction, and len...
Combined Internal and External Fixation (Lengthening Over Intramedullary Rods).A significant disadvantage associated with gradua...
Totally Implantable Lengthening Devices.An intriguing concept is that of totally implantable lengthening devices. Such a device ...
Summary of Lower Extremity Lengthening
Angular Deformity
Etiology
Normal Lower Extremity Alignment
Assessment of Deformity
Principles of Deformity Correction
Surgical Options for Deformity Correction
Hemiepiphyseal Stapling
Hemiepiphysiodesis
Osteotomy
Acute Correction
Internal Fixation.Internal fixation after acute corrective osteotomy may be either definitive, with plate and screws or an intra...
External Fixation.External fixation of corrective angular osteotomies has several theoretical advantages: the amount of soft tis...
Gradual Correction
21 - Limb Deficiencies
Proximal-­Distal Axis
Anterior-­Posterior Axis
Dorso-­Ventral Axis
Genetic Regulation of Limb Development
Progress Zone Model
Early Specification Model
Differentiation Front Model
Two-­Signal Gradient Model
Four-­Dimensional Concept
Classifying Limb Deficiencies
Frantz and O’Rahilly Classification System
International Society for Orthotics/International Society for Prosthetics and Orthotics International Classification System
General Treatment Concepts
Timing of Treatment
Social Factors
Long-­Term Planning
Congenital Absence of Limbs
Timing of Limb Malformation and Deformation
Etiology of Limb Absence
Psychosocial Issues
Congenital Lower Limb Deficiencies
Proximal Focal Femoral Deficiency
Hamanishi Classification
Gillespie Classification
Clinical Features
Treatment
Rotationplasty.Rotationplasty was first described in 1930 by Borggreve, who used the procedure to treat a knee severely damaged ...
Femoral Pseudarthrosis Stabilization.The need to stabilize the upper femoral defect is controversial. Paley and others recommend...
Hip Stabilization.Children with major femoral deficiencies who are managed with either amputation or rotationplasty usually func...
Limb Lengthening.In some patients with PFFD, and in most patients with congenital shortening of the femur, the projected final d...
Fibular Deficiency
Clinical Features
Coventry and Johnson Classification
Achterman and Kalamchi Classification
Birch Classification
Limb Lengthening.Improved techniques have renewed interest in limb-­lengthening procedures to treat deformities and limb length ...
Limb Lengthening.Tibial lengthening is appropriate when the length discrepancy and limb malformation are moderate, as noted earl...
Tibial Deficiency
Classification
Weber Classification
Clinical Features
Complete Tibial Hemimelia
Foot Deficiency
Congenital Upper Limb Deficiencies
Transverse Deficiencies
Amnion Disruption Sequence
Treatment
Radial Deficiency
Classification
Treatment
Complications
Ulnar Deficiency
Classification
Clinical Features
Treatment
Acquired Limb Absences
Primary Causes and Treatment Principles
Trauma
Malignant Tumors
Purpura Fulminans
Surgical Amputations
Upper Limb Amputation
Above-­Knee Amputation
Knee Disarticulation
Below-­Knee Amputation
Complications
Overgrowth After Amputations Through Long Bones
Complications Following Burns or Purpura Fulminans
Immediate Fitting of Prostheses in Young Children
Phantom Pain
Psychosocial Aspects
Multilimb Deficiencies
Bilateral Upper Limb Absence
Bilateral Lower Limb Absence
One Upper-­Limb and One Lower-­Limb Absence
Prosthetic Management
Concepts of Prosthetic Management
Evaluation and fabrication
Nonstandard Prostheses
Modifications
Upper-­Limb Prostheses
Lower-­Limb Prostheses
Guidelines for Replacing Prostheses
Prosthetic Management of Specific Deficiencies
Proximal Focal Femoral Deficiency
Fibular Deficiency
Tibial Deficiency
Foot Deficiency
Foot Amputation
Amputation for Malignant Tumor
Above-­Knee Amputation
Knee Disarticulation
Below-­Knee Amputation
22 - Arthritis
Joints
General Considerations
Joint Fluid Analysis
Gross Appearance
Viscosity and Mucin Clot
Microscopic Examination
Other Examinations
Juvenile Idiopathic Arthritis (Formerly Juvenile Rheumatoid Arthritis)
Definition and Classification
Incidence and Prevalence
Demographics
Etiology
Pathology
Clinical Features
Oligoarticular Juvenile Idiopathic Arthritis
Polyarticular Juvenile Idiopathic Arthritis
Systemic Juvenile Idiopathic Arthritis
Laboratory Evaluation
Radiographic Evaluation
Treatment
Medical Treatment
Physical and Occupational Therapy
Orthopaedic Treatment
Total Joint Arthroplasty
Enthesitis-­Related Arthritis and Spondyloarthropathies
Juvenile Ankylosing Spondylitis
Reactive Arthritis
Psoriatic Arthritis
Acute Transient Synovitis of the Hip
Etiology
Clinical Features
Diagnostic Studies
Differential Diagnosis
Clinical Course
Treatment
Natural History
Neuropathic Arthropathies
Clinicopathologic Features
Radiographic Findings
Treatment
Tuberculous Arthritis
Tuberculosis of the Spine
Gonococcal Arthritis
23 - Infections of the Musculoskeletal System
Overview
Radiology
Plain Radiography
Ultrasonography
Fluoroscopy
Nuclear Imaging
Computed Tomography
Magnetic Resonance Imaging
Laboratory Studies
Complete Blood Count
Erythrocyte Sedimentation Rate
C-­Reactive Protein
Interleukin-­6
Local Tissue and Blood Cultures (Microbiology)
Staphylococcus aureus
Streptococcus pyogenes
Kingella kingae
Streptococcus pneumoniae
Neisseria meningitidis
Neisseria gonorrhoeae
Borrelia burgdorferi
Mycobacterium tuberculosis
Nontuberculous Mycobacteria
Treponema pallidum
Brucella melitensis
Bartonella henselae
Mycotic Organisms
Coccidioides immitis
Blastomyces dermatitidis
Actinomyces israelii
Sporothrix schenckii
Disease Manifestations
Osteomyelitis
Acute Hematogenous Osteomyelitis
Epidemiology
Pathophysiology
Classification
Neonatal.Neonatal osteomyelitis occurs in two distinct varieties. The first is encountered in infants 2 to 8 weeks of age who ar...
Infantile and Early Childhood.Several organisms appear to have the ability to cause deep infection in children between 3 and 36 ...
Childhood.Among children between 3 and 12 years of age, the most common causative organism of AHO is S. aureus (80%–90%); S. pyo...
Adolescent.Invasive musculoskeletal infection in adolescents is most commonly caused by S. aureus, followed by GABHS. Additional...
Treatment
Surgery.Considerable difference of opinion exists regarding the timing, extent, and necessity of surgery to treat AHO.j The prim...
Outcomes of Osteomyelitis
Subacute Osteomyelitis
Epidemiology
Pathophysiology
Classification
Evaluation and Treatment
Outcomes
Chronic Osteomyelitis
Epidemiology
Pathophysiology
Classification
Evaluation
Treatment
Antibiotic Therapy.In most cases, decisions regarding antibiotic selection, route of administration, and duration of treatment a...
Surgery.Débridement surgery is the foundation of osteomyelitis treatment. The major goal of surgery in chronic osteomyelitis is ...
Complications.Recurrence of disease within 2 years has been reported in 20% to 30% of children with chronic osteomyelitis, despi...
