Pediatric Orthopaedic Conditions

An antalgic
gait is characterized by a decreased stance period on the affected limb
as well as a trunk shift over the affected limb during stance.

Evaluation for limb length difference:
palpate the anterior superior iliac spine (ASIS) with the patient
standing. Then, with the patient supine, compare lengths of the lower
extremities with the legs extended. Also, compare lengths of the femurs
by flexing the hips and comparing the relative heights of the knees.

Physical exam should also include the back, sacroiliac (SI) joints, and abdomen as well as the entire extremity involved.

Palpate the entire length of the limb.

Range of motion of the hip, knee, and
ankle joints. Particular attention should be paid to any erythema,
warmth, joint effusion, or focal tenderness.

A thorough neurologic examination should also be completed.

Three-phase bone scan. Useful when source of pain is not easily localizable; sensitive but not specific.

Magnetic resonance imaging (MRI).
Very sensitive and specific. Able to identify areas of bone marrow
edema, soft tissue edema, or fluid collections such as abscesses.

Ultrasound.
Useful to look for hip joint effusions, subperiosteal or soft-tissue
abscesses. May also help guide aspiration of hip joint or soft tissue
abscess.

CAUTION: If septic arthritis is suspected, a joint aspiration should be performed without wasting time waiting for the availability of other additional imaging studies.

Fever, lethargy, malaise, or other constitutional symptoms

Pain: location, severity, duration

Trauma/injury

Onset (sudden, gradual, etc.)

Observe posture of patient/posture of limb

Inspect swelling, redness, deformity

Palpate entire length of extremity, abdomen, spine for sites of pain, mass, warmth

Range of motion (ROM) active/passive, hip, knee, ankle joints

CBC with differential (may be normal)

C-reactive protein (CRP) (most sensitive)

ESR

Blood culture (particularly in setting of fever/sepsis)

Septic arthritis.
Frequently affects the hip joint in toddlers and young children; may
also affect other joints of the lower extremity (knee, ankle) or the
upper extremity (shoulder, elbow, wrist). (See VIII.B for additional information.)

Transient/toxic synovitis (see VIII.C for additional information)

Osteomyelitis. A bacterial infection of the bone (see VIII.A for more information).

Fracture or other injury. If patient is too young to provide history, consider possible fracture or other significant injury.

SCFE (unstable/acute) (see VII.C)

Definition.
An internal foot progression angle during gait. The foot turns in
relative to the line of forward progression during walking. Intoeing is
a frequent cause for parental concern. An important part of the
evaluation should be listening to the concerns expressed by the parents
and answering their questions.

Observation: observe child walk in hallway. Note position of feet relative to line of forward progression (Fig. 5-1).

Examination: evaluate rotational profile. Position patient prone on examination table.

Increased femoral anteversion: rotational twist in femur turns leg in while walking.

Internal tibial torsion: twist in tibia turns lower leg inward.

Metatarsus adductus: curvature of foot turns toes/forefoot inward.

Genu varum (“bowed legs,” genu-knee, varum/varus): the distal segment of the lower leg is aligned toward or close to the midline.

Genu valgum (“knock knees,” genu-knee, valgum/valgus): the distal segment is aligned away from the midline.

Femoral-tibial angle: angle between thigh and lower leg

One can also measure and record the distance between bony landmarks.

“Physiologic”: part of the normal
development. Most children who are referred for evaluation have a
physiologic form of bowing. Children undergo an evolution of their
lower extremity alignment during the first 6 years of life.

Tibia vara (Blount disease)
is an abnormal varus alignment of the knee due to altered growth of the
medial portion of the proximal tibial physis. There is an infantile form for children older than age 2 years and an adolescent form, frequently associated with obesity.

Other causes could include:

For
physiologic conditions, treatment usually consists of observation.
Inform the patient’s parents of the expected course and communicate the
findings and recommendations to the patient’s primary physician.
Continued observation can be performed during routine well-child
checks. If the child’s alignment varies from what is expected, the
child can return for reevaluation.

Children
with conditions which do not fit the typical “physiologic” pattern
should be referred for further evaluation. Further treatment consists
of establishing the underlying cause as well as developing an
appropriate treatment plan. After the diagnosis has been determined,
treatment may consist of:

Description.
A congenital deformity of the foot comprised of ankle equinus, hindfoot
varus, and adduction and supination of the midfoot and forefoot. The
foot “turns in” and “curves under” compared with the normal.

