What is Paediatric Orthopaedics?
Paediatric Orthopaedics was first recognized as a subspecialty under Orthopaedic surgery in the early 1980. Since then multiple advancements and researches have been done in the field with an upsurge in knowledge and awareness. Paediatrics is not a one on one relation between the patient and the doctor but a trivalent association between the child patient, the doctor and the child’s parents or family. Paediatric Orthopaedics is a challenging field for the family to physicians as not only they haveto deal with the child’s condition but also their anxious parents. Furthermore, it’s complicated to communicate with a child as their motor skills may not have developed completely by the time they present with orthopaedic abnormalities. As a child is one of the vulnerable members of the society, his/her well-being is of utmost concern, which requires a multidisciplinary approach between the physician, surgeon, pediatrician, neonatologist and also the parents. Musculoskeletal diseases are one of the commonly affecting conditions seen in children of all ages accounting for approximately one third of the congenital abnormalities. A child’s bones differ from adult bones on the basis of flexibility and superior remodeling capacity. Prompt diagnosis and safe systematic treatment approach provides significant improvement in functional activities and also imparts a psychological benefit.
Causes of Paediatric Orthopaedic diseases:
- Congenital defects: Are predominantly the result of multifactorial inheritance. Reports show that 3% of newborn infants exhibit prominent defects and in another 3% these major congenital defects may be discovered by late infancy. 20% of prenatal deaths appear to be caused by some congenital abnormality. Multiple minor congenital defects have a tendency to predispose towards majors deformities, which lays emphasis on the importance of early and expeditious detection of these defects. Hip dysplasia and clubfeet account for 50% of the primary musculoskeletal defects.
- Chromosomal aberrations: Identifying the position of defective genes which attribute remarkable characteristics of the pathologic condition, at specific regions on the chromosomes, aids in arriving at the diagnosis. These chromosomal defects occur due to variation in number, configuration or composition of the chromosomes. Quantitative changes occur due inability of the chromosomes during cell cycle to separate or a nondisjunction that leads to monosomy or trisomy gametes. Turner’s syndrome is caused by monosomy of sex chromosomes while trisomy causes Klinefelter’s syndrome.Trisomy of chromosome 21 causes Down’s syndrome in which the child may develop hip instability leading to recurrent dislocations. Teratogens are agents that instigate chromosomal structural defects such as deletion in case of ‘cri du chat’ syndrome. Single gene defects can be a result of spontaneous mutation.
- Inherited disorders: An abnormal zygote can be formed by defective genes associated with either the sperm or the ovum. Feature inheritance of a single abnormal gene is dominant in nature, whereas if both genes in a pair are defective it leads to a recessive inheritance. If only the X chromosome is defective then it causes an X-linked inheritance such as in pseudohypertrophic muscular dystrophy. Polygenic or multifactorial inheritance involves numerous genes triggered by an environmental factor as seen in case of clubfeet and hip dysplasia.
- Abnormal morphogenesis: Morphological defects that arise during organogenesis are known as malformations such as phocomelia and limb hypoplasia. It can have a teratogenic or genetic etiology. Dysplasia implies to an abnormal growth which may occur prior or after birth. Dysplastic defects are seen in Achondroplasia, a commonly encountered osteochondral dysplasia in Orthopaedic practice.In the later periods of gestation, morphological disruptions can occur due to a teratogenic or traumatic insult to the fetus altering its growth. Morphological defects occurring during the terminal stages of gestation due to intrauterine crowding are known as deformations which as comparatively milder and may resolve by themselves.
- Metabolic disorders and malnutrition: Inadequate vitamin D intake in infants predisposes to Rickets characterized by osteopenia and gradual bowing of long bones.
- Inflammatory disorders: It can cause growth impairment in the region of the articular cartilage leading to angular deformity. Chronic inflammatory conditions such as rheumatoid arthritis and chronic osteomyelitis in children may cause hyperemia i.e. excess of blood in the vessels, and bone growth might be hastened causing abnormal bone lengthening.
- Physical activity: During the early years treatment of Perthe’s disease involved ling periods of non-weight bearing activity predisposing to limb shortening on the affected side. Likewise in professional tennis players, who begin their careers at an early age, might manifest a comparative overgrowth of the dominant limb.
- Neuromuscular deformity: Muscle imbalance in Cerebral Palsy can cause adductor spasm positions leading to erosive deformation of the cartilage and consequent subluxation and dislocation of the hips.
- Trauma: It can damage the growth plate or cause malformations leading to deformity of bones.
- Iatrogenic deformities: Placing the infant in hip extension position in the cradleboard can predispose to hip dysplasia. In some regions, iatrogenic cultural deformities are induced to enhance beauty such as thoracic deformity and bound feet.