Chronic Recurrent Multifocal Osteomyelitis
Epidemiology
Pathophysiology
Evaluation
Treatment
Complications
Septic Arthritis
Epidemiology
Pathophysiology
Evaluation
Treatment
Antibiotic Therapy
Surgery
Clinical Practice Guideline
Outcomes
Tuberculous Arthritis
Clinical Features
Radiographic Findings
Laboratory Studies
Treatment
General Medical Treatment
Antituberculous Drugs
Orthopaedic Treatment of the Tuberculous Joint
Tuberculosis of the Spine
Pathology
Clinical Features
Radiographic Findings
Treatment
Paraplegia in Tuberculous Spondylitis
Gonococcal Arthritis
Pyomyositis
Epidemiology
Pathophysiology
Evaluation
Treatment
Antibiotic Therapy
Surgery
Complications
Other Soft Tissue Infections of Orthopaedic Significance
Purpura Fulminans
Epidemiology
Pathophysiology
Evaluation and Treatment
Necrotizing Fasciitis
Soft Tissue Abscess and Septic Bursitis
Infection in Challenging Locations
Spine
Pyogenic Infectious Spondylitis
Epidemiology
Pathophysiology
Evaluation
Treatment
Complications
Pelvis
Foot
Hematogenous Calcaneal Osteomyelitis
Plantar Puncture Wounds
Systemic Diseases Associated With Infection
Sickle Cell Disease
Chronic Granulomatous Disease
Human Immunodeficiency Virus
24 - General Principles of Tumor Management
25 - Benign Musculoskeletal Tumors
Simple Bone Cysts (Solitary Bone Cyst, Unicameral Bone Cyst)
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Corticosteroid Injections
Autologous Bone Marrow Injections and Other Bone Substitutes
Decompression of Cysts by Multiple Drilling
Curettage of Cysts Followed by Bone Grafting
Aneurysmal Bone Cyst
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Treatment
Curettage and Adjunctive Therapy
Treatment of Spinal Aneurysmal Cysts
Radiation Therapy
Fibrous Dysplasia
Incidence
Classification
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Nonsurgical Treatment
Surgical Treatment
Osteofibrous Dysplasia of the Tibia and Fibula (Campanacci Disease)
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Solitary Osteochondroma
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Sarcomatous Change
Treatment
Hereditary Multiple Exostoses
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Sarcomatous Change
Treatment
Solitary Enchondroma
Incidence
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Multiple Enchondromatosis (Ollier Disease) and Maffucci Syndrome
Pathology
Clinical Features
Radiographic Findings
Sarcomatous Change
Treatment
Chondroblastoma
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Chondromyxoid Fibroma
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Osteoid Osteoma
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Nonsurgical Treatment
Radiofrequency Ablation
Surgical Treatment
Open Surgical Techniques
Osteoblastoma
Incidence
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Langerhans Cell Histiocytosis (Histiocytosis X)
Eosinophilic Granuloma: Solitary and Multiple Without Extraskeletal Involvement
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Hand-­Schüller-­Christian Disease: Multifocal Eosinophilic Granuloma With Extraskeletal Involvement (Chronic Disseminated Type)
Letterer-­Siwe Disease: Multifocal Eosinophilic Granuloma (Acute Disseminated or Infantile Form)
Nonossifying Fibroma and Fibrous Cortical Defect
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Natural History
Treatment
Primary Synovial Chondromatosis
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Treatment
Pigmented Villonodular Synovitis and Giant Cell Tumor of the Tendon Sheath
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Dysplasia Epiphysealis Hemimelica (Trevor Disease)
Incidence
Etiology
Pathology
Clinical Features
Radiographic Findings
Natural History
Treatment
26 - Malignant Bone Tumors
Osteosarcoma
Classic Osteosarcoma
Pathology
Clinical Features
Magnetic Resonance Imaging and Computed Tomography
Bone Scanning
Angiography
Position Emission Tomography-­Computed ­Tomography
Laboratory Findings
Differential Diagnosis
Staging
Biopsy
Treatment
Chemotherapy
Surgical Treatment
Amputation.Irrespective of the method chosen to treat osteosarcoma, the local tumor must be completely excised with negative mar...
Rotationplasty.An alternative to amputation for distal femoral osteosarcomas is the rotationplasty (Fig. 26.11). Young children ...
Limb salvage.After a complete staging workup, biopsy, and (usually) preoperative chemotherapy, the primary tumor is assessed for...
Metastatic Osteosarcoma
Ewing Sarcoma and Peripheral Primitive Neuroectodermal Tumor
Pathology
Clinical Features
Radiographic Findings
Staging
Biopsy
Prognosis
Treatment
Nonmetastatic Ewing Sarcoma
Chemotherapy
Radiation Therapy
Surgical Treatment
Metastatic Ewing Sarcoma and Peripheral Primitive Neuroectodermal Tumor
Chondrosarcoma
Pathology
Radiographic Findings
Treatment
Soft Tissue Sarcomas
Rhabdomyosarcoma
Pathology
Clinical Features
Radiographic Findings
Biopsy
Treatment and Prognosis
Nonrhabdomyosarcoma Soft Tissue Sarcoma
Congenital and Infantile Fibrosarcoma
Pathology
Clinical Features
Treatment
Nonrhabdomyosarcoma Soft Tissue Sarcoma in Older Children
Clinical Features
Staging and Radiographic Findings
Treatment and Prognosis
27 - General Principles of Managing Orthopaedic Injuries
28 - Spinal Injuries
Traumatic Injuries of the Cervical Spine
Anatomy
Epidemiology
Diagnosis
Radiographic Findings
Cervical Spine Radiographs
Other Studies
Treatment
Atlantooccipital Dislocation
Atlas Fractures
Traumatic Atlantoaxial Instability
Odontoid Fractures
Traumatic Spondylolisthesis of C2 (Hangman’s Fracture)
Fractures and Dislocations of the Subaxial Spine
Traumatic Injuries of the Thoracic and Lumbar Spine
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Nonsurgical Treatment
Surgical Treatment
Pharmacologic Treatment of Spinal Cord Injury
Spinal Cord Injury Without Radiographic Abnormality
Complications After Spinal Cord Injury
29 - Upper Extremity Injuries
Injuries to the Clavicle
Anatomy
Mechanism of Injury
Diagnosis
Birth Fractures
Midshaft Clavicle Fractures
Medial Physeal Separation (Pseudodislocation) of the Sternoclavicular Joint
Lateral Physeal Separation and Acromioclavicular Joint Dislocation
Radiographic Findings
Treatment
Birth Fractures
Midshaft Clavicle Fractures
Medial Physeal Separation (Pseudodislocation) of the Sternoclavicular Joint
Reduction of Anterior Displacement
Reduction of Posterior Displacement
Lateral Physeal Separation and Acromioclavicular Joint Dislocation
Complications
Fractures of the Scapula
Anatomy
Mechanism of Injury
Diagnosis
Treatment
Complications
Associated Conditions
Scapulothoracic Dissociation
Os Acromiale
Fractures Involving the Proximal Humeral Physis
Anatomy
Mechanism of Injury
Classification
Diagnosis
Treatment
Grades I and II Injuries
Grades III and IV Injuries
Complications
Traumatic Dislocation of the Glenohumeral Joint
Anatomy
Mechanism of Injury
Diagnosis
Treatment
Complications
Fractures of the Proximal Metaphysis and Shaft of the Humerus
Anatomy
Mechanism of Injury
Diagnosis
Treatment
Complications
Fractures About the Elbow
Supracondylar Fractures of the Humerus
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Emergency Treatment
Treatment of Nondisplaced Fractures
Treatment of Displaced Fractures
Closed Reduction of Flexion-­Type Fractures
Open Reduction of Supracondylar Humerus Fractures
Percutaneous Pinning
Cast Immobilization
Traction
Timing of Reduction for Type III Fractures
Pinning Technique and Iatrogenic Ulnar Nerve Injury
Management of a Viable, Pulseless Hand
Management of Late-­Presenting or Malreduced Fractures
Complications
Vascular Injury
Peripheral Nerve Injury
Volkmann’s Ischemic Contracture (Compartment Syndrome)
Malunion: Cubitus Varus and Cubitus Valgus
Elbow Stiffness and Myositis Ossificans
Transphyseal Fractures
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Complications
Lateral Condyle Fractures
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Displaced Fractures
Nondisplaced Fractures
Minimally Displaced Fractures
Complications
Cubitus Varus and Lateral Spur Formation
Delayed Union and Nonunion
Fractures With Delayed Union.We use the term delayed union to refer to a minimally displaced fracture that does not heal with 6 ...
Late-1396983920Presenting Fractures.Historically, some have reported better results in patients treated with observation rather ...
Nonunited Fractures.We use the term nonunion to refer to a fracture that has not healed within 3 months. Clinically, nonunion ca...
Growth Arrest
Fishtail Deformity and Avascular Necrosis
Medial Epicondyle Fractures
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Nondisplaced and Minimally Displaced Fractures
Displaced Fractures
Complications
Elbow Dislocations
Anatomy
Mechanism of Injury
Diagnosis
Treatment
Complications
Radial Head and Neck Fractures
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Immobilization
Reduction
Closed Reduction.There are several techniques of closed reduction. Patterson is credited with describing a technique advocated b...
Percutaneous and Intramedullary Reduction.In type II (30 to 60 degrees of angulation) and type III (>60 degrees of angulation) r...
Open Reduction.Salter-­Harris types III and IV injuries, as well as fractures that remain significantly angled after attempts at...
Treatment of Late-­Presenting Displaced Fractures
Radial Head Excision
Complications
Olecranon Fractures
Anatomy
Mechanism of Injury
Classification
Diagnosis
Treatment
Complications
Uncommon Elbow Fractures
Classification
Treatment
Closed Reduction and Percutaneous Pinning.In most type I fractures and in some younger patients with type II or III fractures, c...
Open Reduction and Internal Fixation.Most patients with types II and III injuries and patients with type I injuries in whom anat...