Incidence.
1 in 1,000 live births, unilateral in 60% of patients, and the ratio of
boys to girls is 2:1. There may be a positive family history.

Etiology. Multiple theories exist with the most likely cause being multifactorial.
Theories include arrested fetal development, abnormal intrauterine
forces, abnormal muscle fiber type, abnormal neuromuscular function,
and germ plasm defects.

Prenatal considerations include breech position, large birth weight, and oligohydramnios.

Associated conditions include arthrogryposis, myelodysplasia, congenital limb anomalies, and various syndromes.

Physical examination.
A careful evaluation should include not only examination of the child’s
feet, but also the child’s upper extremities, back, spine, and hips in
order to look for other associated conditions. Examination of the foot
should include evaluation of the ankle dorsiflexion, the hindfoot
position, curvature of the lateral border of the foot, and the forefoot
position as well as an assessment of the degree of flexibility of the
foot. Deep posterior and medial creases are usually present.

Radiographic evaluation.
Radiographs in the newborn period are not useful because the tarsal
bones are not well ossified. Radiographs may be useful after age 3
months for planning or evaluating surgical treatment. They are ordered
less often in nonoperative treatment as the physical examination is
more useful for clinical decision making. When x-rays are ordered, the
most useful images are an AP view and a lateral view in a position of
maximum dorsiflexion. Kite angle is the
angle subtended by the long axes of the calcaneus and the talus on the
AP view. This angle is normally between 20 and 40 degrees. In the
clubfoot, this angle is less than 20 degrees with relative parallel
alignment of the talus and calcaneus. The relationship of the talus and
calcaneus should also be assessed on the lateral view. Again, in the
clubfoot, this shows relative parallel alignment compared with the
normal foot.

Treatment.
The goals of treatment are to achieve a plantigrade, flexible, painless
foot. In the early half of the 20th century, Kite published high levels
of satisfactory results with his casting technique. The later half of
the 20th century saw the emergence and rise in popularity of the
surgical treatment of clubfoot as described by such authors as Turco,
Carroll, Crawford, Simmons, and McCay (5). The
dawn of the 21st century has seen renewed interest in the role of
nonoperative treatment using the method developed by Ponseti. His
experience has produced impressive results at long-term follow up and
is gaining more widespread acceptance and support (6).

Definition. Feet in which the medial longitudinal arch is absent resulting in hindfoot valgus and forefoot supination.

Patient history.
It is important to note when the foot position was first noticed,
whether the foot condition causes problems with function or pain, and
any family history of ligamentous laxity or flatfeet.

Radiographic examination.
For young children with a painless, flexible flat foot, no radiographs
are indicated. If the flat foot is painful or rigid, then standing AP,
lateral, and oblique radiographs of the foot should be obtained.

Flexible flat feet.
The flexible flat foot is a relatively common condition, although the
true incidence is unknown. Most young children start with a flexible
flat foot before developing a medial longitudinal arch during the first
decade of life. Most children are symptom-free, and no treatment is
warranted. For the older child or adolescent with a flexible flat foot
who experiences aching or discomfort associated with particular
activities, one may wish to use an orthotic to support the arch. If the
foot is flexible but there is a contracture of the Achilles tendon, one
should prescribe a course of physical therapy for a heelcord stretching
program. If the patient with an Achilles tendon contracture remains
symptomatic despite physical therapy, one may consider injection of
Botox into the calf muscle, possibly in conjunction with a stretching
cast. For patients that fail conservative therapy, some authors support
surgical correction of the hind foot valgus deformity in conjunction
with lengthening the tight gastrocnemius (7). This is rarely necessary in the growing child with a flexible flat foot deformity.

Rigid flat feet. The most common cause for a rigid flat foot is a tarsal coalition. This is an incomplete separation of the tarsal bones during fetal development. The two most common types are the calcaneonavicular and the talocalcaneal
coalition. The calcaneonavicular coalition may be best seen on the
oblique foot radiograph. The talocalcaneal coalition may be seen on an
axial (Harris) radiograph of the foot. If further radiographic imaging
is required, a computed tomography (CT) scan of both feet is the study
of choice.

If tarsal coalition has been excluded as the cause for the rigid flat foot, other possible causes include a congenital vertical talus, juvenile rheumatoid arthritis (JRA) involving the subtalar joint, osteochondral fractures of the subtalar joint, or neuromuscular conditions.

