Pediatric Orthopedics in Practice

791 Pages·2007·25.79 MB·English

by  Fritz Hefti

Fritz Hefti
Pediatric Orthopedics in Practice
Fritz Hefti
Pediatric
Orthopedics
in Practice
Co-Authors: Reinald Brunner, Carol C. Hasler, Gernot Jundt
Freehand drawings: Franz Freuler
Schematic drawings by the author
Translated into English from the German by Robert Hinchliffe, Lörrach
With 679 Figures (and 1164 individual Illustrations),
79 Cartoons and 121 Tables
123
Fritz Hefti, M.D., Professor In collaboration with:
Chief, Pediatric Orthopaedic Department
Children’s Hospital, University of Basel (UKBB) Reinald Brunner, M.D., Associate Professor
P.O. Box, 4005 Basel, Switzerland Neuroorthopaedics, Pediatric Orthopaedic Department
email: [email protected] Children’s Hospital, University of Basel (UKBB)
P.O. Box, 4005 Basel, Switzerland
email: [email protected]
Franz Freuler, M.D.
Orthopaedic Surgeon
Ruemelinbachweg 16, 4054 Basel, Switzerland
Carol Hasler, M.D.
Traumatoloy, Pediatric Orthopaedic Department
Children’s Hospital, University of Basel (UKBB)
P.O. Box, 4005 Basel, Switzerland
email: [email protected]
Gernot Jundt, M.D., Associate Professor
Basel Bone Tumor Reference Center
Institute of Pathology, University of Basel
Schoenbeinstrasse 40, 4056 Basel, Switzerland
email: [email protected]
ISBN-13 978-3-540-69963-7 Springer-Verlag Berlin Heidelberg New York
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Planning: Antje Lenzen
Project management: Claudia Kiefer
Translated into English from the German by Robert Hinchliffe, Lörrach
Freehand drawings: F. Freuler
Schematic drawings: F. Hefti
Cover design: deblik Berlin
Typesetting: TypoStudio Tobias Schaedla, Heidelberg, Germany
106/2111 – 5 4 3 2 1 0 SPIN 1135 6455
V
For Christiane and for my three sons
André, Philippe and Stephan,
who have repeatedly taught me
how children and adolescents feel
and what their needs are.
The English translation was made possible thanks to the financial
support of the following individuals, companies and institutions:
Department of Surgery, Basel University Hospital, Switzerland
Dr. Andreas Oeri, Basel, Switzerland
Professor André Gächter MD, St. Gallen, Switzerland
Dr. Alex Staubli, Luzern, Switzerland
Dr. R. Peter Meyer, Baden, Switzerland
Dr. Urs Kappeler, Baden, Switzerland
Synthes AG, Oberdorf, Switzerland
Stryker-Osteonics, Grand-Lancy (Geneva), Switzerland
Centerpulse Orthopaedics, Münsingen, Switzerland
Smith + Nephew, Solothurn, Switzerland
Biochimica, Lugano, Switzerland
VI
Forewords
The specialty of pediatric orthopaedics involves a vast I have just finished reading this enjoyable book. I started
array of primary and secondary musculoskeletal condi- out only to scan it but found it to be most enjoyable and
tions influenced by growth and development. Writing a educational and I learned a great deal.
comprehensive textbook is a somewhat herculean task Fritz Hefti has been the first who was appointed as a
which Fritz Hefti and his group have done with wit and full Professor of Pediatric Orthopedics in Switzerland and
style, making this book both instructive and readable. The has had a very large clinical experience at the University
sometimes humorous, cartoon-like illustrations are remi- of Basel. He is, therefore, very qualified to include his
niscent of those drawn by Mercer Rang. These drawings personal indications for chosen treatment programs. His
emphasize important facts, as does the bold colored print book covers all areas of pediatric orthopedics including
throughout the textbook. fractures.
