Nigel S. Broughton

A Textbook Of Pediatric Orthopaedics

Contents

Contributors Vll

Foreword IX

Preface Xl

Acknowledgements xii

- Chapter 1 Orthopaedic assessmentD Robert V Dickens and Nigel S Broughton

Chapter 2 General approach to paediatric orthopaedics 13Malcolm B Menelaus

Chapter 3 Normal and pathological gait 21H Kerr Graham and Donnchadha G Gallagher

Chapter 4 Lower limb deficiencies 27Ian P Torode

Chapter 5 Skeletal dysplasias 39Virginia J Saxton and Mark D O'Sullivan

Chapter 6 Metabolic bone disease 65Mark D O'Sullivan and Virginia J Saxton

Chapter 7 Bone and soft tissue tumours 75Mark D O'Sullivan and Virginia J Saxton

Chapter 8 The orthopaedic management of cerebral palsy 101H Kerr Graham

Chapter 9 Spina bifida 115Malcolm B Menelaus

t:'

Chapter 10 Neuromuscular disorders of childhood 131Gary R Nattrass

Chapter 11 Bone and joint infection 149Virginia J Saxton and Mark D O'Sullivan

Chapter 12 Juvenile chronic arthritis 165Susan M Randle

Chapter 13 Osteochondritic conditions 175D Robert V Dickens

.- Chapter 14 Normal variants: intoeing, bow legs and flat feet 183H Kerr Graham

Chapter 15 The upper limb 193Andrew J Herbert and Nigel S Broughton

vi Paediatric Orthopaedics

Chapter 16 Developmental dysplasia of the hip 203Nigel S Broughton

Chapter 17 Perthes disease 219Malcolm B Menelaus

Chapter 18 Slipped upper femoral epiphysis 229Gary R Nattrass

Chapter 19 The knee 239Nigel S Broughton

Chapter 20 The foot 251D Robert V Dickens

Chapter 21 The spine 267D Robert V Dickens

-Chapter 22 Upper limb trauma 283H Kerr Graham

Chapter 23 Lower limb trauma 299Mark D O'Sullivan

Chapter 24 Limb length inequality 313Ian P Torode

Index 327

Developmental Dysplasia of the Hip 207

a b

Figure 16.4 a Radiograph showing left-sided unilateral DDH in an 18-month-old child. b Radiograph showingbilateral DDH in a 15-month-old child.

months that radiographs are the imaging techniqueof choice (Figure 16.4).

The pelvic radiograph is a static examination, butin the young child allows a useful assessment of therelationship between the metaphysis of the femurand the acetabulum. The pelvis is X-rayed with thelegs in neutral. If the ossific nucleus of the femoralbead has formed, it should be below a projection ofth Hilgenreiner line and the major part medial toth Perkin line, in th inferomedial quadrant. Thedislocated hip shows the ossific nucleus in thesuperolateral quadrant. If there is no ossifi nucleusthe metaphyseal edge (ME) angle, which assesses therelative position of the medial edge of the metaphy­sis to the edge of the bony acetabulum can be useful.The hip is probably dislocated if the medial edge ofthe upper femoral metaphysis lie lateral to thout r edge of the acetabulum. Von Rosen viewscan also be helpful if th re are no ossific nuclei. Thelegs are abducted to 45° and a line is drawn alongthe axis of the femoral shaft. This should project

through the centre of the acetabulum. Disruption ofthe Shenton line should be sought. The acelabularindex has some value in the interpretation of acet­abular dysplasia; however, it is subject to markedinterobserver error (Figure 16.5).

In the older child assessment of any ongoingacetabular dysplasia is carried out by examining aseries of pelvic radiographs and looking at the shapeof the acetabulum, which may involve measuring theacetabular ind x. he centr dge (CE) angle,Shenton line and Moses concentric rings are alsou eful in the older child.

ArthrographyIn the young child in whom there is only a smallossific nucleus and much of the hip is cartilage,arthrography is useful for defining the relationshipbetween the femoral head and the acetabulum. Thisrequires a general anaesth tic. It can defin an hour­glas constriction of the capsule, and the invertedlimbus may show up as the 'rose thorn' sign.

tV = 2.AJ - 2...rI ~N ~!J==l

Perkin line

Hilgenreiner lineI

Head-teardropdistance

~Acetabular

Index/.

a

Fig 16.5 a Diagram showing the acetabular index, Hilgenreiner line and Perkin line. b The centre-edge angle.This becomes useful at about eight years of age.

IndexNote: page numbers in bold indicate tables and numbers in italics indicate illustrations

Abscessesacute osteomyelitis 152-3Brodie 157-8

Acetabulardysplasia 214-16

persistent 214, 217fractures, 301index 207salvage 216

Achilles tendonfiat feet, associated with tight 258lengthening 106-7

Achondroplasia 40-1Acoustic neuromas,

neurofibromatosis 57Acromioclavicular dislocations 284Acute

osteomyelitis 149-54calcaneum 151complications 153distal tibial metaphysis 152epiphyseal 153humerus 151investigations 150-2management 152-3neonatal 153

patellar dislocation 241polyradiculoneuritis 146

Adolescenthip dysplasia 214-16idiopathic scoliosis see Scoliosis:

adolescent idiopathicAggressive fibromatosis 95--6Aitken's radiological classification,

