Angular Deformity

Normal development


1 year:  Bow legs / 15° varus

2 year:  Neutral 

3 year:  Knock knees / 10° valgus


3 year old knock knees


6 year:  Physiological valgus / 6° valgus


Normal valgus six year old


Note range ~ 15° either way at each age

- persistence of physiologic variations may occur

- especially in some families & racial groups


Salenius and Vankka

- chart of normal tibio-femoral variations by age








Unilateral / bilateral

- angular profile

- femorotibial angle

- inter-malleolar / intercondylar distance (quantify)


LLD / rotational profile / joint laxity


Height vs Age




Erect AP Standing Long Leg view

- patella directed forward

- femur & tibia on same Xray



- if pathological form suspected

- asymmetry

- < 5th percentile

- severe deformity

- positive FHx


- other musculoskeletal abnormality


Causes of both Varus and Valgus


Trauma: Malunion / Partial physeal arrest

Rickets / Renal disease







Avoid dogmatic predictions

- clinical course variable

- not all cases resolve


Shoe wedges & other bracing ineffective





- genu valgum may cause CMP / PF Dislocations

- genu varum may cause OA Knee


Varus deformities


Physiologic Bow legs


1. Lateral tibial bowing

- occurs in first year of life

- nearly always resolves


2. Common Bowing

- involving the femur & tibia

- seen in second year

- prior to age 2 years, development of MFC lags behind lateral

- resolution occurs in most children


Management Physiological  


Bracing doesn't affect the NHx

- exclude pathological causes of deformity & reassure parents



- corrective osteotomy / epiphysiodesis / guided growth with 8 plates

- recommended for those children with persistence or worsening of physiologic varus






Trauma - malunion / epiphyseal arrest

Infection - physeal damage

Skeletal dysplasia - achondroplasia / OI / enchondromatosis / metaphyseal chondrodysplasia

Anterolateral bowing - pseudoarthrosis

Fibrous dysplasia



Valgus Deformities


Physiological Valgus



- knock knees very common age 2-6

- starts at 2 years

- maximum 3-4 years

- usually resolves by 7

- may not always resolve

- minimal correction occurs > 8 yo


X-ray if

- asymmetrical / Unilateral

- progressive


- intermalleolar distance > 10 cm

- outside normal parameters i.e. 15° either side normal for age



- no evidence of efficacy


Surgical Indications

- > 15° valgus

- cosmesis

- poor gait / function

- avoided < 12 years



- osteotomy / hemiepiphyseodesis / Guided Growth with 8 plates


Pathological Valgus




1.  Distal femoral physeal injury

- Usually SH I or II 


2.  Proximal tibial metaphyseal fracture / Cozen's

- tendency for valgus deformity

- reason why is uncertain



- rotation on xray hides valgus

- ST interposition

- overgrowth



- careful moulding cast into varus

- usually resolves over time


Infection - physeal injury

Congenital Posteromedial Bowing

Anteromedial Bowing - fibular hemimelia

Skeletal dysplasia - MED / pseudoachrondroplasia / Kneist

NMD - cerebral palsy / spina bifida

Lateral Condylar Hypoplasia








Blount's Disease



Progressive varus deformity of knees

- secondary to abnormality of medial upper tibial physis

- localised varus & internal rotation deformity


Infantile form 

- onset 1-3 years / bilateral


Adolescent form 

- onset > 6 years / unilateral

- 5 times less common

- M:F

- presents 8 - 14 years




Africans / African Americans / West Indians







Early walking




Unknown / Multifactorial



- no consistent inheritance pattern

-  ? related to tendency to obesity 



- most likely due to abnormal compression on medial side of proximal tibial physis

- causes retardation of growth

-  ? traumatic role




Posteromedial disordered endochondral ossification 

- dense islands of hypertrophied chondrocytes

- acellular areas of dense fibrocartilage in resting zone

- abnormal groups of capillaries


Fragmented physis




Infantile presents at 12-36/12 


Bilateral & symmetrical

- bowing noted when commence walking

- associated internal tibial torsion due to fibular tethering normal ER of tibia with growth

- continuum between physiological vara & Blount's (infantile may be severe physiological vara) 

- varus should resolve by the age of 2




Milestones / height & weight percentiles


Knee ROM 


Measure of Genu Varum & Tibial torsion


Ligamentous Laxity





- severe genu varum

- rapidly worsening

- height < 25th percentile

- marked asymmetry

- FHx



- localised deformity at proximal tibia


Metaphyseal - Diaphyseal Angle


Blounts Metaphyseal Diaphyseal Angle



- line drawn perpendicular to axis of tibia 

- line drawn through medial & lateral beaks of metaphysis

- Blount's > 11°

- physiologic bow legs < 11°



- 11° is arbitrary cut off where Blount's is more likely

- 16o definite


Medial Physeal Slope


Blounts Medial Physeal Angle



- line through medial physis & line through lateral physis



- significant if > 60°

- prognostic of progression




Used to identify presense of physeal bar


Langenskiold Classification


Stage I: Beak 2-3 years

- irregular metaphyseal ossification

- medial metaphyseal beaking


Stage II: Saucer 2-4 years

- saucer shaped defect in medial metaphyseal beak

- medial epiphyseal wedging


Stage III:  Step 4-6 years

- saucer deepens into step 

- medial epiphysis irregular


Stage IV: Bent plate 5-10 years

- growth plate inclined distally at medial side

- i.e. epiphysis extends down over meta beak


Stage V: Double epiphysis 9-11 years

- Xray appearance of severe posteromedial depression


Stage VI: Medial physis ossified 10-13 year

- medial physeal closure


Blounts Langenskiold Type VI




Physiological varus

Metaphyseal dysplasia / achondroplasia


Trauma / Tumour / Infection




Physiological Varus

- symmetrical involvement

- normal growth plate

- medial bowing of proximal tibia & distal femur

- metaphyseal-diaphyseal angle < 11°



- short stature, osteopaenic

- widened physes / cupped metaphyses 

- distal Femur Flared too

- may have coxa vara

- hypophosphataemic most common


Renal Osteodystrophy


Metaphyseal Chondrodysplasia

- widened metaphysis, cupped physis

- similar to rickets

- mild short stature

- may have coxa vara as well


Focal fibrocartilagenous dysplasia 

- generalised abnormality or focal deformity in tibia










Progresses to severe OA by early adulthood

- metaphyseal-diaphyseal angle >11° --> likely to progress

- medial-physeal slope >60° likely to progress

- Philadelphia sign: lateral subluxation of tibial epiphysis 

- if restore normal valgus should have good outcome


Need to manage child before they develop a bar (i.e. end stage of growth plate injury)


Management Infantile Type




Depends on

- age of child

- stage of disease


1.  <2 years 




2.  2 - 3 years & Medial Physeal Angle < 60°


KAFO Single Medial upright 

- free ankle with no knee hinge

- flexion limited

- knee cuff pulls it into valgus


Full-time bracing successful > 50%


3. Age > 3 years / Progression in Brace / Medial Physeal Angle > 60° 



- correct varus and internal rotation deformity




A.  Lagenskiold I - IV

- osteotomy

- guide growith


B.  Lagneskiold V / VI

- take down bar and osteotomy or

- epiphysiolysis + medial metaphseal osteotomy


Langenskiold Stages I-IV Surgical Management


1.  Osteotomy



- restore alignment

- deformity reversible

- if restore physiological valgus (7o) then resolution is usual for I & II / possible for III & IV 


Type of osteotomy


A.  Opening / closing wedge

B.  "Smiley" upside down dome

C.  Oblique osteotomy

- Rab biplanar oblique osteotomy

- fix with single screw


Osteotomy Technique


Performed distal to TT

- closing wedge simplest but upside down dome has least shortening

- must osteotomise fibula

- usually want to correct IR deformity at same time

- must release anterior compartment to prevent compartment syndrome

- desired valgus & ER achieved

- fixation with K wires or screw

- POP post operatively


Recurrence after osteotomy


1. Obese

2. > Stage III

3. Medial physeal slope > 60°

4. Age

- > 5 y = 76%  

- < 5 y = 31%


2.  Guided growth / 8 plate


Now common mechanism of treating condition


3.  Osteotomy and external fixation


Langenskiold Stages V & VI 





- need to address physis as well as osteotomy

- usually total physiodesis

- overcorrection 10°



- must do fibula osteotomy as well

- usually perform total physeodesis of ipsilateral side

- always perform fasciotomy

- may need to realign epiphysis in severe forms with large medial-physeal slope

- consider epiphysiodesis of other side to address LLD




1.  Medial Metaphyseal Elevation Osteotomy



- Grade V


Blounts Elevation


2.  Physeal Bridge Resection (physeolysis) + Osteotomy



- Grade VI

- bridge < 30% of physis



- excise bar where CT shows a bridge

- Insert fat into defect


3.  Lateral Hemi-epiphysiodesis + osteotomy



- grade VI

- bridge > 30%




All need fibula osteotomy

All need prophylactic compartment release




Compartment syndrome - must prophylactic release

Recurrence of varus - usually secondary to physeal bar




Adolescent Type




Wait till skeletal maturity, then HTO


Cerebral Palsy




CP is a permanent disorder of movement and posture 

- non-progressive 

- brain injury before the age of two years


Strict definition excludes familial & progressive congenital problems & those acquired in childhood as a result of head injuries




2-3 per 1000 live births


Higher in 

- premature and low birth weight children

- low socio-economic group have higher incidence

- more common in advanced countries

(possible increase due to improved survival of premature and low birth weight infants)


Quadriplegia has diminished


Athetosis has been the most dramatic decrease due to

- Rh immunisation

- the drop in erythroblastosis fetalis

- better treatment of jaundiced infants


Most common

- spastic diplegia or hemiplegia

- 65%


Natural History


About 50% have normal intelligence

- 25% end up independent as adults



- hemiplegics 100% walk

- diplegics 75% walk

- quadriplegics 25% walk 


Likely to walk

- sit by 2 years 

- stand by 4 years




Prenatal (44%)


Maternal infection (TORCHS)

- Toxoplasmosis

- Rubella

- Cytomegalovirus

- Herpes

- Syphilis


Maternal exposure

- Alcohol

- Drugs


Perinatal (27%)


Hypoxia (accounts for <10% of CP)


Low birth weight


Postnatal (5%)



Head injury



Other (24%)


Common Causes


Hemiplegia - obstetric

Diplegic - prematurity

Quadriplegia - anoxia

Athetoid - kernicterus


Prematurity Risk


2500 gms = 0.34% 

1500 gms = 14%

<1500 gms = 90%




The lesion that is seen in common is "Periventricular Leukomalacia "




Anatomic and Pathophysiologic classification


It takes at least 2 years to reach a static state


Pathophysiology Classification


Spastic (60%) 

- hyperactive reflexes

- develops contractures, bony deformity & ultimately joint dislocation 

- benefits from orthotics and surgery


Athetoid (10 - 20%)  

- major problems with control of limb position and limb balance

- succession of slow writhing movements

- rarely benefit from orthotics & surgery

- benefit greatly from therapists in terms of self care & occupation programs


Hypotonia (2-5%)

- common in infancy

- most become hypertonic with time


Ataxic (2-5%)

- uncoordinated, unbalanced, wide based gait



- important to identify these children as the motion disorder affects the outcome of surgery

- typically spasticity & athetosis with total body involvement


Spastic - motor cortex

Athetoid - basal ganglia

Ataxic - cerebellar





(True monoplegia or triplegia probably don't occur)



- lower limbs affected much more than upper limbs

- 75% eventually walk

- IQ may be normal

- strabismus is common



- extensive involvement

- low IQ, high mortality

- only 25% able to walk



- usually with spasticity

- develop early handedness

- 100% walk regardless of treatment


Mercer Rang's Stages of CP


Stage 1:  Dynamic contracture

- secondary to spasticity

- physiotherapy / orthotics / botox


Stage 2:  Fixed musculotendinous contractures

- tendon lengthening / transfer


Stage 3:  Bone & joint involvement

- osteotomy / arthrodesis + tendon lengthening




1.  Weakness   


UMN lesion / loss of voluntary movement


2.  Spasticity


Feature of all pyramidal lesions

- excessive activity of disinhibited neurones / overactive stretch reflex

- hypertonicity with increased DTR

- clonus


3.  Contracture


Shortening of the muscle-tendon unit due to failure to keep pace with bony growth

- normally muscles lengthen as bone grows

- as bone grows this worsens spasticity and shortens muscle

- as the muscles don't lengthen get contractures


The sarcomeres add to the muscle at the musculotendinous junction in response to stretch


4.  Deformity


Secondary to unopposed muscle contracture

- worse in all cases where muscles cross 2 joints

- psoas, RF, hamstrings, T Achilles


Hip dislocation

- persistent adduction leads to valgus neck

- persistent flexion leads to anteverted neck

- acetabular dysplasia (deficient posteriorly), hip subluxation and dislocation can follow


It is actually uncertain how increased / decreased tibial torsion and increased femoral anteversion appear




CNS lesion 

Abnormal neurological activity 


Reduced muscle excursion and growth 


Joint instability 

Subluxation / Dislocation 

Degenerative arthritis 


Clinical Features


Spastic Quadriplegia


Usually due to cerebral anoxia



- floppy child that won't feed

- choking during feeds - bulbar palsy

- failure to thrive


The primitive reflexes (Babinski, Moro, Parachute) are preserved


Intelligence / vision / hearing affected

- usually mentally impaired

- may have epilepsy


Only 10-20% will walk 

- can be delayed up to 7 years

- hip dislocation and scoliosis will develop in non ambulators


Spastic Diplegia


Usually due to prematurity


Lower limb affected more than upper

- all milestones delayed

- most walk by 4 years of age


Can vary from mild toe walker to non-ambulators 


Try to improve efficiency of gait 


Spastic Hemiplegia


Usually due to obstetric complications


Usually noticed at walking age

- don't swing one arm

- limp with one - handedness


Right-sided form may have speech delay


Seizures common


All walk independently 

- aim to improve walking appearance or posture of upper limb 




Gross motor function classification system


I  Essentially normal, decreased speed and balance

- walk stairs without aids

- some difficulty on uneven ground


II Hand rail up stairs


III Walker inside, wheelchair outside


IV Wheelchair inside and out


V Nil head support


Orthopaedic Management




1.  ADL's


Upper limb / spine


2.  Mobility


Walking / transferring

- keeping a GMFCS III walking is crucial 

- keeps them out of nursing Home



- 25% TBI (Total body involvement)

- 100% hemiplegics

- 75% diplegics


Prognostic signs

- > 2 primitive reflexes over 1 year poor sign

- should sit at 2 years, walk at 4 years

- TBI v hemi v diplegic




Expert field


Should never decide on treatment at one visit 

- variable nature


Gait analysis lab 

- can help decide best options 


Single Event Multi Level surgery (SEML)

- avoid birthday syndrome (where children are operated on every year)

- has a psychological impact


Surgery between 4-8 years 

- after 8 years tend to develop fixed deformity


Non-operative Management




No scientific evidence that it alters the outcome

- very important nontheless

- high contact with parents  / children

- keeps joints as supple as possible


Cast correction


Young and mild cases




Useful particularly in the equinus ankle where it can be maintained plantigrade in AFO




Botulinium toxin Type A

- blocks acetylcholine release at NMJ

- 50-60% patients respond well 

- for dynamic deformity UL or LL (R1 v R2)



- every 6/12

- peaks at 4/52

- lasts 3-4/12

- at MT junction

- are maps of injection for every muscle in body



- useful in T Achilles

- useful in hamstrings

- overused in psoas

- very useful in UL



A.  Will only fix dynamic spasticity not fixed contracture of muscle

B.  Expense - $500 per IU




R1 v R2

- R1 is passive range of motion performed slowly

- R2 is passive range of motion performed quickly

- a difference between the two indicates dynamic component




Potentiates GABA


Intrathecal Baclofen


GABA analogue




Gilmartin J Paed Neurology 2000

- significant improvement over placebo 

- indicated for spastic quads / TBI

- pump under abdo wall with reservoir

- into spinal cord


Selective Dorsal Rhizotomy 


Best for Spastic Diplegia < 9 without contractures

- need strong legs (as lose some strength with loss of spasticity)

- able to cooperate in rehab

- UL improvement also





- stimulate rootlets to find which mediate spinal reflex

- if only these cut, sensation unchanged

- 30% of dorsal rootlets cut

- decreases feedback from stretch receptors




Spinal deformity

Weakness / parasthesia / bladder problems


Operative Management




1.  Inability to control spastic deformity by non operative measures


2.  Fixed deformity that interferes with function


3.  Joint instability




Stage 1

- physio to help prevent contractures

- botulinum

- splints

- selective posterior rhizotomy


Stage 2 

- tight muscles released / lengthened

- weak muscles augmented by tendon transfers


Stage 3 

- fixed deformities corrected by osteotomy / arthrodesis





Benefit most from Treatment




1. Tight psoas / Adductors / Hamstrings / T Achilles

2. Increased Femoral Anteversion

3. External Tibial Torsion

4. Valgus Foot




Surgery once walking but before school (3-4)

SEML surgery

Gait analysis lab




True equinus

Apparent equinus (FFD knee and hip)








Contracture of iliopsoas is cause

- preserve iliacus to maintain strength of hip flexors

- lengthen psoas at pelvic brim / Sutherland release not divide at LT

- Sutherland release at brim


B.  Adduction Contracture


C.  Internal Rotation Deformity


Causes intoeing / scissoring gait

- cause unclear

- children with tight hamstring can only sit in W position

- ? causes femoral anteversion


Early release of hamstring can decrease intoeing


DRVO proximal femur




A.  FFD 

- due to hamstring contracture

- often unrecognised co-contracture of quads / rectus femoris

- if hamstrings alone lengthened, stiff flexed knee gait becomes stiff extended knee gait


B.  Spastic Crouch Correction

- gait with flexed knees & hips

- release psoas / hamstrings / rectus


Ankle & Foot


A.  Ankle Equinus


True equinus

- tight T Achilles


Apparent equinus

- tight hamstrings

- patients use equinus to extend knee

- if release T achilles in this situation will cause crouch gait


B.  Ankle Equinovalgus


3 Solutions

- Evans Procedure / Lateral Column Lengthening

- STJ fusion & T Achilles lengthening

- Triple Arthrodesis







- ankle foot orthosis

- knee ankle foot orthosis



- ground reaction AFO


Kaye walker 

- seat on it

- co-ordinates walking


Reciprocal Gait Orthoses




Short adducted leg - dislocated hip


Kyphosis - query secondary tight hamstrings




Decreased velocity 


Coronal Plane

- scissoring / tight adductors)

- asymmetrical arm swing / hemiplegia

- LLD / hip dislocation



- equinus / jump / crouch 


A.  Equinus

- ankle in equinus

- knee straight or in recurvatum

- hip extends full


B.  Jump

- equinus of ankle

- flexion of knees and hips, never extend fully


C.  Crouch

- ankle in dorsiflexion

- over lengthening of T Achilles

- have to flex knees and hips to regain centre of balance 


Lower Limb


R1 - do slowly

R2 - do quickly


Looking for a difference between the R1 and R2

- if reduced ROM on R2, have spasticity / dynamic element

- amenable to botox




1. Psoas

- FFD / Thomas test

- must test knee first

- do over edge of bed if FFD knee


2. Adductors

- scissored gait if bilateral

- apparent leg length inequality if unilateral

- Trendelenburg gait 

- decreased hip abduction


3. Hamstrings

- FFD at knee

- knee flexed at start of stance phase


Popliteal angle (hip flexed at 90°)

- straight is 0˚


Unable to sit up with legs straight

- decreased  SLR

- can't touch toes


4. Triceps Surae

- ankle equinus

- tiptoe gait


Silverskiold test 

- distinguish between the gastrocnemius and soleus

- test ankle DF range with knee flexed and extended

- if gastrocnemius tight, reduced DF with knee extended


On side


5. Iliotibial Tract


Obers' test 

- patient on side and flex knee with hip in neutral abduction then as flex knee further hip abducts 




6. Quadriceps

- stiff leg gait

- inability to flex knee with hip extended suggests tight rectus


Ely test (RF)

- child prone 

- when the knee is flexed the hip flexes suggesting tight RF


7.  Rotational profile




Increased / clonus / clasp knife






Primitive Reflexes



- child supine in arms, allow head to drop back 

- arms & legs stick out in extension

- disappears by 4 months



- arms and legs extend when child held prone

- appears at 5 months



- tone reduced & arms/legs flex when prone but increased tone & extended arms & legs with supine position


Upper Limbs 



- resting position

- contractures

- joint stability


Hand placement

- ability to place hand in space

- < 10 seconds



- ability to identify ojects in hand without looking




1.  Lower limb


All walk

- Ankle > knee > hip



- most require operations for ankles



- unilateral underdevelopment

- LLD 0-5cm (average 2cm)


2.  Lower limb

- one handedness

- decrease movement in swing

- astereogenesis

- usual upper limb contractures




4 problems


1. Equinus 

2. Weak Dorsiflexion

3. STJ Varus

4. Valgus




Non operative


Up to age 4


- Botox

- corrective casts for fixed equinus





- > age 4

- nil heel strike

- recurvatum with fixed equinus 



- Bauman

- Strayer


Remember "Little equinus better than calcaneus"

-  use Gait analysis 


Foot Drop after T Achilles Release




Leaf spring AFO / Articulated AFO




Tendong transfer

- tendon active in swing phase to foot dorsum

- FDL is the best option

- dynamic EMG to decide


Dynamic Equinovarus




Passively correctable

- Botox





Gait analysis important

- caused by T anterior: varus in swing

- caused by T posterior: varus in stance and swing


T posterior

- split transfer to PB

- + T achilles lengthening


T anterior

- SPLATT + T achilles lengthening


Bony changes


Triple arthrodesis


Valgus Deformity


Less Common



- often due to tight T achilles

- attempt DF by escape into valgus




Respond to T achilles lengthening


If severe need Triple arthrodesis


Upper limb


4 problems


1.  Thumb in palm

2.  Flexed wrist / fingers

3.  Elbow contracture

4.  Shoulder IR and Adducted




If astereognosis, correcting the hand posture is unlikely to give functional gains 


Need voluntary control & desire to manipulate environment


Thumb in Palm Deformity


Common but difficult to treat




A.  Adductor Pollicis & Short flexors released

- may need release web space contractures

- FPL lengthened


B. EPB ± EPL reinforced with PL, FCR or BR


C. MCPJ stabilized by capsulodesis or arthrodesis


Wrist & Finger Deformity




Flexed and pronated wrist

Flexed fingers + Swan Neck




Shortening of FCU / FDP / FDS / Pronator

Weakness of wrist extension




Wrist deformity


- wrist arthrodesis salvage


Finger Flexion

- lengthening at musculotendinous junction


Swan-Neck Deformity

- FDS Slip tenodesis PIPJ


Elbow Flexion Contracture



- >45°






Z-Lengthen of Biceps insertion / release of lacertus fibrosis / Release of brachialis


Distal release of PT for pronation contracture


4.  Shoulder


Usually IR & Add




Release of SSC & T major  ± P major






Prevent contractures

Prevent dislocations

Improve walking 

Provide stable and painless sitting

Allow perineal care




Hip Dislocation

Adductor contractures

Flexion contractures


Windswept hips


Hip Dislocation


Natural History


Accepted that a dislocated hip in CP is painful

- unilateral dislocated hips should be reduced unless deformity of femoral head has developed

- less certain of management of bilateral hip dislocation

- importance of vigilant screening




Excessive femoral anteversion

- ? due to tight hip flexors


Excessive neck valgus

- ? due to tight adductors


High Risk


GMFCS 3 / 4 / 5

Spastic quadriplegia

Those wheelchair bound at high risk


Rates Hip Dislocation associated with GMFCS


I    0%

II   15% - adductor surgery


IV  70% VDRO

V   90% VDRO




Non-ambulators annual X-ray essential

- treat tight adduction early / <5 years

- minimum 40° abduction with knees flexed




Reimer's Migration Percentage

- % of epiphysis lateral to acetabulum

- > 30% high risk & requires intervention




Early ST release +/- bony reconstruction 


> 8 years require pelvic procedure (minimal remodelling)


Severely deformed hip - don't reduce


Severe pelvic obliquity / scoliosis - address first




1.  < 5 years old + MP > 30%

- soft tissue procedure

- adductor +/- psoas if tight

- preventative measures

- can use botox


2.  > 5 years old + MP > 30%

- likely to progress

- adductor release + VDRO / varising derotation oseotomy


3.  > 8 years old

- must address acetabulum / add pelvic operation

- CP acetabulum is deficient posteriorly / DDH deficient anteriorly

- Salter worsens posterior deficiency

- Periacetabular osteotomy / Dega


4.  Deformed femoral head / salvage

- Schanz osteotomy / pelvic support osteotomy

- excision deformed femoral head

- valgising osteotomy

- suture ligamentum teres to psoas tendon remnant


Adduction Contractures




Adduction < 30o




Tenotomy adductor longus at groin

- open or percutaneous


Obturator Neurectomy 

- may lead to abducted position and affect gait in ambulators

- not recommended

- it denervates adductor brevis which is an important antigravity muscle

- wide base gait

- no improvement with regard to hip stability with neurectomy over simple adductor tenotomy


Flexion Contracture




FFD > 20o

- lengthening psoas over pelvic brim

- must not do tenotomy if patient walks

- psoas is the main power driver for walking in these children

- may render them unable to walk




Sutherland technique

- find and preserve femoral nerve

- leave iliacus to preserve hip flexor strength






Increased PFA




Subtrochanteric FDRO


Windswept Hips




Pelvic obliquity

- elevated hip adducted and internally rotated 

- lower hip is abducted and externally rotated


Soft tissue releases


Adducted Hip

- psoas / adductors / hamstrings 


Abducted Hip

-  ITB / abductors



- VRDO both sides



Knee & Foot





A little equinus is better than calcaneus

A little valgus is better than varus

A little varus is better than severe valgus

TA lengthening is most over used operation in CP




A little knee flexion is better than recurvatum






Tight hamstrings 

- prevents knee extension with hip flexion


Often have co-spasticity with tightness of quads 

- unmasked when lengthen hamstrings

- limit the amount of knee flexion in gait 

- result in a stiff knee gait which is very energy inefficient

- i.e. must check Ely's / may need release of RF


Jump Gait 




Knee flexed / equinus ankle


Non-operative Management


Botox / physio


Operative Management


Lengthen hamstrings at the musculotendinous junction

- release the Semitendinosis with tenotomy

- intramuscular recession of Semimembranosus 

- usually leave biceps femoris

- aim for Popliteal angle of 70o


Stiff - Knee Gait


Spastic rectus femoris can cause limited flexion of knee during swing phase of gait 

- particularly after hamstring lengthening



- Transfer of this to sartorius / SemiT

- release of rectus is just as good

- find plane of tissue under vastus intermedius






Externally rotated tibia




TDRO / tibial derotation osteotomy

- supramalleolar

- anteromedial approach



Foot and ankle




1.  Equinus

2.  Equinovarus

3.  Valgus

4.  Hallux Valgus




T Achilles lengthening may be the most overused operation in CP

- over-lengthening will lead to slumping in the patient with spastic hamstrings and hip flexors

- crouched posture / debilitating calcaneus


Operative Options


1.  Formal Z lengthening / Zone 3 / tendon

- > 2cm lose up to 80% of power

- soleus important contributer to power

- soleus might not be tight

- Silverskiold test determines gastrocnemius tightness


2. Hoke triple percutaneous slide technique

- proximal and distal cuts medial 

- middle cut lateral

- similar problems to above


3. Musculotendinous release (Zone 1)

- best procedures

- Baumann - multiple perpendicular divisions of aponeurosis of gastrocnemius +/- soleus

- Strayer - gastrocnemius recession / single transverse division of aponeurosis of gastrocneumius






Tibialis posterior and T Achilles both tight

- most common in spastic hemiplegia 




1. Perform intramuscular recession

- never extramuscular procedure for fear of reverse deformity


2. Tibialis posterior split transfer to Peroneus brevis 

- very effective and preserves plantar flexion


3.  Hindfoot deformity fixed 

- Dwyer lateral closing wedge osteotomy 

- lateral calcaneal slide


Valgus Defomity




Always standing Xray of the ankle to ensure no ankle valgus as well

- Coby x-ray


Operative Options


1.  Grice extra-articular subtalar arthrodesis


Results of the Grice are not very good 


Scott etal JPO 1988

- 62 feet - 30% fail, 60% poor

- best in child 4-12 years 


2.  Evans lateral calcaneal lengthening + first MT plantarflexion osteotomy + T Achilles lengthening

- need first MT plantarflexion osteotomy to enable MT to touch ground post lateral calcaneal lengthening

- may need FDL to T Post transfer also


3.  STJ Fusion


Hallux Valgus


Should always fuse

- high failure with anything else 






Scoliosis 10 to 15 x more common in patients with spastic quadriplegia than spastic diplegia



- spastic quadriplegic patient

- long C shaped curve

- lumbar apex

- progressive past maturity

- pelvic obliquity / dislocated or subluxed hips

- can extend into cervical spine

- high risk of respiratory compromise




Sitting in wheelchair


Respiratory problems

Feeding difficulties (can lose peg in abdominal folds)


Non operative Management





- difficult to use


Modified chairs with supports


Operative Management




Curves > 45º

Documented progression of >10º

Deterioration in function especially respiratory




Sitting balance

- level pelvis and shoulders




Typically long instrumented posterior fusion

- proximal TP and pedicle hooks

- distal pedicle screws

- sublaminar wires to aid correction




Post operative pneumonia very high

- need to admit to ICU


Post operative ileus common


Infection rates high /  poor nutrition



Upper Limb

Indications for Surgery


Upper limb surgery is mainly in spastic hemiplegia

- many of the CP' s have sensory neglect for affected limbs   

- won't use limb post surgery anyway


Surgical indications

- a reasonable level of IQ (>70)

- spastic not athetoid 

- voluntary grasp and release

- intact sensation / stereogenesis

- good motivation

- hygiene




1.  Tendon lengthening / division

2.  Tendon transfer

3.  Tenodesis / arthrodesis




1. Lengthening is more predictable than transfer

2. Tendon transfers alone can never overcome rigid osseous deformity

3. Joints which are not under voluntary control should be tenodesed or arthrodesed before tendon transfer

4. Agonist-antagonist tenodesis (spastic coupling) is a good approach because it is symmetrical & balanced


Typical Posture


Shoulder - adducted and internally rotated

Elbow - flexed + pronated

Wrist - flexed + pronated

Fingers - swan-neck +/- flexed

Thumb - in palm




Soft tissue

- lengthening / release of P major and subscapularis



- external rotation osteotomy humerus





- contracture > 45o





- lengthen biceps / lacertus fibrosis / brachialis



- release CFO (Steindler) 

- distal release of brachioradialis and pronator teres + anterior capsulotomy



- release of pronator teres +/- transfer to radius (makes it a supinator of the forearm)

- if severe osteotomy of radius putting it in neutral rotation




Flexion deformity 


Class 1 (mild) 

- fingers can be extended with only 20o or less of wrist flexion 

- Release FCU or CFO slide (Steindler)


Class 2 (moderate)

- full flexion only possible with > 20o wrist flexion 

- A: extensor power present

- B: no extensor power

- CFO release

- transfer FCU to ECRB if no extensor power

- +/- FDS to ECRB transfer


Class 3 (severe) 

- great wrist & finger flexion deformity without extensor motors

- no functional gain is expected 

- surgery here is to improve cosmetic appearance only

- multiple releases +/- wrist arthrodesis




Swan neck deformity



- over pull of extrinsic extensors / central slip shortening / intrinsic spasticity

- final common pathway is volar plate incompetence with hyperextension at the PIPJ



- FDS tenodesis through a volar Brunner incision




Most crippling upper extremity deformity

- can be a significant hygiene problem in severely affected 

- may need surgery despite not fitting criteria set out above

- in practice surgery is directed at what the pathology is 


Type 1 

- weak EPL

- reroute EPL + reinforce with PL or FCR or brachioradialis


Type 2 

- intrinsic contracture & first dorsal interosseous tightness

- release webspace +/- Z plasty


Type 3 

- weak APL & EPB

- APL tenodesis reinforced with PL, FCR or brachioradialis


Type 4 

- spasticity of  FPL

- Z lengthening of FPL







1.  Grice

2.  Lambrinudi

3.  Dunn






Extra-articular STJ fusion

- lateral bony block in sinus tarsi

- prevents valgus deformity

- allows undisturbed foot growth




Flexible valgus hindfoot in children 4 - 12





Fixed hindfoot

CP - high failure rate

Varus - high failure rate




Ollier's incision

- oblique lateral incision

- tip of fibula to base 4th MT


Superficial dissection

- between peroneal brevis and tertius

- elevate EDB

- expose sinus tarsi

- remove all ST from talus and calcaneus

- grooves in calcaneum and talus

- no articular surface is exposed


Bone graft

- reduce hindfoot

- cancellous iliac (no structural)

- tibial wedge (structural)

- may supplement with metalwork / K wires


Post operative

- cast for 6/52


Dennyson and Fulford Modification of Grice


Cannulated screw

- across talus and bone block and into calcaneum





Graft slippage / residual deformity

Overcorrection into varus






Plantar flexion of the talus

- is eventually limited by abutment of the posterior process of the talus

- against the lower end of the tibia


Plantigrade forefoot is fused to the maximally flexed talus




Isolated fixed equinus deformity in patient older than 10 

- tight triceps surae / weak dorsiflexors

- polio most common cause in past


Argument exists that the procedure is not suitable for flail footdrop 

- recurrence of deformity due to stretching of the dorsal and anterior soft tissues

- need strong dorsal capsule +/- dorsal tendon transfers




Ankle joint instability - will be worsened by the procedure as narrow posterior part of talus is in the mortise

Painful pre-existing tibiotalar osteoarthritis

Severe knee or hip instability such that a brace must be worn

Age < 11 years


Operative Technique


Preoperative planning is essential

- lateral X-Ray taken with foot in extreme equinus

- tracing made and sectioned along lines of subtalar and midtarsal joints and size of wedges calculated

- wedges calculated so that forefoot is plantigrade or up to 10o of equinus in relation to the tibia

- hindfoot in neutral or up to 5o valgus

- greater equinus if need to compensate for short limb


Ollier incision

- expose sinus tarsi by elevate EDB

- Z sectioning of peroneal tendons

- CFL divided


Talar osteotomy done parallel to transverse axis of ankle joint with talus in extreme equinus

- microsagittal saw

- correct any hindfoot deformity by resecting appropriate calcaneal wedge 


V shaped trough fashioned in lower part of proximal navicular

- denude calcaneocuboid joint of cartilage

- sharp distal margin of remaining talus wedged into trough in navicular


K wire CCJ and TNJ 

- talus is locked in complete equinus such that no more plantar flexion can occur


N.B.  talonavicular pseudarthrosis is a common cause of failure

- ensure talus well medial in trough

- adequate width and depth of trough to allow sufficient bone contact


Postoperative management

- long leg POP 6 weeks (NWB)

- short leg POP 6 weeks (NWB)

- if united (attention to talonavicular joint) then remove cast and weight bear

- if not united then walking cast until united







- positioning of talus medially in navicular trough crucial 

- loss of correction of up to 20o in 10-20% of cases

- post-operative supination deformity


Painful ankle OA - will develop with instability or talar AVN / often asymptomatic


Talar AVN - avoided by leaving anterior ankle capsule intact



- vast majority talonavicular

- risk factors: early weight bearing, no K-wire fixation


Dunn Arthrodesis




Variant of triple arthrodesis

- adapted to improve muscle balance in paralytic conditions with a predominant weakness of the triceps surae (calcaneus)




Navicular and variable portion of talar head and neck resected

- foot is displaced posteriorly on remaining talus

- lever arm of triceps surae improved

- talus fused to cuneiforms












Congenital Talipes Equinovarus


Congenital abnormality of the foot characterised by 

- hindfoot equinus & varus 

- forefoot Adduction

- midfoot Supination


Latin: talus - ankle / pes - foot / equinus - horse like





- pipe stem calf

- short wide foot

- small heel

- curved lateral border

- short first ray ray


Short T Achilles




ER torsion tibia




1:1000 live births

- 1/1000 Caucasian

- 5/1000 Polynesians

- 0.5/1000 Asian


Boys 2:1


Bilateral 30-50%




Twin studies

- 33% risk in monozygotic twins

- 3% dizygotic twins

- i.e. is not just the placental environment


Sibling or parent

- 3% chance

- 30x increased risk


Sibling and parent

- 10 - 20% risk


Deletion on chromosome 2




Spina bifida & arthrogryposis (teratogenic)



- cerebral palsy

- muscular dystrophies

- spinal muscular atrophy


Theories of pathogenesis


1.  Fetal development arrest in fibular phase

- during first and second months leg and foot coplanar

- by beginning of third month foot is in 90o of equinus, has supinated & adducted with plane at right angles to leg

- by the middle of the 3rd month the equinus has corrected

- by the end of the third month the supination and adduction has corrected to the adult position

- Bohm postulated arrest in the first phase in week 5


2.  Retracting fibrosis (Ippolito and Ponseti)

- decrease in size & number of muscle fibres in posteromedial muscles

- ? fibrous tissue in muscles, tendon sheaths & surrounding fascia

- marked shortening and thickening of the tibionavicular and plantar calcaneonavicular ligaments   


3.  Neurogenic theory

- minor innervation changes in posterior muscles

- subsequent fibrosis and shortening


4.  Myogenic theory

- myofibroblasts in medial fascia


5.  Vascular theory

- anterior tibial artery / dorsalis pedis frequently missing




All tissues in foot abnormal

- bony / muscle / ST / vascular


Bony deformities



- primary deformity

- equinus

- medial deviation of head and neck of talus

- external rotation of body of talus in mortise

- narrow neck & hypoplastic head due to lack of development of articular cartilage on lateral surface of head


Os Calcis 

- equinus

- medial rotation 

- long axes of talus & os calcis are parallel in sagittal & transverse planes



- subluxed medially against medial malleolus



- medial column subluxed medially and adducted

- lateral & medial columns conjoined therefore cuboid subluxed medially also



- adductus but minor compared to talonavicular deformity


Soft Tissues 


Plantar fascia & intrinsics contracted

- long & short plantar ligaments

- contracture plantar fascia

- creates cavus


Tendons short

- T Achilles, T Posterior, FHL and FDL short


Ligaments short

- deltoid

- spring 

- calcaneofibular ligament

- posterior talofibular ligament

- bifurcate


Joint capsules contracted

- posterior ankle joint

- posterior subtalar joint

- talonavicular joint

- calcaneocuboid joint


Muscles atrophied




A.  Postural 

- passive correction possible

- usually corrects spontaneously within days / weeks

- well defined heel, no calf atrophy

- relatively normal foot size

- no transverse medial skin crease


Mild - nearly fully correctable

Moderate - partially correctable 

Severe - slightly correctable


B.  Rigid 

- uncorrectable

- small bean shaped foot, transverse crease, tight skin, atrophic calf

- heel difficult to palpate due to overlying fibrofatty tissue


C.  Teratogenic talipes 

- associated with spina bifida & arthrogryposis

- prognosis is much worse than idiopathic


Pirani Score


Pirani scoring system (0, 1/2, 1) (total out of 6)


Look (3)

- posterior crease / medial crease / lateral curvature


Feel (2)

- head of talus (anterior to lateral malleolus)

- empty heel


Move (1)

- DF range


Can be used to predict likelihood of needing TA tenotomy


Clinical Features




Deformity / CAVES

Cavus - relative pronation of forefoot c.f. hindfoot

Adduction - forefoot

Varus - heel

Equinus - heel

Supination - midfoot


Posterior / medial crease

Curved lateral border of foot

Calf atrophy


Walk older child


Dynamic supination - require T anterior transfer

Metatarsus adductus

Foot progression angle - tibial torsion









Empty heel

Palpable talus - devils thumbprint anterior to lateral malleolus

Navicular fixed to medial malleolus

Os calcis fixed to the lateral malleolus



- spinal dysraphism - look at spine

- arthrogryposis

- neuromuscular disorders


Rotational Profile




Usually not indicated



- calcaneal & talus ossification centres are present at birth 

- cuboid appearing by 6 months

- navicular will not appear until 2-4 years 




AP talocalcaneal angle / Kite's angle

- ankle DF 15° & tube at 30° from vertical

- long axis talus parallel long axis of calcaneum

- normal 20-40°

- <20° hind foot in varus / clubfoot axes approach parallel


Lateral talocalcaneal angle

- long axis of talus parallel to long axis of calcaneum

- normal 25-50°

- < 25° indicates hindfoot in equinus

- clubfoot axes are parallel or negative


Talo-1st metatarsal angle / AP

- long axis of talus to long axis of 1st metatarsal

- normal 5-15° abduction

- clubfoot 0° to negative





Non operative 


Ponseti casting


Aims of treatment

1. Correct the deformity early

2. Correct it fully 

3. Hold the corrected position until foot stops growing


- Denis Browne Boots




Start 1 - 3 weeks

- let parents settle and get used to diagnosis

- explain method and length of treatment required




5 - 6 casts applied weekly

- apply SL, then convert to LL

- minimal wool

- someone holds the foot corrected

- tight about foot and ankle, loose calf

- mould about LM /MM / TA

- covert to LL as high up as possible with soft cast

- use soft cast for this




Thumb on navicular, underhand, IF on heel


1.  Correct cavus

- increase supination / elevate first ray

- matching forefoot to midfoot / hindfoot

- pronating foot worsens cavus


2.  Increase abduction serially

- concept is rotation of calcaneus under the talus

- aiming to correct the STJ

- abduction / ER corrects the varus

- use talar head as fulcrum (Kite's mistake - cuboid)

- maintain elevation of first ray - avoid pronation


3.  No attempt to correct equinus til varus / adduction completely corrected

- usually by week 5



- forceful manipulation to correct equinus prior to correction of hindfoot varus

- will result in either a rockerbottom deformity or a flat top talus


Percutaneous tenotomy



- week 5 / 6



- abduction / ER 60o and DF < 10 - 20o

- 85% need tenotomy



- usually performed in OPD

- LA, beaver blade medially

- can go directly posterior


Post op

- ponsetti cast further 3/52 in abduction and DF




Once cast removed

- 23/24 hours

- 3/12


DB Boots


Denis-Browne / Mitchell boots

- worn at night until 4 years 

- shoulder width apart

- clubfoot 70o, normal foot 40o

- also corrects tibial torsion

- critical to success is compliance

- lack of compliance with DB boots strongly linked to recurrence




Successful 90 - 95%

- 5% require PMR / Ilizarov correction

- 7 - 15% need T anterior transfer


Follow up

- until 8



- metatarsus adductus

- dynamic supination


Operative Management


Open clubfoot release



- aged 9/12 to one year

- usually sufficient for child up to three 


Going out of favour

- joint violating surgery

- may increase recurrence

- increase late stiffness


Approach Options




Incomplete circumferential incision

- perform prone

- good exposure and access, especially lateral

- disadvantage heel pad necrosis




Posteromedial incision 

- curved from base of 1st MT above posterior tubercle of calcaneus to the T achilles

- difficult to explore the posterolateral corner

- may need a seperate lateral incision especially in older child




Two incisions

- curved incision from centre of os calcis to talonavicular joint 

- second incision halfway between T achilles & lateral malleolus


Clubfoot Releases




Identify and protect NV bundle

- first thing

- put vessiloop about them


Tendons behind medial malleolus

- T achilles z lengthened

- T posterior z lengthened

- single suture placed


Capsulotomy AKJ / STJ


Identify Knot of Henry above Abductor Hallucis

- reflect Abductor Hallucis downwards

- may be easiest to follow down from ankle

- release plantar fascia

- section / Z lengthen FDL / FHL


Open and reduce TNJ - K wire


K wire up through STJ




Divide CFL

Open and reduce CCJ

- stabilise with K wire


Post op

- plaster for 6/52, then AFO 3/12





Residual & Recurrent Deformity



1.  Dynamic supination - weak peronei

2.  Metatarsus adductus with curved lateral border of foot 

3.  Tight T achilles

4.  Residual or recurrent equinovarus

5.  Overcorrection / valgus




Soft tissue procedures

Bony procedures


Dynamic Supination




Tibialis anterior inserts into base first MT and medial cuneiform




Split tibialis anterior tendon transfer / SPLATT

Full tibialis anterior tendon transfer / TATT


Both usually in combination with T achilles tenotomy





- < 3

- for dynamic supination / early recurrence

- correct with ponsetti cast 3/52 first

- transfer will only hold correction



- supine, tourniquet

- 2 cm incision over base first metatarsal

- harvest lateral half of T anterior

- divide with knife distally and take off bone

- 2 cm proximal incision above extensor retinaculum

- insert tendon forcep under extensor retinaculum

- grasp lateral half of tendon

- pull proximally out of wound

- tendon will tear nicely along midsubstance

- 2 cm lateral wound over P brevis insertion into base 5th metarsal

- make tunnel under fat between lateral and proximal wound

- pass tendon forceps,  transfer T anterior subcutaneously 

- Pulvetaft weave to P brevis

- make split in P brevis, pass T anterior through

- tension tendon with foot held reduced / pronated

- suture onto itself multiple times

- Ponseti cast for 6/52





- > 3

- for dynamic supination / early recurrence

- need to have bony ossification lateral cuneiform

- indicated in 7 - 15% of cases



- harvest full T anterior as above

- 3.5 mm drill hole through lateral cuneiform

- tie over button


Metarsus Adductus



- depends on age 

- depends if deformity in metatarsals or tarsus




1.  ST release

- abductor hallucis brevis + plantar fascia

- young < 5


2.  MT osteotomies

- deformity distal to navicular


3.  Lateral column shortening  and medial ST release

- medial soft tissue release and medial column lengthening 

- shortening of the lateral column - decancellation of cuboid / closing wedge osteotomy


4.  TDRO / Tibial derotation osteotomy


Hindfoot EquinoVarus




Later age > 5

- soft tissue procedures insufficient

- bony procedures required




1.  Lateral sliding calcaneal osteotomy / lateral closing wedge osteotomy

- varus


2.  Wedge tarsectomy

- correction of equinus


3.  Talectomy 

- rarely indicated

- arthrogryposis or severe neuralgic clubfoot

- resect cuboid also to maintain balance of columns


4.  Ilizarov

- excellent salvage

- correction of equinovarus


Hindfoot valgus








Lambrinudi - for fixed equinus in patients 10 years or older


Triple arthrodesis

- good correction of all elements of club foot 

- used in the late presenting child or late recurrence

- should not be used before foot has stopped growing because it shortens the foot / stops growth







