4. Pediatric Orthopedics

Learning Objectives

• Recognize developmental dysplasia of the hip (DDH) on clinical exam and describe its management by age
• Describe the Ponseti method for clubfoot correction and why early treatment matters
• Differentiate Legg-Calve-Perthes disease from slipped capital femoral epiphysis (SCFE) by age, body habitus, and imaging
• Classify pediatric growth plate fractures using the Salter-Harris system and predict growth disturbance risk
• Build a differential diagnosis for the acutely limping or non-weight-bearing child, prioritizing septic arthritis as a can't-miss diagnosis
• Explain the classification, screening, and treatment thresholds for idiopathic scoliosis
• Identify red flags in a child's musculoskeletal exam that warrant urgent referral rather than reassurance

Quick Answer

Pediatric orthopedics deals with musculoskeletal problems unique to growing bone — an open growth plate changes both the injury patterns children sustain and how those injuries must be treated. The specialty matters because a missed or mismanaged pediatric orthopedic condition (a dislocated hip, a septic joint, a growth plate fracture) can produce lifelong disability, whereas the same conditions caught early are often fully correctable. Core topics include developmental dysplasia of the hip, clubfoot, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, growth plate (Salter-Harris) fractures, scoliosis, and the limping child. The unifying exam principle: because children's bones remodel and grow, timing of diagnosis and treatment matters more here than almost anywhere else in orthopedics.

Why Children's Bones Are Different

Before diving into specific conditions, understand the one anatomic fact that explains almost everything in this chapter: the growth plate (physis).

The physis is a cartilaginous disc near the end of long bones where new bone is laid down, allowing the bone to lengthen until skeletal maturity. It is mechanically the weakest point in a child's bone — weaker than the surrounding bone and much weaker than the ligaments crossing the joint. This has a counterintuitive consequence: a force that would sprain a ligament in an adult is far more likely to fracture the growth plate in a child. This is why the classic teaching is "children don't sprain ankles the way adults do — assume a growth plate injury until proven otherwise" in a child with point tenderness over a physis.

The physis also explains why pediatric bone heals faster and remodels more than adult bone (more angular deformity is acceptable in a 5-year-old than in a 15-year-old, because there is more growth remaining to straighten things out) and why growth plate injuries carry a unique complication that adults never face: growth arrest, leading to limb-length discrepancy or angular deformity years later.

Developmental Dysplasia of the Hip (DDH)

What it is

DDH is a spectrum of abnormal hip development ranging from mild acetabular dysplasia to a fully dislocated hip. It occurs when the femoral head and acetabulum don't develop in proper concentric alignment during fetal and early postnatal life.

Risk factors (the "6 Fs" style mnemonic students use)

• Female sex (girls affected roughly 4-6x more than boys — maternal relaxin crosses the placenta and increases ligamentous laxity)
• First-born (tighter uterus, less room to move)
• Family history
• Frank breech presentation (the single strongest risk factor)
• Oligohydramnios / fetal crowding
• Left hip more commonly affected (fetal position against the maternal spine)

Clinical exam

• Ortolani maneuver: with the hip flexed and abducted, gently lift the femur anteriorly — a "clunk" as the dislocated femoral head reduces into the acetabulum is a positive test.
• Barlow maneuver: with the hip flexed and adducted, apply gentle posterior pressure — a clunk as an unstable hip dislocates out of the acetabulum is a positive test.
• These maneuvers are only reliable in the first few months of life. After about 3 months, the hip may no longer be reducible on exam, and you instead look for asymmetric thigh/gluteal folds, limited hip abduction, and the Galeazzi sign (apparent femur length discrepancy when hips and knees are flexed with feet flat on the table).
• In a walking child with untreated unilateral DDH, look for a Trendelenburg gait — the pelvis drops on the side opposite the affected hip when the child stands on the dislocated hip, because the abductors have no stable fulcrum.

Imaging

• Ultrasound is the imaging of choice before 4-6 months of age (the femoral head is still cartilaginous and doesn't show up on X-ray).
• X-ray (AP pelvis) becomes reliable after ossification of the femoral head begins, roughly 4-6 months onward.

Treatment

• Under 6 months: Pavlik harness — holds the hips flexed and abducted, allowing the femoral head to gradually mold the acetabulum into a normal shape. Success rate is very high if started early.
• 6-18 months: Closed reduction under anesthesia with spica casting if the Pavlik harness fails or presentation is delayed.
• Over 18 months or failed closed reduction: Open reduction, sometimes combined with femoral or pelvic osteotomy.