femoral focal deficiencies 27Aldolase 134Alpha-fetoprotein, prenatal diagnosis

117Amniocentesis, prenatal dignosis 117Amputation

congenital pseudoarthrosis of tibia35

osteosarcoma 89and prostheses, limb length

inequality 31 7Syme 30,317tibial dysplasia-deficiency 33

Amyoplasia see ArthrogryposisAnaesthesia, JCA, difficulties 173

Aneurysmal bone cyst 85, 86Ankle

congenital deficiencies of fibuladisarticulation 31-2stabilization with bone 32

and foot, assessment 9-11spastic diplegia, cerebral palsy

110and subtalar valgus 124valgus deformity 123, 124

Ankle-foot orthoses (AFOs) 104-5,121

Ankylosing spondylitis 168Antalgic gait 3Anterior

knee pain 243-7vertebral body beak, causes 42, 51

Anterolateral reduction, DDH 210­11, 213

combined with Salter osteotomy211

and femoral osteotomy 211Antibiotics

acute osteomyelitis 152septic arthritis 155

Apprehension testpatella 9, 242shoulder 11

Arachnodactyly see Marfansyndrome

Arterial injury, supracondylarfracture 285, 287-8

Arthritis see Juvenile chronic arthritis(JCA); Septic arthritis

Arthrography, DDH 207Arthrogryposis 142--4, 194

multiplex congenita 142Arthroscopy 241,245,247Asphyxiating thoracic dysplasia 43Astereognosis 108, 109Asymmetrical spastic diplegia 110Athetoid cerebral palsy 102Avascular necrosis

causes 222DDH 209, 211-12hip fractures 302limb length inequalities 313, 316Perthes disease 219, 221SUFE 231-2,233,235--6

Avulsion fracturespelvis 299-300

ischial tuberosity 300tibial tubercle 306upper femur 302-3

Baker procedure 107Barlow test, DDH 204, 210Baunlann angle 289Becker muscular dystrophy 135, 136,

137Below-knee amputees, prosthetics 26Benign tumours

bone-forming 78-80cartilaginous 80-3differentiation from malignant 76-7fat 97fibrous 83--4, 95--6neural 96soft tissue, miscellaneous 98synovial 97-8vascular 94-5

Bennett fracture 297Bipartate patella 245Birth

fractures, shaft of femur 194, 303palsies, upper limb 193-5

Bladder paralysis, spina bifida 116Block test

of Coleman see Coleman block testleg length inequality 5

Blount disease 248-9Bone

cystaneurysmal 85,86metaphyseal, Perthes disease 255simple 84-5, 311

decreased density see Osteogenesisimperfecta; Osteoporosis

fragility, spina bifida 119increased density 39, 49-50scan 77

acute osteomyelitis 150-1adolescent idopathic scoliosis 270Perthes disease 221-2septic arthritis 155

tumours 75benign 78-80, 84-8

328 Paediatric Orthopaedics

Bone (continued)tumours (continued)

malignant 88-92metastatic 92-4

see also Metabolic bone diseaseBoston underarm brace 270, 271Botulinum toxin, cerebral palsy 105,

109Bow legs 187-8Brachial

artery, supracondylar fracture 287plexus, obstetric injuries 193-5

Bracingadolescent idiopathic scoliosis

270-1poliomyelitis 145-6

Brodie abscess 157-8Broomstick cast

DDH 210Perthes disease 225-6

Buck-Gramcko procedure 200Buckle fractures, forearm 294

Caesarean section, spina bifida 11 7Cafe au lait spots 4,57Caffey disease 161Calcaneal exostoses 263Calcaneocavovalgus deformity 123Calcaneonavicular bar 259-60Calcaneus 122Calcitonin 66Calve disease 87Camptodactyly 202Carpal injuries 297Carrying angle 11, 12, 288Cartilaginous tumours, benign 80-3Catterall classification, Perthes disease

224Cavovalgus deformity 122, 123Cavovarus feet 133, 260-1

commonest causes 261Friedreich ataxia 142peripheral neuropathies 137-8

Cavus deformity 122, 260Cells, bone 65Central core disease, congenital

myopathy 138Cerebral palsy 101-13

aetiology 101classification 101, 102clinical features 102gait analysis 25, 105-6management 102-6

hemiplegic lower limb 106-8hemiplegic upper limb 108-9spastic diplegia 107-9spastic quadriplegia 109-10

pathology 102recurrent hip dislocation 216

scoliosis 273-4stiff knee gait 22

Cheilectomy 227, 234Chemotherapy

Ewing sarconla 92osteosarcoma 89tuberculosis 161

Chiari osteotomy 216, 227Chondroblastoma 81, 82Chondrodiatasis, limb lengthening

322Chondroectodermal dysplasia 43Chondrolysis 232, 234-5Chondromalacia patellae 9Chondromyxoid fibroma 81, 82Chondrosarcoma 60, 92, 93Christmas disease 173Chromosomal abnormalities 62-3Chronic osteomyelitis 156-9

multifocal, recurrent 157Cincinnati incision 254, 257Clavicle

congenital pseudoarthrosis 11,195-6

injuries 284Cleidocranial dysplasia 54, 56Clinodactyly 202Cloacae 149, 156, 157Club feet see Congenital talipes

equinovarusCobb angle, scoliosis 270, 272Codman triangle, osteosarcoma 89Coleman block test 10, 11, 140, 261Compartment syndrome,

supracondylar fracture,humerus 285, 288

Complete injury, obstetric brachialplexus injury 194

Computerized tomographyacute osteomyelitis 152adolescent idiopathic scoliosis

270bone tumours 77DDH208limb length inequalities 316SUFE233

Condylar injuries, humerus 290-2Congenital

deficienciesfemur 27-31fibula 31-2radius 199-201tibia 27, 32-3

dislocationship see Developmental dysplasia

of the hip (DDH)knee 239patella 239-41radial head 198shoulder 197

flat feet see Congenital: verticaltalus

generalized fibromatosis 96glenoid hypoplasia 197limb length inequality 313muscular dystrophy 137myopathy 137-8myotonic dystrophy 138pseudoarthrosis

clavicle 11, 195-6tibia 33, 35ulna 57

recurvatum, knee 239scoliosis 272-3sensory neuropathies 146talipes calcaneovalgus 256vertical talus 256-7see also Hereditary

Congenital talipes equinovarus(CTEV) 185, 251-65

aetiology 251clinical features 252complications 255-6incidence 251management 253-5pathology 251-2radiology 252-3