Signs & Symptoms of Paediatric Orthopaedic diseases:
- Pain: Leg ache or growing pain is seen in 15-30% of children. It occurs more commonly at night and may precede headache and stomach ache.
- Limp or abnormal gaits: It occurs due to pain, weakness or deformity with hip being the commonly affected site. An antalgic gait is observed as a short stance on the side of the painful limb and a reciprocal longer stance on the contralateral side. A Trendelenburg gait is seen during long periods of walking, where on continued exertion the pelvis seem to tilt towards the unaffected side and to compensate that the trunk moves towards the pathological side. Equinus gait is seen as heel to cord contracture observed in cerebral palsy and clubfoot deformity.
- Dysplastic nails can be observed in nail-patella syndrome.
- Tenderness, fullness and crepitation.
- Swelling, internal bleeding and stiffness of joints.
- Loss of motion and rotation at the joints.
Diagonostictests for Paediatric Orthopaedic diseases:
- Conventional radiography: They are cost effective, easily accessible methods of diagnosis and are less likely to be misread. A limiting factor of conventional radiography is that it is unlikely to demonstrate incipient bone changes as traditionally bone density ought to be diminished by at least 30% to be evident on radiographs. Positioning the child at the indicated place for optimum radiography may require the assistance of parents or the physician. Radiation exposure should be limited to as minimal as possible. The gonads should be shielded adequately except when taking a pelvic image. Taking screening radiographs in the initial stage of investigation is advisable, eg. In a suspected case of spondylolisthesis, a single lateral standing spot radiograph of the lumbosacral junction can exhibit the pathology, prior to obtaining antero-posterior and oblique views. The lower limbs and spine are radiographed in an upright position.
- Computerized Tomography (CT) Imaging: CT is the standard diagnostic imaging technique for assessment of the soft tissues as well as hard tissue details. Using computer graphics the soft tissue details can be optimally segregated depending on varying intensities. CT is a comparatively expensive imaging technique which requires the child to be sedated for the procedure and exposed to higher levels of radiation as compared to conventional radiography. CT is advised in cases where conventional radiographs fail to produce the pathologic details, such a sin inflammatory, neoplastic and traumatic lesions of the spine and pelvis, in complex cases of hip disfigurement prior to surgical manipulation, complex fractures and physeal bridge assessment.
- Computerized Tomography (CT) Myelography: CT imaging can be integrated with contrast media for additional diagnostic evaluation known as CT Myelography. It produces a 3-dimnesional image along the transverse, frontal and sagittal plane with advanced graphic display, consequently demonstrating a superior relationship between the soft and hard tissues of the body. It is advantageous in cases of assessing the concentricity of hip reduction wherein it displays fine details of dysplasia.
- Arthrography: It is an imaging technique of the soft tissues of the joint cavity. In this procedure a contrast media such as air or nitrogen or carbon dioxide or an iodinated contrast agent, is injected into the joint space followed by a CT imaging or tomography. Arthrography is indicated in cases of hip and knee pathologies, septic arthritis to establish the joint entry pathway, to demarcate foreign bodies in the joint space in meniscal lesions and hip dysplasias.
- Scintography: It uses technetium-99m, gallium-67, and indium-111 to provide images of diverse tissue. This technique has the additional benefit of demonstrating early radiographic changes seen as abnormal intakes. Due to its superior sensitivity, bone scans can also be used to assess obscure skeletal pain. It is the best diagnostic method for evaluation of incipient lesions and for screening purposes. Bone scans can be used for site localization in cases of limping, identify stress fractures in traumatic cases, localization and differentiation of tumors, identifying the site of infection in osteomyelitis and in cases of avascular necrosis.
- Magnetic Resonance Imaging (MRI): MRI is an eminent diagnostic technique for evaluation of soft tissues of the body. It omits the risk of exposure to ionizing radiation however it’s an expensive, technique sensitive imaging modality that requires sedation and immobilization hence limiting its use. MRI can be used by localization of meniscal lesion in the affected cartilage, identifying regions of growth plate injuries, for assessing regions of avascular necrosis, identifying tumor margins and staging of tumors, evaluate infectious soft tissue lesions and locate spinal cord pathologies.
- Ultrasound (US): It is a safe, comparatively cost effective, versatile yet an underutilized imaging technique. During the prenatal period ultrasound can be used for the diagnostic evaluation of musculoskeletal conditions such as Clubfeet, Skeletal dysplasias, Limb deficiencies, Spina bifida, and Arthrogryposis. Postnatal ultrasound imaging is advisable in suspected cases of abscess and joint effusions, foreign body localization in the foot, identifying cystic variants of tumors and cartilaginous trauma in young children.
