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 Pediatric Orthopaedics
Pediatric

A Quick Reference Guide

Pediatric Orthopaedics and Sports Injuries
and Sports Injuries
A Quick Reference Guide 3rd Edition
John F. Sarwark, MD, FAAP, FAAOS • Cynthia R. LaBella, MD, FAAP, FAMSSM Orthopaedics
and Sports Injuries
Fully updated and revised, the third edition of this quick reference delivers targeted
guidance on the diagnosis, treatment, and management of musculoskeletal problems
and sports-related injuries.
You’ll turn here often for concise summaries of disorders and injuries; proven

3rd Edition
evaluation, treatment, and rehabilitation approaches; practice-tested tips; and invaluable
clinical pearls.
EFFICIENTLY RESPOND TO DIVERSE CLINICAL CHALLENGES.
Get all the essentials for addressing
• Common sports injuries
A Quick Reference Guide
• Fractures NEW IN THE 3RD EDITION
• Trauma • Femoroacetabular impingement 3rd Edition
• Limb disorders • Pediatric athletes with disabilities
• Spine disorders • Bone health evaluation
• Hip and pelvis disorders Plus, you’ll find step-by-step help
• Infections with musculoskeletal examina-
• Tumors tion and evaluation, casting and
• Skeletal dysplasias splinting, imaging techniques, and
• And more… rehabilitation strategies.
FAST-ACCESS FEATURES
STREAMLINE ORTHOPAEDIC HELP YOU GET RIGHT TO
PROBLEM-SOLVING. THE POINT.
Each condition-focused chapter steps you Bulleted, outline-format text
through every stage of patient care. lets you rapidly focus in on what
• Etiology/epidemiology you need.
• Signs and symptoms Full-color clinical photographs
• Differential diagnosis and illustrations, as well as radio-
• Diagnostic considerations

SARWARK • LABELLA
graphic images, demonstrate exami-
• Treatment nation techniques and pathologic
• Expected outcomes/prognosis physical findings. Multiple tables
• When to refer and figures help simplify diagnosis.

For other pediatric resources, visit the American Academy of Pediatrics at

shop.aap.org.

John F. Sarwark, MD, FAAP, FAAOS • Cynthia R. LaBella, MD, FAAP, FAMSSM

AAP
 Pediatric
Orthopaedics
and Sports Injuries
A Quick Reference Guide
3rd Edition

John F. Sarwark, MD, FAAP, FAAOS

Cynthia R. LaBella, MD, FAAP, FAMSSM
 American Academy of Pediatrics Publishing Staff
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Marketing, and Publishing
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subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of all infants,
children, adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of
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MA1018
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Cover and publication design by Peg Mulcahy
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To the pediatricians, primary care professionals, medical/surgical specialists, residents and
fellows in training, health care professionals in training, and research professionals
who devote their careers to the well-being of our children
Contents

EDITORS/CONTRIBUTORS������������������������������������������������������������������������������������� ix

PREFACE����������������������������������������������������������������������������������������������������������������xv

PART 1 GROWTH AND MOTOR DEVELOPMENT............................................. 1

Chapter 1 Typical Growth and Motor Development.................................................. 3
Chapter 2 Atypical Musculoskeletal Growth and Motor Development...................... 17

PART 2 MUSCULOSKELETAL EVALUATION..................................................... 23

Chapter 3 History.................................................................................................. 25
Chapter 4 Physical Examination............................................................................. 33
Chapter 5 Musculoskeletal Imaging Studies............................................................ 63
Chapter 6 Laboratory Studies................................................................................. 75

PART 3 MUSCULOSKELETAL INFECTIONS...................................................... 79

Chapter 7 Osteomyelitis......................................................................................... 81
Chapter 8 Septic Arthritis....................................................................................... 95
Chapter 9 Miscellaneous Infections....................................................................... 101

PART 4 EVALUATING THE LIMPING CHILD................................................... 107

Chapter 10 The Limping Child: General Approach and Differential Diagnosis......... 109

PART 5 SPINAL DEFORMITIES...................................................................... 119

Chapter 11 Idiopathic Scoliosis and Congenital Scoliosis......................................... 121
Chapter 12 Kyphosis.............................................................................................. 133
Chapter 13 Spondylolysis and Spondylolisthesis...................................................... 141

PART 6 BACK PAIN........................................................................................ 151

Chapter 14 Back Pain: General Approach and Differential Diagnosis........................ 153

PART 7 PEDIATRIC CERVICAL SPINE............................................................. 163

Chapter 15 Pediatric Cervical Spine: Basic Radiographic Interpretation................... 165
Chapter 16 Torticollis............................................................................................ 171
Chapter 17 Atlantoaxial Rotatory Subluxation or Fixation....................................... 179

PART 8 HIP DISORDERS................................................................................ 187

Chapter 18 Developmental Dysplasia of the Hip..................................................... 189
Chapter 19 Perthes Disease.................................................................................... 195
Chapter 20 Slipped Capital Femoral Epiphysis........................................................ 199
Chapter 21 Snapping Hip....................................................................................... 205
Chapter 22 Femoroacetabular Impingement .......................................................... 211
vi Contents

PART 9 ROTATIONAL AND ANGULAR DEFORMITIES................................... 219

Chapter 23 Rotational and Angular Deformities: General Treatment Guidelines....... 221
Chapter 24 In-toeing.............................................................................................. 223
Chapter 25 Out-toeing........................................................................................... 229
Chapter 26 Angular Variations: Genu Varum (Bowleg) and Genu Valgum
(Knock-Knee)...................................................................................... 231

PART 10 UPPER EXTREMITY PROBLEMS........................................................ 235

Chapter 27 Brachial Plexus Injuries........................................................................ 237
Chapter 28 Nursemaid Elbow (Radial Head Subluxation)....................................... 249
Chapter 29 Congenital Upper Limb Differences...................................................... 253

PART 11 PEDIATRIC SPORTS MEDICINE AND INJURIES................................. 271

Chapter 30 Preparticipation Physical Evaluation..................................................... 273
Chapter 31 Strains, Sprains, and Dislocations......................................................... 283
Chapter 32 Traumatic Muscle Injuries.................................................................... 301
Chapter 33 Overuse Injuries................................................................................... 311
Chapter 34 Patellofemoral Disorders...................................................................... 343
Chapter 35 Internal Derangement of the Knee (Knee Injury).................................. 355
Chapter 36 Sports-Related Concussion................................................................... 375
Chapter 37 Pediatric Athletes With Disabilities........................................................ 389

PART 12 COMMON FRACTURES AND PHYSEAL INJURIES............................ 405

Chapter 38 Pediatric Trauma Overview................................................................... 407
Chapter 39 Imaging Fractures................................................................................ 409
Chapter 40 Fracture Types Overview...................................................................... 411
Chapter 41 Stages of Fracture Healing.................................................................... 415
Chapter 42 Physeal Fractures................................................................................. 419
Chapter 43 Bone Health Evaluation in the Child Vulnerable to Fracture................... 425
Chapter 44 Common Fractures of the Upper Extremities........................................ 433
Chapter 45 Common Fractures of the Lower Extremities........................................ 451
Chapter 46 Casting and Splinting........................................................................... 465
Chapter 47 Occult Fractures (Injury Not Detected by Radiography)........................ 479
Chapter 48 Compartment Syndrome...................................................................... 483
Chapter 49 Nonaccidental Trauma......................................................................... 489