Deformity characterised by 

- dorsiflexion of calcaneus 

- plantarflexion of forefoot / plantaris / forefoot equinus


Both sides of foot have elevated arch




Weakness of triceps surae 

- polio - most common worldwide

- spina bifida


Polio LegPolio Leg



Spinocerebellar degeneration / Friedreich's Ataxia


Spinal dysraphism

Compartment Syndrome / Deep Posterior 




Imbalance of T achilles and dorsiflexors

- dorsiflexion of calcaneus

- moves insertions of T achilles anterior

- further weakens the lever arm


Forefoot becomes flexed because of

- gravity 

- action of muscles during gait




Difficulty walking 

Obvious deformity 

Shoe fitting & wear problems 

Painful callosities




Elevated longitudinal arch 


Prominent heel with abundant callus on plantar aspect 

- called pistol grip deformity 

- usually claw toes 


Heel usually in neutral




Lateral XR Foot 


1.  Calcaneal pitch > 30o

- dorsiflexion of calcaneus  

- < 20o normal


2.  Meary's angle > 10o

- talus - first metatarsal


MRI Spine


Exclude Spinal dysraphism






Modification of shoe wear / orthoses






1. Correct deformity by soft tissue releases & osteotomy

2. Tendon transfer to calcaneus


Age 0-5



- spina bifida

- other conditions cause little disability

- don't operate




1.  T Achilles to fibula 

- prevents varus & stimulates fibula growth


2.  T Anterior to T Achilles


Age 5-12


Grice arthrodesis STJ + T Achilles transfer to fibula


Age > 12


Triple arthrodesis






Condition present at birth

- ankle dorsiflexed & in valgus

- foot abducted




1 in 1000 births




Probably result of intrauterine positioning

- packaging defect







Increased incidence of flexible pes planus in later life




Foot can usually be completely corrected passively




Congenital Posteromedial Bow of Tibia

- foot dorsiflexed

- tibial bow can be palpated

- confirmed with Xray

- not harmful

- can be associate with LLD / 2 cm

- strong association with calcaneovalgus


Congenital Vertical Talus

- calcaneus in equinus

- rockerbottom deformity

- deformity can't be corrected

- confirmed on xray


Neurological Dysfunction

- spinal dysraphism L5

- absence of triceps surae function

- may be cutaneous manifestation on back

- confirmed with spine xray




Usually resolves spontaneously in first year


If severe, treated with regular manipulation


Occasionally need plantarflexion-inversion splintage








Congenital Vertical Talus



Rockerbottom foot / Persian Slipper Foot






50% bilateral


Doesn't delay walking

- may present in toddler with callus under talus head




Congenital anomalies

- CNS disorders

- spina bifida & diastematomyelia ~10%

- arthrogryposis

- neurofibromatosis 


- Trisomy 15-18





- result of muscle imbalance

- arrested foot development



- contracture of T Achilles posteriorly pulling calcaneus into equinus 

- contracture EDL anteriorly pulling navicular dorsally

- absence of plantar intrinsics







- in equinus / valgus / laterally displaced

- sustentaculum tali hypoplastic & doesn't support head



- hypoplastic & in plantar flexion 

- only posterior 1/3 articulating with tibia



- displaced dorsally onto talus neck 

- wedge shaped


Forefoot abducted





- triceps contracted



- T anterior, long extensors & peronei are contracted


T posterior & peronei subluxed anteriorly / become dorsiflexors




STJ facets abnormal

CCJ abnormal




Dorsal ligaments contracted


Interosseous Talocalcaneal Ligaments / Dorsal TN

- thickened and contracted


Attenuated spring ligament


Clinical Features


Plantar aspect of foot convex

- rocker-bottom appearance



- heel in fixed equinus

- key differential positional calcaneovalgus



- dorsiflexed

- abducted


Head of talus prominent

- palpable medially in sole



- medial column long & convex

- lateral column abducted

- tight tendoachilles





- talus vertical

- calcaneum equinus

- increased talo-calcaneal angle / near 90o

- TNJ dislocated


Maximum Dorsiflexion view

- fixed equinus, talus still vertical


Maximum Plantarflexion view

- irreducibility of midfoot onto hindfoot

- relationship of talus to navicular fixed & rigid




1. Severe positional calcaneovalgus

2. Severe idiopathic flatfoot (with oblique talus)

- can reduce the TNJ with DF

3. Valgus everted foot of CP 

4. Overcorrection of CTEV with broken midfoot








Reverse Ponseti technique

- some good results reported

- stretches tissue preoperatively






Correct hindfoot equinus

Correct forefoot dorsiflexion

Reduce dislocated TNJ




One or two stage /  usually one stage




Between 12 and 18 months




Cincinnati incision 

- patient prone

- from medial cuneiform to lateral malleolus


Release hindfoot equinus

- T Achilles lengthening

- posterior capsulotomy AJ & STJ

- release interosseous talo-calcaneal ligament

- release CFL / PTFL


Reduce TNJ

- capsulotomy TNJ & locate head

- K wire


Release forefoot dorsiflexion

-  lengthening of EDL, EHL & T Ant

-  ± calcaneocuboid capsulotomies 



- calcaneum fixed to tibia via wire through heel

- 2nd wire across TNJ in PF

- ± Wire across CCJ


Tibialis Anterior usually transferred to neck talus


Late Presenting


Age 2-6

- subtalar fusion if painful

- Grice arthrodesis



- triple arthrodesis


Metatarsus Adductus



Metatarsus varus

- adduction of the forefoot at the TMTJ


Intrauterine positional deformity / packaging defect





- M = F 

- bilateral in 50%

- 10% have CDH







- intrauterine positioning defect

- prone nursing




85% resolve by age 3 years



- 31 patients 45 feet with 33 year followup

- 16 feet mild or mod deformity passively correctable, no treatment

- 29 feet partially flexible or rigid treated manipulation or casting

- good results in all the untreated feet

- 90% good results of the casted feet


No poor results






Hyperactive Abductor Hallucis



Clinical Features


Curved lateral border

- forefoot adducted & slightly supinated

- deformity usually fully correctable

- prominent base of 1st metatarsal


Heel Bisector line

- line through midline axis hindfoot

- should pass through second web space


Intoed gait

- exclude ITT

- exclude PFA




Metatarsus adductus

- full range of ankle dorsiflexion & mobile hindfoot




Grade 1 - actively correctable deformity

Grade 2 - passively correctable

Grade 3 - unable to passively correct




Not routinely required








< 6/12

- observation only

- sleep supine


> Age 6/12

- rigid deformity

- serial casting changed every 2 to 3 weeks

- 8-12 weeks treatment

- most will tend to partially recur over time


Operative Management






Surgery if difficulty wearing shoes / severe / > age 3




1.  Abductor hallucis release 


2.  MT osteotomy


3.  Supramalleolar derotation osteotomy


4.  Opening wedge osteotomy medial cuneiform, closing wedge osteotomy cuboid, osteotomies of 2-4


Pes Planus



No good definition

- flexible flat foot

- medial longitudinal arch of foot in weight-bearing is in contact with ground or closer to ground than 'normal'





- almost always bilateral

- strong familial tendency






All infants have flat feet

- at birth foot is in calaneovalgus & there is no medial arch

- when child begins to walk, feet evert & ER 

- foot has large medial fat pat 


Arch begins to develop in 2nd & 3rd year to variable degree


Thus flatfeet are

- usual in infants

- common in children

- in normal range for adults




Due to another anatomical variation


1. Genu Valgum

- physiological knock-knees most pronounced at age 3-4

- leads to apparent flatfoot

- corrects by ~ age 6


2. Out-Toeing

- ER of foot causes body weight to fall anteromedial to ankle

- result is valgus of heel & flatfoot


3. Tight Tendo achilles

- lack of DF compensated by heel eversion & forefoot pronation


4. Joint laxity

- i.e. Marfan's, Ehlers-Danlos




Almost always asymptomatic

- may cause aching midfoot

- pain incidence may equal general population




On weight bearing have combination of

- flat longitudinal arch

- pronated forefoot

- valgus heel


Flexible flatfoot

1. Foot appears normal when suspended / NWB

2. Recreation of longitudinal arch & heel varus on toe raise / windlass

3. Recreation of longitudinal arch by passive DF of Hallux (Jack's test) with weight bearing

4. Mobile or hypermobile STJ

5. Weight bearing callus on lateral longitudinal arch


Physiological FlatfootJacks TestSingle Heel Raise Arch Restoration


Must look at back

- exclude spinal dysraphism







- compensatory - tight T achilles / out-toeing / genu valgum

- physiological


Rigid - CVT / tarsal coalition / skewfoot




Trauma - midfoot fracture / Lisfranc / rupture spring ligament / rupture plantar fascia

Neuromuscular - CP, spina bifida, polio




Pes Planus Xray Mearys Angle


Weight bearing lateral and AP

- Meary's angle - talo - first metatarsal < 100


Harris axial / oblique for coalition



- hindfoot alignment view

- see that calcaneum is under the fibula not tibia




Look for coalition





- coalition

- inflammatory arthritis

- tibialis posterior dysfunction








Usually resolves by age 5 or 6

- 20% adults have some degree of asymptomatic flexible flatfoot

- no treatment needed unless symptomatic


Some patients will suffer from midfoot pain






Wenger 1989 JBJS

- orthoses & shoe modifications have no effect on outcome


Will not reverse pes planus


Indications insoles

- relieve pain 

- allay parental anxiety

- improve life of footwear



- soft - heel cup + arch support

- hard - custom moulded insole / UCBL insert






Disabling pain not responsive to non-operative measures




Skeletally immature

- Grice arthrodesis

- subtalar arthroesis + plantarflexing medial cuneiform osteotomy


Skeletally mature

- medial sliding calcaneal osteotomy

- lateral column lengthening + 1st metatarsal plantarflexing osteotomy


Subtalar arthroeresis with plantar flexing medial cuneiform osteotomy




Sinus tarsi implants

- axis altering device / blocking

- resist excessive pronation

- prevent adaptive changes


Lateral column lengthening / Evans procedure + 1st Metatarsal Osteotomy




Lengthen lateral column


Have to combine plantarflexion first MT osteotomy to enable toe to touch floor


Pes Planus Lateral Column Lengthening FDL transfer and Metatarsal OsteotomyPes Planus Lateral Column Lengthening FDL transfer and Metatarsal Osteotomy





- oblique Ollier's / from tip of fibula

- must preserve peroneals and sural nerve

- reflect peroneals  superiorly

- elevate EDB



- 1.5cm proximal to CCJ

- vertical incision in periosteum

- osteotomy between middle and anterior facets medially

- care to protect medial NV bundle



- use osteotome to free medially

- lamina spreader

- open 1 cm, bone graft

- fixation varies - plate, staple


Medial incision

- medial reefing of spring ligament

- tightening of tibialis posterior +/- FDL transfer


First metatarsal plantarflexion osteotomy





Pre-axial / great toe / 15%

Central / 2-4 MT / 5%

Post-axial / 5th MT / 80%


Type A - articulated

Type B - rudimentary 




2 in 1000 births

- 30% positive FHx

- autosomal dominant


Associated MT anomalies common

- block MT / Y-shaped / T-shaped /wide head




Rudimentary / Type B

- ligate at birth 

- allow to auto-amputate


Articulated / Type A

- excise at 1 year

- do at any time before school



- medial toe excised



- usually lateral excised 

- unless have syndactyly to 4th

- address MT or syndactyly at same sitting






Polysyndactyly:  duplication + webbing

Zygosyndactyly:  webbing alone

Acrosyndactyly:  distal webbing / Apert's




Usually none required



Skew Foot



Larsen Syndrome 

- AD, very rare

- associated with ligamentous laxity and dislocations, amongst other things




Hindfoot valgus

Talonavicular lateral subluxation

TMT adduction




Difficult to treat




1.  Medial calcaneal sliding osteotomy


2.  Opening wedge cuboid osteotomy


3.  Closing wedge cuneiform osteotomy


4.  Metatarsal osteotomy


Tarsal Coalition



Congenital fibrous, cartilaginous or bony connection of 2 or more tarsal bones

- due to failure of segmentation


Peroneal Spastic Flat Foot

- tarsal coalition

- tarsal pain

- reduced STJ motion

- rigid pes planus

- peroneal muscle spasm / tightness




Present in 6% of population

- symptomatic in 1% of population


Bilateral in 50%


20% multiple coalitions


AD with variable penetrance


Calcaneo-Navicular most common (2/3)

- talocalcaneal middle facet is next most common (1/3)

- rest uncommon




Symphalangism (congenital end to end fusion of phalanges)


Fibula hemimelia

Other gross limb anomalies




Secondary to failure of differentiation & segmentation of mesenchyme

- supported by intertarsal bridges in fetal tissue




Multiple coalitions may occur

- do 2 plane CT with fine cuts to look for other coalitions

- will get poor results if not addressed


May develop ball and socket ankle joint

- due to stiffness of STJ

- develop inversion / eversion in AKJ


Valgus deformity leads to adaptive shortening of peroneal tendons

- may cause reflex spasm of tendon




1. Location

- CN / TC / TN / CC


2. Ossification

- synostosis - completely ossified

- synchondrosis - partly cartilaginous

- syndesmosis - fibrous




Majority are asymptomatic & remain so in adulthood


If symptomatic, symptoms usually develop in adolescence when bar ossifies

- due to reduction in STJ movement & joint stress


Calcaneonavicular coalition

- 8 - 12 years of age


Talocalcaneal coalition

- 12 - 16 years of age




Present with

- recurrent ankle sprains

- pain over sinus tarsi or over sustentaculum tarsi

- vague aching pain aggravated by activity




Stiff STJ 

- especially talocalcaneal bar

- may still have movement if not ossified


Fixed Pes Planus 

- doesn't correct on heel raise or Jack's Test

- heel doesn't swing into varus

- valgus heel with talocalcaneal bar


Peroneal tendons may be shortened but rarely spastic






Oblique xray

- often diagnoses CN bar

- Anteater sign - elongated process on calcaneus or prolongation of navicular 




1.  Talar Beaking

- very suggestive of TC bar

- traction spur due to increased stress


Talar Beaking


2.  C sign

- seen on lateral xray

- continuous C shaped line

- from talus to sustenaculum tali


3.  Ball and socket ankle joint

- secondary to TC bar


4.  Harris axial view

- visualise talocalcaneal

- 40° axial view shows middle facet 

- ski jump view




May be helpful for cartilaginous or fibrous bar



CT scan


Very good for bony bars




Any condition that injures STJ

- traumatic / osteochondral fracture

- inflammatory / RA

- tumour / osteoid osteoma

- infection


Flexible flat foot








Avoid aggravating activities

Moulded longitudinal arch support

SL FWB cast for 6/52







Persistent pain

Minimal degenerative changes




Resection of bar

Isolated STJ fusion - degeneration of STJ only

Triple Arthrodesis - rigid planovalgus foot


Criteria for Resection


All relative

- young < 14 years

- absence of complete bony bar

- no degenerative changes 

- presence of talar beaking is not a contraindication

- no fixed deformity


Calcaneonavicular bar resection


NHx compared with talo-calcaneal bar

- possibly settle down long term

- better prognosis / less arthritis / present younger

- more likely amenable to resection

- most do well




Aim is 1 cm gap


Ollier approach

- 1cm distal to fibular tip

- obliquely across sinus tarsi

- to superolateral margin TNJ


Superficial Dissection

- protect superficial CPN

- EDL & P tertius anteriorly / peroneals plantarward


Deep dissection

- elevate EDB proximal to distal  

- beware of its motor branch from DPN

- show sinus tarsi / anterior process calcaneum

- expose bar

- may need to open TN and CC joints to know exact location



- resect 1cm of bone with osteotomes

- protect talus and STJ from damage

- check with on table oblique lateral II

- suture fat / EDB into defect / over button and felt pad


Post op

- 2 weeks POP

- moon boot / WBAT /ROM

- button out at 6/52




Gonzalez et al JBJS Am 1990

- 75 feet in 48 patients

- good or excellent results in 77%

- poor in 7%

- best results with cartilaginous coalition and patients < 16


Mubarak et al J Pediatr Orthop 2009

- CN resection and fat graft interposition

- 5% incidence of symptomatic regrowth requiring repeat resection

- 74% had improvement of subtalar joint motion

- 82% improvement of plantarflexion

- felt fat graft better choice than EDB as can completely fill gap


Talocalcaneal Bar




1/3 develop arthritis

- operative results not as successful as CN

- resection more difficult

- results less predictable

- tend to be more conservative with this than CN bar 





- < 16 years

- < 50% surface area of posterior facet 

- nil arthritic changes

- < 16o valgus



- > 50% of post facet 

- i.e. middle facet bar is > 50% of posterior facet

- heel valgus > 16°

- narrowing of STJ i.e. arthritic changes

- lateral talar process impinging on calcaneum





- is best option if failed non-operative

- always worth trying prior to arthrodesis

- try to return some STJ motion


Calcaneal Osteotomy

- re-centres heel

- realigns weight bearing

- not everyone uses it



- in mature foot > 12 years


Resection Technique 



- curved incision

- navicular tuberosity to medial border T Achilles

- 2cm superior to superior calcaneal tuberosity


Superficial dissection

- through flexor retinacular sheath 

- elevate T Post and FDL tendon anteriorly

- neurovascular bundle and FHL retracted plantarward

- identify posterior facet



- resection of bone until middle facet seen + mobile

- remove more bone from talus than sustentacular side 

- 2/3 of resection from talus

- key to operation is anterior process of calcaneus & follow posterior

- fat graft or silicon insertion


Post operative

- early ROM important




Very rare

- ossifies at 3-5 years

- therefore symptoms early


Toe Walking



70% male

70% positive FHx

20% learning difficulties


DDx toe walking


Early / late onset

Unilateral  / bilateral


1.  Habitual


Toddlers - child can heel walk


2.  Structural


Fixed equinus - CTEV / arthrogryposis

Short / tight T Achilles

Space occupying lesion in calf


3. Neuromuscular



Spinal dysraphism

Duchenne's Muscular Dystrophy



4. Short Leg


Real (DDH)

Apparent (knee or hip deformity)


Natural History Habitual


Initially toddlers walk on toes 3-6/12

- graduate to strike on flat of foot

- rinally develop normal heel-toe gait

- mature gait pattern by 3 years


Idiopathic Toe walker

- normally bilateral

- usually from birth


Beware 5 year old who has recently begun to toe walk, especially unilateral






Family history

How long on tip toes ?

Walking age 

All the time or not ?




Rule Out


1. CP

2. Duchenne's MD

3. CMT

4. Short Leg / DDH

5. Dysraphism



- Trendelenberg 




- signs spinal dysraphism

- scoliosis



- Heel / Toe walk 

- running coordination - hemiplegic / brings out very minor posturing / look at UL


Gower's sign

- Duchenne's muscular dystrophy

- ask to squat then stand up

- have to hand walk up their legs as severe proximal muscle weakness


Upper limbs

- for hemiplegia, increased tone



- active +/- passive ROM 

- sole of foot - if always on toes then heel will be soft

- Silverskiold


Neurological exam 

- especially abdominal reflexes




Spine Xray / MRI


Gait analysis 




Serum CPK

- DMD > 5000

- proceed to muscle biopsy if elevated


Nerve biopsy - rare but may need in peripheral neuropathy




Non Operative



Serial casting 

Botulinum A toxin in CP 





Percutaneous T achilles lengthening 



- ? about 7 years or older

- wait till at least > 4 years

- many resolve by age 10



- 75% will still toe walk after treatment  





Acetabular Dysplasia

Acetabular Dysplasia

DefinitionLateral Subluxation Hip


Abnormal development of acetabulum with decreased femoral head coverage







NMD e.g. cerebral palsy

Skeletal Dysplasia (MED etc)



- trauma

- infection 




Females > Males

- keeping with DDH

- males usually with other diagnosis

- considerable number are asymptomatic diagnosis on X-ray


Problem of late teens / early twenties




3 important factors


1.  Degree of lateral subluxation

- CE < 20° = 80% OA

- unknown if covering head decreases OA

- 20 - 50% so called primary OA due to dysplasia


2.  Young age

- acetabulum can remodel to age 5

- dysplasia improves only with concentric reduction

- most rapidly in first 6 months


3.  Symptomatic 

- natural history of asymptomatic subluxation is unknown

- likely to be much more benign

- it is known that early symptomatic acetabular dysplasia has a much poorer prognosis

- i.e. the twenty year old with a symptomatic hip will likely have severe arthritis in ten years

- untreated DDH said to lead to OA by age 50 in 50%


Weinstein JBJS July 2000


1.  Subluxation 

- all get severe OA & clinical disability

- age of symptoms depends on severity


2.  Dysplasia 

- NHx difficult to predict

- strong association between women & degenerative joint disease


3.  Dislocated hips (untreated) 

- may have no disability

- if have well developed false acetabulum may develop severe DJD




3 peaks of patient presentation

- depends on degree of subluxation


1.  Severe subluxation - patient in teens

2.  Moderate subluxation - patient in 20 & 30's

3.  Minimal subluxation - postmenopausal patients


Acetabular Rim Syndrome Ganz JBJS Br 1991 

- patients with acetabular dysplasia found to have 20% incidence of labral tear

- complain of sharp knife like pain in groin and giving way or locking

- elicited by flexion and IR

- brings proximal & anterior femoral neck into contact with rim of acetabulum

- this is where labrum is likely to be damaged -> superolateral quadrant


X-ray Measurements


1.  Shenton's Line

- Cooperman found it to be best prognostic sign


2.  Acetabular Index 

- paediatric

- triradiate cartilage to lateral edge of acetabulum

- birth 30°

- at 2 years - 20°

- N = < 30°

- DDH > 35°


3.  Sharp's Acetabular Angle 1961

- adult 

- inferior tip tear drop to lateral edge acetabulum

- > 42° Abnormal


Sharp's Acetabular Angle /> 40


4.  Centre Edge Angle of Wiberg 1939

- Perkin's line and line to centre femoral head

- < 20° abnormal / dysplasia

- > 40° Protrusio

- demonstrated increased increased of OA smaller the CE angle


Centre Edge < 20 degrees


5.  Sourcil angle

- line of angle of sourcil (sclerotic weight bearing area of femoral head)

- horizontal line

- normal     < 10°

- dysplasia  > 10° 


Sourcil Angle /> 10 degrees


6.  Weinstein Extrusion Index

- Head Covered / Total Width

- < 75% head covered abnormal


7.  Lateral Subluxation 


Teardrop to femoral head


Ganz Group I   13+/- 4mm

        Group II    6+/- 2mm


8.  Peak to Edge Distance


Ganz group I    3+/- 5mm

         group II 16+/- 4mm


CT Reconstruction


Probably best anatomical view of hip prior to deciding on osteotomy




Aim is to decrease cartilage stress below stress threshold

- by increasing joint surface area  & decrease joint reaction force

- decreasing later OA & providing a painless functional joint


Controversy regarding treatment painless hip  with CE < 20o




1. Femoral osteotomy

- varising ostetomy


2. Acetabular osteotomy

- Reconstructive - Salter / Ganz

- Salvage - Chiari / Shelf


3. Both


4.  Hip Arthroscopy

- debridement labral tear




Pelvic Osteotomies



Establish normal biomechanical forces about the hip


Decision Making


1.  Will the hip remodel? - < 8 years old

2.  Can congruency be obtained?

3.  How much correction is required?


Types of Pelvic Osteotomies


1.  Reconstructive Osteotomy

- redirectional

- reshaping


2.  Salvage Osteotomy


Reconstructive Osteotomy


Best option for the young patient with symptomatic acetabular dysplasia

- i.e. AI > 40o and CE < 20o with mild OA



- AI > 40o

- CE < 20o

- symptomatic dysplasia 

- congruent joint

- spherical head

- preserved articular space (relative) / mild OA

- minimum 70° flexion / extension arc

- subluxation can be reduced


A.  Redirectional


Single osteotomy - Salter


Double osteotomy - Sutherland


Triple - Steele / Tonnis / O'Hara Interlocking Modification


Periacetabular Osteotomy - PAO / Bernese / Ganz


B.  Reshaping


Pemberton / Dega


Salvage Osteotomies




If the OA is too severe for a reconstructive osteotomy


In the age of modern THR

- THR is probably a more reproducible option than a salvage osteotomy 




Shelf /Staheli / Melbourne



Specific Osteotomies


1.  Salter



- single osteotomy /  innominate

- can do in older patient but difficult unless experienced with operation

- relies on motion at symphysis pubis to rotate acetabulum



- can't do bilateral Salters

- mild to moderate dysplasia / DDH

- concentric reduction

- near normal ROM

- no OA

- undeformed head



- correct CE 10o



- add 1 cm LL

- leave deficient posteriorly




Salter CORR 1974

- 53 adults 4 year followup

- increased CEA by average 18° 

- decreased AI average 50° to 38°

- 63% no pain / 40% no limp (compared with all patients preop)

- 79% trendelenburg negative (compared with 96% positive preop)






Smith Petersen approach

- anterior 2/3 crest

- 5cm below ASIS

- between TFL and Sartorius

- protect LFCN medially

- tie ascending branch LCFA

- between G medius and R femoris

- clear glutei and iliacus off pelvis


Right angle about G Sciatic notch

- protect SGN and SGA

- gigli initially in notch

- anterior saw blade above acetabulum between AIIS and ASIS


Leg in figure 4

- rotate acetabulum anterolaterally through symphysis pubis

- x-ray shows narrowing of obturator foramen

- 30o iliac wedge crest

- fix with threaded K wires

- protect for 6 / 52


2.  Sutherland



- double osteotomy

- Salter plus osteotomy lateral to pubic symphysis



- can be difficult to move because osteotomy further away from acetabulum 


3.  Steele 



- triple / innominate osteotomy

- salter with two pubic osteotomies

- similar to Tonnis but ostetomies are a bit further away from acetabulum



- for older child with less mobile pubic symphysis



- osteotomy at base of ischial rami via posterior approach

- osteotomy superior pubic rami



- allows more correction whilst not laterally displacing the joint as a Salter tends to do

- can improve CE 20o


4.  Tonnis



- Salter osteotomy plus pubis and ischial between ischial tuberosity and acetabulum

- get better or easier correction because osteotomies are closer to acetabulum


5.  Ganz



- periacetabular osteotomy

- posterior column left intact for stability



- older adolescent and adults

- with residual dysplasia



- excellent rotation with medialisation

- increase CE 27o



- isolate acetabulum from ileum / ischium via 3 part osteotomy

- separate superior rami osteotomy at base


6.  Dial



- curved osteotomy following periphery of acetabulum

- don't see sciatic nerve

- a lot of operation is done by feel



- risk of acetabular AVN and fracture

- technically very difficult


7.  Pemberton 



- incomplete transiliac osteotomy

- cut into iliopubic and ilioischial limbs triradiate cartilage

- bends through triradiate cartilage



- only in those < 8 with open triradiate cartilage



- decreases volume of acetabulum

- provides very good cover



- may sublux the hip after reduction so always check


8.  Dega



- incomplete trans-iliac osteotomy

- rely on plasticity of superior acetabular margin rather than triradiate



- excellent reduction of AI 

- improvement CE average 31o

- very stable



- anterior approach

- osteotomy sites 15 mm from articular surface

- hip capsule not violated

- anterior and middle portions ileum cut

- leave posterior wall and G sciatic notch intact

- directed downwards


9.  Shelf


Hip Lateral SubluxationHip Subluxation Reduced with AbductionShelf Osteotomy



- older child > 12 years

- congruent reduction impossible



- extra-articular bony buttress over uncovered anterolateral portion of  femoral head

- iliac wing graft placed over hip capsule

- place graft under reflected head of RF

- can be modified depending on where cover is needed



- if not weight bearing (i.e. too high) will undergo resorption

- if too low, will cause pain


Stahelli Technique

- take off reflected head of rectus

- supra-acetabular slot, matchstick corticocancellous iliac graft

- graft strips are placed into slot which is checked radiographically to ensure as low as possible

- rectus tied over the top

- pack morselised graft over the top 


10.  Chiari



- medial displacement to develop shelf

- cartilage interposed to develop fibrocartilage




Luiket al  JBJS 1991

- 82 of Chiari's original patients

- 20 required THR

- 75% good

- best results: 80% coverage, < 45 years, high osteotomy slope, adequate medialisation


Reynolds JBJS 1986

- 90% success at 5 years



1. Distal fragment must go medially & adducted

2. Must angle osteotomy anterolaterally distally to posteromedial proximally

3. Anterior defect needs bone grafting


Specific Indications




Dislocation / 18 months

- Salter

- Dega

- Pemberton


Residual Dysplasia


Before Maturity

- Salter (through pubis)

- Dega

- Pemberton (through triradiate)


After Maturity

- Tonnis

- PAO i.e. Ganz



- Chiari / Shelf



- Salter

- Triple

- Shelf


CP / Neuromuscular

- Dega / Triple

- Shelf / Chiari



Coxa Vara



Deformity of proximal femur with neck-shaft angle <125°


Characterised by

- coxa vara

- decreased femoral anteversion

- limp / trendelenberg

- stress fractures

- early OA








2° to underlying disorder

- rickets

- renal osteodystrophy

- hyperparathyroidism

- Perthes disease

- infection

- trauma with early closure physis

- tumour



Congenital Coxa Vara





- Achondroplasia

- Cleidocranial dysostosis

- Fibrous Dysplasia


Developmental / Infantile

- progressive disorder that develops in early childhood

- due to limb bud abnormality

- not congenital really infantile as appears after birth

- includes PFFD & congenitally short femur


Cretinism  (hypothyroid)


Developmental Coxa Vara



- rare

- sex & side incidence equal

- bilateral in 1/3

- increased familial incidence - AD




Unknown / Multifactorial



1. Metabolic abnormality - deficiency in proximal femur ossification

2. Excessive intrauterine pressure - causes depression in femoral neck

3. Non-specific mechanical abnormality - occurs during development

4. Vascular insult - arrest in neck development

5. Localized dysplasia - faulty maturation of cartilage & bone in femoral neck




Abnormality in medial proximal physis & adjacent neck

- cartilage

- 2° metaphyseal bone


Abnormality characterised by

- increased width of physis

- loss of progress of columns

- nests of cartilage in metaphysis

- porotic metaphyseal bone





- epiphyseal angle < 45°

- corrects spontaneously



- epiphyseal angle > 60°

- neck - shaft angle < 110o


Bilateral severe coxa vara with OA




1.  Limp / trendelenberg


2. Stress fracture of femoral neck


3.  Early degenerative changes 

- untreated get severe early OA & often require THR early




Present at walking age with abnormal gait

- painless limp




Patient is short with hyperlordosis of spine & waddling gait

- limb-length discrepancy

- trendelenburg sign

- mimic DDH 



- short-leg

- trendelenburg sag 

- abductor lurch

- if bilateral - waddling gait


Decreased ROM 

- especially abduction & IR




Inverted Y

- inferior sclerotic metaphyseal triangle

- pathognomonic of developmental


Varus femoral neck

- neck-shaft angle < 125° (normal is 150° in infant)

- difficult to define with severe disease


Hilgenreiner's Epiphyseal angle 

- angle between Hilgenreiner's & Physeal line

- normal < 25°

- < 45° should resolve

- 45-60° - watch

- > 60° will progress



- decreased femoral anteversion / retroversion

- coxa breva






Correction of varus angle

Conversion of femoral neck forces from shear to compression

Correction of LLD

Establish correct abductor tension


Management based on Epiphyseal Angle


<45°    - no treatment

45-60° - observe

>60°    - valgus osteotomy


Operative Indications


1.  Epiphyseal Angle > 60° 

2.  Epiphyseal Angle 45-60° with limp & progression of varus





Valgus derotation subtrochanteric osteotomy

- need to overcorrect to 150˚

- epiphyseal angle < 40o

- correct to anteversion 10o




Lateral approach

- K wire in central head

- mark distal and proximal with drill hole for rotation

- open periosteum and protect with homans

- sub-trochanteric osteotomy with saw

- application of 150o Synthes offset locking plate

- need also IR of about 20° at time of osteotomy


May require

- adductor tenotomy

- femoral shortening

- GT transfer


Plaster spica for 6 weeks post-op


If bilateral do about 6 months apart




1.  Loss of correction 

- related to undercorrection


2.  Premature physeal closure 

- related to increased pressure

- seen in 90% cases


3.  Greater trochanter overgrowth 

- associated with premature physeal closure


4.  Acetabular dysplasia 

- associated with premature physeal closure and undercorrection









Developmental dysplasia of the hip

- the femoral head does not have the normal relationship with the acetabulum

- child with subluxable, reducible or irreducible hip

- may not be present at birth (hence not called CDH)



- ability to dislocate or reduce femoral head into or out of acetabulum



- complete loss of contact



- unable to be reduced



- partial contact



- an abnormal acetabulum 

- it is both shallower than normal & its inclination is more vertical than normal





- DDH = 2: 1000 (requiring treatment)

- instability 10 : 1000 


Influenced by

- presence of screening

- age of baby at examination

- experience of examiner



- females 7x 

- first-born

- L > R (L 2/3 of cases / LOA lie)


Bilateral 20%




Congenital Torticollis - 20%

Metatarsus Adductus - 2%




Nursery screening has decreased incidence of late dislocation

- decrease of 85% in incidence of walking CDH

- increase of early instability




1.  Ligamentous laxity


Different in sexes

- maternal hormones

- female baby have increased response to relaxin 


Familial hyperlaxity in males

- usually familial hyperlaxity with collagen alteration


2.  Positional


A.  Breech position 

- important risk factor

- 25% of DDH were breech

- normally 2.5% of births


Female breech

- 1 :35 = dislocated hips

- 1:15 = unstable hips


B.  Oligohydramnios


C.  Twins


D.  Firstborn - ? small uterus 


E.  Increased L>R

- usually LOA (vertex) position 

- adduction left hip against mother's spine


E.  Post-natal

- decreased where babies carried astride waist (Eskimos and Africans)

- increased where babies strapped to cradle board (Indians)


3.  Genetic


Nature of genetic predisposition unclear

- may be related to familial ligamentous laxity

- increased in Indians and Lapps

- decreased in Chinese and Africans


If child has DDH

- 5% of siblings DDH

- 1% of brothers 

- 10% of sisters 



- 12 % for child


4. Teratologic Dislocation 


Associated with other malformations

- irreducible at birth

- Arthrogryposis

- Larsen's





- hip is spontaneously dislocating & reducing

- minimal anatomical changes

- lax joint capsule

- shallow acetabulum

- flattening of posterosuperior labrum




Acetabular Dysplasia

- muscle action encourages proximal and lateral migration of head

- acetabulum and head rely on each other for development

- unreduced acetabulum becomes vertical and shallow

- becomes more anteverted


Femoral head

- dislocates upwards & backwards

- head becomes more globular & less spherical

- neck becomes more anteverted



- enlarges & narrows at isthmus 

- where iliopsoas crosses

- Zona Orbicularis


Ligamentum teres

- longer & thicker



- fills with thickened fat pad


Transverse ligament

- pulled superiorly and blocks inferior socket



- may invert




Space between head & medial wall of acetabulum widens


Dysplasia of acetabulum develops

- vertical

- shallow

- increased anteversion




50% of unstable hips resolve without treatment



- acetabular dysplasia

- always leads to early OA



- long term follow up 

- 60% significant pain & disability

- 40% no pain but abnormal gait 

- increased incidence of pain & OA with well-developed false acetabulum




Suspected in Neonate

- female

- firstborn / breech / twins 

- FHx of DDH / ligamentous laxity

- metatarsus adductus / torticollis / calcaneovalgus



- difficulty with nappies due to limited abduction

- shortening of thigh



- delay in walking or running

- limp

- increased lumbar lordosis

- unilateral toe walking

- intoeing





Septic dislocation


Coxa vara


Neurological - CP, Spina bifida




All neonates within 48 / 24

- treatment begun ASAP

- ultrasound "At risk" population



- CTEV / torticollis

- breech

- FHx


Examination Neonate


Thigh folds


Reduced abduction

- dislocated


Ortolani Test

- hip is out, tests reduces hip

- thumb on adductor tubercle & ring finger on GT

- place in 90° flexion

- abduct both hips & lift GT forward

- clunk of reduction felt 


Barlow Provocation Test

- push hip back out

- one hand holds pelvis

- adduction to 10o while axial pushing thigh backward

- dislocates in this position over post lip / feel clunk of dislocation

- may feel sliding of subluxable hip

- very deficient lip may give false negative with no clunk


Hip may be

- stable 

- subluxable

- dislocatable 

- dislocated (reducible / not reducible)



- not significant

- innocent clicks secondary to ligamentum teres / iliopsoas / iliotibial band


Examination Infant



- decreased abduction (< 60° suspicious, < 45° definite)

- apparently short femur - Galleazi's

- extra thigh folds



- more difficult

- symmetrical decrease of Abduction


Signs shortening above the GT


Klisic's line 

- line from ASIS to GT

- should point to umbilicus

- points horizontally in DDH


Nelaton's line

- line from ischial tuberosity to ASIS

- thigh adducted & flexed

- normally GT caudad to it

- in DDH GT cephalad to it


Examination Child



- limp

- abductor lurch / trendelenberg gait

- short-leg component

- decreased ROM / mild FFD / decreased abduction

- full rotation



- increased lumbar lordosis

- waddling gait / bilateral trendelenberg gait

- bilateral decrease ROM





- AP after 6/12

- when SFE ossified 

- obturator foramina should be symmetrical / no rotation




Hilgenreiner's Line

- horizontal through triradiate cartilages


Perkin's Line

- vertical through lateral edge of bony acetabulum


4 quadrants

- ossific nucleus usually lies in inferior / medial quadrant




1.  Delayed development of ossific nucleus / smaller


2.  Ossific nucleus in upper / outer quadrant


3.  Disruption Shenton's Line

- curved line along inferior neck

- inferior border superior ramus


4.  Head to Teardrop Distance

- lateral tear drop to medial ossification centre

- use metaphyseal edge if no SFE

- wide medial joint space compared with normal side


5.  Acetabular Index

- angle between Hilgenreiner's & acetabular lines

- 30° at birth to 20° at 2 years

- Normal < 30°

- DDH > 35°


6.  Centre - Edge Angle

- angle between Perkin's & CE line

- measure of coverage of femoral head

- Normal 30°

- DDH < 20° Protrusio >40°


Von Rosen's view




AP pelvis with legs abducted 45° & IR 20°

- lines along femoral shafts should pass through centre acetabulum & intersect at sacrum

- DDH line not through acetabulum & intersects to side of sacrum




Use in late presentation

- if femoral head reduces with von rosen then suitable for pelvic osteotomy only 

- if head appears to articulate on edge of acetabulum may have  false acetabulum

- then must do open reduction, femoral osteotomy & pelvic osteotomy






Best imaging before 4 - 6 months when pelvis cartilaginous

- very accurate

- static & dynamic images

- coronal view most important


No role in general screening as is too sensitive

- many hips with alpha angles 50 - 60o will resolve


Alpha Angle

- between ilium & bony roof acetabulum

- normal > 60°


Beta Angle

- between ilium & cartilage roof / labrum  

- normal < 60o


Dynamic stress

- is the head reducible

- perform Ortolani's under ultrasound


Graaf's Classification


Type Alpha Beta    
1 > 60 < 60 Normal  
2A 50 - 59   Immaturity < 3/12  
2B 50 - 59   Delayed Ossification > 3/12  
2C 43 - 49 < 77    
2D 43 - 49 >77 Labrum everted  
3 < 43 >77 Dislocated  
4 <43 >77 Dislocated & Labrum interposed  




Normal hip shows projection of labrum


Abnormal hip shows

- widened medial joint space / medial pooling

- blunting / infolding of labrum superiorly

- enlargement of ligamentum teres

- neolimbus bulge in acetabular cartilage

- hourglass constriction of capsule


Useful in evaluating reduction intra-operatively





- assess post operative hip reduction when child in spica


Management Algorithm


0 - 6 months


Attempt closed reduction

- Pavlik harness 

- von Rosen splint


6 - 18 months


Closed reduction

- adductor tenotomy / hip spica


Open reduction

- medial approach

- Smith Petersen approach


After age of 1 consider adding

- acetabular osteotomy to address acetabular dysplasia

- FDRO if required to obtain reduction


18 - 3 years


Dislocated hip

- open reduction + acetabular osteotomy

- femoral osteotomy if difficulty reducing hip


Acetabular dysplasia

- hip reduced but large acetabular index

- > 30o and not improving with time

- acetabuloplasty


> 3 years


Dislocated hip

- open reduction

- acetabular osteotomy to correct acetabular index

- hip will be difficult to reduce so need to shorten femur / FDRO


Complications Management






Result of treatment

- doesn't occur in untreated DDH


1.  Excessive abduction / splint / traction

2.  Forceful closed reduction

3.  Vascular damage at open reduction


Reduced by


Adductor tenotomy

Femoral osteotomy

Avoid medial reduction


X-ray Classification


Kalamachi and McEwan 1980


1. Nucleus only 

- temporary irregular fragmentation of SFE

- head will subsequently be normal


2. Lateral Physis 

- early lateral premature fusion

- femoral head will tilt into valgus

- lateral portion of femoral neck short


3. Central physis involved

- femoral neck will be short / coxa breva

- coxa vara secondary to due to GT growth


4. Whole physis involved

- femoral neck will be short & in valgus

- GT overgrowth




Coxa breva / Coxa valga / Coxa vara

Relative overgrowth of GT


Trendelenberg gait




1. Trochanteric Physiodesis

- to reduce overgrowth

- if <7


2. Trochanteric transfer

- if trochanter has reached level of femoral head

- transferred distally & laterally







Management 0 - 6 months



To obtain and maintain a concentric reduction without complication




0 - 6 /12

- best time for treatment

- maintain reduction of head & allow normal acetabular development


Equivocal Hip


Obtain ultrasound


Graaf 2A and 2B

- Alpha angle 50 - 59o range

- many will resolve without treatment

- reassess at 3/12 with ultrasound and 6/12 with xray


Graaf 2C or more / Alpha angle < 49o

- manage as below




1.  Hips subluxed or dislocated but reducible


Splint 6/52

- ultrasound 2/52 to confirm head enlocated

- check splint every 2 weeks (pressure sores / fitting correctly / femoral nerve / safe zone)


Ultrasound at 6/52

- alpha angle > 60° / no further splint

- alpha angle < 60° / 3/12 treatment in total



- very successful in Graaf 2C / D and 3

- 50% successful in Graaf 4


Follow up

- xray at 6/12 until 2 years

- final assessment 12 years


Hips dislocated & irreducible



- trial Pavlik harness 4/52


Failure treatement

- closed reduction +/- open reduction after 6/12


Hips locatable, but unstable in safe range abduction



- trial harness only in safe range


Failure treatment

- closed reduction +/- open reduction after 6/12 age


Treatment Options


A.  Pavlik harness

- most common in world


B. Von Rosen Splint


C.  MUA / Spica


Pavlik Harness



- can reduce dislocated hip

- able to clinically check reduction with harness on

- can ultrasound with harness on to check is reduced




Muscle imbalance / spina bifida

Stiffness / arthrogrypotic

Age over 8/12




Chest strap - at or slighly below nipple line

Shoulder straps 

Boots attached to chest strap

Anterior straps located in anterior axillary line 

- tightened to achieve 100o-110o flexion 

- no more or risk femoral nerve palsy

Posterior straps lightly tightened

- allow adduction to within 7 cm of knees touching

- maximum abduction 30 - 50o to reduce risk AVN


Follow up


Review 1 week

- ensure enlocated with US
- ensure no femoral nerve palsy


Repeat US at 6/52 and 3/12




Mostert et al J Paediatr Orthop 2000

- prospective study of 41 hips treated with Pavlik harness

- 97% success in 29 Graaf type III

- 50% success in 12 Graaf type IV




1.  Failure to achieve reduction


Require closed +/- open reduction at 6/12


2.  AVN


Very low if safe ranges respected


Peled et al CORR 2008

- pavlik harness used in 78 Graaf 3 or 4 hips

- no AVN in any patient


3.  Femoral nerve palsy


Probably due to very chubby thighs / excessive flexion

- suspect in persistently crying baby


Murnaghan et al JBJS Am 2011

- review of 30 babies with femoral nerve palsy from Pavlik harness

- 87% presented in first week

- more likely in larger babies with more severe DDH

- femoral nerve palsy strongly predictive of treatment failure


Von Rosen Splint




Best suited to newborn




Non dynamic

- hip must be reduced / reducible


Cannot ultrasound with splint on

- must be removed




Padded malleable aluminium splint

- 2 shoulder uprights

- 2 legs for thighs

- 2 wings for torso


Different sizes depending on weight


Hips in 60-90° flexion & 45° abduction (safe zone)


Parents don't adjust




Wilkinson et al JBJS Br 2000

- suggested better outcomes than Pavlik harness

- fewer required operative reduction




Skin irritation


AVN 2%


Treatment failure





Management 6 - 18 months

Two groups of dislocated hips


1.  Late presenters

2.  Failures of splint in those < age 6/12




1.  Adductor tenotomy + closed reduction

- most surgeons will attempt this initially

- risk of AVN wilth forceful reduction / excessive abduction


2.  Open Reduction

- for failure of closed reduction




When safe for anaesthetic

- generally 6 - 12 months of age


Adductor Tenotomy / Closed Reduction




> 6 months




If irreducible or unstable / outside of safe zone need to proceed to open reduction






Percutaneous adductor tenotomy

- assess range of maximum abduction


Closed reduction

- hip abducted / flexed


Ramsey's Safe Zone

- position between re-dislocation & maximum abduction 

- has to be at least 20°

- i.e. if have to position hip within 20o of maximum abduction to obtain reduction

- high risk of AVN


MUA / Arthrogram

- confirm reduction

- inject contrast

- nil medial pooling in abduction

- head reduced


Apply hip spica


Post operative


Hip Spica for 3/12

- change at 6/ 52 as child grows

- keep in safe zone / Abduction < 60o / Flexion 90o


Confirm reduction CT / MRI

- assess medial joint space

- < 5 mm = Good outcome

- > 7 mm = Poor outcome


Open Reduction




Rely on reduction of the head stimulating the acetabulum




1. Unstable hip

- have to abduct > safe zone to maintain reduction


2. Irreducible hip


3. Unacceptable widening of medial joint space


5 Blocks to reduction


1.  Capsule with hourglass constriction from psoas

2.  Labrum

3.  Thickened ligamentum teres

4.  Inverted inferior transverse ligament

5.  Pulvinar / thickened fat


Surgical Options


Medial Approach

Anterior Approach




> 1 year old

- consider adding osteotomy

- pelvic or femoral


Medial / Ludloff Approach



- direct and simple access to blocks to reduction

- adductors / iliopsoas / inferior capsule / inferior transverse ligament



- risk of AVN / injury to medial circumflex femoral

- can't perform capsulorraphy

- not suitable > 1 year as cannot combine with pelvic osteotomy



- superficial interval between longus and gracilis

- deep interval between brevis and magnus 

- anterior and posterior branches obturator nerve on brevis

- divide psoas (MCFA is medial to tendon)

- take circumflex vessels off capsule


Smith Petersen approach + / - FDRO



- can perform capsulorraphy

- reduced risk AVN

- can perform pelvic ostetomy (Salter / Dega)



- more difficult to access blocks to reduction



- vertical incision not very cosmetic

- use horizontal / bikini incision to reduce hip

- between sartorius and TFL to access blocks to reduction

- split apophysis if performing pelvic osteotomy

- separate lateral approach if adding FDRO





Management > 18 months

Dislocated Hip




Hip has been out for some time

- degree of acetabular dysplasia evident

- less time for remodelling

- increased instability if not addressed




Open reduction + FDRO / Pelvic Osteotomy 

- usually perform pelvic osteotomy to correct acetabular dysplasia

- reserve FDRO for > 3 years / or if difficult reducing hip


Post operative


Hip spica for 3/12

- change at 6/52

- CT to confirm enlocated




Redirectional / Salter


From G. Sciatic notch anteriorly to between ASIS and AIIS

- gigli saw posteriorly

- oscillating saw anteriorly to guide cut

- use apophysis as bone graft

- covers acetabular defect anterolaterally

- stabilised with K wires




1.  Provides anterolateral cover

- if combine with FDRO at same time can dislocate the head posteriorly

- i.e. is quite technically difficult to do both femur and acetabulum together


2.  Cannot do bilaterally as hinge on pubic symphysis


Reshaping / Pemberton or Dega



- transiliac into tri-iradiate



- incomplete transiliac

- relay on plasticity of acetabular roof


Periacetabular osteotomy

- osteotomy follows acetabular curve

- use curved osteotomes

- insert iliac crest bone graft

- fix with pins



- simple

- can do bilaterally


> 3 years dislocated hip




Open reduction + Pelvic Osteotomy + DVRO with shortening

- need to add DVRO to obtain reduction




> 4 yrs and bilateral

- don't treat

- shown to have poor results

- head is aspherical

- transform painless hips to painful


2 - 3 years Acetabular Dysplasia




Hip enlocated / Acetabular index > 300 and not improving

- pelvic osteotomy



Surgical Techniques

Hip Arthrogram



- under II

- 10 mls contrast mixed with 10 mls saline

- prime the line

- spinal needle

- do not spill contrast over front of hip as will obstruct view


A. Lateral approach

- 45° angle with thigh

- insert just inferior & anterior to the greater trochanter

- advance 5-10 cm

- enter joint medially


B.  Anterior approach 

- preferred technique

- palpate femoral artery just below inguinal ligament

- femoral head is halfway between ASIS and pubic tubercle

- insert needle 2.5 cm below ASIS, aim to go behind NV bundle

- at 45° angle to skin

- aim for anterior neck


C.  Medial approach 

- MUA & arthrogram in young child

- excess extra-articular contrast will pool inferior & medial to joint so not to obstruct view of joint

