1104
U N I T 1 2
Musculoskeletal Function
principal goals for treatment of children 6 months to
2 years of age are to obtain and maintain reduction of the
hip without damaging the femoral head. Closed reduction
is often performed under general anesthesia, followed by
several months of immobilization in a hip spica cast, plas-
ter splints, or an abduction splint. Surgical treatment may
be required for children who fail to maintain a stable hip
with closed reduction methods. The most serious com-
plication of any treatment is avascular necrosis of the
femoral head as a result of the forced abduction.
63
This
most often occurs as a complication of a closed or open
reduction in an older child. In addition, hyperflexion has
the potential to cause femoral nerve palsies.
Congenital Clubfoot
Clubfoot, or talipes, is one of the most common pediat-
ric orthopedic conditions. The clubfoot deformity may be
positional, congenital, or associated with a variety of other
underlying congenital conditions.
56,57
The positional club-
foot is a normal foot that has been held in a deformed posi-
tion in utero and is found to be flexible on examination in
the nursery. The congenital clubfoot involves a spectrum
of severity, while the clubfoot associated with other con-
genital conditions is typically rigid and difficult to treat.
Congenital clubfoot has an incidence of approximately
1 to 2 cases per 1000 live births, is bilateral in about 50%
of cases, and affects boys more often than girls.
56,57
Like
developmental dysplasia of the hip, its occurrence follows
a multifactorial inheritance pattern.
68,69
Clubfoot may be
associated with chromosomal abnormalities or congenital
syndromes that are transmitted by mendelian inheritance
patterns. However, it is most commonly idiopathic and
found in normal infants in whom no genetic or chromo-
somal abnormality or other extrinsic cause can be found.
In forefoot adduction, which accounts for approxi-
mately 95% of idiopathic cases, the foot is plantar flexed
and inverted or twisted toward the midline of the leg.
56
This
is the so-called
equinovarus type
of clubfoot (Fig. 43-22).
The other 5% of cases are of the equinovalgus type, or
reverse clubfoot, in which the foot is dorsiflexed and
everted. Reverse clubfoot can occur as an isolated condition
or in association with multiple congenital defects. At birth,
the feet of many infants assume one of these two positions,
but they can be passively overcorrected or brought back
into the opposite position. If the foot cannot be overcor-
rected, some type of correction may be necessary.
Treatment of clubfoot is begun as soon as the diag-
nosis is made. When treatment is initiated during the
first few weeks of life, a nonoperative procedure may
be effective. Serial manipulations and casting are used
gently to correct each component of the deformity. One
method, called the
Ponseti method,
involves weekly
gentle stretching and manipulation of the misaligned
bones followed by application of a well-molded long leg
plaster cast with the knee held at a right angle.
56,57,69–71
The cast maintains the correction and allows for further
relaxation of tight structures in anticipation of the next
week’s casting. Correction of the deformity is usually
obtained within 6 to 8 weeks. Frequently, a percutaneous
Achilles tendon lengthening is performed using a topical
anesthetic cream before application of the final cast to
allow for complete correction of the equinus deformity.
The correction is maintained by wearing a brace full time
for 3 months and part-time wear during napping and
at night for approximately 2 to 3 years.
56
Surgery may
be required for severe deformities or when nonopera-
tive treatment methods are unsuccessful. It is performed
most commonly between 6 and 12 months of age.
56
Juvenile Osteochondroses
Juvenile osteochondroses
are a group of children’s dis-
eases in which one or more growth ossification centers
undergo a period of degeneration, necrosis, or inactivity
that is followed by regeneration and usually deformity.
The osteochondroses are separated into two groups
according to their causes. The first group consists of the
true osteonecrotic osteochondroses, so called because
the diseases are caused by localized osteonecrosis of an
apophyseal or epiphyseal center (e.g., Legg-Calvé-Perthes
disease, Freiberg infraction, Panner disease, Kienböck
disease). The second group of juvenile osteochondroses
is caused by abnormalities in ossification of cartilagi-
nous tissue resulting from a genetically determined nor-
mal variation or from trauma (e.g., Osgood-Schlatter
disease, Blount disease, Sever disease, Scheuermann
disease). The discussion in this section focuses on Legg-
Calvé-Perthes disease from the first group and Osgood-
Schlatter disease from the second group. Slipped capital
femoral epiphysis is a disorder of the growth plate.
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes disease is an idiopathic osteone-
crotic disease of the proximal (capital) femoral epiph-
ysis with later reabsorption.
72–74
The disorder usually
FIGURE 43-22.
Newborn with clubbing of the left foot. (From
the Centers for Disease Control and Prevention Public Health
Images Library. No. 2632. Courtesy of JamesW. Hanson.)