PART 13 FOOT AND ANKLE........................................................................... 499

Chapter 50 Foot and Ankle: General Considerations............................................... 501
Chapter 51 Clubfoot.............................................................................................. 505
Chapter 52 Flatfoot................................................................................................ 511
Chapter 53 Metatarsus Adductus and Metatarsus Varus........................................... 515
Chapter 54 Pes Cavus and Cavovarus..................................................................... 519
Chapter 55 Calcaneal Valgus................................................................................... 523
Chapter 56 Foot and Ankle: Miscellaneous Conditions............................................ 525
 Contents vii

PART 14 BENIGN AND MALIGNANT MUSCULOSKELETAL TUMORS............. 547

Chapter 57 Evaluation of Benign and Malignant Musculoskeletal Tumors................ 549
Chapter 58 Common Benign Tumors..................................................................... 555
Chapter 59 Malignant Tumors................................................................................ 577

PART 15 LIMB-LENGTH DISCREPANCY........................................................... 589

Chapter 60 Limb-Length Discrepancy.................................................................... 591

PART 16 NEUROMUSCULAR DISORDERS, PART 1.......................................... 601

Chapter 61 Cerebral Palsy...................................................................................... 603
Chapter 62 Myelomeningocele (Spina Bifida)......................................................... 611

PART 17 NEUROMUSCULAR DISORDERS, PART 2.......................................... 621

Chapter 63 Neurodegenerative Disorders................................................................ 623
Chapter 64 Hereditary Neuropathies: Charcot-Marie-Tooth Disease........................ 631
Chapter 65 Spinal Muscular Atrophy...................................................................... 637
Chapter 66 Friedreich Ataxia.................................................................................. 645
Chapter 67 Arthrogryposis..................................................................................... 653

PART 18 GENETIC DISEASES AND SYNDROMES WITH

MUSCULOSKELETAL MANIFESTATIONS........................................... 661
Chapter 68 Skeletal Dysplasias............................................................................... 663
Chapter 69 Metabolic Bone Diseases...................................................................... 675
Chapter 70 Neurofibromatosis 1............................................................................. 683
Chapter 71 Hemophilia.......................................................................................... 689
Chapter 72 Achondroplasia.................................................................................... 695
Chapter 73 Down Syndrome.................................................................................. 701

PART 19 RHEUMATOLOGIC AND CONNECTIVE TISSUE DISEASES............... 707

Chapter 74 Juvenile Idiopathic Arthritis.................................................................. 709
Chapter 75 Autoimmune Connective Tissue Diseases.............................................. 723
Chapter 76 Inherited Connective Tissue Diseases.................................................... 737

INDEX���������������������������������������������������������������������������������������������������������������� 747
Editors
John F. Sarwark, MD, FAAP, FAAOS Cynthia R. LaBella, MD, FAAP,
Professor of Orthopaedic Surgery FAMSSM
Northwestern University Feinberg School of Professor of Pediatrics
Medicine Northwestern University Feinberg School of
Martha Washington Professor of Medicine
Orthopaedic Surgery Medical Director, Institute for Sports
Head, Orthopaedic Surgery Medicine
Ann & Robert H. Lurie Children’s Hospital Ann & Robert H. Lurie Children’s Hospital
of Chicago of Chicago
Chicago, IL Chicago, IL

Contributing Authors
Lindsay M. Andras, MD, FAAP Jennette L. Boakes, MD
Associate Professor of Orthopaedic Surgery Pediatric Orthopaedic Surgeon
Children’s Orthopaedic Center Shriners Hospitals for Children – Northern
Children’s Hospital Los Angeles California
Los Angeles, CA Clinical Professor of Orthopaedic Surgery
University of California, Davis School of
Arvind Balaji, MD, FAAP
Medicine
Fellow, Primary Care Sports Medicine
California Northstate University College of
Children’s Hospital of Philadelphia
Medicine
Philadelphia, PA
Sacramento, CA
Holly J. Benjamin, MD, FAAP,
Susannah M. Briskin, MD, FAAP
FACSM
Associate Professor of Pediatrics
Professor of Orthopaedic Surgery and
Division of Pediatric Sports Medicine
Rehabilitation Medicine
Rainbow Babies & Children’s Hospital
Professor of Pediatrics
University Hospitals Cleveland
Director of Primary Care Sports Medicine
Medical Center
University of Chicago
Cleveland, OH
Chicago, IL
Rebecca Carl, MD, MS, FAAP
David T. Bernhardt, MD, FAAP Institute for Sports Medicine
Professor
Ann & Robert H. Lurie Children’s Hospital
Department of Pediatrics
of Chicago
Department of Orthopedics and
Assistant Professor of Pediatrics
Rehabilitation
Northwestern University Feinberg School of
Division of Sports Medicine
Medicine
University of Wisconsin School of Medicine
Chicago, IL
and Public Health
Madison, WI
x Editors/Contributors
Priya Chandan, MD, MPH
Assistant Professor of Physical Medicine &
Rehabilitation
University of Louisville
Louisville, KY
Steven Cuff, MD, FAAP
Associate Professor of Pediatrics
Division of Sports Medicine
Nationwide Children’s Hospital
The Ohio State University College of
Medicine
Columbus, OH
Jon R. Davids, MD
Assistant Chief of Orthopaedic Surgery
Medical Director, Motion Analysis
Laboratory
Shriners Hospitals for Children – Northern
California
Ben Ali Chair in Pediatric Orthopaedics
Department of Orthopaedic Surgery
University of California, Davis School of
Medicine
Sacramento, CA
Kelsey Davidson, MD
Pediatric Orthopaedic Surgeon
Shriners Hospitals for Children – Chicago
Chicago, IL
Deirdre De Ranieri, MD, RhMSUS
Program Director, Division of
Rheumatology
Ann & Robert H. Lurie Children’s Hospital
of Chicago
Northwestern University Feinberg School of
Medicine
Chicago, IL
Rebecca A. Demorest, MD, FAAP
Director of Pediatric & Young Adult Sports
Medicine
Webster Orthopedics
San Ramon and Dublin, CA
Mary E. Dubon, MD, FAAP
Instructor, Physical Medicine and
Rehabilitation
Pediatric Rehabilitation Medicine
Pediatric Sports Medicine
Boston Children’s Hospital
Spaulding Rehabilitation Hospital
Harvard Medical School
Boston, MA
Brett Dusenberry, MD, FAAP
Ann & Robert H. Lurie Children’s Hospital
of Chicago
Chicago, IL
Amanda Fingarson, DO, FAAP
Assistant Professor of Pediatrics
Northwestern University Feinberg School of
Medicine
Division of Child Abuse Pediatrics
Ann & Robert H. Lurie Children’s Hospital
of Chicago
Chicago, IL
Gaia Georgopoulos, MD, FAAOS
Associate Professor of Orthopedic Surgery
Division of Pediatric Orthopedics
University of Colorado, Denver
Denver, CO
Matthew Grady, MD, FAAP, CAQSM
Program Director, Primary Care Sports
Medicine Fellowship
Associate Professor of Clinical Pediatrics
University of Pennsylvania Perelman School
of Medicine
Division of Orthopaedics
Children’s Hospital of Philadelphia
Philadelphia, PA
Andrew Gregory, MD, FAAP,
FACSM, FAMSSM
Associate Professor, Orthopaedics,
Neurosurgery, and Pediatrics
Vanderbilt University Medical Center
Nashville, TN
 Editors/Contributors
Kelsey A. Gregory, MD, FAAP
Fellow, Child Abuse Pediatrics
Ann & Robert H. Lurie Children’s Hospital
of Chicago
McGaw Medical Center of Northwestern
University
Chicago, IL
Mark Halstead, MD, FAAP
Associate Professor of Pediatrics and
Orthopedics
Washington University School of Medicine
Director, St Louis Children’s Hospital
Young Athlete Center
St Louis, MO
Thomas N. Harris, MD
Department of Pediatrics
University of Wisconsin School of Medicine
and Public Health
Madison, WI
William Hennrikus, MD, FAAP
Professor and Associate Dean
Penn State College of Medicine
Hershey, PA
Brittany E. Homcha, MD
Department of Orthopaedics and
Rehabilitation
Milton S. Hershey Medical Center
Hershey, PA
Kenneth David Illingworth, MD
Assistant Professor of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
Pediatric Orthopaedic Surgeon
Children’s Hospital Los Angeles
Los Angeles, CA
Henry J. Iwinski, MD, FAAP
Chief of Staff
Shriners Hospitals for Children Medical
Center – Lexington
Lexington, KY
Rajat Jain, MD
Team Physician, Northwestern University
Northwestern University Health Service
Evanston, IL
xi
Michelle A. James, MD, FAAP
Chief of Orthopaedic Surgery
Shriners Hospitals for Children – Northern
California
Professor of Clinical Orthopaedic Surgery
University of California, Davis School of
Medicine
Sacramento, CA
Kerwyn Jones, MD
Surgical Quality Officer
Department of Orthopedics
Akron Children’s Hospital
Akron, OH
Harry K.W. Kim, MD, MS
Director, Center for Excellence in Hip
Scottish Rite for Children
Professor of Orthopaedics,
University of Texas Southwestern Medical
Center
Dallas, TX
Jennifer R. King, DO, FAAP, CAQSM
Assistant Professor of Pediatrics
John A. Burns School of Medicine,
University of Hawai’i
Section Chief, Pediatric Sports Medicine
Kapi’olani Bone and Joint Center, Hawaii
Pacific Health
Kapi’olani Women and Children’s Medical
Center
Honolulu, HI
Mininder S. Kocher, MD, MPH
Professor
Department of Orthopaedic Surgery
Harvard Medical School
Chief, Division of Sports Medicine
Orthopedic Center
Boston Children’s Hospital
Boston, MA
xii Editors/Contributors

