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Volume One Tachdjian’s Pediatric Orthopaedics From the Texas Scottish Rite Hospital for Children John A. Herring, MD Chief of Staff Emeritus Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Professor Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas Sixth Edition Volume Two Tachdjian’s Pediatric Orthopaedics From the Texas Scottish Rite Hospital for Children John A. Herring, MD Chief of Staff Emeritus Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Professor Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas Sixth Edition Elsevier 1600 John F. Kennedy Blvd. Ste 1600 Philadelphia, PA 19103- 2899 TACHDJIAN’S PEDIATRIC ORTHOPAEDICS: FROM THE ISBN: 978- 0- 323- 56769- 5 TEXAS SCOTTISH RITE HOSPITAL FOR CHILDREN: SIXTH EDITION VOL I: 978- 0- 323- 79169- 4 VOL II: 978- 0- 323- 79170- 0 Copyright © 2022 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted © 2014, 2008, 2002, 1990, 1972 by Saunders, an imprint of Elsevier Inc. Library of Congress Control Number: 2020947229 Senior Content Strategist: Belinda Kuhn Senior Content Development Specialist: Joanie Milnes Publishing Services Manager: Catherine Albright Jackson Senior Project Manager: Doug Turner Designer: Amy Buxton Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 CONTRI BU T OR S Megan E. Anderson, MD Christine A. Ho, MD Orthopedic Surgeon Staff Orthopaedist Orthopedic Center Department of Orthopaedic Surgery Boston Children’s Hospital Texas Scottish Rite Hospital for Children Assistant Professor of Orthopedic Surgery Division Director Harvard Medical School Department of Pediatric Orthopaedics Boston, Massachusetts Children’s Health Dallas Professor Jane S. Chung, MD Department of Orthopaedic Surgery Staff Sports Medicine Physician University of Texas Southwestern Medical School Department of Orthopaedics Dallas, Texas Texas Scottish Rite Hospital for Children Assistant Professor Charles E. Johnston, MD Department of Orthopaedic Surgery Chief of Staff Emeritus University of Texas Southwestern Medical Center Department of Orthopaedic Surgery Dallas, Texas Texas Scottish Rite Hospital for Children Professor Lawson A.B. Copley, MD, MBA Department of Orthopaedic Surgery Professor University of Texas Southwestern Medical Center Departments of Orthopaedic Surgery and Pediatrics Dallas, Texas University of Texas Southwestern Medical Center Pediatric Orthopaedic Surgeon Lori A. Karol, MD Department of Orthopaedic Surgery Chief Children’s Medical Center of Dallas Division of Pediatric Orthopaedic Surgery Dallas, Texas Rose Brown Chair of Pediatric Orthopaedics Professor Donald Cummings, CP, LP Department of Orthopedics Director of Prosthetics University of Colorado School of Medicine Texas Scottish Rite Hospital for Children Aurora, Colorado Dallas, Texas Harry K.W. Kim, MD Henry Bone Ellis, Jr., MD Director Staff Sports Medicine Surgeon Center for Excellence in Hip Disorders Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Texas Scottish Rite Hospital for Children Professor Associate Professor Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Texas Southwestern Medical Center University of Texas Southwestern Medical Center Dallas, Texas Staff Orthopaedic Surgeon Department of Orthopaedics Amy Lake, OTR, CHT Children’s Medical Center Occupational Therapist Dallas, Texas Texas Scottish Rite Hospital for Children Dallas, Texas John A. Herring, MD Chief of Staff Emeritus Amy L. McIntosh, MD Department of Orthopaedic Surgery Associate Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic Surgery Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic Surgery Dallas, Texas University of Texas Southwestern Medical Center Dallas, Texas v vi Contributors Scott Oishi, MD Mouin G. Seikaly, MD Director of Hand Service Medical Director Texas Scottish Rite Hospital for Children Metabolic Bone Disease Clinic Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic and Plastic Surgery Professor University of Texas Southwestern Medical School Department of Pediatric Nephrology Dallas, Texas University of Texas Southwestern Medical Center Dallas, Texas David Podeszwa, MD Pediatric Orthopedic Surgeon Chris Stutz, MD Co- director, Center for Excellence in Limb Lengthening Staff Hand Surgeon Texas Scottish Rite Hospital for Children Hand Service Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic Surgery Assistant Professor University of Texas Southwestern Medical Center Department of Orthopaedic Surgery Dallas, Texas University of Texas Southwestern Medical Center Dallas, Texas Marilyn Purano, MD Professor of Pediatrics Daniel J. Sucato, MD University of Texas Southwestern Medical School Chief of Staff Dallas, Texas Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Brandon A. Ramo, MD Professor Staff Orthopaedist Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Texas Scottish Rite Hospital for Children Dallas, Texas Dallas, Texas Philip Wilson, MD Karl E. Rathjen, MD Assistant Chief of Staff Assistant Chief of Staff Department of Orthopaedic Surgery Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Texas Scottish Rite Hospital for Children Professor Professor Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Texas Southwestern Medical Center University of Texas Southwestern Medical Center Dallas, Texas, Assistant Chief of Staff Dallas, Texas Director, Pediatric Sports Medicine Department of Sports Medicine and Orthopaedics Anthony I. Riccio, MD Texas Scottish Rite Hospital for Children North Staff Orthopaedic Surgeon Frisco, Texas Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Robert Lane Wimberly, MD Professor Medical Director of Movement Science Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children University of Texas Southwestern Medical Center Associate Professor Dallas, Texas Department of Orthopaedic Surgery University of Texas Southwestern Medical Center B. Stephens Richards, MD Dallas, Texas Chief Medical Officer Texas Scottish Rite Hospital for Children Professor Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas PRE FACE This edition of Tachdjian’s Pediatric Orthopaedics is the The authors of this book are experienced clinicians fourth that has been written and edited by the staff of the with expertise and training in pediatric orthopaedics, Texas Scottish Rite Hospital for Children. As we research and most have subspeciality interests and expertise. They and reevaluate each chapter, we are usually surprised to are leaders in their fields and base their discussions and see how many things have changed between editions. recommendations on a very rich clinical experience in For example, in recent years we have seen considerable an academic practice. An important feature of our aca- growth in the knowledge and practice in the field of demic environment is the vigorous preoperative group pediatric sports subspecialization. In recognition of this discussion of surgical procedures. As academic leaders, growth, we have added a new chapter dedicated to pedi- they regularly present their research at national and inter- atric and adolescent sports conditions, which includes national meetings. Their work is widely published and the most recent developments in the management of