As near as I can tell, all important aspects of pediatric It is a detailed work that is educational as well as
orthopaedic conditions are covered in this textbook. Each humorous. The line drawings make the points in an
new disease or section begins with a discussion of etiol- unforgettable way.
ogy, complemented by a full description of diagnostic, The references are up to date. Since the work was done
historical and physical findings. Diagnostic studies are in Europe it includes many important references from
recommended with an eye towards the efficient use of journals not included in the English works.
resources in »working up« a patient. Recommended treat- Fritz Hefti worked with me at the beginning of his
ment is outlined with frequent discussion of personal, career. He was an excellent clinical and research fellow
Basel, Swiss, or European experience. Reference to the and since then I appreciate him very much. He is very
Basel Tumor Database and other datasets is helpful to the proficient in English and the book is easily read.
reader. I know that you will enjoy it as much as I have.
Whether you are searching for information on tumors,
regional pediatric orthopaedic conditions or genetic dis-
eases, you will find it in this textbook. In addition to being G. Dean MacEwen, M.D.,
a reference source for answering a question about a spe- Newark, Delaware
cific disease, one can read the text in a journey through
pediatric orthopaedics as it is written in a stimulating and
entertaining style rather than simply a listing of facts.
I’ve known Fritz Hefti for 25 years and have ad-
mired his thoughtful approach to pediatric orthopaedics.
Through this textbook, others will have an opportunity
to be exposed to the wit and wisdom of an outstanding
Swiss pediatric orthopaedic surgeon.
James R. Kasser, M.D.,
Chief of Orthopaedics at the Children’s Hospital Boston
John E. Hall Professor of Orthopaedic Surgery at Harvard
Medical School
VII
Preface
»
Children are »patients«, not »customers«, that is pushing the crooked tree trunk in the cover il-
«
they require »care«, not »management« lustration). This requires close cooperation with parents,
(G.A. Annas) pediatricians, other therapists, orthopaedic technicians
and nursing personnel. The idea for this book originated
from pediatricians who were frequently encountering
patients with musculoskeletal problems and who, during
a course in pediatric orthopaedics, expressed a wish for a
book that would take into account the standpoint of the
pediatrician, as well as those of the children and parents.
It has since grown into a comprehensive volume. Not all
readers will have so much to do with »crooked« children
that they will want to read everything. But perhaps they
might wish to refer to this book upon encountering a
specific problem. There may also be those who are not
directly involved in treatment, but who would probably
like to know the various available options and the corre-
sponding factors considered in their selection. For practi-
cal purposes, this book also aims to stress the regional
(rather than a systematic) subdivision of disorders. After
all, a child does not come to the doctor’s office saying »I’m
suffering from a growth disorder« or »I have a congenital
condition«. Rather he or she will say »my back hurts« or
»I have a stabbing pain in my knee«. The reader will there-
fore find most conditions presented under the relevant
body region, whereas complex diseases are addressed in
a »supraregional« manner only at the end of the book.
Where possible we have cited current literature sources to
back up all our statements. For ease of legibility, authors’
names are only mentioned in the text if they designate a
The term »childhood illnesses« conjures up images of classification or treatment method.
a feverish condition with red spots or a baby’s teething The variability in clinical pictures in pediatric ortho-
troubles – reminiscent of the scenario with a brand new paedics is considerable, and no single individual can
car when the engine mysteriously starts to shudder on an be an expert in every field. We in Basel are in a doubly
uphill incline – but rarely evokes crooked backs or bandy fortunate position: not only is the pediatric orthopae-
legs. Orthopaedics has long since outgrown its children’s dic department located in a children’s hospital (with all
shoes, particularly since its first steps stretch right back pediatric specialists in-house), it is also an independent
to Hippocrates (…on clubfeet one might say). Orthopae- department with attending physicians in charge of their
