Pediatrics



Pediatrics


John E. Tis

Jaysson T. Brooks

Rushyuan Jay Lee



PEDIATRIC MULTITRAUMA


General Principles



  • More elastic bone


  • Thicker periosteum—easier to hold reduction


  • Remodeling



    • Correction of deformity with growth


    • Highest in younger children, plane of motion, and when fracture is near physis


  • Injury to growth plate



    • Most relevant in lower extremity—leg length discrepancy (LLD)


    • More likely to occur with displaced fracture through physis


    • Treatment



      • Bar excision



        • >2 years growth remaining


        • <50% physeal involvement


      • Epiphysiodesis: >2 cm growth remaining in contralateral physis (lower extremity)


  • Salter-Harris classification (Figure 3.1)



    • Risk of growth arrest related to amount of displacement


    • Type V—rare crush injury—high risk of growth arrest


  • Nonaccidental trauma (NAT) (child abuse)



    • Most common fracture is isolated long-bone fracture.


    • Suspect NAT in:



      • Any fracture before walking age


      • Femur fracture before age 3


      • Multiple, unwitnessed injuries


    • Get skeletal survey


    • Full examination for burns/bruising, sexual abuse, and retinal hemorrhages


    • Failure to report—10% mortality






Figure 3.1 Salter-Harris classification of physeal fractures. Type I: fracture line is entirely within the physis. Type II: fracture line extends from the physis into the metaphysis. Type III: fracture enters the epiphysis from the physis and almost always exits the articular surface. Type IV: fracture extends across the physis from the articular surface and epiphysis, to exit in the margin of the metaphysis. Type V: crush injury to the physis with initially normal radiographs with late identification of premature physeal closure. From Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Water PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th ed. Philadelphia, PA: Wolters Kluwer Health; 2015:133-163.



Multitrauma



  • Epidemiology



    • Most common cause of death in children >1 year


    • Mortality up to 20%


    • Falls


    • Motor vehicles



      • Children <8 years—high risk of C-spine injury



        • Large/heavy head


        • Inability to restrain head


  • Positioning for transport—cutout in board or padding under back


  • Assessment



    • Primary/secondary


    • Glasgow Coma Scale (3-15)



      • <8 indicates higher mortality.


    • Look for abdominal bruising (lap belt)


  • Resuscitation



    • Large physiologic reserve hides fluid loss (vitals may be normal).


    • If venous access unsuccessful, use intraosseous.


UPPER EXTREMITY FRACTURES


Clavicle Fractures



  • Classification



    • Medial



      • Last physis to close (age 23-25)


      • May be mistaken for sternoclavicular dislocation


    • Shaft


    • Lateral


  • Treatment—sling for 4 to 6 weeks


  • Operative indications



    • Open fractures


    • Medial fracture with posterior displacement and mediastinal impingement—percutaneous with towel clip or open


    • Severely displaced lateral fractures (controversial)


Proximal Humerus Fractures



  • Assessment: careful neurovascular assessment


  • Classification: Neer and Horowitz



    • Grade 1: displacement ≤ 5 mm


    • Grade 2: displacement ≤ one-third of humeral diameter


    • Grade 3: displacement ≤ two-thirds of humeral diameter


    • Grade 4: displacement > two-thirds of humeral diameter


  • Treatment



    • Sling/immobilizer/coaptation splint or hanging arm cast for all grades 1 and 2


    • Reduce grades 3 and 4 fractures, especially in adolescents (90° abduction and external rotation [ER])


  • Operative indications (closed or open reduction and pinning)



    • Open


    • Irreducible grades 3 and 4 fractures in adolescents



Humeral Shaft Fractures



  • Current treatment—sling, hanging arm cast, coaptation splint, fracture brace


  • Operative indications



    • Open


    • >30° angulation in adolescent


    • Flexible nails or plate


Distal Humerus Fractures



  • Supracondylar



    • Epidemiology



      • Half of pediatric elbow fractures


      • 95% extension type


      • Vascular injuries (1%)


      • Neurologic



        • Acute interstitial nephritis—most common


        • Ulnar—rare; iatrogenic from medial pin


    • Assessment



      • Careful neurologic and vascular examination


      • If well perfused (good color and capillary refill), no vascular intervention indicated even if pulses are absent.