- Genetic evaluation: Identifying chromosomal abnormalities can be suggestive of syndromic conditions. It helps in evaluation of multiple systems congenital malformations, identifying non-specific mental retardation and assessment of hands, feet, ears and skin pathologies.
- Bone mineral content evaluation: Quantitative assessment of bone mineral content can be useful in chronic diseases and idiopathic osteopenia.
- Laboratory studies: Such as hematology, serum chemistry, enzymatic analysis and joint fluid assessment can be utilized in cases of growing pain, stress fractures and infections.
Types of Paediatric Orthopaedic diseases:
- Lower limb pathologic deformities: Leg length deformity or anisomelia is described as a discrepancy of 1cm or more seen in conditions such as hip dysplasia, congenital hypo or hyperplasia, Perthes disease and physeal injury. Genu varum and genu valgum are knee deformities in the frontal plane with deviation beyond normal limits also referred to aa bow legs or knock knees respectively. Tibia vara or Blount disease is a growth imbalance affetcing the medial part of the proximal tibial growth plate with a subsequent localized varus deformity. Fibula deficiency is the most common lower limb deficiency disorder.
- Foot deformities: Pauciarticular Arthritis characterized limping, confined movement of the ankle and swelling persisting for more than 6 weeks duration. Köhler disease or Osteochondritis which causes inflammation and limping due to avascular necrosis. Anterior tarsal impingement causes anterior foot pain. Tarsal tunnel syndrome is characterized by foot pain, positive Tinel’s sign and dysesthesias. Polydactylic toe deformity is seen in Chondoectodermal dysplasia and syndactyly in Apert syndrome. Cavus feet are characterized by an increased height of the arch of the foot.
- Knee and tibia: Osteochondritis Dissecans causes pain and effusion in the medial or lateral condyle or patella. Discoid meniscus is a ligamentous lesion causing loss of knee extension. Tumors of the knee such as meniscal cysts and popliteal cysts are seldom observed. Synovial disorders such as Intraarticularhemangiomata cause thickening and bleeding of the synovium. Juvenile rheumatoid arthritis causes joint stiffness.
- Hip: Hip problems account for 15% of the Paediatric Orthopaedic cases. Developmental hip dysplasia comprises a diverse spectrum of deformities ranging from mild defects to severe teratogenic dislocations. Legg-Calvé-Perthes disease is identified as an idiopathic juvenile avascular necrosis involving the femoral head. Slipped Capital Femoral Epiphysis is the most commonly encountered adolescent hip disorder. Coxavara describes a neck–shaft angle deformity.
- Spine and pelvis: Diastematomyelia is identified as a central cartilagenous-bony projection which roughly divides the spinal cord. Neuroblastoma and sarcoma can cause neural compression. Spondylolysisis caused by uni or bilateral defects of the pars interarticularis. This can cause vertebral displacement known as Sondylolisthesis which accounts for the maximum number of back pain cases. Scoliosis defines a fronta; plane deformity of >10 degrees.
- Upper limbs: Torticollis or wryneck may occur following trauma or a respiratory infection. Sprengel deformity is described as a congenital elevation of the scapula.Neonatal brachial plexus palsy is a traction injury occurring during delivery.
Treatment of Paediatric Orthopaedic diseases:
Surgical intervention is the mainstay of treatment in Paediatric Orthopaedics.
- Preoperative management: On an average a young child experiences 4-5 respiratory tract infections annually. If the infant is less than a year in age and presents with viremia or bacteremia associated with respiratory infections, then the surgical intervention ought to be postponed for at least 2 weeks following cessation of symptoms and 2-6 weeks following lower respiratory tract infections. For infants below 6 months of age breast milk feeding is restricted for approximately six hours prior to surgery while for older infants and children eight hours prior and intake of clear fluids in both is restricted three hours before surgery.
- General anesthesia: The induction method is decided based on the child patients’ age and the type of surgical intervention. In case of infants below six months of age rectal anesthesia may be used while in adolescents an intravenous technique of induction is advisable. First an inhalational anesthesia is induced and as the child falls asleep then the intravenous anesthesia is injected slowly. Regional anesthesia can be used for treating upper limb pathologies. Some cases can be managed under sedation.
- Position: Patient is placed in prone position for treating clubfoot and for correction of knee flexion deformity and on the side for surgery of the front or rear side of the body.
- Skin preparation: The surgical site is marked prior to draping. A surgical preparation of 1% of iodine in alcohol is used as an effective and efficient antiseptic. A bacteriostatic soap solution can be when treating open wounds. Non-operative extremities are draped taking care to provide adequate operative area.
