Pediatrics

APGAR

APGAR is an acronym for a scoring system to evaluate perinatal asphyxia. It is not an indicator of long-term outcome, but rather an indicator of immediate needs. The score is the sum of points gained on assessment of the following five signs.

Sign	0	1	2
Appearance	Blue/pale	Body pink/blue extremities	Pink
Pulse	Absent	<100	>100
Grimace	No response	Grimace	Cry
Activity	Limp	Some flexion	Active motion
Respiratory effort	Absent	Some/irregular	Good/crying
Score: Add the scores from all five signs to assess infant.

0-2	Serious asphyxia
3-4	Moderate asphyxia
5-7	Mild asphyxia
8-10	Normal

DEVELOPMENTAL LANDMARKS

3 months	Lifts head up when prone
6 months	Rolls over
9 months	Sits up
12 months	Stands/cruises
14 months	Walks
15-18 months	Uses words
18-21 months	Combines words
21-24 months	Three word sentences
36 months	Child develops a propulsive gait

CHILDHOOD IMMUNIZATION SCHEDULE

SPLINTS AND BRACES

Splints and braces are used between 3 months and 3 years. When sizing a splint with a bar, measure from one ASIS to the other plus 1 inch. Splints used to abduct the foot are best used with triplanar varus wedge to prevent subluxation of the MTJ, and braces that have a rigid bar connecting the feet should have a 15° to 20° varus bend to prevent subluxation of STJ or MTJ. Splints and braces are best used on positional abnormalities, which are soft tissue problems (i.e., internal and external femoral rotation), as opposed to bony abnormalities or torsional problems (i.e., tibial torsion). Splints and braces should be worn as much as possible at night, during naps, and as much as tolerated during the day. If splints follow serial plaster immobilization, wear splint for twice as long as total casting time.

Ganley Splint

First splint to treat combination foot and leg disorders

Same indications as Denis-Browne bar but also allows FF to RF control

If treating internal rotational problems, torque bar is placed between the rearfoot plates, and if treating an external rotational problem, the torque bar is placed between the two forefoot plates.

Adjustments are made by simply bending the aluminum bars.

Denis-Browne Bar

Has been used to treat metatarsus adductus, convex pes planovalgus, and positional abnormalities of the leg

Originally designed to treat clubfoot

The bar is screwed or riveted on the child’s shoes.

Fillauer Bar

Same as Denis-Browne bar except it clamps to soles of patient’s shoes

Requires rigid soled shoes for attachment

Unibar

Same as the Denis-Browne bar except it has a ball and socket joint beneath each foot, which can be tightened into a varus position (preventing STJ and MTJ subluxation) eliminating the need to bend the bar.

Counter Rotation System (Langer)

Designed to correct torsional abnormalities of the leg

Functionally the same as the Denis-Browne bar, but several hinges allow greater freedom of motion

Best tolerated splint; allows unencumbered crawling

Bebax Shoe

Used to treat forefoot to rearfoot abnormalities such as metatarsus adductus

Recommended for use after serial casting of metatarsus adductus, but not for primary correction

Also available is the Clubax, a device designed for rearfoot or leg deformities specifically clubfoot.

Standard AFO

Ankle set at 90°

Used in various neuromuscular disorders that may cause equinus (CP, muscular dystrophy [MD])

Also used to treat drop foot

Wheaton Brace

Used for metatarsus adductus

Designed as an alternative to serial casting for metatarsus adductus

Similar in appearance to an AFO, with a medial flare to abduct the forefoot

Wheaton Brace System

This additional AK piece is designed to lock into the BK component.

The knee is fixed at 90°, preventing twisting of the femur or hip and allowing isolated unilateral treatment of tibial torsion.