Treatment of
the rigid flat foot. The goal of treatment is to achieve a pain-free,
asymptomatic foot. Approximately 75% of patients with tarsal coalitions
are asymptomatic. Frequently, the onset of pain coincides with the
transition of the coalition from a fibrous or cartilaginous junction to
a bony bar. For the calcaneonavicular bar, this occurs around ages 8 to
12 years old; for the talocalcaneal bar, this usually occurs between 12
and 16 years of age. Nonoperative treatment consists of applying a
short-leg walking cast for 6 weeks followed by use of a molded
orthotic. This results in a resolution of the patient’s symptoms in a
large number of patients. For patients who do not respond to casting
treatment or for whom the symptoms recur, surgery is indicated.
Operative treatment usually consists of excision of the coalition along
with interposition of fat, muscle, or tendon to prevent recurrence. For
patients with a talocalcaneal coalition that comprises more than 50% of
the subtalar joint surface, some authors have questioned the role of
resection of the coalition. For patients with severe degenerative
arthrosis of the subtalar joint or persistent pain following previous
resection, a triple arthrodesis should be considered (8,9).

Definition.
An abnormal bony prominence of the medial eminence of the first
metatarsal associated with a hallux valgus deformity of the great toe.
It is frequently associated with a medial deviation of the first
metatarsal (metatarsus primus varus).

Patient history.
These patients are most often adolescent or teenage girls with
complaints of pain over the medial eminence, difficulty with shoe wear,
or concerns regarding appearance. There may be a positive family
history.

Physical examination.
Clinically assess presence of hindfoot valgus and presence of a
coexisting flat foot in addition to presence and severity of hallux
valgus deformity. Evaluate degree of angulation as well as rotation of
great toe.

Radiographic evaluation.
Standing AP and lateral radiographs of the foot are recommended. On the
AP radiograph, one can assess the following parameters:

Treatment. It is important to distinguish the functional
problems that the patient is experiencing as well as the patient’s and
the parents’ concerns. In the adolescent patient in whom the primary
concern is the appearance of the foot, every effort should me made to
educate and counsel the family. For patients with a symptomatic hallux
valgus deformity, strong consideration should be accorded to postponing
any surgical treatment until skeletal maturity is reached because there
is a high recurrence rate of bunions in adolescent patients. If surgery
is considered, careful examination of the foot is necessary to correct
all of the underlying deformities, thus decreasing the risk of
recurrence and increasing the likelihood of patient satisfaction. For
patients with an underlying flexible flat foot condition, initial
treatment should consist of a custom-molded, flexible medial-arch
supporting foot orthotic. This will frequently correct the foot
deformity and improve the hallux valgus deformity as well.

Surgical options. There are numerous surgical options.

Trauma/injury

Swelling of joint

Locking/buckling of knees

Location of pain

Association of pain with specific activities (running, descending stairs, sitting)

Knee ROM

Hip ROM (remember referred pain from hip)

Effusion of knee joint

Joint line tenderness

Tenderness over patella/tibial tubercle

Assess ligamentous stability

Definition. A
spectrum of disorders ranging from complete dislocation of the femoral
head to a reduced hip joint with acetabular dysplasia.

Incidence. Approximately 1 in 1,000 live births.

Risk factors:
include first born, female, breech position in utero, oligohydramnios,
and a positive family history. It has also been associated with other
congenital conditions including congenital muscular torticollis,
metatarsus adductus, and clubfeet.

Physical examination.
In the newborn child or young infant, physical examination should start
with a careful evaluation of the other parts of the child other than
the hips, including the spine, neck, and upper and lower extremities.
Then, focus examination on the hips, trying to detect any evidence of
instability. The clinical tests performed include the Barlow/Ortolani
and Galeazzi tests. The Barlow and Ortolani
tests are performed with the clinician stabilizing the pelvis with one
hand and grasping the child’s femur with the other, placing the thumb
over the medial femoral condyle and the long finger over the greater
trochanter. The hip is flexed to 90 degrees and held in neutral
abduction. The Ortolani maneuver consists of abducting the hip and
trying to detect the “clunking” sensation of the dislocated femoral
head relocating into the acetabulum. Likewise, the Barlow test consists
of two maneuvers. The first consists of adducting the hip with gentle
longitudinal pressure to provoke the hip to dislocate or subluxate. The
second maneuver is the same as that described for the Ortolani maneuver
to achieve reduction of the dislocated hip. The Galeazzi
test consists of comparing the height of the knees with the hips flexed
to discern any apparent femoral shortening. One should also check for
symmetric degrees of hip abduction as well as for asymmetry of the
perineal skin folds. Finally, DDH can be bilateral, which can be easily
missed clinically because there is no apparent asymmetry. These
children may first come to attention after walking age, with increased
lumbar lordosis, limb length difference, or a “waddling gait.”