Meghan C. Kostyk, APRN, MSN, Joel A. Lerman, MD, FAAP

CPNP, CCD Pediatric Orthopaedic Surgeon
Advanced Practice Provider and Certified Shriners Hospitals for Children – Northern
Clinical Densitometrist California
Division of Orthopaedic Surgery and Sports Clinical Associate Professor, Department of
Medicine Orthopedics
Ann & Robert H. Lurie Children’s Hospital University of California, Davis School of
of Chicago Medicine
Chicago, IL Sacramento, CA

Chris Koutures, MD, FAAP Joseph Paul Letzelter III, MD

Pediatric and Sports Medicine Specialist Orthopaedic Surgeon
ActiveKidMD Department of Orthopaedic Surgery and
Anaheim Hills, CA Sports Medicine
Children’s National Medical Center
Michele LaBotz, MD, FAAP, CAQSM
Washington, DC
InterMed Sports Medicine
Portland, ME Sonya Levine, BA
Clinical Assistant Professor Research Project Administrator
Department of Pediatrics Pediatric Orthopedics and Spine
Tufts University School of Medicine Columbia University
Boston, MA New York, NY

Jill E. Larson, MD Robert Listernick, MD

Assistant Professor Professor of Pediatrics
Division of Pediatric Orthopaedic Surgery & Northwestern University Feinberg School of
Sports Medicine Medicine
Northwestern University Feinberg School of Co-Director, Neurofibromatosis Program
Medicine Division of Advanced General Pediatrics &
Chicago, IL Primary Care
Ann & Robert H. Lurie Children’s Hospital
Zoe Lasky, DNP, APRN, CPNP-PC
of Chicago
Advanced Practice Registered Nurse
Chicago, IL
Division of Orthopaedic Surgery and Sports
Medicine David Lyons, DO
Ann & Robert H. Lurie Children’s Hospital Orthopaedic Surgeon
of Chicago MidMichigan Medical Center
Chicago, IL Midland, MI

Claire M.A. LeBlanc, MD, FAAP Julie E. Martin, APRN, PNP-PC

Associate Professor of Pediatrics Pediatric Nurse Practitioner
McGill University Division of Orthopaedic Surgery and Sports
Montreal, QC Medicine
Canada Ann & Robert H. Lurie Children’s Hospital
of Chicago
Chicago, IL

Megan M. May, MD
Assistant Professor of Orthopedic Surgery
Baylor College of Medicine
Houston, TX
 Editors/Contributors xiii

Jeffrey M. Mjaanes, MD, FAAP Sonia Ruparell, MD

Director of Sports Medicine and Head Pediatric Sports Medicine Fellow
Team Physician Department of Orthopedics & Sports
Northwestern University Health Service Medicine
Evanston, IL Ann & Robert H. Lurie Children’s Hospital
of Chicago
Jose A. Morcuende, MD, PhD, FAAP
Chicago, IL
Marvin and Rose Lee Pomerantz Chair in
Orthopaedic Surgery Brian A. Shaw, MD, FAAP, FAAOS
Professor of Pediatrics Associate Professor of Orthopedic Surgery
Professor of Orthopedics and Rehabilitation University of Colorado School of Medicine
Department of Orthopedics and Children’s Hospital Colorado
Rehabilitation Colorado Springs, CO
University of Iowa
Eric D. Shirley, MD
Iowa City, IA
Pediatric Orthopaedic Surgeon
Neeraj M. Patel, MD, MPH, MBS Naval Medical Center Portsmouth
Attending Surgeon Portsmouth, VA
Ann & Robert H. Lurie Children’s Hospital
Mariah N. Sisson, MD
of Chicago
Pediatric Resident
Assistant Professor of Orthopaedic Surgery
Department of Pediatrics
Northwestern University Feinberg School of
University of Iowa Stead Family Children’s
Medicine
Hospital
Chicago, IL
Iowa City, IA
Andrew R. Peterson, MD, MSPH,
Peter A. Smith, MD
FAAP, FAMSSM
Pediatric Orthopaedic Surgeon
Professor of Pediatrics
Shriners Hospital for Children
Stead Family Department of Pediatrics
Professor
Carver College of Medicine
Department of Orthopaedic Surgery
Head Team Physician
Rush University Medical Center
University of Iowa
Chicago, IL
Iowa City, IA
Mary Solomon, DO
Vince W. Prusick, MD
Associate Professor of Pediatrics
Assistant Professor of Orthopaedic Surgery
Division of Pediatric Sports Medicine
University of Kentucky
University Hospitals Rainbow Babies &
Pediatric Orthopaedic Surgeon
Children’s Hospital
Shriners Hospitals for Children Medical
Cleveland, OH
Center – Lexington
Lexington, KY Daniel J. Sucato, MD, MS
Chief of Staff
Vanna J. Rocchi, DO
Texas Scottish Rite Hospital for Children
Lieutenant Commander, Medical Corps,
Professor
US Navy
Department of Orthopaedic Surgery
Pediatric Orthopaedic Surgeon
University of Texas Southwestern Medical
Naval Medical Center Portsmouth
School
Portsmouth, VA
Dallas, TX
xiv Editors/Contributors