broadly respected. concussion. In the scoliosis chapter, exciting new infor- Users of the text include students from all levels from mation about the rapidly evolving management of early medical school, residency, fellowship, new and estab- onset scoliosis has been added, including important non- lished physicians, and non-p hysician practitioners, as well operative measures such as serial casting and bracing, as as established professors as they augment their publica- well as the use of tethering. The field of genetics is con- tions. The text of this edition is fully produced in two print tinually expanding, and genetics-related content, which volumes. To lighten the load of the textbook, a compre- appears in many of our chapters, has been updated to hensive bibliography is available in the online version. This reflect current understanding. placement facilitates Internet access to other resources. Twenty years ago, we took on the challenge to build As in prior editions, our popular surgical videos are on the groundwork laid by Dr. Mirhan Tachdjian in his available online. These videos present the important steps two editions. Our goal has been to produce a textbook of actual surgical cases and are narrated by the operating that fully encompasses the broad field of pediatric ortho- surgeons. We receive frequent positive comments from paedics. We have based our descriptions on the best avail- surgeons throughout the world who find these very use- able published knowledge. We have sought to present the ful for planning their surgical procedures. Other videos in most current evidence from the literature from level 1 to the collection cover non- operative subjects such as cast 5 in a succinct and readable format. We have augmented application for scoliosis, club foot casting, and Pavlik har- the discussions with recommendations based on personal ness application. experiences of a top-l evel clinical faculty. When presenting I am sincerely grateful to each of our authors and truly controversial topics, we prefer to give the reader the evi- appreciate the effort involved in making the sixth edition a dence from the different arguments so that the reader can reality. We welcome two new authors, Dr. Jane Chung and make a reasoned decision after reviewing the conflicting Dr. Shane Miller, who are pediatric- trained practitioners evidence. We carefully avoid the “cookbook” approach in with expertise in sports medicine. We continue to be grate- which one puts forth their preferred treatment as gospel. ful for the contribution of our Boston colleagues, Professor We continue to insist that our text be comprehensive, Mark Gebhardt and Dr. Megan Anderson, who are respon- even though a shorter text would be more convenient to sible for the chapter on malignant tumors. I especially want handle. We fully present each topic, include the descrip- to thank my administrative assistant, Louise Hamilton, who tion of a disorder, and discuss appropriate history and had the huge task of putting the whole project together. physical exam, relevant studies, differential diagnosis, and She was able to devote the time needed for this edition details of treatment. We believe that it is important to because of coverage by the other administrative assistants, present the important details of decision making, and we including Stacy Duckworth, Lisa Sherman, Rebecca Fuller, emphasize the complexity of overall patient care. Our sur- Amy Park, and our administrative director, Laura Griffiths. gical discussions stress proper preoperative planning and Again, our heartfelt appreciation goes to our families, who preparation, as well as description of operative details. We are vitally important in every facet of our lives; thanks for also provide the important postoperative protocols that giving us your support and understanding. are necessary to ensure the best results. John A. Herring, MD vii C H A P T E R 1 Growth and Development John A. Herring Normal Growth and Development Chapter Contents Neonates are primarily reflexive, but they do exhibit some Normal Growth and Development 3 cognitive traits.8 These traits include showing more curiosity Disorders of Normal Growth and about facelike FIG.s than about other FIG.s of comparable Development 3 brightness, as well as a preference for black- and- white tones Evolution of Proportionate Body Size 5 rather than gray. Neonates should turn their eyes toward sound Physical Growth 5 and be able to distinguish their mothers from other people. Developmental Milestones 6 The normal neonate is born with a predominant flexor tone, and physiologic flexion contractures are typical (Fig. 1.2). At birth the newborn’s limbs are maintained in flexion This chapter on growth and development is presented first posture, and passive movement of the extremities and neck for several important reasons. One of the unique aspects of elicits strong flexor tone. A normal neonate’s limbs move in pediatric care is the dynamic evolution of each individual an alternating fashion when they are stimulated. from neonate to adolescent. During this period, a remark- Normal development progresses cephalocaudad; infants able process of growth and development takes place in gross acquire the ability to control their head and hands before and fine motor skills; intellectual, social, and verbal skills; they are able to control their legs.8 During the first few body size; gait; and sexual characteristics. months, gaining head control predominates. Hand control, Growth refers to an increase in an individual’s total body size such as the ability to grasp objects, follows. As development or to an increase in the physical size of a particular organ or organ continues, the infant gains more and more control of the system.9,17 References to normal human growth parameters legs. from the third trimester to adulthood are provided in Proceed- To determine whether an infant’s growth and develop- ings of the Greenwood Genetic Center: Growth References.10 ment are progressing normally, the examiner needs to find This publication also provides parameters for growth patterns out from the parents what developmental milestones the seen in specific diseases, such as achondroplasia, diastrophic child has attained and when and then compare them with dysplasia, Down syndrome, Marfan syndrome, and skeletal the norms. If the child appears to have developmental dysplasias (comparative curves). Growth standards are also delays, referral to a physician who specializes in growth and available in Hensinger’s Standards in Pediatric Orthopedics.7 development problems is recommended. Development refers to the physical changes of matura- Because of the wide variations in the times at which devel- tion that occur as a child ages. The developmental process opmental milestones are achieved and the numerous reasons encompasses other aspects of differentiation of form, but it for delays, the diagnosis of developmental delay can be diffi- primarily involves changes in function that transform humans cult to make in the very young child. In addition, a child may into increasingly more complex beings.9 Development is exhibit delay in acquiring certain skills and unusual rapidity