Complications
Medial Condyle Fractures
Classification
Treatment and Complications
Treatment
Coronoid Fractures
Trochlear Fractures
Lateral Epicondyle Fractures
Associated Conditions
Nursemaid’s Elbow (Pulled Elbow, Traumatic Subluxation of the Radial Head)
Fractures of the Forearm
Monteggia Fractures
Anatomy
Classification
Mechanism of Injury
Diagnosis
Radiographic Findings
Open Reduction and Fixation
Complications
Chronic, Missed, or Neglected Monteggia Fracture
Recurrence of Radial Head Dislocation
Malunion of the Ulna
Stiffness
Nerve Palsy
Compartment Syndrome and Volkmann’s Ischemic Contracture
Fractures of the Shaft of the Radius and Ulna
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Treatment
Follow-­Up.After reduction and splinting or casting, the patient is discharged with instructions to elevate the arm “with the fi...
Parameters of an Acceptable Closed Reduction.Unfortunately, the limits of an acceptable reduction are unknown. The goal of treat...
Operative Treatment
Open Reduction and Internal Fixation.Open reduction plus internal fixation with compression plate and screws, the standard of ca...
Flexible Intramedullary Fixation.The advent of image intensification has made closed reduction and percutaneous intramedullary f...
Single-­Bone Fixation.There have been reports of successful management of both-­bone forearm fractures with stabilization of onl...
External Fixation.External fixation of children’s forearm fractures can refer to treatment with traditional external fixation de...
Malunion
Delayed Union or Nonunion
Synostosis
Compartment Syndrome
Peripheral Nerve Injury
Other Complications
Fractures of the Distal Forearm
Anatomy
Mechanism of Injury
Classification
Diagnosis
Radiographic Findings
Greenstick Fractures
Metaphyseal Fractures
Nondisplaced Metaphyseal Fractures.Nondisplaced metaphyseal fractures only need to be immobilized in a short-­ or long-­arm cast...
Displaced Distal Metaphyseal Fractures.There has been considerable controversy over the treatment of displaced distal fractures ...
Treatment by Closed Reduction and Casting.Despite one report supporting closed treatment without manipulation,66 we still treat ...
Operative Treatment.Indications for operative treatment include open fractures, irreducible fractures, fractures associated with...
Parameters of an Acceptable Reduction.The factors that affect remodeling are discussed in detail in Chapter 31; these include th...
Distal Radial Physeal Fractures
Distal Ulnar Physeal Injuries
Galeazzi Fractures
Complications
Malunion
Re-­fracture
Growth Arrest
Peripheral Nerve Injury
Compartment Syndrome and Acute Carpal Tunnel Syndrome
Nonunion, Cross-­Union, Infection, and Tendon Rupture
Reflex Sympathetic Dystrophy
Fractures and Dislocations of the Wrist and Hand
Fractures of the Scaphoid
Anatomy
Radiographic Findings
Routine Scaphoid Radiographic Series
Computed Tomography Scans
Magnetic Resonance Imaging
Unstable or Displaced Scaphoid Fractures
Chronic Scaphoid Fractures
Fractures and Dislocations of the Hand
Metacarpal Fractures
Distal Phalanx (P3)
Intraarticular Fractures
30 - Lower Extremity Injuries
Pelvis and Acetabulum
Pelvis
Anatomy
Mechanism of Injury
Classification
Associated Injuries
Clinical Features
Radiographic Findings
Treatment
Types of Injuries (Torode and Zieg Classification)
Type III: Simple Pelvic Ring Fractures. This injury ­includes fractures of the pubic rami, disruptions of the pubic ­symphysis, ...
Type IV: Pelvic Ring Disruption Fractures. Pelvic ring disruption fractures include the following: bilateral pubic rami fracture...
Straddle Fracture. Straddle fractures consist of bilateral fractures of both the superior and inferior rami or separation of the...
Double-­Ring Fracture. The second group of type IV fractures includes vertically or rotationally unstable pelvic fractures (or b...
Lateral Compression. A lateral compression–type injury (Fig. 30.11) that produces an anterior pelvic ring fracture and partial s...
Anterior Compression. Anterior compression–type injuries (Fig. 30.12) in children younger than 10 years usually heal without dif...
Vertical Shear. A Malgaigne-­type injury (Fig. 30.13) is characterized by complete disruption of the entire hemipelvis with a ve...
Treatment Techniques
Open Reduction and Internal Fixation of the Symphysis Pubis. The indications for ORIF of the symphysis pubis are similar to thos...
Internal Fixation of the Sacroiliac Joint. Injuries to the sacroiliac joint, including dislocations and fracture-­dislocations, ...
Complications
Acetabulum
Anatomy
Mechanism of Injury
Classification
Associated Injuries
Clinical Features
Radiographic Findings
Treatment
Types of Injuries
Type II Fractures. Type II fractures are often associated with other pelvic ring fractures, which must be assessed and treated a...
Type III Fractures. Type III fractures are treated similarly to those in adults with assessment of the fracture pattern. Applica...
Type IV Fractures. Type IV fractures with a central fracture-­dislocation should be treated initially by skeletal traction in an...
Triradiate Cartilage Injuries. Although isolated triradiate cartilage injuries account for a small percentage of acetabular frac...
Treatment Techniques
Complications
Hip
Hip Dislocations
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Anterior Dislocation.To reduce an anterior dislocation of the hip, a modification of the Allis technique entails initially flexi...
Central Dislocation.Central dislocations require skeletal traction through a distal femoral pin to reduce the femoral head to it...
Open Reduction
Posterior Approach.A standard posterior approach (Southern or Moore) to the hip is used (Fig. 30.33).39 The sciatic nerve should...
Anterior Approach.An anterior approach for an anterior hip dislocation can be either a direct anterior (Smith-­Petersen) or an a...
Surgical Hip Dislocation
Hip Arthroscopy.Hip arthroscopy may be considered to address labral pathology or to assist with a nonconcentric reduction when a...
Postreduction Treatment
Complications
Avascular Necrosis
Sciatic Nerve Palsy
Recurrent Hip Dislocation
Degenerative Arthritis
Vascular Injury
Hip Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Type I: Transepiphyseal Fractures
Type II: Transcervical Fractures
Type III: Cervicotrochanteric Fractures
Type IV: Pertrochanteric or Intertrochanteric Fractures
Stress Fractures
Complications
Avascular Necrosis
Predisposing Factors.Several studies found the following risk factors for AVN: fracture displacement, which is the most importan...
Clinical Features and Radiographic Findings.Symptoms of AVN may occur early, with complaints of groin pain. Radiographic evidenc...
Patterns.Three patterns of AVN have been described by Ratliff (Fig. 30.50). 49
Treatment and Prognosis. In general, AVN after hip fractures in children results in poor outcomes in up to 60% of cases
Coxa Vara
Nonunion
Premature Physeal Arrest
Infection
Femur
Femoral Shaft Fractures
Anatomy and Development
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
7 Months to 5 Years.When shortening of the fracture is limited to less than 2 to 3 cm and the fracture has a stable, simple patt...
6 to 10 Years.Femoral shaft fractures in children between 6 and 10 years of age are routinely treated by closed or open reductio...
11 Years to Skeletal Maturity.Flexible intramedullary rodding is an acceptable choice with a stable fracture pattern. Submuscula...
Skin Traction.Skin traction is a noninvasive technique that is used in two settings. First, in a small child whose fracture is t...
Skeletal Traction.Skeletal traction is a more powerful technique to apply traction to the femur, although its use is limited to ...
Results and Cautions.Traction should reduce the fracture to within 2 cm in a younger child, and end-­to-­end apposition should b...
Spica Casting.Immediate spica casting has been advocated in a child with an isolated stable femoral shaft fracture and less than...
External Fixation.The main indications today for external fixation are as follows: (1) an open fracture with severe disruption o...
Open Reduction and Internal Fixation.Proponents of internal fixation with plates and screws recommend this form of treatment for...
Submuscular Bridge Plating.Submuscular plating through a limited approach with indirect fracture reduction has been shown to be ...
Intramedullary Fixation: Overview.Intramedullary fixation has assumed a more prominent role in the treatment of femoral shaft fr...
Procedure.The fracture pattern most amenable to this treatment is a transverse stable fracture with minimal comminution. Long sp...
Complications.The incidence of complications with flexible nails in appropriate fracture patterns is low. Complications are more...
Results.Comparison studies of other techniques generally indicate that flexible nails yield superior results in treating femoral...
Complications.Although relatively rare, the most severe complication from intramedullary nailing of a femoral shaft 1396983920fr...