Twister Cables

Belt (around waist) cables (inside pant leg course down to shoe)

Controls the degree of abduction at heel contact

Used to treat scissors gait of CP patients

Friedman Counter Splint or Flexosplint

A dynamic splint consisting of a belt around the posterior heels, allowing motion in all planes except internal rotation

Indicated for internal tibial torsion

IPOS Shoe

Anti-adductus orthosis type 2

Indicated for metatarsus adductus

Functions by the use of varied correctional elastic tension bands (formerly springs were used)

OSTEOCHONDROSIS (EPIPHYSEAL ISCHEMIC NECROSIS)

A disease of the growth or ossification center in children, which begins as a degeneration or necrosis and is followed by regeneration or recalcification

Blount Disease

Osteochondrosis of the medial portion of the proximal epiphyseal ossification center in the tibia causing bowing of the leg or legs. Symptoms include limping and lateral bowing of the leg. Radiographic evaluation reveals sclerotic medial cortex with spurring.

Infantile Type

Occurs before age 6 years

Caused by early walking and obesity

Adolescent Type

Occurs at 8 to 15 years

Caused by trauma and infection

Freiberg Infraction

Osteochondrosis of the metatarsal head. The 2nd metatarsal head is most frequently involved followed by the 3rd, 4th, and then 5th. The condition is more common in girls and usually occurs between ages 10 and 18 years. The condition can occur in adults. Radiographic evaluation reveals sclerosis and fragmentation of the metatarsal head with flattening of the articular surface.

Köhler Disease

Osteochondrosis of the navicular (tarsal scaphoid). The condition is more common in boys and occurs between ages 3 and 6 years.

Legg-Calvé-Perthes Disease

Osteochondrosis of the femoral head occurring primarily in males (5:1) between ages 3 and 12 years. Ten percent of cases are bilateral, and a history of trauma precedes 30% of cases. Legg-Calvé-Perthes is the most common form of osteochondrosis; the younger the child; the better the prognosis.

Osgood-Schlatter Disease

Osteochondrosis of the tibial tuberosity. More common in boys and occurs between ages 10 and 15 years. Caused by excessive traction on the patellar ligament. Symptoms include local pain and swelling with tenderness on palpation. The condition is self-limiting, and treatment is symptomatic.

Sever Disease

Osteochondrosis of the calcaneus (apophysis) caused by excessive traction of the Achilles tendon

Occurs between ages 6 and 12 years and is more common in patients with equinus. Radiographic diagnosis is difficult because the normal epiphysis can have multiple ossification centers and irregular borders and is often sclerotic.

Other Less Common Osteochondrosis

Buschke dz

Osteochondrosis involving the cuneiforms

Diaz or Mouchet dz

Osteochondrosis involving the talar body (usually associated with trauma)

Thiemann dz

Osteochondrosis involving the epiphyseal ossification centers in the phalanges

Iselin dz

Osteochondrosis involving the 5th metatarsal base

Lewin dz

Osteochondrosis involving the distal tibia

Ritter dz

Osteochondrosis involving the fibular head proximally

Treve dz

Osteochondrosis involving the fibular sesamoid

Renandier dz

Osteochondrosis involving the tibia sesamoid

Lance dz

Osteochondrosis involving the cuboid

Assmann dz

Osteochondrosis involving the head of the 1st metatarsal

CONGENITAL DISLOCATED HIP

Occurrence is 0.1%.

Sixty percent are on left side, 20% to 30% B/L

Increased incident in:

1. Females (five to eight times greater)

2. Children with older sibling with a dislocated hip (10 times more likely)

3. Breech presentation

4. Joint laxity

5. First born

Classical signs in older children include limited abduction, asymmetric thigh folds, relative femoral shortening, a limp, positive Trendelenburg test, externally rotated foot, waddling gait.

Best position for the hips to prevent dislocation is flexed and abducted.

When a dislocation occurs, the femoral head is usually posterior and superior to the acetabulum.

Most dislocations occur during the first 2 weeks after birth.

It is commonly associated with oligohydramnios, torticollis, metatarsus adductus, and calcaneal valgus.