The take-home exam point: DDH treated in the newborn period is a harness problem; DDH missed until walking age is a surgical problem. This is exactly why every newborn gets a hip exam at birth and at well-child visits.

Clubfoot (Congenital Talipes Equinovarus)

What it is

A congenital deformity in which the foot is turned inward and downward. It's remembered by the mnemonic CAVE: Cavus (high arch), Adductus (forefoot turned in), Varus (heel turned in), Equinus (ankle plantarflexed, heel can't touch the ground). Incidence is roughly 1 in 1,000 live births, bilateral in about half of cases, and more common in boys.

Treatment: the Ponseti method

The Ponseti method has essentially replaced early surgery as first-line treatment worldwide because it produces a flexible, functional, pain-free foot without the scarring and stiffness that surgical release used to leave behind.

1. Serial manipulation and casting — weekly gentle stretching and above-knee casting, correcting the components of the deformity in a specific sequence (cavus first, then adductus and varus together, equinus last).
2. Percutaneous Achilles tenotomy — most infants need a simple tenotomy to fully correct the equinus component, done under local anesthesia in clinic.
3. Foot abduction bracing — after casting, the foot is held in a brace (boots connected by a bar) worn full-time for about 3 months, then part-time (naps and overnight) until around age 4. Bracing non-compliance is the single most common cause of relapse — this is a critical, testable teaching point.

Legg-Calve-Perthes Disease

What it is

Idiopathic avascular necrosis of the femoral head in a child, due to a temporary interruption of blood supply to the femoral epiphysis. The bone undergoes necrosis, collapse, and then a slow process of revascularization and remodeling (creeping substitution) that can take 2-4 years.

Classic presentation

• Age 4-10 years (peak around 5-7), boys affected roughly 4-5x more than girls
• Insidious onset of a painless or mildly painful limp, often with referred pain to the groin, thigh, or knee (the hip and knee share the obturator nerve, so hip pathology classically presents as knee pain in children — a frequently tested fact)
• Limited internal rotation and abduction of the hip on exam
• Typically a lean, active child (contrast this with SCFE below)

Imaging

X-ray shows a progression: increased density/flattening of the femoral epiphysis, subchondral fracture ("crescent sign"), fragmentation, and eventually reossification. MRI is more sensitive early in the disease when X-rays are still normal.

Treatment

Younger children (under 6) with less than half the femoral head involved often do well with observation, because they have more remodeling potential and a mobile hip. Older children or more severe involvement need containment strategies — bracing or surgical osteotomy to keep the softened femoral head deep within the acetabulum ("the acetabulum acts as a mold") while it heals, aiming to prevent a flattened, incongruent femoral head that leads to early arthritis.

Slipped Capital Femoral Epiphysis (SCFE)

What it is

Posterior and inferior displacement of the proximal femoral epiphysis relative to the femoral neck, through the growth plate itself — essentially a Salter-Harris I fracture through the weakened physis of an adolescent hip.

Classic presentation (this is a favorite exam contrast with Perthes)

• Age 10-16, classically an obese adolescent male during a growth spurt (though it occurs in females too and increasingly in normal-weight teens)
• Hip, groin, thigh, or referred knee pain (same obturator nerve mechanism as Perthes) with a limp
• On exam, as the hip is passively flexed, it obligately externally rotates ("obligate external rotation with flexion") — this is a hallmark finding
• Endocrine associations: hypothyroidism, growth hormone therapy, renal osteodystrophy — think of these particularly if SCFE occurs in a child who is not the "typical" obese adolescent, or if it's bilateral

Diagnosis and management

Frog-leg lateral X-ray of the pelvis is the best view to see the slip — on AP view alone, subtle slips can be missed. SCFE is an orthopedic emergency-equivalent: the child should be made non-weight-bearing immediately once suspected, because continued weight-bearing risks converting a stable slip into an unstable one, which carries a much higher risk of avascular necrosis. Treatment is surgical: in-situ percutaneous screw fixation to prevent further slippage. Up to 20-40% of patients eventually develop a contralateral slip, so many surgeons monitor the other hip closely.

Salter-Harris Classification of Growth Plate Fractures

Because the physis is often the weakest structural point in a child's limb, fractures through it are common and classified by the Salter-Harris system. The mnemonic SALTR captures the pattern and, usefully, correlates roughly with severity and growth-disturbance risk:

• S — Slipped (Type I): Fracture straight through the physis, no bone fragment. Can be subtle on X-ray; diagnosed clinically by point tenderness at the growth plate even with a "normal" X-ray.
• A — Above (Type II): Fracture through the physis and metaphysis (the fragment is "above" the physis, away from the joint). Most common type overall.
• L — Lower/beLow (Type III): Fracture through the physis and epiphysis, extending into the joint. Higher risk of growth disturbance because it disrupts the epiphysis and articular surface.
• T — Through (Type IV): Fracture through metaphysis, physis, and epiphysis — through all three. High risk of growth arrest and often needs precise surgical reduction to realign the physis.
• R — Rammed/cRush (Type V): Compression injury to the physis without an obvious fracture line. Easily missed on initial imaging; often only diagnosed in retrospect when growth arrest appears months later. Worst prognosis for growth disturbance despite looking the "mildest" on the initial film.

Exam pearl: growth disturbance risk roughly increases from Type I to Type V, but Type V is the sneaky one — it looks the least dramatic radiographically yet carries the worst prognosis because the germinal (reproductive) layer of the physis itself is crushed.

The Limping or Non-Weight-Bearing Child

This is one of the highest-yield "can't miss" pediatric orthopedic presentations because the differential spans from benign to limb- or life-threatening, and age narrows it dramatically.

Septic arthritis vs. transient synovitis

This distinction is one of the most commonly tested pediatric orthopedic scenarios because missing septic arthritis destroys the joint within days, while over-treating transient synovitis with unnecessary joint aspiration carries its own risks.

The Kocher criteria help estimate probability of septic arthritis in a child with hip pain:

1. Fever (>38.5°C)
2. Non-weight-bearing on the affected side
3. ESR > 40 mm/hr
4. WBC > 12,000/mm³

The presence of all four criteria correlates with a very high probability of septic arthritis; zero criteria makes it very unlikely. Any child with hip pain and even one or two of these criteria, especially with a joint effusion on ultrasound, warrants urgent orthopedic evaluation for joint aspiration — synovial fluid analysis (cell count, Gram stain, culture) is the definitive test. Septic arthritis of the hip is a surgical emergency requiring urgent operative washout because the femoral head's blood supply can be compressed by the pressure of infected joint fluid, causing avascular necrosis within as little as 24-48 hours.

Transient synovitis is a self-limited, presumed post-viral inflammatory reaction of the hip synovium. The child is well-appearing, low-grade or no fever, mild elevation (if any) of inflammatory markers, and improves with rest and NSAIDs over days. It's a diagnosis of exclusion — you rule out septic arthritis first, you don't rule in transient synovitis.

Idiopathic Scoliosis

What it is

A three-dimensional lateral curvature of the spine with rotation, most commonly idiopathic (no identifiable cause) and diagnosed in adolescence (adolescent idiopathic scoliosis, AIS), more often in girls, and more likely to progress in girls as well.

Screening and diagnosis

• Adam's forward bend test: the child bends forward at the waist with arms hanging; the examiner looks from behind for asymmetric rib or paraspinal prominence (a "rib hump"), which indicates the rotational component of the curve.
• Scoliometer measures the angle of trunk rotation during the forward bend test to help decide who needs an X-ray.
• Cobb angle on a standing full-spine X-ray is the definitive measurement — the angle between the most tilted vertebrae above and below the curve apex. A Cobb angle ≥ 10° with rotation defines scoliosis.

Treatment thresholds (frequently tested cutoffs)

• Cobb angle < 25°: Observation with periodic X-rays, especially important during the adolescent growth spurt when curves progress fastest
• Cobb angle 25-45° in a skeletally immature patient: Bracing (e.g., Boston brace), worn most of the day, aims to prevent progression rather than correct the existing curve
• Cobb angle > 45-50°, or progressive despite bracing: Surgical correction (spinal fusion with instrumentation)

Non-idiopathic causes to keep in the back of your mind when a curve looks atypical (very young age, painful, rapid progression, unusual curve pattern, or leftward thoracic curve): congenital scoliosis (vertebral segmentation defects), neuromuscular scoliosis (cerebral palsy, muscular dystrophy), or an underlying syrinx/tethered cord — these warrant MRI of the spinal cord before assuming "idiopathic."

Other High-Yield Conditions

• Nursemaid's elbow (radial head subluxation): Occurs in toddlers (typically 1-4 years) after axial traction on an extended, pronated arm (being pulled up by the hand). The annular ligament slips over the radial head. The child holds the arm slightly flexed and pronated, refusing to use it, but is otherwise well and not tender to palpation along the bone. Reduced by supination-flexion or hyperpronation maneuver — often resolves in seconds with a palpable/audible click, no imaging needed if the history and exam are classic.
• Osgood-Schlatter disease: Traction apophysitis at the tibial tubercle from repetitive quadriceps pull through the patellar tendon, in active adolescents during growth spurts. Presents as a tender, sometimes visibly prominent bump below the knee, worse with running/jumping. Self-limited; treated with activity modification and stretching, not surgery.
• Blount disease (tibia vara): Pathologic bowing of the tibia from abnormal growth at the medial proximal tibial physis, distinguished from normal physiologic bowing of toddlers by persistence beyond age 2-3 and progressive worsening rather than spontaneous correction.
• Osteogenesis imperfecta: Genetic collagen (type I) disorder causing bone fragility and recurrent fractures with minimal trauma; classic associated findings include blue sclerae and dentinogenesis imperfecta. Important because recurrent unexplained fractures in a young child also raise the question of non-accidental trauma (child abuse) — distinguishing the two is a genuinely important clinical and ethical skill.
• Juvenile idiopathic arthritis (JIA): The most common chronic rheumatologic disease of childhood, defined as arthritis persisting more than 6 weeks in a child under 16 with no other identified cause. Subtypes include oligoarticular (≤4 joints, highest risk of asymptomatic uveitis requiring regular ophthalmology screening), polyarticular (≥5 joints), and systemic JIA (fever, rash, arthritis, and systemic inflammation — can mimic infection or malignancy at onset).

Key Terms

Term	Definition	Related Concept
Physis (growth plate)	Cartilaginous disc responsible for longitudinal bone growth	Weakest point in pediatric bone; site of Salter-Harris fractures
DDH	Developmental dysplasia of the hip — spectrum from mild instability to full dislocation	Ortolani/Barlow tests, Pavlik harness
Ortolani/Barlow tests	Maneuvers to detect a reducible or dislocatable infant hip	Reliable mainly in the first 3 months of life
Ponseti method	Serial casting, tenotomy, and bracing protocol for clubfoot	Replaced early surgery as first-line treatment
Legg-Calve-Perthes disease	Idiopathic avascular necrosis of the femoral head in children	Age 4-10, painless limp, referred knee pain
SCFE	Slipped capital femoral epiphysis — displacement of femoral epiphysis through the physis	Obese adolescent, obligate external rotation with flexion
Salter-Harris classification	System (Types I-V) grading pediatric growth plate fractures	SALTR mnemonic; Type V has worst growth prognosis
Kocher criteria	Four clinical/lab criteria estimating probability of septic arthritis	Fever, non-weight-bearing, ESR >40, WBC >12,000
Transient synovitis	Self-limited, post-viral hip synovitis in children	Diagnosis of exclusion after ruling out septic arthritis
Cobb angle	Radiographic measurement of spinal curve severity in scoliosis	Determines observation vs. bracing vs. surgery thresholds
Nursemaid's elbow	Radial head subluxation from axial traction on a pronated arm	Reduced by supination-flexion maneuver
Growth arrest	Premature closure of part or all of a physis after injury	Complication of high-grade Salter-Harris fractures

Common Mistakes

Misconception: A normal hip X-ray in a newborn rules out DDH. Why it's wrong: The femoral head is largely cartilaginous at birth and doesn't ossify enough to be reliably visualized on X-ray until roughly 4-6 months of age. A newborn X-ray can look deceptively normal despite significant hip instability. Correct understanding: Ultrasound, not X-ray, is the imaging modality of choice for suspected DDH before 4-6 months. Clinical exam (Ortolani/Barlow, thigh fold asymmetry, Galeazzi sign) remains essential at every age.

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Misconception: Hip pain in a child always means the problem is in the hip. Why it's wrong: The hip and knee joints share sensory innervation via the obturator nerve, so hip pathology (Perthes disease, SCFE, transient synovitis, septic arthritis) very commonly presents as isolated knee pain, especially in younger children who localize pain poorly. Correct understanding: Any child presenting with knee pain and a normal knee exam should have the hip examined and imaged — this referred-pain pattern is one of the most frequently tested pitfalls in pediatric orthopedics.

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Misconception: If a child can still walk (even with a limp), septic arthritis is unlikely and can be managed conservatively. Why it's wrong: Early or partially treated septic arthritis, especially in children who received recent antibiotics for another reason, can present with a milder clinical picture than the classic non-weight-bearing, febrile, toxic-appearing child. Correct understanding: Use the Kocher criteria as a probability estimate, not an absolute rule-out. Any child with an irritable hip and elevated inflammatory markers or a joint effusion needs urgent orthopedic evaluation, because the consequence of a missed septic hip (avascular necrosis within 24-48 hours) is severe and largely irreversible.

Comparison and Connections

Feature	Legg-Calve-Perthes Disease	Slipped Capital Femoral Epiphysis (SCFE)
Typical age	4-10 years	10-16 years
Typical body habitus	Lean, active	Often obese, rapid growth spurt
Underlying pathology	Idiopathic avascular necrosis of femoral epiphysis	Displacement through the proximal femoral physis
Classic exam finding	Limited internal rotation and abduction	Obligate external rotation with hip flexion
Best imaging view	AP and frog-leg pelvis X-ray; MRI early if X-ray normal	Frog-leg lateral X-ray (subtle on AP alone)
Weight-bearing status	Often allowed with activity modification early on	Non-weight-bearing immediately once suspected
Definitive treatment	Observation or containment (bracing/osteotomy) depending on age/severity	Urgent percutaneous screw fixation in situ
Key complication if missed	Femoral head deformity, early osteoarthritis	Avascular necrosis, chondrolysis, contralateral slip

Practice Questions

Recall

1. List the four Kocher criteria used to estimate the probability of septic arthritis in a child with an irritable hip. Answer guidance: Fever >38.5°C, non-weight-bearing on the affected side, ESR >40 mm/hr, WBC >12,000/mm³. All four present correlates with a very high probability of septic arthritis.

2. What does the CAVE mnemonic stand for in describing clubfoot deformity? Answer guidance: Cavus (high arch), Adductus (forefoot turned in), Varus (heel turned in), Equinus (ankle plantarflexed).

Understanding

3. Explain why a child with hip pathology often presents with knee pain instead of hip pain. Answer guidance: The hip and knee joints share sensory innervation from the obturator nerve, so pain from conditions like Perthes disease or SCFE can be referred to the knee, especially in younger children who localize pain imprecisely.

4. Why is Salter-Harris Type V considered to have the worst prognosis despite appearing the least severe on X-ray? Answer guidance: Type V is a crush injury to the physis without an obvious fracture line, so it's easily missed initially, but it damages the germinal layer responsible for future growth, leading to growth arrest that often only becomes apparent months later.

Application

5. A 6-year-old boy presents with a several-week history of a painless limp and hip stiffness. He is thin and active. X-ray shows flattening and increased density of the femoral epiphysis. What is the diagnosis and how should it be managed? Answer guidance: Legg-Calve-Perthes disease. Given his young age, observation with monitoring may be appropriate if less than half the femoral head is involved; older children or more severe involvement need containment (bracing or osteotomy) to preserve femoral head shape.

6. A 13-year-old obese boy reports several weeks of vague knee pain and is noted to walk with the affected leg externally rotated. What is the most likely diagnosis, the next best imaging step, and the immediate management priority? Answer guidance: SCFE. Obtain a frog-leg lateral X-ray of the pelvis. Immediately make the patient non-weight-bearing to prevent progression to an unstable slip, then arrange urgent orthopedic referral for in-situ screw fixation.

Analysis

7. Compare and contrast Legg-Calve-Perthes disease and SCFE in terms of age, body habitus, underlying pathology, and urgency of management. Answer guidance: Perthes affects younger, typically lean children and results from idiopathic avascular necrosis; management urgency depends on age/severity and can sometimes be observational. SCFE affects older, often obese adolescents and results from mechanical displacement through the physis; it requires immediate non-weight-bearing status and urgent surgical fixation because delay risks converting a stable slip to an unstable one with much higher avascular necrosis risk.

8. A 2-year-old girl refuses to bear weight on her leg after being swung by the arms during play, and separately a 4-year-old boy has an acutely painful, swollen, hot knee with fever and refusal to move the leg at all. How does your diagnostic and management approach differ between these two children? Answer guidance: The 2-year-old's history (traction on the arm, not the leg) doesn't fit nursemaid's elbow (which affects the arm); a toddler refusing to bear weight after minor trauma should raise concern for a toddler's fracture (spiral tibia fracture) — evaluate with a focused exam and X-ray. The 4-year-old with fever, hot swollen joint, and complete refusal to move the limb should be treated as septic arthritis until proven otherwise — urgent labs (CBC, ESR, CRP, blood cultures), joint aspiration, and likely emergent surgical washout, because delay risks irreversible joint damage.