Vineeta T. Swaroop, MD Kevin D. Walter, MD, FAAP

Associate Professor of Orthopaedic Surgery Associate Professor of Orthopaedic Surgery
Northwestern University Feinberg School of & Pediatrics
Medicine Medical College of Wisconsin
Ann & Robert H. Lurie Children’s Hospital Director of Sports Medicine, Children’s
of Chicago Wisconsin
Chicago, IL Milwaukee, WI

Jarrod Tembreull, MD Joshua Wathen, MD, FAAP

Sports Medicine Fellow Pediatric Sports Medicine Fellow
Maine-Dartmouth Sports Medicine Baylor College of Medicine
Fellowship Texas Children’s Hospital
Augusta, ME Houston, TX

Jeffrey D. Thomson, MD Amanda Weiss Kelly, MD, FAAP

Director of Orthopedic Surgery Division Chief, Pediatric Sports Medicine
Connecticut Children’s Medical Center Professor of Pediatrics
Hartford, CT University Hospitals Case Medical Center
Professor of Orthopedic Surgery Case Western Reserve University
University of Connecticut Cleveland, OH
Farmington, CT
Sigrid F. Wolf, MD, FAAP, CAQ
Michael Vitale, MD Assistant Professor of Pediatrics
Director of Pediatric Orthopaedics Division of Pediatric Sports Medicine
Columbia University Medical Center Northwestern University Feinberg School of
New York, NY Medicine
Ann & Robert H. Lurie Children’s Hospital
Kelly Waicus, MD, CAQSM
of Chicago
Team Physician
Chicago, IL
University of North Carolina Sports
Medicine
Chapel Hill, NC

American Academy of
Pediatrics Reviewers
Council on Child Abuse and Neglect Section on Neurology
Council on Genetics Section on Orthopaedics
Council on Sports Medicine and Fitness Section on Rheumatology

The AAP is committed to principles of equity, diversity, and inclusion in its pub-
lishing program. Editorial boards, author selections, and author transitions (publica-
tion succession plans) are designed to include diverse voices that reflect society as a
whole. Editor and author teams are encouraged to actively seek out diverse authors
and reviewers at all stages of the editorial process. Publishing staff are committed to
promoting equity, diversity, and inclusion in all aspects of publication writing, review,
and production.
 Preface

The purpose of this book is to provide primary care physicians, pediatricians,

orthopaedic surgeons, residents, medical students, and health care professionals
with a brief and complete discussion of orthopaedic problems and common sports
injuries in children and adolescents. The book can serve as a quick reference guide
for health care professionals who evaluate and manage musculoskeletal and sports-
related concerns in the pediatric population.
The book offers an overview approach and includes differential diagnosis and work-
up of patients with musculoskeletal concerns, injuries, or related conditions. A lim-
ited number of specific references and a few key resources are included for further
in-depth reading. Cross-referencing is extensively provided to avoid repetition and
redundancy. We have presented the material in a simple and practical manner.
For this fully updated and revised third edition, three new chapters have been
added. The new topic areas focus on bone health, femoroacetabular impingement,
and pediatric athletes with disabilities, all of which we feel broaden the scope and
utility of the book. We hope these additions will prove valuable to the reader.
We thank the contributors for their authoritative contributions to this guide. We
greatly appreciate the outstanding editorial assistance of Chris Wiberg, senior editor,
and to the publishing staff of the American Academy of Pediatrics for their help and
support. We hope that our readers—everywhere—will find this book highly useful.

John F. Sarwark, MD, FAAP, FAAOS

Cynthia R. LaBella, MD, FAAP, FAMSSM

NOTE: In the interest of brevity, the term “parent” is used in this book to refer to a
parent or other legal guardian.
Part 1: Growth and Motor
Development
TOPICS COVERED
1. Typical Growth and Motor Development.........................................3
Somatic Growth
Typical Motor Development
Sex Differences in Motor Development
Sports Readiness
2. Atypical Musculoskeletal Growth and Motor Development.............. 17
Atypical Musculoskeletal Growth
Atypical Motor Development

1
 CHAPTER 1

Typical Growth and Motor

Development
•• Typical growth and maturation of a child’s musculoskeletal system and
development of motor skills are determined by numerous factors, including
genetics, nutrition, hormones, illness, physical activity, social conditions, race,
culture, and geographic location.
•• This chapter describes typical growth and maturation of the pediatric
musculoskeletal system; typical patterns of motor skill development; and methods
of evaluating growth, maturation, and development and identifying anomalies and
concerns.

Somatic Growth
•• Somatic growth refers to the increase in weight, height, and organ size.
——Assess somatic growth by comparing a child’s height and weight to a
population of other children at the same chronological age (CA). For children
younger than 24 months, use growth charts developed by the World Health
Organization (WHO). From 2 years to 20 years, growth can be assessed using
Centers for Disease Control and Prevention (CDC) growth charts.
——These charts include the range of height, weight, head circumference, and
body mass index (BMI) obtained from different populations of children.
——WHO growth charts use data from an international cohort of breastfed
children obtained in the first 2 years after birth.
——CDC growth charts include data from a sample of children in the United
States aged birth to 20 years.
——While frequently used as a marker of health and nutritional status, somatic
growth is not a reliable indicator of biological maturity. There is significant
individual variation in the timing (when the growth spurt occurs) and tempo
(rate or speed at which growth spurt occurs) of growth.
•• Growth rate varies with age: it is greatest from birth to 2 years, declines during
childhood, and briefly increases again during the adolescent growth spurt
(Table 1-1, Figure 1-1).
•• During the prepubertal stage between 6 and 12 years of age, growth averages
3 to 3.5 kg and 6 cm per year, with minimal difference between boys and girls
(­Figure 1-1).

3
4 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

Table 1-1. Rates of Growth in Weight and Height by Age

Daily Weight Gain Monthly Weight Growth in Length

Age (g) Gain (cm/mo)
0–3 mo 30 2 lb 3.5
3–6 mo 20 1.25 lb 2.0
6–9 mo 15 1 lb 1.5
9–12 mo 12 13 oz 1.2
1–3 y 8 8 oz (0.5 lb) 1.0
4–6 y 6 6 oz 3 cm/y

Adapted from Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadel-
phia, PA: WB Saunders Co; 2004:35, with permission from Elsevier.