Connective tissue disorders 53-4Conradi-Hiinermann syndrome 45Consultation 14-16Cord, tethering 121Coronal plane deformities 187-90Coronoid fractures 292-3Cortical destruction, tumour

diagnostic factor 77Corticosteroids 66, 170, 171

intra-articular 171, 172osteoporotic changes 170

Cotrel-Dubousset system 272Coventry and Johnson classification,

congenital deficiencies, fibula31

Coxa vara, infantile 35, 36-7Creatinine phosphokinase (CPK) 133Curly toes 263-4Cutaneous lesions see SkinCyclosporin 171Cyst

boneaneurysmal 85, 86metaphyseal, Perthes disease 225simple 84-5, 311

popliteal 248Cytomegalovirus 161

Deficiencies see Congenital:deficiencies

Delivery fractures 194, 303Denis Browne splint 208-9, 253, 254

Dermatomyositis 98, 138, 169Developmental delay 1, 2Developmental dysplasia of the hip

(DDH) 3-4, 8, 203-17diagnosis 204examination 204-5

under anaesthetic 209incidence 203management 208-11

(}-3 months 208-96-12 months 209-101-3 years 21(}-11over 3 years 211complications of treatment 211­

12, 313operative procedures 212-14

pathology 203--4radiology 205-8see also Hip: dysplasia, adolescents

withDial osteotomy 216Diaphyseal

aclasia see Heriditary multipleexostoses

dysplasia 50fractures

forearm 294-5limb length inequalities 313

Diastematomyelia 129Diastrophic dysplasia 43Dillwyn Evans procedure, CTEV 256Discitis 161-2Discoid lateral meniscus 247-8Distraction, limb lengthening 319-21DNA diagnosis, neuromuscular

disorders 134Down syndrome see Trisomy 21Duchenne muscular dystrophy 135-7,

275-6Dynamic contractures, cerebral palsy

102, 105Dyschondrosteosis 59, 134Dysplastic form, spondylolisthesis 278Dystrophin testing, neuromuscular

disorders 134

Edwards syndrome 63Ehlers-Danlos syndrome 39, 53Elbow

assessment 11-12dislocation 290, 291flexion deformity, cerebral palsy

108floating 288, 289fractures 289-93

Electromyographygait analysis 22neuromuscular disorders 134

Ellis-van Creveld syndrome 43

Elmslie technique 244Emery-Dreifuss muscular dystrophy

137Enchondroma 8(}-1Enchondromatosis 6(}-1, 314

with haemangiomas 60,61,95Energy studies, gait analysis 22-5Engelmann disease 39, 50Enneking classification, bone and soft

tissue tumours 78Enthesopathy 169Eosinophilic granuloma 86, 87Epiphyseal

disorders 43--4dysplasia, multiple 43, 44, 222injuries

classification 283, 284, 290, 294,305

forearm 294humerus 290limb length inequalities 313

lesions, lytic 82osteomyelitis 153

Epiphyseodesis 29,233,318Epiphyseolysis, partial growth plate

arrest 324-5Equinocavovarus deformity,

Duchenne muscular dystrophy136

Equinovarus deformitycerebral palsy 108spina bifida 121-2

Equinus 4, 122Erb-Duchenne type paralysis 194Erb palsy, right arm 193Erlenmeyer flask deformity 53Ewing sarcoma 90,91,92,93, 152Examination 16-17

assessment 2-12normal variants 183--4

Exquisitely tender lesions 99External rotation

hip, torsional profile 184osteotomies, bilateral femoral 110tibia 124

Eye involvement, pauciarticular JCA166

Fairbank triangle, infantile coxa vara35-6

Falling fragment sign 84Familial

hypertrophic osteoarthropathy 50hypophosphataemic rickets 67,

68-9Family history 2Fanconi syndrome 67, 199Fascioscapulohumeral muscular

dystrophy 137

Index 329

Fat tumours, benign 97Femoral

deficiencies 27-31,313with abscence of fibula 31

dysplasia, upper 216-17fractures

fracture-separation, distal physes304-5

shaft 303-4SUFE, in situ pinning 236supracondylar, spina bifida 119upper, avulsion 302-3

head, Perthes diseasefragmentation and displacement

220uncovering at presentation

223-4osteotomy

and anterolateral reduction,DDH 211

Perthes disease 227partial growth plate arrest 323rotation

external osteotomies, spasticdiplegia 110, III

range 7shortening 318, 319

Fibrocartilaginous dysplasia 62, 83-4Fibrodysplasia ossificans progressiva

58Fibroma

non-ossifying 83, 311of Reye, recurring digital 96

Fibromatoses 95-6Fibrosarcoma 92Fibrous

cortical defect and non-ossifyingfibroma 83

dysplasia 61-2, 83, 314hamartoma of infancy 95tumours, benign 83-4, 95-6

Fibulacongenital deficiencies 31-2

associated with short femur 28,29

see also Tibia and fibulaFibular grafts, vascularized 35Fifth toe, overriding 264Flail

hips 125shoulder 144undeformed knee 124-5

Flat feet 10, 189-90, 257-60Flexion supracondylar fracture,

humerus 287Floating elbow 288, 289Floor reaction orthoses 105, 121Floppy baby 131Foot 251-64

and ankle assessment 9-11

330 Paediatric Orthopaedics

Foot (continued)deformities

arthrogryposis 144cerebral palsy 107-8peripheral neuropathies 139, 140spina bifida 121--4spinal dysraphism 129-30

fractures and dislocations 310progression angle (FPA) 6, 184-thigh angle (FTA) 6-7

Forearmfractures 293--4

diaphyseal, middle and upperthirds 294-5

distal third 294Galeazzi fracture dislocation 297Monteggia fracture dislocation

292,296hemiplegia, cerebral palsy 108radial club hand 199-201radial head, dislocation 198-9radio-ulnar synostosis 199ulna, congenital pseudoarthrosis 57