    • Classification (modified Gartland)



      • Type I—nondisplaced; long arm cast 3 to 6 weeks


      • Type II—intact posterior hinge


      • Type III—completely displaced, no hinge


      • Type IV—completely displaced, unstable flexion and extension


    • Treatment



      • Vascular injury—reduce



        • If poor perfusion after reduction, then emergent vascular intervention is indicated.


      • Type I: long arm cast


      • Type II: long arm cast if:



        • Anterior humeral line intersects capitellum


        • No coronal plane malalignment


        • Closed reduction and percutaneous pins (CRPP) if above criteria not met


      • Type III: CRPP


      • Type IV: CRPP


      • Lateral pins confer equivalent clinical stability to crossed pins but without 3% to 8% ulnar nerve injury


      • Divergent configuration—most stable


      • Open reduction if inadequate closed reduction or perfusion does not return after closed reduction


    • Complications



      • Volkmann ischemic contracture—avoid casting in >90° flexion


      • Malunion



        • Varus (Gunstock)—lower in type 2 fractures if reduced and pinned



          • If severe, increases incidence of lateral condyle fractures


          • Requires corrective osteotomy if severe


        • Recurvatum


  • Lateral condyle



    • Assessment—need oblique view


    • Classification—fracture displacement




      • Type I: <2 mm displacement


      • Type II: 2 to 4 mm displacement


      • Type III: displaced > 4 mm


    • Treatment



      • Type I: Long arm cast for 6 weeks



        • Need frequent follow-up with oblique views to check for displacement


      • Type II: Closed or open reduction and pinning



        • Need arthrogram to check articular congruity if treated closed


      • Type III: Open reduction and pin or screw fixation


      • Lateral approach preferred: Avoid posterior dissection



        • Visualize joint surface


    • Complications:



      • Osteonecrosis—from posterior dissection


      • Nonunion—from posterior dissection or inadequate stability



        • May lead to valgus and tardy (late) ulnar nerve palsy


        • Treat with screw fixation and bone graft


  • Medial epicondyle



    • Epidemiology



      • 50% associated with elbow dislocations


    • Assessment



      • Look for entrapped fragment in the ulnohumeral joint


      • Ulnar palsy—usually transient from stretch


    • Treatment



      • Remove entrapped fragment using supination, valgus, and finger extension


      • Early motion (3-5 days)


      • Surgery



        • Absolute—entrapped fragment


        • Relative (controversial)—weight-bearing athlete (gymnast) or dominant elbow in throwing athlete


        • Open reduction with screw ± suture anchor for comminuted fragments


      • Complications



        • Stiffness—common with closed or open treatment


        • Instability


  • Transphyseal fracture



    • Epidemiology



      • Most common in age < 3 years


      • Often associated with NAT in children < 3 years of age


    • Assessment



      • Differential includes elbow dislocation



        • In transphyseal fracture, capitellum is in line with radius.


        • Arthrogram definitive


    • Treatment—similar to supracondylar fractures



      • Closed reduction, percutaneous pinning


    • Complications



      • Malunion—from late diagnosis


      • Closed reduction not indicated >7 days postinjury


Other Elbow Injuries



  • Radial neck fractures



    • Classification



      • Nondisplaced, minimally displaced


      • Displaced >4 mm or angulated >30°


    • Treatment



      • Nondisplaced: 3 to 7 days splinting followed by mobilization


      • Displaced




        • Closed reduction (multiple techniques)


        • Percutaneous reduction with K-wire


        • Retrograde flexible nail (Metaizeau)


        • Open reduction—rare


        • Usually are stable following reduction using any technique


        • Avoid implant across radiocapitellar joint


  • Olecranon fracture



    • Assessment—look for radial displacement from capitellum (Monteggia) on lateral


    • Classification and treatment



      • Nondisplaced—casting in 45° of flexion


      • Displaced (>2 mm)—open reduction and internal fixation (ORIF) with tension band or plate (comminuted)


  • Monteggia fracture—dislocation



    • Radial head dislocation matches direction of ulnar apex angulation



      • Recognition is paramount.


      • May occur with plastic deformation of ulna


      • Differential: congenital dislocation of radius (do not reduce)



        • Often bilateral


        • Convexity of radial head and deformity of capitellum


    • Treatment



      • Closed reduction and casting



        • Radial head reduces and is stable once ulna is reduced.