Figure 1-1.
2 to 20 years: Girls NAME
Stature-for-age and Weight-for-age percentiles RECORD # Stature for age
12 13 14 15 16 17 18 19 20 and weight for
Mother’s Stature
Date Age Weight
Father’s Stature
Stature BMI*
AGE (YEARS)
cm in
76
age for girls (A)
190
74
and boys (B).
185 S
72
180 T
70 A
95
175 T
90
68 U
170 R
75 66
165 E
in cm 3 4 5 6 7 8 9 10 11 50
64
160 25 160
62 62
155 10 155
60 5 60
150 150
58
145
56
140 105 230
54
S 135 100 220
T 52
A 130 95 210
50
T 125 90 200
U
48 190
R 120 85
E 95 180
46
115 80
44 170
110 90 75
42 160
105 70
150 W
40
100 75 65 140 E
38 I
95 60 130 G
50
36 90 H
55 120
25 T
34 85 50 110
10
32 80
5
45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Published May 30, 2000 (modified 11/21/00).
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts
 Chapter 1: Typical Growth and Motor Development 5

Figure 1-1.
2 to 20 years: Boys NAME Stature for age
Stature-for-age and Weight-for-age percentiles RECORD #
and weight for
12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in age for girls (A)
AGE (YEARS) 76
Date Age Weight Stature BMI*
190
and boys (B),
95 74
90
185 continued.
72 S
75 T
180
50 70 A
175 T
25 68 U
170 R
10 66
165 E
in cm 3 4 5 6 7 8 9 10 11 5
64
160 160
62 62
155 155
S 60 60
T 150 150
A 58
T 145
U 56
140 105 230
R
54
E 135 100 220
52
130 95 95 210
50
125 90 200
90
48 190
120 85
46 180
115 80
75
44 170
110 75
42 160
105 50 70
150 W
40
100 65 140 E
25
38 I
95 60 130 G
10
36 90 5 H
55 120
T
34 85 50 110
32 80 45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Published May 30, 2000 (modified 11/21/00).
SOURCE: Developed b y the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion(2000).
http://www.cdc.gov/growthcharts

ADOLESCENT GROWTH SPURT

•• The adolescent growth spurt begins at about 9 to 10 years of age for girls and 11
to 12 years of age for boys.
——Boys experience a growth spurt about 2 years after the onset of puberty,
heralded by the onset of gonadal enlargement.
——Girls experience a growth spurt as soon as 6 months after the appearance of
breast buds.
——The growth spurt starts peripherally with enlargement of the hands and feet,
then progresses centrally to the arms and legs, and lastly the trunk.
——The peak growth rate occurs earlier for trunk length and later for leg length
compared with stature; thus, the late childhood growth spurt is characterized
by rapid trunk growth and the early adolescent growth spurt is characterized
by rapid growth of the legs.
6 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

HEIGHT
•• The rate of height growth accelerates until it reaches a maximum, termed the peak
height velocity (PHV), which occurs about 2 years after the start of the adolescent
growth spurt.
•• The growth spurt lasts anywhere from 24 to 36 months (Figure 1-2).
•• Standard deviations of age at PHV range from 0.7 to 1.2 years, indicating
significant individual variation in the timing of the growth spurt.
•• Age at PHV is a reliable indicator of somatic maturity in boys and girls.
•• Boys reach PHV at an average age of 14 years at a rate of 10.3 cm (4.3") per year
and then decelerate to a stop by age 18 years.
•• Girls reach PHV at an average age of 12 years at a rate of 9 cm (3.8") per year
and stop growing approximately 2 years earlier than boys (usually by age
16 years).
•• The onset of menses generally follows PHV by 1 year and is associated with a
rapid deceleration in growth and limited additional gains in stature (Figure 1-2).
•• PHV and magnitude of height gained is 3 to 5 cm greater in boys than in girls.
•• Girls achieve a final mean adult height of 163.8 cm compared with 176.8 cm for
boys, for an average adult height difference of 13 cm between men and women.
This difference in final adult stature is because of the smaller PHV and the earlier
termination of growth in girls compared with boys.
•• Pubertal growth accounts for almost 25% of final adult height.
•• The genetic contribution to final adult height is approximately 60%.

Figure 1-2. Summary of pubertal devel-

opment in girls (A) and boys (B). Menarche
generally occurs shortly after peak height
velocity is attained.
From Rosen DS. Physiologic growth and
development during adolescence. Pediatr Rev.
2004;25(6):194–200.
 Chapter 1: Typical Growth and Motor Development 7

•• There is a trend for youth who attain PHV at an earlier age to be slightly taller at
that age, but ultimately there seems to be no relationship between age at PHV and
final adult stature.
•• Children who mature earlier generally have a higher PHV than those who mature
late, and late maturers on average are taller when the growth spurt begins;
consequently, the mean adult height of early and late maturers is usually the same.
•• Height differences among boys with differences in age of pubertal onset will
generally disappear by late adolescence.
•• Similarly, children with constitutional growth delay will “catch up” with their
peers by late adolescence.

ESTIMATING ADULT HEIGHT

•• Mid-parental height is a frequently used method to estimate a child’s genetic
height potential based on the child’s sex and the biological parents’ height, with a
standard deviation of approximately 2 inches.
——Mid-parental height for boys = paternal height + maternal height + 5 (inches)/2
——Mid-parental height for girls = paternal height + maternal height − 5 (inches)/2
•• Multiplier method
——Height at given CA (cm) × multiplier = adult height (Table 1-2, Table 1-3)

Table 1-2. Height Multiplier Table for Boys

AGE (Y + MO) M AGE (Y + MO) M

Birth 3.535 8+6 1.351
0+3 2.908 9+0 1.322
0+6 2.639 9+6 1.298
0+9 2.462 10 + 0 1.278
1+0 2.337 10 + 6 1.260
1+3 2.239 11 + 0 1.235
1+6 2.160 11 + 6 1.210
1+9 2.088 12 + 0 1.186
2+0 2.045 12 + 6 1.161
2+6 1.942 13 + 0 1.135
3+0 1.859 13 + 6 1.106
3+6 1.783 14 + 0 1.081
4+0 1.731 14 + 6 1.056
4+6 1.675 15 + 0 1.044
5+0 1.627 15 + 6 1.030
5+6 1.579 16 + 0 1.021
6+0 1.535 16 + 6 1.014
6+6 1.492 17 + 0 1.010
8 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

Table 1-2. Height Multiplier Table for Boys, continued

AGE (Y + MO) M AGE (Y + MO) M

7+0 1.455 17 + 6 1.006
7+6 1.416 18 + 0 1.005
8+0 1.383 Mature Heights = Ht x M
Abbreviation: M, multiplier.

From Paley J, Talor J, Levin A, Bhave A, Paley D, Herzenberg JE. The multiplier method for prediction of adult
height. J Pediatr Orthop. 2004;24:732–737 (https://journals.lww.com/pedorthopaedics/Abstract/2004/11000/
The_Multiplier_Method_for_Prediction_of_Adult.25.aspx). Reprinted with permission from Wolters Kluwer and
the Pediatric Orthopaedic Society of North America.

