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CG PEDICON 2006, 7-8th Oct 2006, Rajnandgaon, Chattisgarh
Dr. Viraj U. Shingade
M.S.(ortho) DNB (Ortho)
Fellow, Paediatric Orthopedics, (UK, South Korea)
Central India Institute for Children Orthopedic care
Nagpur (M.S)
Paediatric Orthopedics has been evolved as a separate specialty in developed world since last more than 70 years. In India this specialty is taking its shape with the need of time. I still remember those days, when I was doing my post graduation in Orthopedics and we were told that there is no solution for many of the Pediatric Orthopedic conditions, which previously were though to be non treatable .
As we all know, right from history taking, through examination, to diagnosis everything differs in Pediatrics. Cartilaginous nature of bone, growth potential in bones, recurrence of deformities due to growing bone, delicacy required in surgeons hand while handing soft cartilaginous bone, small structures including neurovascular bundles, smaller or mini incisions, learning new approaches to minimize trauma to normal tissues, minimal scar expectation from parents, and most important the long term, regular follow up at least till skeletal maturity these are the factors which make this branch more demanding and challenging.
The incidence of cerebral palsy is rising very high as low birth weight and premature babies are being saved due excellent NICU care at peripheral centers. It is very important to generate awareness amongst parents of spastic children that cerebral palsy is a totally different condition than poliomyelitis and they should not confuse these two conditions. I have seen many surgeons who operate theses spastic children in surgical camps for poliomyelitis and which ultimately lead in to disasters. Many of these spastic children go for camps advertised by spiritual channels on television, and they land – up with trouble. Cerebral palsy is a subject where we need to keep the child under regular follow up; we have to assess the power and spasticity in muscle groups at regular intervals. Before taking the surgical decision, surgeon has to think many times, whether surgery is really going to give benefit to the child or not. By doing the surgery one should not loose the exciting power of the muscles. Basically surgeon has to balance the art of deformity correction and maintain the exciting power of muscles. Tendon cutting surgeries performed in free surgical camps like in polio, lead in to disasters in cerebral palsy and hence they should be condemned strongly. I have seen many children who were walking independently before surgery have gone in to crippled, non-ambulatory stage due to incorrect surgeries in these camps. With recent advances, newer medicines (Botulinum toxin) are available, which, when induced locally, can reduce the spasticity for certain period of time with maintaining the power of muscles. If child is diagnosed as a spastic child in early ages, and if they receive Botulinum toxin locally in to tight muscles with regular coverage of physiotherapy, lots of deformities can be prevented. Overall development of these kids is very good as we prevent the deformities and hence antagonist group of muscles develop fully with good power, which ultimately lead to early independent walking ability and leading to overall good development of a child.
Paediatric fractures are not taken very seriously by many surgeons. The general belief is that there is a good inherent remodeling potential in children’s bone and hence they can be managed by application of plaster in anyway. This is totally a wrong approach. Many of these fractures are missed due to cartilaginous nature of bone; many of them are not managed properly and subsequently they result in to growth abnormalities, rotational mal-alignments and eventual deformities of bone. Surgeons are aware of these facts as these are not immediate effect, but they are seen in long-term follow up. It is mandatory to keep all these children in long term follow up, which is usually forgotten. If fracture is not reduced by closed method, surgeons go for open reduction with big incision and scar. This can be avoided by the knowledge of lots of new techniques which are mini- invasive and prevent damage to normal structures as well as the big surgical scar. Supracondylar area of the humerus (arm bone) is a commonest area to get fractured when child falls with an outstretched hand. I have described a beautiful mini-invasive technique for reducing difficult severely displaced fracture supracondylar humerus in children, in which closed reduction attempts are failed. This mini-invasive technique can reduce any difficult fracture of this area without damaging any vital structure and giving almost an invisible or minimal scar. The technique has been recently published in world famous Orthopedic journal–Acta Orthopaedica Scandinavica – Dec. 2005.
There are many congenital anomalies which can be managed excellently with recent technique. Club–foot is one of the commonest congenital anomalies seen in day-to-day life. Previously application of plaster or posteromedial release or bony procedures, these were the only options available to surgeons. Now with better understanding of the pathology of this entity, minimal invasive techniques like Ponsetti methods are available and hence better correction is achieved in majority of the cases without going for extensive release surgeries. It is very important to start the treatment as earliest as possible (day 1 or first 7 days of life), as the results are very good if treatment is started in first few weeks of life. Also in neglected cases, presenting at late age group, good correction is possible with llizarov frame and other newer techniques.
Other common congenital anomalies of upper and lower limbs (radial club hand, fibular hemimelias, polydactyly, syndactyly) in which either the bone is missing, or extra or deformed, are getting treated with excellent results, due to availability of newer external stabilization systems and improvement in micro- vascular techniques.
Congenital dislocation of hip lead to severe arthritis of joint and associated lurch while walk. Now, congenital dislocation of hip can be diagnosed in early stages due to advances in USG. The results are excellent, if it is diagnosed, and treated in early age. Many pelvic osteotomies are now available to redirect the acetabulum; they require a skillful approach and technical expertization on part of the surgeon.
Treatment for upper limb birth injuries and Erb’s palsy should be started as earliest as possible; as results are good if treatment is initiated in early stages. Lots of newer techniques of muscle and tendon transfers are available, which give excellent functional hand in long term.
Simple looking problems like flat feet in children can be dangerous, as they might be part of symptom complex, or secondary to many congenital pathologies of foot bones or could be manifestation of neurological pathologies; hence immediate opinion should be sought from a paediatric Orthopedic Surgeon rather than just neglecting it as an untreatable entity.
Scoliosis (congenital or developmental deformity of back–bone/spine) was previously thought to be untreatable and was neglected by the surgeons due to involved morbidity in surgery, and was accepted by parents as an untreatable entity. These children on follow up used to get decreased vital capacity with increasing severity of spinal curve. Due to availability of allograft (human donated bone) newer instrumentation techniques, and good ventilatory support, the surgery has become very safe with excellent correction of spinal curvature.
Pyogenic infection of bone (osteomyelitis), particularly in neonate is still, a common thing in day-to-day practice. It requires an emergency management within golden period. If managed urgently with skillful decisions and good new generation antibiotic coverage, many of these patients do well. Some of them results in to dislocation of joint (particularly hip joint) and require reduction either by closed or by open methods. Tuberculosis of bones and joints also require a skillful management to give a good functional joint.
Congenitally or developmentally short limbs and bones are getting lengthened with llizarov techniques. Special computerized techniques which guide the progress of limb lengthening and deformity corrections (Taylor’s frame) are available. Although they are expensive but are accurate and give excellent results.
For malignant tambours in childhood, like Osteogenic Sarcoma, or Ewing’s sarcoma, amputation of the limb was the only choice in past. With availability of neo-adjuvant chemotherapy (cancer-cell killing toxic drugs) and advances in radiotherapy now there is no need of amputation of the limb. After resection of the bone tumor, the limb reconstruction is done by putting a metal prosthesis (metal joint) in place of previous pathological bone. This, not only preserves the limb, but also gives a functional joint required for locomotion.
With availability of 3-D USG scans, many of the congenital pathologies like clubfoot, dislocation of hip, scoliosis are getting diagnosed prenatally. Treatment of these conditions in early neonatal period give excellent results on long-term follow up.
Scientists are working hard, on “stem–cell research“. Although the research is in experimental basic stage, the day is not far when word “incurable” will vanish from dictionary of Paediatric Orthopaedics.
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