        • Cast in supination if dislocation is anterior or lateral


        • Cast in neutral or pronation if dislocation is posterior (uncommon)


      • ORIF



        • Only needed in open/unstable fractures


        • Intramedullary (IM) flexible nail


        • Plate for comminuted fractures


      • Complications



        • Delayed treatment leads to arthritis and lack of motion.


        • Reduce all dislocations <12 months old


        • May need osteotomy and reconstruction for chronic, unrecognized dislocations


Forearm Fractures



  • Diaphyseal or distal (metaphyseal)



    • Almost all can be treated nonoperatively.


    • Treatment



      • Diaphyseal



        • Look for compartment syndrome


        • Reduction and long arm cast for 6 weeks


        • Surgery



          • Open fracture, grades 2 and 3


          • Angulation after reduction >15° in any child


          • Angulation after reduction >10°/bayonet apposition in children >10 years of age


          • IM nail or plate


        • High refracture rate


      • Distal



        • Reduction and short arm cast 4 to 6 weeks


        • Most remodel


        • Surgery



          • Open fractures (avoid plate near physis—smooth pins usually sufficient)


          • Significant displacement or angulation after reduction in child with <2 years growth remaining



      • Complications



        • Compartment syndrome


        • Loss of rotation (especially with loss of normal radial bow)


        • Physeal arrest (displaced Salter-Harris fractures)


Hand Fractures



  • Similar principles as in adults—almost all are treated nonoperatively


  • Less stiffness than in adults


  • Fractures in the distal part of the phalanges cannot remodel and so require near anatomic closed or open reduction.


PELVIC AND LOWER EXTREMITY FRACTURES


General Concepts



  • Fractures adjacent to physis can remodel, and fracture through physis can cause growth disturbance.



    • Both dependent on contribution of growth from particular physis.


  • Surgical fixation



    • Avoid physis if possible


    • If crossing physis, use smooth pins or plan on removing fixation


    • If nearing skeletal maturity, may use adult options for fixation, that is, rigid nailing


  • External fixators—an option for damage control


Pelvic Fractures



  • Stable fractures treated with protected weight bearing


  • Unstable fractures—external fixation or ORIF


  • Premature triradiate closure results in LLD.


Pelvic Avulsion Fractures



  • From sprinting other explosive maneuvers


  • Treatment



    • Activity modification and gradual return to activities


    • Surgery uncommon


Hip Dislocation (Figure 3.2)



  • Usually posterior


  • Require timely closed reduction, to reduce osteonecrosis risk


  • Open reduction for nonconcentric reduction, entrapped fragments


Hip Fractures



  • Delbet classification (Figure 3.3)


  • Types I to III require urgent closed reduction and internal fixation



    • Osteonecrosis risk higher with more proximal fractures


    • Consider needle decompression or capsulotomy for hematoma evacuation to decrease osteonecrosis risk


  • Possible coxa vara and nonunion with nonsurgically treated fractures


Femoral Shaft Fractures



  • Consider Child Protective Service evaluation for young and nonambulatory patients







    Figure 3.2 Nonconcentric reduction of left hip. A, Injury. B, Postreduction radiograph. C, Postreduction computed tomography (CT) demonstrating entrapped bony fragments. Copyright R. Jay Lee.







    Figure 3.3 Delbet classification of pediatric hip fractures. Type I: transepiphyseal fracture. Type II: transcervical fracture. Type III: cervicotrochanteric fracture. Type IV: intertrochanteric fracture. From Epps HR. Pediatric lower extremity injuries. In: Brinker MR, ed. Review of Orthopaedic Trauma. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:467-486.







    Figure 3.4 Submuscular bridge plating for displaced diaphyseal femur fracture. From Sink EL, Ricciardi BF. Submuscular plating of femoral shaft fractures. In: Flynn JM, Sankar WN, eds. Operative Techniques in Pediatric Orthopaedic Surgery. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2016:202-206.