FAQ

Why do doctors treat suspected SCFE as an emergency when the child isn't obviously that sick? Because the danger isn't systemic illness — it's mechanical. A "stable" slip (child can still bear some weight) can become an "unstable" slip if the child keeps walking on it, and unstable slips have a dramatically higher rate of avascular necrosis of the femoral head, which can lead to lifelong hip arthritis and disability in a teenager. Making the diagnosis and stopping weight-bearing immediately, even before imaging confirms it, is standard practice whenever SCFE is clinically suspected.

If DDH is often not painful, why does it matter if it's caught late? An unreduced dislocated hip forces the femoral head to sit outside the acetabulum, which never develops a normal socket shape without the femoral head's molding pressure. Left untreated, the child develops a limp, leg-length discrepancy, and early degenerative arthritis. The later DDH is found, the more invasive the treatment needed (harness in infancy vs. open surgery and osteotomy after walking age), which is exactly why newborn hip screening exists.

Is bowlegged (genu varum) or knock-kneed (genu valgum) appearance in toddlers always abnormal? No — physiologic bowing (genu varum) is normal and common up to about age 2, and physiologic knock-knee (genu valgum) is normal roughly between ages 2 and 7, as part of the natural sequence of lower limb alignment during growth. What's abnormal is bowing that persists beyond the expected age, is asymmetric, or is progressively worsening — these findings should raise concern for pathologic causes like Blount disease or rickets rather than being reassured as "normal variant."

Why does a torn ligament in a child sometimes turn out to be a growth plate fracture instead? Because the growth plate (physis) is mechanically weaker than the ligaments crossing the same joint in a child, whereas in an adult the physis is closed (fused) and the ligament becomes the weakest link. A force that would sprain an adult's ankle ligament is more likely to fracture the distal fibular or tibial physis in a child — this is why point tenderness directly over a growth plate in a child should be treated as a probable fracture even if the X-ray looks normal (a Salter-Harris Type I injury can be radiographically occult).

Does every child found to have scoliosis on a school screening need to see an orthopedic surgeon? Not necessarily. A positive forward bend test or scoliometer reading prompts an X-ray to measure the Cobb angle; small curves (under 20-25°) in a skeletally immature child are typically followed with periodic observation rather than immediate referral for bracing or surgery. Referral urgency increases with larger Cobb angles, documented progression on serial X-rays, younger age (more growth remaining means more time to progress), or atypical features suggesting a non-idiopathic cause.

Quick Revision

• The growth plate (physis) is the weakest point in a child's bone — this is why children fracture where adults sprain
• DDH: Ortolani/Barlow tests in infancy, Pavlik harness under 6 months, surgery if diagnosed late (after walking age)
• Clubfoot (CAVE deformity) is now treated with the Ponseti method: casting, tenotomy, then bracing — bracing non-compliance is the top cause of relapse
• Legg-Calve-Perthes disease = idiopathic AVN of the femoral head, ages 4-10, lean active child, painless limp
• SCFE = physeal displacement in obese adolescents, obligate external rotation with hip flexion, requires immediate non-weight-bearing and urgent screw fixation
• Hip pathology commonly presents as referred knee pain in children (shared obturator nerve innervation)
• Salter-Harris (SALTR) classifies growth plate fractures; Type V (crush) has the worst growth-arrest prognosis despite looking mild on X-ray
• Kocher criteria (fever, non-weight-bearing, ESR >40, WBC >12,000) estimate septic arthritis probability — treat as emergency until excluded
• Transient synovitis is a diagnosis of exclusion after ruling out septic arthritis
• Scoliosis: Cobb angle determines management — observe under 25°, brace 25-45° in growing children, surgery above 45-50°
• Nursemaid's elbow: toddler with arm pulled, holds arm flexed/pronated, reduced by supination-flexion, no imaging needed if classic
• Recurrent unexplained fractures in a young child should prompt consideration of both osteogenesis imperfecta and non-accidental trauma

Related Topics

Prerequisites: Bone anatomy and physiology, growth plate biology, basic musculoskeletal exam, Fractures and Dislocations

Related Topics: Fractures and Dislocations (Salter-Harris system), Musculoskeletal Disorders (JIA, osteoporosis analogues), Orthopedic Surgery Techniques (osteotomy, screw fixation), Sports Medicine (overuse injuries, Osgood-Schlatter)

Next Topics: Orthopedic Surgery Techniques, Musculoskeletal Disorders, Sports Medicine