Radiographic evaluation.
In the young infant, ultrasound is the modality of choice to detect any
evidence of hip abnormality. The ultrasound allows a static assessment
of acetabular development (alpha and beta angles) and percentage of
femoral head coverage as well as dynamic assessment of femoral head
stability with stress maneuvers. In children older than 6 months, plain
AP radiographs are sufficient.

Definition. Idiopathic avascular necrosis to the femoral head in children.

Presentation.
Most often affects children aged 4 to 8 years; however, it may affect
children as young as 2 or as old as 12 years. The ratio of incidence in
boys to girls is 4:1. The disease may be bilateral in 10% of patients.
Patients frequently have younger skeletal age than cohorts. Frequently,
the disease presents as a painless limp (Fig. 5-2).

Etiology: idiopathic. It has been associated with abnormalities of thrombolysis as well as deficiencies of protein C, protein S, or thrombolysin.

Differential diagnosis.
If bilateral hip involvement is present on radiograph, then other
possible etiologies should be excluded, including renal disease,
hypothyroidism, multiple epiphyseal dysplasia or spondyloepiphyseal
dysplasia, systemic corticosteroid use, storage disorders, and
hemoglobinopathies.

Stages.
Waldenström originally described evolutionary stages that the disease
course follows. These have been modified from the original description
to include the following:

Classification systems. To describe and to compare the results of treatment, various classification systems have been described.

Treatment.
For patients with Legg-Calvé-Perthes disease, it is important to
determine which patients will benefit from treatment as well as how to
treat them.

Risk factors for a poor prognosis include:

Definition. A
disorder of the upper femur in which there is a separation (acutely or
chronically) of the femoral epiphysis from the femoral neck through the
region of the physis (growth plate). The femoral head becomes
positioned posterior and inferior relative to the femoral neck.

Incidence.
Approximately 3 in 100,000; boys more frequently than girls. Bilateral
involvement occurs in between 20% and 60% of cases. SCFE is seen most
frequently in boys aged 12 to 16 years and in girls aged 10 to 14
years. SCFE is associated with obesity, with more than half of affected
individuals weighing greater than the 95th percentile. (Note: Not all
patients with SCFE are obese.) Patients with an underlying hormonal or
endocrine disorder have an associated increased risk for development of
SCFE. For patients with an unusual presentation such as atypical age
(before age 10), bilateral involvement at presentation, or with other
signs of possible endocrine abnormalities, a careful evaluation for
endocrine disorders including hypothyroidism, hypopituitarism or
hypogonadism should be conducted.

Treatment. The most widely recommended form of treatment is surgical stabilization with percutaneous pinning in situ. For a stable SCFE, this can usually be accomplished with a single, cannulated screw inserted under fluoroscopic control (19).
The aim of the procedure is to insert the screw perpendicular to the
femoral head in both the AP and lateral planes with close attention to
avoid penetrating the femoral head and entering the hip joint. In cases
of an unstable SCFE, a second screw may be inserted to further
stabilize the femoral head (Fig. 5-3).

Complications. The primary complications associated with SCFE are avascular necrosis and chondrolysis. Avascular necrosis is uncommon with stable SCFE treated with pinning in situ.
There is a greater incidence of avascular necrosis associated with
unstable SCFE. A vigorous attempt at reduction of an unstable SCFE
should NOT be performed. Chondrolysis is a
gradual loss of the joint space following stabilization of the SCFE. It
has been associated with treatment with one or more pins as well as
with a spica cast in which no internal fixation was used.

Definition. A bacterial infection of the bone.

Etiology.
Bacterial seeding can occur through several methods: direct inoculation
(open fractures, penetrating wounds), local extension from adjacent
sites, or hematogenous spread from distant sites. Children are
skeletally immature and have physes at the ends of their long bones.
The metaphyseal region of the bone just below the physis is a frequent
location for osteomyelitis to occur.