dics has since veered in the direction of orthogeriatrics, own specialist departments. My former boss and teacher,
as orthopaedists worldwide are now predominantly oc- E. Morscher, realized that pediatric orthopaedics offered
cupied in alleviating the infirmities of the elderly (and the greatest opportunities in terms of autonomy and, prior
since bone is the »firmest« structure in the human body, to his retirement, he led what was then a subdivision of
»infirmities« might well be viewed primarily as an or- adult orthopaedics into independence. In our unit the
thopaedic problem…). Nevertheless, we still need the attending physicians R. Brunner and C. Hasler are pri-
»straight trainers«, as »orthopaedists« might be described marily concerned with neuro-orthopaedics and pediatric
according to a literal translation from the Greek. Trains traumatology respectively. The chapters contributed by
are pushed or pulled. But trainers should not »pull« or my two highly esteemed colleagues represent extremely
»push« (see cover illustration) too much, since this is valuable additions to this book. My own specialist areas
of limited benefit with today’s children, unless the child are spinal surgery and orthopaedic tumors. In addition
actually wants to be pulled or pushed. Pediatric ortho- to the collaboration with pediatric oncologists, my cor-
paedics ultimately involves motivating children »to want dial relationship with the bone pathologist G. Jundt has
to be straight« (which explains why it is the child himself proved particularly fruitful. He heads the Basel-based
VIII Preface
Bone Tumor Reference Center and has contributed his
considerable expertise to the corresponding chapters of
the book. I have also been especially fortunate to benefit
from the amicable collaboration with the privately prac-
ticing orthopaedist F. Freuler. On the one hand, he has
clearly depicted the examination methods with his out-
standing drawings (and in such a way that anyone can see
that children are involved rather than sexless and ageless
examination dolls). On the other, he has translated many
ideas into visual gags with his numerous amusing car-
toons. This adds a playful touch to the book which, after
all, deals with children, who always want to be taken seri-
ously, but ideally in a humorous way. Certain situations
can be described much more quickly and precisely with
the help of drawings than with text alone. Who would
grasp the meaning of the terms »achievement by proxy«
or »early childhood development program« so quickly
without the drawings on pages 8 and 9? Nor is there any
reason, why reading a scientific book should not also be
fun. Since our brain can store information only via the
emotional center (the amygdala) we should make every
effort to ensure that the transmission of knowledge is
associated with positive emotions, so that what is read is
also stored.
I should like to thank the staff of Springer Verlag for
readily accepting these illustrations, which are unusual in
a textbook, and for their active support for the project.
The first edition of this book appeared in German in
1997. A completely revised 2nd edition of the German
version was published in 2006. This has now been trans-
lated into English by Robert Hinchliffe. He has produced
an extremely competent translation, in both subject- and
language-related respects, which required almost no fur-
ther editing. I should like to thank him for his excellent
work. The content of certain chapters has been updat-
ed since the publication of the German edition several
months ago. The translation was made possible thanks
to generous financial support, and the necessary fund-
ing would not have been obtained without the initiative
of my friend, the orthopaedist Dr. Rainer Peter Meyer in
Baden, Switzerland. He deserves my special appreciation.
I should also like to thank the individuals, companies and
institutions listed below for their financial contribution to
the translation costs. My thanks are also due to my staff
at Basel University Children’s Hospital, who made many
useful suggestions. Numerous ideas also emerged from
discussions with the pediatricians in our hospital. Finally,
I should like to thank my dear wife Christiane, who has
always shown understanding for this time-consuming
»leisure« activity, who also helped read through the texts
and repeatedly made useful suggestions.
Basel, August 2006
F. Hefti
IX
Contents
3.1.6 Spondylolysis and spondylolisthesis . . . . . . . . . . . . . .101