  • Treatment



    • <6 months—Pavlik harness


    • 6 months to 5 years—spica cast


    • 5 to 11 years—flexible nails, submuscular plating for comminuted (Figure 3.4)


    • 10 to 11+ years—rigid nailing, avoid piriformis starting point


    • External fixator for open fractures, polytrauma, and damage control


  • Expect overgrowth up to 1 to 2 cm


  • Rotation does not correct, varus/valgus less well tolerated than procurvatum/recurvatum


Distal Femur Fractures



  • Distal femur metaphyseal fractures



    • Long leg cast


    • Surgical treatment if unstable or irreducible


  • Physeal fractures



    • Vascular examination important


    • Long leg cast for extra-articular fractures


    • Surgical treatment for displaced intra-articular fractures


    • Avoid physes if possible; if crossing physes, use smooth pins


    • High rate of growth arrest 50%


Patella Fractures



  • Bipartite patella (Figure 3.5)



    • Anatomic variant—leave alone if asymptomatic


    • Usually superior lateral pole, with round edges


    • Can be symptomatic and require excision







      Figure 3.5 Bipartite patella, superolateral location (arrow). From Staheli LT. Knee and tibia. In: Fundamentals of Pediatric Orthopedics. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016:185-200.






      Figure 3.6 Patellar sleeve fracture in a 10-year-old boy. The inferior pole of the patella is displaced anteriorly (curved arrow). The bone fragment seen (straight arrow) was avulsed by, and remains attached to, the patellar tendon. From Thompson RW, Kim Y-J, Lee LK. Musculoskeletal trauma. In: Bachur RD, Shaw KN, eds. Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia, PA: Wolters Kluwer; 2016:1195-1237.



  • Patellar sleeve fractures (Figure 3.6)



    • Can be missed


    • Chondral sleeve avulsion without bony component


    • Radiographs show only patella alta after trauma.


    • ORIF, reduce chondral surfaces if significant


  • General



    • Casting if extensor mechanism intact, less than 2-mm step off at articular surface


    • Otherwise ORIF as in adults


Tibial Tubercle Fractures



  • Classification (Figure 3.7)



    • Type I: distal avulsion


    • Type II: exiting before tibial articular surface


    • Type III: exiting in tibial articular surface


    • Type IV: though proximal tibial physis


    • Type V: multiple variants


  • Treatment



    • Cast if nondisplaced


    • Surgical fixation for any displacement and/or extensor lag, with screw fixation


    • Compartment syndrome risk with injury to recurrent branch of anterior tibial artery


Tibial Spine Fractures



  • Traditionally the pediatric anterior cruciate ligament (ACL) injury



    • Classification: Meyers and McKeever (Figure 3.8)



      • Type I: minimally displaced


      • Type II: posterior hinge


      • Type III: completely displaced without hinge


      • Type IV: completely displaced and comminuted






        Figure 3.7 Tibial tubercule fractures. Type I is a fracture within the tubercle. It may be minimally displaced, designated A, which is difficult to differentiate from chronic Osgood-Schlatter condition, or displaced, designated B. Types II and III may be subdivided into A without or B with fragmentation of the displaced fragment. In type IV, force lifts tibial tubercle, then continues along the proximal physis of tibia. From Diab M, Staheli LT. Trauma. In: Practice of Paediatric Orthopaedics. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2016:147.







        Figure 3.7 (continued)







        Figure 3.8 Meyers and McKeever classification with Zaricznyj modification. Type I has minimally displaced fragments. Type II has displacement through the anterior portion of the fracture with an intact posterior hinge. Type III has complete displacement of the fracture fragments. Type IV has complete displacement and comminution of the fracture fragments. From Gans I, Ganley TJ. Arthroscopy-assisted management or open reduction and internal fixation of tibial spine fractures. In: Flynn JM, Sankar WN, eds. Operative Techniques in Pediatric Orthopaedic Surgery. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2016:396-404.


  • Treatment



    • Casting for type I, closed reduction and casting for type II


    • Surgical fixation for unreducible type II and most types III and IV, avoid physis


    • Block to reduction, most commonly medial meniscus


  • Arthrofibrosis risk, ACL laxity not always clinically significant, impingement with malunion







Figure 3.9 Patient with a proximal tibial Cozen fracture. From Lamont LE, Garner MR, Widmann RF. Salter-Harris distal femur and proximal tibia fractures. In: Cordasco FA, Green DW, eds. Pediatric and Adolescent Knee Surgery. Philadelphia, PA: Wolters Kluwer; 2015:274-283.


