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
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 > 5°
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
Scheuermann Kyphosis
Criteria
>45° thoracic kyphosis or >30° thoracolumbar kyphosis
>5° wedging in at least three vertebraeRelated posts:
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