Presentation.
Patients may present with pain, limping, or refusal to walk or bear
weight on the affected lower extremity. Constitutional symptoms of
fever, malaise, and flu may or may not be present. One should inquire
about immunization status as well as history of recent illnesses [e.g.,
otitis media, chicken pox, strep pharyngitis, upper respiratory tract
illness (URTI)].

Physical examination.
Site of involvement may or may not be easy to identify, particularly in
younger patients. Careful palpation of entire extremity and the
metaphyseal regions in particular is important. All joints should be
placed through a range of motion. Inspect for areas of redness,
swelling, or warmth.

Laboratory studies.
CBC with differential, ESR, CRP, and blood cultures are helpful in
making the diagnosis. The CRP has been recognized as a more rapidly
responsive test than the ESR, increasing more quickly early in the
evolution of the condition and declining more rapidly in response to
treatment. If the diagnosis remains unclear, consider other diagnostic
possibilities such as JRA, Lyme arthritis, and poststreptococcal
arthritis.

Radiographic studies.
Plain radiographs of the affected area should be obtained. In
osteomyelitis they may frequently be normal for the first 7 to 14 days.
However, the radiographs may also be useful to rule out other
diagnostic possibilities. In patients with normal radiographs in whom
the diagnosis is still unclear, a technetium bone scan is a sensitive
test for acute osteomyelitis. It is particularly helpful in cases
involving the pelvis, proximal femur, and spine. MRI is also very
sensitive and has the added benefit of having greater soft-tissue
detail allowing assessment of marrow involvement, soft-tissue extension
or abscess formation, and presence of joint effusions. However, an MRI
may require significant sedation or anesthesia for younger patients.

Aspiration.
In patients with an identified focus of infection, an attempt at
aspiration is recommended by many authors to identify the organism.
This may be done with sedation in the emergency department or the
fluoroscopic suite or, alternatively, under anesthesia in the operating
room.

Organisms. On the basis of patient age:

Treatment.
Appropriate intravenous antibiotic based on culture or most likely
organism. Duration of antibiotic coverage is typically 6 weeks. After 2
to 3 weeks of IV treatment, the patient may be switched to oral
antibiotics if the following criteria are met: (a) the organism has
been identified, (b) there is

a
satisfactory oral antibiotic to which the organism is sensitive, (c)
the child will take the oral antibiotic, and (d) satisfactory serum
levels can be achieved with oral therapy (20).

Surgical treatment.
If the patient does not respond to antibiotic treatment after the first
24 to 48 hours, consider the possibility of a subperiosteal or
intraosseous abscess as well as other diagnostic possibilities.
Consider surgical drainage of abscess or intramedullary canal if
necessary (21).

Definition. An infectious arthritis of a joint, usually bacterial in nature.

Etiology.
Most frequently, it occurs as a result from adjacent osteomyelitis in
which the metaphyseal portion of the bone is intraarticular (e.g., hip,
shoulder, elbow, ankle). When pus from metaphysis decompresses itself
through cortex, joints can become infected. Infection is also possible
through hematogenous spread or direct inoculation.

Joints most commonly involved: knee (41%), hip (23%), ankle (14%), elbow (12%), wrist (4%), and shoulder (4%).

Presentation.
Young children usually refuse to walk or bear weight on the lower
extremity. The child will usually be febrile and may show signs of
sepsis. If infection is in the upper extremity, children refuse to use
the affected extremity. Septic arthritis may also occur in the newborn
child; babies in the neonatal intensive care unit (NICU) may present
with pseudoparalysis of the affected limb with failure or refusal to
move it.

Physical examination.
If the joint involved is superficial, classic signs of joint redness,
swelling, and warmth are present. However, if the joint is not
superficial (hip, shoulder), no visible abnormality may be detectable.
However, the patient will hold the affected limb in a position of
maximum comfort (e.g., keep the hip in flexion and external rotation).
Any attempt at passive range of motion is painful and restricted
because of guarding.

Laboratory studies
include CBC with differential, ESR, CRP, and blood culture. The CRP and
ESR will become significantly elevated. The CBC may remain normal.

Radiographic studies.
Plain radiographs of the affected joint should be obtained to look for
any evidence of bony destruction or erosions. For patients with
suspected hip pain, an ultrasound of the hip may confirm the presence
of a hip joint effusion. In some institutions, aspiration is performed
under ultrasound guidance.