Unacceptable Angulation
Rotational Deformities
Nonunion and Delayed Union
Compartment Syndrome
Traction Injuries
Vascular Injury
Knee
Distal Femoral Injuries and Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Distal Femoral Metaphyseal Fractures
External Fixation.We limit the indications for external fixation to the following: significant soft tissue injury associated wit...
Closed Reduction and Internal Fixation.The method of closed reduction of the distal metaphyseal fracture depends on the deformit...
Open Reduction and Internal Fixation.Indications for this technique include fractures that are irreducible by closed means and a...
Nondisplaced Physeal Fractures.Nondisplaced physeal injuries can be treated with a long-­leg cast for 4 to 6 weeks, depending on...
Salter-­Harris Type I Fractures.A Salter-­Harris type I injury in a newborn can be treated by immobilization without attempts at...
Salter-­Harris Type II Fractures.Of all type II fractures, 60% to 75% are displaced at the time of initial evaluation.16,41,67 I...
Salter-­Harris Type III Fractures.Type III injuries of the distal femur are relatively less common, are usually displaced, and g...
Salter-­Harris Type IV Fractures.Management of type IV fractures is similar to that for type III fractures: anatomic reduction t...
Complications
Peroneal Nerve Injury.Peroneal nerve injury may result from direct trauma on the posterolateral aspect of the leg or from a seve...
Ligamentous Injuries.Associated ligamentous injuries occur relatively commonly in injuries to the distal femoral physis. A compi...
Loss of Reduction.Loss of reduction occurs because of suboptimal stabilization of the unstable fracture, usually a result of ina...
Angular Deformity.Angular deformity is less frequently seen than limb length discrepancy, with a reported incidence of 29% (49 o...
Loss of Knee Motion.Loss of knee motion occurs in approximately 27% of distal femoral physeal injuries (45 of 167 patients in fi...
Patellar Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Sleeve Fracture
Displaced Transverse Patellar Fracture
Comminuted Fracture
Ipsilateral Femoral or Tibial Fracture
Marginal Fracture
Complications
Tibial Tuberosity Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Complications
Proximal Tibial Physeal Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Closed Reduction
Open Reduction
Complications
Proximal Tibiofibular Joint Dislocations
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Tibia and Fibula
Anatomy
Tibial and Fibular Fractures
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Proximal Tibial Metaphyseal Fractures
Mechanism of Injury
Clinical Features and Radiographic Findings
Treatment
Complications
Tibial and Fibular Diaphyseal Fractures
Mechanism of Injury
Classification
Nondisplaced Oblique or Spiral Tibial Fracture With an Intact Fibula (Toddler’s Fracture).The so-­called toddler’s fracture was ...
Displaced Tibial Fracture With an Intact Fibula in an Older Child.The second category of fracture amenable to nonoperative treat...
Displaced Tibial Fracture With a Fibular Fracture in an Older Child.The third major category of tibial diaphyseal fractures in c...
Operative Treatment
Open Tibial Diaphyseal Fractures
Mechanism of Injury
Classification
Treatment
Early Treatment: Antibiotics, Débridement, and Splinting
Wound Management
Soft Tissue Management
Management of Bony Defects
Fracture Stabilization
Treatment of Neurovascular Injury
Complications
Compartment Syndrome
Other Complications
Distal Tibial Metaphyseal Fractures
Stress Fractures of the Tibia
Ankle
Anatomy
Ankle Fractures
Classification
Supination-­Inversion Injury
Supination–Plantar Flexion Injury
Supination–External Rotation Fracture
Pronation–Eversion–External Rotation Fracture
Axial Compression Injuries and Other Physeal Injuries
Clinical Features
Radiographic Findings
Treatment
Salter-­Harris Types I and II Distal Fibular Fractures
Salter-­Harris Type I Tibial Fractures
Salter-­Harris Type II Distal Tibial Fractures
Salter-­Harris Type III Distal Tibial Fractures
Salter-­Harris Type IV Distal Tibial Fractures
Salter-­Harris Type V Distal Tibial Fractures
Complications
Premature Closure of the Physis
Delayed Union or Nonunion
Valgus Deformity Secondary to Malunion
Distal Tibiofibular Synostosis
Tillaux Fractures
Mechanism of Injury
Clinical Features
Treatment
Closed Reduction.When closed reduction is attempted, the maneuver includes internal rotation of the foot to allow the anterior t...
Open Reduction and Internal Fixation.The indications for ORIF are fracture displacement of more than 2 mm after an attempt at a ...
Results
Triplane Fractures
Mechanism of Injury
Radiographic Findings
Treatment
Closed Reduction.Most authors recommend nonoperative treatment of fractures with minimal or mild displacement (<2 mm). In these ...
Open Reduction and Internal Fixation.The indication for ORIF is failure to achieve adequate closed reduction to within 2 mm of t...
Results
Syndesmosis Injuries
Foot
Talar Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Fractures of the Neck of the Talus
Fractures of the Body of the Talus
Fractures of the Lateral Process
Complications
Calcaneal Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Complications
Tarsometatarsal (Lisfranc) Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Closed Reduction
Open Reduction and Internal Fixation
Complications
Metatarsal Fractures
Mechanism of Injury
Clinical Features
Radiographic Findings
Closed Reduction
Open Reduction and Internal Fixation
Fractures of the Base of the Fifth Metatarsal
Anatomy
Classification
Treatment
Zone I Fractures
Zone II Fractures
Zone III Fractures
Phalangeal Fractures
Lawnmower Injuries
Puncture Injuries of the Foot
31 - Disorders of the Brain
Levels of Involvement
Spinomuscular Level
Spinal Level
Neural Level
Myoneural Level
Extrapyramidal Level
Pyramidal (Corticospinal) Level
Cerebellar Level
Cerebral Palsy
Definition
Epidemiology
Etiology
Prenatal
Perinatal
Postnatal
Classification
Physiologic
Geographic
Functional
Evaluation
History
Reflexes
Balance, Sitting, and Gait
Other Assessments
Histopathologic and Imaging Findings
Gait Analysis
Muscle Strength
Prognosis for Ambulation
Treatment
Casting
Orthoses
Timing of Surgery
Anesthetic Concerns
Postoperative Management
Management of Foot Involvement in Cerebral Palsy
Equinus
Differential Diagnosis of Equinus
Clinical Features
Treatment
Postoperative Care
Complications
Preferred Procedure
Treatment
Clinical Features and Radiographic Findings
Treatment
Ankle Valgus
Hallux Valgus
Dorsal Bunion
Management of Knee Involvement in Cerebral Palsy
Surgical Technique
Postoperative Care
Results
Indications for Distal Hamstring Lengthening With Simultaneous Rectus Femoris Transfer
Clinical Features
Surgical Technique
Derotational Osteotomy
Management of Hip Involvement in Cerebral Palsy
Diagnosis
Surgical Technique
Diagnosis
Surgical Treatment
Diagnosis
Treatment
Complications
Anterior Dislocation of the Hip
Sensory Impairment
Effects on Growth
Treatment
Nonsurgical Treatment
Motor Examination.The typical posture of a spastic upper limb is elbow, wrist, and finger flexion and forearm pronation. Muscles...
Sensory Examination.Awareness of the limb and discrimination of pain and temperature are critical for incorporation of the limb ...
Pronation Contracture.Pronation contracture of the forearm develops insidiously and, with growth, causes a rotational deformity ...
Management of Spinal Deformity in Cerebral Palsy
Scoliosis
Nonoperative Treatment
Surgical Treatment
Segmental Instrumentation of Scoliosis.Segmental instrumentation is recommended in patients with scoliosis secondary to CP. Subl...
Galveston Technique.Fusion of the spine to the pelvis was classically accomplished with the Galveston technique, as described by...
Dunn-­McCarthy Technique.Another form of fixation that was used for patients with CP was the Dunn-­McCarthy technique, in which ...
Iliac and Sacroiliac Screw Fixation Technique.Recent advances in modular spinal instrumentation have improved the ease and secur...
Growing Rod Instrumentation.Growing rod instrumentation has been used in small numbers of very young children with CP and scolio...