- flex & abduct leg

- insert needle inferior to adductor longus tendon

- use II

- advance below femoral artery to head or neck

- generally inferior aspect of neck just below head


Open reduction via Smith-Peterson approach



- damage LFCN

- stiffness (large dissection)

- access to inferior capsule and transverse ligament difficult



- reduced risk of AVN

- can perform pelvic osteotomy through approach





- use bikini incision modification

- start 3cm below ASIS

- parallel to inguinal ligament 7cm

- longitudinal causes excess scarring, especially in young girl


Superficial dissection

- interval between sartorius & TFL

- LFCN retracted medially on top of sartorius

- ascending branch LCFA tied off in interval

- superior plane continued proximally by splitting apophysis 

- if needed to perform pelvic osteotomy

- peel glutei off llium to expose supra-acetabular region


Deep dissection

- between G medius and RF

- both heads rectus divided

- reflected head blends with capsule and superior rim acetabulum

- straight head to AIIS



- psoas released under iliacus

- careful capsulotomy at acetabular edge

- remove capsule off lateral acetabulum

- to medial corner under direct vision

- any blocks to reduction removed

- excision of ligamentum teres

- transverse ligament division

- pulvinar removed

- evert inverted labrum 


Gentle reduction of head


Tight capsulorrhaphy performed 

- especially superiorly to remove lax capsule


Pelvic osteotomy

- if over 1 year of age with dysplasia

- redirectional or reshaping


Femoral osteotomy 

- performed if excessive traction at time of reduction

- avoid AVN


Spica cast applied


Medial Open Reduction



- risk of AVN via MCFA damage

- only < 1 year as no access to periacetabular region

- unable to perform capsulorraphy



- easy access to blocks to reduction

- especially psoas / inferior capsule

- reduced blood loss





- supine

- hip abducted & flexed / frog legs



- adductor longus & pubic tubercle



- parallel to & 1cm below groin crease

- over adductor longus


Superficial dissection

- between gracilis / posterior & adductor longus / anterior


Deep dissection

- between adductor magnus & adductor brevis

- protect anterior branch obturator nerve on brevis

- protect posterior branch obturator nerve on magnus

- retract adductor brevis anteriorly

- will expose lesser tuberosity with psoas tendon inserting onto it

- isolate psoas tendon before division



- protect MCFA as it passes between adductor brevis & psoas at LT

- runs around the medial side of psoas / anterior to psoas tendon

- fully isolate psoas before dividing



- release psoas at LT

- T Capsulotomy

- divide transverse Lligament

- ligamentum teres can be used to pull head into acetabulum

- suture to anteromedial capsule

- may need to place radial splits in limbus 


Salter Osteotomy



- corrects anterior and superolateral acetabular deficiency

- less than 5 years but > 18/12

- mild - moderate dysplasia

- need concentric reduction



- Smith Peterson approach

- iliac apophysis split

- subperiosteal dissection to sciatic notch reflecting gluteals

- Gigli saw - osteotomy through GS notch

- emerge anteriorly between ASIS and AIIS

- acetabulum rotated anteriorly and laterally

- triangular graft from crest

- K wire fixation



- 25% leg lengthening


Periacetabular osteotomy



- leaves posterior wall intact

- relies on plasticity of superior acetabulum



- osteotomy includes posterior column

- bend through tri-radiate cartilage


Smith - Petersen approach

- split apophysis

- curved osteotome

- parallel superior dome of acetabulum

- 15 mm above

- can leave posterior column intact

- bone graft +/- K wires


Femoral Derotaton and Varising Osteotomy


Technique Antero-lateral 


Open reduction as above


Separate lateral approach

- elevate vas lateralis

- 2 x K wires centrally in neck, short of physis

- check II

- open and protect periosteum with homans

- mark distal and proximal femur with drill holes to check rotation later

- osteotomy with microsagittal saw 1 cm below LT

- don't need to resect wedge with Synthes offset locking plate

- may need to shorten

- decrease anteversion by IR distal fragment

- check range of ER of hip / should be reduced


Osteotomy fixed Synthes Offset Locking Plate

- 125o for some varus









Proximal Focal Femoral Deficiency

- congenital malformation

- characterised by failure of normal development of the proximal femur





- 1 in 50 000


Bilateral in 15% 

- usually more severe




Fibular hemimelia in 2/3

ACL deficient


May also be associated with


- Cleft palate


- Congenital spinal deformity

- Dysraphism


Aitken's Classification


Class A

- short femoral shaft with coxa vara

- head of femur present, neck may be absent early

- adequate acetabulum


- bony connection between head & neck present at maturity

- may be pseudarthrosis at point of connection


Class B

- pseudoarthrosis between head and shaft

- shorter femoral shaft with small bony tuft on proximal end

- head of femur present

- adequate acetabulum



Class C

- no femoral head

- acetabulum severe dysplastic

- very short femoral shaft with bony tuft proximally


Class D

- femoral head & acetabulum completely absent

- femur consists of condyles only




Child with very short leg

- large shoe raise

- LLD above GT


DDx of shortening above GT

- DDH 


- Tom Smith arthritis / post septic arthritis

- Tumour



- short involved thigh segment

- characteristic posture (Flex / Abducted / ER hip)

- Ship's Funnel Sign 


Bulky upper thigh segment

- sharply tapering to knee




1.  Pseudoarthrosis

2.  Instability of the hips

3.  Coxa vara

4.  LLD

5.  Inadequate lateral femoral condyle

6.  Inadequate proximal musculature

7.  Malrotation




Class A & B


Femoral heads present


1.  Stabilize pseudarthrosis with IM Rod

2.  Hip stabilisation 

- pelvic osteotomy

- femoral osteotomy

3.  Limb lengthening


Class A


1.  Realign Coxa Vara

- subtrochanteric osteotomy


2.  Equalise LLD

- lengthen femur or

- shorten / epiphysiodesis other femur



- if lengthen femur need to watch knee doesn't dislocate 

- ACL deficient

- may have to bridge knee with external fixator


Class B


1.  Fuse pseudarthrosis 


2.  Limb lengthen or amputate as required


Class C & D


No femoral heads


Stabilise hip

- pelvic support osteotomy

- osteotomy proximal femur

- supported by ischium

- distal osteotomy for mechanical axis

- need lengthening as well


Foot above contralateral knee

- knee fusion + symes

- essentially AKA


Foot below contralateral knee

- rotate then fuse knee / Van Ness Rotational Osteotomy

- ankle acts as knee joint / essentially BKA

- BV become anterior

- require good functioning foot




Usually Class C or D

- can usually walk well without prosthesis

- surgical procedures usually detract from mobility

- should not be treated surgically unless such severe foot deformity that cannot ambulate without prosthesis / Symes







Aetiology & Classification



Idiopathic condition of the immature femoral capital epiphysis involving varying degrees of osteonecrosis



- Legg-Calve-Perthes disease

- coxa plana


Described in separate publications in 1912 by

- Legg (Boston)

- Calve (France)

- Perthes (Germany)




M: F    4:1


1 in 740 males


Onset usually at age 4-8

- early as 2 to late as 12


Children small and thin & hyperactive with delayed bone age


Bilateral - between 8 - 24%

- will not be symmetric

- if symmetric think other causes


Risk Factors


Sex : M: F 4:1

Geographic Location - 1/1200 US; 1/12 000 UK ; More common in urban areas

Social Class - Higher incidence in lower socio-economic classes

Race - Caucasian > Asian > African (extremely rare)

Perinatal Factors - Maternal Smoking ; Breech ; Prematurity/ Low Birth Weight ; Older Parental Age






Multiple ischemic events causing AVN

- ? lateral epiphyseal blood vessel occlusion

- sole blood supply 4-8 years




1.  Microtrauma to retinacular vessels


2.  Increased synovial pressure 

- e.g. transient synovitis


3.  Venous HTN 2o to thrombotic occlusion

- hyperthrombotic state

- hypofibrinolysis 


Glueck 1996 JBJS

- 75% coagulation abnormality  

- decreased Protein C ± S / increased lipoprotein A

- this has never been a found association in any study since


Blood supply immature femoral head


Medial and lateral circumflex femoral 

- cruciate and trochanteric anastomoses

- extracapsular ring at base of neck

- retinacular vessels run in capsule

- intracapsular ring at base of head

- lateral epiphyseal artery most important


Ligamentum teres

- artery viable up to age 2




Short stature & delayed maturation 


Attention Deficit Hyperactivity Disorder / ADHD



- parents often relate onset of symptoms to traumatic event 

- this association not clearly established


Irritable hip ~ 1%






Various areas of necrosis / revascularisation

- reossification from periphery

- typically anterior & lateral


Ossified epiphysis small

- stops growing

- cartilage keep growing with blood from synovium

- increased head to teardrop appearance but head does not subluxe


Head deformity secondary to collapse

- biological plasticity during creeping substitution

- head subjected to uneven & excess forces

- flattening or saddle deformity 

- anterolateral extrusion of cartilage


Coxa Magna 

- flattening of head with lateral extrusion of physis + periosteal new bone





- growth arrest

- disordered cartilage columns in physis


Coxa Breva

- physeal arrest with short neck & long GT 

- LLD & Trendelenberg gait





- Waldenstrom


Extent of femoral head involvement 

- Catteral

- Salter-Thompson

- Herring



- Mose 

- Stuhlberg


Waldenstrom Stages


History : Swedish Surgeon ; Described disease 1910 prior to being named by Legg-Calve-Perthe in 1912


1. Initial


Duration : 3- 6 months



- may be normal

- small, sclerotic epiphysis

- joint space widening

- increased density of ossific nucleus & cessation of growth


2. Resorption / fragmentation


Duration : 6/12


Pathologic Process

- necrotic bone irregularly resorbed / creeping substitution

- replaced with vascular fibrous tissue

- may be associated with collapse


XRay - Fragmentation of Physis


3.  Reossification


Duration : 1.5 - 3 years


Pathologic Process

- starts at margins & progresses centrally

- eventually new areas coalesce & epiphysis regains normal strength & density



- Better defined shape

- Return of bone density


4. Remodelling


Duration : Occurs until skeletal maturity


Xray - May have flattening of the head and neck


Herring Lateral Pillar


AP xray when disease in fragmentation / divide femoral head into 3 pillars

- lateral (25%)

- medial (25%)

- central (50%)


Group A

- no lateral pillar collapse or radiolucency

- all become Stuhlberg 1 & 2


Group B

- > 50% of lateral pillar height maintained

- outcome depends on age

- < age 9 almost all become Stuhlberg I and II

- > age 9 30% become Stuhlberg II / 70% become Stuhlberg III or IV


Group C

- pillar < 50% normal height

- majority do poorly





- uses AP & lateral xray

- 4 groups

- significant inter & intra-observer error


Group I

- < 25% involved

- anterocentral head


Group II

- 25-50% head

- anterolateral region / lateral column intact


Group III

- 50-75% head involvement

- moderate collapse 


Group IV

- 100% of head sequestered

- severe collapse




Group A

- Catterall 1 and 2

- < 1/2 of head involved

- viable lateral pillar 

- good prognosis


Group B

- Catterall 3 and 4

- > 1/2 head involved, loss of lateral pillar

- poorer prognosis




Quantifies degree of sphericity

- graded according to variance from perfect circle in either AP or lat

- many authors do not agree that Mose sphericity is accurate predictor of long term outcome

- good or fair Mose rating = good result

- poor Mose rating not necessarily = poor result


Good - no deviation on the 2 views 

Fair - up to 2 mm variance 

Poor - 3 mm or more variance 




Based on congruency & sphericity


Class 1 

- normal 

- 0 % OA


Class II:  Spherical & Congruent

- femoral head spherical (mose circles overlaid on AP / lateral of femoral head show <2mm variation)

- At least 2 other abnormal features including Coxa Magna , Coxa Breva or Abnormally Steep Acetabulum

- 15% OA


Class III:  Aspherical Congruity

- head ovoid (mushroom or umbrella shaped) and aspherical i.e Mose circles show > 2mm variation  

- 60% OA in middle age


Class IV: Aspherical Congruous Incongruity

- head flat, steep acetabulum

- 75% OA usually in middle age


Perthes Stuhlberg Class IVPerthes Stuhlberg Class IV lateral


Class V:  Aspherical Incongruous Incongruity

- head flat, normal acetabulum

- 80% OA at young age before 50


Natural History


Osteoarthritis 10x more prevalent than general population


Only 40% have normal radiographs


20-40 years after onset of symptoms

- 80% active & pain-free

- only 10% have THR


At 50 years after onset of symptoms

- 50% have disabling pain

- 40% have THR



- probably best you can say is function deteriorates with time

- 50% THR at 50 years


Prognostic Factors


1. Age of onset

- most important

- < 6 good Stulberg I-II

- 6-9 variable Stulberg I-IV

- > 9  Stulberg III & IV

- related to amount skeletal growth & thus remodeling available


2. Sex

- F worse than M

- ? early maturation, less time to remodel


3. Extent head involvement

- quantified by Caterall / Salter-Thompson / Herring classification


4. Containment of head

- extrusion and asymmetric growth leads to worse prognosis


5. ROM

- hip irritability causes adductor tightness

- loss of abduction ROM prevents remodeling head by acetabulum


7. Lateral Pillar Collapse


Catterall "Head at Risk" Signs


Only lateral subluxation shown to be prognostic 


5 Xray


1. Lateral subluxation head

2. Lateral epiphyseal calcification

3. Gage Sign - V shaped defect in lateral physis

4. Horizontal physis angle

5. Metaphyseal cysts


4 Clinical


1. Progressive loss ROM

2. Adduction contracture

3. Flexion with abduction

4. Obesity


Gage's sign

- lateral bulge of metaphysis

- extruded cartilage may calcify lateral to acetabulum 

- gives appearance of head extrusion

- coxa breva




Most present early 

- 75% during necrotic / fragmentation stages

- insidious painless limp commonest

- ache groin / anterior thigh or knee

- exacerbated by activity




Short stature 

- usually short with delayed bone age


Antalgic / Trendelenberg gait


Decreased ROM



- synovitis with tight adductor and/or psoas

- loss abduction in extension and flexion

- loss IR / flex into ER



- bony impingement

- "hinge subluxation" 

- lateral extrusion, flattening & enlargement of head prevent normal motion


LLD usually small

- apparent LLD from adduction contracture


Occasionally thigh / gluteal wasting in advanced cases




Grade stage of Perthes

Lateral Pillar classification




Nonspecific findings of synovitis usually found

- thickening synovial membrane vs. synovitis

- synovial effusion




Perthes CT





- can assess amount of cartilaginous head outside of acetabulum

- very good way of assessing containment of cartilage head









- bilateral and symmetrical

- acetabular involvement

- no metaphyseal cysts

- other physeal involvement therefore consider skeletal survey in those with bilateral "perthes"




Complications of Perthes


1. LLD 25% 



- subchondral fracture & collapse 

- arrest proximal femoral epiphysis

- adductor contracture

- varising osteotomy


2. Trendelenburg gait


Proximal greater trochanter

- collapse of epiphysis / coxa breva

- varus osteotomy



- growth arrest of greater trochanter at 10 years or distal transfer

- femoral neck lengthening osteotomy


3. Hinge abduction


Extrusion of epiphysis laterally



- treat with cheilectomy once physis closed

- has poor reputation 

- may worsen arthrosis by exposing fresh bone

- if done prior to physeal closure may cause SUFE or growth arrest


4. Labral tears 



- abnormal stress by head on lateral acetabulum


5. Secondary OA




Prevent head deformity & secondary OA

- interfere as little as possible with child's development




1. Restore & maintain ROM

- allow abduction which covers anterolateral extruded head 

- important range is abduction in extension

- aim 30o abduction or 75% of contralateral side 

- can consider adductor tenotomy


2. Head containment i.e >80 % coverage of the femoral head


3. Relief of symptoms




1. Observe

- normal ROM


2. Symptomatic treatment

- physio for decreased abduction


3. Definitive early treatment

- Herring B & B/C > 8 years old

- femoral varising osteotomy / containment


4. Late surgical treatment of deformity / degeneration

- Shelf osteotomy

- Valgus osteotomy

- GT osteotomy




Concept ~ Petrie

- location of capital femoral epiphysis within acetabulum



- molding action

- subjects head to molding action of acetabulum

- leads to more spherical head / more congruous joint 

- if the head remains in the acetabulum it usually remains spherical

- subluxed head associated with deformity


Herring et al JBJS Am 2004



- 337 patients with 345 affected hips in a prospective multicenter study

- all patients were between 6.0 and 12.0 years of age at the onset of the disease

- none had had prior treatment

- followed up until skeletal maturity

- no treatment / brace treatment / range-of-motion exercises / femoral osteotomy / innominate osteotomy



- no differences in outcome in hips with no treatment / bracing / range-of-motion therapy

- no differences between the hips treated with a femoral varus osteotomy / innominate osteotomy

- no effect on children with a chronologic age of 8.0 years or less / skeletal age of 6.0 years or less at the onset of the disease

- > 8 at time of disease onset with lateral pillar B group and B/C border group did better with operative

- 8.0 years old or less at the onset of the disease in lateral pillar group B did equally well with nonoperative and operative treatment

- hips in lateral pillar group C had the least favorable outcomes with no differences between the operative and nonoperative groups

- female patients > 8 at onset did significantly worse than male patients




Age onset < 8 (chronological ; skeletal age 6) - no treatment

Ages onset > 8 and B or BC - containment surgery

Class C - salvage / Shelf


Varsing osteotomy as good as Salter


Non-operative Containment





- placing hip in abduction whilst allowing hip motion & ambulation

- worn until reossification phase of lateral epiphysis 

- usually 6-18 / 12 

- no evidence for effect


Petrie Abduction Casts 

- two long leg casts with abduction bar

- 30o abduction & 5o IR


Scottish Rite Brace

- two thigh cuffs with abduction bar





- if can maintain good abduction, then no need for varising ostetomy

- see child every 6 weeks to 3 months

- ensure no adduction contracture

- hydrotherapy


Operative Containment




Permanent containment enhances remodeling




Risks of surgery




Femoral varising osteotomy

Acetabular osteotomy




> 8 at onset and B or B/C

No hinge abduction


Hinge abduction



- abducted hip does not obtain full coverage of cartilage / full containment

- hinging on abucted portion of femoral head

- a varising osteotomy with increase point loading and worsen symtoms



1.  MRI with hip in abduction

2.  MUA pre varising osteotomy

- hinging / rose thorn appearance

- medial pooling

- i.e. whole cartilaginous head not entering acetabulum



1.   Trial adductor tenotomy / physio +++

- if hinge abduction resolves can proceed to operative intervention

2.  Valgus osteotomy

- salvage


Lloyd-Roberts Varising Femoral Osteotomy



- seat head deep in acetabulum

- remove vulnerable anterolateral portion from acetabular edge

- decrease JRF on head



- sufficient varus to permit entire ossified epiphysis to be covered by ossified acetabulum

- derotation can be added to reduce anteversion and increases cover



- Herring grade B or B/C

- > 8 years at age on onset

- must be able to obtain full containment of cartilaginous head




Patient supine on radiolucent table

- preop antibiotics

- frog leg laterals when needed


Lateral approach

- elevate vastus lateralis

- incise and reflect periosteum, then protect with homanns before osteotomy

- "be good to the periosteum and it will be good to you"

- drill holes in femur proximal and distal to osteotomy site in line with each other

- allows guide to rotation after osteotomy

- place cannulated wires into femoral head now

- leave short of physis, check AP and lateral

- subtrochanteric osteotomy with saw / osteotome

- ER distal fragment (no more than 15o)

- apply Synthes proximal locking plate

- has offset otherwise have to step cut femur

- multiple angles available

- aim for 115o of varus

- avoid excessive varus < 100o to keep GT distal to femoral neck



- operates on affected side of joint

- less demanding than acetabular surgery

- results equivocal



- LLD increased

- coxa vara

- trendelenberg gait / may require GT fusion or advancement in future

- have to remove metal in future with risk refracture

- potential difficulty of THR in future / insertion of femoral stem


Salter Innominate Osteotomy



- redirects acetabulum to provide coverage for anterolateral head



- full or almost full ROM 

- reasonable congruence on abduction / X-ray in full abduction confirms containment

- fragmentation stage



- avoids shortening, coxa vara

- nil trendelenberg



- more difficult

- lengthens leg

- operate on normal side of joint

- increase joint pressure


Late Salvage 



- failure of containment techniques

- significant femoral head deformity with hinge abduction




1. Shelf Arthroplasty

- laterally subluxed femoral head in older child

- allows some continued remodeling of the femoral head


2.  Cheilectomy femoral head

- wait till physis closed

- extruded rim of bone & cartilage excised

- poor results


3.  Valgus Osteotomy

- hinge abduction > 12 years

- redirect normal portion of head to acetabulum


4.   GT osteotomy

- distal & lateral transfer of GT 

- aim to decrease JRF

- may relieve trendelenberg gait





Background & Management



Displacement of proximal femoral epiphysis in the immature hip

- due to imbalance of mechanical and endocrine factors 




Age Peak Incidence : M 12-14; F 11-13; Slight downward trend due to earlier maturation of children

L hip > R

10 / 100 000


Bilateral SUFE


No endocrine abnormality

- 20% at time of of diagnosis

- another 20% during diagnosis

- up to 60% with long term follow up


Endocrine abnormality

- up to 75%


Risk Factors


Demographic Factors

- Increased Weight and Height (50% over 95th percentile weight; 50% over 97th percentile height); Average BMI 27  

- Race : Increased risk in Black pts (4X) ; Polynesian ; Hispanics

- Sex : Male 2.5 x risk

- Family History - 7 % risk to other family members


Hip Mechanical Factors - increased shear forces

- increased slope (at adolescence growth plate goes from horizontal to vertical position)

- increased retroversion Southwick angle > 14

- reduced neck shaft angle



Imbalance of

- Testosterone - causes physeal fusion

- Growth hormone - causes physeal hypertrophy / weakens



- hypothyroidism

- hypopituitary

- acromegaly or growth hormone supplementation

- CRF/ Renal Osteodystrophy



Connective Tissue Disorders - Marfan's / Downs / Ehlos Danlos

Chemo therapy / DXRT




Widened hypertrophic zone 

- constitutes 60% of physeal width 


Abnormality at Hypertrophic & Proliferative Zones junction

- failure occurs here

- disordered chondrocyte columns

- decreased number of cells

- cells smaller

- increased number of dead and degenerative cells


Head remains in acetabulum via L. Teres

- neck displaces anterosuperior on physis and ER

- head slips posterior / inferior on neck






Acute < 3/52 symptoms

Acute on Chronic 

Chronic >3/52




Southwick Slip angle

- Wayne Southwick ; 1st Chairmen of Orthopaedics at Yale University

- lateral X-ray  / frogs legs

- epiphyseal-shaft angle 

- angle of interest is the angle of the affected side subtracted from the normal contralateral side ; if contralateral SUFE then 12 degres as normal    

- <30° / 30- 50 / >50°

- mild / moderate / severe




Loder JBJS 1993



- able to weight bear / 0% AVN



- unable to weight bear / AVN rates 10 - 60%




Overweight adolescent boy hip or knee pain; 30% present only with knee pain





Walk with ER (chronic) i.e increase in foot progression angle

Obligate abduction and external rotation with flexion

Limitation IR / Abduction

LLD (real and apparent)








Trethowan Line / Kleins Line

- line along superior neck usually transects 20% head

- originally described as AP but can also be used as lateral


Widened physis


Inferomedial remodelling in chronic slip


Metaphyseal Blanch Sign of Steel

- Increased cresenteric density in the metaphysis due to overlapping of the metaphysis with the epiphysis


Capener's Sign

- the posterior acetabular margin normally cuts the medial corner of the metaphysis

- in a slip the whole of the metaphysis remains lateral to the acetabular margin


Frog Leg Laterals / Shoot through lateral


SUFE Lateral


Shoot through lateral

- best to avoid frog leg lateral as may displace slip


Posteriorly displaced & angulated


Measure Southwick Angle

- calculate severity of slip

- also estimates risk of slip of other side / looking for retroversion






1.  Prevent further slip / obtain physis fusion

- 30% will continue untreated


2   Prevent deformity and OA

- MUA / ORIF / osteotomy


3.  Avoid complications 




Loder RT et al. What is the best evidence for treatment of slipped capital femoral epiphysis?

Journal of Pediatric Orthopaedics. 2012 Sept : 32 (Suppl 2) S158 - 65


Stable : Insitu Pinning current gold standard


Unstable : Two schools of thought

  1) < 24 hours old

- Consider treatment as a surgical emergency

- urgent reduction (gentle traction, flexion and internal rotation) +/- joint decompression

- probably results in lowest AVN rates (Petersen et al - refer below)

- alternatively consider discussion with tertiary paediatric referral centre


  2) > 24 hours

- Discuss with specialist paediatric centres

- possibility of surgical dislocation and realignment i.e. Modified Dunn Procedure


In Situ Pinning


Gold Standard (Techique refer below)


CT post operatively

- ensure no screw protrusion


TWB 6/52


Serial Xray

- ensure epiphysis doesn't grow off screw

- screw can break / can lose position

- observe til physis closes

- no indication to remove pin




Weinstein et al JBJS Am 1991

- 40 year follow up of 155 hips

- some pinned in situ / some realigned / some reduced

- rates of OA / AVN / chondrolysis increased with severity of slip

- rates of OA / AVN / chondrolysis increased with reduction / realigned

- regardless of severity of slip, pinning in situ had best results with lowest complications


Closed Reduction Prior to Pinning




Traditionally associated with higher risk AVN





- may decrease AVN in severe, unstable hips

- prevent severe deformity / late OA




Acute & unstable < 24 hours




Peterson et al J Paediatr Orthop 1997

- 91 cases of severe, acute, unstable slips

- 42 closed reduction < 24hrs AVN 7%

- 49 closed reduction > 24hrs AVN 20%

- hypothesised that had acute obstruction of epiphyseal vessels 

- timely decompression allows revascularisation

- treat an acute unstable slip as per a fracture

- these have up to 50% AVN rate anyway

- emergency operation


Chen et al J Paediatr Orthop 2009

- 30 acute, unstable slips

- 25 closed reductions and 5 open reductions with release hematoma

- 4 cases of AVN


Open Reduction Prior to Pinning



- severely displaced slips



- moderate or severe slips do poorly in long term

- best treatment is intra-capsular reduction or osteotomy

- risk AVN either way

- acute open reduction easier

- also decompress hip


Modified Dunn Procedure


Ziebarth et al. Capital realignment for moderate and severe SCFE using a modified dunn approach.

Clin Orthop Relat Res. 2009; 467(3): 704 - 16

- Ganz type transtrochanteric approach

- Z shaped capsulotomy to preserve superior vessel along neck, along anterior acetabulum and inferior neck

- capsule banana skinned off neck

- hip dislocated via adduction and external rotation and transection of the round ligament

- epiphysis taken off neck, still attached to capsule

- intraoperative monitoring of epiphyseal perfusion via 2mm hole drilled in the anterior neck or via insertion of ICP monitor into the epiphysis

- neck debrided to avoid tensioning of posterior vessels

- head replaced and pinned as per normal




Sankar WN et al. The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicentre prospective.

JBJS (Am). 2013; 95:585- 91.

- 26% Rate of AVN

- 15% Revision of metalwork rates

- therefore capable of restoring anatomy but ongoing risk of AVN and metalwork complications.


Prophylactic Pinning




Can justify but may cause complications 

- i.e. chondrolysis, subtrochanteric fracture secondary to screw


Incidence bilateral slips

- unknown

- may be > 35%

- high incidence of asymptomatic and mild contralateral slips


Major indications

- young i.e < 10 years

- unreliable parents

- geographic isolation

- Secondary SUFE eg endocrinopathy


Technique of Pin in Situ


Vumedi Insitu Pinning technique


Set up


1.  Supine on radiolucent table

- very easy to set up

- much faster if pinning both sides / reduced set up

- theoretical risk of displacing slip / inadvertant manipulation

- lateral by flexing and full ER of hip / frog legs


2.  Traction Table

- easy to get AP and lateral

- need 2 set ups for bilateral pinning

- takes longer in this regard




Draw anterior and lateral lines

- get AP, draw line mark using radiopague ruler to centre of head

- get lateral, repeat

- intersection of points is incision site


Stab incision

- guide wire percutaneously to neck

- more anterior entry point on femoral neck required the more the epiphysis is displaced posteriorly

- more anterior entry point ensures less likely to start at a subtrochanteric position and risk stress fracture

- central in head on both views

- ensure don't penetrate head

- cannulated drill

- 6.5/ 7.0/ 7.3 screws

- 8-10 mm or 4-5 threads across physis

- do far and away screening / approach withdraw; circumferential screening

- this ensures screw is not in joint





- loss of 50% joint space or < 3mm joint space



- female 2:1

- 10-20% of SUFE 




1.  Head penetration

- use only 1 screw


2.  Immunologically mediated global loss of articular cartilage

- can occur in no treatment of SUFE



- painful and reduced ROM

- flexion / adduction contracture



- rest / ROM exercises / NSAID

- ilizarov distraction - unknown long term results

- 50% resolve

- very difficult problem - may need THR / arthrodesis





- 5 % in chronic slips

- 20% in acute on chronic slip  

- up to 50% in unstable slip

- much worse if MUA


Risk factors


1. Reduction 

2. Posterosuperior quadrant pin placement

3. > 1 pin 

4. Severity slip 

- ? results skewed by increased MUA in this group

5. Unstable SUFE - unable to weight bear / Loder


Salvage options


1.  Hip distractor

2.  Valgus osteotomy

- redirect WB area away from AVN


Subtrochanteric Fracture



- too low screw entry

- multiple drill holes to get correct entry



- > 15 reconstruction nail

- < 15 DHS or DCS


Further physeal slipping



- poor screw positioning

- young patient

- failure physeal fusion

- removal of screw before fusion




Epiphysis heals in a posterior and inferior position = abnormal contact of relatively anterior neck on the acetabulum



- common with moderate - severe nonrealigned



1) Joint Preserving

 - Arthroscopic - Osteochondroplasty

 - Open - Osteochondroplasty with open surgical dislocation +/- Dunn Osteotomy at the level of the femoral neck  


2) Joint Sacrificing - THR for advanced cases




Natural History


Not completely known

- still occurs in uncomplicated treatment SUFE 

- ? 10% Adult OA

- even unknown if pistol grip deformity is from SUFE



- mild slip 36% no degenerative changes

- moderate or severe slip all had OA




Varus / extension / external rotation





Base of Neck





Valgus / flexion / internal rotation


Intertrochanteric / Southwick 



- biplanar

- valgising / flexion / internal rotation 

- removal anterolateral bone wedge below LT



- no AVN / safest

- improves hip motion



- worsens LLD

- difficult THR


Base of neck / Kramer



- closing wedge anterior and superior



- risk AVN

- shortens neck further - worsens LLD


Intra-capsular / Subcapital





- trapezoid osteotomy



- cuneiform



- anatomical correction



- risk AVN






Septic Arthritis



Unwell / irritable


Not feeding

Unable to weight bear / limp

Knee pain





Limited / painful ROM

Hip held flexed and externally rotated

- maximises volume of capsule


Lab tests


WCC > 12 000

ESR > 40

CRP > 10

Blood cultures


Joint Aspiration

- Innoculate directly into culture bottles to increase yield of fastidious organisms eg Kingella

- WCC >50 with >80% PMN suggestive




May demonstate hip subluxation




Confirms hip effusion




Can be useful

- identifies proximal femoral osteomyelitis



- requires GA usually


Kocher Criteria


Kocher MS et al. Differentiating between septic arthritis and transient synovitis of the hip in children : an evidenced-based clinical prediction algorithim. JBJS (Am). 81 (12): 1662 - 70.

- Criteria :

   ESR > 40

   WCC > 12

   Fever >38.5

   Inability to weight-bear

- Risk of Septic Arthritis - 0/4 - .2% ; 1/4 3%; 2/4 40%; 3/4 93% ; 4/4 99%




Staph aureus most common; MRSA increasingly common

Group B Strep

Kingella Kingae (fastidious organism; increasingly common in < 3 years)  

Gonococcus (Sexually active adolescents)


Operative Management



- raised inflammatory markers

- fever

- ultrasound with effusion




No antibiotics unless positive blood culture


Smith Petersen approach

- remove window of capsule

- washout +++

- don't close capsule

- leave in drain


Drill proximal femoral metaphysis / femoral neck

- diagnose / decompress osteomyelitis



- ensure hip is stable

- may require posteroperative spica if unstable


Post operative



- broad spectrum initially

- targetted antibiotics with positive culture

- IV until child well and inflammatory markers normalised

- oral until 6 weeks


TWB 6/52


Xray follow up minimum 2 years


- chondrolysis

- physeal arrest

- subluxation / dislocation



Transient Synovitis



Transient synovitis of unknown aetiology with complete resolution




Most common cause of hip pain

- 1 /1000


May occur in 3% of children with majority not seeking medical attention


Wide range of age

- from 9 / 12 to teenagers

- usually 3 - 8 years

- peak 6 years / same as Perthes


More common in

- boys 2:1

- caucasian

- never bilateral




1/3 viral 1/3 trauma 1/3 unknown


1. Infection


? Infectious condition

- supported by frequent association with current or antecedal illness

- viral or bacterial

- most commonly ENT

- no specific viral antibodies found


2. Trauma


May be contusion of hip

- history of trauma in 30%


3. Allergic hypersensitivity


May be hypersensitivity response

- 25% have atopia

- dramatic response to antihistamines & steroids




Culture negative synovial effusion


Synovial hypertrophy 2° to non-pyogenic inflammatory reaction




Limited duration of symptoms

- average 10 days

- may be 8 weeks


Recurrence uncommon < 10%


Associated with Perthes Disease in 1.5%

- probably not causative




Acute onset of unilateral hip pain

- usually hip & groin

- may be thigh & knee





Inability to weight bear

Hip held in flexion & ER

Protective muscle spasm

Restricted ROM especially IR

May be low-grade fever < 38°


Blood Tests


May be mild elevation of 







Usually normal

- exclude other conditions


May be mild changes in hip

- coxa magna / femoral neck widening

- ? 2° to hypervascularisation

- not symptomatic




May show effusion


Differential Dx


Septic Arthritis

- see Miscellaneous / Infection / Septic Arthritis

- Kocher criteria (WB / ESR / fever / WCC)



Perthes / SUFE / JRA 




Important to rule out other pathology


Symptomatic only

- rest in bed and analgesia until FROM shown to decrease recovery time & recurrence

- traction only for severe cases that fail to settle


- PWB on crutches until limp resolves




ACL Avulsion Fracture

Myers & McKeever classification


Type I:   Undisplaced avulsion fracture


Type II:  Anterior portion displaced & hinged


ACL Avulsion Type 2


Type IIIA:   Displaced

Type IIIB:   Displaced & Rotated


Type 3 ACL Avulsion




I - III A 


Attempt closed reduction

- anaesthesia / II control

- long leg cast in full extension

- trap fragment under condyles


Block to reduction

- usually medial meniscus / intermeniscal ligament


ACL avulsion reduced in extension


IIIB & Failed MUA


1.  Medial arthrotomy / arthroscopically

- need to remove portion of fat pad for visualisation

- intermeniscal ligament usually blocks reduction

- removed callus / hematoma

- replace fragment under intermeniscal ligament

- want to impact fragment to tension stretched ACL


2.  Repair Options


A.  No 2 suture

- bunnell suture through ACL above bony fragment

- pass 2 x limbs through bony fragment

- insert beath pins to retrieve suture limbs through tibial insertion

- two separate tunnels

- tie over bony bridge in tibia

- protect in plaster in extension


B. ORIF physeal sparing screw

- II guided

- directed posteriorly and obliquely






Some stretch of ligament occurs, but most knees are stable




Occasionally fragment can block full extension


ACL Avulsion MalunionACL Avulsion MRI Malunion







ACL Rupture



1.  More common recently

- more high level sport


2.  High risk of reinjuring knee from instability

- can suffer permanent severe chondral and meniscal damage


3.  Risk of physeal arrest high if bone block across physis

- risk is growth arrest with ACL reconstruction





- 60% children have ACL tear


ACL tear

- 20% have mensical injuries


Most occur within 6-12 months of skeletal maturity




Non operative




1. Non complicance children / young adolescents high

- high risk of chondral and meniscal damage


2.  Best to delay surgery if able til close to maturity

- avoid growth arrests




No sport / ACL brace / ACL rehabilitation

- until 2 years from skeletal maturity




Aichroth et al JBJS Br 2002

- 60 children with ACL deficient knees 1980-1990 

- average age 12.5 years

- 23 patients treated conservatively, NHx was severe instability & poor knee function

- 15 knees had meniscal tear, 3 osteochondral fractures, 10 knees developed OA changes

- 37 knees with Hamstring ACL reconstruction average age 13 years

- no physeal arrest and satisfactory results in 80%






1.  Meniscal tear / displaced / blocking extension


2.  Failure non operative treatment

- continued instability

- high risk of chondral damage


3.  Within 2 years of maturity




Growth arrest / angular deformity / LLD


Predicting growth potential


Skeletal age with Greulich-Pyle atlas

Anderson table predict growth remaining using height and growth potential




Extra-articular / over the top


- physeal sparing

- partial transphyseal

- transphyseal


Extra-articular / Over the Top



- > 5 years to maturity

- avoid physeal injury




McIntosh procedures

- ITB over the top

- combined intra-articular and extra-articular reconstruction


Technique Kocher JBJS Am 2005



- lateral incision

- entire ITB taken

- left attached distally, detached proximally

- tubularised with no 5


Arthroscopy performed

- removal of ACL stump

- minimal notchplasty to avoid injury perichondral ring distal femur



- ITB passed extra-articular around lateral femoral condyle

- over the top position

- passed out anteromedial portal



- 4 cm incision over anteromedial tibia

- clamp passed into knee under intermeniscal ligament

- groove for tendon made in epiphysis in this area

- graft passed through


Fixation femur

- knee 90o and foot ER 15o

- sutured to lateral intermuscular septum / extra-articular


Fixation tibia

- 20o flexion

- II used to assess location of growth plates

- groove made in proximal tibia

- graft sutured in place


Post op

- TWB 6/52

- restricted ROM 0 - 90o first 2 weeks




Kocher et al JBJS Am 2005

- 44 patients average age 10

- ITB extra-articular physeal sparing / McIntosh modification

- 2 revisions for graft failure at 5 and 8 years

- no angular or leg length deformity

- excellent IKDC and Lysholm scores

- pivot shift normal in 31 and nearly normal in 11


Intra-articular reconstruction



- < 5 years to maturity


Assessment of Bone Age


Xray right hand / Greulich-Pyle atlas

- estimate bone age

- estimate amount of growth from femur and tibia




4 strand hamstring graft


Tunnels < 5% physeal area do not cause growth disturbance

- i.e. 6 - 8 mm drill hole

- need to keep vertical to minimise area


Tunnels 7 - 9% of growth area

- if leave transphyseal tunnels empty or have bone inside

- will form physeal bars

- if place soft tissue across (i.e. graft) will not form physeal bar



1.  Physeal sparing

2.  Partial transphyseal

3.  Transphyseal


A.  Physeal sparing / transepiphyseal




Avoiding tibial physis

- tunnel anterior tibial epiphysis / trans epiphyseal

- graft secured with screw post / staple into tibial metaphysis


Avoiding femoral physis

- femoral tunnel horizontal and remains in femoral epiphysis

- transphyseal

- entrance in ACL origin

- use II guidance to spare the physis

- tunnel at 90o

- secured with endobutton

- 'over the top' position




Anderson et al JBJS Am 2003

- 12 immature patients

- no LLD, stable knees


B.  Partial transphyseal




Tibial tunnel transphyseal

- keep small (6 mm)

- keep vertical


Femoral tunnel as above

- over the top

- physeal sparing


C.  Transphyseal




Analogous to adult reconstruction


Preventing growth arrest

- tunnels < 7% physeal area (7mm tunnels)

- soft tissue interposition across physis

- tunnels are vertical as possible

- central in the physis to avoid angular deformity

- single pass, wash +++

- anchorage away from physis

- endobutton for femur

- short screw / staple / post for tibia

- graft only across physis




Kocher et al JBJS Am 2007

- 61 knees in patient average age 14

- 3% / 2 patients revision for graft failure at 14 and 21 months postoperatively

- pivot shift normal in 51 and nearly normal in 3

- no angular or LLD

- 3 cases of arthrofibrosis requiring MUA




Congenital Knee Dislocation




- 2:100 000

- 1/100 as common as DDH

- 1/3 bilateral 

- F:M 2:1




45% DDH

30% CTEV


Larsen Syndrome

Down's Syndrome







Two Theories

1. Intra-uterine packaging defect

2. Quadriceps intrinsic contracture / fibrosis




Knee hyperextended 

- tibia dislocated anterior to the femur



- quadriceps are tight

- absent cruciates

- patella hypoplastic or absent 

- patella alta

- valgus deformity

- hamstrings act as extensors




Type 1 

- can passively flex to 90°

- Subluxation / Hyperextension are minimal


Type 2

- can flex to 45°

- Moderate subluxation



Type 3

- -90 to 10o flexion

- complete dislocation

- no contact




Congenital Recurvatum of the Knee

- similar condition, but knee located 

- hyperextension is correctable, but flexion is limited

- splint knee to increase flexion

- KFO to maintain flexion

- good prognosis




Non operative


Type 1


Attempt closed reduction & Pavlik harness


Type 2 & 3


Gentle MUA & serial casting


Once 90o, Pavlik harness 3/12


If DDH as well

- reduce knee first

- usually splint from foot to hip till 45° flexion 

- then Pavlik


Operative Management




Failure non-op treatment


Surgery often in syndrome e.g. arthrogryposis




Open reduction at 6/12 of age

- quadriceps engthening via anterior approach

- anterior capsulotomy / capsulectomy to reduce tibia onto femur


Ligamentous instability later very common









Congenital Patella Dislocation




- ? dislocates in utero or post-natal period


Usually bilateral






Associated with Down's / Larsen's & Arthrogryposis




Persistent lateral patella dislocation

- hypoplastic flat LFC

- aberrant lateral insertion quadriceps

- hypoplastic flat patella




FFD knee

Valgus knee



- laterally rotated patella 

- absent active extension

- difficult to palpate high & lat patella


Common diagnosis as toddler after started walking




Unrewarding till > 3 years

- doesn't usually ossify til 2 - 3 year

- can be delayed until the 6th year

- ossification complete about puberty




Demonstrate dislocated patella






Operate when diagnosis made

- gives chance for PFJ to remodel





1.  Large lateral release

2.  Medial plication / VMO advancement

3.  Roux Goldthwaite


+/- Galeazzi - Semitendinosis transfer

+/- Hamstring release for FFD


Later problems with PFJ incongruity common as have two flat surfaces & hence early location better


Roux-Goldthwait procedure

- lateral 1/2 patella tendon detached 

- transferred beneath intact medial 1/2

- sutured to medial tibia (to insertion of sartorius) 

- modification is transfer medial 1/2 patella tendon to MCL





DDx Adolescent Knee Pain


Remember hip pain as a cause from SUFE / Perthes




Hip - Perthes / SUFE / Infection


PFJ - malalignment, chondromalacia, tendonitis


Cartilage - OCD


Meniscus (+/- discoid)


Ligament injury


Osgood Shlatters


Synovial Plica








Osgood-Schlatter's disease

DefinitionOsgood Schlatter's


Condition of traction apophysis into which part of patellar tendon inserts

- pulling osteochondritis of tibial tubercle




Early teens

- M:F

- corresponds with growth spurt

- M 12-14 

- F 11-13 

- 1/3 bilateral

- athletes 21% vs 5% normal




Traction injury

- due to recurrent tensile microtrauma to an immature patella insertion 

- usually no history of injury




Activity related pain

- especially kicking & jumping

- pain on direct blow

- difficulty kneeling




Tender lump over tibial tuberosity

Pain on active extension


Osgood Schlatters




Exclude other causes

- enlarged fragmented tibial tuberosity


CT scan 


May define ossicle in patellar tendon

- 10%




Usually resolves spontaneously

- NSAID oral and topical

- hamstring stretching

- restriction of provocating activities


Steroid injections contra-indicated


Removal of ossicle if remains painful and mobile


Excision Osgoods 1Excision Osgoods 2Excision Osgoods 3




Leg Length Discrepancy

Congenitally Short Femur



20 - 30 % LLD




Intact femur radiographically +

- foot at contralateral mid-tibial level

- cruciate ligament deficiency

- coxa vara

- hypoplastic lateral femoral condyle with resulting valgus knee

- sclerosed lateral cortex


Amount of femoral shortening is variable patient to patient


Shapiro Type 1 growth disturbance

- i.e. LLD increases with time





Genu valgum

Fat thigh

High riding patella


Foot held externally rotated




Hypoplastic femur

Coxa vara

Lateral sclerosis


2 groups


Simple femur hypoplasia


Femoral hypoplasia with coxa vara




Align early then lengthen in primary school years


1. Realignment may involve


Coxa vara

- proximal femoral valgising osteotomy


Valgus knee

- Supracondylar osteotomy / guided growth 8 plates


2. Lengthen tibia and femur


Caution for dislocated knee

- ACL deficient


3. Contralateral epiphysiodesis








Fibula Hemimelia



Deficiency of bony elements on lateral side of lower limb

- characterised by hypoplastic or aplastic fibula





- abnormal foot



- normal foot




Most common congenital deformity of long bones

- M:F   2:1


May be associated with PFFD



- tibial hemimelia can be inherited







- PFFD with type C / severe

- always slightly short femur



- cruciate deficiency

- hypoplastic LFC / valgus knee



- anteromedial bowing



- equino-valgus / ball and socket

- tarsal coalition



- small limb / foot

- absent lateral ray(s)

- lateral tarsal bones fused or absent


UL deficiency


Classification Coventry


Type 1:  Short or partial proximal absence unilaterally


1A:  Stable ankle joint ± ball & socket joint

1B:  Unstable anklejoint / equinovalgus


Fibular Hemimelia


Type 2: Complete absence unilaterally

- tibia short & bowed anteromedially, dimple at apex

- associated with lateral ray deformity & coalitions


Type 3:  Bilateral

- severe

- associated with PFFD & upper limb deficiency




Fibular hemimelia / dysplasia is a spectrum

- child may have only gracile fibular and short leg in tibia and femur

- attributed to fibula hemimelia as no ACL, short femur etc

- can be pseudoarthrosis of tibia

- realise when tibia fractures and then doesn't heal


Management Issues


1.  Foot / ankle deformity




If less than 2 rays or unstable ankle

- cannot salvage

- symes / BKA


Indication for Syme's Amputation

- severe deficient foot that will not serve any useful purpose

- grossly unstable ankle

- associated tibial deficiency such that LLD & unstable AKJ preclude leg lengthening

- associated PFFD 


2.  LLD 


Usually > 5 inches

- can predict based on difference at presentation 

- can treat if have normal foot


Usual Options

- < 3cm shoe lift

- 3-5 epiphysiodesis

- 5-10 limb lengthening

- 10-16 limb lengthening + epiphysiodesis

- > 16 amputate




5cm at a time

Usually start when child 7-8, can understand reason for operations


3.  Tibial bowing


Least important

- usually corrects




Growth Plate Arrest




- most common

- SH 4

- high energy SH 2 / 1 i.e. distal femur




Thombotic / embolic


Ischaemia (arteritis)






1. Central

- tenting 

- slows longitudinal growth +/- angulation


2. Peripheral

- can lead to rapidly progressive angular deformity

- especially small bar


Distal radius premature lateral growth arrest


3. Linear

- especially SH4

- effect depends on site and size




To assess deformity (angular and LLD)




To accurately map size and position of bar




1.  Epiphysiolysis



- < 50% growth plate

- > 2 year growth

- healthy skin




Excision of bar and interposition graft (fat)

- excision with high speed burr



- via direct approach to growth plate



- more difficult

- via metaphyseal window (avoid damage to the perichondral ring)


2.  Epiphysiodesis 



- remove active part of growth plate

- prevent angular deformity



- use drill under II guidance

- 4.5 mm


3.  Osteotomy



- correct angulation post growth plate fusion / epiphysiodesis







Asymmetry between L and R side more than due to normal variation


Upper limb hemiatrophy




Difficult to determine because no precise definition


Difficult to differentiate hemihypertrophy from normal variation

- enlargement soft tissues & bones also



- 1/13 000 combined

- 1/86 000 non-syndromic


Non syndromic hemihypertrophy associated with 4% incidence tumours






Non-syndromic is sporadic


Clinical Features


Rarely apparent at birth

- thicker skin, more hair, accelerated bone age on involved side

- ipsilateral paired organs increased in size also




Non-syndromic hemihypertrophy


Inguinal hernias



- renal cysts

- cryptorchidism

- sponge kidney

- horseshoe kidney



- non-structural

- compensatory to pelvic obliquity


Syndromic hemihypertrophy


Associated with cutaneous and vascular lesions





- involvement of ipsilateral paired organs



- also divided as per extent of involvement


Classic hemi - UL & LL

Segmental - UL or LL

Facial - head and neck only

Crossed - opposite UL & LL




Normal population may differ up to 1-2 cm in length and circumference


Rush and Steiner 1946

- 1000 US army recruits

- 23% equal leg lengths

- 77% 0.75 cm

- 15% > 1 cm


1cm difference

- in adolescent within normal

- in infant in pathological range   (4.2%)


Hemiatrophy V's hemihypertrophy


Compare length of L and R tibia and femora with normal standards



- no association with tumours


Non-syndromic hemihypertrophy / Beckwith-Weidermann syndrome

- are at increased risk for intraabdominal tumors 


DDX of non-syndromic hemihypertrophy


1. Beckwith- Weidmann syndrome

2. NF

3. Klippel-Trenaunay-Weber syndrome

4. Proteus syndrome

5. Malignant tumours

6. Olliers

7. Fibrous dysplasia

8. Poliomyelitis

9. Spastic hemiplegia of CP

10. Russell-Silver synd (short, cafe-au-lait spots, clinodactaly, hemiATROPHY)

11. JCA or haemophilia (secondary to hyperaemia)

12. XRT

13. Conradi-Hunnerman (chondrodysplasia punctata)


(5 - 13 may have contra-lateral shortened limb)


50% of hemihypertrophy will have syndrome


Beckwith-Weidermann Syndrome




Pre / postnatal overgrowth, birth weight > 90 %

- neonatal hypoglycaemia

- macroglossia

- hemihypertrophy occurs in 13%


Predisposition for embryonal tumors (Wilms)




Genetic abnormality Chr 11 p15

- near gene for IGF -II

- AD transmission but most sporadic




Need abdominal US


BWS with hemihypertrophy c.f. BWS without hemihypertrophy 

- risk embryonal tumour

- 27 V's 9%




NF1 may have overgrowth digit or limb




Characteristed by Hemihypertrophy + vascular malformations


AV Malformation Arm



- varicose veins

- port-wine nevi

- cutaneous and subcutaneous capillary haemangiomas

- cavernous haemangiomas


Proteus Syndrome


Name after Greek god who could change shape


Vascular + lymphatic malformations + lipomas



- haemangiomas

- lipomas

- lymphangiomas

- macrocephaly

- hyperostosis skull

- overgrowth long bones



LLD Aetiology

A.  General Conditions


Hemi-hypertrophy or atrophy



Klippel-Trenaunay-Weber syndrome

Proteus syndrome

Beckwith-Weiderman syndrome

Russel-Silver syndrome (atrophy)


Skeletal dysplasia


Chondrodysplasia punctata

Ollier's / Maffuci's

Multiple hereditary exostoses


Fibrous dysplasia




Closed HI


Spina bifida


Spinal dysraphism / tumor / injury

Peripheral nerve injury


B.  Specific Regions


Tumour / trauma / infection / radiotherapy physis




- Coxa vara



- Perthe's

- Tom Smith arthritis / post septic arthritis



- congenitally short femur



- fibula hemimelia

- tibial hemimelia

- bowing





Effect of LLD


Initially thought gives pain in back and contralateral knee and hip

- this may be debatable


1.  Short leg gait

- increased energy expenditure is the only proven effect of LLD


2.  Back 

- pelvic tilt and secondary scoliosis

- initially compensatory

- can become fixed

- ? causes LBP - now thought no different from general population

- most children's spines adapt (not so with adults)

- up to 2 cm easily tolerated


3. Contralateral Hip 

- uncovering of hip on long leg side in stance

- AKA long leg arthropathy

- ? increased OA 

- no evidence 


4.  Contralateral Knee 

- ? increased knee pain in athletes




2° Proliferative Zone chondrogenesis


Proximal Femur

- 3mm / year

- 15% leg


Distal Femur

- 9mm  / year

- 37% leg

- 70% of femur


Proximal Tibia

- 6mm / year

- 28%

- 60% tibia


Distal Tibia

- 3mm / year

- 20%


Growth Cessation


14-15 Girls

16-17 Boys




LL vs Chronological Age

- steady growth occurs

- growth spurt in early adolescence


LL vs Skeletal Age 

- Green & Anderson curves

- Growth vs Skeletal age

- shows no growth spurt

- because growth spurt & maturation spurt occur together


Skeletal Age & Chronological Age

- maturation can occur at different rates

- if early, are tall early & stop growing early

- can have spurt where mature more than age

- pass through skeletal ages more quickly




Determine cause

Determine deformity




LLD Assessment & Quantification

Quantification of LLD




1. Teleroentgenogram

- single exposure both legs

- long film with ruler

- Parallax errors


2. Orthoroentgengram

- same long Xray

- separate exposures hip, knee & AJ 

- eliminates parallax error

- problem artefact 


3. Scanogram

- similar separate exposures

- film moved between exposures

- smaller film

- multiple exposures


CT scan


Software measures distances 

- accurate to 0.2 mm

- legs must be in same position

- fast


Skeletal Age


1. Greulich- Pyle Atlas


Xray Left hand (non dominant)

- correlated with Green- Anderson table LL

- less accurate < 6

- improved accuracy by focusing on hand bones rather than carpal bones


2. Tanner- Whitehouse Atlas

- more refined

- 20 landmarks graded L Hand

- more accurate

- can't use as not correlated with LL


Prediction of Growth


Note that all methods have an inherent error of 12 months

- gives accuracy to 1.5 cm


Need > 3 measures 4/12 apart for all methods

- If inadequate data wait till older or wait till skeletally mature

- If acquired event caused LLD, can plot onto graph


1.  Menelaus "Rule-of-thumb" Method


Less accurate

- based on chronological age

- only valid from age ten

- convenient / easy / simple


Basic rules

- girls stop growing at 14 

- boys stop growing at 16

- distal femur 9 mm 

- proximal tibia 6 mm 

- distal tibia / proximal femur 3 mm 


Calculate how much growth lost from fusion of physis / Predict effect of epiphysiodesis

- Effect = Physis rate x years of growth Left


2.  Green & Anderson tables


Growth remaining method

- uses skeletal age

- requires graph

- estimates growth potential in distal femur and proximal tibia at various skeletal ages

- separate charts for girls and boys


3.  Moseley


Straight - Line Graph Method  

- uses Green & Anderson data

- applied to a chart


At least 3 measurements each time

1.  Length long leg

2.  Length short leg

3.  Skeletal age


Do so 3 times separated by 3-6 months

- accuracy improves with increased plotting


Plot the points for long and short leg on a vertical line for chronological age of either boy or girl

- create 2 lines for short and long leg over time

- line of best fit

- gives LLD at maturity at right of graph



- plot Long leg length on long leg line against skeletal age

- plot Short leg length on short leg line against skeletal age

- able with at least 3 measures to create line of best fit

- extend lines to maturity

- difference is LLD


Growth rate of each leg = slopes

- parallel or divergent 

- AKA static or progressive


Then use Menelaus rule of thumb to determine appropriate age for epiphysiodesis


4.  Paley multiplier


State of the art

- 2000

- take LLD for boy or girl

- multiplier for chronological or skeletal age

- predicts LLD at maturity


Patterns of LLD


Adds to difficulty

- static

- progressive

- regressive




1982 5 developmental patterns

- 75% types I and II


I Increasing

- LLD increases at constant rate

- hemihypertrophy / atrophy

- tibial pseudoarthrosis


II Increasing plateau

- similar early, but annual rate of increase diminishes thereafter

- Perthes


III  Plateau

- discrepancy increases, then stabilises

- fracture femur


- Polio


IV Increasing- decreasing

- similar to III, then late increase at end of growth


- hemihypertrophy


V Decreasing

- Initial increase, steady, then decrease


Progressive LLD


Progression Rate = Change LLD / Time


Final LLD

- add Current LLD to Prog Rate x Time to Skeletal maturity






LLD Examination

Four Physical Outcomes


1.  Symmetrical Stance & Level Pelvis 


A.  LL Equality

- components equal with no deformity


B.  Components equal with bilateral symmetrical deformity

- eg bilateral varus knees


2.  Symmetrical Stance with Oblique Pelvis 


Uncompensated LLD


3.  Asymmetrical Stance & Level Pelvis 


A. Fully Compensated LLD

- flexed contralateral knee 

- equinus ipsilateral ankle


B. Sagittal deformity with ipsilateral sagittal compensation

- FFD knee with equinus & hip flex OR

- fixed equinus with flex knee & hip OR

- FFD hip with equinus & flex knee


C.  Coronal deformity with contralateral coronal deformity

- valgus of knee & contralat varus of knee


4. Asymmetrical Stance with Oblique Pelvis 


A.  Partly compensated LLD

- partly flexed contralateral knee

- partly equinus of ipsilateral ankle


B. Coronal hip deformity with sagittal compensation

- fixed hip adduction with contralateral knee flexion / ipsilateral equinus

- fixed hip abduction with ipsilateral knee flexion / contralat equinus


C.  Sagittal deformity with coronal compensation

- FFD knee c ipsilateral hip abduction

- fixed equinus c ipsilateral hip ADD


Leg length Examination


1.  Look



- flexed knee


Signs hemihypertrophy

- NF
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)



- trauma, infection


2.  Gait




Compensate well 

- walk on toes short leg usually / equinus

- flexion long knee uncommon as energy++




Compensate less well

- walk with bilateral heel-toe gait

- vaults over long leg

- excess sagittal head motion


3.  Measure LLD

A.  Functional LLD

- on blocks

- heels flat, nil knee FFD (if able)

- correct pelvic tilt

- should correct scoliosis



- if can make pelvis stable

- ASIS equal

- blocks are a quantitative measure of functional LLD


B.  Apparent LLD


Lying on bed

- measure from xiphisternum to medial malleolus

- no correction for contractures


C. Real / True LLD


Must correct for deformity in coronal and sagittal plane



- hip adduction / abduction contracture

- hip FFD

- knee FFD



1.  Hip FFD

- pillow under both thighs

2.  Knee FFD

- pillow under both knees

3.  Hip adduction contracture won't correct to neutral

- measure each leg crossed over the other

4.  Hip abduction contracture won't correct to neutral

- place both legs in similar position


If there is a contracture, perform the above measures

- then meaure the intercalated segments

- from ASIS to medial joint line

- medial joint line to medial malleolus


4.  Identify site of shortening



- must not forget can have small foot / old calcaneal fracture / wasted buttock

- hips and knees flexed

- side by side

- look for tibial / femoral shortening


If shortening above knee, find out if shortened above greater trochanter

- i.e. hip deformity


Bryant's triangle

- line perpendicular to GT and ASIS

- distance between

- quantify in fingerbreadths


Nelaton's line

- line from ischial tuberosity to ASIS

- GT should be on or below line


Klisics line

- GT to ASIS

- should aim to umbilicus

- will be more parallel


5.  Other


Examine knee stability

- can have problems lengthening femur if ACL deficient

- i.e. fibula hemimelia






LLD Management



1. Equal leg lengths

- goal is mild to moderate isolated discrepancy


2. Unequal leg lengths

- goal with paralysis / equinus foot

- aim 1-2 cm short for clearance


3. Level Pelvis

- should use blocks to estimate functional correction


4. Vertical LS Spine

- vertical spine more important than level pelvis


5. Equalisation with Prosthesis

- goal with excessive LLD

- usually femur < 1/2 normal length or LLD >15cm




Correct coexisting deformity first

- can decrease discrepancy


May require correction of other problems first

- release of contractures

- correct angular deformity

- correct spinal deformity

- excision of bony bridge

- completion of partial arrest


Treatment guidelines by projected discrepancy


0 - 2 cm

- no treatment, heel raise


2- 6 cm

- shoe lift, epiphysiodesis

- maximum subtalar joint can take


6 - 15 cm 

- lengthening + epiphysiodesis


> 15 cm 

- amputation




Shoe Lift / sole raise


Good treatment if 2-5 cm

- aim is to improve gait



- > 5 cm ankle sprains

- joint unable to cope

- need patten boot (steel reinforcements of STJ)



- 0 - 1.5cm heel raise

- 1.5 - 5cm heel and sole raise

- 5 - 12cm patten and boot

- 12 - 20cm patten and AFO / prosthesis

- 20+cm prosthesis






Often treatment of choice

- low morbidity

- accurate

- can shorten at level of deformity




Operate on normal leg

- get loss of height & proportions




Anticipated LLD 2-6 cm


If > 6 cm LLD 

- excessive height loss

- knees at different level 


Phemister Technique


Create bony bridge

- medial & lateral approaches

- access window removed

- physis excised with curette


Percutaneous Technique 


Under II guidance

- percutaneous incision

- medial and lateral drilling into physis

- angle drill anterior and posterior

- entry points anterior, middle and posterior

- see white growth plate on drill




Continued longitudinal growth or angular deformity

- failure to eliminate growth plate


Femoral Shortening




Maximum 2 - 6 for reasons above


Consider if

- too old, insufficient growth remaining

- can't predict LLD and wait til maturity


Usually performed over a nail


Tibial Shortening



Max 3cm


Growth Stimulation


Stimulate physis by hypervascularity 2° irritative

- insert vicryl into growth plate

- moderate success


Leg Lengthening


See Limb Lengthening






Limb Lengthening



Concept of distraction osteogenesis


Popularised by Ilizarov in the Soviet Union 

- initially in the 1940's

- popularised in the 1980's

- also created the circular fixator



- low energy osteotomy

- attempt to minimise damage to blood supply and periosteum

- avoid use of saw

- minimise thermal necrosis



- gradual incremental distraction of a fracture callous after a latency period

- intramembranous ossification in zone of distraction

- type 1 collagen with osteoid laid on collagen




Maintains height & proportions

- Avoids operating on normal side





- steep learning curve

- complication rate 10 - 250%




General rules

- LLD 6-15 cm

- over 15 cm risks outweigh benefits

- < 20% limb

- 5cm in femur / 5 cm in tibia


Limitation is due to muscles / ligaments / nerves

- can repeat at staged procedures

- i.e. 5 cm per bone at any given time




Site of deformity best


Metaphyseal lengthening easiest

- large cancellous surface area

- thin cortex

- best blood supply




Mentally or medically unstable

- long and demanding process

- 12 months or more


Unstable joints


Associated neurology

- Weakness /  Insensate




1. Osteotomy & Frame / Nail

2. Latency Period

3. Distraction Period 

4. Consolidation Period


Maintaining blood supply via periosteum is the key


1A.  Osteotomy with Periosteal Preservation


Open Corticotomy


Drill-holes & closed osteoclasis / Di Bastiani


Used in the femur

- percutaneous skin incision

- multiple drill holes first to weaken bone

- osteotome to complete

- apply force to complete fracture


Usually stablise initially with temporary external fixator

- perform osteotomy

- insert nail / ISKD

- remove frame


Tibial technique with Gigli saw


Proximal corticotomy in metaphyseal bone

- below tibial tuberosity

- frame on initially to stabilise

- incision lateral crest tibia, elevate periosteum lateral tibia

- incision medial border tibia, elevate periosteum medial tibia

- pass artery clip between periosteum and bone on one side

- pass wire on other side, retrieve with clip

- pass suture, then pass gigli saw

- perform subperiosteal corticotomy, periosteum intact


Wagner Osteotomy


Contra-indicated now

- osteotomy and acute resection

- distraction

- bone grafting and plating

- superceded by lizarov techniques


1B. Devices


Need stable device or risk non-union with fibrocartilage


Uniplanar Device 

- Wagner, Orthofix

- simple

- no angular correction

- "Cantilever Loading"

- problems with pin loosing

- often necessary in femur



- multiplanar correction


IM nail  / ISKD


Self lengthening nail

- movement of leg induces lengthening mechanism

- maximum of 5 cm

- if only want 3 cm, lengthen 2cm before insertion



- all internal 

- no pin site complications

- easier for patient




Runaway nail 

- lengthens too quickly

- cause contractures and nerve injury

- nothing can be done about this

- incidence 5%


Jammed nail 

- take to theatre to unblock

- may have to debride callus if lengthening too slow


2.  Latency period 


Usually 1/52

- allow callus to form before distraction

- reduce latency period in child as may start to ossify

- increase latency period in diabetics / steroids


3.  Distraction Period


Rate / Regenerate


Optimum 1mm / day turning 4x / day

- balance premature union vs non union

- slower in adults / diabetics

- i.e. 2-3 x day


Stop if

- poor new bone formation

- nerve palsies

- joint subluxation

- joint contracture 


4.  Consolidation


1 month per cm or

Double the distraction period




Pin infection



- early oral antibiotics

- patient should have script at home

- take if pin site appears red or begins leaking fluid

- increase frequency of pin site cleaning



- tight well tensioned pins

- don't place pins throught muscle


Nerve  injury

- demyelinate if lengthen > 6%



- muscle elongates poorly

- max 1mm / day

- congenital LLD more susceptible than acquired



- T achilles contracture in tibia

- FFD / adduction femur

- knee FFD


Device failure

- broken pins, loss of position



- inadequate consolidation before device removal

- 10 - 15% incidence

- can result in loss of length or angular deformity


Premature Consolidation

- unable to distract

- break pins / wires


Poor regenerate

- inadequate latency period

- too rapid distraction

- poor blood supply


Joint subluxation

- ligamentous insufficiency


Delayed or non union

- constant observation


Bone growth impairment

- damage to physis

- likely secondary to pressure

- best if delayed until after skeletal maturity


Psychological Stress


Distraction Physiolysis



- tibial lengthening by distraction across physis

- similar results to metaphyseal lengthening



- need extra length in skeletally immature




Physeal injury risk


Chondrodiastasis if < 1mm / day




Tibial Hemimelia



Paraxial deficiency of skeletal elements on medial aspect of lower limb




Only skeletal deficiency with a documented familial occurrence 

- AD


1/ 1 000 000


Bilateral 30%




Leg short +++


Tibial Anterolateral Bowing


Foot fixed in severe varus

- can mimic CTEV

- sole facing perineum




- may be unstable

- no quads mechanism




Cleft hand

Reduplication of toes

CDH 20%




MRI to assess extent of proximal failure


1.  Unilateral Complete Type 1


No proximal tibial remnant

- usually foot abnormalities

- distal femur is hypoplastic & ossification delayed

- knee is featureless / unstable


Tibial Hemimelia Complete



- amputation early

- around 1 year before child gets attached to it


2.  Unilateral Partial Type II


Well developed proximal tibia & knee joint


Tibial Hemimelia Partial




A.  Knee

- proximal tibiofibular synostosis to prevent proximal migration

- fuse distal fibula to end of tibia

- then either symes or fuse fibula into calcaneus


B.  Ankle foot

- distal tibial deficiencies

- get equinovarus deformity similar to club foot

- tibiofibular synostosis

- then either keep foot if good or Symes


3.  Bilateral




A.  Bilateral through knee amputation


B.  Can try to make fibula into tibia and perform symes on one side

- Brown procedure

- need good quadriceps






Acutely Limping child





Transient Synovitis/ Septic Arthritis






Inflammatory Arthritis




0-2 DDH

2-5 septic arthritis

2-10 synovitis

5-10 perthes

10-15 SUFE


5 questions


Is limp due to pain?

What type of limp?

Is limp gradual / sudden?

Any localizing features?

Is the child unwell?






Supine on couch





Bone Scan



Haematological tests









Arthrogryposis Multiplex Congenita



AMC characterised by non progressive congenital rigidity of 2 or more joints

- Arthrogryposis means curved joint

- Arthrogryposis refers to 150 syndromes




1.  Amyoplasia

- involves all 4 limbs


2.  Distal Arthrogryposis

- AD

- type 1 98% hand / 87% feet

- type 2 involve other systems




1 in 3000 live births

-  hereditary pattern unknown




Fibrosis of periarticular soft tissues during joint development

- leads to development of incomplete fibrous ankylosis

- unknown cause


Numerous theories

- CNS abnormality / anterior horn cell 

- environmental factors - toxins / virus

- packaging defect

- oligohydramnios

- limitation of foetal movement




Muscles replaced by fibrous tissue

Spinal cord decreases in size, especially at the limb enlargements

- decreased number of anterior horn cells


Clinical feature


Normal intelligence


Wooden doll facies


Usually involves all 4 limbs (AMC)

- joint contractures with webbing


Marked limitation of joint ROM

- no skin creases

- scant subcutaneous tissue & muscles

- skin tense & glossy

- ± dimpling at joints


Typical Deformities



- shoulders adducted and IR

- elbows extended

- wrists flexed, pronated & UD



- hips flexed, ER & abducted / dislocation

- knees flexed





- teratologic DDH

- teratologic CTEV

- congenital patella dislocation






Achieve maximum function

Permit mobility / ability to transfer

Enable Feeding & hygiene




Lower limbs first

- plantigrade feet first

- extend knees

- reduced hips


Upper limbs

- ability to bring hand to mouth / elbow flexion

- ability to toilet & push off when rising with other hand



- correct all LL deformity by 2 years to allow walking

- address UL deformities later

- allows bimanual function to be established

- allows functional assessment



- full-time bracing until age 6

- night splints until skeletal maturity

- soft tissue procedures in young child

- bony procedures as approach skeletal maturity


Talipes Equinovarus



- rarely responds to bracing

- requires PMR before walking age

- AFO's required post-operatively until skeletal maturity

- failure be require talectomy


Older child

- triple arthrodesis is procedure of choice


Knee Flexion Contracture



- daily passive ROM

- serial casts

- night splints

- surgery for resistant cases




Surgical release 

- capsule

-  ± collaterals & cruciates

- hamstring lengthening

- serial casting post-op



- supracondylar osteotomy near skeletal maturity


Hip Dislocation




Open reduction ± femoral shortening & derotation osteotomy

- age 1

- when knee FFD corrected

- accept situation if reduction not achieved by 2 years

- because of increased risk of unilateral failure with pelvic obliquity & scoliosis consider accepting if bilateral 


Hip Contractures




Hip FFD > 30°

- increases lumbar lordosis

- increases knee flexion contracture

- crouch gait


Non operative

- correction of knee contracture

- maintaining patient prone



- subtrochanteric osteotomy near skeletal maturity




Little to offer for severe deformity


Wrist flexion


1.  Hand stiff


Non operative

- pronated flexed wrist enables forearm radial borders to appose each other to produce pincer grip


2.  Hand functional


Treat FFD

- Gives same range of wrist movement, but in more functional position


A.  Dorsal closing wedge capitate / FCU transfer

B.  Carpectomy

C.  Wrist fusion


Shoulder Internal Rotation




Should be addressed before elbow corrected




External rotation osteotomy in proximal shaft


Elbow Extension




Need one elbow bent & one straight





- unilateral posterior capsulotomy & triceps transfer

- steindler flexorplasty

- pectoralis major bipolar transfer




Brace may be successful

Often requires segmental fusion



Congenital Sclerosis



Diaphyseal dysplasia (Engleman’s)

Metaphyseal Dysplasia (Pyles Disease )


Caffey's / Infantile Cortical Hyperostosis

Osteoarthropathy Familial Hypertrophic



Melorheostosis / Mastocytosis / Myelosclerosis

Osteopathia striata


Osteopoikilosis (bone islands)







Developmental Milestones


3 months - head control / lifts head when prone

6 months - rolls over

9 months - sits up without support


12 months - walks with one hand support

15 months - walks by themselves


2 years - ascends stairs & can run forwards

3 years - pedals tricycle

4 years - balances on one foot

5 years - hops on one foot





Down's Syndrome



Trisomy 21


1 in 800




Advanced maternal age

- 1/ 50 mothers > 45

- however mothers < 30 still most common



- 95% non disjunction during meiosis

- 4% are result of translocation (Chr 21 joins to Chr 14)

- 1% are mosaics


General Features


Mental retardation / Developmental delay


Short stature




Simian crease (palmar)



- coronal deformity fifth ray

- can see at US screening


Ligament Laxity 

- patellar subluxation 

- planovalgus feet


Characteristic Facies 


Foreshortened head

Eyes slant upwards

Prominent epicanthic folds

Ears low-set 

Nose flattened

Lips parted



Medical Complications


Cardiac defects (ASD VSD)

- 50%


Endocrine disorders

- hypothyroidism 15%

- DM 1%


Duodenal atresia 10%


Alzheimers 70%


Orthopaedic Issues


2 main orthopaedic problems

- atlanto-axial instability

- hip instability



- scoliosis

- spondylolithesis


- patella dislocation


Atlantoaxial Instability



- present in 20%

- diagnosed with dynamic views

- usually causes no problems

- occasionally have neurological defects from dislocation




Children shouldn't

- play contact sports

- dive

- perform gymnastics




Children should undergo C1/2 fusion 


Hip Instability



- 3% incidence dislocating hip

- doesn't present at birth

- presents later in life

- can be highly unstable



- ligamentous laxity

- capsule thin and deficient

- increased femoral anteversion

- acetabulum shallow and anteverted / deficient posteriorly



- walk ER to maintain location

- can dislocate hip spontaneously



- MUA arthrogram demonstrates subluxation



- FDRO + capsular plication

- spica 6/52, abduction brace 6/12 at night



- 1/4 poor results, continued instability

- difficult problem to treat







Juvenile Chronic Arthritis





- heterogenous inflammatory joint disease

- °infective aetiology 

- > 3/12 duration & < 16 years old


Systemic / Pauciarticular / Polyarticular




1: 10000

- M = F

- Different subgroups have associated with different HLA types





- ?  Immune aberration to infectious agent

- Similar to RA

- Genetic predisposition




Must be > 6/52

Classify after 6/12


1. Systemic JCA 

- Still's disease

- fever, rash, lymph nodes, hepatosplenomegaly

- 20%

- poorest long term prognosis


2. Pauciarticular JCA 

- < 4 joints

- 30%


Divided into

A. Early onset < 6


- F > M

B. Late onset

- like Ankylosing Spondylitis / HLA B27

- M > F


3. Polyarticular JCA >5 joints

- 60%

- most common


Divided into

A.  Seronegative

B.  Seropositive

- more severe with joint destruction


Systemic / Still's Disease




Usually < 3 years old

- M = F 

- usually not ANA or RF +ve


Systemic symptoms


Febrile ~ 40°

Maculopapular rash 




Joint symptoms occur weeks after onset




Initially mild swelling & pain

- may progress to Polyarthritis

- commonly Knee / Wrists / Ankle & Midfoot

- flexor Tenosynovitis

- MCPJ & PIPJ swelling


Usually resolves with systemic illness

- long term affects hips and cervical spine




Fluctuates with the fever 

- may only appear at night or in evening 

- i.e. not when seen in clinic

- salmon pink




ESR ~ 100

Increased WCC + Neutrophilia

Mild Anaemia

Increased IgG

RF negatgive

Increased CD4 T Cells




Children almost always get spontaneous resolution of disease as teenager

- left with degenerative joints

- moderate to severe arthritis in ~ 50% 

- frequent involvement of hips


Stunted growth 

- steroids make stunting even worse




Very typical case presents with monoarticular arthritis of knee

- < 5 joints in 1st 3/12 

- no Stills symptoms


A. Early onset / 50 - 60% ANA Positive



- <6 years 

- F>M


Medium joints

- Knee / AJ / Elbow

- Flexor Tenosynovitis



Chronic Iridocyclitis

- 50%

- resolves after few years

- follow up until late teens for eyes


B Late onset / Positive HLA B27



- > 9 years

- M > F 

- positive FHx

- RF negative


Most develop Sacroiliitis & Spondylitis


LL affected 

- KJ / AJ / Hip



- Plantar Fascia / TA / Tib Tubercle



- commonest cause of blindness in western world 

- can be treated with steroids 

- must all see ophthalmologist every 3 months until 20 years old even if in remission


Overall excellent prognosis 

- minimal drug treatment required

- Main problem is actually the iritis





- > 5 joints within first 3/12 

- F > M 

- ANA positive in 50%

- symmetrical polyarthritis

- small & large joints


A. Seronegative


More common 

- 85% of polyarticular


Affects KJ most commonly

- wrists / ankle / C spine

- flexor tenosynovitis

- 1st MTPJ


B. Seropositive / Juvenile RA


Older girls

- Small joints of hands & feet

- nodules

- +ve RF


Rapidly progressive with joint destruction

- more likely to be persistent into adulthood



- non-specific changes early

- have severe periarticular osteopenia

- later joint erosion & deformity





Nonoperative Management





- prevent contractures

- prevent wasting



- dampen infection

- aid ADL's and schoolwork





- mainstay of treatment

- paediatric suspensions available

- avoid Salicylates because of Reye's disease


IV Immunoglobin

- Still's



- increased use

- much higher doses in kids

- attempt to prevent progression

- aggressive treatment in polyarticular disease with poor prognosis


Gold & Penicillamine 

- seropositive



- spondyloarthropathy


Systemic Steroids



- doesn't affect progression of disease 

- se limited by SE: stunting / osteoporosis



- unresponsive Still's / Polyarthritis


Alternate day treatment

- minimal stunting

- avoid suppression hypothalamic - pituitary axis





- flares of pauciarticular disease 

- knee / flexor sheaths



- non specific temporary palliative treatment

- allows good pain relief

- early mobilisation

- therefore preventing contractures / muscle atrophy

- preserving function




Monoclonal anti TNF antibody

- effective in 60%

- 5% develop allergic reactions

- 10% develop new autoantibodies


Operative Management





- may require soft tissue releases + synovectomy



- may need synovectomy + radial head resection



- very frequently involved

- short ulna

- ulnocarpal deviation (c.f. radial deviation in adult RA)

- require synovectomy / fusions



- radial deviation (c.f. ulna deviation in adult RA)

- synovectomy / realignments / replacement



- much less likely to be involved than adult form

- Boutonniere

- Swan neck quite rare



- may develop flail thumb secondary to erosion



- Otto pelvis

- bilateral protrusio

- atlantoaxial subluxation




Most common in wrist / hand / elbow

- limits pain and improves function in short term

- does not affect long term outcome or ROM (> 3 years)




Growth defects

- growth retardation with steroids


Epiphyseal disturbances 

- external tibial torsion

- dysplasia of distal ulna (commonly short)

- dens hypoplasia 

- scoliosis



- pauciarticular disease

- can lead to blindness



- long standing Still's

- may be fatal





- juvenile or systemic usually only last about 6/52

- 75% long remission with little residual disability


Poor prognosis

- systemic with multiple joint involvement

- RF +ve

- onset < 1 year old

- long active period disease > 5 years


Death uncommon

- infection early

- amyloidosis late


Marfan syndrome



Inheritable disorder of connective tissue




Male = Female

1 in 5000


Nil geographical variation







- FNB1

- fibrillin

- chromosome 15


Now diagnosed by genetic studies




Fibrillin is a component of elastic fibres





- no FHx

- diagnose via urinalysis

- presents the same way


Ehler Danlos

- very fragile, mobile skin


Ehler Danlos Fragile Skin



- mental impairment


Clinical Features


Major criteria

- FHx

- pectus excavatum requiring surgery

- pectus carinatum

- arm span : height ratio > 1.05

- wrist sign (LF and thumb overlap)

- thumb sign (projects past ulna border palm)

- scoliosis > 200

- pes planus

- protrusio



- pectus excavatum

- minor scoliosis

- thoracic lordosis

- high arch palate

- joint hypermobility


Need 2 major or 1 major / 2 minor





- long fingers and toes


Thumb sign

- protrudes past ulna border palm


Pectus excavatum / carinatum


Ligamentous laxity

- genu valgum

- PFJ instability



- 60% patients

- right thoracic

- 20% need OT

- complicated by thoracic lordosis




Dural ectasia


Flat feet

- ligamentous laxity



- consider triradiate cartilage fusion


Elbow joint contractures




High arched palate


Lens dislocation

- also short sighted, astigmatism



- AR, MR

- aneurysm

- dissection


Spontaneous Pneumothorax







NF1 / Von Recklinghausen 

- most frequent of these disorders 

- 1/3000 - 1/4000. 



- VIII nerve schwannomas

- nil musculoskeletal manifestations





- 50% due to new mutation


Gene protein neurofibromin




Young children 

- multiple café-au-lait spots that appear in the first year of life.


The NIH Consensus Development Conference Statement

- diagnostic criteria for NF1 are met in an individual who has two or more of the following:


1.  Six or more café-au-lait spots over 5mm in prepubertal individuals and over 15mm in postpubertal individuals

2.  Two or more neurofibromas of any type or one plexiform neurofibroma

3.  Freckling in the axillary or inguinal region

4.  Optic glioma

5.  Two or more Lisch nodules (iris hamartomas)

6.  A distinctive osseous lesion such as sphenoid dysplasia or thinning of the long bone cortex with or without pseudarthrosis

7.  A first degree relative (parent, sibling, or offspring) with NF1 by the above criteria.


Clinical Features


Café au lait


< 2 normal

6 or more > 0.5cm, smooth edges

Aid early suspicion of NF1





- raised over the skin

- bluish in colour

- increase in number ofter puberty and with pregnancy

- nil malignant potential

- develop from small cutaneous nerves



- bag of worms feeling

- usually develop from major nerves

- potential to become malignant


Axilllary / Inguinal Freckling


Aids early diagnosis

- second most common feature in children

- 80%


Lisch Nodules


Hamartomas in iris

- 90% patients over 6


Optic Glioma


&0% found in NF1

- usually benign and small

- can sometimes rapidly increase in size




Dermatological manifestation

- large soft tissue masses

- rough, raised vilous skin


Verrucous Hyperplasia

- skin overgrowth

- velvety, soft papillary





- 30 - 50 years

- large deep lesion

- increasing in size

- apin


Neurofibrosarcoma NF Leg MRI Coronal T2Neurofibrosarcoma NF Leg MRI Axial T1


Congenital Tibial Pseudoarthosis

- normally 1 per 140 000

- 3% of NF1

- see article


Spinal Deformities / Kyphosis / Scoliosis

- 30% have spinal deformity

- dystrophic and non dystrophic

- recommend earlier fusion at curves > 35o

- higher incidence of pseudoarthrosis

- all require MRI prior as high incidence of intraspinal lesions

- see Paediatrics / Spine / Scoliosis / Other / Neurofibromatosis





Neuromuscular Conditions

Charcot Marie Tooth

Hereditary Motor Sensory Neuropathies I-III




1: 3000




Group of inherited peripheral sensory & motor neuropathies

- includes Charcot Marie Tooth Disease




Hypertrophic vs Neuronal HMSN 


I   Hypertrophic CMT

II  Neuronal CMT

III Infantile Hypertrophic Neuropathy - Dejerine-Sottas

IV  Refsum's disease


Orthopaedic Complications


Cavovarus Foot


Claw Toe


Hip Dysplasia


10 % CMT

- muscle imbalance promotes femoral anteversion & valgus neck

- 2° acetabular dyplasia



- as per usual

- NB care with sciatic nerve as more susceptible than normal

- usually bony surgery





- management as per idiopathic


Hypertrophic CMT HSMN I




Demyelinating peripheral neuropathy

- repetitive demyelination & remyelination leads to nerve hypertrophy = Onion bulb

- more demyelinated fibres than myelinated


Characterised by

- demyelination

- areflexia

- decreased nerve conduction velocity





- triple dose of peripheral myelin protein 22 

- chromosomal linkage on chr 17 (17p11.2) 

- gene encodes periph myelin ptn 22




Demyelination & fibrosis

- 'Onion-bulb' appearance


Clinical Features


Present in children / teens


Lower limbs more affected




Symmetrical distal muscle weakness and wasting

- weakness progresses to all muscles distal to knee

- develop high-stepping drop-foot gait

- inverted champagne bottle


Stork legs CMT Stork Legs CMT 2


Glove and stocking sensory loss



- initial mild cavus & toe clawing

- becomes rigid 


CMT Foot 1CMT Foot 2


Upper limb involvement 

- begins later 

- starts with intrinsic wasting

- mixed median and ulnar 

- then radially supplied muscles


CMT Hands 1CMT Hands 2




Motor nerve conduction velocities decreased by > 50%




Nerve Biopsy


Genetic testing

- mutation in 17q11 or X-linked connexin 33


Neuronal CMT HSMN II



- axonal neuropathy without demyelination

- reflexes preserved 

- normal nerve conduction velocity





- abnormality in spinal cord neurones



- neuronal degeneration with preservation of myelin


Clinical Features


Present in teens / early adulthood

- less disabling than HSNM I

- upper limb involvement less severe than Type 1


Reflexes present 


Glove and stocking sensory loss only mild


More profound distal lower limb involvement than Type 1

- stork-leg appearance

- wasted distal thigh / leg muscles

- flail foot

- calcaneocavus deformity


CMT Stork LegsCMT Cavus




Motor NCS normal


Infantile Hypertrophic Type III




Dejerine-Sottas disease

- AR (no normal gene for peripheral myelin ptn 22 present)




Hypertrophic interstitial neuropathy

- histology shows segmental demyelination & marked nerve thickening with Perineural fibrosis


Clinical Features


Presents in infancy

- pes cavus & drop foot

- stocking-glove sensory loss

- significant spinal deformity

- confined to wheelchair by 30s




Markedly slowed motor NCS


Refsum's disease Type IV



- rare disease with Cranial Nerve involvement






X linked recessive

Lack of dystrophin





Boys only


Decreased intellectual capacity / average IQ 80 - 90




Delay in walking

- test CPK in any boy not walking by age 18 months


Toe walking


Parents have noticed waddling gait and stiff feet





- have trouble rising from floor

- rear in the air first

- use arms to walk up legs


Proximal muscle weakness

- symmetrical


Calf hypertrophy

- pseudohypertrophy


Toe walking


Lumbar lordosis




Creatinine Phosphokinase / CPK

- normal < 200

- DMD > 5000


Muscle biopsy

- absent dystrophin protein

- definitive diagnosis




Loss of independent walking by 10 years

Rapid scoliosis progression by 14 years

Wheelchair bound by 15 years

Death in late teens (<20 years) due to respiratory infection




Non operative Management


Physiotherapy / occupational therapy


Prevent contractures

- hip adduction / tendoachilles







- prolongs walking

- improves strength

- delays scoliosis

- improves respiratory function



- age 7 or 8




- mood swings

- cataracts

- short stature

- Cushingoid features


Operative Management




Bracing not effective / can compromise respiratory function


Need early posterior fusion when scoliosis 20o


Malignant Hyperthermia


All patients high risk

- must be screened preoperatively

- give prophylactic dantrolene

- avoid inhalational anaesthetics / suxamethonium





- hip adductors

- T achilles

- T posterior






Friedreich's Ataxia



Hereditary Spinal Cerebellar Ataxia

- degenerative

- onset by age 10








Spinal cord shows atrophy of

- cerebellar tracts

- posterior columns

- dorsal root ganglia



Clinical Features 


Cerebellar features

- ataxic gait

- dysarthria

- tremor

- nystagmus

- difficulty with fine motor hand control 


Neurological examination shows

- muscle weakness

- decreased vibration sense

- decreased proprioception

- absent DTR

- upgoing plantar response

- positive Rhomberg's Sign


May be unilateral at first but becomes bilateral




Remissions & stable periods seen

- progression usually slow

- usually confined to wheelchair by 30




Marked decreased sensory action potential

Slight decrease in motor conduction velocity


Medical Complications


Bulbar palsy / Cardiomyopathy

- either may cause death

- usually by age 40


Orthopaedic Complications


Pes Cavus




Similar curve pattern to Idiopathic form

- manage similarly





Muscular Dystrophies






Spinal Muscular Atrophy

Juvenile Dermatomyositis

Guillian Barre


Becker Muscular Dystrophy


Similar to Duchene but milder

- mild proximal muscle weakness

- calf hypertrophy


Myotonic Dystrophy


Most common form of adult muscular dystrophy




- chronic

- slowly progressive

- highly variable

- often associated with intellectual impairment


Clinical Features


Gradual onset of muscle weakness

- myotonia - difficulty grasp release

- expressionless face - typical


Check mother's grip

- difficulty with grasp release


Variable expression

- muscle weakness

- talipes, pes cavus and scoliosis

- dysphagia and constipation

- drop foot, high stepping gait


High anaesthetic risk




CK Normal


EMG - pathognomonic pattern


DNA analysis


Spinal Muscular Atrophy


Anterior horn cell degeneration




Type 1 

- die soon after birth from resp failure


Type 2 

- normal until 6 months

- never learn to walk independently


Type 3 

- milder

- normal milestones for first year

- present similar to Duchene

- flat footed (compared with Duchenne which tip toe walk)

- reflexes are depressed




Proximal > distal weakness

- suppressed reflexes

- extremely floppy



- respiratory compromise

- scoliosis

- flexion contractures




CK Normal

DNA testing


Juvenile Dermatomyositis


Onset insidious age 2 onward

- miserable weak child 

- butterfly facial rash

- toe walk

- violaceous rash




Steroids and immunosuppressives


Guillain Barre


Demyelinating polyneuropathy

- common in childhood

- may be life-threatening


20% present with waddling gait like Duchene

- most present with distal > proximal weakness 

- minimal sensory findings








Osteogenesis Imperfecta



Abnormality of type 1 collagen

- amino acid substitution of glycine with another amino acid

- prevents triple helix formation


Many many deformities described

- some 286 mutations of Type 1 collagen described


Sillence Classification


There are actually now 7 


Type I

- mild

- AD

- blue sclera


Type II

- lethal in utero

- AR

- blue sclera


Type III

- severe

- AR

- white sclera

- multiple deformities without intervention

- wheelchair bound and non ambulatory


Type IV

- moderate to severe

- white sclera

- AD

- very rare









Skin biopsy

- assessment of type 1 collagen

- fibroblast cell culture


DNA study


Skeletal Manifestations


Frequent multilevel fractures with limb deformity

- tibia

- femur

- forearm


Osteogenesis Imperfecta ForearmOsteogenesis Imperfecta Wrist


Osteogenesis Tibial BowOsteogenesis Imperfecta Tibial Bow 2


OI ForearmOI Shoulder


Coxa vara

- femoral neck shaft < 110o

- correct with multiple osteotomies





- indicated for curve reaching 40o as will be progressive and non flexible

- > 60o impairs respiratory function



- bony fragility

- increased use of pedicle and TP hooks and sublaminar wires


Basilar impression / invagination


Very serious problem

- the foramen magnum invaginating into the posterior fossa

- leads to stenosis with resultant hydrocephalus 

- compression of the cerebellum, brain stem, and cervical cord


Lateral cervical spine radiograph

- upward migration of the cervical spine into the base of the skull

- deformity may be subtle and requires careful scrutiny of the radiographs


Various descriptions of the characteristic skull shape

- Darth Vader


Extraskeletal Manifestations


Blue sclera 

- due to translucent sclera can see underlying choroid and blood vessels

- due to defect type 1 collagen


Dentinogenesia imperfecta 

- teeth appear brownish or bluish

- are soft, translucent and prone to cavities

- defect type 1 collagen


Hearing problems

- defect hearing bones


Fragile skin and fragile capillaries


Valvular Disease


Mitral prolapse and Aortic Regurgitation




Nonoperative Management




Increase BMD and cortical thickness and cancellous trabeculation

- reduces bone pain

- decrease fracture rate

- maintains shape of long bones and vertebrae


Mechanism of action

- inhibits osteoclasts



- very poor bioavailability (.6 - 7)

- incorporated into skeleton

- long half life there (1.5 - 10 years)



- need period off medications

- doesn't decrease fracture healing but probably does decrease osteotomy healing (i.e. avoid around time of IM rodding)

- osteonecrosis of the jaw: a rare side effect in adults, not seen in children




Glorieux et al NEJM 1998

- increased BMD by 40%

- reduced fracture rate by 1.7 per year

- evidence new bone formation in vertebrae

- did not alter rate fracture healing


Bone marrow transplant


Increased mesenchymal stem cells


Operative Management




Prevent fractures

Treat or prevent deformity




Multilevel osteotomy with IMN

- must be expandable or get fracture and deformity below level


Expandable telescopic IM rods



- lengthen as the bone grows

- male and female portions

- lock in epiphysis top and bottom


Sheffield Rods

- T piece

- 20% revision at 5 years


Fassier-Duval Rods

- epiphyseal portion is threaded





DefinitionPelvis Osteopetrosis


Inheritable bone disorder characterised by defective osteoclasts

- resulting in hard and brittle bone




Defect of osteoclasts

- unable to acidfy Howship's lacunae

- unable to resorb bone

- missing ruffled border


Heterogenous group

- 60% defect of proton pump

- 5% carbonic anhydrase defect


Inability to remodel bone with thickened sclerotic cortex

- impinges on medulla

- woven bone architecture

- thickened cancellous trabeculae


Unresorbed calcified cartilage

- prone to fracture




1.  Malignant AR


Few survive first decade

- bony overgrowth of medulla

- blocks hematopoiesis

- anaemia/neutropenia/thrombocytopenia

- need bone marrow transplant to survive


Cranial nerve compression

- overgrowth foramina

- optic, auditory, facial n




2.  Intermediate AR


Moderate anaemia

Some nerve compression symptoms

Frequent fractures in first decade


3.  Benign AD 


Most common

- diagnosed after fracture

- 40% asymptomatic

- due to variable penetrance


Clinical Features


1.  Frequent long bone fractures

- femur and tibia


2.  Long bone deformity

- callus slow to organise

- lateral bowing of femur


3.  Hip

- coxa vara


4.  OA

- common in hip

- compression of cartilage on hard bone


Hip Osteopetrosis OA


5.  Spondylosis


6.  Osteomylelitis

- 10 % patients

- most often in mandible

- lack of marrow vascularity

- impairment of white cell function


7.  Cranial nerve compression

- 20-25%

- optic, auditory, trigeminal, facial




Generalised sclerosis

- subchondral sclerosis in pelvis



- bone within bone

- failed resorption of primary spongiosa


Vertebral end plate thickening

- rugger jersey vertebrae


Erlenmeyer flask deformity

- widened club like metaphysis

- in children


Transverse banding of metaphyses




Non operative


1.  Interferon gamma



- increases bone resorption

- improves hematopoiesis and leucocyte function


2.  High dose vitamin D / diet low in calcium



- stimulates osteoclasts


3.  Bone marrow transplant



- children with malignant form


Operative Management




Attempt to treat non operatively if possible

- ORIF difficult

- nil medullary canal

- break drill bits




Plates often fail

- IM load sharing devices best


Increased time to union


Difficulty drilling, inserting screws and pins

- drills over heat and break

- advance 1cm at a time

- frequent cleaning and cooling

- alternate drill bits


Longer surgical time




Technical difficulties


Unable to use hand reamers

- recreate medullary canal

- burrs needed

- use II to check

- short narrow stems

- can consider resurfacing




Increased risk intra-operative fracture


Increased risk infection






Sprengel Shoulder



Congenital elevation of shoulder




AD & Sporadic 


Tends to be in girls & on left

- like CDH


Associated with other congenital abnormalities




Failure of descent of arm bud

- arm bud appears in week 3 (level of C5 to T1)

- scapula develops in arm bud in week 5 (Opposite C5)

- descends over next 3/12


Usually by 3rd fetal month to level of T2 to T7


Clinical Features


Scapula small 

- scapula elevated

- superior angle rotated upwards & forwards

- shoulder musculature deficient


Limited shoulder abduction

- scapula joined to cervical spine by fibrous or bony bar

- Omovertebral bar


Usually presents as Neonate, but if mild presents later 


Associated Abnormalities




Klippel-Feil Syndrome (usually bilateral)