Etiology

Ligamentous laxity

Acetabular dysplasia

Malpositioning

In utero (i.e., breech)
Postnatal (carrying babies with hips adducted and extended)

Clinical Diagnostic Studies

Ortolani Sign

With the baby supine, hips and knees are flexed to 90°. The hips are examined one at a time by grasping the baby’s thigh with the middle finger over the greater trochanter and lifting and abducting the thigh while stabilizing the pelvis and opposite leg with the other hand. The test is positive when a palpable click is felt as the femoral head is made to enter the acetabulum.

Barlow Sign

With the baby supine, the hips and knees are flexed. With the thumb on the lesser trochanter in the groin and the middle finger of the same hand on the greater trochanter laterally, gently apply pressure down on the knee while simultaneously applying lateral pressure with the
thumb. The dislocatable hip then becomes displaced with a palpable clunk as the head slips over the posterior aspect of the acetabulum. This is a provocative test, which actively dislocates an unstable hip.

Anchor Sign

With the baby prone, legs are adducted and extended. Look for asymmetry of thigh and gluteal folds. There will be more folds on the dislocated side.

Galeazzi Sign

Also known as Allis sign. While the hips and knees are flexed, a dislocated hip results in a lower knee position on the affected side. May be false-positive in B/L cases.

Abduction Test

With the baby supine, hips and knees are flexed to 90°. Abduct the knees to resistance. A dislocated hip will have limitation of abduction on the affected side.

Nelaton Line

Particularly useful in children with B/L dislocations. An imaginary line is drawn connecting the anterior iliac spine and the tuberosity of the ischium. If the tip of the greater trochanter is palpable distal to this line, the hip is dislocated.

Radiographic Diagnostic Studies

Hilgenreiner line (Y line): A line connecting the most inferior portion of the acetabulum on both sides

Ombrédanne line (Perkins vertical line): Draw a line perpendicular to Hilgenreiner line at the outer most aspect of the acetabulum

Quadrant System

After drawing the Hilgenreiner and Ombrédanne lines, the normal position of the developing femoral head should be in the lower medial quadrant. A dislocated hip will show at
least part of the femoral head in the outer upper quadrant.

Acetabular Index

Draw a line extending through the most medial and lateral aspect of the acetabulum. The angle created between this line and Hilgenreiner line is the acetabular index. This value should be between 27° and 30° at birth and decrease to 20° by age two. An angle greater than 30° indicates a dislocated hip.

Shenton Curved Line (Menard Curved Line)

Draw a line up the medial side of the femoral neck to continue up into the obturator foramen. This should be a continuous arc; with a hip dislocation, the obturator foramen is too low.

Von Rosen Sign (Frog Leg View)

An A/P radiograph is taken with the hips extended and the thighs abducted 45° and medially rotated. A line is drawn through the long axis of the femur. In a normal hip, this line should extend through the lateral corner of the acetabulum. In a dislocated hip, the line will bisect the ASIS.

Von Rosen Method

Draw the Hilgenreiner line and then draw a parallel line passing through the upper margin of the pubic symphysis. In a dislocated hip, the femur will extend up between these lines.

Wiberg CE Angle

Based on the assumption that if the femoral head is inadequately covered by the acetabulum, it will develop DJD. This test shows how much is covered. Draw a line connecting the center of the femoral head (C) with the lateral most aspect of the acetabulum (E). Measure the angle created by this line and Ombrédanne line. If this angle is less than 20° in a child over 5 years, there is an increased likelihood of developing DJD.

CLUBFOOT (TALIPES EQUINOVARUS)

Introduction

A triplanar deformity involving:

Ankle equinus

Hindfoot varus

Forefoot adduction

1:1,000 live births

Male to female (2:1)

Fifty percent of cases are bilateral.

Occurs in the right foot more than the left

Lowest incident in Asians; highest in Polynesians

Types

Idiopathic	Intrauterine position
Nonidiopathic	Spina bifida, CP, MD, meningitis, postpolio, traumatic, Streeter dz

Evaluation

Sign		Normal	Clubfoot
Kite’s angle		20°-40°	0°-15°
Calcaneal inclination angle		20°-25	˜17°
Talar head/neck relative to body:
	Adduction	10°-20°	80°-90°
	Plantarflexion	25°-30°	45°-65°