Pediatric Orthopedics
Some of the most common complex hip disorders affecting children are
Limb Deformity
Pediatric Fractures
Neuromuscular Disorders
Spinal Deformity
Perthes Disease
Hip Dysplasia
SCFE
Hip Dysplasia
Pediatric hip conditions can affect children of any age. Hip dysplasia is a condition where the hip socket does not form correctly and can be associated with hip dislocation at birth or abnormal development of the socket as the child grows. If pediatric hip dysplasia is left untreated, it can lead to early hip problems in adulthood, including hip arthritis. Your child may be made to try nonsurgical methods to help the hip develop normally, such as braces or casts.
Some pediatric hip conditions require surgical treatment in order to allow the hip joint to develop normally. These procedures may include cutting and realigning the pelvic and thigh bones and reconstructing the hip joint, procedures known as pelvic and femoral osteotomies. Some osteotomies are appropriate only in small children, while others may be beneficial for older children with hip dysplasia. One such osteotomy, the periacetabular or "Ganz" osteotomy, may prevent the development of early arthritis in older children with hip dysplasia. Emory is one of a small number of centers in the region where this osteotomy is performed.
It usually affects the left hip and is predominant in:
Girl, first-born children, babies born in the breech position (especially with feet up by the shoulders)
Symptoms may include
Legs of different lengths
Uneven skin folds on the thigh
Less mobility or flexibility on one side
Limping, toe walking, or a waddling, duck-like gait
Treatment
Appropriate evaluation by a pediatric orthopaedic specialist will determine the best treatment options and will work with you to create a plan of care for your child so that they may become ambulant at the earliest
Perthes Disease
Perthes is a condition in children characterized by a temporary loss of blood supply to the hip. Without an adequate blood supply, the rounded head of the femur (the " ball " of the hip) dies. The area becomes intensely inflamed and irritated. Perthes disease is usually seen in children between 4 to 10 years old. It is five times more common in boys than in girls.
Symptoms of Perthes Disease include
Limping
Mild pain in parts of the leg, such as the groin, thigh, or knee
When the hip is moved, the pain worsens. Rest often relieves the pain.
The child may have had these symptoms intermittently over a period of weeks or even months. Pain sometimes is caused by muscle spasms that may result from irritation around the hip.
Treatment for Perthes
Treatment may require periods of immobilization or limitations on usual activities. The long-term prognosis is good in most cases. After 18 months to 2 years of treatment, most children return to normal activities without major limitations.
Non-Surgical Treatment of Perthes Disease
Anti-inflammatory medications
Physical therapy
Bed rest in traction may be needed in some cases
Surgical Treatment of Perthes Disease
Surgical treatment re-establishes the proper alignment of the bones of the hip. The head of the femur is placed deep within the socket, or acetabulum. This alignment is kept in place with screws and plates, which will be removed at a later time. In some cases, the socket must also be made deeper because the head of the femur has actually enlarged during the healing process and no longer fits snugly within. After either procedure, the child is often placed in a cast from the chest to the toes for 6 to 8 weeks.
After the cast is removed, the child will again participate in physical therapy. Activities will be designed so that the child only partially bears weight on the affected hip. X-rays will show when the final stages of the healing are underway.
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the adolescent hip. For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to the weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.
The condition is diagnosed based on a careful history, physical examination, observation of the gait/walking pattern, and X-rays of the hip. The X-rays help confirm the diagnosis by demonstrating that the upper end of the thigh bone does not line up with the portion called the femoral neck.
Symptoms
History of several weeks or months of hip or knee pain and an intermittent limp. He or she walks with a limp. Will be unable to bear any weight on the affected leg in severe cases. The affected leg is usually turned outward in comparison to the normal leg. The affected leg may appear to be shorter.
Treatment
The goal of treatment, which requires surgery, is to prevent any additional slipping of the femoral head until the growth plate closes. If the head is allowed to slip farther, a hip motion could be limited. Premature osteoarthritis could develop. Treatment should be immediate. In most cases, treatment begins within 24 to 48 hours. Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip. Fixing the femoral head with pins or screws has been the treatment of choice for decades.
Depending on the severity of the child's condition, the surgeon will recommend one of three surgical options.
Placing a single screw into the thigh bone and femoral epiphysis.
Reducing the displacement and placing one or two screws into the femoral head.
Removing the abnormal growth plate and inserting screws to aid in preventing any further displacement.
Limb Deformity
While knock knees and bow legs are common in childhood and usually resolve as the child grows, certain limb conditions do not correct on their own and may lead to leg length differences or angular deformity.