Table 1-3. Height Multiplier Table for Girls

AGE (Y + MO) M AGE (Y + MO) M

Birth 3.290 8+6 1.254
0+3 2.759 9+0 1.229
0+6 2.505 9+6 1.207
0+9 2.341 10 + 0 1.183
1+0 2.216 10 + 6 1.160
1+3 2.120 11 + 0 1.135
1+6 2.038 11 + 6 1.108
1+9 1.965 12 + 0 1.082
2+0 1.917 12 + 6 1.059
2+6 1.815 13 + 0 1.040
3+0 1.735 13 + 6 1.027
3+6 1.677 14 + 0 1.019
4+0 1.622 14 + 6 1.013
4+6 1.570 15 + 0 1.008
5+0 1.514 15 + 6 1.009
5+6 1.467 16 + 0 1.004
6+0 1.421 16 + 6 1.004
6+6 1.381 17 + 0 1.002
7+0 1.341 17 + 6 —
7+6 1.309 18 + 0 —
8+0 1.279 Mature Heights = Ht x M
Abbreviation: M, multiplier.

From Paley J, Talor J, Levin A, Bhave A, Paley D, Herzenberg JE. The multiplier method for prediction of adult
height. J Pediatr Orthop. 2004;24:732–737 (https://journals.lww.com/pedorthopaedics/Abstract/2004/11000/
The_Multiplier_Method_for_Prediction_of_Adult.25.aspx). Reprinted with permission from Wolters Kluwer and
the Pediatric Orthopaedic Society of North America.
 Chapter 1: Typical Growth and Motor Development 9

WEIGHT
•• On average, peak weight velocity (PWV) is greater in boys than in girls. PWV
coincides with PHV in boys but occurs about 6 to 9 months after PHV in girls.
•• Girls reach PWV at age 13 years at a rate of 8.5 kg per year followed by a decrease
to less than 1 kg per year by 15 years.
——Pubertal weight gain in girls is caused primarily by ongoing increase in fat
mass (FM) rather than an increase in skeletal and muscle mass.
•• Boys reach PWV at age 14 years at a rate of 9.5 kg per year followed by a decrease
to less than 1 kg per year by 17 years.
——Pubertal weight gain in boys primarily is caused by increases in height (skeletal
mass) and muscle mass with a stable FM.
•• Weight gains during puberty account for approximately 40% to 50% of ideal
adult weight in both sexes.

BONE GROWTH
•• Primary ossification centers are the first areas of a bone to ossify and are found in
the shaft of long bones and the center or body of irregular bones. For most bones,
the ossification process begins during prenatal development.
•• Secondary ossification centers appear later, developing during infancy and early
childhood, and fuse with primary ossification centers during late childhood,
adolescence, and early adult life.
•• The cartilage between the primary and secondary ossification centers of long
bones becomes the physis, or growth plate.
——The growth plate is responsible for longitudinal growth and is subject to
pressure or axial forces.
——Long bones of the upper and lower extremities (femur, tibia, fibula, humerus,
radius, ulna) grow in length through the process of endochondral ossification, the
proliferation of cartilage cells in the epiphyseal plate, which then ossify to bone.
•• All the bones in the body form through endochondral ossification except for the
flat bones of the skull, mandible, and clavicles, which undergo intramembranous
ossification.
•• At the ends of each long bone, the epiphysis is covered by articular cartilage and
forms the joint surface.
——Typical development of joints requires a functioning neuromuscular system to
allow normal motion.
•• Ring epiphyses surround the periphery of round bones, such as the tarsal bones
and vertebrae, which grow circumferentially.
•• Apophyses are growth plates at the surface of bones such as the iliac crest.
——Most apophyses serve as sites of muscle-tendon attachments, such as the tibial
tubercle or ischial tuberosity, and thus are subject to traction forces.
——Apophyses contribute to adult bone shape and may look like a bony outgrowth
or bump.
•• Ossification begins first in the scapula, humerus, radius, and ulna, and then
additional ossification centers develop in a predictable order.
——Humeral head appears at age 0–2 months in girls, 0–3 months in boys.
10 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

——Capitellum appears at age 1–6 months in girls, 0–8 months in boys.

——Radial head appears at age 3–5 years in girls, 4–5 years in boys.
——Femoral head appears at age 1–6 months in girls, 2–8 months in boys.
——Patella appears at age 1.5–3.5 years in girls, 2.5–6 years in boys.
——Navicular appears at age 1.5–3 years in girls, 1.5–5.5 years in boys.
•• On average, ossification centers develop earlier in girls than in boys.
•• Long and short tubular bones are mature when the diaphyses and the epiphyses
fuse.
•• Round or irregularly shaped bones are mature when they achieve final adult
shape.
•• During the fetal period, the metaphyses are composed of woven bone that has
scattered collagen fibers, giving it the flexibility needed for birth. By 4 years of
age, most woven bone has been converted to lamellar bone, which has collagen
fibers arranged in parallel to form tight sheets, making it much stronger than
woven bone.
•• Cortical bone thickness increases throughout childhood, resulting in increased
diaphyseal thickness with age. Conversion to lamellar bone gives mature bone
greater tensile strength but much less flexibility.
•• The peak velocity of bone mineral accumulation lags behind PHV by an average
of 1 year.
•• Greater than 90% of peak skeletal bone mass is present by age 18 years.
•• The rate of bone growth is precisely regulated, and each growth center
contributes a specific percentage of final bone length (eg, 80% of the length
of the humerus comes from its proximal physis and only 20% from its distal
physis).
•• The trunk grows most rapidly during childhood.
•• Growth occurs earlier in the upper limbs than in the lower limbs, which grow the
fastest during adolescence.
•• The foot grows earlier than the rest of the lower limb and achieves its adult length
earlier than the rest of the body; half of the adult foot length is achieved between
12 and 18 months of age.
•• A child’s level of habitual physical activity does not affect the rate of skeletal
maturation and has no effect on final adult body stature.

GROWING PAINS
•• Growing pains are defined as limb pains that cannot be traced to trauma or
disorders of bone, muscle, or joints, and are common in the pediatric age group,
with a prevalence of 4% to 36%.
•• They most commonly occur from 3 to 5 years of age and from 8 to 12 years of
age and occur more often in girls than boys.
•• Pain is usually in the lower extremities and occurs at rest or during the night and
not with physical activity.
•• Affected children have typical physical examination findings and no evidence of
other systemic disease.
•• The etiology is unknown; growing pains are benign and self-limited, with no effect
on growth velocity.
 Chapter 1: Typical Growth and Motor Development 11

ASSESSING SKELETAL MATURITY

•• Level of ossification, or skeletal maturation, is the best indicator of biological
maturity.
•• Progression from a cartilaginous skeleton to a fully ossified adult skeleton is
radiographically visible.
•• Assessment of skeletal age (SA), or bone age, is based on bone development.
•• A single radiograph of the left hand is most commonly used to assess skeletal
maturity.
——The bones are compared with those in a standard radiographic atlas, either
Greulich-Pyle or Tanner-Whitehouse, using a defined set of criteria.
——The SAs derived from the different atlases are not equivalent and cannot be
used interchangeably.
——An important limitation of these atlases is that they are based on data from
Scandinavian children and may not exactly apply to other populations.
•• SA may be compared to CA, expressed as a difference between SA and CA or as
a ratio of SA to CA.
——For example, a child with an SA of 11.8 years and a CA of 10.1 years is said
to have advanced skeletal maturity for CA. SA minus CA yields a difference
of +1.7 years, and SA divided by CA yields 1.2. A ratio above 1.0 indicates
advanced skeletal maturity; conversely, a ratio below 1.0 indicates delayed
skeletal maturity.
•• Children may be classified as having an SA that is advanced, average, or delayed.
——Children whose SA is within 1 year of CA are classified as average maturers.
——Children whose SA is 1 year or more behind CA are classified as delayed or
late maturers.
——Children whose SA is 1 year or more ahead of CA are classified as advanced or
early maturers. Early maturers tend to be heavier and taller compared with late
maturers at all ages, but final adult height typically is similar.
•• SA is better correlated with stage of pubertal development than with CA and can
be useful in predicting adult height in early or late maturers.
•• Height, weight, and stages of pubertal development have become the main clinical
tools for monitoring adolescent development because of the cost, inconvenience,
and radiation exposure associated with using radiography to assess SA.