Cervical ribs

Fused or absent Thoracic ribs

Thoracic Vertebral anomalies

Hypoplastic Humerus or Clavicle




Small high scapula


Omovertebral bone

- can see bone linking scapula and hyoid


Bilateral abduction xray reveals lack of ST motion


Operative Management





Attempt to improve abduction range




Hypertrophic scar due to high strain on scar

Brachial Plexus Injury




1.  Scapula Resection


Simplest procedures

- only cosmetic

- excision of prominent angle (excise scapula above spine)

- excision of Omovertebral bar


2.  Woodward Procedure



- principle concern is brachial plexus palsy

- best outcome in children 3 - 8




A.  Midline incision

- clavicular osteotomy to protect brachial plexus

- excise omovertebral bar


B.  Mobilise scapula caudally


C.  Detach Trapezius & Rhomboids from spinous process insertion

- reattach to supraspinous ligaments more inferiorly

- dynamic force inferiorly on scapula


3.  Green Procedure


Osteotomy clavicle first

- avoiding plexus injury


Scapula release

- released from medial border of scapula

- reattach after scapula reduced



Wormian Bones



Intra-sutural ossicles in lambdoidal, posterior sagittal and tempero-squamous sutures

- normal up to 6 months of age

- multiple areas of ossification skull cranial sutures

- early fusion can give papilloedema


Cremmin et al Skeletal Radiology 1982 8: 35-38

- size of greater than 6mm by 4mm

- mosaic rather than linear pattern

- more than 10 in number







Osteogenesis Imperfecta

Rickets in healing phase

Kinky hair syndrome of Menke


Cliedocranial Dysplasia

Hypophosphatasia (also hypothyroidism)

Otopalatodigital syndrome

Primary Acroosteolysis, Pachydermoperiostosis

Syndromes and Chromosome disorder; esp 21














Involvement epiphysis or apophysis of immature skeleton

- heterogenous group of eponymous conditions


- usually occurs at time of greatest growth




Features of

- sclerosis

- fragmentation

- decrease in size of ossification centre




Some progress to OA

Some are self-healing




Affected portion of bone has features of osteonecrosis


Thought to be due to recurrent minor trauma & avascularity


Three types





- Kohler's (4 year old boys)

- Freiberg's  (11 year old girls)

- Panner's (young child or teens)

- Kienbock's (20-30 years)




Spontaneous necrosis of 

- ossific nucleus of long bone

- cuboidal bone of wrist or foot


Pathological changes of AVN

- bone death

- fragmentation

- collapse

- new bone formation





- Osgood-Schlatter

- Sever's

- Sinding-Larsen-Johansson

- Menalaus-Batten




Excessive traction by large tendon to unfused apophysis

- repetitive microtrauma

- no bone necrosis 

- apophysis becomes painful

- may be tenosynovitis




OCD of Knee / Ankle / Hip


Uncertain aetiology but thought to be combination of microtrauma & hypovascularity






Kohler's Disease

DefinitionKohler's Disease


Osteonecrosis of the navicular




Present at age 4-6 years

- same as Perthes disease


M:F 5:1


Bilateral in 20%




Repetitive trauma to maturing ossific nucleus

- avascular necrosis


Clinical Features


Pain & soft tissue swelling over navicular




Flattening & sclerosis of navicular



- usually resolves within 18 - 36 months




Aim to provide symptomatic relief

- rest from sport

- analgesia

- SL cast for 6-8 weeks if required




Panner's Disease



Crushing AVN of capitellum

- 4 - 10 years

- maximum 14 years

- usually boys, baseball pitchers




Valgus compression

- i.e. baseball pitchers


Two forms


1.  True Panner's / Crushing Osteochondritis

- young patient


2. OCD form in older boys

- older than 10

- loose bodies

- locking / catching symptoms


Clinical Features


Pain with throwing

- tender lateral aspect elbow

- FFD or lack of flexion





- epiphysis condensed & fragmented



- localised area of AVN




Useful in grading OCD





- usually reconstitutes without disability 

- immobilise 4 weeks, NSAIDS

- avoid throwing for period

- gradual strengthening and return

- good prognosis



- grade and treat appropriately

- pin in situ if able

- remove loose bodies / microfracture

- arthroscopy

- prognosis much worse especially in competitive athlete


See Elbow / Capitellar OCD




Sever's Disease



Calcaneal apophysitis / Pulling osteochondrosis




Young boys

- peak age 10

- bilateral in 60%




Overuse injury of calcaneal apophysis

Repeated microfracture




Mechanical heel pain

Worse if barefoot




No redness or swelling

Tenderness on sides of tendon insertion

Restricted ankle dorsiflexion




Controversial whether normal

- increased fragmentation & density of apophysis

- may be the same on the other side


Primarily performed to exclude other conditions

- giant cell tumours







Restrict activities for 1-3 months



- oral

- topical



- T achilles stretching / dorsiflexion exercises



- heel raises

- custom made heel cups & insoles

- short leg cast for 4/52 if symptoms severe









- paediatric disorder characterised by deformity and growth retardation

- secondary to defective mineralisation of the growth plate



- adult disorder

- defective mineralisation of osteoid




Generation of Vit D


Vitamin D3 ingested and absorbed

- activated by sunlight

- need 10 - 15 minutes 3 x per week


25 hydroxylated in liver


1 alpha-hydroxylase in kidney

- active 1,25 vit D3

- calcitriol

- this is under PTH control


Action Vit D



- increases Ca and PO4 absorption



- decreases Ca and PO4 excretion



- increases Ca and PO4 release





- hypertrophic zone widens

- provisional zone never forms

- no mineralisation of osteoid







- usually develops during periods of rapid growth

- not seen in newborn

- see in toddlers



- recurrent clavicle fractures

- stress fractures



- delayed formation

- increased dental caries




Short stature

- adults < 5 foot




Tibial and femoral bowing


Pathognomonic signs

- widened physeal plate

- cupping of the metaphysis


Blood Results


Ca2+ low

Phosphorus low

Alk Phos high

Vit D low





1.  Vitamin D deficiency



- inadequate sun exposure

- low dietary intake


More common in dark skinned children

- exclusively breastfed

- live in northern cities with low sunlight

- vegetarian diet



- daily vitamin D

- 30 minutes daily sunshine


2.  Congenital disease


A.  Vitamin D dependent rickets Type 1

- defect in 1 alpha hydroxylase

- converts 25 (OH) to 1,25 (OH)

- 1,25 biologically active


B.  Vitamin D independent rickets Type 2

- mutations in the vitamin D receptor

- more than 10 types


C. Familial X linked hypophosphataemic rickets

- AD, most common form

- vitamin D resistant rickets

- impaired tubular resorption phosphate

- treatment phosphate + calcitriol


3.  Vitamin D metabolism abnormalities



- renal failure

- phenytoin



Rotational Profile

External Tibial Torsion



Presents in late childhood


Often unilateral


More often right side




Tends to increase with age

- rarely a problem until late childhood

- associated with PF instability & pain




Spina bifida / CP


Torsional Malalignment Syndrome


Miserable Malalignment Syndrome

- IFT with compensatory ETT




Non-operative Management



- rarely indicated on functional grounds

- lever action of foot is not lost until the FPA > 60°


Operative Management



- osteotomy indicated if TFA > 40°

- certain cases of CTEV & NMD 






General Principles



1. Physiological


2. Non Physiological

- congenital

- acquired





- normal rotation



- rotation 2 SD <> mean


Femoral Version

- angular difference between transcervical & the transcondylar axis


Tibial Version

- angular difference between transcondylar axis of knee & transmalleolar axis


Normal Development


Lower limb bud develop during 4/52

- great toe points lateral

- during 7th week bud IR 

- brings hallux into midline


Limb continues to ER through intra-uterine and childhood

- femoral anteversion decreases

- tibial ER increases


Neonates have ER hip contracture that masks the femoral anteversion 


Natural History


In-toeing toddlers become outoeing adults


Femoral anteversion decreases with age

- 40° neonate

- 15° adult


Tibial ER increases with age

- 5° neonate

- 15° adult




Toeing In

- Internal Femoral Torsion IFT / Femoral anteversion FAV

- Internal Tibial Torsion ITT

- Metatarsus Adductus 


Toeing Out

-  Physiological

-  External Tibial Torsion ETT

-  Pronation / Abduction of the Feet





- increased FAV

- CP

- genu varum

- metatarsus adductus (residual CTEV)







Presentations by Age


1st Year of Life

- intoeing usually metatarsus adductus


2nd Year of Life

- intoeing usually FAV


After 3rd Year of Life

- bilaterally intoeing FAV

- unilaterally intoeing ITT

- unilateraly outoeing ETT




1.  Is it in femur?

2.  Is it in tibia?

3.  Is it in foot?




Age of onset


Disability - i.e. clumsiness

Age first walked

Previous management


If walking age delayed consider CP

- FHx of In / Out Toeing

- sitting W position





- genu varum



- squinting patella (increased FAV)

- patella anterior (ITT)

- out toeing


Spine / scoliosis


Staheli's Torsional Profile (6)


1.  Foot Progression Angle 

- assessed on gait

- usually 10° out (0°-30°) 


2.  Hip IR

- child prone

- usually < 65° 

- > 70° = FAV


3. Hip ER 

- usually 40° (20-60°)

- greater in young child

- note IR + ER should = 90°


4. Thigh- Foot Angle TFA

- child prone & knees flexed

- reconstruct foot

- usually 15° (0°-30°) ER

- measures tibial torsion


5. Transmalleolar Axis (TMA)

- prone & knees flexed

- usually 0 - 30° ER


6. Foot

- shape of foot

- Metatarsus adductus / everted foot affects foot progression angle




AP Pelvis

- acetabular version



Malligan Technique

- AP & lateral hip allows calculation of version 

- using tables by Magilligan

- converts measurements of neck length into an FAV angle


CT scan


Direct measurement of femoral & tibial version




General Principles


1. Trying to control the sleeping, walking, or sitting of infants & children is impossible


2. Splints are of no benefit & interfere with child


3 Observational Management successful >99%, only 1 in 1000 need OT


4. OT correction effective but carries significant risk


5. OT only justified in the child with severe deformity that has failed to resolve with time 

- ITT < -10° 

- ETT > 40° 

- FAV > 50°


6. At least > 8 years old prior OT







Internal Femoral Torsion



Transverse plane rotation of the femoral neck axis anteriorly relative to the transcondylar axis




F:M = 2:1

Bilateral, symmetrical









Increases up to age of 5

- resolves by age of 8 


Resolves in 95%

- compensatory ETT may develop after 5 years

- little functional disability


>50% of patients with persistent femoral anteversion achieve normal gait


Doesn't predispose to OA




Intoeing in early childhood

- starts 3 years old

- maximum 4-6 years old




Squinting patellae


Sit in W 


W sitting


Run like egg beaters & trip over


Prone Rotation test / Gages Trochanteric Angle

- find position where GT most prominent laterally

- angle tibia makes from vertical is FAV


Increased IR

- abnormal if IR > 70° 

- if severe, no ER possible 


CT scan


If surgical intervention deemed likely




If unilateral / progressive rule out DDH / CP


Non operative


No evidence for orthoses






Very severe functional gait disturbance



Age > 10


Rotational criteria

- IR > 85° & ER <10° 

- measured Anteversion > 50°




Leave until at least > 8-10 years old because many resolve

Not required if 10° ER present


Subtrochanteric derotation osteotomy


Proximal femoral plate

Aim IR = ER on table






Internal Tibial Torsion



Angular difference between transcondylar axis of knee & transmalleolar axis




Though to be a packaging disorder




Number 1 cause of intoeing in 2 year odl

- does not occur in preterm infants 


10% < 2 years ITT 

- 2/3 bilateral 

- 1/3 unilateral of these usually left side




Normal 0 - 30o ER


Most cases of ITT resolve by 2 years of age

- TMA increases 0-5° from age 1 to 2 years

- few resolve > 8 years

- resolution not universal

- positive FHx association with poor prognosis




Associated with MT Adductus in 1/3







Tibia vara




Children tend to trip & appear clumsy




Patella normal position

- in-toeing

- thigh foot angle < 0o

- TMA < 0o




Non-operative Management


Splints shown not to work


Operative Management


Complication rate of proximal tibial osteotomy very high


Supramalleolar Osteotomy 



1. TMA > 3 SD (< -10° or > 40°)

2. Age 10+ years

3. Severe disability



- anterolateral approach

- DCP plate




Skeletal Dysplasia

A Background

Definition Short Stature


< 1.25 m in adult




1.  Proportionate dysplasia

- mucopolysaccharidoses

- Morquio's, Hurler's, Hunter's


2.  Dysproportionate dysplasia

- short trunk / SED

- short limb / achondroplasia & MED


Proportionate dysplasia / Symmetrical decrease in limb and trunk length 



- Morquio's, Hurler's, Hunters


Cleidocranial Dysplasia 

Severe OI

Severe Osteopetrosis




Dysproportionate dysplasia


A.  Short trunk 


- Kniest's syndrome

- Metatropic dysplasia


B.  Short limb

- Achondroplasia / Pseudoachondroplasia


- Diastrophic dysplasia


Rhizomelic - proximal

Mesomelic - middle

Acromelic - distal


Specific Conditions


1.  Achondroplasia / Pseudochondroplasia


Dysproportionate dwarfism

- short limbs, normal trunk



- coxa vara, genu varum

- radial and tibial bowing

- radial head dislocation

- metaphyseal flaring with inverted V shaped distal femoral physis

- Square iliac wings



- spinal problems i.e. stenosis

- coxa vara / genu varum


2.  MED


Dysproportionate dwarfism

- short limbs, normal trunk



- irregular delayed ossification at multiple epiphyses



- coxa vara, genu valgum


3.  SED


Dysproportionate dwarfism

- short trunk



- similar to MED but involves spine



- coxa vara / genu valgum

- spine (kyphoscoliosis / platyspondyly / ondontoid hypoplasia /atlanto-axial instability)


4. Metaphyseal chondrodysplasia



- metaphyseal changes with normal epiphyses

- can look like rickets



- coxa vara / genu valgum


5.  Progressive Diaphyseal Dysplasia 


Engelmann Disease



- diffuse sclerotic thickening of cortex


6.  Dysplasia Epiphysealis Hemimelica 


Trevor's Disease



- epiphyseal osteochondroma

- affects one joint only

- often ankle

- often medial


7.  Mucopolysaccaridoses


Proportionate dwarfism with complex sugars in urine


Morquio's syndrome

- AR

- presents 18 months to 2 years with waddling gait

- keratan sulphate in urine

- normal intelligence






8.  Dysplasias associated with Benign Bone growths


Diaphyseal aclasia / multiple osteochondromas

Fibrous dysplasia







Dysproportionate dwarfism

- short limbs and normal trunk

- rhizomelic



- physeal dysplasia (SED, MED)




FGF Receptor 3 

- point mutation

- decreases endochondral ossification

- normal intramembraneous ossification

- FGFR3 is found in all pre-bone cartilage & in CNS

- FGFR3 inhibits chondrocyte proliferation in the proliferative zone

- appears that in achondroplasia the receptor is overactive & inhibits the proliferative zone  





- 85% from spontaneous mutation




Defect in enchondral bone formation / Proliferative zone

- dalteration in normal chondrocyte maturation, hypertrophy & degeneration

- abnormal clustering of chondrocytes


Hypertrophic Zone 

- narrow & irregular cells of differing sizes


Clinical Presentation


At birth 

- short limbs & normal trunk


Lower Limbs



- bowing




Genu varum 

- long fibula

- may need fibula epiphysiodesis


Inverted V shaped distal femoral epiphysis

- flared metaphysis with ball in socket epiphyseal/metaphyseal junction




FFD hips + increased lumbar lordosis


Coxa vara

- short femoral necks

- horizontal acetabular roof




Square iliac bones 

- " elephant ears"

- narrow siatic notch


Champagne-glass pelvic cavity

- the pelvis is wider than it is deep






Achondroplasia Decreased Interpedicular DistanceAchondroplasia Increased Lumbar Lordosis Platyspondyly


Increased lumbar lordosis


Non-rigid TL kyphosis 

- usually resolves with ambulation

- due to hypotonia


Spinal canal stenosis

- decreased inter-pedicular distance 

- narrows from L1  down (normally increases)

- short pedicles



- bullet shape vertebrae 

- anterior inferior body beak T12- L2

- posterior scalloping of vertebral bodies


Achondroplasia MRI Spinal Stenosis.jpgAchondroplasia Short Pedicles




Foramen magnum stenosis

- responsible for higher mortality in infants

- may have symptoms myelopathy

- often presents with apnea / snoring

- can cause sudden death

- MRI / sleep studies


Upper Limbs




Trident hand in 50%

- persistant space between middle & ring in extension


Stubby tubular bones 

- normal bone girth


Fingertips only reach to hips

- difficulty with hygiene 



- posterior bowing / limitation of extension



- cubitus varus



- bowed ulna

- radial head dislocation




Large skull with frontal bossing


Operative Management


Spinal Stenosis


Present later in life

- 50% or more of patients

- require multilevel laminectomy +/- fusion


Chondrodysplasia Punctata




Multiple punctate calcifications of dysplastic epiphyses 




Enzymatic defect in peroxisomes

- causes calcification






Asymmetric limb shortening

- Vertebral anomalies & Scoliosis

- Epiphyseal stippling


Stippling gone by age  4 yrs


Long bones, pelvis & vertebrae

- Epiphyses may remain irregular like Epiphyseal Dysplasia

- Skull normal


Sheffield Form


Milder form 


Autosomal Recessive Form 


Lethal by age 1




Diaphyseal Dysplasia

Engelmann's Disease


Progressive diaphyseal dysplasia

- marked thickening of cortices of long bones




Young child with gait disturbance and limb pain




Bilateral symmetrical diaphyseal sclerosis of long bones

- Affects endosteal & periosteal new bone

- Metaphysis & epiphysis are normal


Skull base sclerotic

- can get blindness and deafness




Diastrophic Dysplasia


Diastrophic Dwarfism

- twisted dwarf

- disproportionate dwarfism

- very short limbs

- rhizomelic

- AR


Clinical Features



- Superimposed calcified pinnae

- swollen cauliflower ears




Cervical Kyphosis

- May be vertebral wedging

- may need immediate surgery


Thoracic Kyphoscoliosis 

- Progressive structural curve


Lumbar lordosis - 2° to flexion contractures


Interpedicular narrowing from L1 to L5 


Spina bifida occulta


Long Bones


Short & broad long bones

- Flaring of metaphyses

- Flattened & irregular epiphyses


Shortened ulna/ fibula



- Delayed appearance of capital femoral epiphyses

- Central saucer-shaped defect in capital femoral epiphysis

- Hip dislocation common


Hitchhiker thumb

- abducted over a short MC


Severe joint contractures 

- hip and knee requiring release

- Subluxed or dislocated Patella



- hitchhiker great toe


Cleft palate


MED - Multiple Epiphyseal Dysplasia



Disturbance of endochrondral ossification of epiphyses of tubular bones

- preservation of vertebrae (c.f. SED)




Dysproportionate dwarfism with normal trunk

- not as severe as achondroplasia

- usually 145 - 170 cm tall


Characterised by small flattened irregular epiphyses

- symmetrical

- leads to OA by 3-4th decade




Limb length may be affected, not as severe as achondroplasia (usually 145 - 170cm tall)


Spectrum of involvement



- mild form

- affect only the hips



- more severe

- affect the epiphyses of all long bones





- variable expression

- affects collagen IX / COMP




Disturbance of enchondral ossification in epiphysis & physis 

- deficient proliferative region of physis

- rongue-like projections of cartilage into metaphysis




Epiphyseal ossification

- delayed / smaller

- appear fragmented

- symmetrical involvement


Joint surfaces flattened & irregular

- Leads to premature osteoarthritis


Vertebral ring epiphysis maybe affected, only mildly


Clinical Feature


Varies in severity

- polyarticular or pauciarticular

- Some cases only couple of joints involved, others condition is widespread


Most commonly affects 

- hips / knees / ankles / wrists


Spine, skull & face - normal 


Mild shortness of stature


Normal intelligence




Present with stunted growth or joint pain  and progressive deformity

- problems walking in childhood


Premature OA in adulthood




Most frequently & severely involved

- Coxa vara

- small irregular & fragmented capital epiphyses

- progressive flattening & extrusion of  head

- poor head coverage




Premature OA common



- valgus intertrochanteric osteotomy +/- shelf




1.  Perthe's

- asymmetrical

- has metaphyseal cysts

- MED affects acetabulum


2.  Cretinism


3.  Pseudoachondroplasia


4.  SED




Femoral condyles flattened & rectangular

Slanted tibial physis

Genu valgum common




Short stunted metacarpals

Digits shortened





Metaphyseal Chondrodysplasia



Short limbed dwarfism, normal trunk and spine




Metaphyseal changes of tubular bones

- Normal epiphyses

- metaphysis adjacent to physis very broad and mildly scalloped

- resembles healing rickets




Defect in proliferative and hypertrophic zones of physis




Jansens (Rare)

- most severe

- defect PTHrP (AD)

- extensive calcification

- retarded

- very short

- striking bulbous metaphyseal expansion long bones



- more common, less severe

- present later (AD)

- defect type X collagen



- associated immune defects





- coxa vara



- genu valgum





- normal blood tests


Metaphyseal Dysplasia

AKA Pyle's Disease


No dwarfism (c.f. chondrodysplasia)




Clinical Features


Genu valgum




Sclerosing bone deformity

- Usually incidental finding on XR


Erlenmeyer Flask Deformity



- Gauchers

- metaphyseal chondrodysplasia



Nail Patella Syndrome



Relatively common


Autosomal Dominant


Clinical Features


Hypoplastic / dystrophic nails


Absent or hypoplastic patellae


Radial head subluxed laterally/dislocated


Horns on post/lat aspect of iliac blades


Club Feet




Other Associated Problems


Proteinuria (50%) and renal failure (5%)






Spondyloepiphyseal Dysplasia



Disproportionate dwarfism with a short trunk


Problems with dwarfism, spine, vision and hearing




Primary involvement of vertebrae & epiphyseal centres of limbs


Resulting short-trunk dwarfism

- Limb are short, but trunk is even shorter


(cf Metaphyseal Chondrodysplasia - Short limbed Dwarf)





- AD, usually spontaneous mutation

- more severe, early



- X linked recessive

- late presentation

- spine and hips




Defect Type II Collagen Gene

- Disorder of growth plate

- Abnormality of Proliferative zone - Microcystic areas

- Surrounded by ring of abnormal chondrocytes


Clinical Features


Short limbs

- Rhizomelic - short proximal segment

- Normal hands & legs


Shorter trunk 

- Neck almost absent



- Increases lumbar lordosis


Genu valgum


Club foot


Adolescent kyphoscoliosis



- Cleft palate

- Pectus carinatum & barrel-shaped chest

- Protruberant abdomen




Morquio's disease

- But shortening in distal limb segments (acromelic)

- Urinalysis = Keratan Sulphate excretion

- hands and feet severely affected



- normal trunk

- abnormal face

- nil platyspondyly

- rhizomelia - short long bones


Medical Complications


Eye problems common

- Myopia

- Retinal detachment




Epiphyses appear late (like MED)





- Flatten or oval vertebral bodies


Schmorl's nodes - indentations of end plates


Irregularity of the vertebral bodies ring epiphyses


Odontoid hypoplasia


Thoracic kyphoscoliosis

- Usually progresses and should be braced early, may need fusion


Lumbar lordosis 




Odontoid hypoplasia 

- atlantoaxial subluxation

- Cord compression result in cervical myelopathy


Treat with posterior atlantoaxial or occipitoaxial fusion




Delayed ossification of capital femoral epiphysis

- Coxa vara - valgising IT osteotomy

- Varus may progress to discontinuity of femoral neck

- May be progressive dislocation




Trevor's Disease


Dysplasia Epiphysealis Hemimelica


So called because affects half of epiphysis




Epiphyseal osteochondroma

- on histology




Spontaneous mutation




Partial cartilaginous overgrowth of an epiphysis

- usually medial half

- Usually one joint

- Usually ankle (tarsus, carpus, knee, ankle)




Partial excision of overgrowth

- do well but

- Recurrence common

- May need later osteotomies





Congenital Kyphosis



Kyphosis due to congenitally anomalous vertebrae

- characterized by severe angular deformity

- prominent gibbus at the apex of the curve




Type I - Failure of formation


Failure formation anteriorly + preservation of posterior elements

- hemivertebrae / wedge vertebrae

- most common

- produces the worst deformity

- NHx is one of relentless progression

- 7per year

- most likely to result in paraplegia


Congenital Kyphosis XrayCongenital Kyphosis CT


Type II - Failure of segmentation


Anterior unsegmented bar

- better prognosis

- produces more rounded kyphosis

- deformity progresses more slowly

- paraplegia is uncommon


Type III


Mixed pattern


Clinical Features


Severe deformity maybe obvious at birth

- less obvious deformities may not appear until later

- may be accentuated during adolescent growth spurt


Progression occurs to end of growth & often after growth complete




Due to

- growth differential

- erosion of vertebral body from mechanical pressure




Deformity can become very severe (Type I)

- breakdown of the overlying soft tissues

- compression of abdominal viscera

- impairment of pulmonary function


Paraplegia may occur (Type I)




Non operative not effective


Work up


MRI / Neurosurgery

- exclude intraspinal pathology



- cardiac abnormality


Abdominal US

- renal abnormality




Type I


Ideal treatment is early detection & early posterior fusion

- best results if fusion by age 3

- can be done as early as 6/12


A.  < 5 years & curve < 50o

- posterior spinal fusion


B.  > 5 years and > 500

- anterior and posterior fusion


C.  Neurology

- anterior decompression first


Congenital Kyphosis CTCongenital Kyphosis Correction Lateral


Type II 


If early, can treat with anterior osteotomy of unsegmented bar

- i.e. epiphyseolysis


If late, requires posterior fusion







Atlanto-axial Rotational Instability



Paediatric populations predisposed

- due to lateral mass anatomy and ligamentous laxity

- both alar ligaments and facet capsules must be torn to occur




Due to forced rotation and lateral tilt

Can be spontaneous




Most patients have torticollis and limited rotation


Cock robin position 

- lateral flexion and rotation to other side


Fielding Classification


1. Rotatory fixation without anterior displacement


2. Rotatory fixation with anterior displacement 3 - 5 mm


3. Rotatory fixation with anterior displacement > 5mm

- indicates disruption of both facet joints and transverse ligament


4. Rotatory fixation with posterior displacement






Klippel Feil








Atlantoaxial rotatory fixation

Ondontoid fracture

Os Ondontoid


Grisel's syndrome


Pyogenic atlanto-axial subluxation

- after upper respiratory tract infection

- inflammation induced ligamentous laxity

- can be post tonsillectomy


Present with painful torticollis and limited rotation




Widened atlanto - lateral mass interval


Dynamic CT


Head turned to left then to right

- demonstrate fixed subluxation




Atlanto-axial instability


1.  Early presentation

- i.e. first day or two

- trial soft collar / analgesics

- see 1 week later


2.  Reduce any anterior displacement with halter traction

- add sequential weight

- check X-ray to ensure no C0/1 displacement

- valium and Phenergan

- if successful apply HTB

- flexion extension views out of HTB for residual instability


3.  Failure halter traction / Trial skeletal traction


4.  Failure skeletal traction / Open reduction and fusion


Residual instability


C1/2 Gallie fusion




> 3/12

- consider fusion in situ




Usually will reduce spontaneously


First week

- NSAIDS and hard collar


Failure or > 1 week symptoms

- soft halter traction


> 4 weeks

- skeletal traction and HTB once reduced



Basilar Invagination



Cranial prominence of odontoid into region of foramen magnum

- upper cervical spine encroaches on brain stem




Congenital syndromes

- Klippel Feil Syndrome

- Achondroplasia

- OI

- Downs 

- Morquio


- NF


Congenital abnormalities

- atlas hypoplasia

- bifid posterior arch atlas

- occipitocervical synostosis




- Rickets

- RA


Clinical Features


Become symptomatic in third decade

- neurological compression 15%




McRae's line 

- line along foramen magnum 

- Basion to Opisthion

- dens above line = basilar invagination


MacGregor' s Line

- hard palate to inferior aspect occiput

- < 4.5mm above line


Ranawat Criterion

- distance between centre of C2 pedicle & transverse axis of C1

- men < 15mm

- women < 13mm




Delineate pathology




Consider surgery if symptomatic




1.  Severe pain


2.  Neurology


3.  Progression

- basilar invagination > 5mm




Surgery complex & fraught with complications


1.  Fusion

- Gallie C1/2 fusion if reducible

- occipitocervical fusion if not with C1 laminectomy


2. Excision of odontoid





Congenital Muscular Torticollis



Twisted / Wry neck secondary to fibromatosis in sternocleidomastoid




Packaging defect

- commonest first born 

- 75% on right




CDH 20%

Metatarsus adductus 15%

Breech presentation

Klippel - Feil Syndrome





Fibrosis of SCM on one side

Fails to grow & causes progressive deformity








1. Ischaemia secondary to position in utero 

- compartment syndrome SCM


2. Birth injury with haemorrhage


Natural History


Many resolve spontaneously


However if untreated get permanent facial asymmetry




Lump may be noticed in first few weeks of life 

- often disappears


Head tilted to one side so ear approaches shoulder


Head turned towards other shoulder


Associated facial asymmetry






Congenital fibrosis SCM


Congenital vertebral anomaly

- Klippel Feil

- os ondontoid

- C1-2 fusion

- unilateral C1 deficiency

- many others





- atlantoaxial rotatory subluxation

- # C1 /2


Grisel's syndrome

Ocular dysfunction

Infection / Discitis

SCM scar / tumour





To exclude congenital vertebral anomaly

- 17 cases of unilateral C1 deficiency with wry neck in literature


Indicated with failure non operative management




Non operative


Stretching exercises


90% successful




1.  Parents taught to carry child with their arm under flexed side of neck 

- stretches SCM whilst carrying


2.  Passive stretching exercises

- lateral head bend away from affected side

- head rotation towards affected side

- 90% success 






If persists past 1 year age chance of resolution very poor

- operate especially if > 30o limitation of movement




Ling et al Clin Orthop 1976

- 103 operations

- high rate scar tethering if released <1 year old




1.  Distal release first

- if not successful proximal release also


2.  Distal and proximal release

- often at age 4-6

- expose both and mark with sling (more difficult to isolate after one end divided)

- complete release both




Distal release 

- 5cm transverse incision 1cm above medial end clavicle

- incise tendon sheath

- draw tendons out (NB sternal and clavicular heads)

- divide / Z plasty / excise 2 cm of both tendons 

- explore wound digitally for any fibrous bands and divide these

- if release incomplete perform proximal release


Proximal release

- incision immediately behind & below ear

- divide SCM transversely just distal to tip of mastoid process

- NB spinal accessory nerve at risk


Post operative

- manual stretching 3x /d starts at 1 week post-op




Congenital Odontoid Abnormalities





Three 1° Ossification centres

- two lateral masses with posterior arch in between

- anterior arch which appears at 1 year

- posterior arch fuses at 4 years

- anterior & posterior fuses to body at 7 years




Five 1° Ossification centres

- two neural arches / lateral masses

- two 1/2 dens

- body


Five 2° Centres

- Os Terminale (Appears 3, fuses 12)

- inferior ring apophysis

- 2 transverse processes

- 1 spinous process


Body of odontoid fuses by birth from two centres

- failure = Dens Bicornis


Dens separated from body by Dentocentral Synchondrosis

- present at birth

- fuses by 6 years


Tip of Odontoid not ossified at birth

- ossifies by age 3

- fuses by age 12

- Ossicum Terminale Persistens if doesn't fuse




1. Os Odontoideum

- failure of fusion of base of odontoid

- normally fuses by age 6

- appears like Type II fracture


2. Odontoid Hypoplasia

- congenitally small odontoid

- asssociated with Morquio Syndrome & SED

- can get AAI 2° Hypoplasia 


3. Odontoid Aplasia

- absent odontoid


4. Os Terminale Persistens

- unfused terminal apophysis

- normally fuses by age 12


Os Ondontoideum







- ? os odontoideum is a traumatic event


Clinical Features


Usually asymptomatic


May present in adulthood with

- pain (Usually dull ache)

- neurologic symptoms

- Lhermitte sign / lightning pain

- long tract signs

- risk of sudden death




Open-mouth view



- > 3.5 mm translation on FE views

- ADI > 5 mm

- SAC also important if < 14 mm


Surgical Indications


Non syndromic


1.  > 10 mm FE motion

2.  Painful neck with instability 

3.  Neurology


Prophylactic neck fusion is controversial

- if asymptomatic avoid contact sport


SED /  Morquio


ADI > 5mm = Fusion




Gallie Fusion

- involves using notched bone graft

- sitting it between the posterior arch of C1 and the spinous process and medial lamina arch of C2

- secured by sublaminar wires 

- this is not inherently rotationally stable

- usually requires halo immobilisation








Klippel Feil Syndrome

DefinitionKlippel Feil


Congenital synostosis of cervical vertebrae

- refers to patients with any element of cervical spine fusion

- ranges from 2 vertebrae to whole spine


Classic triad 


1. Short neck

2. Low posterior hairline

3. Stiff neck


Triad present in <50%




Failure of normal segmentation of mesodermal somites of neck

- during 3rd to 8th week

- may be AD inheritance






Stiff especially lateral movements

- usually hypermobile at unaffected levels




Short neck


Head arises from shoulders


Often associated with webbing of neck


Low posterior hairline

- on level with shoulders




Degenerative OA

- caused by hypermobility of adjacent segments

- leads to instability & degenerative OA

- presents 3rd decade



- associated abnormalities


Other congenital cervical spine abnormality

- occiptiocervical synostosis

- basilar impression

- odontoid anomalies



- 60%

- congenital type

- associated respiratory problems

- need to consider neck problems when treating scoliosis


Sprengel's Deformity

- 30%

- same insult that causes KF halts descent of scapulae



- 35%

- renal failure often occurs early



- 30%

- affects development of speech & language



- 20%

- involve paired movements of hands

- abnormal pyramidal tracts

- usually resolves



- 15%

- various congenital defects

- need preoperative investigations / echo




Vertebral fusions


Klippel Feil Xray


Thoracic abnormalities

- scoliosis

- kyphosis


CT scan


Body fusion / block vertebrae


Flattening & widening bodies

Hypoplasic discs

Cervical spina bifida


Klippel Feil CT SagittalKlippel Feil CT Coronal




1.  Manage associated conditions





2.  Neck Deformity


Little can be done for neck deformity


Avoid contact sports as sudden death & neurology reported 

- worse if small mobile segment adjacent to long fused segment




Paediatric Back Pain



Spondylosis / spondylolisthesis

- most common cause

- adolescent playing sport


Scheuermann kyphosis
- 1/3 of patients


HNP - rare



Apophyseal ring fracture

- traumatic fracture between vertebral body and cartilaginous ring

- apophysis displaced posteriorly with disc

- decompression if causes neurological symptoms


Discitis / Osteomyelitis



- benign: OO / OB / ABC / Giant cell / EG

- malignant: Ewings / OS / Chordoma / Leukaemia




Juvenile Osteoporosis




Pain character

- aspirin relief / night pain

- osteoid osteoma


Associated neurology & deformity


Systemic features / Red flag signs

- fever / weight Loss




Standing PA & Lateral




For spondylithesis




Low threshold

- may need GA










Paediatric Discitis



1.  Infection

- usually haematogenous 

- some direct spread from vertebral osteomyelitis

- usually frankly infective with marked vertebral body end plate changes

- elevated temperature & ESR


2.  Inflammatory 

- probable auto-immune picture with minimal bone changes

- no need for antibiotics




Blood supply

- nucleus pulposis never has blood supply

- annulus fibrosis has blood supply until age 20

- primary infection possible in infants


Natural History


60% resolve

20% auto-fuse

20% chronic pain




1-12 years / symptoms age dependent


0 - 3

- refusal to walk / weight bear / limp

- irritability


3 - 9

- abdominal pain


> 9

- back pain



- stiff flexed spine 

- tight hamstrings & decreased SLR

- scoliosis




50% positive blood culture

66% positive CT guided biopsy

- usually not required



- Staph 60-70%

- Streptococcus

- Gonococcus > 12 years

- E Coli in neonates

- Atypicals (TB, Brucellosis)




Initial xray normal



- loss of disc height

- end plate irregularity & sclerosis

- disc can regain height, but endplate changes remain




Child may need sedation / GA





- leukaemia, metastasis (vertebral)

- EG (vertebra planar)

- OO, OB


Epidural abscess

Paraspinal abscess

SI joint septic arthritis






Controversial as whether to treat with antibiotics or not

- most authors agree that there is a bacterial component to the process

- most recover with or without antibiotics


Appropriate ABx (broad spectrum)

- bed rest

- brace


Usually rapid response

- CT guided biopsy if fails to resolve with above 




Kayser et al Spine 2005

- 25 patients with spondylodiscitis

- most had long delays to treatment due to non specific symptoms

- inflammatory markers usually only mildly elevated

- 48% had evidence of vertebral body destruction

- 60% healed with disc narrowing, 40% with fusion


Garron et al J Paediatr Orthop 2002

- 35 needle aspirations of the disc

- 55% Staph

- 27% Kingella Kingae









Congenital Scoliosis



Lateral curvature of the spine 2° to vertebral anomaly

- causes an imbalance in longitudinal spine growth




True incidence unknown


F > M


Typically Thoracic




No association in twins / suggests not inherited

5% risk in family if complex multi-level




Occurs during mesenchymal development 4-8/52  

- unknown foetal insult

- high incidence other anomalies 



V vertebral and spinal abnormalities

E endocrine

C cardiac

T tracheo-esophageal fistulas

R renal

R radial club hand

A anus imperforate/ urogenital (cloacae abn)

L limb Sprengel shoulder, club hand, CTEV

S single umbilical artery





- neurosurgery

- cardiology

- urology


Spinal Dysraphism (25%)

- failure of neural tube closure

- diastematomyelia , syrinx, tethered cord, arnold chiari malformation, fibrous dural bands, intradural lipoma, SB

- clinically associated with hair patches, dimples, lipomas, tails

- all should have MRI especially presurgery

- can have rib abnormalities / fusions

- can have posterior element abnormalities


Genitourinary 25%

- 6% have obstructive uropathy

- horse shoe kidneys

- lifethreatening

- all have ultrasounds +/- urology opinion


Cardiac 10%

- all murmurs should be investigated

- ASD, VSD, PDA, Tetralogy Fallot

- all patients have echo prior to surgery



- radial club hand

- congenital amputations

- cavovarus foot / CTEV


Klippel-Feil 25%




International  Spine Society / MacEwen

- failure formation

- failure of segmentation

- mixed

- unclassifiable


Most common

- unilateral bar

- fully segmented hemivertebrae

- semi segmented hemivertebrae


Failure of Formation


A.  Partial / Wedge Vertebra (5%)


B.  Complete / Hemivertebra (30%)


Fully Segmented

- common

- open disc above & below

- greatest growth disturbance


Semi Segmented

- 1 growth plate (either above or below)


Non Segmented / Incarcerated

- no disc above or below

- minimal growth potential


Failure of segmentation


A.  Unilateral / Unilateral Unsegmented Bar (50%)


B.  Bilateral / Block Vertebra (5%)




Combination both / Commonest


Unclassifiable (20%)




Anomaly present at birth but may not become evident until later life


Diagnosed < 3 or 9-14 years old


Associated with most rapid growth periods for the spine

- in utero

- from birth to 5 years

- puberty




Progression occurs if differential growth

- if more physis on one side 

- count number of physes


25% show no progression


50% progress rapidly


25% progress slowly


Prognostic Features





- worst prognosis with clinical deformity in first year of life



- higher in the spine, less likely to progress

- upper thoracic curve best

- lumbar worst


Worst  10° / year


Unilateral unsegmented bar + fully segmented contralateral hemivertebrae

- over 14 years can get 140 - 180o curve


Intermediate 5˚


Unilateral unsegmented bar 


Fully segmented hemivertebra

- most common

- usually a problem

- 2 growth plates

- 2 consecutive hemivertebra a problem


Semisegmented hemivertebrae

- second most common

- single growth plate

- curve at maturity usually < 40o


Consecutive Hemivertebrae


Best < 2˚


Block vertebra best

- bilateral growth impairment


Non segmented / incarcerated hemivertebrae

- may produce slowly progressive curve




Single hemivertebra unpredictable

- act as enlarging wedge

- often small with limited growth potential (incarcerated)




Lesion often difficult to interpret


See fused ribs


3D CT 


Excellent guide to anatomy




Should be performed before operative intervention

- assess for vertebral abnormality (40%)

- exclude Diastematomyelia / Tethered cord / Syrinx / Arnold Chiari Malformation




Renal ultrasound





Key is identification of curves likely to progress to prevent severe deforrmity




Bracing not indicated


Observe each 6/12

- look for progression

- examine for neurology

- continue until skeletal maturity





- progressive > 4-6o per year

- >40°

- high likelihood severe deformity i.e. unilateral unsegmented bar

- unbalanced child e.g. L5 hemivertebrae



- fusions (posterior, anterior/posterior)

- hemi-epiphysiodesis

- hemivertebrae excision

- corrective osteotomy + instrumentation

- growing rods

- expansion thoracoplasty


Growth Inhibition


Each vertebrae contributes 1 cm in height in normal spine


Not true in abnormal spine

- delaying fusion actually makes patient shorter due to increasing deformity

- best to operate early

- unbalanced growth centres don't contribute to vertical height




Fully segmented hemivertebrae


1.  Stop growth on affected side

- segments above & below fused unilaterally on side of hemivertebra

- hemi-epiphyseodesis performed anterior & posterior

- effectively produce contralateral unsegmented bar above & below


2.  Excision of hemivertebrae

- more common

- especially at lumbosacral junction


Unilateral bar


Stop growth on other side

- hemi-epiphyseodesis anterior / posterior on  convex side 

- < 5 years

- segment effectively converted to block vertebra


Other options


Growing Rods


For patient < 5

- long segment involved


Expansion Thoracoplasty


Fused ribs common

- excise fusion

- vertical expandable titanium rib

- allows chest expansion and normal development of ribs



Idiopathic Scoliosis

Adolescent Idiopathic Assessment

DefinitionScoliosis Thoracic Major


Lateral curvature of the spine with vertebral rotation

- defined as > 10o coronal plane deformity

- occurs at or near the onset of puberty 

- no cause is established


Planes of Deformity



- coronal / scoliosis

- sagittal / thoracic lordosis

- transverse / rotational


General Categories




Fixed lateral curvature with rotational deformity

- intrinsic anatomical change


1.  Idiopathic 75%

2.  Neuromuscular 10%

3.  Congenital 10%

4.  Other 5%


Non structural


Reversible, non rotational and disappears with sitting

- nil intrinsic anatomical change


Compensatory / Hysterical / Irritative / Postural / Sciatic




< 10o - 2.5 %

> 30o 4 / 1000 

> 40o 1/1000



- little difference overall

- females more likely to have larger curves

- females more likely to progress




Scoliosis Research Society (SRS)


Infantile: 0-3 years onset 


Juvenile: 3-10 (Puberty)


Adolescent: 10 - Cessation of Growth (20 years)




Early Onset - < 5 years 

- rare and severe

- male 2:1

- left sided

- if less than 1, 90% resolve

- >1, 20% resolve

- many other congenital anomalies


Late Onset  - > 5 years

- Adolescent Idiopathic

- females 6:1

- right thoracic

- nil associations

- FHx common




Structural Differences


Intervertebral Disc

- decreased GAG in Nucleus and increased collagen content 


Paravertebral Muscles 

- differences in muscle fibres on either side of curve 

- more type I fibres on the convex side of curve 


Ligaments and Tendons 

- PLL thickened 



- patients with idiopathic scoliosis often taller 

- normal GH but altered Somatomedin levels - ? significance 


Vertebral Body

- structures on concave side hypoplastic 

- structures on convex side hyperplastic

- due to persistent asymmetrical loading


Postural Equilibrium

- abnormality in vestibular system in brainstem 

- scoliosis induced in bipedal rats with destruction of brainstem 

- not conclusive - ? effect rather than cause 




Scoliosis produced when the pineal gland removed from chickens 

-  transmitter found to date - ? melatonin




Increased incidence in affected relatives 


Mother with scoliosis

- 10% chance for female child


Sister with scoliosis

- 20% chance for female child


Mother and father with scoliosis

- 80% chance for female child




Biomechanical initiator of the deformity

- thoracic lordosis normally lies in front of the normal axis of rotation

- causes the lumbar lordotic section to rotate in flexion 

- the tethering of the posterior elements (thickened PLL) also contributes to rotation in flexion

- explains the Crank Shaft Phenomena 


Adolescent Idiopathic Scoliosis 




Prevalence dependant on the size of the curve 


As the curve increases in magnitude the female preponderance increases as well 


Overall is 3.6:1  F:M


Curve Patterns


There are five major curve patterns in decreasing order they are


Right Thoracic

Double major (Thoracic dominant)


Double major (Lumbar dominant)

Left Lumbar 






Absolute increase in Cobb angle of 10o

- or 5o over two consecutive visits 


Remember the interobserver error of Cobb angles is +/- 4o

- can vary with the time of day (increases in the pm)


Factors related to progression




Magnitude:  curve > 20o

Risser:  0 or 1

Sex:  Female

Menarche: premenarche

Age: < 12

Pattern:  Thoracic & double curves most


Growth Remaining



- 66% prior to and 33% after menarche 

- most growth is 1 year before and 1 year after menarche

- have on average 2 years growth left

- have passed PHV



- peak height velocity / most important factor

- adolescent growth spurt

- girls 8 cm / year

- boys 9.5 cm / year

- before menarche / at Risser 0 / open triradiate cartilage

- PHV generally over 2 years


Tanner sign 

I - Pre-pubertal 

II - Breast buds  - related to adolescent growth spurt

III- Pubic hair 

IV- Menarche 


Triradiate cartilage

- may be more sensitive in judging the maturity 

- Risser 0 + open triradiate cartilage indicates a lot of growth to go

- closes in the middle of the PHV


Risser sign 


Risser grade relies on ossification of the iliac apophysis from lateral to medial and is completed with maturity

- Grade 0 to 5 

- Grade 0 means no ossified apophysis present

- Grade 1 means appearance of apophysis laterally / after menarche

- Grade 5 is fusion of the apophyseal cap to ilium / little growth remaining / 14-16 Boys and 11-13 Girls

- can be difficult to distinguish between 0 and 5


Curve Pattern 


Double curves have higher incidence of progression than single curves

- single thoracic > single lumbar

- lumbar the least


Curve Progression Studies


1.  Lowenstein Study of Curve Progression


Looked at Risser sign + intial curve in regards to curve progression


Risser   0 - 1 2 - 5
Initial curve 0 - 19o 22% 2%
Initial curve 19 - 290 66% 22%


2.  Weinstein and Ponsetti 


Looked at the progression after maturity  / 30 year study

- curves less than 30o as rule DO NOT progress after maturity 

- 50 - 75o progressed most ( 1o/ year ) 

- this is the basis for surgery for curves 450 plus


Slowed over 100o with costopelvic impingement 



- mortality 2x expected

- high percentage disability pension

- none in heavy work

- nil increase incidence LBP


Natural History of Untreated Scoliosis


Back Pain 


Most studies suggest that the incidence of back pain is no higher than in general population 


Back pain seen in thoracolumbar or lumbar curves of > 45o

- particularly if large apical rotation or imbalance 


Pulmonary Function 


Affect on pulmonary function not seen until curves of 80o reached  

- restrictive pattern

- linear relationship between FVC and PaO2 and curve size 

- nil effect with curve < 60o

- 1/3 with curve 60-100o

- 1/2 with curve > 100o




Nachemson 1968

- not increased until curve of 100o noted


Cor Pulmonale 


Seen at 40 and 50 years of age if curve > 80o






How detected 

Presence of progression 

Associated complaints 

- pain 

- neurological symptoms 

- respiratory symptoms 


Status of growth 

- growth spurt

- menarche

- changes in puberty 


Want to ensure is idiopathic

- normal delivery / normal milestones

- bladder troubles (NM)

