Pediatric Residency Training Program



Sharon L. Young MD

  1. Upper Extremity
  2. Brachial plexus injury

most commonly occurs as a result of birth trauma from excessive traction on the neonate's head, neck, or arm, which stretches the nerves of the brachial plexus. Congenital aplasia of the brachial plexus accounts for a very small percentage of cases.

  1. Erb's palsyis an upper brachial plexus injury involving the C5 and C6 nerve roots. It is the most common brachial plexus injury and most often involves the right arm. Clinical features include a flaccid arm and an asymmetric Moro reflex. (See Chapter 2, Table 2-2 for a description of the Moro reflex.) The arm is held in internal rotation with the elbow extended, forearm pronated, and the wrist and fingers held in flexion. This positioning is often described as the “waiter's tip.”
  2. Klumpke's palsyis less common and is the result of a lower brachial plexus injury caused by upward traction on the arm. It involves the C7 and C8 nerve roots. Clinical featuresinclude a claw hand owing to unopposed finger flexion and decreased ability to extend the elbow and flex the wrist. Horner's syndrome (ipsilateral ptosis, miosis, and anhydrosis) may be present if the sympathetic fibers of the first thoracic nerve have also been damaged.
  3. Diagnosisis on the basis of history and physical examination but may include a plain radiograph of the shoulder to evaluate for an associated clavicular fracture. Electromyography (EMG) and nerve conduction studies may be considered to assess for a neuropathy or myopathy.
  4. Management. Treatment includes observation and range-of-motion physical therapy to prevent contractures. Improvement is often noted within 48 hours; however, should the arm not improve within 18 months, surgery may be necessary.
  5. Nursemaid's elbow

is a subluxation of the radial head. The usual mechanism of injury is an upward force on the arm, such as pulling a toddler upward by the hand to make the child stand. The radial head in children younger than 6 years of age has a slender shape, allowing it to slip out of the annular ligament, which normally keeps it in place.


  1. Clinical features
  2. Sudden onset of pain, which is difficult to localize
  3. The elbow is held flexedand no swelling is present. The child is unwilling to use the affected arm, but hand function is normal.
  4. Diagnosisusually is on the basis of the clinical presentation in patients younger than 6 years of age. No radiograph is needed; however, if a film is ordered, the technologist may accidentally reduce the subluxation in the process of positioning the arm for the radiograph.
  5. Management.Treatment of the subluxation is to reduce it by simultaneously flexing the elbow and supinating the hand.
  6. Prognosisis excellent. Usually, the child will start to use the arm within 15 minutes of the reduction, but use of the arm occasionally may be delayed for up to 24 hours. Subluxation may recur.
  7. Anterior shoulder dislocation

is the most common type of shoulder dislocation. It occurs with excessive external rotation, abduction, and extension of the shoulder, as may occur in gymnastics or wrestling.

  1. Diagnosisis on the basis of radiographs (especially an axillary view) of the glenohumeral joint to visualize the dislocation.
  2. Management.Treatment is immobilization after closed reduction. Recurrence of dislocation approaches 90% in the adolescent population. Therefore, some physicians recommend early surgery to restore stability.
  3. Spine
  4. Disorders of the Cervical Spine
  5. Torticollisis defined as the tilting of the head to one side. It is either congenital or acquired.
  6. Congenital torticollisis very common and is usually the result of uterine constraint or birth trauma, either of which causes contracture of the sternocleidomastoid muscle. Congenital torticollis caused by cervical spine deformities is rare; however, an example is Klippel-Feil syndrome (see section II.A.3).
  7. Clinical features
  8. Head is tilted toward the affected side with the chin pointed away from the contracture. Decreased range of motion and stiffness are noted when stretching the head to the opposite side.
  9. A soft tissue mass may sometimes be palpated within the sternocleidomastoid muscle representing bleeding into the muscle (this may occur from birth trauma).
  10. Asymmetry of the head and ears may be noted in untreated torticollis.
  11. Diagnosisis on the basis of physical examination. If the neck is very stiff, radiographs of the cervical spine can be used to assess for abnormalities of the cervical spine.



  1. Management.Treatment includes stretching exercises to relieve the muscle contracture. If head asymmetry is noted, helmet therapy must be initiated by 4–6 months of age to correct the head shape as the head grows.
  2. Complicationsinclude skull deformity and facial asymmetry (plagiocephaly, see Chapter 1, section II.B.2.d) if torticollis is not treated promptly.
  3. Prognosisafter 6 months of diligent muscle stretching is complete resolution in 90%.
  4. Acquired torticollisis torticollis arising later in childhood. It is rare compared with congenital torticollis. Causes may include cervical adenitis, peritonsillar or retropharyngeal abscess, cervical diskitis or osteomyelitis, neoplasms, strabismus and refractive errors, trauma, gastroesophageal reflux disease (Sandifer syndrome), and dystonic drug reactions.
  5. Atlantoaxial instabilityis caused by an unstable joint between the occiput and the first cervical vertebrae or between the first and second cervical vertebrae. The first and second cervical vertebrae may be abnormal in syndromes such as Down syndrome, skeletal dysplasias (see Chapter 5, section III.D), and Klippel-Feil syndrome (see section II.A.3).
  6. Clinical features.Physical examination is usually normal and patients are often asymptomatic. However, spinal cord injury may occur if a patient with instability sustains injury. A high index of suspicion for the above-mentioned syndromes is important to prevent injury.
  7. Diagnosisis made on the basis of lateral flexion-extension radiographs of the cervical spine.
  8. Managementincludes fusion of C1 and C2 if instability is severe.
  9. Complicationsinclude paralysis or even death if the instability is not detected before injury.
  10. Klippel-Feil syndromeis defined as failure of normal vertebral segmentation that results in relative fusion of the involved vertebrae. The fusion usually occurs in the cervical spine but can occur in the lumbosacral vertebrae or in groupings of vertebrae throughout the vertebral column. Associated abnormalities may include congenital torticollis, genitourinary anomalies, congenital heart disease, hearing loss, and Sprengel's deformity (congenital abnormality of the scapula in which the scapula is rotated laterally leading to shoulder asymmetry and diminished shoulder motion).
  11. Scoliosis

is defined as lateral curvature of the spine. This disorder occurs equally in males and females, but adolescent females require treatment eight times more frequently.

  1. Etiology
  2. Most cases of scoliosis (80%) are idiopathic.
  3. Other causes include leg length discrepancy, neuromuscular disorders, connective tissue disorders, vertebral anomalies, and genetic syndromes.
  4. Clinical features.Asymmetry of the shoulder height, scapular position, and the waistline may be present. As the patient bends forward, a hump,


representing posterior displacement of the curved spine, may be seen (Adam's forward bending test; Fig. 17-1). Pain is absent and, if present, is a sign of an underlying disorder that should be investigated.