Proximal Tibial Fractures



  • Physeal



    • Vascular examination for popliteal artery injury


    • Casting for reducible fractures, ORIF irreducible fractures


  • Metaphyseal



    • Cozen fracture, or late genu valgum (Figure 3.9)—should remodel, so observe


    • Casting for most


Tibial and Fibular Shaft Fractures



  • Toddler fractures



    • Low-energy minimally displaced fractures


    • Brief immobilization 3 to 4 weeks


  • General tibial and fibular fractures



    • Most amenable to casting


    • Surgical fixation for unstable fractures, unacceptable angulation >5° to 10°, shortening


Distal Tibial and Fibular Physeal Fractures



  • Suspected distal fibular physeal injuries are more commonly lateral ankle sprains.


  • Distal tibial physis closes centrally, medially, and, finally, lateral, giving to distinct transition injuries.


  • Computed tomography (CT) can better demonstrate articular displacement if radiographs unclear.



  • Tillaux fractures (Figure 3.10)



    • Salter-Harris type III—anterolateral tibial epiphysis


    • 12 to 14 years, slightly younger


    • Amenable to casting if minimally displaced <2 mm


    • Reduction and epiphyseal screw fixation if displaced


  • Triplane fractures (Figure 3.11)



    • Salter-Harris type IV—anterolateral tibial epiphysis with metaphyseal fragment


    • 13 to 15 years, slightly older


    • Can be comminuted


    • Amenable to casting if minimal displaced <2 mm


Foot Fractures



  • Accessory ossification centers are common in the foot and may be mistaken for a fracture.



    • If symptomatic, treat with period of immobilization


  • Most minimally displaced pediatric foot and toe fractures may be treated with casting.


  • Suspected occult fractures in a limping child, brief immobilization, repeat examination, or radiograph


  • Exclude infection, neoplastic process


SPINE CONDITIONS


Congenital Torticollis



  • Diagnosis



    • Examination—tight sternocleidomastoid muscle


    • Head tilted to same side and rotated to the opposite side


    • May have associated mass in muscle






      Figure 3.10 Three-dimensional computed tomography (CT) reconstruction of juvenile Tillaux fracture. A, Coronal CT image of minimally displaced juvenile Tillaux fracture. B, Sagittal CT image of minimally displaced juvenile Tillaux fracture. C and D, Three-dimensional reconstruction of juvenile Tillaux fracture. From Shea KG, Frick SL. Ankle fractures. In: Waters PM, Skaggs DL, Flynn JM, eds. Rockwood and Wilkins’ Fractures in Children. 9th ed. Philadelphia, PA: Wolters Kluwer; 2020:1120-1172.







      Figure 3.11 Triplane fracture of the distal tibia in a 12-year-old girl with computed tomography (CT) evaluation. A, The anteroposterior radiograph shows a Salter-Harris type III fracture. B, The lateral radiograph shows an apparent Salter-Harris type II fracture. This indicates a triplane injury. C, Three-dimensional reconstruction demonstrates the fracture from the anterolateral and the posteromedial views. D, Closed reduction was unsuccessful. Arthroscopically assisted open reduction was performed. The fracture was stabilized with a single anterolateral cannulated screw inserted percutaneously. From Sink EL, Flynn JM. Thoracolumbar spine and lower extremity fractures. In: Weinstein SL, Flynn JM, eds. Lovell and Winter’s Pediatric Orthopaedics. Vol 2. 7th ed. Philadelphia, PA: 2014:1773-1829.







      Figure 3.11 (continued)



  • Differential diagnosis



    • Congenital scoliosis or other vertebral anomaly


    • Ophthalmologic abnormality


    • Tumor


    • Vestibular abnormality


  • Associated conditions



    • Hip dysplasia (5%-20%)


    • Metatarsus adductus


  • Etiology



    • Sternocleidomastoid compartment syndrome


    • Must rule out other causes with careful examination and ophthalmologic consult


  • Treatment



    • Stretching—90% successful if initiated within the first year of life


    • Surgical treatment



      • Indicated if nonoperative treatment fails after 12 to 24 months


      • Unipolar or bipolar release of sternocleidomastoid muscle from distal attachments


  • Complications



    • Plagiocephaly/facial asymmetry—if torticollis is left untreated or deformity persists


Atlantoaxial Rotatory Subluxation



  • Etiology



    • Upper respiratory infection (Grisel syndrome)


    • Trauma (may be minor)


