The scope of pediatric orthopedics ranges from congenital anomalies
to injuries in the adolescent. The pathophysiologic manifestations
of many of these disorders differ from analogous adult problems
because of the added dimension of growth. The physician’s
relationship with the pediatric patient generally occurs in the
context of a protective family environment, in contrast to the more independent
relationship the physician may form with an adult. The natural tendency
for children to be active and the remarkable regenerative processes
of the immature skeleton frequently make formal rehabilitation unnecessary
following surgery or serious injury.
The following rules may be helpful when applying general orthopedic
principles to the child:
1. A growing bone normally
tends to remodel itself toward the adult configuration. This process occurs
faster in younger children and in deformities near the ends of bone.
Remodeling is faster when deformity is in the plane of motion of
the nearest joint.
2. Skeletal deformities worsen
as abnormal growth continues (eg, following permanent damage to the
growth plate), especially near rapidly growing areas such as the
knee. This characteristic is exaggerated in younger children.
3. Children tolerate long-term
immobilization better than adults and tend to recover soft-tissue mobility
spontaneously following most injuries.
4. Fracture healing is usually
more rapid and predictable in the actively growing skeleton than
in the adult skeleton.
5. Joint surfaces in children are
generally more tolerant of irregularity than those of the adult. Although
degenerative arthritic changes may follow childhood injury, there
is often an asymptomatic interval of many decades before the process
becomes clinically evident.
6. Many so-called deformities,
such as metatarsus adductus, internal tibial torsion, and genu valgum (knock-knee),
are actually physiologic variations that correct spontaneously with
growth. Thus, the clinician must distinguish between conditions
that need no treatment and those requiring early intervention.
General skeletal growth is discussed in detail in Chapter 1.
Limb-length inequality may reflect either a congenital deficiency
or any of a wide variety of acquired conditions (Table
11–1). Upper extremities of unequal length are usually
only of cosmetic interest and can easily be compensated for by modifying
clothing. In the lower extremities, however, length discrepancies
may be severe enough—greater than 1 inch (2.5 cm)—to
limit function and require treatment. Lesser discrepancies can be
managed with a shoe lift.
11–1. Causes of Limb-Length Inequality. |Favorite Table|Download (.pdf)
11–1. Causes of Limb-Length Inequality.
|Isolated limb paralysis|
|Malunion of long bones|
|Avascular necrosis of femoral head (and physis)|
of Limb Length at Maturity
Clinical management of limb-length inequality in pediatric patients