CHANGES IN BODY COMPOSITION

•• Body composition is most often described as a two-compartment model, a
combination of lean or fat-free mass (FFM) and FM.
•• The primary components of FFM are bone, skeletal muscle, and nonskeletal
muscle soft tissue; the primary component of FM is adipose or fat tissue.
•• Subcutaneous “baby fat” develops during the first year after birth and gradually is
burned up by increased mobility in early childhood.
•• FM and FFM gradually increase as body size increases between 2 and 6 years
of age, but on average FM decreases more in boys than in girls due to increased
energy expenditure and decreased caloric intake in boys.
•• Body physique remains relatively stable from 6 to 12 years of age, and FFM on
average is 80% in a prepubertal child.
12 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

•• BMI is weight divided by height squared (kg/m2) and is related to FFM in

children and adolescents.
——BMI increases in infancy, decreases through early childhood to a low point
around 5 or 6 years of age, then rises again through the rest of childhood and
adolescence.
——Children with the same BMI can have significantly different percentages of
fat and FFM, and therefore elevated BMI is not uniformly a good indicator of
body fat percentage in childhood and adolescence.
•• FFM undergoes a well-defined spurt during adolescence (Figure 1-3).
•• Throughout adolescence, lean or fat-free body mass increases from 80% to
90% in boys but decreases from 80% to 75% in girls as they accumulate more
subcutaneous fat.
•• During the interval of PHV, boys gain approximately twice as much FFM as girls
(14 kg vs 7 kg), while girls gain twice as much FM as boys (3 kg vs 1.5 kg).
•• Women have almost twice the percentage of body fat as men.
•• Girls continue to gain FM but not FFM into late adolescence (16–20 years of age).
——Girls enter puberty with 15.7% average body fat, and as adults average 26.7%.
——Boys enter puberty with 4.3% average body fat, and as adults average 11.2%.
•• Adult men have 150% of the FFM of an average adult woman.
•• Young women have more subcutaneous fat deposits in the pelvis, breast, upper
back, and arms compared with young men.
•• The effect of heredity on body mass and composition is about 40%.
•• Children who have higher body fat percentage after 6 years of age are at increased
risk of retaining fat through childhood and into adulthood.

Figure 1-3. Growth curves for fat-free mass, fat mass,

Changes in Body Composition from
Late Childhood to Young Adulthood and percent fat.
kg From Malina RM, Bouchard C, Beunen G. Human growth: se-
65 Fat-free mass
lected aspects of current research on well-nourished children.
60
55 Ann Rev Anthropol. 1988;17:187–219. Reprinted by permis-
50 sion of Annual Reviews, Inc.
45
40
35
30 Boys
25 Girls
20
15 Fat mass
10
5
0
%
30 Percent fat
25
20
15
10
8 9 10 11 12 13 14 15 16 17 18 19 20
Age, years
 Chapter 1: Typical Growth and Motor Development 13

CHANGES IN MUSCLE MASS AND STRENGTH

•• The percentage of muscle, or muscle mass, increases with age.
•• During middle childhood, muscle strength, coordination, and endurance increase
through maturation and training.
•• Small sex differences in muscle strength begin to appear in middle to late childhood.
•• The greatest gains in muscular mass and strength occur during adolescence in
both boys and girls, with boys showing overall greater gains in both.
•• The muscular strength gains in early adulthood occur at a much slower rate than
in puberty.
•• In boys, muscle strength increases linearly with age from early childhood through
age 13 or 14 years and then experiences a marked acceleration through late
adolescence into early or mid-20s.
•• In girls, muscle strength also increases linearly through age 15 years but without
an adolescent spurt.
•• For boys, this increase in muscle is a dominant change during puberty. The
increase in strength is more than that predicted from growth in stature.
•• On average, the peak gains in muscular strength and power occur after PHV and
around PWV. The peak increase in muscle strength lags behind the increase in
mass, occurring in the final stage of pubertal development.
•• Increase in muscle mass peaks around 3 months after height spurt in boys and
girls, and the increase in mass is double that in boys compared with girls.
•• The sex difference in strength is more marked in the upper extremity and trunk
than in the lower extremity.
•• Boys who are early maturers tend to be taller and have greater muscle mass and
greater strength than boys who are late maturers.
•• Girls who mature early tend to only have a minimal increase in strength.

FLEXIBILITY AND JOINT MOBILITY

•• Joint hypermobility, or ligamentous laxity, is defined as the ability to extend a joint
beyond its normal range of motion.
•• The most commonly used method to screen for generalized joint hypermobility is
the Beighton score (see Chapter 4, Physical Examination, Figure 4-2).
•• During ages 6 to 12 years, muscle flexibility and joint mobility may be increased.
The prevalence of joint hypermobility is highest in school-aged children,
approximately 5% to 7%.
•• During puberty there is increased tightness of the hamstrings and calf muscles,
which is greatest during the height spurt for boys and girls.
•• In general, girls show greater muscle flexibility and joint mobility at all ages
compared with boys.

EXERCISE CAPACITY
•• In middle childhood, aerobic and anaerobic exercise capacity increase slowly and
are limited compared with adolescence.
•• When maximum aerobic capacity is expressed relative to body weight, mean
values remain constant for boys but decrease with age for girls from 6 to 16 years
of age because of greater accumulation of fat.
14 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

•• Increases in maximum aerobic capacity are strongly related to physical maturity,

specifically heart, lung, and muscular growth.
•• For boys, there is evidence of an adolescent growth spurt in maximum aerobic
capacity, with maximum gain around PHV. There is no evidence for this in girls.
•• Anaerobic capacity increases more gradually than aerobic capacity, and aerobic
capacity continues to increase into early adulthood but at a slower rate than in puberty.

Typical Motor Development

•• Average age for acquisition of motor skills in the first years after birth is shown in
Table 1-4.