influenced by many interrelated factors, including genetics, in acquiring others. When a delay is evident, the physician physical trauma, nutrition, and socioeconomic status.17 must determine the cause, which may be a neuromuscular The age at which children reach specific milestones of condition. Factors suggesting a neurologic cause include fail- development depends on the maturation rate of their cen- ure of normal developmental responses to appear, prolonged tral nervous system (CNS), which varies from child to child. retention of primitive infant reflexes, or a delay in achieving Ranges for variations in normal have been developed to assist gross motor milestones within normal limits. in the assessment of the pediatric patient, and the most com- monly used assessment tool is the revised Denver Develop- Disorders of Normal Growth and mental Screening Test (DDST)(Fig. 1.1).5-7 It is important to know when a child should normally achieve expected Development milestones of growth and development so that potentially abnormal situations are evident to the physician who is tak- Many pediatric orthopaedic problems result from disor- ing a patient’s history and performing a physical examination. ders or conditions that adversely affect normal growth and The significance of various findings must be related to development. The four major failures of normal growth and the child’s particular stage of growth and development. development are malformations, deformations, disruptions, Although no one should expect a 4-m onth- old infant to be and dysplasias.4,12 walking, it is distinctly abnormal for an 18- month- old child not to be doing so. Similarly, a 12- month- old child is likely Malformations to have some degree of genu varum, whereas the presence of genu varum in a 3-y ear- old child should be cause for con- Malformations are structural defects that result from inter- cern and a focus of further investigation. ruption of normal organogenesis during the second month of 3 4 SECTION I Disciplines DENVER ll Examiner: Name: Date: Birthdate: ID#: Months 2 4 6 9 12 15 18 24 Years3 4 5 6 prepare cereal Percent of children passing brush teeth, no help play board/card games 25 50 75 90 dress, no help test item put on t-shirt 86% name friend copy wash and dry hands brush teeth with help draw person, 6 parts copy , demonstrate put on clothes pick longer line feed doll copy + remove garment draw person, 3 parts use spoon/fork help in house copy 88% wiggle thumb drink from cup define 7 words tower of 8 cubes initate activites imit. vert. line name 2 opposites play ball with examiner tower of 6 cubes count 5 blocks wave bye-bye tower of 4 cubes know 3 adjectives indicate wants tower of 2 cubes define 5 words play pat-a-cake dump raisin, demonstrated name 4 colors cial work ffoere tdo yself put block ins ccruibpbles speech all unudnedrsetarsntadnadb le4 prepostitions So regard own hand bang 2 cubes know 4 actions – smile held in hands use of 3 objects al spontaneously thumb-finger count 1 block son sremsipleo nsively take 2 cubgerassp use of 2 objects er regard pass cube name 1 color P face know 2 take raisin adjectives look for yarn know 2 actions balance each foot 6 sec Adaptive htofaognlelodtwhsree 1gr8a0rd° raisinreaches speecnha hmanelaf 6um nbedo e4dr ypsn tipacaatmnurdtresea 4sb lpeicturebsalance eachb afolaobntac 3lea hsneeecaceecl h-et oafo-ctoohte f4 ow osate l5ck sec or- grasp name 1 picture hops ot rattle combine words balance each foot M follow past point to pictures 2 sec e midline 6 words balance each Fin ftool lmowid ln. 3 words foborot a1d s jeucmp 2 words throw ball overhand 1 word jump up Dada/Mama specific kick ball forward jabbers walk up steps combine syllables runs Dada/Mama nonspecific walk backward imitate speech sounds walk well single syllables stoop and recover turn to voice stand alone turn to stand 2 sec rattling sound get to e squeals sitting guag "Ooo/laaauhg"hs stand pstualln tdo an vocalizes holding on L respond sit–no to bell support pull to stand no head lag roll over chest up arm support wear wt. on legs sit-head steady or ot head up 90° M head up 45° ss lift head o Gr emqouvael ments Months 2 4 6 9 12 15 18 24 Years3 4 5 6 FIG. 1.1 The revised Denver Developmental Screening Test showing the range of age when a child should achieve milestones in the de- velopment of gross motor skills, fine motor–adaptive skills, language, and personal-s ocial skills. (Modified from Frankenburg WK, Dodds JB. The Denver Developmental Screening Test. J Pediatr. 1967;71:181; Hensinger RN. Standards in Pediatric Orthopedics. New York: Raven Press; 1986.) CHAPTER 1 Growth and Development 5 gestation. Examples include myelomeningocele, syndactyly, either by eliminating the deforming force or by counteract- preaxial polydactyly, Poland syndrome, and proximal focal ing the force with stretching, casting, or bracing.  femoral deficiency (congenital femoral deficiency).  Disruptions Deformations Disruptions are morphologic abnormalities that result from Deformations are defects in the form, shape, or site of body an extrinsic interference with or breakdown of the nor- parts caused by mechanical stress. The mechanical stress, mal growth and development process. Disruptions can be which may be intrinsic or extrinsic, alters or distorts tissues. caused by drugs or toxic materials. These structural defects Because the fetus grows considerably faster than the infant, may affect organs or systems that were normal during fetuses are more vulnerable to deformations. Examples organogenesis. A congenital constriction band in the limb is include supple metatarsus adductus, calcaneovalgus feet, con- an example of a disruption.  genital knee hyperextension, and physiologic bowing of the tibia. Dysplasias Differentiating deformations from malformations is important. During a cursory examination, severe deforma- Dysplasias are structural defects caused by abnormal tis- tions may look like malformations.3 Careful assessment is sue differentiation as cells organize into tissues. Examples essential if the child is to receive appropriate care for the include osteogenesis imperfecta, achondroplasia, and spon- condition. Malformations cannot be corrected directly, dyloepiphyseal dysplasia.  whereas deformations can often be reversed relatively easily Evolution of Proportionate Body Size At birth, the neonate’s head is disproportionately large, comprising approximately one-f ourth of the body’s total length. During the first year of infancy, the head contin- ues to grow rapidly, and the head circumference usually is greater than the circumference of the infant’s chest. The evolution of body proportions is indicated by a change in the child’s upper to lower segment ratio (the relation of the center of gravity to body segments). This ratio is measured as the distance from the top of the head to the symphysis pubis, divided by the distance from the symphysis pubis to the bottom of the feet (Fig. 1.3).7 At birth, the ratio is approximately 1:7. At approximately 10 years of age, the upper and lower segments are almost equal in length (i.e., the ratio is ≈1.0). After 10 years of age, as individuals become adolescents and adults, the ratio normally becomes less than 1.0, as the upper segment becomes shorter than the lower segment.  