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14 visible knowledge nodes in pediatrics
Achondroplasia — Orthopaedic Issues
Autosomal dominant **FGFR3** mutation → rhizomelic limb shortening with normal trunk, macrocephaly. Neonates risk **foramen magnum stenosis** and central apnea; screen in infancy. Orthopaedic: **thoracolumbar kyphosis**, **genu varum**, and **lumbar spinal stenosis** in adulthood. Management includes posture/physio, guided growth or tibial osteotomy for varus, and decompressive laminectomy when symptomatic stenosis. Discuss limb lengthening carefully—psychosocial and complication considerations.
Open topicBlount’s Disease — Langenskiöld Classification
Pathologic varus from disordered endochondral growth of medial proximal tibial physis; early walkers/obesity risk. **Langenskiöld stages I–VI** describe progressive physeal/epiphyseal changes (beaking → depression → physeal bar). Differentiate from physiologic bowing using **metaphyseal–diaphyseal angle** (>11° suggests Blount). Management: **Bracing** in early Stage I–II (
Open topicClubfoot — Ponseti Technique
Correct deformities in **CAVE** order: **C**avus → **A**dductus → **V**arus → **E**quinus. Use **Ponseti casting** with abduction and supination around talar head; avoid pronation/forceful correction. Most require **percutaneous Achilles tenotomy** before final cast. Maintain with **foot abduction brace (FAB)** 23 h/day initially, then during sleep until 4–5 yrs to prevent relapse. Atypical/complex clubfoot needs modified slower casts; beware dorsal creases and short forefoot.
Open topicCongenital Talipes Equinovarus — Relapse & Tibialis Transfer
Relapse often due to **brace non‑compliance**; dynamic supination is common in toddlers. Initial management is **re‑casting** following Ponseti principles; evaluate for residual equinus/adductus. **Tibialis Anterior Tendon Transfer (TATT)** indicated for persistent dynamic supination after walking age. Technique: split or whole TATT to lateral cuneiform (through bone tunnel or anchors) with foot held in dorsiflexion/eversion. Severe rigid relapses may require posteromedial release or external fi...
Open topicDevelopmental Dysplasia of Hip (DDH) — Pavlik to Osteotomy
Early detection with Barlow/Ortolani; ultrasound (Graf) guides treatment under 6 months. Pavlik harness is first‑line for reducible dislocation under ~6 months; avoid excessive extension/abduction to reduce AVN risk. Failed Pavlik → closed reduction and spica; if unstable/obstructed, open reduction with capsulorrhaphy and femoral shortening/derotation as needed. Residual acetabular dysplasia treated with pelvic osteotomies (Salter, Pemberton, Dega) based on age and pathology. Complications: AVN...
Open topicEpiphyseal Growth Plate — Zones & Regulation
Zones: reserve (resting), proliferative, hypertrophic (maturation, degeneration, provisional calcification). Regulation: Ihh/PTHrP feedback loop, GH/IGF‑1 axis, local factors (TGF‑β, BMPs, FGFs, Wnt). Hypertrophic zone is weakest → site of Salter‑Harris fractures. Vascular invasion and endochondral ossification occur at metaphyseal side. Clinical: growth arrest, bar formation, angular deformity after physeal injury; SCFE affects hypertrophic zone. Imaging: physeal widening (rickets), metaphyseal...
Open topicLegg‑Calvé‑Perthes — Staging & Prognosis
Idiopathic avascular necrosis of capital femoral epiphysis in 4–8‑year‑olds (boys > girls). Radiographic **Waldenström stages**: Initial, Fragmentation, Re‑ossification, Healed. **Prognosis/Severity**: **Catterall** (I–IV) and **Herring (lateral pillar)** (A–C); age >6 yrs and Herring C predict poorer outcomes. Goal: **containment** of the femoral head within acetabulum to maintain sphericity (abduction bracing or osteotomy). MRI detects early marrow changes; lateral extrusion (loss of containme...
Open topicOsteogenesis Imperfecta — Sillence Types
OI due to COL1A1/2 defects; **Sillence I–IV** (classic) with expanded types V–VII; severity ranges from mild to perinatal lethal. Clinical: **blue sclerae**, dentinogenesis imperfecta, ligamentous laxity, short stature, recurrent fractures, hearing loss. Medical therapy: **bisphosphonates** (IV pamidronate/zoledronate) improve BMD and reduce fracture rate. Surgical: **intramedullary rodding** (telescopic Fassier–Duval) to correct deformity and reduce fractures. Multidisciplinary care: dental, au...
Open topicPediatric Supracondylar Humerus Fracture
Gartland I–III (± IV for multidirectional instability). Complications to watch: **brachial artery injury**, **median/anterior interosseous nerve palsy**, **compartment syndrome**, **cubitus varus**. Radiographic checks: **Baumann angle**, **anterior humeral line** intersecting capitellum, and **medial comminution** (varus risk). Preferred fixation: **crossed pins** for maximal stability vs **lateral‑entry 2–3 pins** to avoid ulnar nerve injury—technique‑dependent choice. Urgent reduction/pinning...
Open topicPhyseal Injuries — Salter–Harris & Ogden
Physis has zonal architecture; hypertrophic zone is weakest and fails in most injuries. Salter–Harris I–V (Slip, Above, Lower, Through, Rammed) with Ogden’s extension (VI–IX). Aim for **anatomic reduction**, especially for SH III–IV to prevent joint incongruity and growth arrest. Consider percutaneous reduction techniques to minimize physeal damage; avoid repeated forceful attempts. Long‑term surveillance for growth disturbance with Park–Harris lines and contralateral comparison.
Open topicProximal Tibia Metaphyseal Fractures — Pediatrics
Occurs in ages 3–6; risk of late valgus (Cozen phenomenon) due to asymmetric overgrowth. Usually metaphyseal greenstick/complete fractures from low‑energy mechanisms (trampoline, slide). Treat with long‑leg cast in slight varus; close follow‑up for 12–18 months. Most remodel; corrective osteotomy for persistent valgus >10–15° after growth potential declines. Beware associated fibular injury and compartment syndrome (rare).
Open topicRickets — Orthopaedic Sequelae
Failure of mineralization at the growth plate → metaphyseal cupping, fraying, and splaying with genu varum/valgum. Differentiate **nutritional vitamin D deficiency** from **X‑linked hypophosphatemic rickets (XLH)** and renal rickets; labs guide diagnosis. Medical therapy first: vitamin D and calcium for nutritional; **phosphate + active vitamin D** (calcitriol) for XLH; burosumab in select cases. Orthopaedic: guided growth hemiepiphysiodesis for coronal deformity; corrective osteotomy when sever...
Open topicSCFE — Loder Classification & Fixation
Loder classification: **Stable** (able to walk, even with aids) vs **Unstable** (non‑ambulatory) — strongest predictor of AVN. Typical patient: obese adolescent (boys > girls), endocrine risk (hypothyroid, GH therapy). Imaging: AP pelvis and frog‑leg lateral; Klein’s line, Trethowan sign; quantify slip by **Southwick angle**. Treatment: **In‑situ single‑screw fixation** for stable slips; **urgent gentle reduction and pinning** for unstable slips in theater with minimal manipulation. Consider **c...
Open topicTibial Spine Avulsion — Pediatrics
Pediatric equivalent of ACL tear — bony avulsion of tibial eminence. Meyers–McKeever Types I–III (and IV comminuted) guide management. Type I: cast in extension; II–III/IV: arthroscopic reduction and fixation (sutures or screws). Beware entrapped intermeniscal ligament or meniscal tissue blocking reduction. Rehab mirrors ACL protocols with protected ROM initially.
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