Freiberg disease 10, 179Freijka pillow 208Friedrich ataxia 141-2Functional disorders 17-18

Gage sign 224Gait 3--4, 21--6

cerebral palsy 105--6cycle 21Trendelenburg 3--4, 22, 210see also Intoe gait; Limp

Galeazzifracture dislocation 297test, limb length inequality 5, 315

Galveston technique 274, 275Gartland classification, supracondylar

fractures, 285grade 111287

Gaucher syndrome 52-3Genetic counselling, spina bifida 11 7Genu valgunl 188-9Giant cell tumour 85--6, 87Glenohumeral dislocation 284Gold 170-1Gowers sign 3, 131, 132Gradual distraction, limb lengthening

319-22Grars DDH ultrasound classification

206Grafts, vascularized fibular 35Green and Anderson, limb length

inequality assessment 317Green procedure, Sprengel shoulder

197Greenstick fractures, forearm 294Grice procedure 108, 111

Ground reaction AFO 105Growing pains 191Growth plate

arrest, limb shortening 318disorders 40-3premature arrest 322-5vascularized transfer 325

Gruca procedure 32Guhl arthroscopic classification,

osteochondritis dissecans 247Guillian-Barre syndrome 146

Habitual dislocationpatellar 240-1shoulder 197-8

Haemangioma 88, 94Haemophilia 173,315Haemophilus 154Haemophilus influenzae type b (HIB)

150Haemostatic disorders 173Hallux

rigidus 263valgus 261-3

Handassessment 12camptodactyly 202clinodactyly 202dislocations 297hemiplegia, cerebral palsy 109Kirner deformity 202trigger thumb 201-2and wrist injuries 297

Hand-Shuller-ehristian disease 87Harrington system 272Heel bumps 263Hemiatrophy syndromes 314-15Hemihypertrophy syndromes 314-15Henlimelica epiphyseal dysplasia 45,

46Hemiplegia

lower limb 106-8upper limb 108-9

Hereditarymotor and sensory neuropathies

138--40multiple exostoses 11, 59--60spinal cerebellar ataxia 141-2see also Congenital

Herndon-Heyman procedure 234Heterotopic ossification, spina bifida

119Hilgenreiner

epiphyseal angle, infantile coxa vara36

line 207Hinged AFO 105Hip

adductors, spasticity 111

arthrogryposis 143--4arthrotomy 155assessment 8dislocation 125

causes 203secondary to septic arthritis 155spina bifida 126, 127traumatic 301

dysplasiaadolescent with 214-16developmental see

Developmental dysplasia of thehip (DDH)

neuropathies 140spinal muscular atrophy 141

fixedadduction contracture 6flexion deformity 8

fractures 301-2irritability 8rotation 7spastic diplegia, cerebral palsy 109spina bifida 125-6surgery

reconstructive and salvage 112­13

soft tissue release, cerebral palsy111-12

transient synovitis of 162--4tuberculosis 160, 222see also Perthes disease

Histiocytosis X 86-7, 88History taking 1-2, 14-16Hitch-hiker's thumb 43HLA B27-positive JeA 168, 169,

170Hoke triple cut technique, Achilles

tendon 107Holt-Dram syndrome 199Homocystinuria 72-3Hospitals and children 18Humeral fractures

diaphyseal 285distal 11-12, 285--92epiphyseal, distal 290proximal 284T and Y condylar 292

Hunter syndrome 50, 51Hurler syndrome 51Hydroxychloroquine 17025-hydroxylation, deficiencies 66I-hydroxylation, deficiencies 66Hyperparathyroidism 70Hypertrophic callus formation 120Hypertrophy syndromes and vascular

malformations 94-5Hypocalcaemia, effects 66Hypochondroplasia 42Hypophosphatasia 73Hypothyroidism 71

Idiopathicjuvenile osteoporosis 72, 73scoliosis 267

adolescent 267, 268, 269-72infantile 267, 268

toe walkers 190Iliofemoral fusion, proximal focal

femoral deficiency 30Ilizarov

frame 256, 320, 321ring fixators 35

Immunosuppressants 171Implantable intramedullary

distractors 322In situ pinning, SUFE 231,232-3,

236further slipping 236

Indolent toe ulcers 146Infantile

cortical hyperostosis 161coxa vara 35, 36-7idiopathic scoliosis 267, 268

Infection, bone and jointdiscitis 161-2limb length inequalities 313-14osteomyelitis see Osteomyelitisperiosteal reaction 161pin tract 321septic arthritis see Septic arthritissyphilis, bone 161transient synovitis, hip 162-4tuberculosis 159--61viral osteopathy 161

Inflammatory myopathies 138Injured child 18Innominate osteotomy 28

Perthes disease 223,226-7Internal rotation

femoral 186-7hip 184tibial 124, 186, 188, 256

Intoe gait 184-7assessing 7-8congenital talipes equinovarus

256Intramedullary

nail, distraction over, limblengthening 322

rodding and bone grafting, tibialpseudarthrosis 34

Intrapelvic shortening 318-19Involucrum 149, 156,157Iritis, pauciarticular JCA 166Irritable hip see Transient synovitis of

the hipIsthmic form, spondylolisthesis 278

Jansen type metaphysealchondrodysplasia 46

Jeune syndrome 43Joint

contractures, arthrogryposis 142replacement, JCA 172-3

Juvenile chronic arthritis (JCA) 165-73

classification 165forms, summary of features 166incidence 165limb length inequalities 315pauciarticular 166polyarticular 166, 167-9systenlic 166, 169-73

management 17~2orthopaedic management 172-3

Juvenile subcutaneous fibromatosis95

Juxtacorticalchondroma 81-2osteosarconla 89, 90

Kalamchi and McEwen classification,late effects of avascularnecrosis, DDH 212

Kinematics, gait analysis 22cerebral palsy 25normal and severe asymmetric

spastic diplegia 23Kinetics, gait analysis 22Kirner deformity 202Klippel-Feil syndrome 58-9, 196-7Klippel-Trenaunay syndrome 93Klippel-Trenaunay-Webber

syndrome 314Klumpke paralysis 194Knee 239-49

anterior pain 243-7arthrogryposis 144assessment 8-9congenital

dislocation 239recurvatum 239

in congenital short femur 28fractures and dislocations 304-6fusion, proximal focal femoral

deficiency 30knock 188-9monoarthritis 167recurvatum 125, 177, 239spastic diplegia, cerebral palsy 109­

