Chapter 10. Pediatric Orthopedic Surgery

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.

Guidelines for Pediatric Orthopedics

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, genu valgum (knock-knee), and bowed legs, are actually physiologic variations that correct spontaneously with growth. For example, physiologic bowing is common and benign. It is typically symmetric, involves both the femur and tibia, and is most prominent in toddlers. It usually resolves by 2 years of age, but there is great variability. By age 36 months, almost all children will correct spontaneously. 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

Essentials of Diagnosis

• Commonly asymptomatic difference in limb length must be detected to plan for appropriate treatment.
• Congenital anomalies may lead to significant inequality.
• Proper evaluation and planning allow optimal treatment during growth.

General Considerations

Limb-length inequality may reflect either a congenital deficiency or any of a wide variety of acquired conditions (Table 10–1). Posttraumatic physeal arrest occurs most commonly after injury in the distal medial tibia. Injuries of the distal femoral and distal ulnar physis have a high incidence of growth arrest as well. Upper extremities of unequal length are usually only of cosmetic interest and can easily be compensated for by modifying ...