  1. Diagnosisis on the basis of clinical findings and radiologic confirmation. Standing posterior-anterior (PA) and lateral radiographs of the spine are needed to confirm the curvature and are used to calculate the Cobb angle. The Cobb angle, which measures the degree of scoliosis, is measured by drawing a line along the superior aspect of the most angulated vertebrae at the top of the curvature and drawing another line along the inferior aspect of the lowest most angulated vertebrae of the curvature. The angle at the intersection of these lines is the Cobb angle.
  2. Management.Treatment may include observation, bracing, and surgery. Bracing prevents progression of curvature. Surgery is required for very severe curves or to stop curve progression. Progression of scoliosis occurs only during growth or if the spinal curvature is greater than 50°. It is important to remember that almost all growth in females ceases within 6 months of menarche.

Figure 17-1. Scoliosis. A. Curve is visible when standing. B. Rib hump is visible when child performs Adam's forward bending test.

  1. P.493
  2. Before and during growth spurt:
  3. For 10–20° of scoliosis, a follow-up scoliosis film is obtained 4–6 months later to assess for progression. Five degrees of progression is considered significant and warrants referral to an orthopedic surgeon.
  4. For 20–40° of scoliosis, bracing is indicated.
  5. For > 40° of scoliosis, surgery is indicated.
  6. After growth has concluded, surgery is considered if scoliosis is > 50°.
  7. Complications, such as respiratory or cardiovascular compromise, may occur if scoliosis is > 60–65°.
  8. Kyphosis

is defined as anterior-posterior (AP) curvature of the thoracic spine. A hunched back in the thoracic region is present.

  1. Flexibility in the rounded area should be assessed by having the patient extend his or her back while prone. Most adolescents with kyphosis have flexible kyphosisin which they can voluntarily correct the rounded area.
  2. Scheuermann's kyphosisis a stiff idiopathic kyphosis in which three consecutive vertebrae are wedged. It develops in previously normal adolescents.
  3. Back pain

is an infrequent pediatric complaint. Therefore, any complaint of back pain that interferes with play should be evaluated for significant disease. The differential diagnosis is extensive and includes fractures, osteomyelitis, rheumatologic diseases, neoplasms, and pyelonephritis. Some common causes include:

  1. Back strainis defined as muscular soreness from overuse or bad body mechanics. Back strain is the most common cause of back pain in children.
  2. Clinical features.Diffuse muscular pain is present without neurologic deficits. Physical examination is normal.
  3. Management.Treatment includes rest and analgesics.
  4. Spondylolysisis a stress fracture in the pars interarticularis (i.e., bone that connects the superior and inferior articular facets of a vertebral body) secondary to repetitive hyperextension of the spine, as occurs in gymnastics, tennis, and diving. It typically involves the lumbar region, particularly L5. Pain is localized and increases with hyperextension.
  5. Diagnosisis on the basis of AP, lateral, and oblique views of the lumbar spine. Because spondylolysis is a stress fracture, plain films may not detect the fracture. Therefore, a bone scan or a single photon-emission computed tomographic (SPECT) scan may be used for diagnosis if the fracture is acute.
  6. Management.Treatment includes rest and analgesics for pain. Casting or bracing for immobilization may be necessary if pain persists. Surgery is sometimes required.
  7. Complicationsinclude spondylolisthesis, which is discussed below.
  8. Spondylolisthesisoccurs when the body of the vertebra involved in the spondylolysis slips anteriorly (i.e., subluxation of the vertebra). The subluxed


vertebra can impinge on nerve roots. Diagnosis and treatment is the same as for spondylolysis. Indications for surgery include nerve impingement, persistent pain, or progression of the subluxation.

  1. Diskitisis defined as infection (Staphylococcus aureus is the most commonly identified causal organism) or inflammation (idiopathic, trauma, or rheumatic disease are causes) of the intervertebral disk.
  2. Clinical features.Diskitis typically begins with signs and symptoms of an upper respiratory illness or minor trauma, which are followed by back pain with tenderness over the involved disk. Fever is sometimes present. Children refuse to flex the spine, and young children may refuse to ambulate.
  3. Diagnosis.Clinical features are the basis of diagnosis. Erythrocyte sedimentation rate (ESR) is elevated. Magnetic resonance imaging (MRI) and bone scan can confirm the diagnosis.
  4. Management.Treatment includes bed rest. Use of antistaphylococcal antibiotics may be considered for patients thought to have infection.
  5. Herniated intervertebral diskis much more common in adults but may occur in adolescents. The lumbar region is most commonly affected. Unlike in adults, herniation in adolescents is caused by repetitive activity and rarely by trauma. Treatment is conservative initially with bed rest. Surgery to remove the disk is necessary only if symptoms persist or if the neurologic examination is abnormal.

III. Hip

  1. Developmental Dysplasia of the Hip (DDH)

occurs when the acetabulum is abnormally flat, leading to the easy dislocation of the head of the femur. The spectrum of disease severity ranges from hip joint laxity to frankly dislocated hips. DDH was formerly termed congenital hip dysplasia; however, the name was changed because the hip in DDH may be normal at birth yet develop an abnormal acetabulum months later.

  1. Epidemiology
  2. DDH is more common in girlsthan in boys (6:1 ratio).
  3. Sixty percent of cases involve the left hip, twenty percent involve the right hip, and twenty percent involve both hips.
  4. Risk factors include female sex, first born, breech presentation, family history of DDH, and oligohydramnios.
  5. Clinical features.DDH is asymptomatic in infants. Physical examination shows the following findings:
  6. Positive Barlow maneuver.(The Barlow maneuver attempts to dislocate a dislocatable hip.) With the hips at 90° flexion, place the thumb on the medial side of the thigh and the middle finger on the greater trochanter and apply gentle pressure posteriorly and laterally to dislocate the hip. A “clunk” is felt as the hip dislocates.
  7. Positive Ortolani maneuver.(The Ortolani maneuver attempts to reduce a dislocated hip.) In the same position described above, abduct the hip, applying gentle pressure upward with the middle finger to


slide the head of the femur back into the acetabulum. In a positive Ortolani maneuver, the hip can be felt slipping into the acetabulum as it is being reduced.

  1. Abnormal Galeazzi sign, which assesses asymmetry of femur position. The Galeazzi sign is performed by placing the hips in flexion at 90°. If the hip is dislocated, the affected femur is shifted posteriorly compared with the normal limb. If both hips are dislocated, the Galeazzi sign is normal.
  2. Asymmetric abduction of the hips and asymmetric thigh or buttock folds.The older the infant, the more difficult it is to diagnose DDH using the Barlow or Ortolani maneuvers. Decreased ability to abduct the affected hip and asymmetric buttock folds are particularly useful in the diagnosis of DDH in older infants.
  3. Diagnosis.Physical examination alone may be the basis of diagnosis. However, if the examination is equivocal, imaging may be helpful.
  4. Ultrasound is used to assess for DDH in young infants because the femoral head does not ossify until 4–6 months of age.
  5. AP radiographs of the pelvis may be used to assess for DDH if the infant is older than 6 months of age.
  6. Management.Treatment depends on the age of the patient at the time of diagnosis. The earlier the diagnosis, the less likely surgical intervention will be necessary.
  7. The Pavlik harnessholds the head of the femur against the acetabulum to stimulate formation of the normal cup shape of the acetabulum. It is typically used for 2–3 months if the diagnosis is made by 6 weeks of age. It is successful in 90–95% of cases.
  8. Surgerymay be required if the diagnosis is made beyond 6 weeks of age, the hips are bilaterally dislocated, the hips are not reducible on physical examination, or the Pavlik harness fails to stabilize the hip. Surgery generally involves closed reduction of the hip. However, if closed reduction fails, open reduction may be necessary. After surgery, the infant is in a cast for 2–3 months.
  9. Complications
  10. Avascular necrosis of the femoral head
  11. Limb length discrepancy, painful abnormal gait, and osteoarthritisif DDH is not treated
  12. Limp

is a common symptom during childhood. The differential diagnosis is extensive and is listed in Table 17-1. The more common causes include the following:

  1. Septic arthritisis a bacterial infection of the joint, which can be caused by hematogenous spread, contiguous spread, or direct inoculation. Septic arthritis of the hip is an orthopedic emergency.
  2. Epidemiology
  3. The age ranges from birth to 4 years of age; the peak is 1 to 3 years of age.
  4. The hip is most commonly affected in younger children, whereas the knee is more commonly affected in older children.



Table 17-1. Differential Diagnosis for a Painful Limp

Mnemonic: “The joint STARTSS HOTT”
S Septic arthritis
T Transient synovitis
A Acute rheumatic fever
R Rheumatoid arthritis
T Trauma
   Strain or sprain
S Sickle cell disease
   Pain crisis (vasoocclusive crisis)
S Slipped capital femoral epiphysis
H Henoch-Schönlein purpura
O Osteomyelitis
T Tuberculosis
T Tumor

Other causes of limp:
   D Developmental hip dysplasia
   D Diskitis
   L Legg-Calvé-Perthes
   L Limb length discrepancy
   L Lyme disease

  1. Staphylococcus aureusand Streptococcus pyogenes are the most common organisms. Neisseria gonorrhoeae may cause septic arthritis in adolescents.
  2. Clinical features
  3. Fever and irritabilityare common.
  4. Limp, refusal to walk, and pain with movement of the jointmay occur. The patient refuses to move the joint, and any attempt to move the joint results in significant pain. If the hip is affected, it is usually held in flexion, abduction, and external rotation to relieve the pressure within the joint capsule.
  5. Erythema, swelling, and asymmetry of soft tissue foldsmay be present.
  6. Diagnosis
  7. Laboratory studiesinclude an elevated white blood cell (WBC) count, elevated ESR, and elevated C-reactive protein.
  8. Blood culture is positive in 30–50% of cases.
  9. Analysis of the synovial fluid for cell count, Gram stain, and culture is useful. Synovial fluid demonstrating a WBC count > 50, 000–100, 000 cells/mm3is suggestive of septic arthritis. However, culture of the synovial fluid is positive in only 60% of cases.
  10. Imagingmay be useful.
  11. Ultrasound is the best imaging screen and demonstrates fluid in the joint capsule.



  1. Plain radiographs may reveal a widened joint space but are often normal.
  2. Management
  3. Surgical decompressionby joint aspiration is necessary to avoid avascular necrosis and to diagnose infection.
  4. Empiric intravenous antibioticsto cover Gram-positive organisms should be started after cultures are obtained. Duration of antibiotic treatment is 4–6 weeks.
  5. Complications.The femoral head is vulnerable to ischemic injury. Ischemia may lead to avascular necrosis and cartilaginous damage.
  6. Transient synovitis(also known as toxic synovitis) is a common self-limited, postinfectious response of the hip joint. Upper respiratory infection or diarrhea often precede transient synovitis. Transient synovitis is a diagnosis of exclusion. It is important to rule out septic arthritis, especially if a patient appears toxic or irritable, because the consequences of misdiagnosed septic arthritis can be serious.
  7. Epidemiology
  8. Transient synovitis is the most common cause of a painful limp in toddlers.
  9. Its peak age of presentation is 2–7 years.
  10. It is more common in males.
  11. Clinical features
  12. Low-grade fever, limp, and mild irritability may be present. Patients usually appear relatively well.
  13. Hip painmay be acute or insidious in onset. Although patients may be more willing to move their legs than patients with septic arthritis, they may also hold their legs in a flexed, abducted, and externally rotated position, similar to the position seen in septic arthritis.
  14. Diagnosisis often on the basis of the history and physical examination.
  15. The WBC count and ESR are normal or only slightly elevated.
  16. There may be an effusion in the hip, and if fluid is present, it should be aspirated and analyzed to rule out septic arthritis.
  17. Management.Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), bed rest, and observation.
  18. Prognosisis excellent. Pain usually improves within 3 days with analgesics and rest. Complete resolution of symptoms usually occurs by 3 weeks. Recurrence is unusual unless vigorous activities are resumed too soon.
  19. Legg-Calvé-Perthes(Perthes) disease is idiopathic avascular necrosis of the femoral head.
  20. Epidemiology
  21. The age of onset is 4–9 years.
  22. The disease is more common in Caucasians and Asians.



  1. The disease is more common in boys and has a male-to-female ratio of 4:1.
  2. Patients are typically active, thin boys who are small for their age.
  3. Clinical features.Children have a slightly painful limp with decreased internal rotation and abduction of the hip. This can be assessed on examination by log-rolling the leg internally. Pain may be referred to the knee and to the groin.
  4. Diagnosisis on the basis of AP and frog-leg lateral radiographs of the pelvis, which show increased density in the affected femoral head or a crescentic subchondral fracture in the femoral head, termed the “crescent sign.”
  5. Management.Treatment involves containment, or ensuring that the femoral head is positioned within the acetabulum to facilitate its remolding and reossifying.
  6. Physical therapyand restriction of vigorous exercise are effective. If pain persists, analgesia, traction, casting, or crutches may be used.
  7. Surgeryis indicated if there is more than 50% damage to the femoral head or if there is movement of the femoral head out of the acetabulum.
  8. Prognosisis best in younger patients. If children develop the disease when they are younger than 9 years of age, complete resolution within 2 years is the norm. The majority of patients who are older than 9 years of age when they develop the disease develop osteoarthritis in the affected hip as adults.
  9. Slipped capital femoral epiphysis (SCFE)is slipping of the femoral head off the femoral neck.
  10. Epidemiology
  11. Age of onset is usually during adolescence.
  12. The male-to-female ratio is 2–3:1.
  13. The typical patient is an obese adolescent boy.
  14. Clinical features.Patients have a painful limp with pain in the groin, hip, or knee. The degree of pain varies from severe (acute slip) to mild (chronic slip). Internal rotation, flexion, and abduction are usually decreased in the affected hip. SCFE is bilateral in 30% of cases, and patients with hypothyroidism are especially more likely to develop bilateral disease.
  15. Diagnosis.AP and frog-leg lateral radiographs of the pelvis confirm the slipped epiphysis. A line drawn flanking the superior edge of the femoral neck (Klein line) crosses 10–20% of the epiphysis in a normal hip. However, in SCFE, the Klein line will not cross the epiphysis at all.
  16. Management.Treatment involves pinning the epiphysis to prevent further slippage. The femoral head is not placed back into a normal position with the femoral neck because the force required may cause avascular necrosis.
  17. Complications
  18. Avascular necrosisand collapse or deformity of the femoral head
  19. Chondrolysis(degeneration of articular cartilage of the hip)



  1. Limb length discrepancy, which may cause limp and pain
  2. Osteoarthritis
  3. Osteomyelitisis an infection of the bone.
  4. Epidemiology
  5. The peak ages of onset are less than 1 year and between 9 and 11 years.
  6. The male-to-female ratio is 2:1.
  7. Etiology
  8. aureusand S. pyogenes are the most common organisms. Salmonella should be considered in patients with sickle cell anemia. Pseudomonas aeruginosa infection of a bone in the foot can occur if a child steps on a nail while wearing sneakers.
  9. Although contiguous spread and direct inoculation can cause osteomyelitis, children most commonly acquire infection by hematogenous seeding.
  10. Clinical features
  11. Feverand irritability
  12. Bone painerythema, swelling, and induration, which may develop in the area over the osteomyelitis
  13. Painful limp
  14. Diagnosis
  15. Laboratory studiesinclude an elevated WBC count, ESR, and C-reactive protein.
  16. Blood culture is positive in 50% of cases.
  17. Blood culture in combination with a culture of the aspirated bone can identify the organism in 70% of cases.
  18. Imaging, using bone scan or MRI, detects osteomyelitis a few days after the onset of symptoms. A plain radiograph is not a good initial studybecause it will be normal early in the infection. After 10–14 days of infection, a plain radiograph begins to reveal elevation of the periosteum, suggesting osteomyelitis.
  19. Management
  20. Antibiotics should be given for 6 weeks, although the length of treatment varies depending on the organism.
  21. Decreasing ESR generally indicates response to intravenous antibiotics, at which time oral antibiotics usually can be used to complete the antibiotic course.
  22. Surgery is necessary to drain and debride a subperiosteal abscess if fever and swelling persist despite 48 hours of intravenous antibiotics.
  23. Complications
  24. Spread of infectionmay occur, either by contiguous spread infecting a joint or distant seeding causing pneumonia.
  25. Chronic osteomyelitisresults from a nidus of residual infection, such as a sequestrum (i.e., focus of necrotic bone) or an involucrum (i.e., formation of new bone or fibrosis surrounding the necrotic, infected bone). Symptoms of chronic osteomyelitis are


usually insidious, so the diagnosis is often delayed and complications are common. Both surgery and antibiotics are needed.

  1. Pathologic fractureat the site of the infection may occur as a result of healing and remodeling of bone, bone necrosis, or an involucrum. Activity should be restricted during antibiotic therapy to prevent a fracture, especially if the diagnosis of osteomyelitis was initially delayed.
  2. Angular deformity or limb length discrepancyif the growth plate is involved in the infection
  3. Lower Extremity
  4. Torsional Abnormalities
  5. In-toeingis a common parental concern. Most in-toeing is normal and corrects with growth. The following are the most common causes of in-toeing:
  6. Metatarsus adductusis medial curvature of the mid-foot (metatarsals).
  7. Epidemiology and etiology
  8. Metatarsus adductus occurs in children younger than 1 year of age.
  9. It is usually caused by intrauterine constraint.
  10. Clinical featuresinclude a C-shaped foot that can be straightened to varying degrees by gentle manipulation. Dorsiflexion is intact, but if the ankle cannot dorsiflex, clubfoot should be considered.
  11. Diagnosisis by physical examination. Radiographs are not needed.
  12. Management
  13. Flexible foot that can overcorrectwith passive motion needs observation only.
  14. Flexible foot that can correct with passive motion, but not overcorrect, will benefit from exercises to stretch the foot.
  15. Stiff foot that cannot be straightenedwarrants evaluation by a pediatric orthopedic specialist. Casting of the foot for 3–6 weeks may be necessary.
  16. Prognosisis excellent. Resolution occurs in almost all patients.
  17. Talipes equinovarus (clubfoot)is a fixed foot in inversion with no flexibility. Bilateral involvement occurs in 50% of cases.
  18. Epidemiology
  19. Incidence is 1 in 1, 000; it is increased to 6 in 1, 000 in Pacific Islanders.
  20. The male-to-female ratio is 2:1.
  21. Etiologyis multifactorial, but genetics is thought to play a strong role because of the increased incidence of clubfoot within families. Talipes equinovarus is associated with DDH, myelomeningocele, myotonic dystrophy, and some skeletal dysplasias.



  1. Clinical features.The ankle is held in plantarflexion and inversion. The forefoot is curved medially (metatarsus adductus). The deformity is rigid with very little range of motion in the ankle.
  2. Diagnosisis generally on the basis of physical examination.
  3. Management.Treatment involves casting within the first week of life. If the deformity is severe or if there is no improvement after 3 months of casting, surgical correction may be necessary.
  4. Prognosisis good, with 30–50% of patients improving with casting alone. Surgical correction is successful in 85% of patients.
  5. Internal tibial torsionis a medial rotation of the tibia, causing the foot to point inward.
  6. Epidemiology and etiology
  7. Internal tibial torsion is the most common cause of in-toeing in children younger than 2 years of age.
  8. It is caused by in utero positioning.
  9. Clinical featuresinclude a foot that points medially when the knee is flexed to 90°. The patella faces forward. Bilateral torsion is more common, but unilateral torsion also occurs. Torsion is present at birth but is often noted between 1 and 3 years of age when the child starts to stand.
  10. Managementinvolves observation only.
  11. Prognosisis excellent with improvement by 3 years of age and resolution by 5 years of age.
  12. Femoral anteversion(or medial femoral torsion) is an inward angulation of the femur.
  13. Epidemiology.Femoral anteversion is the most common cause of in-toeing in children older than 2 years of age. The female-to-male ratio is 2:1.
  14. Clinical features
  15. Feet and patella point medially.
  16. Hips are able to internally rotate more than normal.External rotation is more limited than normal.
  17. Child prefers to sit in a “W” position(opposite of sitting crossed-legged on the floor).
  18. Managementis observation only.
  19. Prognosisis excellent with resolution by 8 years of age.
  20. Out-toeing.The major cause of out-toeing is a calcaneovalgus foot, which is a flexible foot held in a lateral position.
  21. Epidemiology and etiology.Out-toeing occurs because of uterine constraint and is most common in firstborn infants.
  22. Clinical featuresinclude a flexible foot with the toes pointed outward. Plantar flexion is restricted. The foot is instead excessively dorsiflexed, and the dorsum of the foot can easily be placed into contact with the anterior leg.
  23. Managementincludes stretching the foot. Rarely, casting may be needed.
  24. Prognosisis excellent; the condition is self-limited.



  1. Angulation of the knee
  2. Bowed legs (genu varum) is symmetric bowing of the legs in children younger than 2 years of age. Bowed legs are a normal variation until 2 years of age, when the legs straighten.
  3. Clinical features
  4. “Cowboy” stance.When the child stands erect with the feet together, the knees bow laterally and the patella point forward.
  5. Normal gait, with the body weight held in midline throughout the gait cycle. If the weight seems to shift from side to side, then Blount's disease must be considered (seesection IV.A.3.b).
  6. Diagnosisis on the basis of physical examination. Genu varum is present at birth but is usually not noticed until the child begins to walk. A standing AP radiograph of the lower extremities is indicated only if bowing is unilateral, is severe, or persists after 2 years of age to assess for pathologic bowing as may occur with rickets, growth plate injury, Blount's disease, or skeletal dysplasias.
  7. Managementis observation. Progression of bowing may be monitored by measuring the intercondylar distance when the patient stands erect with the feet together. Bracing or corrective shoes are not necessary.
  8. Prognosisis excellent with resolution by 2 years of age.
  9. Blount's disease (tibia vara) is a progressive angulation at the proximal tibia.
  10. Epidemiology and etiology
  11. It is more common in obese African American boys who are early walkers.
  12. It is thought to be a result of overload injury to the medial tibial growth plate causing inhibited growth only on the medial side.
  13. Clinical features
  14. Angulation just below the knee
  15. Lateral thrust with gait(i.e., the shifting of weight away from midline while walking)
  16. Diagnosis.Blount's disease should be suspected in any child with progressive bowing, unilateral bowing, or persistent bowing after 2 years of age. Diagnosis is on the basis of a standing AP radiograph of the lower extremities. A metaphyseal-diaphyseal (M-D) angle > 11° is consistent with Blount's disease.
  17. Management
  18. Bracingfor 1 year if the M-D angle is greater than 16° or if the patient is 2–3 years of age
  19. Surgical osteotomyif there is no improvement with bracing, if the patient is older than 4 years of age, if there is recurrence of angulation, or if the deformity is very severe
  20. Prognosis
  21. Osteoarthritisis common if angulation is not corrected.



  1. Recurrence of angulationis common in obese children if treatment is started after 4 years of age or if the epiphysis is fragmented from injury.
  2. Knock-knees (genu valgum) is idiopathic angulation of the knees toward the midline.
  3. Epidemiology and etiology
  4. Age of onset is 3–5 years.
  5. Most cases are physiologic as a result of overcorrection of normal genu varum.
  6. Clinical features
  7. Separation of the ankleswhen standing erect with knees together
  8. Swinging of legs laterally with walking or running
  9. Diagnosisis on the basis of physical examination.
  10. Managementis observation for the majority of patients. Surgical intervention is indicated only if genu valgum persists beyond 10 years of age or causes knee pain.
  11. Prognosisis excellent as the condition spontaneously resolves in the majority of patients. Osteoarthritis may occur if the angulation persists beyond adolescence.
  12. Osgood-Schlatter disease

is an inflammation or microfracture of the tibial tuberosity caused by overuse injury.

  1. Epidemiology.Osgood-Schlatter disease is the most common apophysitis, which is an inflammation of a tuberosity.
  2. Age of onset is most commonly 10–17 years.
  3. Osgood-Schlatter disease usually occurs in children who participate in sports involving repetitive jumping, such as basketball or soccer. The disease is more common in boys.
  4. Clinical featuresinclude swelling of the tibial tuberosity and knee pain with point tenderness over the tibial tubercle. Pain occurs with extension of the knee against resistance. The pain worsens with running, jumping, and kneeling.
  5. Diagnosisis on the basis of history and physical examination. Radiographs are not necessary.
  6. Managementincludes rest, stretching of the quadriceps and hamstrings, and analgesics.
  7. Patellofemoral syndrome (formerly patellar chondromalacia)

is a slight malalignment of the patella that causes knee pain.

  1. Epidemiology.Patellofemoral syndrome is common in adolescent girls.
  2. Clinical features
  3. Knee paindirectly under or around the patella
  4. Pain is worse with activity or with walking up and down stairs. It is relieved with rest, although pain may be noted shortly after sitting down.
  5. Physical examination of the knee may show the patella in a lateral position.



  1. Diagnosisis on the basis of history and physical examination. A “sunrise view” radiograph of the knee may show the patella in a lateral position.
  2. Managementincludes rest, stretching, and strengthening of the medial quadriceps.
  3. Growing Pains

are idiopathic bilateral leg pains that occur in the late afternoon or evening but do not interfere with play during the day.

  1. Epidemiology.Growing pains are very common and occur in children 4–12 years of age.
  2. Clinical features.Children may awaken at night crying in pain; however, the physical examination is normal.
  3. Management.Treatment includes analgesics and reassurance.
  4. Common Fractures
  5. Describing fractures

is critical because it may dictate the management of a fracture.

  1. Open or closed fracturedescribes whether a break in the skin overlies a fracture. In a closed fracture, the skin is intact. In an open fracture, the skin is broken and antibiotics are required because of the risks of local infection and osteomyelitis.
  2. Spatial relationship of the fractured endsdescribes the orientation of the fractured ends.
  3. Nondisplaced or nonangulateddescribes fracture ends that are well approximated and in normal position.
  4. Displaceddescribes fractured ends that are shifted.
  5. Angulateddescribes fractured ends that form an angle.
  6. Overridingdescribes a fracture whose ends override without cortical contact.
  7. Types of fractures (Fig. 17-2)
  8. Compression fracture (torus or buckle fracture) occurs if the soft bony cortex buckles under a compressive force. This type of fracture commonly occurs in the metaphysis and requires only splinting for 3–4 weeks.
  9. Incomplete fracture (greenstick fracture) occurs if only one side of the cortex is fractured with the other side intact. The intact side is the site of compression injury and may be bent, whereas the fractured side receives the tension and fractures. Because angulation can increase even within a cast, reduction may include fracturing the other side of the cortex.
  10. Complete fractures
  11. Transversedescribes a fracture that is horizontal across the bone.
  12. Obliquedescribes a diagonal fracture across the bone.
  13. Spiraldescribes an oblique fracture encircling the bone. Spiral fractures may occur with twisting injury and therefore may be associated with child abuse.
  14. Comminuteddescribes a fracture that is composed of multiple fracture fragments.

Figure 17-2. Salter-Harris Classification





  1. Location of the fracture
  2. Epiphysealfracture involves the end of the bone.
  3. Physealfracture involves the growth plate. The Salter-Harris classification describes fractures involving the physis. Table 17-2 contains a mnemonic to help remember the classification, and Figure 17-3 illustrates this classification.
  4. Because the growth plate has not calcified, children are especially vulnerable to injuries involving the growth plate.
  5. The Salter-Harris classification is an important prognostic factor in determining subsequent growth of the limb. For example, subsequent bone growth is affected in somegrade II–IIISalter-Harris fractures and all grade IV–V Salter-Harris fractures.
  6. Metaphysealfracture involves the ends of the central shaft (i.e., between the epiphysis and diaphysis).
  7. Diaphysealfracture involves the central shaft of the bone.
  8. Clavicular fractures

are common fractures in childhood and are usually caused by falling onto the shoulder. Birth injury is the major cause of clavicular fractures in neonates.

  1. Clinical features
  2. Infantsmay be asymptomatic or may present with an asymmetric Moro reflex or pseudoparalysis (refusal to move extremity because of pain). Crepitus may be felt over the fracture.

Table 17-2. Salter-Harris Classification



Description of Fracture



Same: Fracture is within the physis



Above: Fracture is in the physis and above into the metaphysis



Low: Fracture is in the physis and below into the epiphysis



Through and through: Fracture is in the physis through both the metaphysis and the epiphysis



Crush: Crushing of the physis


Figure 17-3. Salter-Harris classification of fractures. Grade I is a fracture within the physis. Grade II is a fracture within the physis and into the metaphysis. Grade III is a fracture within the physis and into the epiphysis. Grade IV is a fracture through the metaphysis, physis, and epiphysis. Grade V is a crush fracture of the physis. (Redrawn with permission from Tolo VT, Wood B. Pediatric Orthopaedics in Primary Care. Baltimore: Williams and Wilkins, 1993:3.)

  1. P.507
  2. Children typically hold the affected limb with the opposite hand, and the child's head is often tilted toward the affected side. Point tenderness and deformity may be noted over the fracture.
  3. Diagnosisis on the basis of plain radiographs showing the fracture. Most fractures caused by trauma involve the middle and lateral aspects of the clavicle.
  4. Management.Treatment includes placement in a sling for 4–6 weeks to assist in immobilizing the limb. A “figure-of-eight bandage” can be used to draw the shoulder back but is cumbersome. Neonates with clavicle fractures often do not require any treatment.
  5. Complications.Injury to nerves and vessels is rare. However, brachial plexus injuries can coexist with clavicular fractures in neonates as a result of birth injury.
  6. Supracondylar fracture

occurs when a child falls onto an outstretched arm or elbow. Children younger than 10 years of age are most at risk for this type of fracture because the mechanical force of the impact is transmitted to the supracondylar area. A supracondylar fracture is an orthopedic emergency if the fracture is displaced and angulated because of the risk of neurovascular injury and compartment syndrome.

  1. Clinical features
  2. Point tenderness, swelling, and deformity of the elbowmay be seen.
  3. It is important to assess the pulse, sensation, and movement of the fingers to detect neurovascular injury.If the fractured fragment is angulated or displaced, it can cause injury by stretching the radial or median nerves or the brachial artery.
  4. Pain with passive extension of the fingers is suggestive of compartment syndrome.
  5. Diagnosisis on the basis of AP and lateral radiographs. A triangular fat pad shadow posterior to the humerus may be observed if a fracture is present (i.e., “posterior fat pad sign”).
  6. Management.Passive movement of the elbow (i.e., when the examiner moves the arm) may increase the risk of further neurovascular injury. Therefore, if a supracondylar fracture is suspected, never passively move the arm.
  7. Nondisplaced and nonangulated fracturesrequire casting.
  8. Displaced or angulated fracturesrequire surgical reduction and pinning.
  9. Complications
  10. Compartment syndromeoccurs when the pressure within the anterior fascial compartment is greater than 30–45 mm Hg, leading to ischemic injury and Volkmann's contracture (flexion deformity of the fingers and the wrist). The “5 Ps” of compartment syndrome (pallor, pulselessness, paralysis, pain, and paresthesias) are late signs. A more sensitive indication of impending compartment syndrome is pain with passive extension of the fingers.



  1. Injury to the radial, median, or ulnar nervemay cause temporary palsy but usually resolves.
  2. Cubitus varusis a decreased or absent carrying angle as a result of poor positioning of the distal fragment.
  3. Forearm Fractures
  4. Common types of forearm fractures
  5. Colles fractureis a fracture of the distal radius.
  6. Monteggia fractureis a fracture of the proximal ulna with dislocation of the radial head.
  7. Galeazzi fractureis a fracture of the radius with distal radioulnar joint dislocation.
  8. Diagnosisis on the basis of AP and lateral radiographs.
  9. Management.Treatment includes open or closed reduction and splinting. A cast replaces the splint in 4–7 days after the swelling has resolved. Forearm fractures heal within 6–8 weeks.
  10. Femur fractures

require a great deal of mechanical force. Therefore, it is important to assess for other injuries in the joint above and below the fracture.

  1. Clinical featuresinclude erythema, swelling, deformities, and point tenderness.
  2. Diagnosisis on the basis of AP and lateral radiographs that include the joint above and below the area of injury.
  3. Management.Treatment includes casting for 8 weeks. Some femur fractures require traction for callus formation before casting, whereas others may be internally or externally fixated.
  4. Toddler's fracture

is a spiral fracture of the tibia. This type of fracture may occur after very mild or no identified trauma. The fibula remains intact.

  1. Epidemiology.Toddler's fractures usually occur between 9 months and 3 years of age. Typically, they occur when a child trips and falls while running or playing.
  2. Clinical features.The child refuses to bear weight but is willing to crawl. Erythema, swelling, and mild point tenderness may be found over the distal tibia on examination.
  3. Diagnosis.Oblique views of the tibia may show the fracture line, although sometimes plain radiographs do not visualize the fracture.
  4. Management.Treatment involves a long leg cast for 3–4 weeks.
  5. Fractures typical of child abuse

Certain fractures should raise suspicion for abuse and must be investigated. (See also Chapter 20, section VI.B.2.d) A “skeletal survey” (radiographic studies of all bones) is the screening tool used to assess for current and previous bony injuries. The following fractures should make the clinician suspect abuse:

  1. Metaphyseal fractures (corner or bucket handle fractures)
  2. Posterior or first rib fractures



  1. Multiple fractures at various ages of healing
  2. Complex skull fractures
  3. Scapular, sternal, and vertebral spinous process fractures
  4. Any fracture whose mechanism does not fit the history provided or the child's developmental abilities(e.g., spiral fracture of the lower extremities in a nonambulatory child)



Review Test

  1. A healthy, developmentally normal 15-month-old boy is brought to the emergency department because he is irritable and refuses to walk after falling down on carpet this afternoon. His parents report that he was running when he fell, but the fall did not seem to be very forceful. A radiograph of the right tibia reveals a nondisplaced spiral fracture. The fibula is intact. Which of the following is most appropriate in the management of this patient?

(A). Casting only

(B). Immediately filing a report with Child Protective Services for suspected abuse

(C). Consulting orthopedics for operative management of the fracture

(D). Ordering a skeletal survey and awaiting the results before calling Child Protective Services

(E). Beginning intravenous antibiotics

  1. A 15-year-old girl comes to your office complaining of knee pain. She is on the high school basketball team, and she began having knee pain after 4 weeks of preseason training. On examination, she has mild tenderness and swelling over her left anterior tibial tuberosity; the examination is otherwise normal. Which of the following is the most appropriate management step?

(A). Casting for suspected fracture

(B). Sunrise radiograph of the knee to confirm patellofemoral syndrome

(C). Hip ultrasound for possible transient synovitis

(D). Explanation to the patient that these are growing pains and do not require treatment

(E). Temporary restriction from athletics, muscle stretching, and pain control

  1. The parents of a 6-month-old boy are concerned because his feet “turn in.” They noticed his “pigeon” toes since he was a few months old. On examination, the infant's mid-foot curves inward but can be straightened by gentle manipulation, even beyond midline. Which of the following is the most appropriate treatment?

(A). Reassurance only

(B). Referral for corrective orthotic shoes

(C). Prescription of special shoes that are connected by a bar to point the toes outward

(D). Referral for casting

(E). Referral to pediatric orthopedic surgery for operative repair

  1. A 15-month-old boy is brought to the emergency department because of a 1-day history of high fever to 103°F (39.4°C) and refusal to walk. He previously was able to walk without difficulty. No known trauma has occurred. On examination, the child is fussy but consolable, and manipulation of his left hip elicits moderate discomfort. Range of motion in the left hip, however, is normal. Laboratory studies reveal a white blood cell count of 28, 000 cells/mm3and an erythrocyte sedimentation rate of 42 mm/hr. Which of the following is the next most appropriate management step?

(A). Order an ultrasound of the hip.

(B). Order magnetic resonance imaging of the hip.

(C). Admit the patient to the hospital and immediately begin intravenous antibiotics.

(D). Order plain radiographs of the spine and pelvis.

(E). Discharge the patient home with reassurance and close follow-up.



  1. A 15-year-old girl is brought to your office because the school nurse noticed possible scoliosis on a screening examination. She is a previously healthy girl. Menarche occurred at 13 years of age. On examination when she stands upright, the iliac crests appear level, but there is an obvious curvature of the back and the left shoulder is 1.5 cm lower than the right shoulder. When she bends forward at the waist, there is a rib hump in the right thoracic region. You order a standing spine radiograph, which reveals scoliosis with a Cobb angle of 30°. Which of the following is the most appropriate treatment at this point?

(A). Referral for surgery

(B). Referral for bracing

(C). Referral for shoe orthotics

(D). Referral for physical therapy for anticipated back pain associated with scoliosis

(E). Reassurance that her curve will not worsen significantly because the majority of her growth has concluded

  1. An 8-year-old boy is brought to the emergency department after being hit by a car after he ran into the street. Lower extremity radiographs reveal a physeal fracture of the proximal tibia that extends into the medial metaphysis. Which of the following is the Salter-Harris grade of this fracture?

(A). Grade I

(B). Grade II

(C). Grade III

(D). Grade IV

(E). Grade V

  1. A 7-year-old girl is jumping up and down on a bed when she falls onto her outstretched right hand. She has severe elbow pain and is brought to the emergency department. On examination, she is crying and holding her right arm at her side. Because of the mechanism of injury, you suspect a supracondylar fracture. A radiograph confirms your suspected diagnosis and demonstrates a displaced and angulated supracondylar fracture. Which of the following statements regarding her fracture is most likely correct?

(A). Pain with passive flexion of the fingers is an early sign that she may have compartment syndrome.

(B). Passive movement of the right elbow should be performed by the examiner to assess for neurovascular involvement.

(C). Even though the fracture is displaced, casting within the emergency department with outpatient orthopedic follow-up is an appropriate management step for this type of fracture.

(D). Child Protective Services should be consulted because this fracture is unusual in a child of her age and is suggestive of child abuse.

(E). Orthopedics should be contacted immediately because this is an orthopedic emergency.

  1. A 12-year-old obese boy is brought to your office for pain in the right hip and thigh during the past 24 hours. He is also limping. Six months ago he was diagnosed with slipped capital femoral epiphysis (SCFE) of the left hip and underwent surgical repair. You suspect he may have SCFE involving the right hip. Which of the following tests would be appropriate to assess for other pathology associated with bilateral SCFE?

(A). Antinuclear antibody

(B). Rheumatoid factor

(C). Thyroid studies

(D). Calcium level

(E). Magnesium level



  1. During a 2-week health maintenance evaluation, you notice that a 15-day-old male infant seems to favor looking to the right side only. On examination, range of motion in the neck is also diminished, and there is stiffness of the left sternocleidomastoid muscle. Within the body of the muscle, you appreciate a soft 1 × 2 cm mass. Which of the following statements regarding the most likely diagnosis is correct?

(A). The symptoms are most likely caused by a congenital cervical spine abnormality.

(B). Urgent ophthalmologic referral should be made for possible lack of vision in the left eye given the patient's right gaze preference.

(C). Plagiocephaly is a potential complication.

(D). Neurosurgical consultation should be obtained to rule out atlantoaxial instability.

(E). Otolaryngology consultation should be obtained to biopsy the mass within the sternocleidomastoid muscle.

  1. A 7-year-old girl presents with low back pain of 4 days' duration. Although she had a cold 3 weeks ago, she now has no cough, dysuria, or abdominal pain. No history of trauma is noted. On examination, she hunches her shoulders forward and begins to cry as you extend her low back. There is tenderness over the space between L2 and L3, and the range of motion of the spine is limited. A plain radiograph of her spine is normal. Which of the following is the most likely diagnosis?

(A). Spondylolysis

(B). Spondylolisthesis

(C). Scheuermann's kyphosis

(D). Diskitis

(E). Herniated intervertebral disk

  1. A 17-year-old boy is evaluated in the emergency department after falling down an embankment while hiking. His left mid-thigh is swollen and tender with deep lacerations. Lower extremity radiographs reveal a left femur that is fractured at the middle portion of the shaft, with the ends overlapping side by side, without angulation. Which of the following best describes this fracture?

(A). Closed, nondisplaced, nonangulated, transverse, diaphyseal fracture of the femur

(B). Closed, overriding, angulated, transverse, diaphyseal fracture of the femur

(C). Open, displaced, angulated, transverse, diaphyseal fracture of the femur

(D). Open, nondisplaced, nonangulated, transverse, diaphyseal fracture of the femur

(E). Open, overriding, nonangulated, transverse, diaphyseal fracture of the femur

  1. A 12-year-old girl with Down syndrome is in your office for a sports physical examination before participation in the Special Olympics. She would like to be on the gymnastics team. On examination, the typical facial and body features of Down syndrome are noted, and the musculoskeletal examination is normal. Which of the following is an appropriate management step at this point?

(A). On the basis of a normal musculoskeletal examination, approve her to participate in gymnastics.

(B). Order lateral flexion-extension radiographs of her cervical spine.

(C). Order a complete skeletal survey to fully evaluate her bones to assess for osteopenia and a risk of fracture.

(D). Order pulmonary function testing.

(E). Restrict her from participating in gymnastics because of the risk of injury in a patient with Down syndrome.