1 General 3.1.7 Congenital malformations of the spine . . . . . . . . . . .108
3.1.8 Congenital muscular torticollis . . . . . . . . . . . . . . . . . . .117
3.1.9 Thoracic deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
1.1 What do the »straight-trainers« 3.1.10 Neuromuscular spinal deformities . . . . . . . . . . . . . . . .124
do with crooked children? – or: F. Hefti and R. Brunner
What is pediatric orthopaedics? . . . . . . . . . . . . . . . 2 3.1.11 Spinal deformities in systemic diseases . . . . . . . . . . .134
3.1.12 Spinal injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
1.2 Orthoses, prostheses, theories and 3.1.13 Inflammatory conditions of the spine . . . . . . . . . . . . .147
inventive individuals – a historical review . . . . 16 3.1.14 Tumors of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
3.1.15 Why do backs that are as straight as candles
1.3 Changing patterns of pediatric orthopaedic frequently cause severe pain? – or:
diseases – Developments, trends . . . . . . . . . . . . 22 the differential diagnosis of back pain . . . . . . . . . . . .157
3.1.16 Summary of indications for imaging
investigations for the spine . . . . . . . . . . . . . . . . . . . . . . .162
3.1.17 Indications for physical therapy for back
problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162
2 Basic principles
3.2 Pelvis, hips and thighs . . . . . . . . . . . . . . . . . . . . . . 164
3.2.1 Examination of hips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
2.1 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 3.2.2 Radiographic techniques . . . . . . . . . . . . . . . . . . . . . . . . .168
2.1.1 General examination technique . . . . . . . . . . . . . . . . . . .28 3.2.3 Biomechanics of the hip . . . . . . . . . . . . . . . . . . . . . . . . . .169
2.1.2 Neurological examination . . . . . . . . . . . . . . . . . . . . . . . . .31 3.2.4 Developmental dysplasia and congenital
R. Brunner dislocation of the hip . . . . . . . . . . . . . . . . . . . . . . . . . . . .177
2.1.3 Gait analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 3.2.5 Legg-Calvé-Perthes disease . . . . . . . . . . . . . . . . . . . . . .201
R. Brunner 3.2.6 Slipped capital femoral epiphysis . . . . . . . . . . . . . . . . .216
2.1.4 Imaging diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 3.2.7 Congenital malformations of the pelvis,
2.1.5 School medical examination . . . . . . . . . . . . . . . . . . . . . .38 hip and thigh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
3.2.8 Neuromuscular hip disorders . . . . . . . . . . . . . . . . . . . . .235
2.2 Development of the musculoskeletal R. Brunner
system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 3.2.9 Fractures of the pelvis, hip and thigh . . . . . . . . . . . . .249
2.2.1 Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 C. Hasler
2.2.2 Physical development . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 3.2.10 Transient synovitis of the hip . . . . . . . . . . . . . . . . . . . . .258
2.2.3 The loading capacity of the musculoskeletal 3.2.11 Infections of the hip and the femur . . . . . . . . . . . . . . .261
system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 3.2.12 Rheumatoid arthritis of the hip . . . . . . . . . . . . . . . . . . .265
3.2.13 Tumors of the pelvis, proximal femur and
femoral shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .267
3.2.14 Differential diagnosis of hip pain . . . . . . . . . . . . . . . . .276
3.2.15 Differential diagnosis of restricted hip
3 Diseases and injuries by site movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277
3.2.16 Indications for imaging procedures
for the hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278
3.1 Spine, trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 3.2.17 Indications for physical therapy in hip
3.1.1 Examination of the back . . . . . . . . . . . . . . . . . . . . . . . . . .57 disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278
3.1.2 Radiography of the spine . . . . . . . . . . . . . . . . . . . . . . . . .63
3.1.3 Can the »nut croissant« be straightened out by 3.3 Knee and lower leg . . . . . . . . . . . . . . . . . . . . . . . . . 279
admonitions? – or: To what extent is a bent back 3.3.1 Examination of the knees . . . . . . . . . . . . . . . . . . . . . . . .279
acceptable? – Postural problems in adolescents . . .66 3.3.2 Radiographic techniques . . . . . . . . . . . . . . . . . . . . . . . . .284
3.1.4 Idiopathic scolioses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 3.3.3 Knee pain today – sports invalid tomorrow?
