Specialized Orthopaedic Care for Growing Children

Understanding Pediatric Orthopaedics in the Indian Context

Childhood bone and joint conditions—clubfoot, hip dysplasia, scoliosis, growth plate fractures—require specialized expertise distinct from adult orthopaedics. At Ajuda Hospitals, our pediatric orthopaedic program treats growing skeletons with child-friendly techniques, family-centered care, and long-term follow-up to ensure healthy development into adulthood.

Children's bones differ fundamentally from adults:

• Growth Plates (physes): Active cartilage zones at bone ends where lengthening occurs. Injury can cause permanent shortening or angular deformity if improperly treated.
• Remodeling Potential: Children's bones can spontaneously correct angulation <20° in plane of joint motion—many fractures heal with casting alone.
• Congenital Conditions: Birth defects (clubfoot, DDH) are best treated early in infancy when tissues are malleable—results superior to delayed surgery.
• Rapid Healing: Fractures unite in 3-6 weeks (vs 6-12 weeks in adults)—shorter immobilization, faster recovery.

Hyderabad's population shows regional prevalence patterns: clubfoot 1-2 per 1000 births, DDH 1-2%, childhood scoliosis 2-3%. Early detection through newborn screening (Barlow-Ortolani test for hips) and school screening (Adam's forward bend test for scoliosis) enables timely intervention before complications arise.

When to Consult Our Pediatric Orthopaedic Specialists

Newborn Screening Red Flags:

• Clubfoot (foot points down and inward)
• Hip "click" or asymmetric skin folds (DDH)
• Leg length inequality
• Breech presentation at birth (high DDH risk)

Childhood Red Flags:

• Persistent limp >1 week (rule out septic arthritis, Perthes disease, slipped capital femoral epiphysis)
• Night pain or systemic symptoms (fever, weight loss)—rule out bone tumor/infection
• Worsening deformity despite bracing

Our Diagnostic Approach

Developmental & Motor Assessment

Infants (0-12 Months):

• Hip Examination: Barlow test (adduction-posterior force dislocates unstable hip), Ortolani test (abduction-anterior force reduces dislocated hip). Asymmetric skin folds, leg length inequality, limited hip abduction (<60°) indicate DDH.
• Foot Alignment: Clubfoot (rigid equinovarus deformity), metatarsus adductus (flexible forefoot adduction), calcaneovalgus (flexible dorsiflexion deformity—self-resolves).
• Motor Milestones: Head control 3-4 months, sitting 6-8 months, cruising 9-12 months. Delays warrant neurological evaluation.

Children (1-18 Years):

• Gait Analysis: In-toeing (femoral anteversion, internal tibial torsion), out-toeing, toe-walking (Achilles contracture, cerebral palsy), antalgic limp (painful condition).
• Limb Alignment: Physiologic bow-legs until age 2; physiologic knock-knees age 3-6 (resolves by age 8). Persistent >age 8 or progressive deformity requires treatment.
• Spine Screening: Adam's forward bend test reveals rib hump (scoliosis). Scoliometer >7° warrants X-ray. Measure Cobb angle (curvature severity).

Pediatric Imaging Protocols

Ultrasound (First 6 Months):

• DDH Screening: Graf classification (Type I normal, Type II immature, Type III-IV dislocated). Real-time dynamic assessment during Barlow/Ortolani maneuvers.
• Advantages: No radiation, visualizes cartilaginous structures not visible on X-ray, can screen all newborns in high-risk populations.

X-rays (>6 Months & Skeletal Conditions):

• Low-Dose Protocols: Minimize radiation; use gonad shields; avoid repeated films if unnecessary
• Growth Plate Analysis: Salter-Harris classification (Type I-V) determines fracture prognosis. Risser grade (iliac crest ossification) assesses skeletal maturity for scoliosis bracing decisions.
• Standing Full-Leg Films: Measure mechanical axis for bow-legs (Blount disease), knock-knees, limb length discrepancy.

MRI (Complex Cases):

• Soft tissue masses (benign vs malignant), spinal cord anomalies (tethered cord, syrinx), avascular necrosis (Perthes disease, SCFE), occult fractures.

CT Scan (Rare):

• 3D reconstruction for complex fractures (intra-articular, spine), congenital deformities (tibial hemimelia), tumor extent. Higher radiation—reserved for surgical planning only.