10spina bifida 124-5

Knee-ankle-foot orthoses (KAFOs)118

Knock knees 188-9Kohler disease 177-8Kyphosis

Scheuermann 277spina bifida 126, 127

Index 331

Lachman test, knee 9Langenskoild classification, Blount

disease 249Langerhans cell histiocytosis 86-7, 88Larsen syndrome 53, 55, 239Larsen-Johannson disease 177Lateral

condylar fracture, elbow 291epicondyle, elbow, fractures 290and medial condylar physes, injuries

290-2pillar ossification, Perthes disease

223Lead poisoning 71Leaf spring AFO 104Leg length discrepancy see Limb

length inequalitiesLeontiasis ossea 62Leri-Weill disease 201Letterer-Siwe disease 87Leukaemia 93,94, 191Ligamentous laxity, normal 2-3Limb length inequalities 5-6, 27, 313-

25aetiology 313-15assessment 315-16clinical features 315growth plate arrest 322-5lengthening 27, 28, 319-22management 317-22poliomyelitis 145, 314prognosis 316-17radiology 315-16shortening 317-18spina bifida, hip dislocation 125

Limb-girdle muscular dystrophy 137Limb-salvage resection, osteosarcoma

89Limp 3-4

Perthes disease 220see also Trendelenburg gait

Lipoma 97Liposarcoma 99Looser zones 67, 68Lordosis 277-8

spina bifida 126Low-flow vascular malformations 94,

95Lower limb

arthrogryposis 143-4assessment 5-11contractures, Duchenne muscular

dystrophy 136deficiencies 27-37hemiplegic 106-8JCA 167osteochondritic conditions 176-81trauma 299-312

Lower motor neurone lesions 132Lumbar lesions, spina bifida 118

332 Paediatric Orthopaedics

Lung metastases, osteosarcoma 89Luque system 272, 274, 275Lymphoma 93

McCune-Albright syndrome 62McKusick type metaphyseal

chondrodysplasia 46Madelung deformity 59, 60, 63, 201Mafucci syndrome 60, 61, 95Magnetic resonance imaging (MRI)

acute osteomyelitis 152adolescent idopathic scolios'is 270bone tumours 77-8DDH208Perthes disease 221, 222

Malabsorption 66Malalignment, lower limb deficiencies

33Malignant bone and soft tissue

tumours 88-92, 98-9,314differentiation from benign 76-7

Malignant changesenchondromatosis 61fibrous dysplasia 62hereditary multiple exostoses 60

Malunion, supracondylar fractures,humerus 11-12,286,288

Marfan syndrome 12, 39, 53, 54,276

Massive osteolysis 87Matrix, bone 65Medial

condylar injuries, elbow 290-2epicondyle, elbow, fractures 290femoral torsion and lateral tibial

torsion 187open reduction, DDH 210, 212­

13Median nerve palsy, supracondylar

fracture 287Melbourne modification, Coleman

test 10, 11Melorheostosis 61Menelaus and Westh technique, limb

length inequality assessment317

Menelaus-Batten syndronle 177Meningococcal septicaemia 154Meningocoele 115, 116Meniscal tear 246Meryon 'fall through' sign 132Metabolic bone disease 65-73Metabolism, bone 65Metacarpal injuries 297Metaphyseal

chondroplasia 45-7cyst, Perthes disease 225disorders 45-7dysplasia 47

Metastasesgiant cell tumour 85leukaemia 93, 94neuroblastoma 93, 94osteosarcoma 89

Metastatic bone tumours 92, 93, 94Metatarsus

adductus 185varus 186

Metatrophic dysplasia 42, 43Methotrexate 171Milwaukee brace 270, 271Monoarthritis, knee 167Monteggia fracture dislocation 292,

296Morquio syndrome 39, 44,52Moseley graph technique, limb length

inequality assessment 317Mucopolysaccharidoses 50-2Multidisciplinary team, spina bifida

116-17Multiple

disabilities 14epiphyseal dysplasia 43, 44, 222exostoses, lirrlb length inequalities

314Muscle

biopsy, neuromuscular disorders134, 135

contractures, cerebral palsy 102,105

imbalance, spina bifida 120-1strength, MRC grading 3

Muscular dystrophies 3, 134-7, 275-6Mycobacterium tuberculosis 159Myelocoele 115, 116Myelomeningocele see Spina bifidaMyeloschisis 115, 116Myotonic syndromes 138

Nail-patella syndrome 54, 55, 56,198

Navicular, osteochondritis 177-8Nemaline (rod-body) myopathy 138Neonatal

osteomyelitis 153, 194rickets 70

Nerve conduction studies 134Nerve palsy

fractures of humerus 285, 287, 288limb lengthening 322upper limb birth palsies 193-5

Neural tube defects 115see also Spina bifida

Neural tumours, benign 96Neurilemmoma 96Neuroblastoma 93, 94Neurofibroma 96

multiple 54

Neurofibromatosis 4,55-7, 96, 276,313

Neurogenic bowel 116-17Neurological assessment 3Neuromuscular disorders

diagnosis 131-4disorders

arthrogryposis 142-4, 194congenital myopathy 137-8Friedreich ataxia 141-3hereditary 138--40inflammatory myopathies 138muscular dystrophies 134-7,