Physical Growth Head Circumference FIG. 1.2 Typical position of the neonate with vertex presentation. The hips and knees are flexed, the lower legs are rotated internally, During infancy it is essential to obtain individual or serial and the feet are rotated further inward on the lower leg. The lower measurements of the patient’s head circumference to deter- limbs are contracted into this position for a variable period after mine whether head growth is slower or faster than normal. birth. FIG. 1.3 Evolution of head- to- trunk proportion throughout growth. In the neonate the head is pro- portionately significantly larger relative to the trunk than it will be at skeletal maturity. (Reproduced from Hensinger RN. Standards in Pediatric Orthopedics. 6 mo fetus Newborn 2 yr 5 yr 13 yr 17 yr Adult New York: Raven Press; 1986.) 6 SECTION I Disciplines Head circumference should be measured at every physical The approximate ages at which children should normally examination during the first 2 years and at least biennially attain various gross motor skills are given in Table 1.1. thereafter. With the child supine, the examiner places a cen- By 3 months of age, infants should be able to hold their timeter tape over the occipital, parietal, and frontal promi- heads above the plane of the body when they are supported nences of the head. The tape should be stretched and the in a prone position. By 6 months of age, the head should not reading noted at the point of greatest circumference. Possible lag when infants are pulled from a supine to a sitting posi- conditions that can affect head circumference and growth tion. Normally, infants will begin to roll over between 4 and include microcephaly, premature closure of the sutures, 6 months of age and can sit with minimal external support hydrocephalus, subdural hematoma, and brain tumor. Head at 6 to 7 months. They should be able to pull up to a stand- circumference should be charted for age and percentile, as ing position by holding onto furniture at 9 to 12 months and noted in Fig. 1.4.  stand without support by 14 months. The average milestones of development of locomotion are as follows: the infant should be able to crawl by 7 to 9 Height and Weight months of age, cruise and walk with assistance at 12 months, A child’s growth, as demonstrated by an increase in body walk forward without support by 12 to 16 months, and run height and weight within predetermined normal limits, is at 18 months of age.1,2,11 Children should be able to ascend one of the best indicators of health during infancy and child- stairs with support by 18 months of age and without sup- hood. The child’s height and weight should be plotted on port by 2 years of age. They should be able to descend stairs a standard growth chart to verify that normal progress is with support at approximately 3 years of age and without being made. Numerous tables, charts, and graphs depict- support by 4 years. ing pediatric growth standards are available in Hensinger’s On gross inspection the independent gait of the infant has Standards in Pediatric Orthopedics7 and in Proceedings of a wide base, the hips and knees are hyperflexed, the arms are the Greenwood Genetic Center: Growth References.10 The held in flexion, and the movements are abrupt. With matura- World Health Organization published an extensive study of tion of the neuromuscular system, the width of the base gradu- child growth standards for length and height for age, weight ally diminishes, the movements become smoother, reciprocal for age, weight for length, weight for height, and body mass swing of the upper limbs begins, and step length and walking index for age.18 Height and weight should be charted for velocity increase.13 The adult pattern of gait develops between age and percentile, as noted in Fig. 1.5. If growth measure- 3 and 5 years of age.14 A more complete description of normal ments are lower than the 3rd percentile or higher than the pediatric gait patterns is provided in Chapter 5.  97th percentile, or if a recent deviation from previously stable percentile rankings is noted, further investigation is Fine Motor Skills warranted.  The approximate ages at which children normally attain various fine motor skills are listed in Table 1.2. A child’s Epiphyseal Growth and Closure exploration of the environment by touch and the devel- During normal growth and development, the pattern in the opment of manual skills should emerge in an orderly and appearance of centers of ossification and fusion of epiphy- sequential manner. At 3 months of age, infants can apply ses in the upper and lower limbs is orderly. This pattern lip pressure and coordinate sucking and swallowing during varies among individuals and is different for boys and girls feeding (the sucking reflex is present at birth in all normal (Figs. 1.6–1.9). Thus the orthopaedist must understand full- term neonates but usually disappears at 3–4 months of the ranges of normal when treating the pediatric patient, age). By 6 months of age, children are able to feed them- particularly when interpreting radiographs. The percentage selves from hand to mouth. By 9 months, children can feed contribution of each epiphysis to longitudinal growth of the themselves food such as cookies. By 12 months of age, chil- upper and lower extremity long bones is shown in Figs. 1.10 dren can pick up a spoon from the table, chew cookies or and 1.11.  toast, and drink milk from a cup if assisted. Between 12 and 18 months, they are able to feed themselves (messily) with a spoon and drink from a cup by using one or two Tanner Stages of Development hands. By 24 months, they can feed themselves semisolid The physical maturation of a child can also be compared food with a spoon and drink holding the cup in one hand with his or her chronologic age by using the pubertal or using a straw. stages of development as described by Tanner (Figs. 1.12 Children should be able to purposefully grasp objects and 1.13).15,16 The Tanner stages of maturation are based such as a bottle or toy rattle by 6 months of age. At 9 on breast size in girls, genital size in boys, and pubic hair months of age, children use their fingers and thumb to grasp stages for both girls and boys. The onset of menstruation objects and are able to transfer objects from one hand to is also an important milestone in the physical maturation the other. By 12 months, children’s hand skills are such that of girls.  they are able to hit two objects together, voluntarily release objects, manipulate and throw objects on the floor, and hold crayons and imitate scribbling. Between 18 and 24 months Developmental Milestones of age, their hand skills evolve to the point that they can build block towers, turn pages one at a time, and throw a Gross Motor Skills ball (but inaccurately). Between 2 and 3 years of age, their The development of gross motor skills depends on maturation writing skills evolve from imitating vertical, horizontal, and of the CNS, which proceeds in a cephalocaudal direction.8 circular strokes to copying circles.

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Volume One Tachdjian’s Pediatric Orthopaedics From the Texas Scottish Rite Hospital for Children John A. Herring, MD Chief of Staff Emeritus Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Professor Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas Sixth Edition Volume Two Tachdjian’s Pediatric Orthopaedics From the Texas Scottish Rite Hospital for Children John A. Herring, MD Chief of Staff Emeritus Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Professor Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas Sixth Edition Elsevier 1600 John F. Kennedy Blvd. Ste 1600 Philadelphia, PA 19103- 2899 TACHDJIAN’S PEDIATRIC ORTHOPAEDICS: FROM THE ISBN: 978- 0- 323- 56769- 5 TEXAS SCOTTISH RITE HOSPITAL FOR CHILDREN: SIXTH EDITION VOL I: 978- 0- 323- 79169- 4 VOL II: 978- 0- 323- 79170- 0 Copyright © 2022 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted © 2014, 2008, 2002, 1990, 1972 by Saunders, an imprint of Elsevier Inc. Library of Congress Control Number: 2020947229 Senior Content Strategist: Belinda Kuhn Senior Content Development Specialist: Joanie Milnes Publishing Services Manager: Catherine Albright Jackson Senior Project Manager: Doug Turner Designer: Amy Buxton Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 CONTRI BU T OR S Megan E. Anderson, MD Christine A. Ho, MD Orthopedic Surgeon Staff Orthopaedist Orthopedic Center Department of Orthopaedic Surgery Boston Children’s Hospital Texas Scottish Rite Hospital for Children Assistant Professor of Orthopedic Surgery Division Director Harvard Medical School Department of Pediatric Orthopaedics Boston, Massachusetts Children’s Health Dallas Professor Jane S. Chung, MD Department of Orthopaedic Surgery Staff Sports Medicine Physician University of Texas Southwestern Medical School Department of Orthopaedics Dallas, Texas Texas Scottish Rite Hospital for Children Assistant Professor Charles E. Johnston, MD Department of Orthopaedic Surgery Chief of Staff Emeritus University of Texas Southwestern Medical Center Department of Orthopaedic Surgery Dallas, Texas Texas Scottish Rite Hospital for Children Professor Lawson A.B. Copley, MD, MBA Department of Orthopaedic Surgery Professor University of Texas Southwestern Medical Center Departments of Orthopaedic Surgery and Pediatrics Dallas, Texas University of Texas Southwestern Medical Center Pediatric Orthopaedic Surgeon Lori A. Karol, MD Department of Orthopaedic Surgery Chief Children’s Medical Center of Dallas Division of Pediatric Orthopaedic Surgery Dallas, Texas Rose Brown Chair of Pediatric Orthopaedics Professor Donald Cummings, CP, LP Department of Orthopedics Director of Prosthetics University of Colorado School of Medicine Texas Scottish Rite Hospital for Children Aurora, Colorado Dallas, Texas Harry K.W. Kim, MD Henry Bone Ellis, Jr., MD Director Staff Sports Medicine Surgeon Center for Excellence in Hip Disorders Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Texas Scottish Rite Hospital for Children Professor Associate Professor Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Texas Southwestern Medical Center University of Texas Southwestern Medical Center Dallas, Texas Staff Orthopaedic Surgeon Department of Orthopaedics Amy Lake, OTR, CHT Children’s Medical Center Occupational Therapist Dallas, Texas Texas Scottish Rite Hospital for Children Dallas, Texas John A. Herring, MD Chief of Staff Emeritus Amy L. McIntosh, MD Department of Orthopaedic Surgery Associate Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic Surgery Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic Surgery Dallas, Texas University of Texas Southwestern Medical Center Dallas, Texas v vi Contributors Scott Oishi, MD Mouin G. Seikaly, MD Director of Hand Service Medical Director Texas Scottish Rite Hospital for Children Metabolic Bone Disease Clinic Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic and Plastic Surgery Professor University of Texas Southwestern Medical School Department of Pediatric Nephrology Dallas, Texas University of Texas Southwestern Medical Center Dallas, Texas David Podeszwa, MD Pediatric Orthopedic Surgeon Chris Stutz, MD Co- director, Center for Excellence in Limb Lengthening Staff Hand Surgeon Texas Scottish Rite Hospital for Children Hand Service Professor Texas Scottish Rite Hospital for Children Department of Orthopaedic Surgery Assistant Professor University of Texas Southwestern Medical Center Department of Orthopaedic Surgery Dallas, Texas University of Texas Southwestern Medical Center Dallas, Texas Marilyn Purano, MD Professor of Pediatrics Daniel J. Sucato, MD University of Texas Southwestern Medical School Chief of Staff Dallas, Texas Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Brandon A. Ramo, MD Professor Staff Orthopaedist Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Texas Scottish Rite Hospital for Children Dallas, Texas Dallas, Texas Philip Wilson, MD Karl E. Rathjen, MD Assistant Chief of Staff Assistant Chief of Staff Department of Orthopaedic Surgery Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Texas Scottish Rite Hospital for Children Professor Professor Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Texas Southwestern Medical Center University of Texas Southwestern Medical Center Dallas, Texas, Assistant Chief of Staff Dallas, Texas Director, Pediatric Sports Medicine Department of Sports Medicine and Orthopaedics Anthony I. Riccio, MD Texas Scottish Rite Hospital for Children North Staff Orthopaedic Surgeon Frisco, Texas Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children Robert Lane Wimberly, MD Professor Medical Director of Movement Science Department of Orthopaedic Surgery Texas Scottish Rite Hospital for Children University of Texas Southwestern Medical Center Associate Professor Dallas, Texas Department of Orthopaedic Surgery University of Texas Southwestern Medical Center B. Stephens Richards, MD Dallas, Texas Chief Medical Officer Texas Scottish Rite Hospital for Children Professor Department of Orthopaedic Surgery University of Texas Southwestern Medical Center Dallas, Texas PRE FACE This edition of Tachdjian’s Pediatric Orthopaedics is the The authors of this book are experienced clinicians fourth that has been written and edited by the staff of the with expertise and training in pediatric orthopaedics, Texas Scottish Rite Hospital for Children. As we research and most have subspeciality interests and expertise. They and reevaluate each chapter, we are usually surprised to are leaders in their fields and base their discussions and see how many things have changed between editions. recommendations on a very rich clinical experience in For example, in recent years we have seen considerable an academic practice. An important feature of our aca- growth in the knowledge and practice in the field of demic environment is the vigorous preoperative group pediatric sports subspecialization. In recognition of this discussion of surgical procedures. As academic leaders, growth, we have added a new chapter dedicated to pedi- they regularly present their research at national and inter- atric and adolescent sports conditions, which includes national meetings. Their work is widely published and the most recent developments in