- Marfinoid / OI / NF




See the section on examination for detail


AP Film


Standing AP or PA films of whole spine including the iliac crests 

- PA has less radiation to ovaries and breasts 

- AP has less magnification 


1.  Neutral / end vertebrae


End vertebra is the last vertebra that tilts into the concavity of the curve

- when the end plates are parallel, the one furthest from the apex of the curve is the end vertebra


Scoliosis End Vertebrae


2.  Cobb Angle 


Detect the end vertebrae where the end plates are last to converge 

- line drawn along upper plate of the upper end vertebrae and lower plate of the lower end vertebrae 

- perpendiculars to these lines 

- intersection angle measured 


If double curve

- one vertebrae is upper end vertebrae for the lower curve 

- lower end vertebrae foe the upper curve 


Measurements all taken from same vertebrae in future 


Scoliosis Cobb Angle


3.  Identify Apical Vertebrae


In centre of curve

- furtherest from central sacral line

- not tilted / most horizontal

- maximum rotation


T10 above apical - Thoracic

T11 - L1 apical - Thoracolumbar

L2 down - Lumbar


4.  Stable Vertebrae


Central sacral line

- lowest vertebrae this bisects or

- line between 2 pedicles

- lowest vertebrae instrumented in surgery


Scoliosis Central Sacral Line


5.  Look at shoulders


Important in double thoracic major

- high structural thoracic curve

- if left shoulder high in right thoracic curve

- need to instrument to T2 to correct this


Lateral Films 



- measure the kyphosis and lordosis via Cobb method

- important presurgery

- want to correct this intra-operatively

- usually need to recreate thoracic kyphosis


Lateral Bend Films 


Push prone

- supine with maximal voluntary bend 

- differentiates structural from compensatory curves 




If suspect intraspinal pathology 

- Brain + 3 level spine / neurocentral


Indications for MRI


Scoliosis Left Lumbar Curve


Left sided 



Rapidly progressive 

Neurological abnormality present 




Right sided curve: 20% have pathology 

Left sided curve: 80% have pathology 


Assessment of Rotation 


Rib Hump / Scoliometer 


Adams forward bend test

< 5o tilt = < 30o rotation

> 7o tilt = > 30o rotation


Rotation of Pedicles

- indicates the structural curve






3 areas of curve

- main thoracic: MT

- proximal thoracic: PT

- thoracolumbar / lumbar: TL/L



- curve location

- lumbar modifier

- thoracic sagittal profile


Type 1 Main Thoracic

- MT structural

- PT non structural

- TL/L non structural


Scoliosis Main Thoracic


Type 2 Double Thoracic

- MT and PT structural

- TL/L non structural


Type 3 Double Major

- MT and TL/L structural

- PT non structural


Type 4 Triple Major

- all 3 structural


Type 5 Thoracolumbar / Lumbar

- only TL/L


Scoliosis Lumbar


Type 6

- TL/L and MT structural

- TL > MT by more than 10o


King-Moe  Classification

Very poor inter observer reproducibility


Type I -  Lumbar Dominant Double T + L

- both the thoracic and lumbar curves cross the midline 

- lumbar curve larger and more rigid 


Type II - Thoracic  Dominant Double

- both the thoracic and lumbar curves cross the midline 

- thoracic curve larger and more rigid 


Type III -  Short Thoracic 

- thoracic curve 

- lumbar curve doesn't cross the midline 

- lumbar curve not structural


Type IV - Long thoracic 

- long thoracic curve extends to lumbar spine 

- L5 over the sacrum 

- L4 tilted into the curve (stable vertebrae)


Type V -  Double structural thoracic 

- double thoracic curve with L upper, R lower

- tilting of T1 into the upper curve / elevation of L first rib

- cervical extension

- compensatory lumbar curve with upper curve structural




Adolescent Idiopathic Management



Curves < 20o observation only at 3-6 month intervals depending on growth rate 


Non Operative Management / Bracing 


Never brace curves if patient Risser 4 or 5 




1.  Risser 0-2 (growth potential)


2.  Curve >30o adolescent


3.  Curve >25o with progression (5o in six months)


4.  < 10 years old

- very young with high progression potential

- high risk crankshaft if operate


5.  Willingness to comply




Angle                      High Growth Potential                Lowth Growth Potential

<20°                                   observe                               observe or DC

20°-30°                               observe/brace                     observe

30°-45°                               brace                                  observe

>45°                                   surgical                               surgical / observe




Will control curve only

- end result is initial curve + 5o


Brace should be customised to patients curve 

- designed to prevent progression NOT to achieve correction 

- generally see a moderate amount of correction when using the brace

- then slow steady progression of curve back to original magnitude during weaning 

- best curves to brace are those < 40o


Bracing complications


Failure to prevent progression

Skin irritation

Pressure areas

Abdominal discomfort, eating habit disruption

Cast syndrome - SMA / duodenal obstruction



Milwaukee Brace  / CTLSO


Best for curves with apex above T8 

- three point fixation technique 

- less efficacious for curves > 40o


Consists of 

- well moulded pelvic piece above the iliac crests (most important)

- two posterior uprights and one anterior upright 

- neck piece with plastic throat mould anteriorly and two occipital pads posteriorly         

- thoracic pad placed over the apex of convexity of curve 

- lumbar pad over TP between lowest rib and iliac crest on concave side 

- active correction by muscle contraction pulling body away from pads




23 out of 24 hours a day

- result dependant on time in brace


Need to check regularly and readjust after 1-2 weeks 

- Xray on 6 month basis 

- if progresses > 45o then surgery


Aim for 30-50% correction in first 6 months 

- if not achieved consider surgery 




Once skeletal maturity / Risser 4 / full height 



- 20 hours for 4 months 

- 16 hours for 4 months 

- 12 hours for 4 months 

- night time only for 4 months 


TLSO (Under arm or Boston Brace)


If apex < T8 


Higher compliance 

May not be as efficacious in holding correction 

Made from cast


Operative Management




1.  Immature / Risser 1 /2

- Cobb > 40o with documented progression

- peak height velocity

- will progress 1o per month

- need to stabilise early


2.  Mature

- T > 45 - 50o

- TL or L > 30o with marked rotation

- double major > 50o

- significant coronal imbalance

- cosmetic deformity

- failure bracing


This curve will progress slowly

- patient has time to make up mind




Solid arthrodesis that prevents progression

Balanced spine

Correction of deformity

Prevent respiratory compromise




1.  Most curves 

- posterior instrumented fusion


2.  Lumbar curves

- anterior instrumented fusion


3.  Large curves > 70o / young patients

- anterior and posterior surgery




Fuse the structural curve with minimum segments

- to stable vertebra

- minimise the levels (preserve motion segments)

- avoid to L5 and above T1 (may increase pain)

- if fuse to L5, only 1 motion segment left, risk LBP


Correct curve in sagittal and coronal planes


Best to wait til 10 - 12 years to avoid crankshaft


Structural Curve


1.  Largest curve

2.  One to which trunk shifted

3.  Least correction on AP lateral bending Xray

4.  Pedicles rotated


Posterior Instrumented fusion


Multisegmental Hook and Pedicle screw systems

- allows for correction via Compression / Rotation / Distraction


Crankshaft phenomenon



- seen in young child with high growth potential

- pre PHV surgery or with open triradiates

- pivot on posterior fusion

- vertebral bodies and discs bulge towards convexity



- get loss of correction, increase in rotation, recurrence of rib hump


At risk

- Risser 0

- girls < 10

- boys < 13


Specific Surgery


Lenke Type 1

- main thoracic

- posterior stabilisation

- usually limit to T4 as shoulders equal


Scoliosis Fusion Long Thoracic


Lenke Type 2

- double thoracic / MT and PT

- need to instrument to T2

- equalise shoulders


Scoliosis Fusion Double Thoracic


Lenke Type 3

- double major / MT and TL/L

- long posterior instrumented fusion


Lenke Type 4

- triple major

- very long posterior instrumented fusion


Lenke Type 5

- thoracolumbar / lumbar curve

- can fuse short curve this through bed of T9 / T10 rib

- otherwise posterior instrumented fusion


Scoliosis Lumbar Curve Fusion


Lenke Type 6

- TL > MT structural

- long posterior instrumented fusion


Technique Posterior Instrumented Fusion





Cell saver

- accumulate large blood loss

- often large exposure

Xmatch blood

2 x milled femoral head allograft 

Spinal monitoring / SSEP's

- needles scalp / hands / feet

- begin pre-op once asleep as baseline


Pedicle screws / TP hooks / rods available

Post op ICU bed especially neuromuscular




4 Poster Bed

Protect eyes, knees, elbows

No pressure on abdomen / reduce venous bleeding




Posterior approach

- betadine pack buttocks

- midline incision

- divide thoracolumbar fascia midline

- split apophysis with knife (if present)

- subperiosteal elevation strap muscles

- use diathermy, cobb

- sequentially pack with rolled up packs to control bleeding


Lumbar spine

- expose facet joints and transverse processes

- don't go between transverse processes laterally as nerve roots here

- pedicle screws inserted bilaterally bottom 3 pedicles



- TP hooks above

- pedicle hooks below

- compress


2 x rods prebent in sagittal plane

- correct coronal malignement and rotation as able

- may use sublaminar wires if large long curve

- midsection of curve in concavity

- tie over rod and tighten to correct


Decorticate lamina, add bone graft along each side




Technique Anterior Fusion




Large lumbar curve in young patients 

- skeletally immature patient to achieve growth arrest and prevent crankshaft


Any lumbar curve to decrease fusion length

- this is debatable


Large / rigid curve to achieve mobility 

- severe curves >70o

- supplement posterior fusion




Fewer levels instrumented 

Better correction of rotation

Large surface for fusion

Fusion under compression

Use rib as bone graft




Requires anterior approach

Does not produce lumbar lordosis 

Respiratory problems (need chest drain)

Need to divide segmental vessels




Supine, rolled

- curved right sided approach

- remove 9th rib (save for bone graft)

- through bed of rib

- identify peritoneum, stay outside

- take down diaphragmatic crura

- divide segmental vessels, remove discs

- unilateral screws and rod

- repair diaphragm, close over ICC


Endoscopic Anterior Instrumentation



- reduced blood loss and pain

- better scars and cosmesis



- technically difficult

- respiratory problems / deflate lung


Growing rods




Growing children / open triradiate cartilage

- avoid fusion / crankshaft phenomen

- biannual surgery

- high complication rate 50%

- hook dislocation

- rod breakage


Costoplasty / Thoracoplasty




Partial excision of 5 or 6 ribs from the TP to posterior axillary line 




Corrects the rib hump 

Cosmetic procedure

Good source of graft 

Does not affect the post op morbidity or pulmonary function


Complications G. Coe SRS Report 2006






0.32% in posterior corrections (SRS) in adolescents 

- 2% in adults 

- highest in congenital curves



- SSEP's monitoring in all idiopathic and congenital curves 

- wake - up test in suitable patients (difficult in children)



- stimulate in legs, readings in cortex

- avoid inhalation anaesthetics

- time delay as must average amplitudes and reduce background noise

- issue if lose > 50% amplitudes


If lose SSEP's

- avoid hypotension

- transfuse Hb if low

- check electrodes

- wake up test

- give steroids

- reverse correction

- remove instrumentation


Infection 1.35%


Prophylaxis warranted 

Late chronic infection with Proponiobacterium acnes 


Respiratory 1.6%


- atelectasis


PE 0.02%


Death 0.03%


Ileus - very common


Blood Loss 


Avoided with

- autologous blood 

- cell savers 

- hypotensive anaesthesia

- autotransfusion

- often blood loss that contributes to neurological compromise 


Incorrect fusion levels / wrong level surgery


SIADH secretion 

- decrease UO night of surgery

- steady improvement 2-3/7





- 1% overall

- instrument failure 


Crank shaft Phenomena 


In rapidly growing child after posterior fusion

- spine will rotate as the bodies grow anteriorly

- thus if child with significant growth then add anterior discectomies and fusion


Other solutions

- posterior growing rods

- anterior staples / guided growth


Sagittal malalignment 

- loss of lumbar lordosis

- flat back / loss of thoracic kyphosis


Back Pain 


Related to fusion below L4 and loss of lumbar lordosis 


Levels and back pain

- L5 - 80%, L4 - 60%

- L3 - 40%, L2 - 20%


Late infection - low virulence organism




Gothenburg Sweden 1968

- 23 year follow-up post fusion with instrumentation

- preop Cobb 62°; postop 33°; last followup 37°

- same series had 127 patient braced

- prebrace 33°, best brace position 30°, last followup 38°



Infantile Idiopathic



< 4 years by definition


M : F


75% left thoracic


Actually very uncommon 

- likely most patients once had spinal dysraphism (Arnold-chiari / syrinx / tethered cord)

- reduced by prenatal folate




Age < 1

- 90 % spontaneously regress

- very important

- 10% progress to severe deformities


Age > 1

- 80% progress

- more likely to cause cardio / respiratory compromise

- alveoli not developed til age 8

- lungs need room to develop

- high associated with other abnormalities


Progression Risk


1.  Mehta Angle / Rib-vertebral angle difference / RVAD


Difference in angle at which rib meets spine at Apex of curve on either side on AP x-ray

-  > 20° likely to progress 


Phase one and phase two

- phase 2 : rib head overlaps and angle cannot be measured

- risk of progression high

- indicative of rotation


2.  Degree of Curve


Likely to progress if curve > 25°




Exclude congenital scoliosis





- 20% incidence intraspinal pathology

- syrinx / tethered cord / diastematomyelia / ACM




Non operative




Curve < 25o and RVAD < 20o

- resolve spontaneously

- no need for treatment


Curve > 25o and RVAD > 20o

- brace




Serial cast < 1 year


Brace > 1 year 

- Milwaukee brace can be curative

- younger age group more likely to tolerate this brace than adolescents

- brace must be worn until curve maximally & permanently corrected

- infantile growth spurt continues till ~ age 4-5






Curves > 35o

Progressive curves 5o in 6/12 




Patient < 10 years or before PHV

- high risk crankshaft effect 

- fusions must be anterior and posterior




1.  Posterior growing rods

- obtain correction whilst maintaining truncal growth 

- subcutaneous Harrington rod / Growth Rods / Luque rods

- spine exposed at ends for hook insertion with submuscular or subcutaneous rod insertion

- requires surgical adjustment every year (can be done up to 5 times)

- surgery each time adds to scar and increases risk of problems including infection and cut out

- posterior fusion at later age 


2.  Hemiepiphyseodesis

- fusion of convex side of apical vertebrae

- is difficult to obtain half disc fusion

- may be used supplementary to growing rods


3.  Staples / guided growth hemiepiphyseodesis

- can be done endosopically


4.  Posterior instrumented fusion

- not indicated in young children as causes crankshaft effect due to anterior growth continuing

- can be safely performed at age 12 (girls) or 14 (boys)


5.  Anterior & Posterior instrumented fusion

- avoids crankshaft effect

- inhibits truncal growth




Scoliosis Examination

Aims of Examination


1.  Identify cause

- Marfan's / Neurofibromatosis / Skeletal Dysplasia


2.  Balance & body asymmetry


3.  Exclude LLD as cause

- correct with blocks or sit patient


4.  Forward flexion / Adams forward bending

- look for rotation / rib hump


5.  Assess flexibility if considering surgery


Typical curve

- the right shoulder is raised

- the right scapula is prominent

- the loin creases are asymmetrical

- the pelvis is level

- there is flattening of the normal thoracic kyphosis

- there is a normal lumbar lordosis

- on forward bending, there is a (mild/moderate/severe) (well rounded/angular) rib hump and a mild left lumbar fullness





- cafe-au-lait spots / axillary freckling / neurofibromas



- Lisch nodule (NF)

- blue sclera (OI)

- cloudy cornea (mucopolysaccharidases)

- dislocated lens (Marfan's)

- optic glioma



- abnormal teeth (OI)

- high-arched palate (Marfan's)



- pectus carinatum or excavatum (Marfan's)



- hemihypertrophy

- dolichostenomelia (long limbs)

- arachnodactyly (thumb in palm)

- clubfoot - often first sign of dysraphism

- cavovarus foot






Thoracic kyphosis - reduced / hypokyphotic


Lumbar lordosis - exaggerated, normal or reduced


Protruberant abdomen





- right or left


Balanced / Unbalanced 

- alignment of C7 over gluteal cleft (ask for plumb bob)


Shoulder height


Scapular symmetry


Loin creases / lumbar fullness



- level or not (pant line or PSIS)


Spinal dysraphism

- hyperpigmentation / hairy patch / dimple / lipoma / tail


Leg length 

- if abnormal use blocks & reassess curve


Scoliosis can cause apparent LLD

- true curves rotate into their convexity


A long leg will elevate the hemipelvis / convexity will be to opposite side

- fixed left scoliosis will give apparent left leg shortening


True LLD -> Apparent scoliosis

True scoliosis -> apparent LLD


Adam's test 


Hands together & bend forwards to touch floor

- mild / moderate / severe rib hump

- well rounded or angular

- satisfactory unroll


Meaure rib hump with scoliometer














- hamstring tightness



- reflexes UL / LL / Abdominal / Babinski

- sensation

- power UL / LL


Scoliosis + °Abdominal reflexes & °Axillary sensation 

- syrinx till proven otherwise


Abdominal reflexes disappear during teens








Ligamentous laxity / Wynne Davies criteria



- if forgotten 

- natal cleft / mouth / eyes / axillae


Cephalad joints

- ROM if deformity






"This is a PA spine radiograph of a __ old skeletally mature / immature Risser __ male/ female with scoliosis"


"There is a R/L typical/atypical curve thoracic/lumbar curve ±  a R/L T/TL/L lower curve"


"The spine is/isn't balanced, the pelvis is/isn't level & the curve has a rotational component"


"The curve appears to be Idiopathic / Congenital / NF / NM


Don't mention which is 1°/ 2° or postural or structural


Neuromuscular Scoliosis



Prevalence of 25-100%



- walking decreases incidence



- worse with young onset




Exact biomechanical explanation of origin & progression of curves unclear


Associated with

- weakness 

- poor muscle control

- no proprioception




1. Neuropathic



- CP 

- Friedrich's

- cord tumour / trauma




- Polio

- Spinal muscle atrophy

- Spina Bifida


2. Myopathic

- Arthrogryposis

- Muscular Dystrophy

- Myotonia Dystrophica


NHx compared with Idiopathic 


Onset younger

More rapid progression

Progression after skeletal maturity / throughout life

Longer curve

Cervical involvement

Pelvic obliquity

Pulmonary complications common




Long C shaped curve

- compensatory curve uncommon but possible


Curve associated with

- pelvic obliquity

- hip contractures / dislocation

- cervical involvement


Other problems


Lung disease common (decreased FVC, LRTI) 

Poor nutrition 

Pressure areas

CRF in Spina bifida






Maintain cardiorespiratory function

Promote mobility & ambulation

Preserve sitting balance

Improve cosmesis




Brace till 12 years then fuse


Earlier if

- lose control with rapid progression

- large curve






Small curves < 30°

Large curves in patients with very poor prognosis




Best overall initial treatment

- rate of progression slowed

- allows further spinal growth before definitive treatment



- 2 piece custom moulded

- used to control & correct scoliosis or kyphosis in growing years

- preferable to Milwaukee brace in NM conditions

- easier to make and wear with reduced incidence of press sores

- worn during day while child is upright

- off at night



- very important

- aims to give trunk & spine control

- able to correct postural curves

- no effect on structural curves

- significantly decreases nursing & handling time


1. Tumbleform Seat

- moulded seat for infants

- 3 sizes


2. Commercial Chairs

- pelvic support, abduction pillow, thoracic support, head support


3. Moulded Sitting Support Orthosis


- custom fitted support made from patient mould

- provides maximum sitting support with padded supports & belts




Neuromuscular Scoliosis Posterior Fusion




Solid arthrodesis of balanced spine over level pelvis




Long, solid fusion from upper thoracic to lower lumbar

Rigid instrumentation & massive bone grafting




Increased bleeding

Osteopenic bone / Poor hold

Fusion to pelvis

High pseudarthrosis rate

Poor medical state



- fusion may eliminate ability to ambulate

- trunk movement may be important for ambulation

- obviously lose any spinal movement with flexion

- should test in brace first

- may need to limit extent of surgery




General medical workup

- cardiopulmonary status

- especially Friedreich's & Duchenne MD

- FVC1, FEV, ABG's


Book ICU bed





- most common especially in CP

- moderate curve


Staged Anterior / Posterior

- severe kyphosis / severe rigid scoliosis (> 45°)

- posterior fixation compromised (SB)

- < 9 years to stop crankshaft deformity





- spinal cord monitoring if indicated

- cell saver

- post op ICU bed or HDU



Instrumented fusion

- proximally from T3 or T4 to prevent later subsequent deformities

- caudally to pelvis if >15° pelvic obliquity

- to L4 or L5 if balanced

- often need sublaminar wires for large C shaped curve

- place in midcurve to pull spine to the rods

- large fusions require allograft


Blood Loss

- issue because extensive approach / small  blood volume / osteopenic bone bleeds+++

- addressed with meticulous haemostasis / hypotensive anesthesia / haemodilution / cell saver




Pulmonary complications

- most common cause of death

- nearly all CP patients get pneumonia post op 


Neurological injury

- especially if correcting curve > 90°

- spinal monitoring

- if damaged when wake up, remove metalwork



- careful fluid balance 



- bacteraemia from remote sites especially  UTI

- increased incidence of wound infection


Loss of ability to ambulate

- due to loss of trunk flexion and extension


Cerebral Palsy


Most common neuromuscular cause of scoliosis in western world




Professor Bruce McPhee, Royal Brisbane Hospital

- key is that they all continue to progress past maturity

- says as general rule all need operation so can pick your timing

- try not to fuse too early as get very short trunk

- no longer goes to pelvis 

- feels that stopping at L5 is adequate and pelvis is not worth the morbidity

- insists CP patients have their operation at 50o

- if families decline he won't operative at 70-80o because then they need 2 stage

- high associated morbidity

- follow up every 6 or 12 months




10% in ambulatory patients

70% spastic quadraplegics


Lonstein Classification


Group 1 curves (A&B) have level pelvis

- double thoracic curve

- little pelvic obliquity

- fuse as for idiopathic


Group 2 curves (C&D) have pelvic obliquity

- large lumbar or thoracolumbar curve

- marked pelvic obliquity

- fuse long (T4) to pelvis





- curves up to 30˚ in the growing child

- curves up to 50˚ in skeletally mature



- often only postpones arthrodesis until puberty

- seating most common form of non-operative treatment instituted

- TLSO effective in ambulatory patient




Fusion to sacrum essential with pelvic obliquity

- Galveston technique (iliac wing rod fixation)

- pedicle screws only viable in S1, not S2


Spina bifida




>60% of patients with myelomeningocoele develop scoliosis




The higher the level the more severe

- T12 - 100%

- L1 - 90%

- L2 - 80%

- L3 - 70%

- L4 - 60%

- L5 - 25%

- S1 - 10% 


40% incidence of spinal dysraphism

- may cause scoliosis progression

- hydrocephalus, syringomyelia, tethered cord, Arnold Chiari


20% have congenital component


Most require surgery


Why fuse wheelchair bound Spina Bifida children?





- often use peg

- tends to disappear into skin folds

- hygiene & technical difficulties

Acid reflux when hunched over

Only tolerate small feeds



Pressure areas

Ability to nurse

Takes arm off chair so can do ADL's

Allows stable sitting

Pelvic obliquity

Allows coverage of hips



Self-esteem both patient & carer

Allows better interaction with environment


Poor prognostic signs


Early age of onset

Asymmetrical motor paralysis

Presence of spasticity

10% - 20% have congenital scoliosis




Curve 20-40˚


- but bracing complicated by pressure sores


Curve > 40˚

- anterior and posterior fusion

- need anterior as posterior elements deficient

- pelvis may be deficient

- attempt to preserve lumbosacral segments to aid wheelchair transfers


Duchenne's muscular dystrophy




Usually lose ability to walk during age 9-12 years

- due to progressive weakness

- 80 - 100% develop severe collapsing scoliosis


May progress rapidly (2-3˚/ month)

- can progress to 100o

- 10o per year once in chair




Affects ability to sit


Scoliosis is life threatening

- progressive respiratory compromise

- due to respiratory muscle weakness and curve

- with curve > 35˚, vital capacity 40% of predicted

- further compromises respiratory problems

- death occurs in late teens to early twenties

- may be delayed by curve correction




Orthotic use little success

- almost all progress

- slows progression (15˚ / year comparted with 30˚ / year)


Surgery Indications


Curve greater than 30o

FVC < 30% predicted

Life expectancy > 2 years




Only posterior

- anterior compromises respiratory function too much


Spinal muscular atrophy


Most patients develop scolioses

- onset by age 7

- usually progressive

- consider surgical treatment when curve reaches 40o

- large C shaped curves

- T2 to sacrum


Friedreich's ataxia


All have scoliosis

- 50% have hyperkyphosis

- curve patterns resemble idiopathic rather than neuromuscular

- curves appear later

- late teens or early 20's

- consider surgical treatment when curve reaches 40o


Paraplegia and quadriplegia




Age related with risk of spinal deformity

- 90% if cord injury preadolescent

- due to loss of sensory / proprioceptive / motor functions supporting the spinal column


Posttraumatic angular deformities related to crush fractures




Other Causes Scoliosis






Among the skeletal dysplasias, spinal deformity is seen most commonly in patients with achondroplasia. 




1.  Thoracolumbar kyphosis


Occurs in almost all patients prior to walking

- non rigid, likely due to hypotonia

- resolves with ambulation


Bracing may help to prevent clinically significant kyphosis

- persists in approximately 15% to 20% of patients


2.  Spinal Stenosis



- Short pedicles

- narrow interpedicular distance 

- Stenosis may be present at any level from the foramen magnum down

- most commonly L1-S1




Over 50% of patients with achondroplasia have back pain

- other symptoms may include leg pain, claudication, paresthesias, weakness, and paraplegia. 

- Bowel and bladder difficulties may occur with stenosis in the lower thoracic spine


Symptoms usually occur in early adulthood and are slowly progressive

- Occasionally, symptoms may arise in childhood


Surgical decompression


Wide, multilevel laminectomies

- Disc removal usually is not indicated 

- unless radiculopathy is present

- Early surgical intervention leads to a better outcome


Postlaminectomy instability may occur

- fusion probably should be added in cases of multilevel decompression


3.  TL kyphosis + stenosis


Anterior decompression and strut grafting should be added


Irradiation Induced



Vertebral bodies grow axially by endochondral ossification. 

- radiation can inhibit this




Spinal deformity is the most common side effect of abdominal irradiation

- Children irradiated at age 2 years or younger are most affected


Study of Wilm's tumour patients

- 7 x incidence scoliosis


Reported 10 to 100%


May get LLD

- femoral head

- ilac crests




Irradiation of the entire vertebra

- produces a symmetric hypoplastic vertebral body

- without significant malalignment


Irradiation of a portion of the body

- causes segmental loss of growth 

- resultant scoliotic deformities


Soft-tissue fibrosis and contracture may be a cause of spinal curvature




Milwaukee brace treatment 

- indicated in a young child with a flexible curve caused by irradiation


Early posterior fusion and instrumentation is recommended

- Repeat bone grafting may be necessary

- need longer duration of postoperative immobilization 

- several authors recommend a duration of up to 1 year




Marfan's Syndrome




Spinal involvement occurs in approximately 75% of patients with Marfan's syndrome

- scoliosis is the most common spinal deformity

- the cervical spine is almost always normal


Those who develop scoliosis do so by 9 years of age

- one half of the patients develop it by age 6 years




Curve patterns resemble idiopathic scoliosis

- frequent progression during adolescence


Despite the patients' generalized ligamentous laxity, many of the curves are quite rigid


Thoracic lordosis

- second most common spinal deformity

- associated with loss of normal lumbar lordosis




These curves also tend to be painful, progressive, and often cause respiratory problems


Curve progression rates average 7 - 10o per year

- with the most rapid increase occurring during the early adolescent period




Non operative


Brace treatment



- most patients fail brace treatment

- orthotics may be used as a holding device for patients who eventually will undergo fusion






Posterior spinal instrumentation and fusion 

- mainstay of treatment

- a high rate of pseudarthrosis can be expected

- may lower with addition of an anterior fusion, abundant bone grafting, and postoperative immobilization







- high incidence of malformations

- need good pre op work up


Superior mesenteric artery syndrome

- high incidence if put in jacket











2% scoliosis patients have NF


10 - 30 % NF patients have spinal deformity

- most common skeletal manifestation

- mostly non dystrophic variety




A.  Non dystrophic

- vertebral wedging, angulation and rotation

- very similar to idiopathic scoliosis

- right thoracic


B.  Dystrophic



- may be due to intraspinal lesions such as tumours, meningoceles and dural ectasia

- can simply be bony dysplasia


Characterised by

- short segments, sharp angulation with severe apical rotation

- scalloping posterior margins

- widening of the spinal canal

- enlargement of neural foramina

- widened interpedicular distance

- thinned defective pedicles and lamina

- paraspinal mass

- rotation of ribs - 'pencilling'


Other problems


Cervical spine kyphosis


Atlantoaxial dislocation 

- has been reported in five patients

- flexion and extension views are important in assessing cervical instability

- needed pre-op



- marked acute posterior angulation

- can develop myelopathy and even paralysis


Intraspinal Tumours


Dural Ectasia

- circumferential dilatation of dural sac

- contains CSF and brown material

- erodes osseous structures

- very thin lamina

- can cause great angular deformity

- may have multiple dumbbell appearances


Dumbbell lesion

- single neurofibroma


Meningocoeles / pseudomeningocoeles




Non Operative Management


Brace treatment


Not been effective in dysplastic curves

Can use early in non dysplastic


Operative Management


Non dystrophic




Recommend posterior fusion for progressive

- lower threshold for surgery than in idiopathic

- potential for progression much higher


Surgery as for idiopathic




Brace 20 - 35o

Surgery > 35o






A.  All dystrophic curves need MRI to assess intraspinal lesion


B.  All need C spine screening before surgery

- these patients also often have cervical spine abnormalities and instability


C.  Incidence of pseudoarthroses ranges from 6% to 38% with isolated posterior fusion

- recomment addition of anterior fusion for dysplastic scoliosis is therefore recommended

- anterior release then posterior fusion




Anterior release and fusion followed by posterior fusion if > 50o




Posterior fusion alone is usually insufficient in patients with kyphosis


Decompression of the cord with laminectomy 

- contraindicated because the lesion is usually anterior

- removal of the posterior elements predisposes the patient to further postlaminectomy kyphosis.

- need decompression and fusion


> 50o

- brace early

- need anterior and posterior fusion

- may even need brace post surgery

- if have myelopathy symptoms may also need decompression



- in dystrophic







Osteogenesis Imperfecta



Spinal deformities are found in 20% to 80% of patients with OI


Risk factors


Severe disease with nonambulatory status




Scoliosis in OI may progress after skeletal maturity 

- may be related to weakened osteoporotic bone 




Non operative




Poor results

- risk of rib fractures




Posterior segmental instrumentation / arthrodesis 


A progressive curve that has reached 35 - 40o should be fused

- regardless of the patient's age

- significant correction cannot be expected


Augmentation with segmental sublaminar wiring

- to improve purchase in the osteoporotic bone


OI Scoliosis



Scoliosis Classification



Lateral curvature of the spine with coronal plane deformity > 10°




1.   Structual


Passively non-correctible deformity of a spinal segment 

- vertebral rotation at the apex


2.   Nonstructural (CHIPS)


Secondary or compensatory scoliosis

- no rotational component

- fully passively correctable to the midline









- leg length discrepancy

- hip flexion contracture



- teenage females

- no rotation or wedging on XR



- painful condition of spine

- fracture, tumour, infection



- childhood

- slight correctable curve

- disappears on recumbency



- irritation of nerve root by HNP or tumour

- secondary to paravertebral muscle spasm




Idiopathic  75%


Commences before skeletal maturity

- diagnosis of exclusion


No features to categorise it as 

- Congenital

- Neuromuscular

- Other 



- Infantile < 3

- Juvenile 3 - 10

- Adolescent 10+


Neuromuscular 10%



- UMN:  CP, FA, trauma

- LMN:  Polio, SMA, Spina Bifida 



- Muscular Dystrophy

- Myotonica


Congenital (10%)


Failure of Formation

- wedge vertebra

- hemivertebra


Failure of Segmentation

- unsegmented bar

- block vertebra





Other (5%) NAOMI




Skeletal dysplasias

- Achondroplasia


- Mucopolysaccharidoses

- Diastrophic Dwarfism


Osteogenesis Imperfecta


Collagen disorders

- Marfan's

- Ehlers Danlos


Traumatic - fractures, surgical


Infective - vertebral osteomyelitis





- rickets, juvenile osteoporosis, osteogenesis imperfecta


Tumour - osteoid osteoma




Incidence of curve >30° is 3/1000 in USA


Screening controversial

- cost vs benefit

- increases health costs by 20% vs late fusion for severe disease only

- if believe that bracing works, then should believe in screening before Peak Height Velocity to decrease severe scoloiosis

- if don't believe in bracing, treat scoliosis as it comes later

- it is debatable whether condition is common enough to merit screening


WHO 5 Features of Screening Programme

1. Condition should be important problem

2. NHx should be known

3. An acceptable screening test

4. Acceptable treatment available

5. Programme should be cost effective


Screening Methods


1. Adam's Test

- bend forward with arms free

- Interobserver error

- no threshold value


2. Inclinometer / most common

- assess angular rib hump

- 7° threshold

- will miss 12% 20° curve, but decreases referral rate to 3%

- less sensitive

- more specific




Spinal Dysraphism




Fibrous / cartilage / bony bar creating a longitudinal cleft in the cord




Mainly in lumbar spine / can occur in thoracic




Can lead to cord tethering with associated neurological defects




Hyperreflexia / clonus / asymmetric abdominal reflexes




Inter-pedicular widening / bony bar / spina bifida occulta




May see 2 hemicords

- each within a single dural sac

- each within their own dural sac


Conus Medullaris often extends below L2










Should be resected



Spina Bifida General Principles



1. Spinal dysraphism


Failure of the neural tube to close (i.e. spina bifida + failure of neural tube development)


May see one of 5 telltale skin defects 

- tail

- skin dimpling 

- sacral pit 

- hair tuft 

- lipoma 


Myelodysplasia: Any developmental defect of the spinal cord 


2. Spina Bifida Cystica


Vertebral laminae absent with prolapse of neural elements 


A.  Myeloschisis / Myelocoele

- neural plate material spread out over the surface (most severe form)


B.  Myelomeningocoele

- prolapse of cord & dura in defect (commonest)


C.  Meningocele

- prolapse of dura only

- usually no neurological deficit 


3. Spina Bifida Occulta


Congenital spinal disorder where the two halves of posterior arches fail to fuse leading to bony abnormality

- defect is hidden 

- may have diastematomyelia 

- seen in 5-10% of radiographs in normal population 

- not really related to spina bifida cystica and probably not prevented by folate




1 / 1000 live births 

- varies with geographic location 

- Ireland, England, Wales - 5/1000

- Australia & USA 1/1000


1:20 with one affected sibling 

1:10 with second affected sibling


Girls > boys 




Multifactorial nature 

- polygenic inheritance with teratogenic enviromental factors 


Decreased RBC folate associated with increased risk 

- avoid folate antagonists

- folate taken prior to conception reduces rate of spina bifida by 70%

- need to take before first month of pregnancy

- 0.4 mg per day normally

- 4mg per day if have a previous child with SBC




Early problem 26th gestational day (24-28)


Two theories

A. Failure of neural tube to close  

B.  Initially closed tube which reopens due increased intraluminal pressure


The latter theory is favoured & explains other defects such as diastematomyelia etc


Prenatal Screening


Should be able to detect 90% fetus with an exposed neural defect

- small skin covered defects may be missed


Maternal alphafetoprotein increased 

- test at 16-20 weeks

- detects 90% of spina bifida

- will justify other investigations

- amniocentesis (spontaneous abortion risk 1:200)



- vaginal at 10-12 weeks will identify anencephaly & some spina bifida

- standard 16-18 weeks identify anencephaly & 80% spina bifida


Management of early detection

- deliver by C section to avoid contamination by vaginal flora

- secondary infection which then can lead to loss of level





- without repair nearly 100% will die

- especially in pre-antibiotic day

- increase survival to 50% at 25 years

- antibiotics / selective closure / shunting



- not static & there is often a decline during childhood especially first 4 years

- 60% have neurological deficiency in upper limb

- this is due to syrinx / Arnold Chiari / hydrocephalus



- only 30% are functionally independent as adults

- only 30% will have full or part-time jobs

- 65% will have normal intelligence



- 100% if L1 or L2 or higher

- 80% if L3, L4, L5


Modified Asher & Olson Classification


Lowest level at which Grade 3 power is available i.e. antigravity power


Thoracic: no grade 3 strength in lower leg muscles

L2: hip flexion

L3:      knee extension

L4:      knee flexion

L5:      ankle dorsiflexion

Sacral: ankle plantarflexion


i.e. L4 and below are most likely to walk


Clinical Features


1. Hydrocephalus 


Incidence 90% 

- of these 80% will require shunt

- inserted at time of the defect closure


IQ normal if no hydrocephalus 


Must constantly be on lookout for blocked shunt 

- deteriorating neurological function

- bulging fontanelle

- poor muscle function


2. Hydromyelia / Syringomelia / Syrinx 


Incidence 50%

- related to hydrocephalus 

- fourth ventricle communicates with the central canal of cord 

- increased hydrocephalus pushes fluid into cord 


Leads to

- increased lower limb paralysis & back pain

- progressive scoliosis

- weak upper extremities with increased tone


Usually settles with V-P shunt 


May need drainage prior to spinal procedure 


3. Arnold - Chiari Malformation: (Type II in 90%)


Displacement of medulla into cervical canal

- cerebellar tonsils herniated below foramen magnum on MRI



- periodic apnea 

- stridor 

- weak / absent cry

- nystagmus 

- upper extremity spasm & weakness 


May resolve with shunt / if not then surgically decompress 


4. Tethered Cord    


Attachment of cord to meningocoele sac 

- prevents normal upward migration of the cord during growth

- almost universal to some degree


Only small number have symptoms

- buttock & posterior thigh pain 

- increased spasticity & weakness in lower extremities 

- progressive scoliosis the classic presentation is progressive 

- cavus foot deformity in young child 

- rapid deterioration in quadriceps power in teenager


Surgical release will halt progression but not restore function


5. Urinary Complications


One of major causes of morbidity & mortality in childhood from renal failure



- incontinence 

- hydronephrosis 

- recurrent UTI



- intermittent catheterisation 

- bladder augmentation


6. Skin anaesthesia


Pressure sores major problem with casts

- hip spicas should always include feet


7. Latex Allergy


IgE mediated


Should always provide latex free operating environment 

- assume allergy and prevent development


Can screen with RAST (radioallergosorbent test) / skin test / IgE assay

- IgE assay most sensitive & specific


8. Fractures


Classic exam scenario / clinical photo

- supracondylar femoral fracture is commonest


Often present late 

- picture of infection (redness, swelling, warmth)


Treat with removable splints for short time as get very stiff


9. Upper Extremity Function


60% have abnormality of UL function

- usually weakness with increased tone


Risk factors

- high level

- multiple shunt revisions (ie cerebral damage from hydrocephalus)

- syrinx etc


10.  Orthopaedic Deformity 



- muscle imbalance 2° to UMN or LMN lesion

- intrauterine posture

- habitual posture after birth

- congenital malformation (eg club foot)

- arthrogryposis



- scoliosis

- hip FFD / Dislocation

- Knee hyperextension / flexion contracture / valgus

- teratological CTEV 

- cavus foot

- charcot foot

- ulceration






1.  Ambulation

- level dependent


2. Hips

- reduce hips if unilateral / low level / walk

- different to CP as not painful


3. Foot 

- keep shoeable & plantigrade 

- even if in wheelchair

- avoids ulcers and amputation


4.  Spine

- 80% develop scoliosis


5.  Prevent pressure areas


Always manage in spina bifida clinic


Muscle charting 

- should start 24 hours after birth


1/3 Complete LMN & loss of sensation & bowel control below affected level 


1/3 Complete lesion at some level but distal segment of cord preserved 

- mixed picture of intact DTR & spasticity 


1/3 Incomplete & some movement & sensation preserved 




L1 Level



- iliopsoas grade 2 or better / some weak hip flexion



- Hip flexed, abducted & ER



- HKAFO - hip knee ankle foot orthosis

- RGO - reciprocating gait orthosis, when one hip flexes the other extends

- adults usually wheelchair bound 


L2 Level



- iliopsoas, sartorius & adductors grade 3 or better

- hip flexion & some adduction



- hip flexed and adduction 

- FFD of hip may develop 



- most ambulate as children in HKAFO

- FFD may need to be corrected first 

- adults usually choose wheelchair 


L3 Level



- quadriceps grade 3



- hip flexed & adducted

- knee extended 

- Hip subluxation & dislocation common due to unopposed hip adduction & flexion 



- usually household ambulators 

- grade 4 quadriceps - 80% community ambulators / 98% household ambulators 

- grade 3 quadriceps -  need KAFO to walk & 88% in wheelchair 

- patients with quads & good abductors can ambulate without aids 


L4 Level  



- medial hamstring grade 3

- Tibialis anterior 3 or better

- quadriceps grade 5



- hip flexed & adducted

- knee extended

- ankle in varus due to T anterior



- walk in AFO 


Surgery often required to maintain hip & knee extension / foot plantigrade


L5 Level



- lateral hamstrings >=3

- G medius >=2

- T posterior >=3



- calcaneovalgus or calcaneus foot 

- need T anterior to T Achilles transfer age 3 to prevents foot drop gait



- 95% community ambulators throughout life 


Sacral Level 



- Gastroc/Soleus >/=2 

- G medius >/=3

- G maximus >/=3



- clawing of toes & cavus foot from intrinsic minus



- usually brace free but may need special shoes 

- ie arch supports


At high risk of heel ulcers due to foot imbalance / calcaneus / nil S1 protective sensation





Spina Bifida Levels




- no hip flexion

- no voluntary leg movement



- no ambulation

- hip flexed and ER

- feet equinovarus





- grade 2 psoas



- no ambulation

- hip adducted and flexed

- feet equinovarus





- grade 3 psoas



- hip adducted / flexed

- knee flexed

- feet equinovarus





- grade 3 quads



- hip adducted and flexed / highest risk hip dislocation

- household ambulator only with KAFO

- knee recurvatum / no hamstrings

- foot equinovarus





- > grade 3 quads

- medial hamstrings

- tibialis anterior grade 3




- hip adducted / flexed

- reasonable ambulation with AFO

- knee extended

- foot cavovarus





- lateral hamstrings

- grade 3 abductors



- hip flexed but not adducted

- community ambulator in AFO

- calcaneocavus foot





- grade 3 power T achilles



- claw toes, poor sensation

- still get calcaneus as weak T Achilles





Spina Bifida Management

Closure of defect


Selection of patients for closure of the defect is controversial 

- if not treated most die of meningitis

- remainder have early closure - 50%

- closure of defect within 24 hours with VP shunt insertion

- early closure & shunting survival is 50% at 25 years


Most centres avoid urgent operation if

- level above L1 

- severe deformity 

- marked hydrocephalus 


Principles Orthopedic Management / Menelaus


1. Always manage in Spina Bifida clinic 

2. Select surgery appropriate to future demands 

3. Perform minimal surgery 

4. Condense management 

5. Correct muscle imbalance 

6. Consider absent sensation / bone fragility / infection 

7. Minimise immobilisation time to prevent bone loss & pathological fractures

8. Promote walking to

- allow normal bone development 

- prevent contractures

- psychological advantages

9. Surgery is soft tissue releases and tendon transfers 

10. All surgery at one sitting / SEML

11. Wait until 12 months

- spinal level & deformity evident & assessable

- most shunt & closure problems sorted 


Potential walkers are likely to need more sophisticated surgery


Ambulation Requirements

- extended hips & knees 

- plantigrade feet 

- straight spine

- strong quadriceps as general rule

- strong abductors / if no hip abductors usually need crutches or stick)


Sitting Requirements

- flexed knees 

- feet that are shoeable & placeable in wheelchair 

- straight spine - releases the hands for other activities other than truncal support





- hip dislocation does not alter level of mobility only neurosegmental level does

- a painless dislocated hip is preferable to a stiff, painful, reduced hip

- reduction is dealt with as for DDH hip


Indications / Menelaus


1.  Non walkers

- no quadriceps & bilateral - never 

- no quadriceps & unilateral - sometimes 

- usually doesn't affect ability to sit in wheelchair


2.  Walkers

- quadriceps and bilateral - sometimes 

- strong quadriceps & unilateral - always 




1.  Sharrard procedure 

- soft tissue procedure to prevent and reduce hip dislocation

- transfer psoas to GT / adductor tenotomy

- limited benefit and can compromise walking

- iliopsoas is the major driver of walking


2.  Girdlestone's procedure

- rarely done in spina bifida as not painful

- indicated for painful, arthritic subluxed or dislocated hips

- combine with valgising osteotomy / Schanz


3.  Osteotomy age 1 year 

- varus shortening osteotomy of femur 

- pelvic osteotomy if acetabular dysplasia present






Walker (L3 or better)

- aim for extended knee that is braceable 

- extended knee is stable position 


Non walker

- need knee flexion for wheelchair use


Extension Contracture 


May interfere with walking 

- serial casting best 

- if fails then V-Y quads lengthening 


Flexion Contracture


Hamstrings are usually not tight

- more common with CP

- check popliteal angle in HE/HF




1.  Posterior capsulotomy and gastrocnemius releases 


2.  Anterior hemiepiphysiodesis with Stephens 8 plates

- treat FFD with hyperextension


3.  Extension distal femoral osteotomy

- near skeletal maturity with large FFD


Ankles & Feet




1. Majority have deformity

- 50% equinovarus / CTEV like 

- 20% calcaneus / L5 level

- 20% normal 

- 10% planovalgus, equinovalgus, cavus & claw toes 


2. Aim for braceable plantigrade foot 

- almost all require a brace 


3.  Multiple deformites seen

- very difficult to predict the deformity

- not just due to the muscle imbalance

- can be abnormal secondary to hydrocephalus, tethered cord etc

- may be a mixture of upper and lower cord signs

- due to lesions at various levels / cerebral from ICP / high or low spinal lesions


Equinovarus / CTEV like


Varies from flexible to very rigid 


Splintage & casting initially 

- is not the same as CTEV

- the tendons etc are not just tight

- there is a muscle imbalance


All require OT / PMR at 6 - 12 months

- high risk recurrence

- may be better to resect 1 - 2 cm of tendon



- talectomy 

- triple arthrodesis near skeletal maturity




L5 level most common 


Causes heel ulcers


Surgery at 3 years

1.  Divide the EDL, EHL  +/- anterior AKJ capsule release

2.  Transfer Tibialis Anterior to heel if normal & no tendo achilles function 


>6 years

- deformity osseous

- posterior displacement osteotomy calcaneum


>10 years

- triple arthrodesis for severe deformity




Usually less problem than varus 

- can be managed often with AFO

- may occurs in Ankle or Subtalar joint



- Cobey view

- assesses alignment of AKJ & STJ in weight bearing

- can see where malalignment is


Lateral tilt of ankle in mortise 

- TA to fibular tenodesis - in young child causes overgrowth of fibula due to increased blood supply

- 8 plates medially/ guided growth if sufficient growth remaining  (< 6 years of age)

- supramalleolar osteotomy with medial closing wedge if teenager


Subtalar joint

- Grice arthrodesis

- calcaneal siding osteotomy

- lateral calcaneal lengthening

- triple arthrodesis 




Pressure effects major problem 



- plantar release / metatarsal osteotomies / calcaneal osteotomy  / Jones procedure / claw toe management

