What is Paediatric Orthopaedics?
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Paediatric Orthopaedics is a subspecialty within Orthopaedic Surgery that treats bone and joint conditions in children from birth to adolescence. Since children are growing, the evaluation and treatment required for them can be quite different than that required for an adult, even for the same condition or injury.
Some conditions in children are normal variations that will resolve with time, while other conditions require an active treatment approach. This may involve a period of observation, casting, bracing, physiotherapy or surgery. This often means providing care to children and supporting families throughout the course of treatment, which may be for many years in a growing child.
Many of the most common paediatric orthopaedic conditions are listed here with information and helpful resources for parents and caregivers.
What is Clubfoot?
Clubfoot (Congenital Talipes Equinovarus) is a congenital foot deformity resulting from abnormal development of muscles, tendons and bones inutero. It occurs in about 1 in every 1000 births. We do not understand the exact cause of clubfoot but there is thought be an underlying genetic component. In families where one child is affected with clubfoot, the chances of having a child that is also affected is about 1 in 30. For most children with standard clubfoot treated with current methods, they generally go on to lead active, healthy lives. In the developing world however, clubfoot is still a very significant cause of disability.
Refer to these helpful link below for further information.
How is clubfoot treated?
Clubfoot in an otherwise normal child is usually responsive to serial manipulation and casting using Ponseti method.
This method was developed by Dr Ignacio Ponseti several decades ago and has been used widely for treatment in the last 10-15 years internationally. Treatment begins in the first couple of weeks after birth and involves serial casting every 7 days. The ligaments, joint capsules, and tendons are stretched under gentle manipulations.
The bones are brought into correct position to allow for remodelling and growth. Most feet require 5-7 casts to achieve correction. Once an appropriate correction is obtained, the child then wears boots and bar full-time for 3 months and then during sleeping hours until age 4 years. Non-compliance with bracing is the most frequent reason for relapse or recurrence of clubfoot. Some patients require some minor surgery for fine-tuning of the foot once more growth occurs in childhood.
Developmental Dysplasia of the Hip (DDH)
Developmental Dysplasia of the Hip (DDH) is a common condition within pediatric orthopedics. Other synonyms include 'congenital dislocation of the hip' (CDH) and hip dysplasia.
The hip joint is a ball and socket joint. Normally, the femoral head (ball) sits within the acetabulum (socket). However, for various reasons, the socket can often be under-developed.
Some of the time, babies can have immature hips with maternal hormones still their system. This can result in laxity in the hips that resolves on its own in the first few weeks of life, without treatment. Other babies have true hip dysplasia, which if left untreated can go on to a dislocated hip. Risk factors with hip dysplasia include: Female baby, first born child, twin births, breech, family history of hip dysplasia or other packaging problems during pregnancy.
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We use hip ultrasound during the first six months of life to assess for hip dysplasia. After six months, there is too much bone present for ultrasound to be useful and so at that point we use X-ray as the choice imaging test.
In Canada we are blessed with an excellent system for screening babies and thus there are not nearly as many late presentations for dislocated hips as compared to other countries. However, it is still possible for this diagnosis to be delayed. There can be a range of severity, from mild cases to true dislocations.
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For children who have instability on physical exam, bracing is required for early treatment to get the ball in the socket, thereby encouraging remodelling and growth. Most hips respond to bracing however some hips that are very severe require surgical treatment, even if detected early. Our goal is to get the hips in-joint as soon as possible, with the least number of complications. We are hoping to prevent pain and early-onset arthritis in these patients.
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Refer to these helpful link below for further information.
Bowed Legs (Genu Varum) and Knock Knees (Genu Valgum)
Normally, young children often have bow legs (genu varum). While all babies have this curvature in the legs, it is more notable once the child begins to stand and walk. This is called "physiologic genu varum". With growth, this straightens out, usually by age 3. From ages 3-8, children may develop a knock-kneed appearance (physiologic genu valgum). This usually straightens out over a few years but may take until adolescence. There is a wide range of "normal" in children and adolescents.
Occasionally some children can develop deformities that are not in keeping with normal variations in growth and these can be for multiple reasons, including metabolic conditions, abnormal pressures through the growth plates in the knee due to excess weight, and growth disturbances following trauma.
Refer to these helpful links below for further information.
What is Septic Arthritis?
Septic arthritis is a bacterial infection in a joint. In children, common joints include the hip, knee, ankle and shoulder. It can be caused by bacteria entering the blood stream and traveling to the affected joint. This can occur quite commonly in healthy children. Many times we cannot determine the source of the bacteria. Infection that occurs in the bone (osteomyelitis) near a joint can sometimes spread to the joint. When an infection occurs within the joint, an accumulation of pus occurs. This can occur in neonates, young children, adolescents and adults.
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Signs of Septic Arthritis may include some of the following: rapid onset of painful joint motion, inability to bear weight on the affected joint, fever greater than 38 degrees, generalized unwellness, and a hot, swollen joint. Physicians use history, clinical exam, blood tests, and sometimes the help of various imaging modalities to make the diagnosis. There are other diagnoses (like transient synovitis and inflammatory arthritis) that can sometimes mimick septic arthritis and it is important to differentiate these other conditions.
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Treatment includes drainage of pus from the affected joint under anesthetic, antibiotic therapy, splinting, and careful orthopedic follow-up. In complex cases, particularly those associated with a severe and persistent infection in the bone, growth disturbances and other complications can occur.
Refer to these helpful links below for further information.
What is Osteochondritis Dessicans
Osteochondritis Dessicans is a condition that can affect children and adolescents where there is softening of the bone underneath the joint cartilage. This commonly affects the knee joint, ankle joint and occasionally the elbow. Some patients will get pain with this condition and in some patients, pieces can actually break off, float in the joint and cause locking. If surgical treatment is required, the treatment algorithm depends on whether the cartilage joint surface is intact or not. We determine this with a combination of diagnostic imaging modalities as well as joint arthroscopy. If it is, we leave the cartilage undisturbed and then use a technique called 'anterograde or retrograde drilling' which involves feeding in a small wire into the soft bone under x-ray guidance, drilling over the wire in an effort to stimulate healing, usually in the distal femur or the talus (ankle). If there is a defect in the cartilage, classic technique involves stimulating bleeding in the underlying bone in an effort to stimulate scar-cartilage formation. Either way, the patient must be non-weightbearing, sometimes requiring splint immobilization, for 6 weeks on the affected side.
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Note about Arthroscopy:
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Arthroscopy is an orthopedic surgical technique where small incisions are made to insert a 2.9mm-4.2mm diameter camera into the joint while fluid runs into the joint allowing visualization of pathology as well as treatment of various conditions.
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Ankle arthroscopy is useful for multiple ankle conditions including: removal of loose cartilage or bone pieces, removal of bone spurs, inspection and drilling/treatment of osteochondritis desiccans lesions as well as cleaning out an infected ankle joint. It can be a very effective treatment in these conditions but is not useful in advanced osteoarthritis of the ankle. Knee arthroscopy is common for osteochondritis, meniscal tears, removal of loose bodies (usually floating pieces of cartilage) as well as for assistance with some joint trauma management and ligament reconstructions.
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Surgical intervention usually involves a general anaesthetic or a spinal anesthetic in older patients. A tourniquet is applied to the thigh and is often inflated to limit bleeding and improve visualization in the joint. Two or three small incisions are made, and these facilitate the probing of the anatomic structures in the joint, as well as treatment.