PAEDIATRIC CONDITION

CTEV
CEREBRAL PALSY
DDH
SUFE
Perthes’ Disease
Polidactily
Syndactily
Constrictions band syndrome
Osteogenesis Imperfecta
AMC

Dr. Robert Tirtowijoyo, Sp.OT

Bagian Ortopedi & Traumatologi
 CLUB FOOT
Congenital Talipes equinovarus (CTEV)
1. Anatomy
2. Etiology
3. Pathoanatomy
4. Evaluation (Grading of Severity)
5. Treatment
a. non operative treatment
b. operative treatment
 ETIOLOGY
Theories
 Genetic  gene mutation
 Enterovirus  8 weeks gestation
 Abnormal intra uterine force
 Arrested fetal development
 Abnormal muscle and tendon insertion
 Abnormal rotation talus
 Germ plasma defects (primary bone dysplasia of the talus
 PATHOANATOMY
 Talus – abnormal shape and relationships
 Plantar flexors and invertor shortened
 Contracted --- joint capsule, ligament and fascia
Evaluation (grading of severety)
TREATMENT
NON SURGICAL
 Shortly after birth
 Gentle manipulation (should not
injure cartilage)
 Retention cast
 Weekly cast changes

SURGICAL
 When no further correction
by manipulation
 Soft tissue procedure
 Bone procedure
Non surgical treatment :
a. Ponsetti method
b. Kite’s and Lovell
c. French method
Complication Surgery :
1. Recurrence
2. Over correction
3. Stiffness
4. Pain
 Result Not Completely Normal
 Goal of Treatment
 Plantigrade foot
 Pain free
 Stable over time
 Near anatomically normal
 Normal shoes
 No satisfactory standardized evaluation
Radiology no correlation with the function
Percutaneous Tenotomy ( LA )
2 MONTH 1 YEARS
Use of the foot abduction orthosis following Ponseti casts
 7 Year

1ST Cast 2nd Cast

After The 6th Cast
Plantigrade Feet
Before op. 2 Months Postop
Cerebral Palsy
 Cerebral Palsy
 A non-progressive disorder
 Caused by brain injury pre (70-80%), or postnatal
 Injure occurs before CNS reaches maturity
 Pathology
Of
Cerebral Palsy
 Etiology of CP
 Congenital cerebral defects
 Anoxia at birth
 Hemorrhage at birth
 Pre-maturity
 Infection Toxemia of pregnancy
 Rh incompatibility
 Developmental abnormalities
Clinical Assessment :
Is the Diagnosis CP ?
 History
 Physical Examination
 Investigations : US, CT, MRI
Clinical Assessment :
 Birth History
 Milestones
 Tone
 Deformities
 Radiology
Clinical Assessment :
 Classify CP
 Movement disorder
 Topographical Distribution
 Gross Motor Function
Motor Type Topography
 Spastic  Monoplegia
 Mixed  Hemiplegia
 Dystonic  Diplegia
 Hypotonic  Triplegia
 Ataxic  Quadriplegia
 Spastic hemiplegia spastic diplegia

athetoid cerebral palsy spastic quadriplegia

Manifestations
 Malfunction of motor centers
 Postural and balance difficulties
 Normal life expectancy possible
 Early death respiratory involvement
Characteristics
 Impaired movements
 65% speech defects
 50% are mentally retarded
 50% ocular defects
 25% hearing impairment
 40% seizure disorders
 20% seriously disabled
Head and Neck Findings
 24% inability to chew
 20% inability to swallow easily
 20% frequent dental caries
Spastic CP Findings
 52% of all CPs
 Hyperirritability of muscles
 Arms flexed, legs internally rotated
 Difficulty bending into a sitting position
 Difficulty with head control
 Postural difficulty
 May not have protective extension
 Speech impairment
 Swallowing impairment/drooling
 Spastic tongue thrust
 Primitive reflexes
MULTIDISCIPLINARY CP TEAM
Priorities of a CP Child
 Communication
 Personal hygiene
 Mobility
 Walking
 The Surgical
Treatment of
Cerebral Palsy
Surgery WILL
NOT
make the child
stronger
or
walk earlier
 SOFT TISSUE PROCEDURES
Tenotomy or Lengthening ?
 Tenotomy > muscle weakening
< recurrence
 Lengthening < muscle weakening
> recurrence
Development Dysplasias of the HIP
 L DDH

Bilateral hip
dysplasia
 DDH : Group of disorders of the
neonatal hip in which the head of the
femur is unstable or incongruous in
relation to the acetabulum.
 Early detection and treatment of the
condition generally results in normal
development, whereas late diagnosis
has poor success
 PATHOLOGY OF DDH

Pulvinar

The Normal Hip

PATHOGENESIS OF DDH
 The disorder is not always present at
birth (congenital) and an infant may
have a normal neonatal hip screening
examination
 And subsequently develop a dysplastic
or dislocated hip
EPIDEMIOLOGY
 Incidence 1 in 1000 live birth
 Left > right
 Bilateral > right
 Females : males = 5:1
 White > black
Typical categories
 Dislocated hip
 Dislocatable hip
 Subluxable hip
 Dysplastic hip
 Risk factors
 Breech Presentation
 First born Female
 Family history - 10%
 Associated musculoskeletal pathology
 Diagnosis
 New born : Dislocated hip can be reduced
 In older children : Remains dislocated
Diagnosis in newborn (6 months)
 Ortolani & Barlow
 Ultrasound
 Beware of Developmental dysplasia
Ortolani

Barlow
ULTRASOUND
 Diagnosis: 6 to 18 months
 Decreased abduction - Adductor contracture
 Asymmetrical skin fold
 Galeazzi sign : Apparent shortening
Limited Hip Abduction
Unequal
Skin
Crease
 5/F R DDH

+ve Galeazzi sign – right thigh shorter

X-ray evaluation
 Hilgenreiner’s line
 Perkin’s line
 Shenton’s line
 Acetabular index - 25-30o
 Center Edge angle - 20o
 Delayed ossification
Diagnosis: Walking age
 Waddling gait
 Wide perineum
 Short lower extremity
 Hyperlordosis
 Trendelenburg
7/F - BILATERAL DDH
marked lumbar lordosis

Trendelenburg (+)

Excessive Internal Rotation

 Management
 newborn, birth  6 months  Pavlik harness
Frejka Pillow Von Rosen Splint Triple Nappies

Polyethylene
Abduction
Splint
Failure of Pavlik harness
 6-8 weeks not stabilised
 Traction
 Closed reduction & arthrography
 Open reduction if necessary
Treatment : 6 to 18 months
 Management
 6 to 18 months ,success  Pavlik harness ↓ 
closed manipulation / open reduction.
 standard regimen,treatment :
 adequate preoperative traction,
 adductor tenotomy,
 closed reduction “Safe zone”

 arthrogram
 open reduction  failed closed

avascular necrosis
 hospital

Home
 safe zone

‘‘Safe zone’’ used to determine acceptability of closed

reduction of congenital dislocation of hip.
 Management
open reduction
 Anterior : Beaty, after Somerville
Hip spica
 Aftercare
 Spica for 4 months with cast changes
 Check X-rays or CT scans
Complication of treatment
Redislocation
AVN
Acetabular dysplasia & OA ?
 Management
18 to 36 months :
 open reduction with femoral osteotomy
 pelvic osteotomy,
child and juvenile, ( 3 to 8 years )
 Open reduction + femoral shortening
 Femoral shortening

Adductor tenotomy

derotation Salter procedure

 Bilateral DDH
5Y

Adductor tenotomy
Open reduction
Femoral shortening and derotation
Salter procedure