3.1.5 Scheuermann’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . .95 – Pain syndromes of the knee and lower leg . . . . . .285
X Contents
3.3.4 Osteochondritis dissecans . . . . . . . . . . . . . . . . . . . . . . . .294 3.5.6 Neuromuscular disorders of the upper
3.3.5 Dislocation of the patella . . . . . . . . . . . . . . . . . . . . . . . . .300 extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .485
3.3.6 Congenital deformities of the knee and R. Brunner
lower leg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .308 3.5.7 Fractures of the upper extremities . . . . . . . . . . . . . . . .494
3.3.7 Neurogenic disorders of the knee and C. Hasler
lower leg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .321 3.5.8 Tumors of the upper extremities . . . . . . . . . . . . . . . . .522
R. Brunner
3.3.8 Meniscal and ligamentous lesions . . . . . . . . . . . . . . . .330
3.3.9 Fractures of the knee and lower leg . . . . . . . . . . . . . .336
C. Hasler
3.3.10 Infections of the knee and lower leg . . . . . . . . . . . . . .347 4 Systematic aspects of musculoskeletal
3.3.11 Juvenile rheumatoid arthritis of the knee . . . . . . . . .350 disorders
3.3.12 Tumors in the knee area . . . . . . . . . . . . . . . . . . . . . . . . . .352
3.3.13 Knee contractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361
3.3.14 Differential diagnosis of knee pain . . . . . . . . . . . . . . . .364 4.1 Traumatology – basic principles . . . . . . . . . . . . 532
3.3.15 Indications for imaging procedures C. Hasler
for the knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365 4.1.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .532
3.3.16 Indications for physical therapy in knee 4.1.2 Communication with the parents and
disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365 patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .532
4.1.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533
3.4 Foot and ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 4.1.4 Special injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .536
3.4.1 Examination of the foot and ankle . . . . . . . . . . . . . . . .366 F. Hefti
3.4.2 Radiographic techniques for the foot 4.1.5 Therapeutic principles . . . . . . . . . . . . . . . . . . . . . . . . . . .540
and ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .372 4.1.6 Follow-up management . . . . . . . . . . . . . . . . . . . . . . . . . .543
3.4.3 Congenital clubfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .374 4.1.7 Follow-up controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .543
3.4.4 Congenital flatfoot (vertical talus) . . . . . . . . . . . . . . . .388 4.1.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .544
3.4.5 Other congenital anomalies of the foot . . . . . . . . . . .392
3.4.6 Do skewfeet stop Cinderella from turning 4.2 Axes and lengths . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
into a princess? or: Should one treat metatarsus F. Hefti, C. Hasler
adductus? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405 4.2.1 Are children twisted when they have an
3.4.7 Flatfoot Indians – which ones must be treated intoeing gait or warped if they are knock-kneed
so that they can later become chiefs? – or bow-legged? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .547
or: How do we distinguish between flat valgus 4.2.2 Do children go »off the straight and narrow«
foot and flexible flatfoot? . . . . . . . . . . . . . . . . . . . . . . . .408 when the pelvis is oblique? – or: Causes and
3.4.8 Juvenile hallux valgus . . . . . . . . . . . . . . . . . . . . . . . . . . . .418 need for treatment of pelvic obliquity? . . . . . . . . . . .557
3.4.9 Does one have to walk one’s feet off before 4.2.3 The limping child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .568
the cause of foot pain can be established? –
or: Osteochondroses and other painful 4.3 Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
problems of the feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .422 F. Hefti, G. Jundt
3.4.10 Neurogenic disorders of the ankle and foot . . . . . .428 4.3.1 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .570
R. Brunner 4.3.2 Septic (suppurative) arthritis . . . . . . . . . . . . . . . . . . . . .578
3.4.11 Ankle and foot injuries . . . . . . . . . . . . . . . . . . . . . . . . . . .440
C. Hasler 4.4 Juvenile rheumatoid arthritis . . . . . . . . . . . . . . . 581
3.4.12 Infections of the foot and ankle . . . . . . . . . . . . . . . . . .448
3.4.13 Tumors of the foot and ankle . . . . . . . . . . . . . . . . . . . . .449 4.5 Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
4.5.1 Basic aspects of tumor diagnosis . . . . . . . . . . . . . . . . .585
3.5 Upper extremities . . . . . . . . . . . . . . . . . . . . . . . . . . 454 F. Hefti, G. Jundt
3.5.1 Examination of the upper extremities . . . . . . . . . . . .454 4.5.2 Benign bone tumors and tumor-like lesions . . . . . .595
3.5.2 Radiographic technique for the upper F. Hefti, G. Jundt
extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461 4.5.3 Malignant bone tumors . . . . . . . . . . . . . . . . . . . . . . . . . .611
3.5.3 Congenital deformities of the upper F. Hefti, G. Jundt
extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .464 4.5.4 Soft tissue tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .622
3.5.4 Dislocations of the shoulder . . . . . . . . . . . . . . . . . . . . . .480 G. Jundt, F. Hefti
3.5.5 Growth disturbances of the upper 4.5.5 Therapeutic strategies for bone and soft tissue
extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .484 tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .631