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. 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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 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 sur- paedics. We have based our descriptions on the best avail- geons throughout the world who find these very useful for able published knowledge. We have sought to present the planning their surgical procedures. Other videos in the col- most current evidence from the literature from level 1 to lection cover non-o perative subjects such as cast application 5 in a succinct and readable format. We have augmented for scoliosis, club foot casting, and Pavlik harness application. the discussions with recommendations based on personal I am sincerely grateful to each of our authors and truly experiences of a top- level clinical faculty. When presenting appreciate the effort involved in making the sixth edition a controversial topics, we prefer to give the reader the evi- reality. We welcome two new authors, Dr. Jane Chung and dence from the different arguments so that the reader can Dr. Shane Miller, who are pediatric- trained practitioners make a reasoned decision after reviewing the conflicting with expertise in sports medicine. We continue to be grate- evidence. We carefully avoid the “cookbook” approach in ful for the contribution of our Boston colleagues, Professor which one puts forth their preferred treatment as gospel. Mark Gebhardt and Dr. Megan Anderson, who are respon- We continue to insist that our text be comprehensive, sible for the chapter on malignant tumors. I especially want even though a shorter text would be more convenient to to thank my administrative assistant, Louise Hamilton, who handle. We fully present each topic, include the descrip- had the huge task of putting the whole project together. tion of a disorder, and discuss appropriate history and She was able to devote the time needed for this edition physical exam, relevant studies, differential diagnosis, and because of coverage by the other administrative assistants, details of treatment. We believe that it is important to including Stacy Duckworth, Lisa Sherman, Rebecca Fuller, present the important details of decision making, and we Amy Park, and our administrative director, Laura Griffiths. emphasize the complexity of overall patient care. Our sur- Again, our heartfelt appreciation goes to our families, who gical discussions stress proper preoperative planning and are vitally important in every facet of our lives; thanks for preparation, as well as description of operative details. We giving us your support and understanding. also provide the important postoperative protocols that 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.)