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BASIC ORTHOPEDIC PEDIATRIC

ASSESMENT
Prof. Dr. Chairuddin Rasjad, PhD

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HISTORY TAKING AND
CLINICAL EXAMINATION
• Birth :
– History : antenatal, birth and family history,
parental concerns
– Examination : heart, respiratory system, skin
appearance, fontanalle, mouth, eye, neck,
abdomen, genitalia, hips and limbs

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HISTORY TAKING AND
CLINICAL EXAMINATION
• Postnatal visit
– History : antenatal, birth and family history,
parental concerns
– Examination : skin appearance, fontanelle, ears,
eyes, mouth, chest inspection and respiration,
umbilicus inspection, upper and lower limbs, spine

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HISTORY TAKING AND
CLINICAL EXAMINATION
• 6 to 8 weeks
– History : antenatal, birth and family history,
parental concerns
– Examination : colour, skin appearance, fontanelle,
ears, eyes, mouth, chest inspection, femoral pulses,
DDH (Ortolani-Barlow maneuver, asymmetry of
appearance and ROM/abduction, risk factors)

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HISTORY TAKING AND
CLINICAL EXAMINATION
• 3 months
– History : antenatal, birth and family history,
parental concerns
– Examination : skin, fontanelle, genitalia, DDH
(asymmetry of appearance and ROM/abduction,
risk factors, Galeazzi sign)

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HISTORY TAKING AND
CLINICAL EXAMINATION
• 18 to 24 months
– History : antenatal, birth and family history,
parental concerns
– Examination : observe walking gait and difference
on leg length

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ASSESMENT, EXAMINATION
TECHNIQUES AND REFERRAL CRITERIA
• Good practice for clinical examination
• An approach for examining children :
– Undressing children
– Adequacy of the examination
– Obtain coorperation
– Developmental skills
– Explain the procedure
– Adapting to the child’s age
– Warm, clean hands
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ASSESMENT AFTER WALKING CHILD
• Inspection
• Observe child walking
• Spinal alignment
• Evaluate ROM
• Muscle strength
• Reflexes

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FOCUSING ASSESMENT
• Pain or tenderness
• Muscle spasm
• Masses
• Soft tissue swelling

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OVERVIEW
1. ETIOLOGY
2. NEWBORN EXAMINATION (RT)
3. OTRHOPEDIC EXAMINATION (SIFFERT)
4. CONGENITAL ANOMALY IN CHILDREN

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Etiology

• Idiophatic ( 60-70 % )

• Genetic factor (10%)  Mutation / Gen transmission

• Environmental factor (20%)  Hormonal, drugs,


nutrition, chemical, radiation, infection, mechanical,
term, immature, anoksia.

• Combination

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Diagnostic
 Prenatal
1. Maternal Screening

2. USG ( 20 weeks)

3. Amniosintesis  Alfa feto protein

4. Chorionic vilus examination

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NEWBORN EXAMINATION
 Examination of the baby should be done throughly (head to toe)
with a Siffert Examination

 With a full examination we can see the anomaly in the newborn

 The most important examination in newborn is Rectal Toucher


(RT)

 Orthopaedic Cheklist (Siffert)

 General

 Local  Neck, Shoulder, Superior extremity, Inferior


extremity, etc

 Additional examination : Imaging, Lab, Biopsy


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Congenital Anomaly
 Anomaly formed and function of body organ which
attach from birth

 Incidence: 3-6 % of birth (normal delivery)

 Divided into two appearance :


 Early Diagnostic

 Late Diagnostic

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TORTICOLLIS MUSCULAR
• Shortening and contracture of the sternocleidomastoid muscle to
one side
• Suffered head and neck flexion lateral and difficult restored to the
normal direction.
• Incidence 0,3%-2.0% live births

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MISSING LIMBS
(CONGENITAL AMPUTATION)

