Peter D. Pizzutillo

Developmental Dysplasia of the Hip From Birth to Six Months

&NA; The term “developmental dysplasia or dislocation of the hip” (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint. Unlike the term “congenital dysplasia or dislocation of the hip,” DDH is not restricted to congenital problems but also includes developmental problems of the hip. It is important to diagnose these conditions early to improve the results of treatment, decrease the risk of complications, and favorably alter the natural history. Careful history taking and physical examination in conjunction with advances in imaging techniques, such as ultrasonography, have increased the ability to diagnose and manage DDH. Use of the Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If stable reduction cannot be obtained after 2 weeks of treatment with the Pavlik harness, alternative treatment, such as examination of the hip under general anesthesia with possible closed reduction, is indicated. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step. Toward the end of the first year of life, the toddler’s ability to stand and bear weight on the lower extremities, as well as the progressive adaptations and softtissue contractures associated with the dislocated hip, preclude use of the Pavlik harness.

Spondylolysis and Spondylolisthesis in Children and Adolescents: I. Diagnosis, Natural History, and Nonsurgical Management

Spondylolysis and spondylolisthesis are often diagnosed in children presenting with low back pain. Spondylolysis refers to a defect of the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isthmic spondylolysis, isthmic spondylolisthesis, and stress reactions involving the pars interarticularis are the most common forms seen in children. Typical presentation is characterized by a history of activity-related low back pain and the presence of painful spinal mobility and hamstring tightness without radiculopathy. Plain radiography, computed tomography, and single-photon emission computed tomography are useful for establishing the diagnosis. Symptomatic stress reactions of the pars interarticularis or adjacent vertebral structures are best treated with immobilization of the spine and activity restriction. Spondylolysis often responds to brief periods of activity restriction, immobilization, and physiotherapy. Low-grade spondylolisthesis (< or =50% translation) is treated similarly. The less common dysplastic spondylolisthesis with intact posterior elements requires greater caution. Symptomatic high-grade spondylolisthesis (>50% translation) responds much less reliably to nonsurgical treatment. The growing child may need to be followed clinically and radiographically through skeletal maturity. When pain persists despite nonsurgical interventions, when progressive vertebral displacement increases, or in the presence of progressive neurologic deficits, surgical intervention is appropriate.

Musculoskeletal infections in children: basic treatment principles and recent advancements.

Pediatric musculoskeletal infections are common disorders that can result in significant disability. Because the understanding, diagnosis, and treatment of infections of the bones, joints, and soft tissues have continued to improve over time, it is important for orthopaedic surgeons to have an understanding of the etiology, diagnosis, basic treatment principles, and recent advancements to achieve successful outcomes. Although each infectious process is unique, there are certain treatment principles that apply to all pediatric musculoskeletal infections. These include prevention, a prompt and accurate diagnosis, and timely medical and/or surgical intervention. Continued evaluations are mandatory to assure good long-term outcomes. Because the effects of infection may last beyond the acute episode in pediatric patients, long-term follow-up is needed to assess for late sequelae such as angular deformities and limb-length inequalities.

Family study of spondylolysis and spondylolisthesis.

Summary Seventy index patients and 222 first-degree relatives with spondylolysis or spondylolisthesis have been studied by means of interview and clinical and radiologial examinations. The index patients had an average age of 18 years, and included 43 females and 27 males. Following Wiltses classification. 18 patients had dysplastic lesions and 52 had isthmic defects. The first-degree relatives included 99 parents and 125 siblings and children of the index patients. Both isthmic and dysplastic defects occurred in most families, regardless of the classification of the index patient. Isthmic defects were consistently more frequent than dysplastic defects. Spina bifida occulta occurred at the lumbosacral area in 61% of the index patients: in the first-degree relatives, spina bifida occulta was most common among the siblings and children of index patients, and occurred more often in relatives of index patients with dysplastic lesions than in those with isthmic lesions.

Spondylolysis and spondylolisthesis in the child and adolescent athlete.

Spondylolysis and spondylolisthesis are common causes of low back pain in the competitive athlete. Repetitive loading of the lumbar spine results in stress reactions and spondylytic defects of the pars interarticularis. Spondylolysis and lesser degrees of spondylolisthesis frequently respond to activity restrictions, bracing (in specific situations), and physiotherapy. Spinal fusion is indicated for spondylolysis and spondylolisthesis that remain painful despite nonoperative measures and progressive, high-grade spondylolisthesis. Return-to-play guidelines are made for each athlete individually based on his or her specific diagnosis, response to treatment, and sporting activity.

Tibial shaft fractures in children and adolescents.

&NA; Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft‐tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow‐up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10° to be malunion and indicate that 10° of valgus and 5° of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.

CERVICAL SPINE DISORDERS IN CHILDREN

Care of children with disorders of the cervical spine requires an understanding of the anatomic and biologic features particular to the developing pediatric spine. Congenital and developmental alterations further complicate evaluation and treatment of children. Basic knowledge of pediatric cervical spine disorders in Down syndrome, Klippel-Feil syndrome, osteochondrodysplasias, mucopolysaccharidoses, and post-traumatic instability is essential for all orthopedic surgeons. Thorough patient evaluation and appropriate early management may prevent potentially serious neurologic injury and other complications related to cervical spine pathology.

Fractures of the lateral humeral condyle: Role of the cartilage hinge in fracture stability

This study investigates the hypothesis that the integrity of the cartilage hinge at the distal humeral epiphysis determines the stability of fractures of the lateral humeral condyle. Sixteen patients with lateral humeral condyle fractures were studied with radiographs and magnetic resonance imaging (MRI). The clinical course of each patient was compared using these imaging studies to determine whether initial fracture displacement and the integrity of the cartilage hinge correlated with fracture stability. Radiographically, 4 fractures were considered unstable (with initial fracture displacement >3 mm) and 12 were stable (initial displacement ≤3 mm). On MRI, 6 fractures were complete (with disruption of the lateral cartilage hinge) and 10 were incomplete. All unstable fractures had complete fractures on MRI. Ten of the 12 patients with radiographically stable injuries had incomplete fractures on MRI. None of these displaced during treatment. Two patients had radiographically stable fractures and complete fractures on MRI. One of these fractures displaced, confirming the hypothesis that the stability of lateral humeral condyle fractures is related to the integrity of the cartilage hinge.

Radiologic evaluation of juvenile tillaux fractures of the distal tibia.

This study evaluated the accuracy of plain radiographs and computerized tomography (CT) in assessing juvenile Tillaux fractures of the distal tibia. A simulated Tillaux fracture was made in four cadaver specimens and displaced 0, 1, 2, 3, and 5 mm. Plain radiographs and CT were performed on each specimen at each amount of displacement, and the results were compared with the actual amount of displacement present. Plain radiographs and CT were accurate within 1 mm in depicting the actual fracture displacement about 50% of the time. CT was more sensitive than plain radiographs in detecting fractures with >2 mm of displacement. Fracture displacement of >2 mm is generally considered an indication for fracture reduction. Because of its sensitivity in detecting fractures displaced >2 mm, CT is the preferred imaging modality in the assessment of juvenile Tillaux fractures.

Hip fractures in children

&NA; Hip fractures account for <1% of all pediatric fractures. Most are caused by high‐energy mechanisms, but pathologic hip fractures also occur, usually from low‐energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child’s proximal femur is vulnerable to injury. Surgical options vary based on the child’s age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth‐wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.