Spondylolysis and Spondylolisthesis
Cervical Spine Spondylosis in Athetoid Cerebral Palsy
Rhizotomy
Indications
Surgical Technique
Postoperative Care
Results
Complications
Management of Fractures in Cerebral Palsy
Outcome Assessment
Rett Syndrome
Diagnosis
Pathogenesis
Clinical Features
Treatment
Hereditary Spastic Paraparesis
Pathogenesis
Clinical Features
Treatment
Ataxia Syndromes
Friedreich Ataxia (Hereditary Spinocerebellar Ataxia)
Pathogenesis
Clinical Features
Diagnosis
Medical Treatment
Prognosis
32 - Disorders of the Spinal Cord
Myelomeningocele
Incidence
Embryology
Causative Factors
Folate
Heredity
Pathology
Skin
Meninges
Spinal Cord
Peripheral Nerve Roots
Vertebrae
Brain
Natural History
Prognosis
Associated Health Problems
General or Universal Problems
Upper Extremity Function
Early Puberty
Cognitive Problems
Psychosocial Implications
Upper Lumbar Level
Lower Lumbar Level
Sacral Level
Complications
Latex Allergy
Infection
Pressure Sores
Fractures
Treatment
Multidisciplinary Care
Neurosurgical Treatment
Closure of the Myelomeningocele Sac
Hydrocephalus
Other Spinal Cord Abnormalities
Urologic Treatment
Physical and Radiographic Examination of the Newborn
Periodic Assessment
Equinus
Equinovarus
Calcaneal Deformity
Vertical Talus
Valgus Deformity of the Foot and Ankle
Distal Tibia.Surgical options for the management of distal tibial valgus deformities include distal tibial and fibular osteotomy...
Distal Tibial Osteotomy.Fixation may be done with crossed Steinmann pins, staples, external fixator, or internal fixation with a...
Distal Tibial Medial Hemiepiphysiodesis.If the patient is skeletally immature, with a deformity that does not demand full and im...
Achilles Tendon–Fibular Tenodesis.Stevens and Toomey described the tenodesis of a portion of the Achilles tendon to the distal f...
Subtalar Joint.When radiographs reveal that most of the valgus deformity is in the subtalar region, treatment should consist of ...
Rotational Deformities (Internal or External)
Knee Deformities
Congenital Knee-­Flexion Contracture.Patients can be born with flexion contractures of the knee. Flexion contractures of less th...
Congenital Knee Hyperextension or Dislocation.Congenital knee hyperextension or dislocation may also occur in patients with myel...
Developmental Knee-­Flexion Contracture.In ambulatory and nonambulatory patients, knee-­flexion contractures can occur during gr...
Knee Extension Contracture.Another common problem is extension contracture, although it is not as common as one might expect bas...
Knee Instability or Internal Derangement.Patients with myelomeningocele frequently present with unexplained swelling of the knee...
Hip Deformities
Abduction or External Rotation Contracture.This deformity, which may be congenital or developmental, is typically seen in patien...
Flexion Deformity.Pure hip flexion deformity is usually seen in conjunction with hip subluxation or dislocation (see later), sec...
Paralytic Hip Subluxation or Dislocation.The most frequent and vexing hip deformity is paralytic subluxation and dislocation of ...
Controversies in Treatment.The nature of the problem is perhaps best understood by comparing the treatment of developmental dysp...
Reduction.Based on gait analysis in lumbar myelomeningocele patients with hip dislocation or subluxation, reduction of the dislo...
Surgical Complications.One of the complications of extensive hip surgery is loss of mobility. This may be exacerbated if heterot...
Summary: Management of Paralytic Hip Subluxation and Dislocation.The indications for the surgical treatment of paralytic hip sub...
Spinal Deformities
General Management of the Spine
Kyphosis
Management of Skin Breakdown.The treatment of myelomeningocele-­related kyphosis is always challenging. Lumbar kyphosis can be p...
Definitive Management.There appears to be little, if any, role for bracing in an attempt to control or correct the deformity. De...
Preoperative Preparation.Careful preoperative assessment is necessary. The function of the shunt must be determined and, if it i...
Results.Martin and co-­workers reported improved skin condition and sitting posture in all 10 patients treated by vertebrectomy,...
Scoliosis
Orthotic Treatment.Spinal orthoses such as the Boston brace may have a role in the management of noncongenital scoliosis in pati...
Spinal Fusion.Several aspects of myelomeningocele make scoliosis surgery unique in these patients. Foremost among these is the p...
Technique.My preferred surgical treatment for scoliosis in patients with myelomeningocele is a single-­stage combined anterior s...
Postoperative Management.Urinary tract infection, which threatens the urinary tract and posterior spinal fusion site, wound infe...
Results.Extensive spinal fusion such as that necessary to treat progressive noncongenital scoliosis in myelomeningocele patients...
Hyperlordosis
Hemimyelodysplasia
Lower Lumbar and Sacral Levels.Typically, patients with lower lumbar or sacral-­level paralysis have good to excellent quadricep...
Knee-­Ankle-­Foot Orthoses.KAFOs are required for patients with upper lumbar lesions (weak quadriceps function) and are the reco...
Hip-­Knee-­Ankle-­Foot Orthoses.HKAFOs are extensive braces required for all patients without adequate hip strength or stability...
Reciprocating Gait Orthoses.The concept of RGOs was originally introduced at the Ontario Crippled Children1397969521s Treatment ...
Parapodium.These devices are the equivalent of mobile standing frames. Simple lockable hip and knee hinges are incorporated into...
Wheelchair.Many variations of wheelchairs are available to the paraplegic population. The wisest course for a physician is to re...
Education and Counseling
Summary
Other Forms of Spinal Dysraphism
Lipomeningocele
Clinical Features
Treatment
Tethered Cord (Thickened Filum Terminale)
Diastematomyelia
Clinical Features
Radiographic Findings
Treatment
Spina Bifida Occulta
Pathology
Guille Classification
Clinical Features
Type II.The vertebropelvic junction is stable unless there is associated myelomeningocele. In some patients with myelomeningocel...
Type III.The lumbopelvic junction is relatively stable in this type, despite the absence of the sacrum and, in some cases, L5. P...
Type IV.This type represents the classic, fully manifested form of lumbosacral agenesis. Patients have short stature and a chara...
Type B.The functional level is T12 or L1. Although household ambulation may be possible, wheelchairs are usually necessary
Type C.Patients are nonambulators. For all three types proposed by Guille and colleagues, there was no correlation between the d...
Treatment
Spinal Muscular Atrophy
Etiology
Pathogenesis
Classification
Type I: Acute Infantile
Type II: Chronic Infantile
Type III: Kugelberg-­Welander
Grading
Differential Diagnosis
Diagnostic Evaluation
Treatment
Medical Treatment
Orthopaedic Treatment
Contractures
Hip Subluxation and Dislocation
Scoliosis
Nonsurgical Treatment.Nonoperative treatment of scoliosis in SMA is difficult. Orthoses make sitting easier, but they are ineffe...
Surgical Treatment.The indications for surgical treatment are progressive spinal deformity despite orthotic management, with a c...
33 - Poliomyelitis
Worldwide Eradication Efforts
Postpolio Syndrome
Pathology
Course and Prognosis
Treatment Overview
Acute Phase
Management of Respiratory Involvement
Prevention of Deformity
Management of Muscle Spasm
Convalescent Phase
Management of Muscle Spasm and Prevention of Deformity
Muscle Examination
Preserving and Restoring Neuromuscular Function
Patterns of Motor Activity
Fatigue
Contractural Deformity and Progressive Loss of Function
Chronic Phase
Physical Therapy
Active Hypertrophy Exercises
Passive Stretching Exercises
Functional Training
Orthoses and Other Apparatus
General Principles
Hip.If the muscles controlling the hip are weak, stability of the hip joint can be provided by an ischial weight-­bearing thigh ...
Upper Extremity.In the upper limb the paralyzed shoulder muscles, particularly the deltoid, are best protected from the effects ...
Surgical Treatment
Principles of Tendon Transfer
Postoperative Care and Training
Management of the Hip
Soft Tissue Contracture
Lower Limb
Flexion and Valgus Deformity of the Knee and External Torsion of the Tibia
External Torsion of the Tibia and Subluxation of the Knee Joint
Positional Pes Varus
Pelvis and Trunk
Exaggerated Lumbar Lordosis
Pelvic Obliquity
Treatment
Passive Stretching Exercises
Ober and Yount Fasciotomies
Gluteus Medius Paralysis
Iliopsoas Muscle Transfer for Lateral Stability of the Hip
External Oblique Muscle Transfer for Hip Abduction
Gluteus Maximus Paralysis
Surgical Technique (Barr)
Technique for Correction of Remaining Contractures in Poliomyelitic Deformities
Paralytic Dislocation of the Hip
Surgical Treatment
Muscle Transfer
Varization Osteotomy
Arthrodesis of the Hip
Management of the Knee
Quadriceps Femoris Paralysis
Surgical Technique
Postoperative Care and Functional Training
Complications
Flexion Deformity of the Knee
Genu Recurvatum
Genu Recurvatum Caused by Stretching of the Soft Tissues in the Back of the Knee
Genu Recurvatum Resulting From Ankle Equinus and Hamstring Weakness
Flail Knee
Management of Specific Deformities of the Foot and Ankle
Normal Physiology
Treatment of Muscle Imbalance
Paralysis of the Peroneal Muscles
Paralysis of the Peroneals, Extensor Digitorum Longus, and Extensor Hallucis Longus
Paralysis of the Anterior Tibial Muscle
Paralysis of the Anterior Tibial Muscle, Toe Extensors, and Peroneals
Paralysis of the Triceps Surae Muscle
Arthrodesis of the Foot and Ankle
Triple Arthrodesis
Indications and Preoperative Considerations
Valgus Deformity Correction.Valgus deformity of the foot is corrected by excision of a medially based wedge from the midtarsal a...
Calcaneus Foot Deformity Correction.For restoration of alignment of a calcaneus foot, a wedge of bone based posteriorly is resec...
Pes Equinus Deformity Correction.In correction of pes equinus, fixed contracture of the posterior capsule of the ankle and subta...
Extraarticular Subtalar Arthrodesis
Ankle Fusion and Pantalar Arthrodesis
Anterior or Posterior Bone Blocks to Limit Motion at the Ankle
Management of the Trunk
Management of the Shoulder
Classification
Prime Movers
Treatment by Muscle Transfer
Steering Group
Depressor Group
Treatment by Muscle and Tendon Transfer
Arthrodesis of the Shoulder
Management of the Elbow
Paralysis of the Biceps Brachii and Brachialis Muscles
Results
Complications and Disadvantages
Pectoralis Major Muscle Transfer
Disadvantages
Pectoralis Minor Muscle Transfer
Sternocleidomastoid Muscle Transfer
Anterior Transfer of the Triceps Brachii Tendon
Techniques
Results and Disadvantages
Latissimus Dorsi Transfer
Paralysis of the Triceps Brachii Muscle
Management of the Forearm
34 - Disorders of the Peripheral Nervous System
Hereditary Motor and Sensory Neuropathies
Charcot-­Marie-­Tooth Disease
Genetics
Clinical Features
Diagnostic Evaluation
Medical Treatment
Hip
Spine
Treatment.Reports of treatment to augment upper limb function in patients with CMT have not been widely published. Although nerv...
Pathology
Clinical Features
Diagnosis
Prognosis and Treatment
Refsum Disease
Congenital and Acquired Analgia
Congenital Insensitivity to Pain
Familial Dysautonomia (Riley-­Day Syndrome; Hereditary Sensory and Autonomic Neuropathy Type III)
Congenital Sensory Neuropathy
Hereditary Sensory Radicular Neuropathy (Hereditary Sensory and Autonomic Neuropathy Type I)
Congenital Insensitivity to Pain With Anhidrosis (Hereditary Sensory and Autonomic Neuropathy Type IV)
Lesch-­Nyhan Syndrome
Syringomyelia
Guillain-­Barré Syndrome (Acute Polyradiculoneuritis)
Cause and Pathophysiology
Diagnosis
Clinical Features
Differential Diagnosis
Treatment
Prognosis
Sciatic and Peroneal Nerve Palsy
Causes
Clinical Features
Radiographic Findings
Treatment
35 - Muscle Diseases
Muscular Dystrophies
Overview
Historical Background
Classification
Etiology
Pathology
Laboratory Findings
Electromyography and Nerve Conduction Velocity
Duchenne Muscular Dystrophy
Etiology and Diagnosis
Clinical Features
Physical Examination
Medical Concerns
Corticosteroid Therapy
General Treatment
Physical Therapy
Lower Limb Surgery
Timing of Surgery.The timing of this surgery is controversial.289 There are few studies of orthopaedic intervention since the in...
Techniques.Equinus is managed by percutaneously lengthening the Achilles tendon.296,299 Varus is treated by surgery on the poste...
Spinal Surgery
Timing of Surgery and Indications.The appropriate treatment of scoliosis is surgical intervention. Bracing has been tried but is...
Techniques.Posterior spinal fusion with segmental pedicle screw fixation is currently favored by most surgeons because of improv...
Results and Complications.The effect of spinal fusion and correction of scoliosis on pulmonary function has been studied by a nu...
Anesthetic Considerations
Upper Extremities
Fractures
Prognosis
Becker Muscular Dystrophy
Etiology and Diagnosis
Clinical Features
Medical Concerns
Treatment
Emery-­Dreifuss Muscular Dystrophy
Etiology and Diagnosis
Clinical Features
Laboratory Findings
Medical Concerns
Treatment
Limb-­Girdle Muscular Dystrophy
Etiology
Clinical Features
Laboratory Findings
Medical Concerns
Treatment
Facioscapulohumeral Muscular Dystrophy
Etiology
Clinical Features
Laboratory Findings
Medical Concerns
Treatment
Scapuloperoneal Dystrophy
Congenital Muscular Dystrophy
Orthopaedic Disorders
Myotonic Dystrophy
Etiology
Clinical Features
Medical Concerns
Treatment and Prognosis
Metabolic Diseases of Muscle
Thomsen Myotonia
Pathology
Clinical Features
Laboratory Findings
Differential Diagnosis
Polymyositis and Dermatomyositis
Etiology
Diagnosis
Pathology
Clinical Features
Laboratory Findings
Treatment
Prognosis
Myositis Ossificans
Classification
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Progressive Fibrosis of the Quadriceps
Etiology
Pathophysiology
Clinical Features
Treatment
Myasthenia Gravis
Incidence
Etiology
Clinical Features
Neonatal Transient Myasthenia Gravis
Congenital Myasthenic Syndromes
Juvenile Myasthenia Gravis
Diagnosis
Treatment
36 - Skeletal Dysplasias
Overview
Nomenclature and Classification
Achondroplasia
Genetics
Pathophysiology
Clinical Features
Radiographic Findings
Diagnosis
Orthopaedic Considerations
Craniocervical Stenosis
Hypotonia
Sleep Apnea
Hydrocephalus
Thoracolumbar Kyphosis
Etiology
Treatment
Clinical Features
Radiographic Findings
Treatment
Angular Deformities of the Lower Extremities
Elbow Deformity
Growth Hormone
Outcomes Research
Hypochondroplasia
Genetics
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Treatment
Thanatophoric Dwarfism
Genetics
Prenatal Diagnosis
Clinical Features
Radiographic Findings
Prognosis
Pseudoachondroplasia
Genetics
Pathology
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Lower Extremity Malalignment
Hip
Thoracolumbar Kyphosis and Lumbar Lordosis
Cervical Atlantoaxial Instability
Scoliosis
Spondyloepiphyseal Dysplasia
Spondyloepiphyseal Dysplasia Congenita
Genetics
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Lower Extremities
Pain and Joint Problems
Spondyloepiphyseal Dysplasia Tarda
Genetics
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Multiple Epiphyseal Dysplasia
Genetics
Pathology
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Diastrophic Dysplasia (Diastrophic Dwarfism)
Genetics
Pathology
Clinical Features
Radiographic Findings
Diagnosis
Orthopaedic Considerations
Foot
Hip
Spine
Kyphosis
Scoliosis
Prognosis
Kniest Dysplasia (Pseudometatrophic Dysplasia)
Genetics
Pathology
Clinical Features
Radiographic Findings
Treatment
Orthopaedic Considerations
Chondrodysplasia Punctata
Genetics
Pathology
Clinical Features
Radiographic Findings
Prenatal Diagnosis
Orthopaedic Considerations
Prognosis
Metaphyseal Chondrodysplasia
Jansen Type
Genetics
Clinical Features
Radiographic Findings
Laboratory Findings
Schmid Type
Genetics
Clinical Features
Radiographic Findings
Differential Diagnosis
Orthopaedic Considerations
Cartilage–Hair Hypoplasia (McKusick Type)
Genetics
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Osteopetrosis
Types
Malignant Osteopetrosis
Benign or Tarda Osteopetrosis
Osteopetrosis Associated With Renal Tubular Acidosis
Genetics
Pathology
Clinical Features
Radiographic Findings
Laboratory Findings
Prenatal Diagnosis
Differential Diagnosis
Treatment
Orthopaedic Considerations
Progressive Diaphyseal Dysplasia (Camurati-­Engelmann Disease)
Genetics
Pathology
Clinical Features
Radiographic Findings
Laboratory Findings
Differential Diagnosis
Treatment
Osteopoikilosis
Genetics
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Clinical Course
Osteopathia Striata
Genetics
Clinical Features
Radiographic Findings
Differential Diagnosis
Clinical Course
Melorheostosis
Etiology
Pathology
Clinical Features
Radiographic Findings
Clinical Course
Differential Diagnosis
Treatment
Orthopaedic Considerations
Infantile Cortical Hyperostosis (Caffey Disease)
Genetics
Pathology
Clinical Features
Radiographic Findings
Prenatal Diagnosis
Diagnosis
Differential Diagnosis
Treatment
Orthopaedic Considerations
Clinical Course
Pyknodysostosis
Genetics