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Congenital Amputation

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SPRENGEL DEFORMITY

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SYNDACTYLY

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SYNDACTYLY

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Poland Syndrome

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POLYDACTYLY

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POLYDACTYLY

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FINGER FOOT APLASIA

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CONGENITAL SCOLIOSIS

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FLAT FEET

Can be occur in a normal children


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LOWER LIMB APPLASIA

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FIBULA APLASIA

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CONGENITAL PSEUDOARTHROSIS

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DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) /
CONGENITAL DISLOCATION OF THE HIP (CDH)
Epidemiology :
- 4 – 10 case/1000 of birth
- 60% cases in a first children
- Girl > Boy = 6 : 1

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• Unstable of the hip in the newborn baby
• Asymmetry in the skin folds of the thighs
• Clinical examination

Ortolani Test Barlow Test

Trendelenberg Test
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Galleazi Test
ORTOLANI TEST :
A newborn baby in the supine position and make an
abduction of the thigh and pulled upward

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BARLOW TEST:
To detect the hip joint in normal circumstances but can occur
due to reduced ROM dislocation abduction of the hip joint.

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GALEAZZI TEST:
• The length of the thigh
joint is dislocated or
seem shorter than on
the healthy side when
the pelvis in flexion 90 °
• Trochanter major look
taller and prominent,
excessive lumbar
lordosis mainly on
bilateral CDH

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DDH with Trendelenburg

(-) (+)

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Developmental Dysplasia of The Hip

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ADDITIONAL EXAMINATION
X-Ray :
• Helpful after the age of 4-6 weeks
• Acetabular index> 30 °
• Shenton line disconnected
• Metaphysical located proximal part of the
femur as a lateral line Perkins (Head of Femur
experience migrating laterally and upward)

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 Head of Femur delayed ossification (normally 6-12
months)
 Centre edge (Wiberg) of less than 20 ° - 25 ° 
subluxasi

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Arthrogram : USG :
To determine if there is Useful after a concentric
constriction of the joint reduction.
capsule by pinching the Indicates the degree of
psoas muscle which acetabular anteversion
resulted reduction of and posterior deficiency
mechanical angle. of the acetabulum.

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Theraphy
Newborns - 6 months :
• Age ideal for therapy.
• Abduction orthosis Pavlik harness, provide flexion and
abduction movement.
• If the therapy is successful, continue diving full time brace to
6-8 weeks until a pelvis stable.

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Infants aged 6-18 months :
• Pavlik Harness use are not effective anymore.
• Allows for manipulation permanently. If it fails then performed
open reduction.
• Reduction therapy with the examination evaluation of
arthrografi:
1.Perform stability reduction.
2.Adductor percutaneous tenotomy.
3.Immobilization with a spica cast.
4.Open reduction of a medial approach (ludloff).

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OSTEOGENESIS IMPERFECTA

Insidence = 1 from 20000 – 60000 birth 42


BLUE SCLERAE

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OSTEOGENESIS IMPERFECTA

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ACHONDRPLASIA

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ARTOGRIPOSIS MULTIPLE BIRTH
(AMYOPLASIA BIRTH)
• Less ROM of the joint
• Aplasia/hipoplasia muskuloskeletal

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ARTOGRIPOSIS MULTIPLE BIRTH
(AMYOPLASIA BIRTH)

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RADIAL CLUB HAND

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CONGENITAL TALIPES EKUINOVARUS
(CONGENITAL CLUBFOOT/CTEV

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UNILATERAL AND BILATERAL

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NEGLECTED CTEV

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THERAPHY

• Conservative method (Ponseti


Method) + Dennis Brown Splint
• Ilizarov Technique
• Operative method (Neglected)

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Ignacio V. Ponseti, MD &
Jose A Morcuende,
MD,PhD

• The Ponseti method is a


manipulative technique
without invasive
surgery.
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• Age 2 days

• GIPS 1

• GIPS 3
• GIPS 2 • GIPS543
• GIPS 4 • GIPS 5

• GIPS 6

• GIPS off
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CTEV correction with Ilizarov Technique

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After correction CTEV

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After serial cast proceed to
‘DENNIS BROWN SPLINT’ for 2 years

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FIBULA HEMIMELIA

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BLOUNT DISEASE

Infantile Juvenile Adolescents

Early onset Late onset


>10 y.o
4-10 y.o
1-4 y.o
Overweight or obese.
Marked obesity Unilateral tibial
involvement
Unilateral: 80% of cases

Etiology : Etiology : genetics,


genetics, race, race and obesity The involved leg
early walking sometimes is shorter
than the opposite leg by
as much as 2-3 cm.