- if close to maturity & significant deformity then look at Triple Arthrodesis 




< 2% of children with spina bifida

- manage as per all CVT


External Rotation of Tibia


Commonly associated with valgus ankle 


Requires supramalleolar osteotomy > 8 years of age if severe




Most common skeletal abnormality 80%

- more common in high lesions 




1. Congenital

- congenital spinal deformity 


2. Neuromuscular

- paralysis with nstability of posterior elements 


3. Neurological

- hydrosyringomyelia / malfunction of VP shunt

- tethered cord 



- temporary measure to delay fusion to allow trunk height development 

- pressure sore problems 




Indications for intervention

- failure of orthotic management to maintain curves <45°

- severely affected children will have to support trunk with upper limbs

- makes walking & sitting very difficult


Anterior release & fusion 

- posterior elements usually very deficient & not suitable for bone graft

- posterior approach may be difficult exposure due to previous sacral repair & skin flap




Specific problem in spine in spina bifida



- difficulty sitting in wheelchair 

- ulceration over kyphos 

- breathing difficulties 



- excision of kyphosis & osteotomy of spine 

- excision of distal cord (roll up procedure)

- may need extensive anterior release & full length fusion to pelvis (loss of correction is common)




Usually corrected by FFD / hip correction




Spinal Dysraphism



Spina Bifida is a congenital disorder in which the 2 halves of posterior vertebral arch fail to fuse


Dysraphism is maldevelopment of neural tube and skin


Cutaneous signs


Tuft of hair

Pigmented naevus

Scarred area

Post midline dimple / sinus






Cord tethering


Cysts or lipoma of cord


Arnold Chiari Malformation

- distal tethering may cause herniation of brain stem / cerebellum obstructing CSF flow




10-30% of population

- 25% no cutaneous stigmata

- clinically significant dysraphism is rare




Germ cell problem

- can get deformity in all three germ cell lines


1.  Somatic Ectoderm 

- cutaneous dysplasia

- hairy patch, naevus, dermal sinus


2.  Mesoderm

- vertebral dysplasia

- split in spinous process and laminal defects


3.  Neuroectodermal

- neural tube

- myelodysplasia, intramedullary and extramedullary growths associated with dysraphia


Commonest forms



- spinal cord / filum terminale / both

- split sagittally by bony or fibrocartilaginous septum


Lumbosacral lipoma


Meningocele manque 

- loop of nerve root or trunk becomes adherent to dura

- then returns to cord or cauda close to origin


Arachnoid / Dermoid cyst


Tethered Cord

- tight filum terminale leading to tethered cord

- conus at level of coccyx in fetus

- upper border of L3 at birth

- upper border L2 by 5 years




Clinical Presentation


Vast majority asymptomatic


Any age from birth to maturity with

- short, wasted leg

- small foot

- cavovarus deformity

- paralytic valgus foot deformity

- trophic ulceration




Hemihypertrophy or hemiatrophy if small limb






Investigation of choice < 6 /12 presenting with midline lumbar dermal anomalies





- varying degrees of spina bifida

- vertebral anomalies








Recognise the condition and arrest any further neurological deterioration

- MRI spine

- If find tethered cord etc needs neurosurgical opinion on whether release of cord worthwhile


Address foot deformity along typical lines once neurological deformity stabilised









Progressive and  chronic disorder associated with cord cavitation & gliosis




Muscle wasting

Dissociate anaesthesia


Neuropathic arthropathy




M > F

No familial tendency




1. Idiopathic


2. Hindbrain Herniation / Arnold- Chiari Malformation

- abnormal pressure & circulation of CSF


3. Post-Traumatic

- occurs in 3%

- ? due to subarachnoid block 2° to adhesive arachnoiditis

- more common in complete tetraplegics

- delayed presentation of deterioration

- 3/12 - 30 years


4. Arachnoiditis

5. Intramedullary Tumour

6. Extrinsic Compression With central cord necrosis

7. Necrotic Myelitis


Arnoldi-Chiari Malformation 


Congenital abnormality of Cerebellar Tonsils 

- herniation of medullary tonsils through foramen magnum into cervical canal

- block CSF flow through foramen Lushka & Malgagne blocked

- often need AV shunt


Type I  

- communicating


Arnold Chiari Type 1 MRI


Type II  

- non communicating

- usually larger and associated with spina bifida


Arnold Chiari Malformation with syrinx




Cord damage

- anterior dissection of cavity with interruption of decussating spinothalamic fibres

- effects pain & temperature 

- extension into lateral corticospinal tracts 


Most common in lower C Spine

- may progressively extend up to medulla & down to lumbar 

- fluid-filled tubular cavity

- separate from but usually communicating with central canal


Spastic Paraparesis

- involvement of 2° order neurones


Pain with causalgia




Dissociative sensory loss

Spastic paraparesis

Neuropathic joints especially GHJ

Scoliosis as syrinx is irritative

- scoliosis not due to muscle imbalance as neurology most commonly normal




Cystic space

- lined by thick layer of glial tissue

- gliosis with tendency to infiltrate white matter




Craniovertebral anomalies





Cause of deterioration in Spina Bifida


Shunt malformation

Arnold Chiari

Cord Tether


Neuroenteric cyst



Clinical Features


Classic Triad


1.  Dissociate sensory loss in cape distribution

- loss of pain and temperature

- preservation of light touch (dorsal columns) 

- arms and trunk with cervical

- legs with lumbar


2.  Muscle wasting / weakness with diminished reflexes 

- in UL due to direct pressure on anterior horn cells


3.  Atypical high thoracic kyphoscoliosis


Site of syrinx


1.  Cervico-Thoracic

- dissociate sensory loss in arms & trunk

- weakness & wasting of arms

- absent abdominal reflexes


Syrinx Thoracic MRI SagittalSyrinx Thoracic MRI Axial


2.  Lumbar

- dissociate lumbosacral sensory loss

- weakness & wasting of legs & pelvic girdle

- diminished reflexes / Babinski negative

- impaired bowel & bladder function


3.  Cervico-Medullary 

- AKA syringobulbia

- palatal & vocal paralysis / dysarthria

- nystagmus / dizziness / tongue weakness


Cervicomedullary Syrinx 1Cervicomedullary Syrinx 2Cervicomedullary Syrinx 3





Base of skull




Most sensitive investigation

- main differential is oedema

- need T1 image


Look for obstructions


- spinal cord tumours




Amyotrophic Lateral Sclerosis / Motor Neurone Disease


Cervical Myelopathy

Thoracic Outlet Syndrome

Klippel-Feil Syndrome

Cord Tumour

Brainstem Infarct


Operative Management




Rapid progression of neurology

Short History

Respiratory compromise

Pseudobulbar Palsy

Pre-spinal corrective surgery





- Syringo-Cisternal

- Syringo-Peritoneal


Suboccipital decompression & C1-2 laminectomy


Orthopaedic Implications


Neuropathic Joints


Syrinx is most common cause of UL charcot joint

- shoulder

- elbow

- hot swollen joint may be first presentation of syrinx



- infection

- peripheral neuropathy - DM / Leprosy / Tabes dorsalis




Scoliosis is usually 1° Presentation of syrinx

- curve is idiopathic type

- often left sided thoracic

- corresponds with level of syrinx


Males > Females

- 25% if < 10 year old

- 20% males with scoliosis have syrinx compared with 2% of girls


Neurological deficit usually subtle or absent

- axillary sensation absent

- absent abdominal reflexes



- must correct syrinx first

- malignant progression if syrinx untreated

- cyst rupture during scoliosis surgery may be fatal

- progresses like idiopathic once syrinx treated




Tethered Cord



Conus medullaris below L2 / tethered

- unable to move freely with movement / growth




Thickened filum terminale (> 2mm at L5/S1)

Intradural lipoma



Surgery to close myelomeningocoele

- almost all will have signs of tethered cord at site of surgery




Stretches and damages the cord as child grows

- neurology

- pain

- difficulty walking

- foot deformity


Rapid progression of scoliosis




80 - 90% of children will have cutaneous manifestation






Open surgical release



- child

- neurological symptoms

- progressive scoliosis










Spinal Fractures

Cervical spine Fractures





- < 1% children's fractures


< 7

- upper cervical

- craniocervical junction


> 7

- lower C spine predominate




Very big heads

- will flex neck on spinal board

- need bump under T spine or

- cut out for head




Beware distracting injuries

- cannot clear C spine clinically



- normal mental state

- no distracting injuries

- not intoxicated

- able to adequately communicate

- no neck pain or tenderness

- Full ROM






Soft tissue swelling

- unreliable in crying child


Paeds C spine

- not well cleared by X ray

- much of cervical spine cartilaginous

- CT invaluable


Normal findings


C2/3 pseudosubluxation

- up to 4 mm

- common / seen in 40% < 8 years old

- reduced in extension

- Swischuk's line:  posterior arch C1 - C3, C2 shoulde be within 1.5 mm


ADI > 3 mm in 20% children


Vertebral bodies classically wedged





- may not need sedation


Essential for C0-2 if intubated

- include in any child having CT head


Will pick up vast majority of unstable fractures




Show disruption of endplate / disc junction

Ligamentous injuries





Spinal cord injury without radiographic abnormality

- C spine very flexible

- traction injury with normal X-ray

- usually upper C spine < 8


Immature C spine can stretch 5 cm without fracture

- spinal cord ruptures with 5 mm traction

- it is less elastic and tethered


Must be aware of possibility especially with GCS <3


Management of obtunded patient

- unable to clear C spine

- Aspen collar will cause pressure areas / increase ICP

- MRI within 12 hours


Upper C spine Fractures




< 8

- mobile neck

- ligamentous laxity

- shallow facets

- big head


Usually falls and MVA





- 3 primary

- body and two arches

- fuse age 7



- 4 primary

- body, 2 arches, dens

- dens fuses age 6

- summit ossification appears 3-6, fuses 12




1.  Os ondontoid


Thought to be related to previous trauma

- can give C1 / 2 instability


2.  C0/1 dislocation


Terrible injury

- quadriplegia

- can be fatal



- Basion axial / Basion Dens interval

- each less than 12 mm


Powers ratio

- tip of basion to posterior arch (BP)

- tip of opisthon to anterior arch (AO)

- BP / AO

- > 1 anterior dislocation

- < 1 posterior dislocation


3.  Ondontoid Fractures



- occurs at the synchondrosis

- intact anterior periosteal sleeve



- MVA deceleration injury



- neurological defects rare



- anterior displacement



- reduce with extension and application HTB

- 50% apposition required

- non union rare


Lower C spine




Neurocentral synchondroses fuse 3-6

Bodies wedge shaped until become square at 7

Superior / inferior cartilage end plates attached to disc




Fractures occur between cartilaginous end plate and vertebral body

- between hypertrophic and calcified zones


Thoracic spine fracture



- protected by rib cage



- MVA, falls

- osteopenia ( OI, chemo, leukaemia)


Fracture / dislocations / Chance fractures


High energy

- usually TL junction

- lap belt injuries

- high association with intra-abdominal injuries


Apophyseal ring injuries





Tibial Bowing

Posteromedial Bowing

Clinical picture


At birth

- short tibia

- calcaneovalgus foot

- foot often lies with dorsum against anterior leg

- most bow in distal 1/2




Probably caused by intrauterine fracture or malposition




Calcaneus foot

- triceps surae weakness

- extension contracture of ankle

- anisomelia


Long term


1.  LLD may persist

- remains proportional 

- tend to have static LLD 2cm 



- epiphysiodesis other side


2.  Bowing 

- usually completely resolves 

- varus 6° may persist

- resolution starts at 1 year



- consider osteotomy if at 3 years if progressive or severe deformity / bow not corrected









Tibial Bowing DDx

Four forms


Different consequences predictable by direction of bow


1.  Lateral bowing

- normal variant during first year of life

- usually resolves spontaneously


2.  Posteromedial Bowing

- benign

- packaging defect


3.  Anteromedial Bowing

- fibular hemimelia


4. Anterolateral Bowing

- tibial pseudoarthrosis

- tibial hemimelia




Tibial Pseudoarthrosis



Anterolateral bowing


True bone dysplasia

- hamartomatous area in the tibia

- non union or potential non union through pathological fracture in this region


The defect in the bone is filled with mature, fibrous connective tissue

- not really a pseudoarthrosis

- by definition, a pseudarthrosis has a cleft lined by fibrocartilage containing fluid and bounded by a capsule

- the name is so firmly embedded in the literature that it is retained





- 1:200 000


M = F


50% have NF type 1

- 1-3% of NF have CPT




Cause unknown


Theories include

- intrauterine fracture

- localised vascular abnormality




Hamartomatous cuff present at site of lesion site

Even with NF, no clear histological evidence that fibrous tissue is NF


Crawford Classification


Type I: Non-dysplastic

- anterolateral bowing

- thickened sclerotic cortex


Type II: Dysplastic


IIA Anterolateral bowing

- wide medullary canal

- failure of tubularisation


IIB Cyst +/- Fracture


IIC Frank pseudarthrosis

- atrophied ends




Type 1:  Congenital anterior bowing

- defect present in tibia on x-ray

- rare


Type II:  Congenital anterior bowing with hourglass constriction of tibia

- tapered, rounded & sclerotic

- medullary cavity non continuous on xray

- spontaneous fracture or 2° minor trauma usually < 2 years

- most common & worst prognosis


Type III:  Fracture develops at site of bone cyst


Type IV:  Sclerotic bony segment

- segment may produce complete or partial obliteration of medullary canal

- no narrowing of tibia

- fracture develops like stress fracture


Type VCongenitally dysplastic tibia

- mild bowing ± pseudarthrosis 


Type VIIntraosseous NF or Schwannoma

- ± Pseudarthrosis

- Very rare





- virtually all will fracture by 2 years

- therefore reasonable to prophylactically treat involved segment if has NF


Management Algorithm


No Fracture / Type I or IIA 


Corrective osteotomy contra-indicated

- wll not heal

- must excise hamartoma


Brace all

- KAFO in walking  child

- PTB in older child until skeletal maturity


Prophylactic surgery

- NF 

- discuss excision + graft + stabilisation


Fracture / Type II B&C 



- won't heal non operatively

- treatment is surgical

- excise segment, graft & rod  / frame

- try to avoid until > 2 


Surgery timing

- controversial

- delay: shorter underdeveloped leg

- older patient: increased union rate

- brace till large enough or not controlled by AFO


Difficult surgery

- union difficult to achieve

- high refracture and recurrence rate

- increased with residual malalignment / provides an ongoing stress riser 

- failure of OT with graft resorption associated with amputation in 50%



- varies by type

- worse with tapering and sclerosis




Valgus deformity common

- sloping tibial epiphysis or fibular pseudoarthrosis

- can treat with guided growth


Surgical Options


1.  IM Rod


Several options 

- Sheffield / Fassier-Duval growing rod / Rush pin / Steinman pins

- use Steinmann pin, Rush nail or IM nail depending on size of patient & medullary canal



- anterior incision 

- excise hamartoma and sclerotic bone

- balance between bony resection & minimising LLD

- iliac bone graft

- stabilise with intra-medullary rod extending from calcaneum across STJ / AKJ into proximal tibial metaphysis

- with growth, rod migrates proximally & releases AKJ

- must graft & rod any co-existing fibular pseudarthrosis


Post operatively

- prolonged immobilisation

- spica cast for 6/12

- once united PTB till skeletal maturity

- rods left until skeletal maturity to avoid fracture




Vascularised Free Fibular Graft



- pseudarthrosis segment resected

- contralateral fibula as graft

- can use ipsilateral fibula if no pseudoarthrosis

- stability with external fixation



- valgus deformity of normal AKJ 2° overgrowth of distal tibial epiphysis

- distal fibula acts as tether 

- treat with tibia / fibula synostosis 

- avoid by using ipsilateral fibula

- only possible if fibula not involved


Ilizarov Technique



- pseudarthrosis resected


Bone transport

- 3-level ring fixator applied

- corticotomy of proximal metaphysis performed

- middle tibial segment moved distally 

- metaphyseal lengthening 

- pseudarthrosis compression / docking



- child > 5



- high rate of refracture after removal of frame


Electrical & US Stimulation


Independent use has unknown benefit 

- combine with graft / rod




"Should not be the operation of first resort or last resort"

- severe lesions with poor prognosis

- make early decision








1. Congenital Limb Deformity

- 60%

- rare for UL

- PFFD / Tibial Hemimelia


2. Tumours 


3. Trauma 

- 26%






Diaphyseal amputation removes one of physes

- progessive LLD




1. Preserve physis via disarticulation

2. Preserve as much bone length as possible




Terminal overgrowth of stump

- occurs when appositional growth of bone exceeds that of surrounding soft tissues

- may result in penetration of bone through skin

- occurs in 10%

- most common in humerus, fibula, tibia & femur



1. Stump revision with adequate resection of bone + myoplasty

2. Autogenous osteochondral stump capping 


Phantom Limb sensation


Always occurs in children

- < 10 years old settles rapidly

- not painful usually




Should coincide with normal motor skill development


Upper limb


Age 4-6 months

- when sitting balance required

- passive terminal device


Age 2-3 years

- add active cable control with voluntary terminal opening device

- when starts object manipulating with terminal device


Lower Limb


Age 8-12 months

- terminal device

- for AKA, add knee device when child walking well


Age 5-6 years

- more elaborate devices

- gait retraining







Child Abuse / Non Accidental Injury



Any act or failure to act that

- results in or potentially results in harm / death / physical / emotional / sexual abuse

- by a parent or caretaker who is responsible for the child


4 types



Physical (punch / kick / bite / burn / shake)




Risk factors


Low socioeconomic x25 risk


Single parent

Substance abuse

First child





Parents were abused


Birth parents more likely to abuse


50-80% substance abuse




Abuse second most common cause of death in infants 1-6/12

- SIDS number 1


85% death from child abuse < 5 years


10% trauma < 3 years from child abuse


1962 landmark paper from USA / Kempe

- battered child syndrome

- poor hygiene

- poor nutrition / failure to thrive

- ST / bone injuries

- subdural haematomas




Delay in presenting


History vague, lacking in detail, contradictory

- mechanism of injury insufficient to explain injuries

- history of a fall


Characteristics of child

- less than 3 years old

- poor household environment / drug / physical abuse

- overly aggressive or passive

- behavioral problems

- handicapped child

- stepchild

- premature child

- subnormal growth


Non orthopaedic findings



- bruises (buttocks, perineum and genitalia, trunk, back of head and legs)

- multiple bruises in various stages of healing

- burns (pattern may reflect mechanism of burn)


Head and CNS

- skull fracture (multiple, skull base, crossing suture lines, depressed fractures)

- subdural hematoma, subarachnoid hemorrhage

- retinal hemorrhage, hyphema, retinal detachment

- cognitive disabilities


Chest, abdomen, and pelvis

- rib fractures (posterior, multiple), sternal fractures

- pneumothorax, hemothorax

- rupture of organ (liver, spleen, or pancreas / bowel or bladder rupture)

- intramural bowel hematoma

- kidney contusion, retroperitoneal hemorrhage

- sexual abuse




Musculoskeletal system

- multiple fractures

- fractures in various stages of healing

- metaphyseal corner fracture (pathognomonic)

- femoral fracture in child < 1 (more likely than not)

- humeral shaft fracture child < 3 (almost always)

- vertebral compression fractures, spinous process avulsion

- scapular fracture

- epiphyseal separation




Any obvious injuries


Skeletal survey (< 5 years age)

- AP bilateral arms

- AP bilateral forearms

- AP bilateral hands

- AP bilateral thighs

- AP bilateral lower legs

- AP bilateral feet

- AP and lateral axial skeleton and trunk

- AP and lateral Skull


Bone Scan


Costly / difficult to evaluate / lacks specificity / radiation exposure




Accidental injury




Congenital syphilis


Caffey's disease

- infantile cortical hyperostosis

- < 5 months, fever, pain

- typically mandible

- xrays show hyperostosis

- get periostitis




Failure to Diagnose


30-50% recurrence of abuse

5-10% mortality risk


Reporting is mandatory


Team approach


Paediatrician / social worker / psychologist

General surgeon / Neurosurgeon / Orthopodedic Surgeon / Ophthalmologist / Dermatologist


Notify / discuss with

- primary care provider for background history

- police

- legal counsel

- social services

- child protective services


Hospital admission to treat acute injuries and remove child from dangerous environment


Carefully document all records

Statement regarding level of certainty of abuse


Legal consent still required to treat child or release information from chart

Court custody may be needed if family members not co-operative






Lower Limb Fractures

Ankle Fracture



Distal tibia

- appears by 2 years

- closed at maturity

- asymmetrical closure

- central initially, then posteromedial to anterolateral

- accounts for Tillaux and Triplanar fractures


Distal fibula

- appears by 2 years

- closes 2 years after distal tibia


Medial Malleolar Extension

- begins age 7

- closes age 10


Types of Fractures




SH III - medial malleolus / Tillaux





Salter Harris I


SH 1 Distal Fibula



- 15% of distal tibial physeal fractures



- through zone hypertrophy

- distal fibular most common



- operative if require realignment


Salter Harris II                                                


Paediatric Distal Tibia Salter Harris 2Distal Tibial SH2 AP




40% of distal tibial physeal fractures




Thurston-Holland fragment

- large metaphyseal component


Non operative Management


Acceptable distal tibial alignment

- short leg case 6 weeks


Operative Management


Unacceptable alignment

- attempt closed reduction

- sometimes anterior periosteum can block reduction

- anterior approach / remove periosteum / reduce fracture

- if unstable screws into Thurston Holland fracture

- if fragment too small need fixation across medial malleolus into metaphysis


Late presentation 7-10 days

- may be best left

- prevent damage physis

- later osteotomy if needed





- complete growth arrest


Angular deformity

- partial growth arrest

- uneven Harris growth lines


Salter Harris III / Medial Malleolus





2 problems

- articular disruption

- possible physeal bar




ORIF any > 2mm step

- physeal cannulated screws




Joint incongruity

Growth arrest


Salter Harris III / Tillaux


Tillaux Fracture CT Coronal Tillaux Fracture CT Sagittal



- SHIII of anterolateral distal tibia

- epiphyseal avulsion of AITFL

- supination / ER injury



- usually near skeletal maturity

- transitional fracture

- as distal tibial physis is closing

- anterolateral fragment is last to close


Tillaux Fracture ORIF





- reduce articular step / prevent physeal bar

- anterolateral incision to reduce

- either anterolateral 4 mm cannulated screw or

- place screw percutaneously from medial side


Salter Harris IV




- 25%

- usually associated with triplanar



- bony bar

- articular step




ORIF > 2 mm step

- restore articular surface

- reduce risk of bar


Triplanar Fracture



- fracture in coronal, sagittal and transverse planes

- 2, 3 or 4 part




2 part

- can be medial or lateral based of site of main distal fragment

- typically anterolateral epiphysis attached to posterior metaphysis

- anteromedial intact distal tibia


3 part

- additional separate anterolateral epiphysis / Tillaux


4 part

- additional separate metaphyseal fragment



- fracture extends into medial malleolus




Type III / Tillaux on AP

Type II on lateral




Type III on coronal

Type II on sagittal

3 point star on axial





- > 2mm displacement

- usually anterolateral approach to reduce

- epiphyseal medial-lateral screw

- metaphyseal AP screw




Growth arrest 10%


Salter Harris V


Usually late diagnosis

Growth arrest / LLD




Distal Femoral Physeal Injuries



1.  Undulating growth plate / higher rate of growth plate injury

- growth arrest / LLD

- angular deformity

- need to be warned

- require close and careful follow up especially in first 2 years


2.  Can be unstable / malunion and shortening very problematic in this area




Salter Harris I


Distal Femoral Fracture SH2 APDistal Femoral Fracture SH2 Lateral


Salter Harris II


SH2 Distal Femoral Fracture APSH2 Distal Femoral Fracture Lateral






Extension plaster 6 weeks






Low threshold to ORIF to maintain position

- already have high risk of growth arrest / LLD / angular deformity

- don't wish to deal with malunion / loss of position as well




Block to reduction

- often medial sided periosteum

- may need small medial subvastus / anteromedial approach




1.  Physeal sparing metaphyseal screw in SHII

- good option if Thurston-Holland fragment large enough


Distal Femur Salter Harris 2Distal Femur Salter Harris 2


Distal Femur SH2 ORIFDistal Femur SH2 ORIFDistal Femur SH2 Lateral


2.  Smooth transphyseal large K wires / Steinman pin


- SHII with small Thurston-Holland fragment




Complete growth arrest common


Monitor 6 monthly

- plot short and long leg lengths on Mosely chart

- distal femur contributes 9 mm / year


Manage LLD as per predicted difference

- usually contralateral femoral epiphysiodesis if < 5 mm

- may need femoral lengthening / ISKD on maturity if > 5 mm


Partial growth arrest / angular deformity


Moniter closely and investigate any possible growth arrest



- assess percentage of bony bridge


Bony bridge < 50%

- excision and fat graft

- manage angular deformity with 8 plates / osteotomy


Bony bridge > 50%

- hemi-epiphysiodesis

- may need correction of LLD and angular deformity

- opening wedge femoral osteotomy



Femoral Fractures


Paediatric femoral fracture


Varies per age group



- 60%


Non Accidental Injury

- 15 - 30%

- suspect if non walker / < 1 year

- walking status single best indicator of risk

- paediatric team to investigate

- history taking from parent

- consider metabolic investigations


Osteogenesis Imperfecta / Pathological fracture through cysts

- 10 %




Bimodal distribution

- peaks at 2-3 and 16-19 years

- younger group from falls

- older group from traffic accidents




Immediate management


Gallows traction


Child 0 - 2 years and < 12 kg


Gallows tractionGallows traction

Hamilton- Russell (90/90) traction

- skin traction on lower leg

- place padded sling behind knee to slightly flex




0 - 6 months

- Pavlik harness (neonates with fracture occuring during birth)

- spica


6 months - 4 years

- spica


5 years - 11 years

- length stable - flexible nails

- length unstable - plate (bridge or open)


> 12 years

- length stable - lateral entry nail or TENS (<50kg)

- length unstable - plate



- IMN (lateral or piriformis entry)


Polytrauma/ Soft tissue (any age)

Consider external fixator


Management 0 - 6 months



- difficult delivery

- Osteogenesis imperfecta

- Non accidental injury




A. Pavlik harness


B. Spica


Podeszwa et al. J Pediatr Orthop

- < 1 year child

- 24 in Pavlik compared with 16 in spica

- spica patients tended to be older and heavier

- no difference in outcomes

- 1/3 spica patients had a skin problem


Management 6 months - 4 years



- < 15o angulation in all planes

- < 2 cm shortening




1. Double leg spica

2. Single leg spica


Leu et al. JBJS Am 2012

- RCT of 52 pediatric femoral shaft fractures

- single v double leg

- all healed satisfactorily

- single leg more likely to fit into car seats / chairs


Flynn et al. JBJS Am 2011

- walking hip spica v traditional hip spica

- walking spica patients more likely to need wedge correction of mal-alignment


Paediatric Femur Fracture


Technique Hip spica



- abdo injury

- head injury (high spasticity)


Hip Spica TableHip Spica 1


Hip spica 2Hip spica 3



- under GA, on spica table (posterior thorax on post)

- apply stocking net over body and legs

- pressure pads over ASIS

- wool applied

- must have roll of wool over abdomen to give space to breath

- 90/90 sitting spica (knees 90o, hip 90o), hips 30o abduction, 15o ER


Check position under fluoroscopy

- accept <2 cm shortening

- 15o varus / valgus

- 20o flexion / extension

- 10o rotation



- one and one half leg: to knee on contralateral side, include ankle on ipsilateral side

- single-leg spica cast: to ankle on ipsilateral side, no inclusion of contralateral thigh


Post spiceacare

- weekly x-ray for 2 - 4 weeks to detect malalignment

- usually for 6 - 8 weeks depending on age


Postoperative care instructions from Queensland Health




Paediatric Femur Fracture Hip SpicaPaediatric Femur Fracture 1 monthPaediatric Femur Fracture 2 monthPaediatric Femur Fracture 6 monthsPaediatric Femur Fracture 1 year


Management 5 - 11 years


Immediate Management


Thomas Splint / Balanced Traction


Femoral Fracture Thomas Splint



- analgesia +/- sedation

- Thomas splint with 2 fingerbreadths diameter clearance around thigh

- cushioning for leg to sit in Thomas splint

- traction bed

- application skin traction to leg, tied to end of Thomas splint, traction by twisting paddlepop stick

- weight off end of Thomas over pulley at end of bed

- this pulls splint away from ischium and peroneum

- rope taken over 2 pulleys at top of bed with weight suspended to elevate Thomas splint from bed

- weight is tied to bed at top to prevent falling onto leg

- splint must be checked 2 x day to prevent pressure areas, needs regular oiling


Definitive management


1. Hip spica

2. Titanium elastic nails (length stable)

3. Plate (length unstable)


Hip spica v TENS


Iman et al Arch Bone Jt Surg 2018

- systematic review of 12 studies and 1012 patients

- patients 2 to 16 years

- hip spica v TENS

- reduced malalignment and faster independent walking with TENS


TENS v Plate


Luo et al. Orthop Surg 2019

- plate v TENS in 51 patients

- average union 2.2 months (range, 1 - 6 months)

- no LLD, rotational or angular deformity in any patient


Flexible nails / Titantium Elastic Nails



- length stable i.e simple transverse, short oblique, midshaft

- maximum weight up to 50 kg / 12 years old



- unstable fracture patterns

- > 50 kg


Pediatric Femoral Fracture SpiralPediatric Femoral Fracture Comminuted




Synthes surgical technique PDF



- 30 - 40% of diameter of diaphyseal medullary canal

- i.e. if canal 10 mm wide, use 2 x 4 mm

- 6 - 8 years (3 mm)

- 9 - 11 years (3.5 mm)

- 12 - 14 years (4 mm)

- recommend using 2 wires same diameter to avoid rotational instability

- 3 point bend in wires to get 3 point fixation

- aim for bend at fracture site


Entry points

- medial and lateral insertion

- 1 - 2 cm proximal to distal femoral physis

- oblique entry with awl in direction of nail insertion

- can open with drill bit

- beware proximity of the femoral artery medially

- entry points should be symmetrical


Wire passage

- bend wire for 3 point fixation

- also bend the tip of the wire

- can use F Tool to reduce fracture

- may need small incision and open reduction

- medial entry wire will pass into femoral neck

- lateral entry wire will pass into greater trochanter

- use designated TEN wire cutter to cut wires

- cut off, tap in slightly further, leave 1.5 cm out so can retrieve

- wires that are too prominent can cause bursa / limit flexion / pain / protrude through skin


Vumedi video


Acceptable alignment

- 10o varus / valgus

- 15o flexion / extension

- 15 mm shortening


Post op

- early mobilisation with crutches

- touch weight bearing

- begin full weight bearing with union (typically 6 - 8 weeks)

- remove TENS at 6 months




Narayanan et a. J Paediatr Orthop 2004

- reported on 79 patients treated with flexible nails

- pain and irritation at insertion site common

- malunion / loss of reduction assocatiated with nails of differing diameters and increased comminution


Titanium v stainless steel flexible nails


Mohamed et al. Europ J Orthop Surg Traumatol 2017

- systematic review of 5 papers

- mixed results

- no obvious difference in malunion or union rates





- length unstable fractures (spiral / comminuted)

- very distal or proximal fractures

- patient inability to non weight bear (cognitive impairment / developmental delay)




1. Open Plating


Paediatric Femoral Fracture Plate


2. Submuscular bridge plating


Bridge plating paediatric femur fracture



- supine on radiolucent table or traction table

- incision 5cm proximal or distal (depending # site)

- blunt dissection to periosteal layer

- run bristow or cobb elevator submuscularly

- 3.5 or 4.5mm LCP plate (depending on patient size and age)

- place plate submuscularly

- use stab incisions to place 3 screws above /below fracture

- sufficient spread



- TWB / PWB for 6/52 until union

- removal at 6/12




Abott et al. J Paediatr Orthop 2013

- comparison of open v submuscular bridge plating in 79 patients

- increased blood loss in open plating

- increased rotational asymmetry in bridge plating

- no other difference between two groups


External Fixation



open wounds as temporary stabiliser



- pin site infection

- malunion

- refracture post removal


Management 12 years and over




1. Less potential to remodel (especially > 10)

2. Usually too heavy for flexible nails

3. Risk of AVN with standard nails




MacNeil et al. J Paediatr Orthop 2011

- systematic review of risk of AVN after used of rigid locking nails

- piriformis fossa AVN rate 2%

- tip greater trochanter AVN rate 1.4%

- lateral entry / trans-trochanter AVN rate 0%


Acceptable alignment


Varus / valgus 5o

Flexion / extension 10o

Shortening 1 cm




1. Flexible nails

- < 50 kg


2. Plate



- very safe option

- avoid growth plates



- incidence of refracture with plate removal


3.  Antegrade Lateral Entry Trans-trochanteric Femoral Nail


Keeler et al. J Paediatr Orthop 2009

- 80 femoral fractures treated with lateral entry femoral nails

- no AVN

- no malunion or nonunion


Synthes surgical technique PDF


4.  External Fixation


Management > 15 years old


Standard antegrade nail 

- safe

- no risk of AVN


Subtrochanteric fractures




Non operative treatment rarely indicated in older children as acceptable alignment hard to maintain

- TENS technically more difficult




Plate v TENS


Xu et al. Medicine 2018 PDF

- no difference in outcome between plate and TENS

- plate patients tended to be older and heavier


Neck of Femur Fractures



11-18 years




Usually severe trauma




Head 5-6 months (1)

GT 2-5 years    (5)

LT 9-13 years  (9)


Delbert Classification


Type 1

- transepiphyseal separation / fracture

- rarest

- associated with hip dislocation

- AVN 100%


Type 2

- transcervical fracture

- commonest 50%

- AVN 50%


Type 3

- basicervical

- second most common 30%

- AVN 30%


Type 4

- intertrochanteric fracture

- AVN 10%




Type I 




Rare situation

- spica

- watch carefully for displacement



- would like to stabilise

- any fixation must cross physis






Anatomical reduction

- single closed attempt

- open / Watson Jones approach



- < 3 years K wires

- > 3 years cannulated screws crossing physis


Spica post op < 10 years old


Type II 




Hip spica

- need to watch carefull




Anatomical reduction

- closed + capsulotomy

- open



- < 3 years K wires crossing physis

- > 3 cannulated screws crossing physis


Spica post op < 10 years


Type III




Hip spica v ORIF

- displacement a risk

- can leave fixation short of physis




Closed reduction

- < 3 years K wires

- > 3 cannulated screws / pediatic hip screw


Spica post op < 10 years


Type IV 




Hip spica v ORIF

- displacement a risk

- can leave fixation short of physis


Paediatric Intertrochanteric Hip FracturePaediatric Intertrochanteric NOF ORIF




Closed reduction

- < 3 K wires

- > 3 pediatric hip screw


Spica post op < 10 years






Urgent decompression of hematoma

- no real evidence




- bisphosphonates

- hinged articulated distracting external fixators


Non-union ~13%


Increased with non operative management


Treat with valgising osteotomy +/- BG


Growth Arrest / LLD 


Contra-lateral distal femoral epiphysiodesis


Coxa Vara


Valgising subtrochanteric osteotomy






Paediatric Hip Dislocations



Very rare


Associated Injuries


SH type 1 femoral epiphysis most common


Paediatric Hip Dislocation




Closed Reduction


Assess concentric reduction

Assess stability

Apply spica / traction for 2 weeks

Imaging to ensure no fracture fragments


Open Reduction



- displaced femoral epiphysis



- anterior approach / digastric osteotomy

- reduce eiphysis and neck

- long screw crossing physis




Nirmal et al Arch Orthop Trauma Surg 2009

- 5 cases, 2 with redislocation

- recommended extreme caution post operatively in children < 10 years





Patella Fracture



3 - 5 years old





- manage in plaster in extension


Displaced > 3 mm



Patella sleeve fracture

- usually small inferior fragment seen on xray

- patella high riding on xray / alta

- is actually large cartilaginous fragment avulsed with retinaculum

- can be osteochondral

- patient unable to SLR

- confirm on MRI

- requires ORIF




Pelvic Fractures



Bones more elastic and malleable

- absorb much more energy


Very thick periosteum

- can be periosteal sleeve fracture




Triradiate cartilage fuses 13-16


Iliac / Ilium / ASIS apophysis

- appear as teenager

- fuse a couple of years later

- can confuse with fracture


Classification Key & Conwell 1951


1. No break in continuity of pelvic ring

A. Avulsion fractures

        1. ASIS

        2. AIIS

        3. Ischial Tuberosity

B. Fracture of pubis or ileum

C. Fractured wing of ileum

D. Fracture sacrum or coccyx


2. Single break in ring

A. Fracture of 2 ipsilateral pubic rami

B. Fracture near or subluxation of symphysis pubis

C. Fracture near or subluxation of SIJ


3. Double break in ring

A. Double vertical fractures or dislocation of pubis (straddle fracture)

B. Double vertical fractures or dislocation (Malgaigne fracture)

C. Severe multiple fractures


4. Fracture of acetabulum

A. Small fragment associated with dislocation of hip

B. Linear fracture associated with non-displaced pelvic fracture

C. Linear fracture associated with hip joint instability

D. Fracture secondary to central dislocation


Torode Classification


1.  Avulsion fracture

2.  Pelvic wing

3.  Stable pelvic fracture

4.  Unstable pelvic fracture


Associated Injuries Rang 1983




Haematuria 30%

Urological / bladder 10%

Abdominal injury 11%

Perineal or gluteal lacerations 7%


Vascular injuries much more rare than in adults




Head 61%

Chest 9%

Upper extremity fracture 17%

Lower Extremity fracture 17%


Mortality rate  8%


Death usually not a direct result of pelvic fracture

- rather is due to associated injuries i.e. head injury






Vaginal and rectal examination


Neurological and vascular examination




Avulsion Fractures


Tensor fascia lata, sartorius, RF, Psoas, Hamstrings

- rarely require treatment


Pubic fractures


Exclude genito-urinary injury


Unilateral Fractures

- stable 

- mobilise with crutches

- weight bear as tolerated

- usually 3-4 weeks


Bilateral Fractures



- if associated with posterior ring or sacral fracture

- potentially unstable

- usually doesn't need ORIF

- heals quickly with bed rest



- treat as Adult 

- ORIF where appropriate


Pubic Symphysis Diastasis



- urological injury

- posterior ring injury



- heals with periosteal sleeve

- if wide should close with external fixator

- if remains widened child walks with ER deformity


Acetabular Fractures


Triradiate fractures

- uncommon

- usually from extension of adjacent rami and iliac fracture

- usually stable



- child < 10

- early closure triradiate cartilage

- acetabular dysplasia




Tri-radiate fracture

- skeletal traction

- CT

- if severely displaced fragment ORIF with smooth pins


Physeal bar across triradiate cartilage

- follow up all displaced & non displaced

- consider bony bidge excision and fat graft


Vertical Shear Fractures



- associated visceral injuries

- blood loss is substantial and should be replaced

- is rare for child to die of blood loss from pelvis compared with adults



- 6 weeks of skeletal traction

- rarely need external fixator



- LLD usually < 2 cm

- contralateral hemi-epiphysiodesis





Tibial Fractures

Displaced Tibial Shaft Fractures


Acceptable reduction

- varus / valgus < 5o

- anterior / posterior < 5o

- rotation 5o

- shortening 10 mm


Poor remodelling potential

- valgus 

- apex posterior angulation  / recurvatum

- rotational alignment does not remodel

- shortening / in 2-10 year old average overgrowth is only 5mm





- leg hanging over edge of bed

- gravity assists reduction

- apply short leg cast

- check II


Apply long leg cast in 45° knee flexion

- helps control unstable fractures

- prevents early weight bearing


Plantar flexion ankle

- mild plantar flexion for first 2-3 weeks to prevent posterior angulation

- 20° plantar flexion for middle & distal third

- 10° plantar flexion for proximal third


Need to observe position for first 3 weeks


Time in cast

- neonates 2-3 weeks

- juveniles 4-6 weeks

- adolescents 8-12 weeks


Toddler's Fracture


Toddlers Fracture Tibia




Undisplaced oblique fracture of distal tibia

- usually innocuous injury





- diagnosis aided by bone scan

- shows diffuse uptake throughout the tibia in fracture

- infection will tend to produce focal increased uptake




Heal rapidly 

- can be treated in short leg weight bearing cast for 4 weeks


Open Fractures


Treated along the same principles as adult compound fractures


Buckley et al (1994)

- 42 cases

- average time to union 5 months (range 2-21)

- 4 patients had > 1 cm overgrowth

- 3 infections (7%) all resolved



- first generation cephalosporin for Grade I & II

- add Gentamicin for Grade III injuries

- add Penicillin for farm yard & lawn mower injuries 


Compartment Syndrome 

- as for adults

- measure compartment pressures in ventilated or severely head injured children



- Grade I  - reduced +/- percutaneous pinning, long leg cast once wound closed

- Grade II & III - external fixation



- indications for primary amputations not clear in children 

- accepted indication for primary amputation is open tibia

- + avascular leg with posterior tibial nerve injury and insensate foot

- MESS Score useful predictor of amputation


Proximal Metaphyseal Tibial Fracture / Cozen's Fracture


Paediatric Proximal Tibial Fracture



- may develop long term valgus alignment

- due to medial epiphyseal overgrowth / periosteum medially




Any displacement


- extension long leg cast with varus mould


Management of valgus


A.  < 10 years with < 15o

- will usually remodel


B.  > 10 years with > 15o

- consider operative intervention

- guided growth plates





Tibial Tubercle Fractures



Adolescent boys




Proximal tibia / primary ossification centre


Tibial tuberosity / secondary ossification centre

- eventually merges with primary ossification centre


Ogden Classification


Type I - Tibial tuberosity ossification only


Tibial Tubercle Avulsion Type 1


Type II - Extends into proximal tibial ossification centre / non articular


Type II - Extends into articular surface of proximal tibial ossification centre






Compartment syndrome


Popliteal artery injury


Associated extensor mechanism disruption

- suggest ultrasound




Cast in extension for 6 - 8 weeks




Indicated in type I and II +/- type III


Extend knee

- often require sedation + analgesia

- assess reduction in cast





- type I & II displaced > 5 mm

- residual recurvatum

- type III / intra-articular extension



- open reduction + AP cancellous screws through tibial tuberosity




Mosier et al J Paediatr Orthop 2004

- 19 fractures

- majority from athletics / mainly basketball

- 4 reduced and immobilised, remainder required ORIF

- 3 patients had associated extensor mechanism disruption

- 2 patella tendon avulsions and 1 quadriceps tendon




Compartment syndrome



Poor Remodelling


Midshaft angulation

Older > 11 years

Large angulation > 20-30o

Rotational deformity

Intra-articular deformity

Angulation perpendicular to plane of joint motion


Good remodelling


> 2 years growth remaining

Fractures near end of bone

Angulation in plane of joint motion




Salter Harris



Buckle or Torus fracture

- metaphyseal-diaphyseal junction

- compression fracture

- compression side has undergone plastic deformation


Greenstick Fracture

- diaphyseal injury

- failure tension side

- plastic deformity compression side


Greenstick Fracture APGreenstick Fracture Lateral


Plastic Deformity

- microscopic failure

- forearm and fibula




Primary ossification centres

- diaphyseal


Secondary ossification centres

- epiphyseal


Physeal Anatomy


Reserve Zone

- few cells, high matrix

- cells from Groove of Ranvier

- cells quiescent


Proliferative Zone

- cellular proliferation / mitosis

- columns of cells

- longitudinal growth

- metaphyseal side


Hypertrophic zone


A.  Maturation

- enlarged, swollen, vacuolated


B.  Degeneration

- increase Alk Phos

- increases phosphate for calcification


C. Provisional calcification

- ECM calcify

- cell death


Perichondral Ring of La Croix & Groove of Ranvier


Surround the physis circumferentially at its periphery


Groove - resting and proliferating cells


Ring - cartilage cells that move towards the metaphysis and become contigous with periosteum


Salter Harris Classification


Salter Harris Classification


I.  Whole epiphysis is separated from shaft


II. Fracture through metaphysis and physis


III. Separation of part of the  epiphysis

- fracture through physis and epiphysis


IV. Fracture passes vertically through epiphysis / physis / metaphysis


Salter Harris IV Toe


V. Crushing of part or all of the epiphysis


Physeal fractures


Thought to occur primarily through hypertrophic zone


Reserve zone injury

- increased growth arrest with proximal tibia and distal femur

- because of undulating course of physis

- more likely damage to germinal or resting layers




Do not remanipulate physeal injuries > 7-10 days

- risk injury

- exception type 3/4 

- in these anatomical reduction more important


Metaphyseal / diaphyseal

- can MUA up to 3 weeks after



Upper Limb Fracture

Distal Radial Fractures

IncidenceDistal Radius Fracture


Metaphyseal > physeal / SH2






Operative Management




Visible deformity

> 20o angulation





MUA + K wire stabilisation


Indications K wire


Remanipulation of metaphyseal fracture


Associated with supracondylar fracture




Avoid physis if able in metaphyseal fracture

- dorsal Kapaji technique

- can use this technique laterally


Mercer Rang Remodelling Rules


Best if

- young age (won't remodel much if > 11 years)

- short distance from fracture to physis

- direction of angulation in plane of motion of joint


Won't correct rotation


Rang distal radius remodelling

- < 5      - 25-35° 

- 4 - 9    - 20-25

- 10-12   - < 15°


Rotational malalignment 

- best way to determine proximally is radial tuberosity 

- prominent towards the ulna with supination and disappears with pronation

- at same time radial styloid distal will be prominent with supination




Never for physeal injuries

Up to 3/52 for metaphyseal injuries




Growth arrest



- around 1%

- need to warn parents to represent if child develops angular deformity


Do not MUA or repeat MUA after 1 week

- only reinjure growth plate

- will remodel extremely well

- if severe, simply plan for osteotomy later if required


Physeal injuries distal ulna

- high incidence of growth arrest


Metaphyseal Radius

- incidence growth arrest also 1%


Distal Radius Growth Arrest Original InjuryDistal Radius Growth Arrest K wire


Distal Radius Growth ArrestDistal Radius Growth Arrest






Centres of Ossification

Age of appearance in girls


C (capitellum)               1

R (radiua)                     3

I  (internal epicondyle)   5

T  (trochlea)                  7

O  (olecranon)               9

E  (external epicondyle) 11


Boys: 2 years later in every centre except capitellum




14 - 15 in girls

15 - 18 in boys

Distal Humeral Physeal Separation



Children < 6

- entire distal humerus physis is displaced




Distal Humerus Physis SeparationDistal Humerus Physeal Separation 2


Distal physis not ossified < 1 year

- may be a difficult diagnosis


Radius and ulna lose normal association with distal humerus

- appears like an elbow dislocation

- disruption of radio-capitellar line









MUA + cross K wires



Lateral Condyle Fractures



Average age 6 years


20% distal humeral fracture

- second most common elbow fracture after supracondylar




Pull Off 

- more common 

- fracture begins posterolateral metaphysis

- LCL, ECRL & ECRB attached to fragment


Push off

- varus force to extended EJ






Milch I 

- SH IV through capitello-trochlear groove

- lateral wall of trochlear still attached to shaft

- elbow stable


Push off

- fracture line crosses ossification centre capitellum

- tend to physis arrest

- tend to be stable


Milch II

- SH II into trochlear notch

- lateral wall of trochlear goes with distal fragment


Pull Off

- tend to be unstable

- may be difficult to interpret on Xray


Displacement ~ Wadsworth


Stage I -   Minimally displaced with articular surface intact

Stage II -  Displaced

Stage III - Fragment rotated


Clinical Features


Age 6 

History fall

Lateral pain






- typically metaphyseal flake

- looks minimally displaced on AP and lateral

- perform an internal oblique x-ray to exclude displacement


Lateral Condyle Paeds UndisplacedLateral condyle paeds undisplaced 2



- obvious






Non operative





- rare

- check with internal oblique xray

- splint in neutral

- watch with serial xray +++




Surgical indications


1.  Unstable

- Milch 2


2.  Displaced

- > 2 mm




1.  Closed reduction


Not usually done

- fracture is intra-articular

- want to reduce under direct vision



- reduce by extension / pronation / varus

- pronation uses flexor mass to pull lateral condyle forward


2.  Open reduction


Lateral approach distal humerus

- between BR / ECRL and triceps

- distally can extend limited amount between ECRL and ECRB

- don't dissect posteriorly to protect blood supply

- don't need to dissect distal fragment

- anterior homan to elevate anterior capsule

- can see across distal joint line and perform anatomical reduction under vision

- one K wire horizontal across fracture into trochlea

- one K wire up lateral column

- bury K wires as need to be in for 6 weeks


Post op

- very real risk of non union

- elbow in POP for 6 weeks

- don't remove K wires until obvious union

- do so usually in OT


Late Presentation


Presentation after 2-3 weeks




1. Reduction and ORIF

- documented risk AVN / Physeal Arrest

- exact incidence / risk is unknown

- best option if fragment is displaced and mobile

- may do up to 6 weeks to 6 months

- controversial


2.  Bone graft and screw in situ

- later osteotomy as required




Generally do poorly compared to supracondylar fractures



- intra-articular fracture

- transphyseal fracture

- inherently unstable

- tenuous blood supply (AVN)