the management of broadly respected. concussion. In the scoliosis chapter, exciting new infor- Users of the text include students from all levels from mation about the rapidly evolving management of early medical school, residency, fellowship, new and estab- onset scoliosis has been added, including important non- lished physicians, and non-p hysician practitioners, as well operative measures such as serial casting and bracing, as as established professors as they augment their publica- well as the use of tethering. The field of genetics is con- tions. The text of this edition is fully produced in two print tinually expanding, and genetics-related content, which volumes. To lighten the load of the textbook, a compre- appears in many of our chapters, has been updated to hensive bibliography is available in the online version. This reflect current understanding. placement facilitates Internet access to other resources. Twenty years ago, we took on the challenge to build As in prior editions, our popular surgical videos are on the groundwork laid by Dr. Mirhan Tachdjian in his available online. These videos present the important steps two editions. Our goal has been to produce a textbook of actual surgical cases and are narrated by the operating that fully encompasses the broad field of pediatric ortho- surgeons. We receive frequent positive comments from paedics. We have based our descriptions on the best avail- surgeons throughout the world who find these very use- able published knowledge. We have sought to present the ful for planning their surgical procedures. Other videos in most current evidence from the literature from level 1 to the collection cover non- operative subjects such as cast 5 in a succinct and readable format. We have augmented application for scoliosis, club foot casting, and Pavlik har- the discussions with recommendations based on personal ness application. experiences of a top-l evel clinical faculty. When presenting I am sincerely grateful to each of our authors and truly controversial topics, we prefer to give the reader the evi- appreciate the effort involved in making the sixth edition a dence from the different arguments so that the reader can reality. We welcome two new authors, Dr. Jane Chung and make a reasoned decision after reviewing the conflicting Dr. Shane Miller, who are pediatric- trained practitioners evidence. We carefully avoid the “cookbook” approach in with expertise in sports medicine. We continue to be grate- which one puts forth their preferred treatment as gospel. ful for the contribution of our Boston colleagues, Professor We continue to insist that our text be comprehensive, Mark Gebhardt and Dr. Megan Anderson, who are respon- even though a shorter text would be more convenient to sible for the chapter on malignant tumors. I especially want handle. We fully present each topic, include the descrip- to thank my administrative assistant, Louise Hamilton, who tion of a disorder, and discuss appropriate history and had the huge task of putting the whole project together. physical exam, relevant studies, differential diagnosis, and She was able to devote the time needed for this edition details of treatment. We believe that it is important to because of coverage by the other administrative assistants, present the important details of decision making, and we including Stacy Duckworth, Lisa Sherman, Rebecca Fuller, emphasize the complexity of overall patient care. Our sur- Amy Park, and our administrative director, Laura Griffiths. gical discussions stress proper preoperative planning and Again, our heartfelt appreciation goes to our families, who preparation, as well as description of operative details. We are vitally important in every facet of our lives; thanks for also provide the important postoperative protocols that giving us your support and understanding. are necessary to ensure the best results. John A. Herring, MD vii C H A P T E R 1 Growth and Development John A. Herring Normal Growth and Development Chapter Contents Neonates are primarily reflexive, but they do exhibit some Normal Growth and Development 3 cognitive traits.8 These traits include showing more curiosity Disorders of Normal Growth and about facelike FIG.s than about other FIG.s of comparable Development 3 brightness, as well as a preference for black- and- white tones Evolution of Proportionate Body Size 5 rather than gray. Neonates should turn their eyes toward sound Physical Growth 5 and be able to distinguish their mothers from other people. Developmental Milestones 6 The normal neonate is born with a predominant flexor tone, and physiologic flexion contractures are typical (Fig. 1.2). At birth the newborn’s limbs are maintained in flexion This chapter on growth and development is presented first posture, and passive movement of the extremities and neck for several important reasons. One of the unique aspects of elicits strong flexor tone. A normal neonate’s limbs move in pediatric care is the dynamic evolution of each individual an alternating fashion when they are stimulated. from neonate to adolescent. During this period, a remark- Normal development progresses cephalocaudad; infants able process of growth and development takes place in gross acquire the ability to control their head and hands before and fine motor skills; intellectual, social, and verbal skills; they are able to control their legs.8 During the first few body size; gait; and sexual characteristics. months, gaining head control predominates. Hand control, Growth refers to an increase in an individual’s total body size such as the ability to grasp objects, follows. As development or to an increase in the physical size of a particular organ or organ continues, the infant gains more and more control of the system.9,17 References to normal human growth parameters legs. from the third trimester to adulthood are provided in Proceed- To determine whether an infant’s growth and develop- ings of the Greenwood Genetic Center: Growth References.10 ment are progressing normally, the examiner needs to find This publication also provides parameters for growth patterns out from the parents what developmental milestones the seen in specific diseases, such as achondroplasia, diastrophic child has attained and when and then compare them with dysplasia, Down syndrome, Marfan syndrome, and skeletal the norms. If the child appears to have developmental dysplasias (comparative curves). Growth standards are also delays, referral to a physician who specializes in growth and available in Hensinger’s Standards in Pediatric Orthopedics.7 development problems is recommended. Development refers to the physical changes of matura- Because of the wide variations in the times at which devel- tion that occur as a child ages. The developmental process opmental milestones are achieved and the numerous reasons encompasses other aspects of differentiation of form, but it for delays, the diagnosis of developmental delay can be diffi- primarily involves changes in function that transform humans cult to make in the very young child. In addition, a child may into increasingly more complex beings.9 Development is exhibit delay in acquiring certain skills and unusual