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LANGENSKIOLD STAGING
• Stage I : Irregular metaphyseal
ossification combined with medial
and distal protrusion of the
metaphysis
• Stage II,III, IV - evolves from mild
depression of the medial metaphysis
to a step- off of the medial
metaphysis.

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• Stage V- Increased slope of medial
articular surface and a cleft separating the
medial and lateral epicondyle.
• Stage VI- Bony Bridge across the physis.
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BILATERAL AND UNILATERAL

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RADIOLOGICAL IMAGING

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TREATMENT OF BLOUNT DISEASE

• KAFO (Orthosis)
• Epiphysiodesis :
– Stapler
– Eight Plate and Screw
– Osteotomy (Chairuddin Rasjad Osteotomi
Technique)

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Therapy
• Nonsurgical treatment

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• Surgical treatment
• Internal fixation of tibial osteotomy
• External fixation osteotomy

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Treatment of Blount Disease

Eight plate and screw


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Chairuddin Rasjad Osteotomi Technique

1. Osteotomi Fibula 2. Osteotomi fibula and


graft from fibula 70
Chairuddin Rasjad Osteotomi Technique

3. Inserted plate and screw 4. Plaster


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LEGG CALVE PERTHES (3-11 years old)

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OSTEOMYELITIS
INFECTION AND INFLAMATION
 Non specific (Pyogen)
 Specific (Granulomatous)
Pyogenic bacterial infection (Non Specific)
 Osteomyelitis:
- Acute hematogenous
- Subacute hematogenous
- Chronic
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ACUTE HEMATOGENOUS
OSTEOMYELITIS

Incidence :
• Particularly infants and children
• More frequent in males

Etiology :
• Hemolytic staphylococcus aureus (90%)
• Haemophilus influenza (5-10%)
• B.Coli, pneumococcus, tifosa Salmonella,
Pseudomonas aeroginosa, etc. 74
Spread in two ways:

• Common area (metaphysis) :


– Through circulation
– Embolus through infection
• Local spread :
– Periosteum -> Abses Subperiosteal
– Under the skin -> Cellulitis
– To septic joints -> Arthritis
– Medullary bone circulatory disorders ->
Sequestrum
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A BB C
A C

A. Periosteal edema and swelling of the soft tissues


B. Inflammatory exudate tissue, subperiosteal abscess, cellulitis
C. Periosteal elevation and abscesses in the soft tissues
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Osteomyelitis classification by age :

• In infant
– the absence of an
epiphyseal plate may
allow spread into a
joint.

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• In child
–the path of least
resistance is through
the adjacent cortex
to an extramedullary
abscess.

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• In the mature adolescent
– the thick cortex and
absence of growth plates
allow extension
throughout the
medullary cavity.

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Hematogenous Osteomyelitis in 5 y.o children

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X-ray: early changes such as lucency (arrows)
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The schematic drawing of surgical drainage
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Acute hematogenous osteomyelitis children 6 years
Incision and drainage of pus Subperiosteal
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Chronic Osteomyelitis with sequestrum 85
Bone Chronic osteomyelitis - lower limb bone R in
bone86
children
Chronic osteomyelitis
• Bone thinning and sclerosis
• Cavities with the sequestrum

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Chronic osteomyelitis in metaphysical
distal femur and proximal tibia 88
FRACTURE OF EPHYSIAL PLATE (L)
WITH VALGUS

PRE OP POST OP 89
SLIPPED CAPITAL FEMORAL EPIPHYSIS
( Girls: 8-15 years old; Boys: 10-17 years old)

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IMAGING OF THE SCFE

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CONCLUSION
• Due to many congenital anomalies in newborn
and some are detected several years after
birth we need several examination and follow
up for several years.

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