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Orthopaedic Considerations
Clinical Course
Cleidocranial Dysostosis
Genetics
Clinical Features
Radiographic Findings
Orthopaedic Considerations
Other Considerations
Idiopathic Osteolysis
Types
Gorham Massive Osteolysis
Hereditary Multicentric Osteolysis With Dominant Transmission
Nonhereditary Multicentric Osteolysis With Nephropathy
Radiographic Findings
Differential Diagnosis
Treatment
Mucopolysaccharidoses
Diagnosis
Radiographic Findings
Types
Pathology
Clinical Features
Radiographic Findings
Treatment
Orthopaedic Considerations
Pathology
Clinical Features
Orthopaedic Considerations
Radiographic Findings
Treatment
Clinical Course
Pathology
Clinical Features
Treatment
Diagnosis
Histology
Clinical Features
Radiographic Findings
Prenatal Diagnosis
Orthopaedic Considerations
Mucopolysaccharidosis V (Scheie Syndrome)
Mucopolysaccharidosis VI (Maroteaux-­Lamy Syndrome)
Mucopolysaccharidosis VII (Sly Syndrome)
Niemann-­Pick Disease
37 - Orthopaedic-­Related Syndromes
Marfan Syndrome
Heredity and Incidence
Genetics
Clinical Features
Stature and Proportion
Skull and Facies
Eyes
Cardiovascular System
Other Skeletal Manifestations
Other Associated Anomalies
Diagnosis
Differential Diagnosis
Homocystinuria
Congenital Contractural Arachnodactyly
Loeys-­Dietz Syndrome
Hereditary Juvenile Ophthalmoarthropathy
Other Conditions
Treatment
Cardiovascular System
Protrusio Acetabuli
Developmental Dysplasia of the Hip
Generalized Joint Laxity
Infantile Marfan Syndrome
Prognosis
Hereditary Progressive Arthro-­Ophthalmopathy (Stickler Syndrome)
Clinical Features
Orthopaedic Manifestations
Congenital Contractural Arachnodactyly (Beals Syndrome)
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Homocystinuria
Biochemical Defect and Pathophysiology
Clinical Features
Vascular Changes
Mental Retardation
Dislocation of the Lens
Skeletal Changes
Diagnosis
Treatment
Nail-­Patella Syndrome (Hereditary Onycho-­Osteodysplasia)
Inheritance and Genetics
Clinical Features
Radiographic Findings
Associated Anomalies
Treatment
Larsen Syndrome
Clinical Features
Neurologic Evaluation
Differential Diagnosis
Radiographic Findings
Treatment
Cervical Kyphosis
Congenital Dislocation of the Knee
Congenital Dislocation of the Hip
Foot Deformities
Congenital Dislocation of the Elbow or Radial Head
Scoliosis
Summary
Down Syndrome (Trisomy 21)
Clinical Features
Treatment
Occipitoatlantal Hypermobility
Upper Cervical Spine Hypermobility
Hip Disorders
Patellofemoral Disorders
Foot Disorders
Neurofibromatosis
Historical Perspective
Genetics
Diagnosis
Axillary and Inguinal Freckling
Cutaneous Neurofibromas
Lisch Nodules
Plexiform Neurofibromas
Verrucous Hyperplasia
Optic Glioma
Congenital Pseudarthrosis of the Tibia
Hemihypertrophy
Malignant Degeneration of Neurofibromas
Cognitive Deficits
Neurofibromatosis Type 2
Fibrodysplasia Ossificans Progressiva
Cause
Histology and Pathology
Clinical Features
Radiographic Findings
Treatment
Ehlers-­Danlos Syndrome
Clinical Features
Classification
Type 1: Classic
Type 2: Hypermobility
Type 3: Vascular
Type 4: Kyphoscoliotic
Type 5: Arthrochalasis
Type 6: Dermatosparaxis
Treatment
Gaucher Disease
Genetics and Heredity
Pathology and Diagnosis
Clinical Features
Type 1
Type 2
Type 3
Orthopaedic Manifestations
Bone Marrow Infiltration
Avascular Necrosis
Bone Crises
Pathologic Fractures
Lytic Lesions
Osteomyelitis
Treatment
Splenectomy
Enzyme Replacement Therapy
Bone Marrow and Stem Cell Transplantation
Gene Therapy
Orthopaedic Treatment
Prognosis
Arthrogryposis (Arthrogryposis Multiplex Congenita)
Cause
Genetics
Pathology
Clinical Features
Classic Arthrogryposis
Distal Arthrogryposis
Differential Diagnosis
Treatment
Knees
Knee Hyperextension and Dislocation
Knee Flexion Contractures
Feet
Talipes Equinovarus
Vertical Talus
Cavovarus Deformity
Upper Extremities
Shoulder
Elbow
Posterior Release With Tricepsplasty
Procedures to Achieve Active Elbow Flexion
Bipolar Pectoralis Major Transfer
Bipolar Latissimus Transfer
Triceps Transfer
Transfer of the Long Head of the Triceps
Steindler Flexorplasty
Unipolar Pectoralis Major Transfer (Clark Procedure)
Free Gracilis Transfer
Wrist
Dorsal, Radial Closing Wedge Osteotomy of the Midcarpus With Tendon Transfer
Proximal Row Carpectomy
Wrist Fusion
Hand
Thenar Release
Scoliosis and Spinal Deformity
Craniocarpotarsal Dysplasia (Freeman-­Sheldon or Whistling Face Syndrome)
Clinical Features
Treatment
Cornelia de Lange Syndrome
Rubinstein-­Taybi Syndrome
Orthopaedic Manifestations
Associated Anomalies
Treatment
Otopalatodigital Syndrome
Proteus Syndrome
Clinical Features
Diagnosis
Differential Diagnosis
Orthopaedic Manifestations
Treatment
Klippel-­Trénaunay Syndrome
Pathophysiology
Clinical Features
Nevus
Varicosities
Bone and Soft-­Tissue Hypertrophy
Other Associated Conditions
Diagnosis and Evaluation
Treatment
Metatropic Dwarfism (Dysplasia)
Camptomelic Dysplasia
Chondroectodermal Dysplasia (Ellis-­van Creveld Syndrome)
Genetics
Clinical Features
Radiographic Findings
Treatment
Asphyxiating Thoracic Dysplasia (Jeune Disease)
Pathology
Clinical Features and Radiographic Findings
Treatment
38 - Metabolic and Endocrine Disorders of Bone
Biology of Healthy Bone
Bone Cell Biology
Bone Matrix and Mineralization
Metabolic Bone Disorders
Vitamin Disorders
Vitamin D Disorders
Vitamin D Deficiency Rickets
Pathology
Laboratory Findings
Clinical Features
Radiographic Findings
Treatment of Vitamin D Deficiency
Vitamin D–Resistant Rickets
Hypophosphatemic Rickets
Laboratory Findings
Clinical Features
Radiographic Findings
Orthopaedic Treatment
Vitamin D Dependent Rickets
Clinical Features
Treatment
Medical Treatment
Orthopaedic Treatment
Hypervitaminosis D
Pathology
Laboratory Findings
Clinical Features
Radiographic Findings
Treatment
Disorders of Vitamin A
Clinical Features
Radiographic Findings
Diagnosis
Treatment
Vitamin C Deficiency
Pathology
Clinical Features
Radiographic Findings
Differential Diagnosis
Treatment
Osteogenesis Imperfecta
Normal Type 1 Collagen Metabolism
Pathology
Classifications
Clinical Manifestation
Genotypic-­Phenotypic Correlation
Milder Forms
Laboratory Findings
Survival
Ambulation
Diagnosis
Differential Diagnosis
Treatment
Medical Treatment
Orthopaedic Treatment.The goal of orthopaedic treatment is to maximize the affected patient’s function, prevent deformity and di...
Orthotic Treatment.The orthopaedist will be called on to assist in the rehabilitation of infants with OI who survive the neonata...
Management of Long Bone Fractures.Management of long bone fractures depends on the severity of the fracture and age of the patie...
Management of Long Bone Deformity.Long bone deformity is one of the most frequent conditions requiring treatment in patients wit...
Closed Osteoclasis Without Internal Fixation.Manual osteoclasis of long bone deformity has been described324 and is generally in...
Closed Osteoclasis With Percutaneous Intramedullary Fixation.This procedure is essentially the same as the previous one, except ...
Open Osteotomy With Intramedullary Fixation (Sofield Procedure).A procedure entailing multiple diaphyseal osteotomies (fragmenta...
Use of Extensible Intramedullary Rods.One of the problems that can develop with the use of a fixed-­length intramedullary device...
Management of Spinal Deformity.Involvement of the cervical spine, other than cranial base abnormalities (see later, 1396984945Cr...