  • Classification



    • Fielding I to IV: based on facet subluxation (Figure 3.12)


  • Diagnosis



    • Examination: may demonstrate spasm or fibrosis of sternocleidomastoid muscle on the same side as the chin, in contrast to torticollis that has spasm on opposite side as chin


    • Differential diagnosis (nonidiopathic associated with atlantoaxial instability)



      • Down syndrome—occiput-C2 fusion for neurologic symptoms and atlanto-dens interval (ADI) >5 mm


      • Klippel-Feil syndrome


      • Skeletal dysplasias


      • Mucopolysaccharidoses


  • Imaging—dynamic rotatory CT



    • In atlantoaxial rotatory subluxation, the relationship of C1 on C2 is unchanged when the head is rotated in opposite directions






      Figure 3.12 Fielding classification of atlantoaxial rotatory subluxation. Greenleaf R, Richman RD, Altman DT. General principles of vertebral bony, ligamentous, and penetrating injuries. In: Brinker MR, ed. Review of Orthopaedic Trauma. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:406-417.



  • Treatment



    • Subluxation <1 week



      • Soft collar


    • Subluxation 1 week to 1 month (or failure of soft collar for 2 weeks)



      • Halter traction


    • Subluxation > 1 month



      • Halter traction followed by halter vest


    • Subluxation > 3 months, neurologic deficits, or failed halo traction



      • C1 to C2 fusion


Scoliosis



  • Treatment based largely on etiology: congenital versus neuromuscular versus idiopathic


  • Terminology



    • Congenital—vertebral structural abnormality at birth


    • Idiopathic


    • Other: neuromuscular and syndromic


  • Congenital



    • Types



      • Failure of formation (hemivertebra)


      • Failure of segmentation (bar)


      • Combined (worst prognosis)


    • Congenital kyphosis—often associated with scoliosis



      • Similar surgical indications—include progression of kyphosis


    • Associated conditions (61%)



      • Cardiac (26%)


      • Urogenital (21%)


      • Limb abnormalities



        • Sprengel


        • Hip dysplasia


        • Limb hypoplasia


      • Anal atresia


      • Hearing deficits


      • Facial asymmetry


      • Neural axis abnormality (40%)


    • Imaging



      • Magnetic resonance imaging (MRI) of the spine and kidneys (Figure 3.13)


      • Echocardiogram


    • Treatment



      • Nonoperative (observation) indications



        • No neurologic symptoms


        • No progression >10°


        • No kyphosis >40°


      • Surgical



        • Indications (general)



          • Bracing not effective


          • Significant progression


          • Decreasing pulmonary function


          • Neurologic deficit


        • Hemivertebra excision



          • Truncal imbalance


          • Age <6 (relative)


          • Higher risk in curves >50° and for excision above the level of the conus


        • Early in situ arthrodesis



          • Minimal deformity


          • Usually reserved for failures of segmentation







            Figure 3.13 Coronal T1-weighted image showing scoliosis, absence of the right kidney, and vertebral anomalies at the apex of the spinal curvature (asterisk marks a hemivertebra). The sacrum is absent. From Schwartz ES, Barkovich AJ. Congenital anomalies of the spine. In: Barkovich AJ, Raybaud C, eds. Pediatric Neuroimaging. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:857-922.


        • Hemiepiphysiodesis



          • Age < 5


          • Curve <70°


          • <5 segments involved


        • Thoracostomy—may benefit patients with multiple fused ribs and thoracic insufficiency syndrome


        • Growing rod—may be combined with hemivertebra excision and thoracostomy to release fused ribs


  • Idiopathic



    • Infantile



      • >90% of curves >30° progress; many curves <30° spontaneously resolve


      • Imaging



        • Plain x-ray—rib vertebral angle difference (RVAD) >20° predictive of progression (Figure 3.14)


        • Excessive rotation phase 2 (overlap) rib-vertebra relationship


        • MRI—need in all patients with curves > 20° due to high incidence of intraspinal anomalies (20%)


      • Nonoperative treatment:



        • Observation—indicated for curves < 30°


        • Indicated for patients with curves 20° to 50° that have progressed or at high risk for progression based on excessive rotation seen on plain x-rays


        • Cast treatment—indicated for patients with curves 30° to 50° that have progressed or at high risk for progression based on excessive rotation seen on plain x-rays







          Figure 3.14 The rib vertebral angle difference (RVAD) helps in predicting curve progression. A line (a) is drawn perpendicular to the endplate of the apical vertebra. A second line (b) is drawn from the midpoint of the neck of the rib at the apical vertebra through the midpoint of the head of the same rib and extending to the perpendicular on the convex side. The angle between those two lines is calculated, as is the angle on the concave side. The RVAD is obtained by subtracting the angle on the convex side from the angle on the concave side of the curve. A difference of more than 20° suggests a high likelihood of a progressive form of idiopathic infantile scoliosis (IIS), according to Mehta.