Joint aspiration
is mandatory to confirm the diagnosis. Joint fluid should be sent for
cell count, Gram stain, and culture and, if quantity permits, glucose
and total protein. If the patient is a teenager in whom gonococcal
infection is suspected, the laboratory should be notified in order to
perform cultures on chocolate agar in addition to the routine media.
The Gram stain may be positive for bacteria in only approximately 50%
of patients. The cell count most often has greater than 50,000 white
blood cells (WBCs) and/or greater than 90% polymorphonuclear
neutrophils (PMNs).

Organisms. On the basis of patient age:

Treatment. In
patients suspected of septic arthritis, treatment consists of surgical
incision and drainage of the affected joint. Surgical decompression of
the adjacent bone may also be indicated if there is evidence of an
intraosseous abscess. Intravenous antibiotics should be administered
once intraoperative cultures have been obtained. Empiric coverage
should be started initially based on the most likely organism involved.
Once culture and sensitivities have been identified, antibiotic
coverage can be tailored accordingly. The duration of antibiotics is
usually 4 to 6 weeks. An initial course of intravenous antibiotics is
followed by oral therapy until the patient’s symptoms and laboratory
studies have returned to normal.

Definition. An inflammatory, noninfectious process resulting in joint swelling and pain.

Presentation.
Transient synovitis most frequently occurs in young children aged 3 to
8 years. Patients often may have had a recent upper respiratory tract
illness or other viral illness in the 2 to 3 weeks before onset of
symptoms. Patients are usually afebrile with a history of several days
of pain or limping. The physician must differentiate between transient
synovitis and a truly infectious process such as septic arthritis or
osteomyelitis.

Laboratory studies. CBC with differential, ESR, and CRP are usually within the normal range.

Radiographic studies.
Plain radiographs are usually normal or may show evidence of a joint
effusion. Ultrasound is helpful for confirming the presence of a joint
effusion.

Aspiration.
Because the clinician is often confronted with having to exclude septic
arthritis, joint aspiration can be helpful in order to examine the
joint fluid. A Gram stain, cell count, and culture should be obtained.
The Gram stain should be negative and the cell count should have
between 5,000 and 15,000 WBCs with less than 25% PMNs.

Treatment.
The primary treatment objective in the treatment of transient synovitis
is to ensure that septic arthritis has been excluded. Once septic
arthritis is excluded, then the condition can be treated expectantly
with reduction in activity, NSAIDs, and careful observation (23).

Physical exam. Have patient dressed in examination gown or other appropriate clothing.

Radiologic tests.
If pediatric patient describes significant back pain and/or any
abnormal findings are present on physical exam, it is appropriate to
obtain plain radiographs.

Additional imaging tests.
If neurologic abnormalities are identified on physical exam, consider
MRI of spinal canal. If no neurologic findings are present but pain
presentation is worrisome for underlying bone tumor or structural
abnormality, consider three-phase nuclear medicine bone scan.

Spondylolysis/spondylolisthesis.

Discitis. A
condition in which children develop back pain that arises from a
presumed bacterial infection of the intervertebral disc. They may
present

with
gradual onset of pain, loss of lumbar lordosis, and progressive decline
in activity level potentially to the point of refusing to walk. The
child may remain afebrile. Current theories of etiology suggest it may
start as a vertebral osteomyelitis that spreads to the adjacent disc
space. If suspected, laboratory tests should be obtained including CBC
with differential, ESR, CRP, and blood cultures. The CBC may be normal
but some elevation of the ESR and CRP is frequently present. Initial
radiographs may be normal or may show vertebral end-plate
irregularities. Later radiographs may show a narrowing of the disc
space involved. The diagnosis may be confirmed with specialized imaging
tests such as nuclear medicine bone scan, CT, or MRI. Treatment
consists of antibiotic therapy and, when appropriate, back
immobilization with a removable spinal orthosis for symptomatic support.

Lumbar Scheuermann disease.
A condition in which patients present with lumbar back pain without
radicular symptoms. There are end-plate changes termed “Schmorl nodes”
in the lumbar vertebra on plain radiographs. In contrast to
Scheuermann’s disease of the thoracic spine (see below), which is
associated with significant thoracic kyphosis and vertebral wedging,
these changes are not found in the lumbar spine.

