Page 130 - ASOP ROT Study Guide

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Management
Not all curves progress (get worse) and this should be emphasised to parents. If the curve is progressive,
or is causing distress, treatment should be offered early. Braces have no benefit and should not be used
as they add to the stigma of the disease.

If treatment is demanded due to the progress of the curve or the distress caused by it, then surgical
correction is essential. The rotatory element of the deformity must be corrected, to remove the hump
as this is the cause of most distress to the patient. This is very complex surgery which is only carried
out in a handful of regional spinal centres. All children with scoliosis should be referred for a specialist
opinion if treatment is demanded or if the curve is progressive. The earlier the referral the better.

8 . 5 Limp in Childhood

Introduction
A limp at any age must be taken seriously. Quite often the cause will be obscure and the condition settle.
However, when there is a serious cause it demands treatment and so the conditions below, which occur
within characteristic age bands, must be excluded.

From birth - CDH

- Infection of the hip

Between four and ten - Perthe's Disease

From ten to fifteen - Slipped upper femoral epiphysis

8 . 5 . 1 Perthe's disease

This is an osteochondritis (fragmentation of the bone and overlying cartilage) of the femoral head
epiphysis. It is commoner in boys than girls and in 20% is bilateral. The cause is unknown but it has an
incidence of up to 5 per thousand children.

Clinical presentation
The natural history is for the child to present with a painful limp which is followed by a slow recovery.
Radiologically the femoral head may be normal on first presentation but it fragments to a greater or lesser
degree. Radiographs repeated after a month may show previously unrecorded changes. Ultrasound
reveals excess fluid in the hip joint.

The condition is thought to be an avascular necrosis of the growing femoral head. The cause,
nevertheless, is obscure. Eventually the head will re-vascularize and re-ossify but it may be enlarged
and deformed.

Management
The strategy of treatment is to maintain the head concentrically within the acetabulum until die natural
process of the disease runs its course. Minor degrees of the condition, involving up to half of the femoral
head, need no treatment as the prognosis in such children is good. In older children, when the condition
affects the femoral head, the prognosis is less good. The child will return to normal in the short term,
but will be prone to secondary osteoarthritis in early middle age.

In the severe case, splintage to achieve containment may help. There is a belief that osteotomy, to either
enlarge the acetabulum, or redirect the femoral head, helps. All these treatments are of dubious
value. Careful follow up with periods of traction to alleviate symptoms of pain and limp is probably all that
can be done to help these children.

8 .5 . 2 Slipped Capital Femoral Epiphysis (SCFE)

This is a condition seen in boys of around twelve years old who are sexually immature for their age and in
girls who are a little older and have recently undergone an adolescent growth spurt. It consists of a
slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted.