Handbook of Orthopaedics Hitesh Gopalan U
Chapter Notes

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1Paediatric Orthopaedics
  1. Congenital Anomalies of Lower Extremity
  2. Congenital Anomalies of Upper Extremity
  3. Osteochondrosis and Miscellaneous Diseases
  4. Nervous System Disorders
  5. Skeletal Dysplasias
  6. Miscellaneous Disorders2

Congenital Anomalies of Lower Extremity1

Venn-Watson Classification
  1. Pereaxial polydactyly
    • Short block first metatarsal
    • Wide metatarsal head
  2. Postaxial polydactyly
    • Y metatarsal
    • T metatarsal
    • Wide metatarsal head
    • Complete duplication
Surgical Treatment
Amputation of the accessory digit.
Cleft foot (Lobster foot) is an anomaly in which a single cleft extends proximally into the foot.
Abraham Classification
  • Type I has a central ray cleft or deficiency (usually second or third rays or both) extending up to the mid-metatarsal level without splaying of medial or lateral rays
  • Type II has a deep cleft up to the tarsal bones with forefoot splaying
  • Type III is a complete absence of the first through third or fourth rays, no surgery
  • Type 1: Soft tissue syndactylism with partial hallux valgus correction if needed
  • Type 2: Soft tissue syndactylism, with first-ray osteotomy if needed, before the age of 5 years
  • Type 3: No surgery4
Bleck Classification
  • Mild form: The forefoot can be clinically abducted to the midline of the foot and beyond
  • Moderate form: It has enough flexibility to allow abduction of the forefoot to the midline but usually not beyond.
  • Rigid metatarsus adductus: The forefoot cannot be abducted at all.
  • Mild deformities: No treatment
  • Moderate and severe deformities: Stretching and serial casting
Indications for Surgery
  • Severe deformities uncorrected by conservative measures
  • Pain
  • Difficulty in fitting shoes
  • Objectionable appearance
  • 2-4 years: Heyman Herndon and Strong procedure: Tarsometatarsal capsulotomies
  • >4 years:
    1. Berman and Gartland procedure: Multiple metatarsal dome osteotomies
    2. Medial cuneiform, lateral cuboid double osteotomy
NB: Skew foot: Also called Z foot or serpentine foot. It is a complex deformity consisting of forefoot adduction, mid foot abduction and hind foot valgus.
Theories of Origin
  1. Irani and Shermans theory: Primary germ plasm defect in the talus
  2. Developmental arrest theory.
  3. Dunne's foetal theory: Mechanical block by extrinsic pressure in utero.
  4. Isaacs neurogenic theory: Increased type 1 muscle fibres.
  5. Myogenic theory: Atrophy of leg muscles.
  6. Vascular theory: Hypotrophic anterior tibial artery.5
    Table 1.1   Differentiating features of non-rigid and rigid clubfoot
    Type 1: Extrinsic/non-rigid
    Type 2: Intrinsic/rigid
    Normal size, mild varus
    Smaller, marked varus
    Normal size, can be brought down with ease
    Small, elevated cannot be brought down with ease
    Minimal varus
    Marked varus
    More or less normal
    Deep medial, posterior and plantar creases, reduced creases, laterally
  7. Ippolito and Ponseti's theory of retracting fibrosis: Myofibroblast contraction mainly implicated.
Radiography (Normal Range)
  • Talocalcaneal angle
    • Anteroposterior view: 30 to 55 degrees
    • Dorsiflexion lateral view: 25 to 50 degrees
  • Tibiocalcaneal angle
    • Stress lateral view: 10 to 40 degrees
  • Talus – first metatarsal angle
  • Anteroposterior view: 5 to 15 degrees
Conservative treatment in the form of manipulation, followed by strapping or cast application starting immediately after birth.
Surgery is indicated if there is no correction at the end of 6-9 months.
  • Turco:one-stage surgical release: Posteromedial release
  • Modified McKay procedure: Through a transverse circumferential (Cincinnati) incision. Advantages are:
    1. Correction of three-dimensional deformity of the subtalar joint
    2. Correction of the internal rotational deformity of the calcaneus and
    3. Release of the contractures of the posterolateral and posteromedial foot.
  • For severe deformities: Carroll's 2 incision technique, a curvilinear medial incision and a posterolateral incision.
Treatment of Resistant Clubfoot
Hindfoot varus:
<2-3 years: Modified Mc Kay procedure
3-10 years:
  • Isolated heel varus: Dwyer's osteotomy
  • Short medial column: Dillwyn Evan's procedure
  • Long lateral column: Lichtblau procedure
  • 10-12 years: Triple arthrodesis
  • Mild to moderate deformity: Tendocalcaneus lengthening and post capsulotomy of ankle and subtalar joints
  • Severe deformity: Lambrinudi procedure.
S. Jay Kumar Classification
  • Group I: Supple feet that resemble calcaneovalgus feet. Radiograph needed to make the diagnosis.
  • Group II: Children with rigid feet some of which are part of a syndrome.
  • Group III: Vertical talus associated with trisomy 13-15 or 18.
  • Group IV: Vertical talus associated with neuromuscular problems such as spina bifida.
  • Children 1 to 4 years old: Kumar, Cowell, and Ramsey procedure:
    Open reduction and realignment of the talonavicular and subtalar joints. Navicular excision in children over 3 years or severe deformity.
  • Children 4 to 8 years: Coleman procedure:
    Open reduction and soft tissue procedures combined with Grice Green extra-articular subtalar arthrodesis.
  • Children 12 years old or older are best treated by triple arthrodesis for permanent correction of the deformity.
Congenital angular deformities of the leg are primarily of two kinds:
  1. The apex of the angulation is anterior: potential association with congenital pseudarthrosis of the tibia.
  2. The apex of the angulation is posterior. Posterior angular deformities of the tibia tend to improve with growth.7
  • Anterior angulation: If there is evidence of narrowing or sclerotic lesions: bracing till skeletal maturity.
  • Posterior angulation: Examined yearly for any potential limb-length discrepancy. Contralateral epiphysiodesis or limb lengthening may be done depending on discrepancy.
  1. Bowing of the fibula without pseudarthrosis.
  2. Fibular pseudarthrosis without ankle deformity.
  3. Fibular pseudarthrosis with ankle deformity.
  4. Fibular pseudarthrosis with latent pseudarthrosis of the tibia.
  1. Ankle-foot orthosis till skeletal maturity, at maturity supramalleolar osteotomy to correct the deformity.
  2. Langenskold operation: Synostosis between the distal tibial and fibular metaphyses. Done in children to prevent this valgus deformity or halt its progression.
Boyd Classification
  • Type I: Pseudarthrosis occurs with anterior bowing and a defect in the tibia present at birth.
  • Type II: Pseudarthrosis occurs with anterior bowing and an hourglass constriction of the tibia present at birth. Spontaneous fracture, or fracture following minor trauma. This is the so-called “high-risk tibia”
    • Most common
    • Associated with neurofibromatosis
    • The poorest prognosis.
  • Type III: Pseudarthrosis develops in a congenital cyst junction of the middle and distal thirds of the tibia.
  • Type IV: Pseudarthrosis originates in a sclerotic segment of bone in the classic location.
  • Type V: Pseudarthrosis of the tibia occurs with a dysplastic fibula.
  • Type VI: Pseudarthrosis occurs as an intraosseous neurofibroma or schwannoma that results in a pseudarthrosis.8
McElvenny's Concept
Heavy cuff of tissue surrounding the bone at the pseudarthrosis, may decrease bone production and consequently healing. Resection of this tissue is important during surgery.
  • Types I and II without evidence of fracture: KAFO
  • Type III: Prophylactic curettage and autogenous iliac bone grafting
  • Types IV: The Boyd dual onlay bone graft
  • In types I and II with fracture, types V and VI:
    • Intramedullary fixation, bone grafting and use of osteostimulator.
    • Free vascularised fibular graft
    • Ilizarov ring technique.
Hennigan and Kuo Classification
  • Grade 1 bands involved subcutaneous tissue
  • Grade 2 bands extended to the fascia
  • Grade 3 bands extended to the fascia and required release
  • Grade 4 bands were congenital amputations.
Single stage release by multiple Z plasties.
  • Hypoplasia of the nails with the thumb always affected, second to fifth fingers being affected less severely or frequently.
  • Elbow joints: cubitus valgus, limitation in extension and supination.
  • Pelvis: ‘iliac horns’ increased coxa valgus of the hips with anteversion.
  • Patella hypoplastic, wedge shaped and displaced laterally and present as a recurrent dislocation of the patella.
As for recurrent dislocation patella.9
  • Grade 1: Congenital hyperextension;
  • Grade 2: Congenital hyperextension with anterior subluxation of the tibia on the femur
  • Grade 3: Congenital hyperextension with anterior dislocation of the tibia on the femur.
  • Newborn: Conservative treatment using Pavlik harness and serial casting.
  • 6-18 months: Curtis and Fischer operation. It consists of anterior capsular release, lengthening of the quadriceps mechanism and release of intra-articular adhesions.
  • Older child: Osteotomy.
Familial and bilateral.
  • Release of the contracted structures on the lateral side of the patella (The lateral capsule, iliotibial band, and lateral portion of the quadriceps)
  • Medial plication of the lax capsule
  • Medial transfer of the patellar tendon.
Lateral more common than medial.
Smillie suggested it was failure of the foetal discoid form of the meniscus to involute. The meniscus is derived from mesenchyme, is initially a disc and then forms as a semilunar structure.
  • Preserve the meniscus
  • Aim to refashion the meniscus
  • If type III will require refashioning and stabilisation, using a capsular suture.
Frantz and O'Rahilly Classification
Terminal or Intercalary
  • In terminal deficiencies, there is an amputation with no body parts distal to the site.
  • In intercalary deficits, a middle segment is missing, but the distal segments are present.
  • Terminal and intercalary deficiencies are further defined as transverse or longitudinal.
Jones, Barnes, and Lloyd-Roberts Classification
  • Type 1A deformity there is a complete roentgenographic absence of the tibia and a hypoplastic distal femoral epiphysis.
  • Type 1B deformity, distal femoral epiphysis appears normal in size and shape.
    Proximal tibial cartilaginous anlage present, proximal tibial anlage of a type 1B deformity may ossify to become a type 2 lesion.
  • Type 2 deformity: Proximal tibia of varying size present. The fibula head is proximally dislocated.
  • Type 3 deformity: In which the proximal tibia is not visible. The distal tibial epiphysis sometimes is visible, along with a mature distal metaphysis; the knee generally is unstable.
  • Type 4 deformity (congenital diastasis of the ankle joint and congenital tibiofibular diastasis.): the tibia is shortened and there is a proximal migration of the fibula with distal tibial fibular diastasis.
  • Type 1A: Knee disarticulation followed by fitting with an above-knee prosthesis is the mainstay of treatment.
    • Knee reconstruction by Brown procedure: Fibula is surgically transferred into the intercondylar notch to create a tibia.
    • Success of Brown procedure depends on the
      • * Presence of a functioning quadriceps mechanism,
      • * The absence of flexion contracture, and
      • * An intact proximal tibial anlage
  • Type IB and II: A proximal tibiofibular synostosis combined with a Syme amputation or distal reconstruction is the treatment of choice.11
  • Type III: Knee disarticulation and prosthesis.
  • Type IV: Combinations of distal tibiofibular synostosis and distal fibular epiphysiodesis.
Achterman and Kalamchi Classification
  • Type 1 deformity: Hypoplasia of the fibula.
  • Type 2 deformity: Complete absence of the fibula.
    • Type 1A: The proximal fibular epiphysis is distal to the proximal tibial epiphysis and the distal fibular epiphysis is proximal to the talar dome.
    • Type 1B: The deficiency of the fibula is more severe, with 30 to 50% of the length missing and no distal support for the ankle joint.
    • Type 2 deformity: Complete absence of the fibula. Angulation of the tibia is found most often inpatients with type 2 deficiencies.
Choi Classification for Distal Tibial Epiphysis in Fibular Hemimelia
Distal tibial epiphysis is wedge-shaped. The severity of the wedging: predictive of the severity of foot deformity after tibial lengthening.
  1. Mildly wedged epiphyses (type I), varying degrees of mild growth retardation and minimal foot deformity should be anticipated.
  2. Moderately wedged epiphyses (type II), worsened asymmetrical growth retardation and progressive foot deformity should be expected.
  3. Severely wedged epiphyses (type III), severe growth retardation and severe foot deformities should be expected.
  • When predicted limb length discrepancy is high (>12 cm): early amputation (Syme's) and prosthetic fitting.
  • If mild shortening is expected: Correction of ankle deformity and limb lengthening.
  • Ankle equinovalgus deformity: posterior/lateral release Older children: Wiltse varus supramalleolar osteotomy.
Femoral rotation (Anteversion) decreases with age:
  • Age 1 year—39°
  • Age 2 year—31°12
  • Age 10 year—24°
  • Age 16 year—16°
Reassurance and observation. Usually corrects spontaneously by 8 year.
Derotational femoral osteotomy: Intertroch/subtroch, mid diaphyseal or supracondylar.
It should not be performed before 8 year because of chance of spontaneous recovery. It should not be delayed till late adolescence because of possible development of secondary lateral tibial torsion.
Indications (Tachdjian) for Surgery
  • In child >8 years femoral anteversion>45 degrees.
  • Hip unable to rotate laterally beyond neutral.
  • Lateral tibial torsion does not exceed 35°.
  • Functional disability and severe cosmetic deformity.
Aitken's Classification
(Classes A, B, C, and D)
  • Class A : Normal acetabulum and femoral head with shortening of the femur and absence of the femoral neck on early roentgenograms.
    • With age, the cartilaginous neck ossifies, although frequently associated with pseudarthrosis.
    • Severe coxa vara with significant shortening of the limb.
  • Class B is similar to class A in that an acetabulum and femoral head are present there is no bony connection between the proximal femur and the femoral head, and a pseudarthrosis is present.
  • Class C: In class C dysplastic acetabulum, absent femoral head, and short femur. A small, separate ossific tuft at proximal femur.
  • Class D: In class D the acetabulum, femoral head, and proximal femur are totally absent and, unlike in class C, there is no ossified tuft capping the proximal femur. Class D patients often have bilateral anomalies.13
  • Type A: Proximal femoral osteotomy to correct varus and bone grafts.
  • Type B: Proximal femoral osteotomy to correct varus and secure union. If shortening is marked: Limb lengthening.
  • Types C and D—creative prosthetic application or Van Nes rotationplasty with distal prosthesis.
Paley Classification of PFFD
  • Type 1: Intact femur, mobile hip and knee. Shortening+
    • 1a: Normal ossification
    • 1b: Delayed classification
  • Type 2: Mobile pseudarthrosis
    • 2a:Mobile femoral head and mobile knee
    • 2b:Stiff or absent femoral head and mobile knee
  • Type 3:Diaphyseal deficiency of femur
    • 3a:Partially mobile knee (>45°)
    • 3b:Stiff knee (<45°)
Kalamchi Classification of PFFD
  • Group I: Short femur and intact hip joint.
  • Group II: Short femur and coxa vara of the hip.
  • Group II: Short femur but well-developed acetabulum and femoral head.
  • Group IV: Absent hip joint and dysplastic femoral segment.
  • Group V: Total absence of the femur.
Shapiro's Patterns (1982)
  • Type I: The leg-length discrepancy increases at a constant rate.
  • Type II: It is similar in early to middle childhood but the annual rate of increase diminishes thereafter.
  • Type III: The discrepancy first increases, then stabilises and remains unchanged.
  • Type IV: Similar to type III in early and middle childhood but then increases towards the end of growth.
  • Type V: Consists of an initial increase, stabilisation and then a decrease in discrepancy.
Leg Length Discrepancy Treatment
<2 cm
2-5 cm
Heel and sole raise
5-7 cm
Limb lengthening
>7 cm
Limb lengthening + contralateral epiphysiodesis
Menelaus Method
  • Calculate current discrepancy
  • Calculate the change in discrepancy per year
  • Calculate the time remaining for growth
(girls: 14 - current, boys: 16-current)
Discrepancy at maturity = [current discrepancy + (years remaining × discrepancy per year)]
Uses single exposure with long cassette, with a standardised distance between X-ray tube to cassette.
Several exposures are taken over a single cassette. Eliminates magnification error but child must be able to stand still.
Graf Classification (Table 1.2)
Based on ultrasonography. Effective <6 months.
After taking a mid coronal section, alpha angle is measured between line of ilium and bony acetabulum.
Table 1.2   Graf classification
Alpha angle°
> 60
Delayed ossification in a child > 3 months,
Physiological if < 3 months
< 43
< 43
Dislocated and labrum interposing between head and acetabulum
  • Perkin's line: Vertical line drawn through outer lip of acetabulum.
  • Hilgneriener’ line: Horizontal line through triradiate cartilage.
  • Femoral head normally lies in the inner lower quadrant.
  • CE (Centre edge) angle of Wiberg: Angle between the centre of the femoral head and outer lip of acetabulum.
    • Normal: 20 to 47 degree.
    • Significant if less than 20
  • Acetabular index: Measures the acetabular inclination with respect to the horizontal line. Normal < 30 degree.
  • Von Rosen View: - pt is supine w/hips abducted 45° and maximally internally rotated; AP projection of the pelvis is then obtained.
Should normally pass through the centre of the acetabulum.
Treatment Protocol
  1. Newborn, birth to 6 months of age: ‘Pavlik harness’. It consists of a chest strap, two shoulder straps, and two stirrups.
    Causes of failed reduction:
    • Inverted limbus
    • Pulvinar (Fibro fatty tissue in the acetabulum)
    • Hourglass constriction of joint capsule
    • Iliopsoas tendon
    • Transverse acetabular ligament.
  2. Infant, 6 to 18 months of age:
    Preoperative traction, adductor tenotomy, and closed reduction and arthrogram. Open reduction in children with a failed closed reduction. After open reduction if,
    • Hip stable in neutral position—no osteotomy
    • Hip stable in flexion and abduction—innominate osteotomy
    • Hip stable in internal rotation and abduction—proximal femoral derotational varus osteotomy
    • Double-diameter” acetabulum with anterolateral deficiency—Pemberton-type osteotomy.
  3. Toddler, 18 to 36 months of age: Open reduction with femoral or pelvic osteotomy.
  4. Child and juvenile, 3 to 8 years of age: Primary open reduction and femoral shortening, with or without pelvic osteotomy.
  5. Adolescent and young adult, beyond 8 years of age: Pelvic Osteotomy (Table 1.3).
Table 1.3   Recommended osteotomies for congenital dislocation of the hip
Salter innominate osteotomy
18 mon − 6 yr
Congruous hip reduction; <10-15 degrees correction of acetabular index required
Pemberton acetabulo plasty
18 mon − 10 yr
>10-15 degrees connection of acetabular index required; small femoral head, large acetabulum
Dial or Steel osteotomy
Skeletal maturity
Residual acetabular dysplasia; symptoms; congruous joint
Shelf procedure or Chiari osteotomy
Adolescent–skeletal maturity
Incongruous joint; symptoms; other osteotomy and possible
  1. Hilgenriener's epiphyseal angle: Angle subtended by the horizontal line connecting the tri-radiate cartilage and the physeal line.
  2. Normal angle: 30°
  1. Angle 40-60°: Observation
  2. >60°: Subtrochanteric valgus osteotomy.