Genetic & Metabolic Evaluation

Syndromic Features (multiple anomalies):

• Chromosomal microarray, skeletal dysplasia gene panels (achondroplasia, osteogenesis imperfecta)
• Dysmorphology consultation if short stature, craniofacial anomalies, intellectual disability

Metabolic Bone Disease:

• Rickets: Low vitamin D, calcium, elevated alkaline phosphatase, widened growth plates on X-ray
• Osteogenesis imperfecta: Multiple fractures, blue sclera, dentinogenesis imperfecta; genetic testing (COL1A1/COL1A2)

Family-Centered Care Planning

Parent Education:

• Natural history of condition (will it worsen, improve, stay same?)
• Treatment options: non-surgical (casting, bracing) vs surgical
• Growth implications: limb length discrepancy, angular deformity recurrence
• Long-term outcomes: activity restrictions, recurrence risk, future surgeries

Child Life Specialist: Prepares child for procedures using age-appropriate language, play therapy, hospital tours. Reduces anxiety and improves cooperation.

Treatment Pathways

Our pediatric orthopaedic protocols follow Pediatric Orthopaedic Society of India (POSI) and Pediatric Orthopaedic Society of North America (POSNA) guidelines:

Clubfoot (Congenital Talipes Equinovarus - CTEV)

Ponseti Method (Gold Standard):

1. Weekly Serial Casting (Weeks 1-6): Long-leg plaster cast from toes to groin. Each week, foot progressively manipulated and re-casted to correct cavus, adductus, varus, equinus sequentially.
2. Achilles Tenotomy (Week 6-8): If equinus persists after 5-6 casts, percutaneous Achilles tendon cut (5-min procedure, local anesthesia). Final cast for 3 weeks allows tendon healing in lengthened position.
3. Foot Abduction Brace (FAB): Shoes connected by bar; holds feet in abduction-external rotation. Worn 23 hrs/day for 3 months, then nights/naps until age 4-5 years.

Outcomes: 95% excellent correction; 10-30% relapse if bracing non-compliant (requires repeat casting). Rare surgical need (<5%) for resistant cases.

Surgical Option (Posteromedial Release): Reserved for children >age 2 presenting late or Ponseti failures. Extensive soft tissue release through large incision—higher stiffness and pain than Ponseti. Now rarely performed.

Developmental Dysplasia of Hip (DDH)

Treatment by Age:

0-6 Months (Pavlik Harness):

• Flexion-abduction positioning keeps femoral head centered in acetabulum. Worn 23 hrs/day.
• Weekly ultrasound monitoring first month confirms hip reduction (femoral head covering >50% acetabulum).
• Success: 92% in infants <3 months; 85% at 3-6 months. Failure rate higher if dislocation (vs subluxation), breech presentation, bilateral.
• Complications: Avascular necrosis (AVN) 1-3% if excessive abduction (>70°)—Pavlik removed if hip not reduced by 3 weeks.

6-18 Months (Closed vs Open Reduction):

• Closed reduction under general anesthesia; arthrogram confirms concentricity.
• Spica cast (hip-to-toes plaster) for 3-6 months; cast changes every 6-8 weeks as child grows.
• Open reduction if closed fails: Remove obstacles (pulvinar, ligamentum teres, tight capsule) through anterior or medial incision.

>18 Months (Pelvic Osteotomy):

• Acetabular dysplasia persists despite reduced hip—shallow socket won't contain femoral head long-term.
• Salter innominate osteotomy (reorient acetabulum), Pemberton acetabuloplasty (hinge at triradiate cartilage), or Dega osteotomy (improve lateral coverage).
• Combine with femoral shortening if presentation >2 years (reduces AVN risk).

Outcomes: 92% normal hip with Pavlik treatment; 80-85% if surgery required. Untreated DDH leads to hip arthritis by age 30-40, limp, leg length inequality.

Growth Plate (Physeal) Fractures

Salter-Harris Classification:

• Type I: Through physis only; excellent prognosis. Closed reduction, cast immobilization.
• Type II: Through physis and metaphysis (75% of physeal fractures); good prognosis if reduced.
• Type III: Through physis and epiphysis (intra-articular); requires anatomical reduction (often open surgery) to prevent growth arrest and arthritis.
• Type IV: Through epiphysis, physis, metaphysis; high risk of bony bar formation—requires perfect reduction.
• Type V: Crush injury to physis; rare, diagnosed retrospectively when growth arrest occurs.

Treatment Principles:

• Gentle closed reduction under sedation; avoid multiple attempts (damages physis further).
• CRIF with smooth K-wires if unstable—cross physis perpendicular (minimal damage) or stay in epiphysis/metaphysis.
• Open reduction if closed fails; anatomical reduction paramount for Type III-IV.
• Post-op immobilization 3-6 weeks (shorter than adults due to rapid healing).
• Growth Monitoring: X-rays every 6 months for 1-2 years to detect premature closure (bony bar across physis). If present, bar excision with fat graft interposition may restore growth.

Childhood Scoliosis

Non-Surgical Management (Curves 20-40°):

• TLSO (Boston) Brace: Rigid plastic thoracolumbosacral orthosis. Worn 18-23 hrs/day until skeletal maturity (Risser 4-5).
• Indications: Curves 20-40° in growing child (Risser 0-2), documented progression >5° over 6 months.
• Efficacy: 70% success preventing curve exceeding 50° (surgical threshold). Compliance critical—brace monitors track wear time.
• Exercises: Physiotherapy strengthens core; no evidence it prevents curve progression but maintains flexibility.

Surgical Management (Curves >40-50°):

• Growing Children (<10 years, Risser 0): Growing rods or VEPTR (Vertical Expandable Prosthetic Titanium Rib). Dual rods attached to spine proximally/distally allow lengthening every 6 months to match spinal growth. Prevents crankshaft phenomenon (continued rotation despite fusion).
• Adolescents (Near Maturity): Posterior spinal fusion with pedicle screw instrumentation. Derotation and correction maneuvers. Bone graft promotes fusion. Corrects 50-70% of Cobb angle.
• Complications: Infection 2-5%, proximal junctional kyphosis 10-15%, pseudarthrosis 3-5%. Neuromonitoring (MEPs/SSEPs) reduces spinal cord injury risk to <0.5%.

Limb Length Discrepancy (LLD)

Mild LLD (<2 cm): Shoe lift sufficient. No surgery.

Moderate LLD (2-5 cm): Epiphysiodesis (growth plate tethering or ablation) at appropriate age. Timing calculated using Green-Anderson growth charts and Multiplier Method. Performed 1-3 years before skeletal maturity. Slows long leg growth to allow short leg to catch up.

Severe LLD (>5 cm) or Congenital Shortening: Limb lengthening procedures.

• Ilizarov Method: External circular fixator with tensioned wires through bone. Osteotomy (bone cut) then gradual distraction 1mm/day (0.25mm x4). Forms new bone (distraction osteogenesis). 1 month in frame per 1 cm lengthening. Complications: Pin-site infection, joint contractures, premature consolidation.
• PRECICE Intramedullary Nail: Magnetic intramedullary nail allows gradual lengthening without external frame. External remote control extends nail 1mm/day. Better cosmesis, lower infection risk, faster return to activities. Approved for adolescents >age 12-14. Can lengthen 5-8 cm per nail.

Cerebral Palsy Orthopaedic Management

Spasticity Reduction:

• Botulinum toxin (Botox) injections: Temporary (3-6 months) focal spasticity reduction in specific muscles (gastrocnemius for equinus gait).
• Intrathecal baclofen pump: Continuous spinal delivery of muscle relaxant; indicated for generalized spasticity.

Soft Tissue Procedures:

• Achilles tendon lengthening (equinus contracture)
• Hamstring lengthening (knee flexion contracture)
• Adductor release (hip adduction contracture, scissoring gait)
• Goal: Improve gait efficiency, prevent hip dislocation, facilitate hygiene/seating

Bony Procedures:

• Femoral derotation osteotomy (excessive femoral anteversion causing in-toeing)
• Tibial derotation osteotomy (internal tibial torsion)
• Hip reconstruction (varus-derotation osteotomy, pelvic osteotomy) for hip subluxation/dislocation

Outcomes: Improves gait, sitting balance, ADLs. Requires coordinated multidisciplinary care (neurology, PM&R, orthopaedics, physiotherapy).

Technology & Innovation

PRECICE Intramedullary Lengthening System

How It Works: Magnetic intramedullary nail inserted into femur/tibia. External remote control (ERC) generates rotating magnetic field that extends nail 1mm/day (or 0.75mm or 1.33mm depending on prescription).