          • Mehta derotational technique—serves to straighten spine in younger/flexible patients



            • May be used as a temporizing measure before surgery in more rigid patients


          • Bracing



            • To reduce progression in incompletely corrected curves after casting


            • Older patients who will not tolerate a cast


          • Surgical treatment—avoid early fusion (before age 10)



            • Growing rods—dual construct that allows for thoracic growth through regular lengthening


            • Vertical expandable prosthetic titanium rib (VEPTR)—a growing construct attached to the ribs—may be combined with growing rods in patients with thoracic insufficiency or fused ribs.


            • Shilla technique—short apical fusion with proximal and distal anchors—does not require periodic lengthening


    • Juvenile



      • MRI—indicated for all patients aged < 10


      • Brace treatment—for patients with > 20° curve and > 5° documented progression


      • Surgical treatment—indicated for all curves > 50°



        • Growing rods are used for patients with significant thoracic growth remaining.


        • Fusion may be considered for large/rigid curves in patients aged > 8.



          • Age <10 leads to some pulmonary compromise.


          • Anterior and posterior fusion both equally effective


          • Some investigators advocate adding anterior fusion to posterior fusion for rigid curves >70° and in patients with open triradiate cartilage to avoid crankshaft.


          • Crankshaft may be avoided using multiple pedicle screws (fixation of anterior column).



    • Adolescent: >age 10



      • Indications for MRI—atypical curve



        • Abnormal neurologic examination


        • Left thoracic or right lumbar curve


        • Sharp angular curves


        • Hyperkyphosis


      • Bracing



        • Indications



          • Progression >


          • Curve > 25°


          • Risser 0, 1, 2


        • Wear > 16 hours/d until spinal growth complete or curve > 45°


      • Surgery—curves > 50°



        • Anterior or posterior fusion of all structural curves (any curve that does not correct to < 25° on bending films or has abnormal sagittal contour)


    • Associated diagnoses—Marfan and neurofibromatosis



      • Must have MRI to evaluate for dural ectasia


      • Indications for bracing and fusion are the same as idiopathic.


Spondylolysis and Spondylolisthesis



  • General



    • 25% of patients with spondylolysis have associated spondylolisthesis.


    • Level



      • Most common—L5 (90%) > L4 > L3


    • Wiltse classification



      • Isthmic most common—males > females, but females more likely to develop high-grade slip


      • Dysplastic—higher risk of neurologic compromise


  • Imaging—spot lateral radiograph



    • Oblique radiographs aid diagnosis of spondylolysis.


    • Single-photon emission CT scan most sensitive modality used to detect occult spondylolysis.


  • Spondylolisthesis classification



    • Low grade (≤50% slip)


    • High grade (>50% slip)


  • Nonoperative treatment



    • Observation



      • Asymptomatic spondylolysis


      • Low-grade spondylolisthesis


    • Bracing (lumbosacral orthosis) and therapy



      • Symptomatic spondylolysis


      • Symptomatic or progressive low-grade spondylolisthesis


    • Surgical indications



      • Neurologic symptoms


      • High-grade spondylolisthesis


      • Progressive, symptomatic low-grade spondylolisthesis


      • Persistent pain > 6 months nonoperative treatment


    • Surgical treatment



      • Spondylolysis



        • Pars repair (numerous techniques)


        • L5 to S1 fusion (with or without instrumentation)


      • Spondylolisthesis



        • L4 to S1 for high-grade slips


        • Consider translumbar interbody fusion for high-grade slips



        • Consider decompression in the presence of neurologic symptoms


        • Reduction is controversial and carries risk of L5 nerve root damage.


Scheuermann Kyphosis

Dec 19, 2019 | Posted by in ORTHOPEDIC | Comments Off on Pediatrics
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