Orthopedics focuses on the musculoskeletal system. Learn about the diagnosis, treatment, and rehabilitation of bone, joint, ligament, and muscle conditions.
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Treatment in pediatric orthopedics ranges from simple observation to complex surgical reconstruction. Because of the remodeling potential of children, many conditions that would require surgery in adults can be treated non operatively in kids. Casting, bracing, and physical therapy are the mainstays of conservative care.
When surgery is necessary, the techniques are specific to the growing skeleton. Implants are designed to avoid the growth plates whenever possible. If the growth plate must be crossed, smooth pins are used to minimize damage. The goal is to correct the problem while preserving the child’s ability to grow.
Recovery is generally faster in children, but compliance can be a challenge. Keeping a toddler in a cast dry or stopping a teenager from returning to sports too soon requires active parental involvement.
Casting is the most common treatment for pediatric fractures. Fiberglass casts are lightweight and durable. Waterproof liners are available, allowing children to swim and bathe, which significantly improves quality of life during summer months.
The “cast” is not just a covering; it is a mold. Skilled application can hold a fracture in perfect alignment, utilizing the intact periosteum as a tension band. Serial casting is also used for stretching soft tissues in conditions like clubfoot (Ponseti method).
For long bone fractures (like the femur) in school age children, flexible nails are the standard. These are titanium rods inserted into the hollow center of the bone. Unlike adult rods, they are flexible and springy.
They are inserted through tiny incisions away from the fracture. The nails curve inside the bone, providing internal stability while protecting the growth plates. They allow the child to mobilize quickly and are removed once the fracture heals.
This is a minimally invasive technique to correct crooked legs (knock knees or bow legs). A small plate, the size of a paperclip, is screwed across one side of the growth plate. This acts as a tether, slowing growth on that side.
The other side of the growth plate continues to grow, causing the bone to straighten out gradually over time. It harnesses the power of the child’s own growth to perform the correction. Once straight, the plate is removed, and normal growth resumes.
For fractures around the elbow (supracondylar) or wrist, surgeons often use percutaneous pins. After manipulating the bones back into place while the child is asleep, smooth metal pins are driven through the skin and bone to hold the position.
The pins stick out of the skin or are buried just under it. They hold the fracture for 3 to 4 weeks and are then pulled out in the office. This avoids large incisions and permanent metal plates.
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When a bone deformity is too severe for guided growth, or the child has finished growing, an osteotomy is performed. This involves surgically cutting the bone and realigning it.
The bone is held in the new position with plates, screws, or an external fixator. This is a major reconstruction used for rotational deformities, severe Perthes disease, or Blount’s disease.
For severe curves (usually over 45-50 degrees), spinal fusion is indicated. This involves using screws, hooks, and rods to straighten the spine and fuse the vertebrae together into one solid bone.
For younger children who still have a lot of growing to do, “growing rods” or magnetic expansion rods are used. These control the curve but extend as the child grows, either through surgery or using an external magnet in the office.
The gold standard for clubfoot is the Ponseti method. It involves weekly gentle manipulation and casting of the foot starting shortly after birth. This gradually stretches the tight ligaments.
After the casting phase, a small procedure to cut the Achilles tendon (tenotomy) is usually required. The child then wears a brace (boots and bar) at night for several years to prevent recurrence. Extensive surgery is rarely needed anymore.
Treatment depends on age. Infants use a Pavlik Harness, a soft brace that holds the hips in a flexed and open position, encouraging the socket to deepen.
If diagnosed later, or if the harness fails, a closed reduction (setting the hip under anesthesia) and a spica cast (body cast) are used. Older children may require pelvic osteotomies (cutting the pelvic bone) to reconstruct the socket.
Septic arthritis requires urgent surgical washout (irrigation and debridement) to save the joint cartilage. This can often be done arthroscopically.
Osteomyelitis (bone infection) is usually treated with antibiotics, but if an abscess forms, surgery is needed to drill into the bone and drain the pus. Long term antibiotics via a PICC line are often required.
For significant leg length discrepancies, limb lengthening uses the body’s ability to grow new bone. The bone is cut, and an external frame or an internal magnetic nail is applied.
The device slowly pulls the bone ends apart (distraction) at a rate of 1mm per day. The body fills the gap with new bone (regenerate). This process takes months and requires intensive physical therapy.
A spica cast is a large body cast used to immobilize the hip and thigh. It typically goes from the chest down to the ankle on the injured side and to the knee on the other side. It is used for femur fractures in toddlers and after hip dysplasia surgery.
In children, we often remove metal implants (plates, screws, flexible nails) once the fracture has healed, usually 6 to 12 months later. This is because the bone is still growing, and we don’t want the metal to become buried too deep or interfere with future growth.
The surgery itself is done under anesthesia. Afterward, there is mild soreness for a week or two. The actual process of the legs straightening over the following months is painless. The child does not feel the plate working.
If it is a waterproof cast, they can shower or bathe normally (just rinse the soap out well). If it is a standard cast, it must be kept dry. You can sponge bathe the child or wrap the cast in specialized waterproof bags. Never submerge a standard cast.
The clubfoot has a strong biological tendency to twist back (recur). The casting corrects the shape, but the brace maintains it while the foot grows. Stopping the brace wear too early is the number one cause of the deformity returning.
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