• BONE FRACTURE

• BRACHIAL PLEXUS INJURY

• CONGENITAL DEFORMITY
• CEREBRAL PALSY
• DEVELOPMENTAL DYSPLASTIC HIP DISEASE (
DDH )
• BENIGN BONE AND SOFT TISSUE TUMOR
• MALIGNANT BONE AND SOFT TISSUE TUMOR
• A child’s bones heal faster than an adult’s
because a thicker, stronger, and more
active dense fibrous membrane of
periosteum
• causes a better supply of oxygen and
nutrients to the bones
• a more rapid union of fractured bones and
an increased potential for remodelling
• Bones are softer in children and tend to
buckle or bend rather than completely
break.
• Injury to the epiphysis can lead to limb
length discrepancies or angular
deformities.
• Low bone mineral content
renal diseases
cystic fibrosis
diabetes mellitus
growth hormone deficiency,
osteogenesis imperfecta
Neuromuscular disorders: cerebral
palsy, spina bifida, and arthrogryposis
• Fracture personality : Children with
high activity levels.
• Child abuse
• Greenstick fracture
• Torus or buckle fracture
• Bowing fracture
• Fingertips crushed in a slamming
door
• Put their fingers into machinery or
other equipment
• Falls
• Sports : falls, twisting, or direct
blows or impact to the hand or
wrist.
• finger, wrist, or forearm is not in normal
alignment
• Pain in the injured area
• Swelling in the injured area
• Obvious deformity in the injured area
• Difficulty using or moving the injured area
in a normal manner
• Warmth, bruising, or redness in the injured
area
• Cast immobilization
• Functional cast or brace
• Traction
• Open reduction and internal
fixation
• External fixation
• Analgesic
• Erb’s Palsy, or Erb’s Duchenne Palsy
• Klumpke’s Palsy
• Total Plexus Palsy
•Mechanism
•results from excessive abduction of head away from shoulder, producing traction on
plexus
•occurs during difficult delivery in infants

•Physical exam
•adducted, internally rotated shoulder; pronated forearm, extended elbow (“waiter’s
tip”)
•C5 deficiency
•axilllary nerve deficiency
•deltoid, teres minor weakness
•suprascapular nerve deficiency
•supraspinatus, infraspinatus weakness
•musculocutaneous nerve deficiency
•biceps weakness
•C6 deficiency
•radial nerve deficiency
•brachioradialis, supinator weakness
•Prognosis
•best prognosis for spontaneous recovery
•Mechanism
•rare in obstetric palsy
•usually arm presentation with subsequent traction/abduction from trunk
•Physical exam
•deficit of all of the small muscles of the hand (ulnar and median nerves)
•“claw hand”
•wrist in extreme extension because of the unopposed wrist extensors
•hyperextension of MCP due to loss of hand intrinsics
•flexion of IP joints due to loss of hand intrinsics
•Prognosis
•poor prognosis for spontaneous recovery
•frequently associated with a preganglionic injury and Horner's Syndrome
• Physical exam
– flaccid arm
– both motor and sensory deficits
• Prognosis
– worst prognosis
• Gestational diabetes
• Maternal obesity
• High birth weight
• Disproportionate birth canal length in relation to
the fetus
• Prolonged labor with or without use of
forceps/vacuum for extraction
• Rapid labor which can cause the baby to be
pushed out so fast that the arm gets
stuck, without access to medical assistance
• Breech presentation at birth
• Shoulder dystocia, or dislocation
• Use of forceps or vacuum suction during delivery
• Difficulty lifting arm above head
• Difficulty bringing objects to
mouth
• Difficulty moving fingers
• Lack of sensation in arm, hand or
fingers
• Tingling or pain in arm, hand or
fingers
• Decreased innervation
• Decreased strength and stamina
• Altered movement and biomechanics
• Impaired balance and coordination
• Decreased bimanual dexterity
• Muscle atrophy
• Impaired bone growth
• Joint dysfunction
• Osteoarthritis
• Limb length discrepancy
• Scapular winging
• Glenohumeral dysplasia
• Scoliosis
•Muscles contractures lead to the characteristic deformity that includes
(CAVE) midfoot Cavus (tight intrinsics, FHL, FDL)
•forefoot Adductus (tight tibialis posterior)
•hindfoot Varus (tight tendoachilles, tibialis posterior, tibialis anterior)
•hindfoot Equinus (tight tendoachilles)
•Bony deformity consists of
•talar neck is medially and plantarly deviated
•calcaneus is in varus and rotated medially around talus
•navicular and cuboid are displaced medially
•Table of foot deformity muscle imbalances
Physical exam
•inspection
•small foot and calf
•shortened tibia
•medial and posterior foot skin creases
•foot deformities
•hindfoot in equinus and varus
•differentiated from more common positional foot deformities by
rigid equinus and resistance to passive correction
•midfoot in cavus
•forefoot in adduction
•Radiographs
•recommended views
•dorsiflexion lateral (Turco view)
•shows hindfoot parallelism between the talus and calcaneus
•will see talocalcaneal angle < 35° and flat talar head (normal is
talocalcaneal angle >35°)
•AP
•talocalcaneal (Kite) angle is < 20° (normal is 20-40°)
•talus-first metatarsal angle is negative (normal is 0-20°)
•also shows hindfoot parallelism
•Ultrasound
•helpful in prenatal diagnosis (high false positive rate)
•can be diagnosed as early as 12 weeks of gestational age
•Nonoperative
•serial manipulation and casting (Ponseti method)