- synovial fluid in fracture site (non union)

- often need ORIF - more scarring


1.  Non-Union



- poor vascularity

- synovial fluid

- muscle pull



- leave wires and immobilisation for 6/52





- plain film oblique view

- collar like projection of posterolateral metaphysis attached to physis that hasn't united

- delayed union if present at 5/52

- non-union if present at 3/12





- pain

- loss of ROM

- cubitus valgus

- tardy ulna nerve palsy





- high rate of failure of attempted fixation 


1.  Non displaced non union

- POP til 3/12 mark

- then graft metaphyseal non-union + screw


2.  Displaced non-union

A.  Reduce / graft / screw

- though to be acceptable if < 6 months and fragment mobile

B.  Graft in situ & screw

- later osteotomy for malunion


2.  Cubitus Varus


2° overgrowth lateral condyle

- common problem

- little cosmetic or functional problem


3.   Malunion


Milch II malunion

- varising & lateral translation osteotomy


Milch I malunion

- varising osteotomy


4.  Fishtail Deformity



- 2° Trochlear AVN

- central growth arrest



- usually of little consequence / no need for treatment

- can lead to OA


Trochlea AVN


5.  Cubitus Valgus and Tardy Ulnar Nerve Palsy


Average 22 years later

- from AVN / nonunion / physeal arrest / malunion

- 47% associated with lateral condylar fracture



- anterior transposition nerve

- varus osteotomy will not help nerve


6. MO




Little League Elbow



Medial epicondyle physeal injury




Overthrowing / valgus overload






Medial epicondylar epicondylitis / apophysitis

- traction / fragmentation


Medial epicondylar separation


UCL injury


Capitellum osteochondritis dissecans





Limit pitch counts




Medial Epicondyle / Condyle Fracture

Medial Epicondyle




Apophysis appears around 7 years

Ossifies age 16 years


Normal apophysis may be some distance from shaft

- rarely may be fragmented




Elbow Dislocation Medial Epicondyle Fracture



Valgus deformity


Operative Indications



- entrapped in joint

- ulnar nerve injury

- elbow dislocation




Medial Epicondyle Fracture


Displacement > 5mm 

- good outcomes reported up to 10 mm

- clinically have some valgus instability

- non significant to most patients

- may be significant in the throwing athlete


Farsetti JBJS Am 2001

- 42 patients with displacment > 5 mm

- average age 12 years

- half treated in long arm cast, half ORIF

- no difference in outcome

- poor outcome with fragment excision and ligament reattachment

- in nonoperative group all but two had nonunion radiographically


Entrapped in joint



- secondary to dislocation which has self reduced




< 5 with dislocation

- medial epicondyle not visible

- may be entrapped in joint

- suspect if decreased ROM / pain / non congruent reduction

- can try arthrogram

- may nee open exploration of joint




Can attempt MUA

- valgus and extend wrist to tighten flexor origin

- rarely works


Usually require open reduction + K wire







- usually supine with arm table

- can place patient prone which makes fragment very easy to reduce


Medial incision

- find and protect ulna nerve


Reduce fragment anatomically

- ORIF with K wires or screw


Medial Condyle Fracture





- can be difficult to diagnose

- trochlea may not be ossified

- looks like medial epicondyle injury




ORIF if displaced > 2 mm

- intra-articular fracture

- may require MRI




Nonunion / cubitus varus

Trochlea AVN

Medial overgrowth / cubitus valgus



Paediatric Monteggia APPaediatric Monteggia Lateral




Fracture / plastic malformation of proximal ulna with dislocation of radial head




Radio-capitellar line disrupted


Bado Classification


By position Radial Head



Type I 60%


Monteggia Fracture Anterior


Radial head anterior

- associated with PIN palsy

- immobilize in flexion and supination

- remember in pronation tend to sublux both DRUJ & PRUJ


Type II 15%


Radial head posterior

- associated with ulna nerve palsy

- immobilize in extension and pronation

- commonest in adults


Type III 20%


Radial head lateral

- immobilize in flexion and supination


Type IV 5%


Anterior with radial shaft fracture






MUA Anterior Monteggia

- reduce ulna

- traction with posterior pressure on radial head

- maintain in supination


Unable to reduce radial head

A.  Ensure ulna fracture out to length / stabilise with K wire

B.  Plastic deformity of ulna / may need to perform osteotomy to reduce radial head

C.  May require open approach to radial head with relocation / repair annular ligament

D.  Radial head remains unstable- stabilise with strip of triceps fascia


Late presentation


Open reduction

- principles as above

- may need osteotomy or lengthening




PIN palsy

- from original injury

- will usually recover



- late operation


Radio-ulna synostosis

- fractures at same level



Pulled Elbow



Radial head subluxation




Average 2 - 3 years

- rare > 7

- annular ligament has better attachment after 5

- common, but exact incidence unknown




Axial traction with extended elbow 

- annular ligament subluxes off radial head

- more common with ligament laxity




History axial traction

Snap sometimes heard




Limb in extension & pronation 

- pain on supination




Tender over radial head




Usually normal

- mild increase radio-capitellar line > 3mm




May show increase radio-capitellar distance between elbows

- > 3 mm difference suggestive of subluxation






Pronation tends to sublux both DRUJ & PRUJ

Hence stabilise in Supination




Supination + Flexion 


Mild analgesia

- warn parents

- painful cry then relief


Feel for snap 

- classically immediate pain relief 

- child will use arm immediately


If subluxed for > 12/24 often 2° synovitis has developed

- pain relief not dramatic 

- may not have snap

- place in sling & review next day

- will often self reduce




1.  Unreduced subluxations 


No series reports any long-term sequelae in which the subluxation is not recognized & reduced

Almost all the subluxations reduce spontaneously


2.  Recurrent subluxations 


5% to 39%

- usually respond to the same MUA as the initial injury

- ceases after 5 years of age


3.  Irreducible subluxations 


Open reduction is rarely necessary

- delineate from radial head dislocation which need reduction

- MRI if unreduced after 2/52







Radial Neck Fracture

MechanismPaediatric Radial Neck Fracture



- valgus injury

- don't get radial head fracture as is mostly cartilaginous




SH 1 or 2


Associated Injuries


MCL injury

Olecranon / Medial epicondyle fracture


Non operative




Normal valgus neck is 15o


< 30o angulation acceptable / will remodel


> 30o - risk radiocapitellar OA


Operative Options



- rotate arm to maximum displacement

- use thumb to reduce


K-wire joy stick

- pronate arm to protect PIN

- insert into fracture site

- try to lever fracture into position

- then drive into opposite cortex



- may need open reduction

- then stabilise with K wires



Supracondylar Fracture

MechanismSupracondylar Grade 3 Compound






Age 6 as maximum ligamentous laxity

- < 4 - physeal separation

- > 8 - dislocation


Male > F




Supracondylar region in 6 year old is thin

- thinnest at olecranon fossa (2-3 mm)

- thin lateral & medial columns 


Children also tend to hyperextend at the elbows due to increased ligamentous laxity


With increasing hyperextension, the anterior periosteum hinge is torn








S Shaped arm which is very swollen


Pucker sign

- anterior spike impales brachialis to skin


Nerve examination


1.  Median nerve

- sensation


2.  Anterior interosseous nerve (AIN)

- make circle with index and thumb

- check FPL and FDP index finger

- most common injury


3.  Posterior interosseous nerve (PIN)

- thumb up


4.  Ulna nerve

- cross fingers / spread fingers / sensation


5.  Radial nerve

- decreased sensation first dorsal webspace




Flexion type 2%


Supracondylar Flexion Type


Extension type 98%


Supracondylar Grade 2


Gartland Classification Extension Fractures


Gartland I   Undisplaced

- < 2 mm

- anterior and posterior cortices intact


Gartland 1 supracondylarGartland 2 Supracondylar


Gartland II  Displaced with intact posterior cortex

- > 2 mm

- anterior humeral line passess anterior to capitellum

- posterior periosteum is intact


Supracondylar Grade 2


Gartland III  Displaced, nil cortical contact

- completely displaced

- posteromedial or posterolateral


Supracondylar Grade 3


Gartland IV


Complete periosteal disruption

Extremely unstable at surgery in both flexion and extension planes


Modified by Wilkins


Type IIB Rotated


Gartland IIB Gartland 2B


Type IIIA Posteromedial



- distal fragment goes posteromedial

- cause cubitus varus

- injures radial nerve which is tethered over lateral spike on proximal fragment

- manage by pronation which tightens medial periosteal hinge


Type IIIB Posterolateral


Distal fragment goes posterolateral

- causes cubitus valgus

- tend to ER

- injuries median nerve & brachial artery

- these get tethered over medial spike on proximal fragment

- manage by supination which tightens lateral periosteal hinge 


Lateral Xray


Position for good lateral

- thumb vertical

- hand above elbow


Anterior angulation

- shaft - condylar axis

- normally 40o




Anterior Humeral LineRadiohumeral Line


Anterior humeral line (AHL)

- should pass through middle of capitellum


Radio-capitellar line

- pass through capitellum



- shadow above the capitellum

- anterior dense line: posterior margin of the coronoid fossa

- posterior dense line: anterior margin of the olecranon fossa

- inferior portion: ossification center of the capitellum


AP X-ray


AP elbow paediatricsBaumanns angle paediatric elbow


Baumann's Angle



- angle between longitudinal axis humerus and capitellar physis

- should equal uninjured side

- 75o normal


Cubitus varus

- varus malposition  > 81° 


Cubitus valgus

- < 70o




Free review articles




There is limited remodelling potential of the distal elbow after the age of 4

After age 8 - 10, only 10% of growth of humerus remains




Type 1


Cast / collar and cuff

- flex up to splint with triceps

- 3/52


Type 2A


Closed reduction

- anterior humeral line doesn't contact capitellum

- Baumann's angle > 800 (cubitus varus)

- immobilise in flexion

- careful watching for late displacement


Ojeaga et al. J Paediatr Orthop 2020

- 77 type IIa patients

- 77% successfully treated with closed reduction and cast


Roberts et al. J Paediatr Orthop 2018

- compared collar and cuff / flexion taping with cast in 39 patients

- no difference


Type 2B


Any rotatation

- MUA + K wire


Type III


MUA + K wire


Flexion type


Timing of surgery


Takeaway message

- earlier surgery is probably technically easier due to swelling

- surgery can be difficult

- don't do in the middle of the night unless emergency / vascular compromise


Loizou et al. Injury 2009

- systematic review of 5 non randomized retrospective studies

- 396 patients

- increased failure of closed reduction with conversion to open reduction with surgery performed > 12 hours


Farrow et al. Bone Joint J 2018

- meta-analysis showed no difference between early and delayed surgery


Pauci et al. J Orthop Trauma 2018

- increased incidence malunion in surgery performed after midnight

- fractures treated after midnight tended to be more severe


Surgical technique



- lateral K wires

- crossed K wires


Dekker et al. Injury 2016

- systematic review and meta-analysis

- 11 studies (RCTs and prospective cohorts)

- 1158 patients

- loss of reduction in 11.6% of crossed K wires and 12.4% of lateral K wires

- iatrogenic ulna nerve injury in 4% crossed K wires and 0.3% lateral K wires


Carrazzone et al. J Should Elbow Surg 2021

- meta-analysis of 12 RCTs

- no difference in functional outcome

- reduced risk of iatrogenic nerve injury with lateral K wires

- greater fixation stability and less loss or reduction with crossed K wires


Closed reduction and K wire technique


Vumedi video


Set up


On arm table


Manipulation technique (must have adequate reduction, or very unstable and cannot K wire)


1.  Consider milking any soft tissues that may be trapped (pucker sign)


2.  In line traction at 30o

- 2 minutes to overcome soft tissues

- check fluoroscopy


3.  Reduce translation / rotation / varus and valgus

- adjust carrying angle / Baumann's angle

- avoid medial impaction / cubitus varus

- supination - maximise the traction on the lateral ligments to disimpact lateral side

- pronation - maximise traction on the medial ligaments to disimpact medial side

- check fluoroscopy


4.  Flexion pushing olecranon forward with thumb

- shoot through AP to assess reduction

- check Baumann's angle

- check medial and lateral columns with oblique views


5.  Hand position (point thumb towards side of impaction)

- posteromedial displacement - hyperpronation in flexion

- posterolateral displacement - hypersupination in flexion


6.  Check lateral image

- lock elbow in flexion and rotation

- externally rotate the shoulder

- ensure that the anterior humeral line is correct

- reduction of teardrop on lateral

- may need to increase the flexion


Bony landmarks


In extension

- medial / lateral epicondyle and olecranon all in a line


In flexion

- medial / lateral epicondyle with olecranon from equilateral triangle


2 x lateral K wires


Supracondylar Lateral K wiresSupracondylar Lateral K Wires



- no risk to ulna nerve



- if not correctly done, can be unstable



- hold elbow in flexion

- place K wire into lateral condyle

- place other index finger on the humerus to guide aim

- 2 x lateral 1.6 mm K wires (consider 2 mm K wires)

- one K wire on the direct lateral surface, just lateral to the capitellum

- one on the capitellar surface



- must engage medial and lateral columns (bicortical)

- make pins divergent for increased stability

- only need 3rd pin if first two not divergent enough


Check stability

- place elbow into extension


2.  Crossed K wires 1.6mm


Supracondylar fracture cross K wires



- increased biomechanical strength

- maybe necessary with signification medial comminunation



- ulnar nerve at risk


Small medial open approach

- place arm in external rotation

- place local anaesthetic with adrenaline to decrease bleeding

- mini open approach over medial epicondyle

- dissect down onto the hard medial epicondyle

- identify the common flexor origin to confirm

- K wire directly onto bone

- may need to extend elbow to 90o as in some children the ulna nerve subluxes anteriorly in flexion

- K wire must aim posterior to anterior as medial epicondyle is posterior



- wires must cross above the level of the fracture

- engage medial and lateral cortices


3. Technical issues


1. Significant medial comminution

- cross K wires


2. Unstable with excessive flexion

- cross table lateral

- place bump under humerus

- reduce flexion

- may need cross K wires


3.  Ipsilateral distal radius fracture

- MUA and K wire the distal radius first


Post operative


Check pulse (use doppler if needed)

Bend and leave K wires protruding


Remove K wires at 3 weeks


Irreducible supracondylar


Vumedi video



- brachialis might be trapped

- brachial artery might be in fracture




Supracondylar Open


Sterile tourniquet


Anterior approach

- identify biceps tendon laterally

- identify and tag the median nerve medially

- identify and tage the brachial artery and two venae commitantes between biceps tendon and median nerve

- release soft tissue especially carefully release lacertus

- safest over the median nerve

- open and clean fracture spikes both medially and laterally

- remove any brachialis and periosteum that might block reduction

- perform open fracture reduction with finger

- flex arm and check flouroscopy


Pulseless supracondylar




1.  Pulseless but pink and perfused on presentation


Make vascular surgeons aware


Urgent closed reduction + K wire

- position at 90o

- ensure pulse returns

- observe closely


Louahem et al. Injury 2016

- 42/60 patients had pulse return immediately after closed reduction and pinning


3. Pink and well perfused after reduction, no pulse


The pulse will return in virtually all patients

- some however on surgical exploration or doppler will be shown to have significant vascular injury

- pulse returns eventually due to collaterals

- patients typically do well regardless


Recommend close observation

- consider exploration if no waveform on pulse oximeter

- consider doppler ultrasound


Weller et al. JBJS Am 2013

- 1297 supracondylar fractures

- 20 with pink hand, doppler pulse but non palpable pulse after reduction

- all observed closely

- 19/20 pulse returned by discharge or by first post op visit

- 1/20 developed white hand 9 hours post surgery, and needed urgent vascular repair


Louahem et al. Injury 2016

- 18 patients with pink pulseless hands had a delayed pulse return up to 11 days later


Scannell et al. JBJS Am 2013

- long term follow up on 20 patients with perfused pulseless hand after closed reduced

- all 20 had palpable pulse

- 5/20 had brachial artery occlusion with large collateral vessels on doppler ultrasound

- all patients had normal growth and excellend function


Soh et al. Clin Orthop Surg 2013

- 26 patients with pink and perfused

- pulse oximeter used

- 4/26 no waveform on pulse oximeter, all had vascular injury

- 22/26 had wave on pulse oximeter, pulse subsequently returned in all


Noaman et al. Microsurgery 2006

- 31 patients with no pulse explored

- all 31 had significant vascular findings including traumatic aneurysm and transection


2. Hand white, non perfused, no pulse on doppler after reduction


Surgical emergency

- vascular surgeon

- lazy S approach


Weller et al. JBJS Am 2013

- 1297 supracondylars

- 5 patients with white hand and no pulse

- all 5 underwent either primary repair or saphenous vein graft


4. Pulse present before surgery, no pulse & hand white after closed reduction


Brachial artery entrapped in fracture

- anterior lazy S approach

- expose and release brachial artery

- open reduction and K wire


Too swollen / skin abraded 


1.  Skin traction

- arm straight

- weight over pulley

- body weight counter traction


2.  Dunlop traction

- screw in olecranon

- bent arm traction

- difficult to control rotation




Nerve Injury 


Anterior interosseous nerve (AIN)


Most commonly injured


Indications for exploration

- post reduction nerve injury with non anatomical reduction

- open injury


Barrett et al. JBJS Am 2014

- 35 cases of supracondylar fracture with isolated AIN injury

- all patients had complete return of AIN at mean 49 days (range, 2 - 224 days)


Median / ulna nerve / radial nerve


Ulna nerve

- associated with flexion type supracondylar fractures

- can be injured during medial K wire


Median nerve

- more often injured with severe fractures

- can be injured with lateral K wires


Compartment Syndrome


Extremely rare, case reports only

However, must moniter overnight as the results of missed acute compartment syndrome are devastating


Barrett et al. JBJS Am 2014

- 4400 cases of operatively treated supracondylar fracture

- no patient development compartment syndrome


Volkmann's contractures

- permanent flexion of the wrist and hand

- caused by shortening of the flexor muscles of the forearm






Sagittal plane deformity will remodel

Coronal plane deformity & rotation will not


Cubitus Varus 


Cubitus Varus post supracondylarCubitus Varus


Most common deformity

- mainly cosmetic problem

- can also be due to medial growth arrest



- correct with closing wedge osteotomy


Solfelt et al. Bone Joint J 2014

- systematic review of 894 children treated for cubitus varus

- mean correction 27o

- 88% good or excellent results

- nerve palsy in 2.5%, although the majority were transient


Takagi et al. JBJS Am 2010

- compared coronal plane osteotomy only with multiplane osteotomy

- 86 elbows with cubitus varus

- more loss of correction with multiplane osteotomy


JBJS Essential Surgical Techniques


Cubitus Valgus  



- may cause tardy ulna nerve palsy

- manage by transposing nerve


Cubitus valgus




Myositis ossificans uncommon 

- may be secondary to remanipulation > 1/52 / later presentation


Stiffness usually minimal

- takes up to 1 year to regain full motion

- especially extension


AVN Trochlear 




Produces fishtail deformity

- deepening of trocheal groove

- DDx: trochlear AVN / central growth arrest / non reduced intercondylar fracture

- can be associated with early degenerative changes

- could consider epiphysiodesis of remaining growth plates, but usually well tolerated


Paediatric Elbow Trochlea Avascular Necrosis

Forearm Fractures




- 8 / 52 gestation radius & ulna



- distal radius age 1

- distal ulna age 5


Non Operative Management


Unacceptable Position


< 10:  > 15o malalignment

> 10:  > 10o malalignment


Postreduction Positionin / Rule of Thirds 


1.  Fracture proximal to insertion of Pronator teres


Proximal fragment supinated by biceps

- supinate the forearm

- match proximal fragment 


2. Fracture in the middle 1/3  


Midposition / neutral

- biceps / pronator teres balanced


3. Fracture in the distal 1/3


Proximal fragment pronated by Teres

- pronation is the position of choice




Usually lose more pronation than supination

- pronation can be compensated for with shoulder abduction

- supination loss less easy to compensate for


Operative Management


Options for displaced fractures


1.  MUA



- young patients < 10

- greenstick fractures


2.  Compression Plating


Gold standard

- careful protection of PIN proximally



- rigid, anatomical fixation



- increased scarring

- risk of complications with plate removal

- infection / nerve injury / refracture


3.  TENS Nails



- smaller scars with insertion

- easier to remove than plates

- reduced risk of refracture post plate removal



- non anatomical reduction c.f. plates

- theoretical risk of loss supination / pronation

- ? avoid > 11 - 12

- associated with tendon rupture due to prominence of nails at insertion sites


TENS nails technique


Distal radial entry

- avoid physis / proximal to physis

- skin incision

- blunt dissection to protect SRN

- entry with awl obliquely

- pass nail (preop measure diameter)

- may need small open reduction of radius

- ensures anatomical reduction

- pass nail

- leave slightly short, cut, then insert further

- need to leave some nail protruding to aid removal


Proximal ulna radial sided entry

- avoid ulna nerve

- avoid olecranon apophysis

- similar technique

- often don't need to open if do radius first


Remove nails

- once out of plaster - 6 weeks

- avoid tendon rupture distally





Proximal Humeral Fractures

TypesPaeds Shoulder Fracture


Age 0 - 5

- Salter Harris I


Age 5 - 11

- Salter Harris II


III / IV rare




Great remodelling potential

- 80% growth of humerus from proximal physis


Shoulder ROM compensatory



- even older adolescents do well


Growth Plate Closure


Females 14 - 17

Males 16 - 18


Neer-Horwitz Classification


Type I

- < 5 mm displacement


Paed SNOH Fracture Type 1Paed SNOH Type 1


Type II

- < 1/3rd shaft width


 Paediatric Shoulder Fracture SH 2


Type III

- 1/3 - 2/3rd shaft width


Paed SNOH Type 3Paed SNOH Type 3


Type IV

- > 2/3rd shaft width


Paediatric SNOH Off Ended




Nonoperative Management




Amount of remodelling potential

- patient greater than 11 may risk shortening and loss of abduction


Case:  16 year old boy


Pediatric Proximal Humeral Fracture Remodelling PrePediatric Proximal Humeral Fracture Remodelling Post


Case:  18 year old boy


Pediatric Proximal Humeral Fracture 2 Pediatric Proximal Humeral Fracture Remodelling 2




Age                           Acceptable alignment


< 5                            Up to 70° angulation, 100% displacement

5-12                          Up to 40–70° angulation

< 12                          Up to 40° angulation, 50% displacement


Operative Management




1.  MUA

- displacement rates up to 80%


Paediatric SNOH Pre MUAPaediatric Shoulder Post MUA


2.  MUA + percutaneous pinning

- K wires from metaphysis into head

- +/- K wire from GT down into metaphysis

- axillary nerve at risk


Paediatric Shoulder K wiresPaediatric Shoulder K wire Lateral


3.  MUA + TENS



- 2 x drill holes in lateral supracondylar ridge

- pass 2 x TENS

- standard 0.4 of diameter of bone

- usually 2.5 mm

- radial nerve at risk


Rajan et al J Child Orthop 2008

- 14 cases

- average age 12.5

- good results


Proximal Humerus TENS


4.  Open reduction

- failure of closed reduction

- biceps / periosteum may become entrapped

- deltopectoral approach

- protect blood supply / ascending branch medial circumflex humeral


Upper Limb

Amniotic Bands



Deep skin crease encircling digit




1: 15 000




? Due to amniotic adhesions formed after haemorrhage in the distal rays


40% associated with other congenital hand abnormality


Streeter's syndrome

- hand and feet amniotic bands


Patterson Classification


1.  Simple Ring

- transversely around limb


2.  Deep Ring

- deformity, associated with lymphoedema of distal part


3.  Acrosyndactyly

- fingers formed, then bands form constriction

- proximal fingers open, distal closed


3.  Intrauterine amputations

- usually distal

- usually central fingers




Simple incomplete bands




Vascular compromise with complete bands




Release via multiple Z plasties

- bands with distal lymphoedema

- if band deep may need to be released as staged procedure



- excise a 1- 2 mm margin of normal skin and subcutaneous tissue to minimize the risk of recurrence

- resect all constricted fascia and muscle

- identify and protect neurovascular structures

- debulk excess subcutaneous tissue, especially dorsum fingers

- close the skin with multiple Z-plasties






Axial Deformity

Cleft Hand



Longitudinal failure of formation of central 3 rays




Most unilateral & sporadic

Some bilateral & AD



Two types


1.  Typical 

- long ray only absent


2.  Atypical 

- middle three rays absent




Function often good

- surgery often not required

- occasionally cleft closure undertaken




Hypoplastic Thumb



Radial club hand


Holt Oram


Blauth Classification


Grade I 


Minor hypoplasia, all element presents



- may need opposition tendon transfer if APB and opponens deficient


Grade II 


Thenar muscles hypoplasia / aplasia

MCPJ ligament instability

Normal skeleton

Wed space adduction contracture



1.  Release web space

2.  Oppensplasty


- stabilise MCPJ

- provide opposition 


Grade III


Skeletal hypoplasia

Variable absence MC

Aplasia of CMC

Variable absence of radial carpal bones

Thenar muscle hypoplasia



- pollicisation


Grade IV


Absent metacarpal / rudimentary phalanges

Pouce flottant / floating thumb



- LA & tie off at birth

- pollicisation


Grade V


Total absence



- pollicisation






Use index finger as thumb


Best Results / Aims


30% normal strength

Good opposition

- should get pulp to pulp pinch




Between one and two years




1.  Skin incision for new web space


2.  Isolating on radial and ulna NV bundles

- splitting common digital nerve

- division of radial digital artery to middle finger


3.  Shorten finger

- remove metacarpal


4.  Stabilise MCPJ


5.  Balance MT units

- dorsal interossei becomes thumb abductor

- palmar interossei becomes thumb adductor


6.  Reattach extensor tendons, leave flexors




Radial Club Hand



Radial hemimelia

- longitudinal failure of formation of parts along radial border / preaxial border




1:100 000

4 x Ulna Club Hand

Bilateral 50% 




Scaphoid & trapezium absent in 50% cases


Thumb absent in 80%




Vertebral segmentation deficiencies

Anal atresia


Tracheoesophageal fistula

Endocrine including Fanconi's anaemia

Renal abnormalities

Radial ray deficiencies atresia

Limb - CTEV, radial club hand




Holt-Oram Syndrome




- anaemia & RCH (pancytopenia)


TAR syndrome

- thrombocytopenia absent radius 


Bayne Classification


1.  Short distal radius

- distal radial epiphysis present but delayed in appearance


2.  Hypoplastic radius

- delayed proximal & distal radial epiphyses appearance

- moderate shortening of the radius & thickening of the ulna


3.  Partial absence of radius

- usually distal third absent

- carpus unsupported & radially deviated


4.  Total absence of radius

- most common type




All pre-axial structures may be affected

- forearm is radially bowed

- deviated in radial & volar direction

-  progresses with growth


Ulna is bowed & short by 25%


Carpus attached to ulna by fibrous tissue or small synovial joint


There are also abnormalities of finger joints most marked in radial digits


Median nerve

- is thickened as carries sensation for radial nerve as well

- it is located deep to deep fascia on radial border of forearm 

- at risk from surgery


Radial artery can be absent




Radial & palmar flexed hand 

- forearm is short (50-70%) & radially deviated

- thumb absent / deformed / almost normal thumb 


25% have significant elbow extension contracture

- radial deviation may allow hand to mouth

- imperative this function is not disturbed




Worse than ulna club hand as tend to radially deviate

- OT may not prevent re-deformity

- if occurs wrist fusion at maturity




1.  Splinting & stretching from birth

- prevent excessive radial deviation


2.  Centralisation procedure



- centralising carpus over ulna

- soft tissue release at 1 - 2 years

- maintain with tendon transfers

- transfer ECRL to ECRB 



- lack of hand to mouth function is a contraindication to surgery

- elbow mobility is prerequisite for centralisation


3.  Management of hypoplastic thumb








Ulna Club Hand

ulna club handEpidemiology


4 x less common than RCH


Very rare




Radiohumeral synostosis common

Radial head dislocation seen in 50% cases





Club foot

Spina bifida




Good function

- stretch / splint to avoid UD


OT rare

- excision of proximal ulna to create one bone forearm

- lose forearm rotation








Congenital Anomaly Classification

1.  Failure of Formation


A Transverse Failure


Congenital Amputation



B Axial / Longitudinal Failure


Radial Club Hand

Ulnar Club Hand

Cleft Hand / Foot


2.  Failure of Separation



Apert's Syndrome


3.  Duplication



- pre axial (tibia & radius)

- post axial (fibula & ulna)


4. Overgrowth



Macrodactyly - commonest of these


5.  Undergrowth


Hypoplastic thumb - commonest of these

Hypoplastic hand & digits


6.  Congenital constriction bands


7.   Miscellaneous 


Congenital Trigger Digits


Kirner's Deformity

Delta Phalanx


Madelung's Deformity





- complete absence of limb



- seal or flipper limb

- terminal portion attached to trunk

- intercalary defect

- deformed hand with only 3-4 digits




Absence of major portion of limb

- Radial / Ulnar / Tibial / Fibula



- entire distal 1/2 of limb absent



- greater portion of distal 1/2 of limb absent



- preaxial or postaxial portion of distal 1/2 of limb absent

- preaxial: thumb / radial, tibia

- postaxial: little finger / ulna, fibula



- no unaffected parts distal



- defect extends transversely

- complete absence of some part distal to some point on the upper extremity

- common levels are: fingers, upper third forearm, midcarpal

- 98% unilateral

- aetiology unknown except for thalidomide



- middle portion of limb deficient

- proximal & distal portions present

- can be transverse or paraxial 

- ie fibula hemimelia may have lesser toes present



- fusion of fingers distally with proximal fenestrations



- shortening of syndactyl digit




Normal development

- limb buds develop at 4/52

- apical ectodermal ridge controls underlying mesoderm

- limb segments develop in proximal to distal sequence

- skeletal elements formed as cartilaginous models

- models ossify

- clefts form & develop joints

- embryonic skeleton well formed at 7/52

- sonic hedgehog gene important


Abnormal Development


50% unknown

- genetic factors - Trisomy 21 / 18 / 13

- environmental factors - thalidomide / warfarin / dilantin well established

- combination


May cause

- arrest of development of embryonic limb

- destruction of structures already formed


Must occur between 4th and 7th week



Congenital Hand


MEM camp = bent tent




Greek for bent finger in sagittal plane


Usually little finger


Typical deformity is FFD of PIPJ & extension of MCPJ




<1% of population


Strong familial predisposition

- 60% bilateral

- bimodal pattern

- present in infancy or adolescence

- 1 in 1000 live births





- not related to trauma, infection, NMD

- ? due to incomplete extensor mechanism


Usually due to imbalance of pull between flexor & extensor mechanisms

- contracture of collaterals 

- secondary abnormality PIPJ common

- usually base of P2 is subluxed volar to head P1


Most commonly accepted theory 

- an anomalous insertion of the lumbrical muscle into the flexor sheath causes the abnormality


Multiple causes reported

- aberrant lumbrical insertion 

- flexor sheath contracture

- phalangeal head deformity

- FDS contracture

- abnormal extensor tendon mechanism




1. Infantile

2. Adolescent

3. Severe form affecting all triphalangeal digits




Traumatic boutonnière deformity


Juvenile aponeurotic fibromatosis 

- involves palmar fascia & skin

- increased flexion deformity




80% progress

- progress during growth spurts


Doesn't progress after maturity


Clinical Features


85% present at birth

15% present in adolescence


Volar skin may bowstring

- can be mild to severe FFD

- functional compromise when FFD ->90o


Fixed v flexible




Head of P1 has bullet shape

PIPJ is subluxed






Usual treatment

- watch to see if deformity progresses especially at growth spurts

- some studies show that splinting does work if 24 hours per day

- other studies without 24 hours splinting show not much difference

- passive stretching & static & dynamic splinting


No series has shown surgical release does better than well motivated and controlled regimen of flexion and extension splinting






Progressive deformity

Failure of non-operative management

> 60° & functional disability


Poor outcomes especially loss of flexion

- some series report only 35% success rate





- release all tight volar structures

- skin / FDS / volar plate / capsule

- +/- FDS transfer to the extensor hood


Skeletally mature

- extension osteotomy / dorsal closing wedge

- must avoid excess straightening -> stretch nv bundle 


Do not perform release and simultaneous transfers as need to mobilise immediately post-operatively







Clinodactyly is a fixed abnormal deviation of the finger

- in the coronal or radioulnar plane


Typically affects the middle phalanx of the fifth finger

- produces a radial angulation of the distal interphalangeal joint.


Normal if < 10-20°






Usually little finger

- common

- AD & sporadic forms


80% syndromic

- Down's

- fetal alcolohol syndrome


M > F


Secondary / Delta Phalanx 


Commonest cause

- trapezoid shaped P2

- cosmetic problem only




Primary clinodactyly 



- when fingers overlap 



- closing wedge osteotomy of P1


Secondary / Delta Phalanx

- see additional notes



Congenital Trigger Finger



Most common in thumb


Bilateral in 15%




Present with FFD of thumb / finger





- constriction of A1 pulley



- nodules in FDS or FDP

- catching at A1, A2 or A3

- may have anomalous insertion lumbrical

- often at tendon decussation area


Types Trigger Thumb


1. True congenital

- bilateral in 50% cases

- can be sporadic

- associated with trisomy 18 / mucopolysaccharidases


2. Common type

- presents 6/12 - 3 years





- spontaneous relapse 30% < 1 year

- spontaneous relapse 10% > 1 year



- not present at birth

- usually acquired

- more likely to spontaneously relapse


Operative Management




Before age 3




> 1 year

- release A1 pulley

- careful preservation digital nerves




Extensive exposure / progressive releases / repeat intraoperative examination

- release A1 pulley

- release anomalous insertions

- partial release A2 and A3 pulley

- release single slip FDS





Delta Phalanx



Abnormal extra trapezoidal shaped phalanx 




Strong Family History


Most common in

- P1 Thumb

- P2 Little finger




Abnormal "C" shaped epiphysis brackets one side of phalanx 




Results in angular deformity

- typically centrally deviated


Little finger radially 


Thumb towards ulna


Operative Management




Functional disability




Resection isthmus of "C" shaped continuous epiphysis

- insertion of interpositional fat graft

- if excise delta phalanx -> get excessive shortening



Kirner Deformity



Volar-radial deviation of P3 of little finger

- AD trait

- always bilateral

- presents at age 10

- cosmetic problem only




Frost bite injury to phalanx can mimic it






For cosmesis only




2 volar osteotomies / straighten / K wire






Rare congenital anomaly with enlargement of the finger









Strong FHx




All elements involved

- compared to enlargment from tumour /haemangioma


Index finger most commonly affected

- involved digit is stiff & angulated

- always large at birth compared with 2° enlargement





- true macrodactyly

- all tissues enlarged



- neurofibromatosis

- hemangioma

- lymphangioma


- fibrous dysplasia

- lipoma




1. Static type

- grows with child at normal rate


2. Progressive type

- progressive enlargement out of proportion to normal growth


Operative Management




Most patients will require surgery but surgery often unsuccessful




Debulking procedures

- fat & skin

- may need multiple debulks



- when digit achieved adult length


Finger shortening

- removal of segments from P2 & P3

- has a high complication rate

- stiffness, pain, residual deformity & skin problems


Ray resection

- salvage


Usual approach


Staged procedure

- operative on one side of finger at a time

- convex side first

- remove up to 25% of phalanx

- remove half of soft tissue from each side


Epiphysiodesis once digit same size as parents digits


Uncontrolled growth


Ray resection


May get accelerated growth in adjacent digits after ray amputation







More common in African Americans




Sporadic and AD







Type 1:  Thumb polydactyly

Type 2:  Triphalangeal thumb

Type 3:  Index polydactyly

Type 4:  Polysyndactyly




Duplication of the IF / MF / RF 

- Rare




Type A Extra well formed ulnar digit articulating with a metatarsal

Type B Extra poorly formed ulnar digit / often a skin tag




I   Soft tissue only

II  Bone elements

III Own metacarpal




Simple soft tissue 


Tie string & autoamputates at birth




Operate at ~ 1 year in hand

- once old enough to be safe for operation

- general rule is to amputate outside extra digit


Thumb Polydactyly


Wassell Classification


Most common variety

- duplicated proximal phalanz with single metacarpal

- Type IV


Usually delete radial thumb




1.  Smaller thumb


2.  Unstable MCPJ with type IV

- important to rebalance residual digit with joint capsule & tendon insertions 

- otherwise will end up with Z deformity

- ulna deviation at MCPJ, radial at IPJ


3.  Angular deformity

- caused by supernumerary thumb and delay in surgery

- may need osteotomy







Webbed fingers




Usually spontaneous but can be inherited

Due to a failure of separation during embryonic development




Most common congenital hand abnormality 1:2000


Family History in 20-40% / AD





Amniotic bands

Toe webbing


Craniofacial abnormalities

Apert's syndrome




Simple / Complex 

- simple skin only

- complex has bony involvement


Complete / Incomplete 

- extent of finger involved distally





- fusion of fingers distally with proximal fenestrations



- shortening of syndactyl digit




Middle & ring finger commonest 60%


Thumb & index rarest

- Apert's


Bilateral in 50%


Frequent anomalous sharing of

- musculotendinous structures

- artery / veins / nerves






Surgery aged 1 year

- minimise bony deformity

- especially if thumb / index as in Apert's syndrome

- once child safe for anaesthetic


Important surgical principles


1.  Beware NV abnormality

- usually normal number in simple syndactyly

- may be absent in complex

- may divide much more distally


2.   Skin shortages

- may need FT skin graft


3.   Release one side at a time

- may jeopardise vascularity to finger

- 3/12 between each side


4.   Need to create web space

- Zig Zag incisions with volar or dorsal flap for web space (Vickers) 

- important not to deepen web space too much as looks unsightly

- web space deepening often limited by digital artery bifurcation


5.  Division of border digits done early to avoid angular deformity





- due to shortening of graft

- not seen with Vickers technique


Web creep 

- return of webbing 

- revise as teenager so only need one further surgery

- web space reconstruction


Neurovascular injury





Madelung's Deformity

Madelung's deformity with fracture




Premature fusion of the volar & ulna aspects of the distal radius

- progressive ulnar & volar tilt of distal radial surface


Ulna becomes prominent through normal growth & subluxes dorsally


Lunate lies deeply between lower end of radius and ulna




1. Volar-ulnar radial physeal arrest

- focal physeal dysplasia


2. Carpal tether from same area to lunate

- Vicker's ligament


Anatomy Vickers' ligament 


Vickers describes fibrous band 

- runs from radius to lunate

- volar position

- large ligament ~ 0.5cm diameter

- may be the cause

- if excise early / before age 8 the radius improves in shape




Idiopathic condition

- AD with incomplete penetrance

- F > M

- often bilateral




Turner's Syndrome


Disorder of gonadal differentiation

- 45 X / XO

- female phenotype / sterile

- webbing of neck

- low posterior hairline

- cubitus valgus

- cardiac abnormalities


DDx Madelung Deformity


Post Traumatic

Enchondromatosis (Ollier's)

Hereditary Multiple Exostoses

Turner Syndrome

Idiopathic = Dyschondrosteosis


General dysplasia




Madelung's - ulnar, volar 

Chevron - ulnar, central 

Reverse Madelung - ulnar, dorsal




Usually asymptomatic and good function


Wrist is in radial deviation


Dorsal subluxation of distal ulna


Reduced dorsiflexion / supination




Not apparent in childhood

Usually becomes obvious as hits adolescent growth spurt




Madelungs APMadelung's Lateral


Volar-ulna tilt of the distal radius with dorsal subluxation of ulna / distal radius triangular shape


Proximal carpal row becomes wedge shaped

- lunate "falls into" the radio-ulna gap


DRUJ widened



- proximal carpal row distorted / V-shape

- lunate in apex between radius and ulna




Look for Vicker's ligament




Mothers function is a good guide to management


Surgical Indications


1. Pain 

- must operate

- surgery very good at relieving pain

- in adults division Vickers' ligament almost always relieves pain 


2. Deformity 

- deformity starts ~ age 9 years (doesn't occur much before then) 

- best to operate early as will get good result




1.  Excision Vicker's ligament + Epiphysiolysis of fused physis with fat graft


2.  Complete epiphysiodeses 


3.  Epiphysiodeses of distal Ulna


4. Ulna Shortening / Darrach


Madelung's with Darrachs


5.  Opening Wedge Osteotomy


Madelung's Osteotomy


6.  Wrist Arthrodesis






Obstetric Brachial Plexus Injury



Birth injury of brachial plexus




R > L 

1 / 1000 live births

1 in 10 of these develop significant impairment

Recent increase due to bigger babies / DM




Usually secondary to traction


1.  Big baby / maternal DM / > 4000 gm

2.  Breech

3.  Prolonged / difficult labour

4.  Shoulder dystocia 

- inability to deliver the shoulders after delivery of the head

- indirect traction injury on limb with excessive lateral neck flexion

5.  Forceps delivery

- direct forcep crush injury




Spectrum of injury

- supraclavicular traction injury

- upper roots ruptured

- lower roots avulsed




Erb Palsy

Klumpke Palsy

Total Plexus


ERB Palsy 


A.  C5,6 lesion



- deltoid / rotator cuff

- biceps  - elbow flexion and supination

- wrist extension


Waiter's Tip Deformity

- shoulder adducted & internally rotation (P major / Lat dorsi)

- elbow extended

- forearm pronated

- wrist flexed 2° FCR


May have winging of scapula as compensation


Best prognosis

- 90% recover 6/12


B.  C5,6,7


Additional weakness

- triceps / loss of elbow extension



- 50% recover 6/12


Klumpke Palsy


C8,T1 lesion

- rare

- Horner's Syndrome if preganglionic


Weakness of

- finger flexion

- intrinsics


Numb forearm & hand


Poor prognosis


Total Plexus Injury


C5 - T1

- flaccid numb arm 

- Horner's if preganglionic


Worst prognosis

- 40% recover 6/12




90% recover overall


Biceps best indicator of recovery

- if biceps recovers in 3/12 90% will make full recovery

- also is easiest to assess in young child

- see if child will use that hand to bring something to the mouth


Poor prognosis 

- no recovery 3/12

- Total plexus

- Klumpke

- preganglionic (Horner's, DSN, LTN, SSN)





- clavicle fracture (from delivery)

- humeral fracture



- nil elbow crease

- hasn't flexed in utero


Monoplegic CP



- OM / Septic arthritis

- Congenital shoulder dislocation

- sprengel shoulder

- myelodysplasia




Non operative





- maintain FROM / passive ranging

- no splinting



- assess biceps recovery

- EMG at 3months if no recovery


Long term


Maintain shoulder ER

- prevent posterior shoulder dislocation

- reassess child in clinic every six months


Operative Management




No elbow flexion / biceps recovery at 3 - 6/12

- biscuit test (hold other arm, see if can eat biscuit)

- very difficult to assess shoulder or wrist extension


If children don't have full recovery of biceps at 3/12 will often be left with residual deficit




Valuable if see pseudomeningocoeles

- low chance of recovery of those nerve roots




6/12 to 1 year




Preganglionic avulsion

- nerve transfer



- nerve grafting


Preganglionic Avulsion 


Nerve transfer


A.  Accessory nerve to suprascapular 


B.  Intercostal nerve to MCN


Postganglionic injury 


Neuroma resection & sural nerve grafting


Erbs / C5/6

- resection Erb's point

- nerve grafting



- lateral cord / MCN 

- SS nerve

- posterior division of upper trunk to posterior cord




Late Shoulder Management



- residual internal rotation / adduction contracture

- tight SSC / P major / T Major / short head biceps

- humeral neck retroverted

- develop dysplasia head and glenoid

- GHJ tends to dislocates posteriorly





- more common in C5/6

- due to strong P Major and LD


Management Summary


< 6/12       Observe

6/12           Nerve transfer / graft

<2  years    Release contracture Subscapularis / T major / P major

2-5 years    Lat Dorsi Transfer

>5  years    Derotation Humeral osteotomy




Monitor and maintain ER shoulder

- physio / botox





- limited ER

- anterior shoulder crease



- very sensitive at 6/12 age


Shoulder releases



- < 2 years

- important to do releases early 

- avoids IR contracture 

- avoids consequent need for osteotomy or reduction of dislocation



- P major

- T major

- Subscapularis


Tendon Transfers



- 2-5 years




Lat Dorsi transfer to posterolateral rotator cuff 

- act as shoulder ER 

- often combine with releases


Steindler's flexorplasty


Humeral derotation osteotomy



- CT to assess bony anatomy

- may need posterior glenoid bone block

- shoulder may be dislocated



- > 6-8 years




Pseudarthrosis of Clavicle

Congenital Clavicle Pseuodarthrosis



Rare condition





1. Failure of fusion of 2 ossification centres of clavicle

2. Pressure from subclavian artery


Clinical Features


Painless swelling over mid clavicle

- almost always on Right side

- presents soon after birth






Bulbous ends overlying each other




Birth fracture of clavicle

- painful

- history of traumatic delivery

- callus on Xray


Cleidocranial Dysostosis

- abnormality of intramembranous ossification

- bilateral

- associated facial / jaw & pelvic bone abnormality

- no palpable lump





- no functional problem






Cosmetic issue from lump


Surgical options


1. Excision of prominent lateral end of sternal part

2. Bone graft & internal fixation





Radial Head Dislocation



1. Congenital



- anterior or posterior

- lateral uncommon


2. Acquired

- unrecognised Monteggia

- osteochondroma

- enchondroma


3. Skeletal Dysplasia

- OI - ulna deformity

- Achondroplasia

- Down's Syndrome

- Nail-Patella

- Klinefelter's

- Marfan's

- Hereditary Multiple Exostosis

- Ehlers Danlos

- Larsens






Other congenital problems




Convex radial head

Hypoplastic capitellum

Long radius compared with ulna




No treatment (reconstructions fail)

- most congenital dislocations are asymptomatic 

- good function and ROM

- excise radial head as adult if painful





Radioulna Synostosis





Usually bilateral / AD




Failure of separation of cartilaginous rods that form radius and ulna




Forearm in varying degrees of pronation (supination rare)

- may have difficulty with ADL's




Pronation is more useful position than supination


May need supination on one side

- osteotomy radius and ulna

- changes functional position not arc of range

- high risk of comparment syndrome






Fractures at same level

Most common proximally




Excision of synostosis and interpose fascia 

- poor results



Transverse Deficiencies

Terminal Phocomelia




Complete absence of some part distal to some point on the upper extremity




1:20 0000

98% unilateral




Usually unknown ? AR trait





Commonest level is proximal forearm



- fingers / midcarpal / wrist / mid-forearm / mid arm




Non-operative / Prosthesis


Passive terminal device started 3/12


Active device as child starts to use above device


Krukenberg procedure


Radius and ulna formed into pincers

Only in blind / bilateral


Intercalary Phocomelia




Loss of intercalated segment

- hand suspended from trunk

- loss of elbow joint

- deformed hand with only 3-4 digits




Seen with thalidomide

Often bilateral


Three types


1. Complete 

- hand to trunk


2. Distal 

- hand to arm


3. Proximal 

- forearm to trunk