Answers and Explanations

  1. The answer is A[V.F]. The patient's age, the mechanism of injury, and the radiographic findings are classic characteristics of a toddler's fracture. A toddler's fracture is a spiral fracture of the tibia without concomitant fracture of the fibula. It occurs after little or no trauma. Casting only is appropriate for a nondisplaced toddler's fracture. Although it is always necessary to be vigilant for child abuse, a toddler's fracture alone in an ambulatory child should not raise suspicion of abuse, and therefore neither a skeletal survey nor immediate referral to Child Protective Services is indicated. Operative management is not needed in a nondisplaced spiral fracture. This toddler's fracture is not an open fracture and therefore antibiotics are not required.
  2. The answer is E[IV.B]. This patient has swelling and tenderness over the tibial tuberosity, which is consistent with Osgood-Schlatter disease. Osgood-Schlatter disease is an overuse injury that is characterized by inflammation or microfracture of the tibial tuberosity. It is the most common apophysitis (i.e., inflammation of a bony outgrowth) in childhood. Treatment includes rest, quadriceps and hamstring stretching, and pain control. A fracture is unlikely because the patient has the ability to ambulate, and casting is unnecessary. Patellofemoral syndrome is a misalignment of the patella that results in pain around the patella or directly under the knee. The tibial tuberosity is not involved. Transient synovitis is unlikely because of the absence of hip pain. It is also uncommon during adolescence. Growing pains occur in younger children during growth spurts, not in adolescents. Growing pains, which are bilateral, occur mainly at night and do not interfere with daily activities.
  3. The answer is A[IV.A.1.a]. This child has metatarsus adductus, which is a medial curvature of the mid-foot usually caused by intrauterine constraint. In a child whose foot can be manipulated beyond straight (beyond midline), no intervention is necessary and reassurance alone is sufficient. In contrast, a child with a flexible curved foot that cannot be straightened beyond a straight position would benefit from exercises to stretch the foot. Neither corrective shoes nor shoes with a bar are indicated for metatarsus adductus. Casting is reserved for feet that do not correct with manipulation. Surgical repair is not indicated for metatarsus adductus.
  4. The answer is A[III.B.1.c.2, III.B.1.d, e]. Although transient synovitis is a consideration because this boy is nontoxic and is able to move his hip without severe pain, the presence of high fever, along with an abnormal erythrocyte sedimentation rate and white blood cell count, mandates evaluation for septic arthritis. The most appropriate next test is an ultrasound to assess for fluid in the joint. If fluid is present, it must be aspirated and analyzed. Magnetic resonance imaging can also detect joint fluid, but it is expensive and time-consuming and often requires sedation in a young child to help decrease motion artifact. Intravenous antibiotics and admission to the hospital are required for the treatment of septic arthritis, but antibiotics should be started only after cultures are obtained so that the infecting organism can be identified. A plain radiograph of the pelvis may show a widened joint space but is often normal in septic arthritis. Reassurance without further evaluation would risk missing the diagnosis of septic arthritis, which can potentially lead to avascular necrosis.
  5. The answer is E[II.B.3, 4]. Because the growth spurt in females precedes menarche, almost all growth ceases within 6 months after the onset of menstrual cycles. Menarche occurred 2 years before evaluation of this patient, and therefore no treatment for scoliosis is necessary because growth has likely concluded. Surgery is indicated after the growth spurt if the Cobb angle is > 50°. Scoliosis alone should cause no pain unless the curve is very great. Bracing is not indicated because it only prevents progression of scoliosis during the growth period. Neither shoe orthotics nor physical therapy is useful in scoliosis.
  6. The answer is B[V.A.4.b; Table 17-2; Figure 17-3]. A physeal fracture that extends into the metaphysis is a grade II Salter-Harris fracture. A grade I fracture is within the physis. A grade III fracture is in the physis and into the epiphysis. A grade IV fracture is in the physis and through both the metaphysis and epiphysis. A grade V fracture describes a crushing of the physis.



  1. The answer is E[V.C]. A supracondylar fracture occurs most commonly in a child younger than 10 years of age who falls on an elbow or on an outstretched hand. The displaced and angulated supracondylar fracture in this patient is an orthopedic emergency because of the risks of compartment syndrome and neurovascular injury. Passive extension of the digits of the hand is a sensitive indicator of compartment syndrome. Passive movement of the elbow (examiner moves the extremity) can result in neurovascular injury and should not be performed if a supracondylar fracture is suspected. A fracture that is displaced will very likely require surgical reduction and pinning, rather than casting alone. Abuse should always be considered in any childhood injury. However, a supracondylar fracture is a typical fracture in a child of this age, and this injury fits with the purported mechanism.
  2. The answer is C[III.B.4.b]. Slipped capital femoral epiphysis (SCFE) is a slipping of the femoral head off the femoral neck. It is most common in males and is associated with obesity. Thirty percent of patients have bilateral involvement, and patients with hypothyroidism are especially at risk for bilateral disease. Therefore, it would be appropriate to obtain thyroid studies. Systemic lupus erythematosus and juvenile rheumatoid arthritis can cause hip pain, but they are not associated with bilateral SCFE; thus, neither antinuclear antibody nor rheumatoid factor would be helpful. Neither calcium nor magnesium abnormalities play a role in SCFE.
  3. The answer is C[II.A.1.a]. This patient most likely has congenital torticollis, a tilting of the head to one side as a result of intrauterine constraint or birth trauma. Congenital torticollis is commonly associated with asymmetry of the head and face (plagiocephaly). The treatment of congenital torticollis, including head positioning during sleep and physical therapy, should be started as soon as the diagnosis is made to prevent this complication. A congenital cervical spine abnormality (e.g., Klippel-Feil syndrome) may cause congenital torticollis, but this is uncommon. Vision problems should always be considered in a child with a gaze abnormality, but the presence of a stiff neck muscle makes it unlikely that a problem with vision is the cause of the torticollis. Atlantoaxial instability is an unstable joint high in the cervical spine and does not manifest as congenital torticollis. The mass within the sternocleidomastoid muscle represents bleeding into the muscle body and does not require biopsy by otolaryngology.
  4. The answer is D[II.D.4]. Besides muscle strain, the most common orthopedic causes of back pain in children are diskitis, spondylolisthesis, and Scheuermann's kyphosis. This patient's history and examination are most consistent with diskitis, an infection or inflammation of the intervertebral disk. Diskitis often occurs after minor trauma or an upper respiratory illness, and presentation includes local tenderness, decreased range of motion of the spine, and occasionally fever. Spondylolysis is stress fracture in the pars interarticularis, which may be diagnosed by spine radiographs. It is caused by repetitive spine hyperextension, as may occur in gymnastics, diving, and tennis, and would, therefore, be less likely in a child of this age. Spondylolisthesis is a subluxation of a vertebra, and, like spondylolysis, it would be unusual in a child of this age. Radiographs would also reveal this subluxation. Scheuermann's kyphosis causes a painful “hunched back” that can be diagnosed radiographically by finding three consecutive wedged vertebrae. A herniated intervertebral disk is much more common in adults although it may occasionally occur in adolescents.
  5. The answer is E[V.A]. An accurate description of a fracture is important when determining a need for surgical intervention or consultation with an orthopedic specialist. A description should include whether there is a break in the skin (open versus closed), the spatial relation of the fractured ends (displaced versus angulated), the type of fracture, and the location of the fracture. In this patient, the fracture has resulted in a break in the skin (open fracture), and the ends of the fracture override (overriding ends). The fracture is nonangulated and cuts all the way across the bone (transverse) in the mid-thigh (diaphyseal fracture).
  6. The answer is B[II.A.2]. Children with Down syndrome are at risk for atlantoaxial instability, an unstable joint between the occiput and first cervical vertebrae or between the first and second cervical vertebrae. Children with atlantoaxial instability may be asymptomatic, and physical examination may be normal. Therefore, before participation in athletics, lateral flexion-extension cervical spine radiographs should be performed to rule out any instability. If instability is absent, full sports participation is allowed. Neither pulmonary function testing nor a skeletal survey is indicated.

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