Acetabular Protrusion
Tumors
Cranial Base Abnormalities (Basilar Invagination, Basilar Impression, and Platybasia)
Prognostication and Parental Counseling
Osteoporosis
Radiographic Findings
Diagnosis
Treatment
Hypophosphatasia
Inheritance
Pathogenesis
Pathology
Laboratory Findings
Antenatal Diagnosis
Clinical Features
Treatment
Orthopaedic Treatment
Osteopetrosis
Clinical Features
Radiographic Findings
Diagnosis
Renal Osteodystrophy
Pathophysiology
Pathology
Laboratory Findings
Clinical Features
Diagnosis
Orthopaedic Treatment
Angular Deformity.Angular deformity occurs in ROD because the bone is soft, undermineralized, and prone to bend with weight bear...
Slipped Capital Femoral Epiphysis.SCFE is associated with ROD, but the clinical picture of a patient with renal slips differs fr...
Osteonecrosis.Another orthopaedic complication seen in patients with renal failure is osteonecrosis, usually of the femoral head...
References
39 - Hematologic Disorders
Hemophilia
Incidence
Classification and Inheritance
Hemophilia A
Hemophilia B
von Willebrand Disease
Clinical Features
Hemorrhage
Hemophilic Arthropathy
Site of Involvement.Weight-­bearing joints are the most common sites of hemophilic arthropathy, with the frequency of involvemen...
Pathophysiology.The pathophysiologic process was initially described by Konig in the late 19th century.82 An initial stage of sy...
Clinical Findings.Clinical findings depend on the severity of hemorrhage and whether the hemarthrosis is acute, subacute, or chr...
Differential Diagnosis.A difficult diagnostic challenge is the child with hemophilia and a superimposed joint infection. The dia...
Radiographic Findings.Radiographic findings associated with hemarthrosis depend on the stage of the disease, patient age at dise...
Soft Tissue Bleeding
Intramuscular and Intermuscular Hemorrhage
Diagnostic Ultrasonography
Nerve Palsy
Hemophilic Pseudotumor
Fractures
Dislocations
Myositis Ossificans
Bone Mineral Density
Treatment
Gene Therapy
Medical Management
Treatment on Demand
Prophylactic Treatment
Early Treatment of Bleeding Into Muscles and Soft Tissues
Acute Treatment of Hemarthrosis
Analgesics
Aspiration
Subacute Hemophilic Arthropathy
Chronic Hemophilic Arthropathy
Nonsurgical Treatment of Joint Deformity
Surgical Treatment of Deformity
Hematologic Management
Hemophilic Arthropathy
Synovectomy.The objective of synovectomy is to prevent the progression of hemophilic arthropathy. The rationale for synovectomy ...
Arthroscopic Synovectomy.Although open synovectomy has been used longer than the other methods, it is often complicated by the l...
Open Synovectomy.Open synovectomy of the knee is performed under tourniquet control.117 The surgical approach to the knee is thr...
Postoperative Care.Isometric quadriceps-­ and hamstring-­strengthening exercises are begun immediately. Active ROM exercises sho...
Problems and Complications.Postoperative loss of range of joint motion from adhesions of the patellofemoral and tibiofemoral joi...
Synoviorthesis.A number of methods of synovial ablation using intraarticular radioactive substances have been reported. Children...
Total Joint Replacement and Arthrodesis.Deciding between total joint replacement and arthrodesis is difficult, and the decision ...
Total Joint Replacement.In case of bilateral knee involvement, total joint replacement is indicated with stage IV or V arthropat...
Arthrodesis.Arthrodesis of the ankle, subtalar, and midtarsal joints in the foot and shoulder or knee may be indicated when thes...
Neurapraxia
Fractures
Flexion Contractures
Pseudotumors
Athletic Participation
Sickle Cell Disease
Cause and Pathophysiology
Orthopaedic Manifestations and Treatment
Bone Infarction
Osteomyelitis
Hand-­Foot Syndrome
Vertebral Involvement
Avascular Necrosis
Surgical Considerations
Miscellaneous Bone Changes
40 - Pediatric Sports Medicine: Issues in Contemporary Sports Participation
Current Patterns in Pediatric Sports Participation
Sport Specialization
Overuse
Burnout
Athletic Development
Youth Athlete Development
The Pediatric Athlete’s Shoulder
Anatomy
Little League Shoulder
Pathoanatomy
History and Physical Exam Features
Imaging
Nonoperative Treatment and Therapy
Return to Play
Complications
Glenohumeral Internal Rotation Deficit
Pathoanatomy/Mechanism
History and Physical Exam Features
Imaging
Nonoperative Treatment/Therapy
Operative Treatment
Shoulder Instability
Pathoanatomy/Mechanism
History and Physical Exam
Imaging
Nonoperative Treatment
Operative Treatment
The Pediatric Athlete’s Elbow
Medial Elbow (Epicondyle Apophysitis and Avulsion)
Anatomy
Pathoanatomy/Mechanism
Medial Epicondyle Apophysitis
Imaging
Nonoperative Treatment
Medial Epicondyle Avulsion
History and Physical Exam Features
Imaging
Operative Treatment
Displaced Fractures. While acceptable results for function in the nonoperative extremity athlete may be commonly reported follow...
Physical Therapy and Return to Play
Complications
Ulnar Collateral Ligament Injury
Pathoanatomy/Mechanism
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Lateral Elbow
Pathoanatomy/Mechanism
Osteochondroses of the Elbow (Panner Syndrome)
History and Physical Exam Features
Imaging
Nonoperative Treatment
Osteochondritis Dissecans of the Capitellum
Pathoanatomy/Mechanism
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Physical Therapy and Return to Play
Outcomes
Complications
The Pediatric Athlete’s Hand and Wrist
The Pediatric Athlete’s Hip
Apophysitis of the Hip and Pelvis
Femoroacetabular Impingement
Apophyseal Avulsions
The Pediatric Athlete’s Knee
Overuse Conditions
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Complications
History and Physical Exam Features
Imaging
Nonoperative Treatment
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Discoid Meniscal Pathology
Pathoanatomy
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Physical Therapy and Return to Play
Outcomes
Osteochondritis Dissecans
Pathoanatomy
Hereditary
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Stable Lesion.An intact lesion (cueball, shadow lesion, wrinkle in the rug) may be drilled to promote healing. Good results have...
Locked Door and Trapdoor Lesions.In locked door and trapdoor lesions, in situ fixation and drilling (either retrograde or antegr...
Crater Lesions.When the lesion is partially detached or when it is fully detached with a fresh crater, the fragment should be re...
Complications
Collateral Ligament Injury
Anatomy
Fibular (Lateral) Collateral Ligament Injury
Fibular Collateral Ligament Injury
Combination Injuries
Imaging
Lateral Collateral Ligament Injury
Anterior Cruciate Ligament and Medial Collateral Ligament Injuries
Pediatric Anterior Cruciate Ligament Injuries
Anatomy
Mechanism of Injury
Radiographic Findings
Treatment: Anterior Cruciate Ligament Injury
Surgical Treatment
Skeletal Mature Anterior Cruciate Ligament Reconstruction.In a skeletally mature teenager, a standard arthroscopically assisted ...
Skeletal Immature Anterior Cruciate Ligament Reconstruction.Transphyseal reconstruction with soft tissue grafts in skeletally im...
Complications
Pediatric Posterior Cruciate Ligament Injuries
Anatomy
Mechanism of Injury
Clinical Features
Treatment of Posterior Cruciate Ligament Injury
Meniscal Injuries
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Complications
Tibial Eminence Fractures
Anatomy
Mechanism of Injury
Classification
Clinical Features
Radiographic Findings
Treatment
Type I Fractures
Type II Fractures
Type III Fractures
Posterior Cruciate Ligament Avulsion Fractures
Complications
Patellofemoral Instability
Recurrent Patellar Instability
Pathoanatomy
Patella Alta
Torsional and Angular Deformity
Trochlear Dysplasia
Ligamentous Laxity or Disruption
History and Physical Exam Features
Imaging
Nonoperative Treatment
Operative Treatment
Reconstruction of the Medial Patellofemoral Ligament
Realignment Procedures
Physical Therapy and Return to Play
Outcomes
Complications
The Pediatric Athlete’s Ankle
Ankle Instability
Anatomy
Mechanism of Injury
History and Physical Exam
Imaging
Nonoperative Treatment
Operative Treatment
Physical Therapy/Return to Play
Outcomes
Complications
Osteochondral Lesions of the Talus
Pathoanatomy
History and Physical Exam Features
Imaging
Classification
Nonoperative Treatment
Operative Treatment
Outcomes
The Pediatric Athlete’s Foot