Miss Veronique Spiteri

Paediatric Orthopaedic Consultant

Birmingham Children’s Hospital

Familiarise with commonly encountered paediatric foot and ankle pathology◦ Elective

◦ Trauma

Assessment

Common pitfalls

Management

Short heel cord

Calcaneal apophysitis – Sever’s

Positional calcaneovalgus

Cavus

Clubfoot

Flatfoot

Metatarsus adductus

Toe deformities

Footwear/orthotics

Gait

Shape

Deformity

Flexibility

Skin – abrasions, blisters, callosities, redness

Congenital/Acquired◦ Inability to dorsiflex ankle to at least 10 degrees

above neutral

Treatment ◦ None/high heeled shoes

◦ Serial casting followed by night time splints

◦ Surgery if symptomatic with pain/functional disability

Gastrocnemius / Tendo-Achilles lengthening

Overuse of calacaneal apophysis

Treatment ◦ Activity modification

◦ Achilles stretches

◦ Below knee cast/boot

Corrects without treatment

Most parents are instructed to perform plantar flexion exercises

Acquired

Progressive

Usually associated with neuromuscular disorders

Congenital ◦ Cavus

◦ Adductus

◦ Varus

◦ Equinus

Not correctable passively.

Ponsetti treatment◦ Serial casting +/- Achilles tenotomy

Surgery

Flexible Physiologically normal – No treatment required.

Various insoles used for activity related pain

Flexible – Tight gastrocnemius/ Achilles◦ Stetching exercises

◦ Soft orthosis

◦ Surgery

Flexibility of foot

Congenital

Most correct by age 3

If rigid – serial casting (long leg cast with slight plantar flexion and inversion)

Surgery

? Congenital

Treatment ◦ Footwear modification

◦ Surgery if painful and over-riding on 2nd toe

Polydactyly

Syndactyly

Congenital / Idiopathic

Stretching

Footwear

Surgery (varus and rotation correct gradually)

Injury produces a significant health burden for children, being a leading cause of death and disability

5,402 Children under 16 entered between Jan 13-Dec 14 (119 fatal)

30-60% of ED attendances

About 4 million attendances to ED yearly

Two thirds occur in males

Two Peaks◦ Under 1 year

◦ Second peak – 6 to 13 years

Non-accidental injury 10% of causes for severe injury children under 2 years.

RTA – cause of severe injury in 40% of cases◦ Pedestrians and cyclists – 20%

Cycling injuries more commonly in boys

Horse riding in girls

Sports like – baseball, basketball and football

ABC

GCS – AVPU

Orthopedic injuries

Primary cause of operative intervention in pediatric trauma

Greenstick and buckle fractures

Growth plate injury

Supracondylar fractures

Immobilize and monitor vascular status

Vascular injury

95% limb salvage

30-40% of children involved in major trauma have at least 1 skeletal injury

Assessment and documentation of neurovascular is essential

Primary treatment is effective splinting of the fractured limb and covering of wounds

◦ Reduces pain, bleeding and incidence of fat emboli

Skeletal maturity & pre-existing conditions (OI, osteopenia) influence fracture pattern

Kinetic energy determines the severity and features of a particular fracture – open/closed

Open fractures in children younger than school age – rare Increased protective subcutaneous fat and small body mass

Limited exposure to high risk activities

Loss of life rather than simple injury

Associated soft tissue injury may be significant

Characterised by ◦ Contusions

◦ Deep abrasions

◦ Burns

◦ Separation of superficial skin layers

Can result in full thickness loss of tissue and infection.

Treat as an open fracture

Restoration and preservation of vital functions

Prevention of wound infection

Healing of the soft tissue

Restoration of bony anatomy and union

Recovery of optimal physical and psychosocial function

Wounds covered with sterile dressing and control of bleeding

Gentle traction to align fracture fragments and manipulation followed by splinting for transport

Full history and examination

Tetanus prophylaxis

Antibiotics as required

Vascular injuries (pressure dressings..)

Knee

Tibial Shaft

Ankle

Foot

Supracondylar fractures Salter Harris / Physeal fractures

Cast for non displaced fractures K-wires /ORIF for displaced fractures

High energy required for a fracture of the distal femoral physis makes it more likely to have resultant growth abnormalities

Leg length inequality <2cm require no treatment 2-5 cm epiphysiodesis >5cm lengthen

Osteochondral fractures: Mainly adolescents due to sports

Ligamentous injuries – ACL,PCL

Patellar dislocations ◦ Cricket pad splints

Patella fractures – same as in adults ◦ cylinder cast for undisplaced fractures

◦ TBW – displacement >3mm/step of articular surface

8-12 year olds

POP 6weeks ? Hyperextension and xray

Others 10 degrees to 30 degrees flexion to relax ACL

ORIF if displaced

Metaphyseal –uncommon

NAI

Toddlers fracture-9mths-6 yrs – Long leg cast 2-4 wks

Long leg cast Varus less than 15

degrees Correct angular and

rotational deformity Weekly x-ray 3 weeks Might require wedging

Knee and ankle seen in the same plane

Wide variation of injuries – simple sprain (Salter Harris I) to dislocation

Same principles as adult – reduce dislocation and maintain in POP

Might be difficult due to periosteal interposition

Assess NV status

May require CT – to assess fracture

ORIF accordingly

2nd decade

Medial growth plate closed. Lateral still open.

Salter Harris III on AP and IV on lateral views

Requires CT and ORIF

Dislocations

Most fractures do not require surgery. May need manipulation and neighbour strapping or POP/boot for comfort

Metatarsal fractures (90% of foot fractures in Cincinnati Children’s hospital) Avulsion base of 5th MT

Easily missed or delayed diagnosis in children due to limited ability to communicate

Misconception that compartment syndrome is less common in open fractures. HIGHER in Type III open fractures in children sustaining

multiple injuries

Monitor pressures (>30mmHg above diastolic) if high risk or ischaemic time greater than 4 hours. Decompress multiple compartments. Usually possible to have a delayed primary closure

without the need for skin grafts

5 Ps PAIN Pallor Paresthesia Paralysis Pulseless

Restless, agitation, anxiety Pain with passive stretch

Release all dressings and re-assess. Do not increase elevation excessively. (level of heart).

If no improvement – decompress compartments (not in foot)

As a result of power tools / machinery (lawn mowers – 42% of amputations in children under 10 years)

US – 85% of injuries preventable if children less than 14 years old not allowed near lawn mowers

Seasonal

No definite guidelines in paediatrics

Unrestorable blood supply >6 hours

Unrestorable loss of muscle, serious secondary bone/soft tissue injury in same extremity

MESS >7

NO LONGER using loss of plantar sensatation as an indication for amputation (neuropraxia)

If possible decision to amputate taken at initial debridement – better long term results (adults)

Special Considerations in children with traumatic amputations:

Potential for future growth

Better healing ability

Terminal bony overgrowth

Psychological and social factors

Consider preservation of growth plate during amputation◦ Distal femur provides 70% growth – AKA early

would result in a very short stump and possible difficulties with prosthetic fitting

◦ Estimate of growth remaining in limb to decide length of amputated segment

Bony overgrowth in metaphyseal/diapyseal amputations. – Most common in tibia

Questions ?