Pediatric orthopaedics is a subspecialty of orthopaedics that focuses on the musculoskeletal problems common to children and adolescents. Children are not merely, as the saying goes, small adults—many basic differences exist between the orthopaedic problems frequently seen in adults and those prevalent in children and adolescents.
The most unique characteristic of this age group is that they are actively growing; when physicians deal with pediatric musculoskeletal problems, they must consider the effect further growth will have on any treatments and on the anticipated outcomes.
In recognizing and emphasizing such differences, this subspecialty has opened the door to more careful study of both common and rare afflictions of the musculoskeletal system, which has led upgraded treatment protocols and improved prognoses for many abnormalities.
The pediatric and orthopaedic surgeons at MedStar Health specialize in a wide range of diseases and abnormalities in children and adolescents, including:
- Routine pediatric orthopaedic injuries and conditions
- Hip dysplasia
- In-toeing and out-toeing
- Perthes disease
- Slipped epiphysis
- Sports injuries
- Neuromuscular conditions with spasticity
- Cerebral palsy
- Traumatic brain injuries
- Limb lengthening
A clubfoot is a foot that is deformed at birth, pointing downward and inward as well as rotated. There are four different types of clubfeet: positional, teratologic, syndromic, and congenital. A positional clubfoot is a normal foot that was held in an abnormal position in the uterus. The bony alignment is normal and the foot is usually corrected by stretching or a short course of casting. A teratologic clubfoot is associated with neurologic disorders such as spina bifida. A syndromic clubfoot is associated with an overall genetic syndrome such as arthrogryposis. Both teratologic and sydromic clubfeet almost always require surgery as definitive treatment, although casting does help stretch the soft tissues in preparation for surgery. A congenital clubfoot is a foot with abnormal bony deformity present at birth but not associated with any neuromuscular cause or syndrome. The remainder of this discussion will focus on congenital clubfeet.
In an infant, clubfoot itself is not painful. The bones are abnormally shaped and the tendons, muscles, and ligaments are tight. The foot and calf are usually smaller than normal, and the muscles may be weaker and the nerves may be abnormal. Often the blood supply is abnormal as well. Due to differences in clubfoot, treatments and outcomes may vary. If untreated, the deformity does not improve on its own. Rather, the deformity worsens, and if left uncorrected, will become unsightly and crippling, leading to children walking on the top rather than the bottom of their foot. This eventually creates skin breakdown, ulceration, and infection, and can ultimately lead to an amputation in the most severe untreated cases.
Treatment begins as soon as possible after birth. This usually involves manipulation of the foot into the best possible position and holding it with a long leg casting. However, different physicians may use other treatments such as physical therapy, splints, taping, and short leg casts.
No matter what the treatment, the goal is to create a foot with the sole on the ground, which is flexible and pain free. Most children with corrected clubfeet will be able to participate in most aspects of childhood with little or no difficulty and do well into their adult years. Even after growth is complete, the patient with a clubfoot will need to be followed into their adult years to ensure a well functioning foot.
Fractures in children differ significantly from fractures in adults.
For instance, covering the surface of all bones is a membrane called the periosteum; a child's periosteum is thicker than an adult periosteum and contains active, bone-making cells with a very rich blood supply. Therefore, children's fractures heal much more rapidly than adult fractures.
Children rarely need physical therapy after their fractures heal—once a child's fracture heals and any cast is removed, normal use of the extremity is all that is required to restore function. Additionally, joint stiffness in children is quite uncommon, whereas in adults it is of much greater concern.
However, pitfalls also exist in children's fractures. At the end of each long bone (for example, the bones in arms or legs), children have a soft cartilage growth plate. This growth plate is sensitive to trauma or injury. On occasion, it can close or partially close, which means it can stop growing, leaving a child with a shortened bone or, more commonly, an angular deformity of the arm or leg.
With very severe or unusual injures—such as fractures around the elbow, adjacent to joints, or in or near growth plates—surgery may be necessary to realign the fractured pieces of bone.
Leg Length Discrepancy
Leg length discrepancy, a difference between the lengths of the lower limbs, can occur in children for a number of reasons. A small leg length discrepancy (a quarter of an inch or less) is quite common in the general population and of no clinical significance. Larger leg length discrepancies, though, become more significant.
Frequently, the condition follows a fracture—broken bones in children sometimes grow faster for several years after healing (resulting in a longer leg). If the break occurs in the growth center near the end of the bone, however, it can cause slower growth (resulting in a shorter leg).
A congenital abnormality associated with a condition called hemihypertrophy (asymmetrical body growth) can also lead to leg length discrepancy. Or, it may result from neuromuscular diseases such as polio and cerebral palsy. Still, many times, no cause can be identified.
The long-term consequences of a leg length discrepancy may include knee pain, back pain, and abnormal gait or limp.
To evaluate the condition, Medstar Health specialists will take sequential x-rays to measure the exact discrepancy, while following its progression, and can establish a treatment plan once all the facts are known: the bone age (skeletal age and chronological age are not necessarily equal—frequently, a child's bone age will be significantly different), the exact amount of discrepancy, and the cause, if it can be identified.