Advantages Over Ilizarov:

• No external frame—better cosmesis, psychological acceptance
• Lower infection risk (no pin sites penetrating skin)
• Faster return to school/activities
• Precise control—reverse if lengthening too fast

Limitations: Requires open growth plates closed (age >12-14), cost higher than Ilizarov, magnetic interference with MRI (nail must be removed before spine MRI).

Motorized Growing Rods (MAGEC)

Traditional Growing Rods: Require surgical lengthening every 6 months under general anesthesia (10+ surgeries until skeletal maturity). Infection risk 15-20%, "law of diminishing returns" (scar tissue limits lengthening over time).

MAGEC (Magnetic Expansion Control): Dual rods with magnetic actuators. External remote lengthens rods in clinic (non-invasive). Reduces surgeries from 10+ to 2-3 (initial implantation, 1-2 revisions, final fusion).

Outcomes: Similar curve control and spinal growth to traditional rods; fewer surgeries, lower infection risk, improved quality of life.

Computer-Assisted Pedicle Screw Placement

Navigation Systems (O-Arm + Stealth): Intraoperative CT generates 3D spinal map. Real-time instrument tracking guides pediatric pedicle screw insertion (smaller pedicles than adults—higher perforation risk).

Benefits: Reduces screw misplacement from 10-15% to <2% in pediatric scoliosis surgery. Decreases neurological injury, operative time, radiation exposure.

What to Expect: Your Child's Care Journey

Newborn Screening & Early Intervention (0-6 Months)

• Hip ultrasound if risk factors: breech, family history, hip click/asymmetry
• Clubfoot Ponseti casting starts within first 2 weeks of life (optimal outcomes)
• Parent education: Pavlik harness compliance, cast care, red flags (fever, circulation changes)

Infancy to Toddler (6 Months - 3 Years)

• Developmental milestone tracking: Walking by 18 months
• Gait assessment if in-toeing, out-toeing, toe-walking
• Growth plate fracture management: Gentle reduction, cast immobilization, growth monitoring

School Age (3-12 Years)

• Scoliosis screening: Adams forward bend test at school physicals
• Brace fitting and compliance counseling if scoliosis detected
• Activity modifications: Limit high-impact sports if physeal stress fracture, Osgood-Schlatter disease

Adolescence (12-18 Years)

• Skeletal maturity assessment (Risser grade, bone age X-ray)
• Final scoliosis/limb length correction surgeries timed before growth cessation
• Sports return clearance: Ensure healed fractures, stable deformity correction
• Transition to adult orthopaedic care if ongoing conditions (cerebral palsy, skeletal dysplasia)

Preventing Complications

Early Detection Saves Limbs & Lives

DDH Screening: Universal newborn hip exam (Barlow-Ortolani tests). High-risk infants (breech, family history) get ultrasound at 6 weeks. Late diagnosis (>12 months) often requires major surgery with AVN risk.

Growth Plate Fracture Recognition: Any fracture near joint in child should be evaluated by pediatric orthopaedic surgeon. Improper reduction causes growth arrest, limb shortening, angular deformity—may require corrective osteotomy years later.

Limp Workup: Persistent limp >1 week requires X-ray, labs (CBC, ESR, CRP). Septic arthritis is surgical emergency (joint washout within 6-12 hours prevents cartilage destruction). Transient synovitis (benign) vs Perthes disease vs SCFE (requires pinning) vs tumor—differentiated by imaging and clinical course.

Compliance with Bracing

Clubfoot FAB: Most relapses occur due to poor compliance. Weekly clinic visits first 3 months reinforce importance. Skin checks prevent pressure sores. Brace adjustments as foot grows.

Scoliosis TLSO: Adolescent compliance challenging (social stigma, discomfort). Modern low-profile braces fit under clothing. Smart sensors track wear time. Peer support groups, brace decoration empower patients.

Why Ajuda for Pediatric Orthopaedics?

Take the First Step

If you notice any deformity in your child—clubfoot, hip click, limping, spine curve, or growth concerns—early evaluation by a pediatric orthopaedic specialist can make the difference between simple non-surgical treatment and complex surgery later.

Schedule Your Consultation: Call 9010550550 or WhatsApp for newborn screening, developmental concerns, or childhood deformity evaluation. Bring previous medical records, ultrasound/X-ray reports, and list of motor milestones.

Give your child the gift of healthy bones and joints with Ajuda's specialized pediatric orthopaedic care.