rapidity influenced by many interrelated factors, including genetics, in acquiring others. When a delay is evident, the physician physical trauma, nutrition, and socioeconomic status.17 must determine the cause, which may be a neuromuscular The age at which children reach specific milestones of condition. Factors suggesting a neurologic cause include fail- development depends on the maturation rate of their cen- ure of normal developmental responses to appear, prolonged tral nervous system (CNS), which varies from child to child. retention of primitive infant reflexes, or a delay in achieving Ranges for variations in normal have been developed to assist gross motor milestones within normal limits. in the assessment of the pediatric patient, and the most com- monly used assessment tool is the revised Denver Develop- Disorders of Normal Growth and mental Screening Test (DDST)(Fig. 1.1).5-7 It is important to know when a child should normally achieve expected Development milestones of growth and development so that potentially abnormal situations are evident to the physician who is tak- Many pediatric orthopaedic problems result from disor- ing a patient’s history and performing a physical examination. ders or conditions that adversely affect normal growth and The significance of various findings must be related to development. The four major failures of normal growth and the child’s particular stage of growth and development. development are malformations, deformations, disruptions, Although no one should expect a 4-m onth- old infant to be and dysplasias.4,12 walking, it is distinctly abnormal for an 18- month- old child not to be doing so. Similarly, a 12- month- old child is likely Malformations to have some degree of genu varum, whereas the presence of genu varum in a 3-y ear- old child should be cause for con- Malformations are structural defects that result from inter- cern and a focus of further investigation. ruption of normal organogenesis during the second month of 3 4 SECTION I Disciplines DENVER ll Examiner: Name: Date: Birthdate: ID#: Months 2 4 6 9 12 15 18 24 Years3 4 5 6 prepare cereal Percent of children passing brush teeth, no help play board/card games 25 50 75 90 dress, no help test item put on t-shirt 86% name friend copy wash and dry hands brush teeth with help draw person, 6 parts copy , demonstrate put on clothes pick longer line feed doll copy + remove garment draw person, 3 parts use spoon/fork help in house copy 88% wiggle thumb drink from cup define 7 words tower of 8 cubes initate activites imit. vert. line name 2 opposites play ball with examiner tower of 6 cubes count 5 blocks wave bye-bye tower of 4 cubes know 3 adjectives indicate wants tower of 2 cubes define 5 words play pat-a-cake dump raisin, demonstrated name 4 colors cial work ffoere tdo yself put block ins ccruibpbles speech all unudnedrsetarsntadnadb le4 prepostitions So regard own hand bang 2 cubes know 4 actions – smile held in hands use of 3 objects al spontaneously thumb-finger count 1 block son sremsipleo nsively take 2 cubgerassp use of 2 objects er regard pass cube name 1 color P face know 2 take raisin adjectives look for yarn know 2 actions balance each foot 6 sec Adaptive htofaognlelodtwhsree 1gr8a0rd° raisinreaches speecnha hmanelaf 6um nbedo e4dr ypsn tipacaatmnurdtresea 4sb lpeicturebsalance eachb afolaobntac 3lea hsneeecaceecl h-et oafo-ctoohte f4 ow osate l5ck sec or- grasp name 1 picture hops ot rattle combine words balance each foot M follow past point to pictures 2 sec e midline 6 words balance each Fin ftool lmowid ln. 3 words foborot a1d s jeucmp 2 words throw ball overhand 1 word jump up Dada/Mama specific kick ball forward jabbers walk up steps combine syllables runs Dada/Mama nonspecific walk backward imitate speech sounds walk well single syllables stoop and recover turn to voice stand alone turn to stand 2 sec rattling sound get to e squeals sitting guag "Ooo/laaauhg"hs stand pstualln tdo an vocalizes holding on L respond sit–no to bell support pull to stand no head lag roll over chest up arm support wear wt. on legs sit-head steady or ot head up 90° M head up 45° ss lift head o Gr emqouvael ments Months 2 4 6 9 12 15 18 24 Years3 4 5 6 FIG. 1.1 The revised Denver Developmental Screening Test showing the range of age when a child should achieve milestones in the de- velopment of gross motor skills, fine motor–adaptive skills, language, and personal-s ocial skills. (Modified from Frankenburg WK, Dodds JB. The Denver Developmental Screening Test. J Pediatr. 1967;71:181; Hensinger RN. Standards in Pediatric Orthopedics. New York: Raven Press; 1986.) CHAPTER 1 Growth and Development 5 gestation. Examples include myelomeningocele, syndactyly, either by eliminating the deforming force or by counteract- preaxial polydactyly, Poland syndrome, and proximal focal ing the force with stretching, casting, or bracing.  femoral deficiency (congenital femoral deficiency).  Disruptions Deformations Disruptions are morphologic abnormalities that result from Deformations are defects in the form, shape, or site of body an extrinsic interference with or breakdown of the nor- parts caused by mechanical stress. The mechanical stress, mal growth and development process. Disruptions can be which may be intrinsic or extrinsic, alters or distorts tissues. caused by drugs or toxic materials. These structural defects Because the fetus grows considerably faster than the infant, may affect organs or systems that were normal during fetuses are more vulnerable to deformations. Examples organogenesis. A congenital constriction band in the limb is include supple metatarsus adductus, calcaneovalgus feet, con- an example of a disruption.  genital knee hyperextension, and physiologic bowing of the tibia. Dysplasias Differentiating deformations from malformations is important. During a cursory examination, severe deforma- Dysplasias are structural defects caused by abnormal tis- tions may look like malformations.3 Careful assessment is sue differentiation as cells organize into tissues. Examples essential if the child is to receive appropriate care for the include osteogenesis imperfecta, achondroplasia, and spon- condition. Malformations cannot be corrected directly, dyloepiphyseal dysplasia.  whereas deformations can often be reversed relatively easily Evolution of Proportionate Body Size At birth, the neonate’s head is disproportionately large, comprising approximately one-f ourth of the body’s total length. During the first year of infancy, the head contin- ues to grow rapidly, and the head circumference usually is greater than the circumference of the infant’s chest. The evolution of body proportions is indicated by a change in the child’s upper to lower segment ratio (the relation of the center of gravity to body segments). This ratio is measured as the distance from the top of the head to the symphysis pubis, divided by the distance from the symphysis pubis to the bottom of the feet (Fig. 1.3).7 At birth, the ratio is approximately 1:7. At approximately 10 years of age, the upper and lower segments are almost equal in length (i.e., the ratio is ≈1.0). After 10 years of age, as individuals become adolescents and adults, the ratio normally becomes less than 1.0, as the upper segment becomes shorter than the lower segment.  