275--6myotonic syndromes 138spinal nluscular atrophy 135,

140-1examination 131history 131-3limb length inequalities 314

Neuromuscular scoliosis 273-fJNeuropathies

congenital sensory 146heriditary motor and sensory 138-

40Night cramps 191Non-accidental injury 311-12Non-ossifying fibroma 311Non-steroidal anti-inflammatory

drugs (NSAIDS) 170Non-structural scoliosis 267Normal

gait 21-2variants 183-91

NutrItional rickets 66, 68

Observational gait analysis 22Obstetric injuries see Birth injuriesOccupational therapy 171Oestrogen 66Olecranon fractures 292OIlier disease 60-1, 314Open epiphyseodesis see

EpiphyseodesisOrthofix system, limb lengthening 320Orthotics and prosthetics

ankle-foot orthoses 104-5, 121below-knee amputees 26cerebral palsy 104-5, 274flat feet 189-90floor reaction 105, 121gait analysis 25--6knee-ankle-foot orthoses 118limb length inequality 317reciprocal gait orthoses 25, 118, 121scoliosis 270, 271, 274, 275spina bifida 121, 275

Ortolani test, DDH 204-5, 210Osgood-Schlatter disease 9, 176-7

Osteo-onychodysplasia 54, 55, 56Osteoarthritis

knee, following Hauser technique244

secondary toDDH212Perthes disease 220, 222SUFE236

Osteoarthropathy, familialhypertrophic 50

Osteoblastoma 80Osteochondritic conditions 175-81

lower limb 245-6, 176-81upper limb 175-6

Osteochondritis dissecansfifth metatarsal 179hip 180-1, 222, 227knee 246-7navicular 177-8talus 180

Osteochondroma 80Osteochondromatosis 11, 59-60

synovial 97-8Osteofibrous dysplasia 87, 88Osteogenesis imperfecta 39, 47-9

classification 48fractures 47, 48, 49, 311scoliosis 276-7

Osteoid osteoma 78-80, 191femur 79spine 79

Osteolysis, massive 87Osteomyelitis

acute 149-54chronic 1556-9

recurrent multifocal158, 159epiphyseal 153limb length inequalities 313-14neonatal 153, 194

Osteopathia striata 61Osteopathy, viral 161Osteopetrosis 39, 49-50, 311Osteopoikilosis 61Osteoporosis 7, 39, 72

causes 72idiopathic juvenile 72, 73pathological fractures 311vertebral

collapse 170crush fracture 169

Osteosarcoma 88-9, 90, 93humerus 91juxtacortical 89, 90limb length inequalities 320, 325tibia 90

OsteotomiesBlount disease 247DDH 211distal first metatarsal 262-3femoral 28

innominate 28, 223,226-7lCA 172os calcis 124Pauwel36primary 233--4rotational, femur 110-11, 113scapular 197supramalleolar, tibia 123

Overriding fifth toe 264Oxygen rate and cost, gait analysis

22-5

Pachydermoperiostosis 50Palmar fibromatosis 96Panner disease 175-6Paralytic

convex pes valgus 124flat feet 258

Parathyroid hormone (PTH) 65-6Parkes-Weber syndrome 95Partial growth plate arrest 322-5Patella baja and early osteoarthritis

244Patellar

apprehension test 9, 242dislocation 239--43fractures 306-7squinting 187

Pathologicalbow legs 187fractures 117,310--12spondylolisthesis 279

Pauciarticular lCA 166Pauwels osteotomy, infantile coxa

vara 36Pavlik harness 208, 209Pelvic fractures 299-301

acetabular 301classification 299, 300injuries associated 299pelvic ring, breaks

double 301single 300without 299-300

Pelvic obliquity, fixed 5Pemberton

acetabuloplasty, DDH 214osteotomy 215

Percutaneous K wire fixation 295Periosteal

chondroma 82-3osteosarcoma 89, 90reaction 161

acute osteomyelitis 150general and focal causes 150tumour diagnostic factor 76, 77

Periostitis, tumour diagnostic factor76

Perkin line 207

Index 333

Peronealmuscular atrophy 10

causing pes cavus 260spasmodic flat feet 258

Perthes disease 163--4,219-27aetiology 219clinical features 220differential diagnosis 222incidence 219management 224-7

conservative 225-6surgical 226-7

pathology 219-20prognosis 222--4

factors affecting 223radiology 221-2

Pes cavus see Cavovarus feetPes planus 257-60Phalanges, injuries to 297Phemister technique, growth plate

arrest 318Phosphate deficiency 67Physiological

bow legs 187cost index (PCI) 22, 24flat feet 258

Physiology of bone 65-6Physiotherapy

cerebral palsy 104lCA 171

Pigmented villonodular synovitis 97Planovalgus deformity, foot, lCA

172Plantar

fibromatosis 96response 3

Platyspondyly in childhood 43Plica syndrome 245Pneumococcus 150Poliomyelitis 103, 144-6

limb length inequalities 145, 314Polyarticular lCA 166, 167-9Polymyositis 138Polyostotic fibrous dysplasia 62Popliteal cyst 248Posterior interosseous nerve palsy,

supracondylar fracture 287Posterolateral release, congenital

deficiencies, fibula 32Posteromedial bowing, tibia 35, 36Posture

posturallumbar lordosis 278scoliosis 5

spina bifida 118, 121Premature growth plate arrest 322-5Proportional short stature 39Prosthetics, gait analysis 25-6

see also Orthotics and prostheticsProteus syndrome 315

334 Paediatric Orthopaedics

Proximalfemoral osteotomy 28, 110, 111focal femoral deficiency 29-31interphalangeal joint flexion

contractures 168muscle weakness 131-2realignment, recurrent acute

patellar dislocation 243Pseudarthrosis, congenital

proximal focal femoral deficiency29-30

tibia 34-5ulna, neurofibromatosis 57

Pseudoachondroplasia 42Pseudohypertrophy, calf muscle,

muscular dystrophy 135Pseudoporphyria 170Psoriatic arthritis 168PTH-related peptide 66Pulmonary function, Duchenne

muscular dystrophy 136-7,275

Punctate epiphyseal dysplasia 45, 46Pyknodysostosis 50Pyle disease 47

Quadriplegia 111-13

Radialclub hand 199-201head, dislocation 198-9

Radio-ulnar synostosis 199Radiotherapy, limb length inequalities

315Radius

deficiencies of see Radial: club handfractures

neck 293see also Forearm: fractures

head, dislocation 198-9Realignment procedures

anterior knee pain 245recurrent acute patellar dislocation

243Reciprocal gait orthosis (RGO) 25,

118, 121Recurrent acute patellar dislocation

241-3Recurring digital fibroma of Reye 96Recurvatum, knee

congenital 239with limited flexion 125, 177

Redislocation, DDH 211Reflex sympathetic dystrophy 173Remodelling

fracture 299SUFE deformity 234

Renal osteodystrophy 69-70

Respiratory function, Duchennemuscular dystrophy 136-7, 275

Retinoblastoma 93Reye, digital fibroma of 96Rhabdomyosarcoma 93, 98-9Rheumatoid factor-positive JeA 168Rhizotomy, selective posterior 105Ribs, asymmetrical 4, 5Rickets 66-8

neonatal 70radiological appearance 67-8vitimin D-resistant rickets 67-8

Rifampicin 161Rotation osteotomies, cerebral palsy

110-11Rotational profile, leg 6-7

see also External rotation; Internalrotation

Roux-Goldthwaite technique 240,241,243,244

Rubella 161Russel-Silver syndrome 314-15

Sacralfractures 300lesions, spina bifida 118

Salter innominate osteotomy, DDH213-14,215,216

Salter sign 224avascular necrosis 212Perthes disease 221, 224

Salter-Harris classification,epiphyseal injuries 283, 290,294,305

Scapularfractures 284osteotomy 197

Scheuermann kyphosis 277Schmid type metaphyseal

chondrodysplasia 45-6Scleroderma 169Sclerosing osteomyelitis of Garre 158Scoliosis 6, 267-77

adolescent idiopathic 266, 268, 269-72

aetiology 269clinical features 269-70management 270-2radiology 270

arthrogryposis 144assessment 4cerebral palsy 273-4congenital 272-3Duchenrie muscular dystrophy 136-

7,275-6Friedreich ataxia 141-2infantile idiopathic 267, 268Marfan syndrome 276neurofibromatosis 276

neuropathies 140osteogenesis imperfecta 276-7poliomyelitis 146postural 5spina bifida 126, 127-8, 274-5spinal muscular atrophy 141

Scottish Rite brace, Perthes disease226

Scurvy 70-1Selective posterior rhizotomy 105Septic arthritis 152, 154-6, 163

limb length inequalities 313shoulder 194

Septicaemia, meningococcal 154Sequestrum 149, 156, 157Seronegative enthesopathy and

arthritis (SEA) syndrome169

Serpentine (z-shaped) foot 186Sever osteochondritis of the os calcis

10, 178Shelf procedure, acetabular salvage

216,217Shepherd's crook deformity 62Short limb gait 3Short-limbed short stature 37Shoulder

apprehension test 11assessment 11dislocation 197-8girdle injuries 284late deformity, obstetric brachial

plexus injury 195Sprengel 11, 196-7

Sickle cell crisis 152Silverskiold test 106Simmonds-Menelaus operation,

hallux valgus 263Simple bone cyst 84-5, 311Site, tumour diagnostic feature 76Skeletal dysplasias 39-63, 198

diagnosis 39disorders

chromasomal abnormalities 62-3connective tissue disorders 53-4diaphyseal disorders 47-50epiphyseal 43-5growth plate 40--3metaphyseal 45-6miscellaneous 54-62storage 50-3

radiology 39Skin

anaesthesia, spina bifida 119lesions

cafe au lait spots 4, 57spinal area 4, 128

necrosis, congenital talipesequinovarus 255

Skull, neurofibromatosis 57

Slipped upper femoral epiphysis(SUFE) 229-36, 246

aetiology 229classification 230clinical features 230complications 230incidence 229management 231--4pathology 229radiology 23(}-1

Slow-acting antirheumatic drugs(SAARDS) 17(}-1

Soft tissuechanges, neurofibromatosis 57release

equinovarus deformity 122JCA 172preventative hip surgery, cerebral

palsy 111-12tumours 75

benign 95--6, 98malignant 98-9

Solid AFO 105Spastic

diplegia 109-11quadriplegia 111-13

Spina bifida 115-30aetiology 115clinical features 116embryonal origin and resultant

condition 129foot 121--4gait analysis, oxygen rate and cost

24-5hip 125-8incidence 115knee 124-5i1mb length inequalities 314lumbar level 22management, general 116-17,128

goals and outcomes 118neurosegmentallevel assessment

118-19occulta 115, 116paralytic flat feet 258pathology 115-16prevention 117problems 119-21reciprocal gait orthosis 25recurrence risk 117-21scoliosis 274-5spine 126-8

deformity, classification 126, 127tibia, torsional deformities 124

Spinalcord, tethering 121dysraphism 4-5, 128-30

cavovarus foot 261embryonal origin and resultant

condition 129

muscular atrophy 135, 140-1tuberculosis 160

Spineanterior vertebral body beaking,

causes 51arthrogryposis 144assessment 4-5kyphosis 126, 127, 277lordosis 126, 277-8neurofibromatosis 4, 56, 276normal curvature, comparison with

scoliosis 4see also Scoliosis; Spina bifida

Spondyloepiphyseal dysplasia (SED)43,44-5

Spondylolisthesis 5classification 279spina bifida 126

Spondylolysis/spondylolisthesis 278-81

Spondylometaphyseal dysplasia 47Sprengel shoulder 11, 19fr-7Squinting patellas 187Stable hips, DOH, management 208Staging, bone and soft tissue tumours