Just a few of the conditions that may lead to differences in the growth of the limb are:
Blount's disease
Skeletal dysplasias
Femoral or fibular deficiencies
Physeal bar formation after traumatic injuries
Your surgeon may recommend surgery to help restore the normal alignment of your child's arm or leg. These include slowing down the growth of the longer limb, changing the direction of growth of an angled limb, or sometimes cutting the bone (known as an osteotomy) and realigning the limb into a better position.
Our pediatric orthopedic surgeons have experience using a number of techniques to change limb alignment including guided growth (to use the body's normal growth patterns to correct the deformity), osteotomies and internal fixation (for immediate and accurate correction of limb differences), and external fixation (for lengthening bones and correcting angular deformities).
Neuromuscular Disorders
Our orthopedic care for children with neuromuscular disorders such as cerebral palsy, muscular dystrophy, and Down's syndrome, amongst others. Much of this care can involve coordination of physical and occupational therapy for children, wheelchair fittings, and orthotists to help with braces.
Surgical management for these conditions may be indicated to assist your child in daily activities such as walking, running, and even sitting. These procedures are complex and need to be individualized to each patient to maximize the outcome. Some commonly performed procedures include botulinum toxin-A injections for muscle spasticity, tendon lengthening or transfers, bony realignment procedures known as osteotomies, hip reconstruction, and spinal fusion surgery. Spinal fusion is often performed for scoliosis but may also be required for neck disorders, chest wall deformities, or kyphosis (round back).
Pediatric Fractures
Childhood fractures occur frequently. From common injuries such as broken wrists or elbows to those that are more complex involving multiple bones, our pediatric orthopedists have the experience to treat your child's injury expediently and appropriately. Each child is monitored after his or her injury to ensure that all fractures heal and that no growth plate injury occurred at the time of initial fracture. Potential complications of broken bones including incomplete healing, infection, or injury to the growth plate of the bone may need treatment after the injury. Your child's surgeon will be able to discuss the injury, treatment, and what you can expect down the road.
Pediatric Elbow Fractures
When a child falls on an outstretched arm, the pressure of hitting the ground could be enough to fracture, or break, a bone around the elbow. These fractures that occur in, or around, the elbow account for about 10% of all fractures in children.
Symptoms
Severe pain in the elbow and forearm
Occasionally numbness in the hand, if nerve injury has occurred
Tenderness
Swelling (may be severe or mild)
Bruising
Limited movement
If your child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately.
Pediatric Forearm Fractures
Forearm fractures account for 40% to 50% of all childhood fractures. Children love to run, hop, skip, jump and tumble. But if a child falls onto an outstretched arm, he or she might break one or both of the bones in the forearm.
Symptoms and Signs
Severe pain
Numbness in forearm and hand
Any type of deformity about the elbow, forearm, or wrist
Tenderness
Swelling
An inability to rotate or turn the forearm
Pediatric Growth Plate Fractures
Growth plates are areas of developing cartilage tissue near the ends of long bones. The growth plate regulates and helps determine the length and shape of the mature bone. The long bones of the body do not grow from the center outward. Instead, growth occurs at each end of the bone around the growth plate. When a child becomes full-grown, the growth plates harden into solid bone.
Growth plates are located between the widened part of the shaft of the bone (the metaphysis) and the end of the bone (the epiphysis). This diagram of a femur (thighbone) shows the location of the growth plates at both ends of the bone.
Because growth plates are the last portion of bones to harden (ossify), they are vulnerable to fracture. In fact, because muscles and bones develop at different speeds, a child's bones may be weaker than the ligament tissues that connect the bones to other bones.
Children's bones heal faster than adult's bones. This has two important consequences:
A child with an injury should see a doctor as quickly as possible, so the bone gets the proper treatment before it begins to heal. Ideally, this means seeing an orthopaedic specialist within 5 to 7 days of the injury, especially if manipulation to align the bone is required.
The fracture will not need to stay in a cast for as long as an adult fracture would require for healing.
Appropriate evaluation by an orthopaedic surgeon experienced in orthopaedic trauma will determine the nature of the growth plate injury, will provide counselling about treatment options and will allow for longer-term follow up to assess the outcome of the injuries.
Pediatric Femur Fracture
Events with the highest risk for pediatric femur fractures include:
Falling hard on the playground
Taking a hit in contact sports
Being in a motor vehicle accident
Child abuse
Thighbone fractures are classified depending on:
Location of fracture on the bone (proximal, middle, or distal third of the bone shaft)
The shape of the fractured ends — bones can break all kinds of ways, such as straight across (transverse), or angled (oblique)
Position of the fractured edges (angulated or displaced)
Number of fractured parts
Two parts
Several fractured parts (comminuted)
Symptoms
Severe pain
Thigh is noticeably swollen or deformed
Your child is unable to stand or walk
There is a limited range of motion of the hip or knee
Take your child to the emergency room right away if you think he or she has a broken thighbone. Explain exactly how the injury occurred.