Physical Growth Head Circumference FIG. 1.2 Typical position of the neonate with vertex presentation. The hips and knees are flexed, the lower legs are rotated internally, During infancy it is essential to obtain individual or serial and the feet are rotated further inward on the lower leg. The lower measurements of the patient’s head circumference to deter- limbs are contracted into this position for a variable period after mine whether head growth is slower or faster than normal. birth. FIG. 1.3 Evolution of head- to- trunk proportion throughout growth. In the neonate the head is pro- portionately significantly larger relative to the trunk than it will be at skeletal maturity. (Reproduced from Hensinger RN. Standards in Pediatric Orthopedics. 6 mo fetus Newborn 2 yr 5 yr 13 yr 17 yr Adult New York: Raven Press; 1986.) 6 SECTION I Disciplines Head circumference should be measured at every physical The approximate ages at which children should normally examination during the first 2 years and at least biennially attain various gross motor skills are given in Table 1.1. thereafter. With the child supine, the examiner places a cen- By 3 months of age, infants should be able to hold their timeter tape over the occipital, parietal, and frontal promi- heads above the plane of the body when they are supported nences of the head. The tape should be stretched and the in a prone position. By 6 months of age, the head should not reading noted at the point of greatest circumference. Possible lag when infants are pulled from a supine to a sitting posi- conditions that can affect head circumference and growth tion. Normally, infants will begin to roll over between 4 and include microcephaly, premature closure of the sutures, 6 months of age and can sit with minimal external support hydrocephalus, subdural hematoma, and brain tumor. Head at 6 to 7 months. They should be able to pull up to a stand- circumference should be charted for age and percentile, as ing position by holding onto furniture at 9 to 12 months and noted in Fig. 1.4.  stand without support by 14 months. The average milestones of development of locomotion are as follows: the infant should be able to crawl by 7 to 9 Height and Weight months of age, cruise and walk with assistance at 12 months, A child’s growth, as demonstrated by an increase in body walk forward without support by 12 to 16 months, and run height and weight within predetermined normal limits, is at 18 months of age.1,2,11 Children should be able to ascend one of the best indicators of health during infancy and child- stairs with support by 18 months of age and without sup- hood. The child’s height and weight should be plotted on port by 2 years of age. They should be able to descend stairs a standard growth chart to verify that normal progress is with support at approximately 3 years of age and without being made. Numerous tables, charts, and graphs depict- support by 4 years. ing pediatric growth standards are available in Hensinger’s On gross inspection the independent gait of the infant has Standards in Pediatric Orthopedics7 and in Proceedings of a wide base, the hips and knees are hyperflexed, the arms are the Greenwood Genetic Center: Growth References.10 The held in flexion, and the movements are abrupt. With matura- World Health Organization published an extensive study of tion of the neuromuscular system, the width of the base gradu- child growth standards for length and height for age, weight ally diminishes, the movements become smoother, reciprocal for age, weight for length, weight for height, and body mass swing of the upper limbs begins, and step length and walking index for age.18 Height and weight should be charted for velocity increase.13 The adult pattern of gait develops between age and percentile, as noted in Fig. 1.5. If growth measure- 3 and 5 years of age.14 A more complete description of normal ments are lower than the 3rd percentile or higher than the pediatric gait patterns is provided in Chapter 5.  97th percentile, or if a recent deviation from previously stable percentile rankings is noted, further investigation is Fine Motor Skills warranted.  The approximate ages at which children normally attain various fine motor skills are listed in Table 1.2. A child’s Epiphyseal Growth and Closure exploration of the environment by touch and the devel- During normal growth and development, the pattern in the opment of manual skills should emerge in an orderly and appearance of centers of ossification and fusion of epiphy- sequential manner. At 3 months of age, infants can apply ses in the upper and lower limbs is orderly. This pattern lip pressure and coordinate sucking and swallowing during varies among individuals and is different for boys and girls feeding (the sucking reflex is present at birth in all normal (Figs. 1.6–1.9). Thus the orthopaedist must understand full- term neonates but usually disappears at 3–4 months of the ranges of normal when treating the pediatric patient, age). By 6 months of age, children are able to feed them- particularly when interpreting radiographs. The percentage selves from hand to mouth. By 9 months, children can feed contribution of each epiphysis to longitudinal growth of the themselves food such as cookies. By 12 months of age, chil- upper and lower extremity long bones is shown in Figs. 1.10 dren can pick up a spoon from the table, chew cookies or and 1.11.  toast, and drink milk from a cup if assisted. Between 12 and 18 months, they are able to feed themselves (messily) with a spoon and drink from a cup by using one or two Tanner Stages of Development hands. By 24 months, they can feed themselves semisolid The physical maturation of a child can also be compared food with a spoon and drink holding the cup in one hand with his or her chronologic age by using the pubertal or using a straw. stages of development as described by Tanner (Figs. 1.12 Children should be able to purposefully grasp objects and 1.13).15,16 The Tanner stages of maturation are based such as a bottle or toy rattle by 6 months of age. At 9 on breast size in girls, genital size in boys, and pubic hair months of age, children use their fingers and thumb to grasp stages for both girls and boys. The onset of menstruation objects and are able to transfer objects from one hand to is also an important milestone in the physical maturation the other. By 12 months, children’s hand skills are such that of girls.  they are able to hit two objects together, voluntarily release objects, manipulate and throw objects on the floor, and hold crayons and imitate scribbling. Between 18 and 24 months Developmental Milestones of age, their hand skills evolve to the point that they can build block towers, turn pages one at a time, and throw a Gross Motor Skills ball (but inaccurately). Between 2 and 3 years of age, their The development of gross motor skills depends on maturation writing skills evolve from imitating vertical, horizontal, and of the CNS, which proceeds in a cephalocaudal direction.8 circular strokes to copying circles.

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