- Operative incisions: Incisions are made in the least conspicuous areas so as to prevent future esthetic embarrassment, such as along the bikini line that gives better cosmetic outcome. While operating on the knee an operative longitudinal incision is made in the anterior midline. For treating the upper extremities incision can be placed below the clavicle.
- Fixation: There are multiple options for an osteotomy or fixation of fractures in children. Plate fixation is used for major Orthopaedic procedures such as the repair of congenital pseudarthrosis of the clavicle. Intramedullary fixation via pins and rods is a flexible, stable and less traumatic procedure. When treating conditions that cause permanent bone weakness, the fixators can be left in place indefinitely. External fixators such as cast or frames can be used to stabilize pins when treating pathology involving both the soft and hard tissues.
- Grafts: Bone autograft is a safe, extensively used, easily accessible, rapidly incorporated osteogenic material. Bone can be harvested from the primary operative site, or an iliac or a vascularized graft can be incorporated. Allografts can be used when treating malignant tumors following whichan osteochondralgraft can be used to replace the joint.
- Skin closure: A subcuticular 3-0 absorbable suture can be used to close the site of incision.
Complications and Risk factors associated with Paediatric Orthopaedic diseases
Complications are scarce in paediatrics as the child is more physiologically resilient.
- Wound infections: It is seldom seen in children than in adults. Increased chances of infections are attributable to operative procedures of long duration. Infections involving the bone and joints are more serious than skin infections.
- Skin problems: Skin irritation by the cast is commonly seen in infants treated for hip dysplasia. As a precautionary measure the cast should be kept as dry as feasible. In most of the cases inflammation resolves with cast removal.
- Stiffness: It’s quite rare and resolves spontaneously when the child resumes physical activity. Persistent postoperative stiffness can occur due to compression, ischemia or infection.
Am I a Good Candidate for treatment/surgery?
Indications for a paediatric orthopedic surgical intervention include pain which is not relieved by non-operative methods, non-functionality or limited function, cosmetic disability, or as a precautionary measure to prevent future disability. Prophylactic operations are advised solely in cases of known natural history, when a serious disability is anticipated.Importance of prompt diagnosis can also be not overlooked as in some cases a delay in operative manipulation can be deleterious for the child.
Recovery time and aftercare:
Adaptive equipment such as crutches and splints should be kept ready intraoperatively. Other special needs of the child should be anticipated well in advance and arrangements should be done. The child might be required to take leave from school for 2-3 weeks for complete recovery hence necessary arrangements should be made for home schooling. A family member or an attendant should be made available to the child at all times for adult supervision. Continuous passive motion (CPM) technique for restoring motion is to be continued for approximately 6 weeks.
Young patient’s present better cost-effectiveness provided the increased lifespan and productivity. Basic orthopaedic surgical intervention might cost up to $6000-$8000. Additional rates may fluctuate depending on the number of days required to stay in the hospital, chronicity of the condition, number and type of diagnostic test required for evaluation, type of surgical intervention planned and professional experience of the surgeon.
Why Choose MedcureIndia?
Paediatric Orthopaedic surgery may be of great importance given the benefit of the procedure. The success of surgical intervention is predominantly guided by the judgment and skill of the surgeon. MedcureIndia is associated with an elite panel of paediatricians, orthopaedicians and surgeons with years of superior professional experience. We provide price transparency and quality medical care at affordable prices and also assist the parents to take proper care of their child postoperatively both medically and psychologically.
FAQ (frequently ask question)
• Is Paediatric Orthopaedic surgery safe for my child?
Orthopaedic conditions in children may vary from mild defects to severe malformations. While conditions of physiological variations may resolve on their own yet most of the pathologies require surgical correction. Prompt diagnosis and safe systematic treatment approach provides significant improvement in functional activities and also imparts a psychological benefit.
• Can my child got to school following treatment?
Following orthopaedic surgical treatment the child might have to remain at home under adult supervision for a week or two depending on the procedure. Preparations should be made regarding schooling during that time. Assisted physical activity is advised to be induced as instructed by the physician. Following complete recovery the child is expected to resume his physical activities as before.
• Will additional surgeries be required in the future?
In most of the cases a single surgical procedure should suffice. If a graft is to be placed additional surgery is required to harvest the graft which is mostly planned to be done along with the main surgery to minimize patient discomfort. Removal of casts, sutures or other special material used for the procedure might require the patient to visit the hospital again for removal and post-operative assessment. In complex cases additional surgery can be anticipated as is purely under surgeon’s guidance and decision.