78Staphylococcus aureus 149-50, 154,

156Staphylococcus epidermis 156Staples, growth arrest by 318Stature, skeletal dysplasias 39Steel osteotomy 215Steinert disease 138Sternoclavicular dislocations 284Stiff knee gait, cerebral palsy 22Still's disease see Juvenile chronic

arthritis (JCA): systemicStorage disorders 5(}-3Streptococcus 153, 154, 156Streptomycin 161Stress fractures, tibial shaft 308Structural scoliosis 267Subluxation, lilnb lengthening 321-2Subtalar valgus 124Sulphasalazine 170Supracondylar femoral osteotomy

111Supracondylar fractures, humerus

285-9assessing child 287associated injuries 288classification 285complications 285-6malunion 11-12, 286management 28fr-9

Sutherland osteotomy 215Syme amputation 30, 317Synovectomy

haemostatic disorders 173JCA 172

Index 335

Synovialbenign tumours 97-8osteochondromatosis 97sarconla 99

Syphilis of bone 161Systemic JCA see Juvenile chronic

arthritis (JCA): systemic

Talipescalcaneovalgus 257equinovarus 13, 122see also Congenital talipes

equinovarus (CTEV)Talocalcaneal

angle, congenital talipesequinovarus 252, 253

bar 258, 259, 260Tarsal coalition 258--60Thermal injuries, limb length

inequalities 315Thigh foot angle, torsional profile 184Thomas test 8 'Thomsen disease 138Thoracic lesions, spina bifida 118Thrombocytopenia absent radius

syndrome 199Tibia

congenitaldeficiencies 27, 32-3pseudarthrosi.s 33--4

distal tibial dysplasia-deficiency 33,35

fibrocartilagenous dysplasia 83--4fraeture-separation proximal physis

306fractures 306

avulsion, tubercle 306, 307intercondylar eminence 306, 307proximal metaphyses 308-9shaft 308-9triplanar 309, 310

posteromedial bowing 35, 36pseudarthrosis 34-5shortening 318, 319torsion fr-7, 124vara 248-9

Tibia and fibulafractures 307-10

distal physes 309-10shafts 308

limb length inequalities 313Tibial

hemimelia 27, 32-3osteotomy, Blount diesease 249

Tillaux fracture 309Toddler's fracture, tibial shaft 308Toe

deformities 10overriding fifth 264

336 Paed iatric Orthopaed ics

Toe (continued)recurring digital fibroma of Reye 96ulcers, congenital sensory

neuropathy 146walking 133, 190

differential diagnosis 133Tom Smith disease 313TORCH 101Torsional deformities see External

rotation; Internal rotationTorus fractures, forearm 294Total growth plate arrest 322Traction

DDH 210SUFE 232

Transient synovitis, hip 162-4Traumatic

causes, limb length inequality 313dislocation, shoulder 197spondylolisthesis 278-9

Trendelenburggait 3-4, 22, 210test 5

Trevor disease 45, 46Trichorhinophalangeal syndrome 60Trigger thumb 201-2Triplanar fractures, distal tibia 309,

310Triple

arthrodesis, congenital talipesequinovarus 256

osteotomy 215Trisomy 18: 63Trisomy 21: 62-3Trochanteric surgery, DDH 214True shortening, leg length inequality

5Tuberculosis 159-61

hip 160,222spinal 160

Tumoral calcinosis 98Tumours, bone and soft tissue 75-100

benign 78-88, 96, 98biopsy 78diagnosis 75malignant 88-92, 98-9metastatic 92, 93, 94radiology 7(r8

staging 78see also Malignant changes

Turner syndrome 63, 201

Ulnacongenital pseudarthrosis,

neurofibromatosis 57fractures see Forearm: fractures

Ulnar nerve palsy, supracondylarfracture 287, 290

Ultrasoundacute osteomyelitis 151DDH 204, 205-6prenatal diagnosis, spina bifida 117septic arthritis 155

Unicameral bone cyst 84-5,311Unilateral hemimelia 32-3Unstable hips, DDH, management

208Upper femoral dysplasia 21 (r17Upper limb 192-204

arthrogryposis 144assessment 11-12birth palsies 193-5hemiplegic, cerebral palsy 108-9osteochondritic conditions 175-6trauma 283-97

Upper motor neurone lesions 132Upper root injury, obstetric brachial

plexus injury 194

Valgus deformityankle 123, 124foot 108, 111, 121subtalar joint 124

Van Nes rotationplasty 30Vanishing bone disease 87Varus deformity, foot 107, 108

spina bifida 121Vascular

injuries, limb lengthening 322malformations 94,313tumours, benign 94

Vascularizedfibular grafts 35growth plate transfer 325

Vater syndrome 199Vertebra plana, causes 87Vertebral bodies

anterior beaking 42, 51scalloping 57

Vertical talus 124, 25(r7Viral osteopathy 161Vitamin A toxicity 71Vitamin D deficiencies 66, 67Vitamin D-resistant rickets 67, 68-9Volkmann ischaemic contracture 285-

6,288Voluntary dislocation, shoulder 198,

284Von Recklinghausen disease see

NeurofibromatosisVon Rosen splint 208, 209Von Willebrand disease 173

Wagner technique, limb lengthening319-20

Walk, ability tocerebral palsy 109poliomyelitis 145spina bifida 118

Watson-Jones classification, tibialtubercle avulsion 306

Wheelchairs 121White, slide technique, achilles tendon

lengthening 107Wi1m tumour 93Wilson sign 246Woodward procedure, Sprengel

shoulder 197Wormian bones, causes 49Wrist

assessment 12and hand

injuries 297Madelung deformity 59, 60, 63,

201hemiplegia, cerebral palsy 108-9

Z-lengthening, achilles tendon 107Zone of transition, tumour diagnostic

factor 76

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