Herniated intervertebral disc.
A herniation of the central portion of the disc, the “nucleus
pulposus,” into the spinal canal. Occurs in adolescent and teenage
patients. Symptoms usually have an acute, specific onset and are
associated with radicular symptoms of pain radiating down into the
lower extremity. Neurologic exam is helpful to look for signs of motor
weakness. An avulsion fracture of the vertebral ring apophysis
may also present with sudden onset of back pain with radicular-type
symptoms radiating into the lower extremities. This may be visible on
plain films as a small triangular fragment of bone displaced from the
lower end plate of the vertebra. If a herniated disc or a vertebral
ring apophysis avulsion-type fracture is suspected, an MRI scan can
help confirm diagnosis.

Bone tumors involving the spine.
There are a number of bone tumors that may arise from the vertebral
body or the posterior elements of the spine. They may present with
pain, particularly night pain, deformity, or other associated symptoms.
Physical exam may reveal findings of scoliosis, however, radiographs
may reveal a curvature of the spine without any rotational component
present. This suggests that the curvature is postural, due to the
painful process, rather than a structural, scoliosis-type curve. Benign
tumors that arise in the spine most frequently include osteoid osteoma,
osteoblastoma, and hemangioma. Primary malignant tumors of the bone
that arise in the spine are relatively rare.

Definition. A
deformity of the spine consisting of a lateral curvature measuring
greater than 10 degrees on a spine radiograph that also has a
rotational component. The word “idiopathic” suggests no identifiable,
underlying cause. There may be a genetic component.

Presentation.
Most often patients are adolescent girls who have been detected either
on school screening examination or by an observant primary physician.
Boys are affected less often and have a lower incidence of progressive
curves. The deformity may occasionally be seen in younger children.
Family history is frequently positive. Idiopathic scoliosis should be painless.
The examiner should inquire about any neurologic symptoms including
weakness, numbness, radicular symptoms, or bowel or bladder changes.

Incidence.
For curves greater than 10 degrees, the overall incidence is 2%.
However, for curves measuring greater than 20 degrees and requiring
treatment, the incidence is 0.2%.

Physical examination. All patients should be examined in a gown so that the back can be well visualized. Inspect pelvic height for evidence of limb

length difference. Examine shoulder height and trunk position for
evidence of asymmetry or truncal imbalance. With the patient standing,
have the patient bend forward at the waist. Observe the patient’s back
for evidence of rib hump deformity. This is the Adam forward bending test.
Finally, complete a thorough neurologic examination, including
abdominal reflexes and tests for long tract or upper motor neuron
lesions.

Radiographic evaluation.
PA and lateral spine radiographs on a long cassette to include the
thoracic, lumbar, and sacral regions of the spine. The curvature of the
spine can be measured using the COBB method.

Characteristics. For true idiopathic scoliosis, the curve is most often:

Risk factors for progression
include young age, female gender, prepubertal status, and curve greater
than 11 degrees. The spine curve is at greatest risk for progression
during periods of accelerated skeletal growth (24).

The goal of treatment is to prevent further progression of the curve.

Treatment of
idiopathic scoliosis depends on the size of the curve as well as the
age of the patient at the time of detection. Typically, for curves
greater than 11 degrees and less than 20 degrees, treatment consists of
observation with repeat spine radiographs
obtained in 4 to 6 months. The younger the child at the time of curve
detection, the greater the risk for future progression of the curve. If
the curve is greater than 20 to 25 degrees in a skeletally immature
patient, brace treatment is indicated.
Brace treatment is most effective in moderate-sized and flexible curves
in growing adolescent patients. The goal of brace treatment is to
arrest any further progression of the curve. For patients in whom a
large curve of greater than 45 to 50 degrees is already present or for
whom the curve progresses despite brace treatment, treatment is surgical spinal fusion with instrumentation.

Definition.
An increased curvature of the thoracic spine in the sagittal plane,
either from the side or on the lateral radiograph, producing a
rounded-back appearance.

Characteristics. Normal thoracic kyphosis is 20 to 45 degrees. Scheuermann disease
is a condition in which the thoracic curve on the lateral radiograph is
greater than 45 degrees and associated with wedging of three adjacent
central vertebral bodies of 5 degrees or more. It may be associated
with end-plate changes of the vertebral bodies such as Schmorl nodes.
It should be distinguished from postural kyphosis, in which the
vertebral bodies do not exhibit changes and the curvature resolves with
improvement of the patient’s posture.

Presentation. Patients usually have one of two complaints: pain or concerns regarding appearance.

