Paediatric Orthopaedics

A System of Decision-Making, Second Edition

Benjamin Joseph, Selvadurai Nayagam, Randall Loder, Ian Torode

• Publisher: CRC Press
• Year: 2016
• Print ISBN: 9781498708401
• eBook ISBN: 9780429586446
• Edition: 2
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

Mastering the art and science of paediatric orthopaedics entails the acquisition of theoretical knowledge, the development of surgical dexterity and learning the process of clinical decision-making. Of these three components, clinical decision-making is arguably the most important.Featuring a practical focus, Paediatric Orthopaedics: A System of De

SECTION 1

Deformities

1 General principles of treatment of deformities in children

Selvadurai Nayagam and Benjamin Joseph

2 Equinus deformity

Benjamin Joseph

3 Equinovarus

Selvadurai Nayagam

4 Calcaneus deformity

Benjamin Joseph

5 Cavus

Benjamin Joseph

6 Congenital vertical talus

Selvadurai Nayagam

7 Planovalgus deformity

Benjamin Joseph

8 Valgus deformity of the ankle and subtalar joint

Benjamin Joseph

9 Metatarsus adductus and skewfoot

Selvadurai Nayagam

10 Anterolateral bowing of the tibia and congenital pseudarthrosis of the tibia

Benjamin Joseph

11 Posteromedial bowing of the tibia

Benjamin Joseph

12 Tibial torsion

Benjamin Joseph

13 Flexion deformity of the knee

Benjamin Joseph

14 Genu recurvatum

Benjamin Joseph

15 Genu varum

Selvadurai Nayagam

16 Genu valgum

Selvadurai Nayagam

17 Coxa vara

Randall Loder

18 Femoral anteversion

Randall Loder

19 Cubitus varus and valgus

Benjamin Joseph

20 Varus and valgus deformity of the wrist

Benjamin Joseph

21 Scoliosis

Ian Torode

22 Kyphotic deformities of the spine

Ian Torode

23 Torticollis

Ian Torode

1

General principles of treatment of deformities in children

SELVADURAI NAYAGAM AND BENJAMIN JOSEPH

Introduction

Natural history of the deformity

Consequences of the deformity

Problems of management

Appearance

Loss of function

Pain and giving way (instability)

Secondary adaptive or degenerative changes

Aims of treatment

Principles of assessing deformity

Principles of analysis of deformity

Centre of rotation of angulation

Treatment options

Soft tissue

Bony tissue

Strategies for preventing recurrence

Muscle imbalance

Physeal damage

Metabolic bone disease

Soft tissue contracture

References

INTRODUCTION

Deformity is an alteration of structure (be it length, alignment or joint position) that produces, or has the potential to produce, symptoms or loss of function. It is one of the commonest reasons for consulting a paediatric orthopaedic surgeon. The impact of the visible anomaly to the child and parents is of a worrisome abnormality which the treating doctor will need to distinguish as either normal variant or disease. In the event of the latter, two additional issues need resolving:

1. what is the natural history of this condition?

2. what are the consequences if it is left untreated?

Decision-making becomes a great deal simpler with both questions answered (Table 1.1).

Natural history of the deformity

DEFORMITIES THAT TEND TO RESOLVE SPONTANEOUSLY

A high proportion of children who present to the doctor have innocuous deformities that resolve spontaneously. These normal variants include physiologic genu varum and valgum, infantile flatfoot, neonatal calcaneovalgus deformity and some torsional deformities of the femur and tibia. Recognising these diagnoses allows the doctor to reassure parents. In some children complete correction of such variants may not occur and follow-up until resolution is wise.

DEFORMITIES THAT TEND TO PROGRESS AND/OR RECUR AFTER SURGICAL CORRECTION

Paralytic deformities and those caused by physeal damage tend to progress until skeletal growth stops. Unless the underlying cause is removed (e.g. muscle imbalance or physeal bar), recurrence will follow seemingly satisfactory correction. Certain deformities, such as types of scoliotic curves, may progress even after skeletal maturity.

DEFORMITIES THAT REMAIN STATIC

Some deformities remain static; typically these include fracture malunions that have failed to remodel completely, either from severity of the original malalignment or from the advanced age of the child.

Table 1.1 Decision-making based on the natural history and consequences of deformities

Decision-making on the basis of the natural history of the deformity
Natural history of the deformity	Nature of intervention
Deformities that tend to resolve spontaneously	Reassurance and follow-up
Deformities that tend to progress	Early intervention to correct deformity and prevent progression or recurrence (if cure is not possible, a strategy to prevent progression is warranted)
Deformities that remain static	Decision to intervene based on consequences of the deformity
Decision-making on the basis of the consequences of the deformity
Consequences of the deformity	Decision to intervene
Deformities that are cosmetically acceptable and cause no disability	No intervention
Deformities that are cosmetically unacceptable but cause no functional disability	Consider intervention after weighing the risks potential complications of intervention
Deformities that cause disability	Intervene
Deformities that potentially lead to long-term deleterious consequences	Intervene early to prevent onset or progression of problems
Deformities that may be beneficial	Avoid correction of the deformity

Consequences of the deformity

COSMETICALLY ACCEPTABLE BUT NO FUNCTIONAL DISABILITY

These should be left alone.

COSMETICALLY UNACCEPTABLE BUT NO FUNCTIONAL DISABILITY

Whether a deformity is cosmetically unacceptable will vary between individuals and communities. The treating doctor has to be attuned to these differences.

CAUSES FUNCTIONAL DISABILITY

Treat the deformity and reduce disability.

POTENTIAL TO CAUSE FUNCTIONAL DISABILITY

Should treatment be offered when the child is fine at present but will not remain so if left alone? When supportive evidence is available, such deformities should be corrected before the disability develops. In other conditions, the uncertainty remains and the need for intervention evolves as more information is available.

PROBLEMS OF MANA...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Contributors
• Foreword
• Preface
• Preface to first edition
• SECTION 1 DEFORMITIES
• SECTION 2 DISLOCATIONS
• SECTION 3 DEFICIENCIES
• SECTION 4 DISCREPANCIES OF LIMB LENGTH
• SECTION 5 DECREASED JOINT MOBILITY
• SECTION 6 PARALYSES
• SECTION 7 EPIPHYSEAL AND PHYSEAL PROBLEMS
• SECTION 8 INFECTIONS
• SECTION 9 ACQUIRED DEFECTS IN LONG BONES