•Operative
•posteromedial soft tissue release and tendon lengthening
•medial column lenthening or lateral column-shortening osteotomy,
or cuboid decancellation
•triple arthrodesis
•talectomy
•multiplanar supramalleolar osteotomy
• Syndactyly
• Polydactyly
• Hemimelia
• The term Cerebral palsy includes a group of
disorders which result from non-progressive
brain damage during early development.
• Most often the problems occur during
pregnancy; however, they may also occur
during childbirth, or shortly after birth.
• The incidence is about 2 per 1000 live births.
• The main consequences are the developmental
of neuromuscular inco-ordination, dystonia,
weakness and spasticity; in addition, there may
be convulsions, perceptual problems, speech
disorder and mental retardation.
 Neurological Musculoskeletal Associated Problems

• Muscle Weakness  Contractures • Epilepsy

• Abnormal Muscle Tone  Deformities • Visual Problems
• Balance Problems • Hearing Loss
• Loss of Selective Control • Speech and
• Pathological Reflexes Communication
• Loss of Sensation • Feeding Difficulty &
• Swallowing Difficulty Failure to Thrive
• Respiratory
Problems
• Incontinence
• Intellectual
Impairmen
EARLY DIAGNOSIS LATE DIAGNOSIS
• history of perinatal • develop of symptoms
complications may be such as severe
helpful adhetosis, others are
• early symptoms such ataxia
as difficulty in sucking • majority have spastic
and swallowing paresis
• mother noticed baby • children often
feels stiff or wriggles emotionally unstable
awkwardly • sometimes having fits
• delayed • impaired intelligence
developmental
milestones
• treatment is best carried out in a special
center where there are combined
physiotheraphy, occupational therapy,
speech therapyand remedial education.
• medication - to control fits and
hyperactivity
• splintage - to counteract spastic
deformities or to hold position after
surgery
• corrective surgery
• the condition formerly known as
congenital dislocation of the hip.
• the reported incidence was 5-20 per 1000
live birth.
• girls are much more often affected than
boys about 7:1
• left hip is often affected than right; 1 in 5
cases ondition is blateral
Neonatal Diagnosis
1. Newborn : Positive Barlows and Ortolani test
2. Furthur ultrasonography, if there is signs of instability.

Late Features
1. All children should be examined again at 6 months, 12 months and 18 months -
to be sure that late-appearing signs are not missed.
2. Unilateral dislocation
 Delayed walking will be noticed by parents.
 Skin creases asymmetrical.
 Hip does not fully abduct.
 Leg slightly short (Galleazi Test ) and rotated internally.
4. Bilateral dislocation
 Perineal gap abnormally wide
 waddling gait ( may be mistaken with normal toddling)
5. On x ray examination-
 the bony part of the acetabular roof slopes upwards abnormally
 Socket unusually shallow.
 Underdeveloped femoral head.
signs :
6. Ortoloni test (test reducibility) - abduct
 passively flex hips to 90deg and ABDUCT -> on
impeded hip abduction apply pressure on greater
trochantar -> fell clunk as dislocation reduces and
hip aducts fully
 normally smooth abduction to 90deg

7. Barlow's Test
 Dislocate the hip by flexing the hip joint
abd adducting it followed by posterior
force in the line of the shaft of the femur.
8. Tredenlenburgh's test positive
• Goal management is to achieve concentrically reduced and
stable hips with good acetabular cover ( to avoid early
Osteoarthritis )
– the earlier the treatment the likelier the child will develop a normal
hip
• 0-6 months
– double the napkins or with abduction pillow between the legs for
the first 6 weeks
– those wiith stable hips, observe for at least 6 months.
– those with persistent instability, treated by formal abduction
splintage until hips is stable and shows that acetabular roof is
developing satisfactorily(3-6months)
• 6 months -6 years
– closed reduction
– splintage
– open reduction
• beyond 6 years
– unilateral dislocation = operative reduction still feasible
– bilaterla dislocation = high risk asymmetrical deformity if failure of
one side
Benign:
• Osteoid osteoma and osteoblastoma
• Osteochondroma
• Fibrous dysplasia

Malignant:
• Osteosarcoma
• Ewing sarcoma
 Both are benign neoplasm with very similar histologic features with male predilection
(2:1 for osteoid osteomas)

 They re distinguished from each other primarily by their size and clinical presentation.

 Osteoid osteoma--- arise most often beneath the periosteum or within the cortex in
the proximal femur and tibia or posterior spinal elements and are by definition less
than 2cm , whereas osteoblastoma are larger.

 Localised pain ,most severe at night , is an almost universal complaint of osteoid

osteoma , and is relieved by aspirin.

 Osteoblastoma arise most often in the vertebral column, they also cause pain ,
although it often is more difficult to localize and is not responsive to aspirin.

 Local excision is the treatment of choice; incompletely resected lesions can recur.
• Cortically based sclerotic lesion
with a small central lucency
• are relatively common benign, cartilage-capped tumor
attached by a bony stalk to the underlying skeleton.

• Related to the periphery of the growth plate

• Femur & Tibia are the commonest sites

• Cortex is continuous with the normal bone

• Base is sessile or pedunculated

• In many cases , they are incidental findings. In multiple

hereditary osteochondromas, deformity of the
underlying bone suggests an associated disturbance in
epiphyseal growth.
 Osteochondromas are slow-growing masses that can be
painful if they impinge on a nerve or if the stalk is
fractured.

 Treatment is symptomatic
 Fibrous dysplasia is a benign tumor in which all
components of normal bone are present, but they fail to
differentiate into mature structures.

Fibrous dysplasia manifest with one of three clinical

patterns:
1) Involvement of a single bone (monostotic) – 70%
2) Involvement of multiple bone (polyostotic)
3) Polyostotic disease, associated with café au lait skin
pigmentations and endocrine abnormalities, especially
precocious puberty (McCune-Albright syndrome)
 Most commonly affected sites are ribs , femur ,
tibia , jawbones, calvariae and humerus

--Lesions often are asymptomatic and

frequently discovered incidentally, however,
fibrous dysplasia can cause marked enlargement
and distortion of bone, so that if the face or
skull involved, disfigurement can occur, or it can
cause pain and pathologic fracture.

Fibrous Dysplasia
“ground-glass"
matrix .
• Malignant bone tumor that produces osteoid
or bone
• Most common primary tumour (excluding
multiple myeloma and lymphoma)
• 70% have acquired genetic abnormalities esp
mutations in:
 RB, the retinoblastoma gene, a critical cell cycle
regulator
 p53, a gene whose product regulates DNA repair
• Bimodal age distribution;
– 75%: in < 20 y/o
– 2nd peak in the elderly frequently secondary to
Paget disease, bone infarcts, and prior irradiation
• M/F: 1.6 : 1
• Usually arise in the metaphyseal region of the
long bones of the extremities
• 50% occur about the knee
Major sites of origin of osteosarcomas
 Clinical features:
-Painful, progressively enlarging masses.

 Radiological features:

Sunburst appearance: reactive periosteal bone formation

Codman triangle : triangular shadow between the cortex and raised
ends of periosteum

Periosteal reaction
gives the appearance Codman triangle (arrow).
of a sunburst.
Gross:
– big, bulky, gritty, gray-white mass with areas of hemorrhage
– destroy the surrounding cortices and produce soft-tissue masses

Metastasis:
• 10-20% pulmonary metastases at the time of diagnosis

Treatment:
– Preoperative chemotherapy ; Excision / amputation

The tan-white tumor fills most

of the medullary cavity and
has infiltrated through the
cortex, lifted the periosteum,
and formed soft-tissue masses
on both sides of the bone
• Small round cell tumor that show varying degrees of
neuroectodermal differentiation

• Of 85% of cases have a t(11;22) translocation with resulting EWS-

FLI1 fusion gene.

• Age; 5-20 y.o -Predilection for males

• Of cases, 80% occur in children younger than 20; there is a male

predominance.

• Presented with pain and swelling of affected area

Sites:
• Long bones (more lower extremities)
• Intramedullary, diaphyseal location
• Pelvis and ribs are also common locations
Grossly:

 Gray-white intramedullary mass that is

soft, glistening and moist
 Often necrotic and haemorrhagic
 m/b watery and have the appearance of
pus

Treatment:

 Surgery and chemotherapy may be

combined with radiation therapy. There
is large-term survival in approximately
50% of cases.
References:
 Robbins basic pathology , ninth
edition
 Apley's Consice System of
Orthopaedics