Physical examination.
Careful examination of the back with the patient standing, on forward
bending, and with hyperextension in the prone position can help
determine the flexibility of the kyphosis. Increased thoracic kyphosis
is frequently associated with increased lumbar lordosis. The
possibility of hip flexion contractures should be assessed. A careful
neurologic examination should also be performed.

Radiographs. Standing PA and lateral thoracolumbar spine radiographs should be obtained.

Treatment.
Options include observation, bracing, and surgery. For patients who are
asymptomatic with a relatively small curve, one may consider

continued
observation. For symptomatic patients who are skeletally immature with
curves greater than 45 to 50 degrees, one may consider brace treatment.
The indications for surgical treatment include kyphosis greater than 70
degrees, progressive deformity, recalcitrant pain, and concerns
regarding patient appearance in the setting of significant deformity (25).

Definition. An increase in “swayback” appearance of the lower lumbar spine.

Presentation. The patient may complain of low back pain, concern regarding appearance, or both.

Etiology.
Possible causes include posture (especially in younger patients),
bilateral congenital dislocation of the hip, hip flexion contracture,
hamstring weakness, increased thoracic kyphosis,
spondylolysis/spondylolisthesis, and congenital spinal deformity.

Physical examination
should include careful evaluation of the back, hips, and lower
extremities and should also include a thorough neurologic evaluation.

Radiographs. PA and lateral thoracolumbar spine radiographs should be obtained.

Treatment.
Careful exclusion of underlying abnormalities should be undertaken. If
other underlying causes have been excluded and the cause is thought to
be postural, then treatment may consist of further observation.

Definition. A
nonprogressive disorder resulting from an injury to the brain, usually
within the first year of life, and resulting in impairment in motor
function.

Classification can be geographic (part of body most affected) or by type of motor dysfunction.

Nonambulatory patients.
The principal difficulties that affect patients with total body
involvement are hip dislocation and neuromuscular scoliosis. These are
important issues for these patients because they are wheelchair bound
and frequently mentally handicapped. Painful sitting or difficulty with
sitting balance resulting from scoliosis or pelvic obliquity can
interfere significantly with their activities of daily living, personal
care, and activity level. Patients should be monitored regularly for
early detection of either hip dislocation or scoliosis.

Ambulatory patients.
If children have independent sitting balance by age 2 years old, then
there is approximately a 95% chance that they will eventually be able
to ambulate. Children with cerebral palsy who can ambulate usually have
difficulty because of increased motor tone, poor selective motor
control, which results in co-contracture of muscle groups, and poor
balance. Frequently, muscle contractures and bony deformities develop
over time. Three-dimensional gait analysis is useful to assess walking
in these children in order to identify a problem list of orthopaedic
issues or deformities that are contributing to the patients difficulty
in walking. Orthopaedic surgery usually consists of muscle lengthening
or transfer procedures combined with bony realignment procedures for
underlying torsional deformities of the lower extremities. Most often,
these are combined in one surgical setting to minimize recovery time
and to speed the child’s return to activities. The selective dorsal rhizotomy
is a procedure to decrease lower extremity tone by cutting
approximately 30% to 40% of the dorsal afferent sensory nerve rootlets.
It is indicated for children with spastic diplegia who have pure
spasticity, no contractures, and good balance. It is usually performed
in children between the ages of 4 and 8 years old. For children with
cerebral palsy, optimum treatment consists of a combined approach
involving the physiatrist, the neurosurgeon, the orthopaedic surgeon,
the physical and occupational therapists, and the orthotist.

Definition. A
malformation of the spine, resulting from incomplete closure of the
posterior elements of the spine as well as of the neural tube in which
the meninges and neural elements are exposed at birth.

Etiology is
multifactorial. There is a genetic component in that there is increased
risk for first-degree relatives of patients with spina bifida. There is
also an environmental role linked to insufficient dietary folic acid
for women of childbearing age.

Classification is based on the level of neurologic deficit.

Associated disorders
include hydrocephalus requiring ventriculoperitoneal shunting, tethered
spinal cord, Arnold-Chiari malformations, syringomyelia, and urologic
problems.

Orthopaedic conditions
include scoliosis for patients with high thoracic level deficits,
excessive spinal kyphosis, hip dislocation, and foot deformities.

Ambulatory function
is determined primarily by level of deficit. Patients who ambulate are
usually patients who maintain active control of knee flexion and
extension. Many children ambulate when young, but as they get older, it
takes greater energy and oxygen consumption, and many resort to using a
wheelchair.