Table 1-4. Acquisition of Motor Skills in First 5 Years After Birth

Milestone Average Age of Attainment (mo)
Gross Motor
Head steady in sitting 2
Pull to sit, no head lag 4
Hands together in midline 4
Rolls back to stomach 7
Sits without support 10
Crawls 10
Walks alone 15
Crawls up stairs 15
Sits on small chair 18
Runs well 24
Goes up stairs alternating feet 30
Rides tricycle 36
Climbs well 48

Skips 60
Fine Motor
Reaches for and grasps objects 4
Transfers object hand to hand 7
Grasps object with thumb and forefinger 10
Turns pages of book 12
Builds tower of 3 cubes 15
Imitates vertical stroke 18
Circular scribbling 24
Makes vertical and horizontal strokes 30
Copies a circle 36
Copies a square 48
Copies a triangle 60
 Chapter 1: Typical Growth and Motor Development 15

•• Many variables regulate fundamental and complex motor skill development,

including somatic growth and maturation, heredity or inherent skill, and
environmental factors such as socioeconomic status, quality of instruction, child
and parent interest, and opportunities to engage in physical activity.
•• Children achieve or improve their motor skills with age in a similar sequence but
at different rates, resulting in wide variability in motor skills at specific ages.
•• Fundamental motor skills are common motor activities with specific, observable
patterns that are prerequisites for acquiring more complicated skills necessary for
sports, games, and other physical activities.
•• These fundamental motor skills can be divided into 3 basic categories:
——Locomotive skills (walking, running, jumping, hopping)
——Manipulative skills (kicking, throwing, catching, striking, bouncing, pulling,
pushing)
——Non-manipulative skills (turning, balancing, leaping, sliding)
•• Beyond the basic skills of walking and running, children exhibit a wide range of
ability with more advanced activities such as throwing, catching, and kicking.
•• Adeptness in motor skills is incremental and related to body size, maturity, agility,
and balance.
•• The prepubertal period from infancy through 9 years of age is critically important
for the acquisition and development of motor skills in a growing child.
•• Handedness is usually established firmly by age 3 or 4 years.
•• Early handedness can be a sign of a neuromuscular disorder.
•• By 5 to 7 years of age, most children demonstrate mature fundamental movement
patterns, which are coordinated and mechanically efficient.
•• Children younger than 7 to 8 years cannot perform complex tasks requiring much
coordination, but by 11 to 12 years of age, children can perform high-level motor
skills, including faster and more precise performance of complicated tasks and
foot skills.
•• Puberty is the final critical period for motor skill development.

GAIT
•• Early gait typically begins to develop between 8 and 16 months and is
characterized by a fast cadence with short steps and a wide-based gait, with the
knees and arms flexed and the trunk rotating with each stride.
•• After several months of walking, toddlers walk more slowly with a longer
stride, a more stable torso, extended knees, and arms swinging at the side for
balance.
•• By 3 or 4 years of age, most children walk with adult gait patterns, although
continued changes in gait velocity, stride length, and cadence occur into
adulthood.

Sex Differences in Motor Development

•• Girls generally perform better than boys in fine motor tasks, while boys perform
better than girls in gross motor tasks. These differences in motor ability increase
with age and are primarily explained by specific gender-oriented types of sports
and activities, encouragement, opportunity, and expectations.
16 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

Table 1-5. Average Age at Which Highest Developmental Level of

Fundamental Motor Skills Is Achieved in Boys and Girls

Motor Skill Boys (y) Motor skill Girls (y)

Running 4 Running 5
Throwing 5 Skipping 6
Skipping 6.5 Catching 6.5
Catching 7 Hopping 7
Kicking 7 Kicking 8
Striking 7 Striking 8.5
Hopping 7.5 Throwing 8.5
Jumping 9.5 Jumping 10

Data are derived from Seefeldt V, Haubenstricker J. Patterns, phases, and stages: an analytical model for the
study of developmental movement. In: Kelso JAS, Clark JE, eds. The Development of Movement Control and
Coordination. New York, NY: John Wiley & Sons; 1982.

•• Certain fundamental motor skills (skip, catch, hop) initially appear in girls ahead
of boys, but the most mature developmental stages of other skills (run, throw,
kick, strike, jump) are attained sooner in boys than in girls (Table 1-5).
•• Motor performance levels in girls are relatively stable across time, but boys may
experience a temporary disruption of motor coordination during their growth
spurt, termed adolescent awkwardness.
•• Sex differences in motor performance are relatively low or moderate before
puberty but quite large after puberty.
•• While environmental influences primarily account for the sex differences in motor
performance prior to puberty, both environmental and biological factors account
for the rapid and large increases after puberty.

Sports Readiness
•• Children acquire motor skills in similar sequence but at different rates, so sport
readiness must be assessed individually.
•• Many children younger than 7 years cannot perform the complex motor tasks
necessary for competitive sports.

Resources for Physicians

•• WHO Growth Charts (https://www.cdc.gov/growthcharts/who_charts.htm)
•• CDC Growth Charts (https://www.cdc.gov/growthcharts/cdc_charts.htm)
 CHAPTER 2

Atypical Musculoskeletal
Growth and Motor
Development
Atypical Musculoskeletal Growth
•• Constitutional growth delay: Weight and height decrease toward the end of infancy,
remain below family pattern but with stable growth velocity during middle
childhood, and then increase toward the end of adolescence, resulting in normal
adult stature. Bone ages are typically delayed, and there is often a family history of
delayed growth (“late bloomer”).
•• Familial short stature: The child and parents are small, and the child’s growth
remains below but parallels the normal curves.
——There is a risk of overdiagnosing or underdiagnosing atypical growth findings in
children with extremely tall or short parents if parental height is not taken into
account. Midparental height can be used to estimate genetic potential for height.
•• When examining growth, most children and adolescents track between one or
2 growth percentiles. Deviation from this warrants additional consideration and
possible evaluation.
•• Appropriate nutrition is the critical environmental factor that supports normal
biological maturation; adequate food intake supports normal weight gain and
linear growth.

NUTRITIONAL CAUSES
•• Failure to thrive: Exact definition varies, but generally considered to be weight
less than the fifth percentile or weight percentile that declines more than 2 major
percentile lines (eg, declines from the 80th percentile to the 40th percentile).
•• Undernutrition: Weight for age typically declines (wasting) before height for age
(stunting) and weight for height (or body mass index).
——Undernutrition is often associated with delay in skeletal maturity relative to
chronological age and delay in attainment of peak height velocity and pubertal
development.
•• Obesity and overweight are often associated with advanced maturation, including
growth and pubertal development, although in adolescent males they can be
associated with delayed pubertal development.

17
18 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

NON-NUTRITIONAL CAUSES
•• Non-nutritional causes of atypical growth include genetic causes, endocrine con-
ditions, infection, trauma, and tumors.
•• Growth plate injuries and metabolic disorders (eg, rickets) can inhibit growth.
•• Inflammatory disorders or trauma may damage the growth plate or articular
cartilage and result in malunion, shortening, or angular deformity.
•• Pituitary tumors, chronic osteomyelitis, foreign body reaction, and some fractures
may accelerate growth.
•• Non-nutritional causes affect weight and length in different ways than nutritional
causes.
——Genetic causes (eg, skeletal dysplasias) tend to affect weight and length
symmetrically.
——Endocrine causes (eg, hypothyroidism, Cushing syndrome, growth hormone
deficiency) tend to affect length more than weight.

CONGENITAL GROWTH DEFECTS

•• Musculoskeletal problems account for about one-third of congenital defects, with
hip dysplasia and clubfoot accounting for half of the primary musculoskeletal
defects.
•• Three percent of newborns have major defects, that is, those that are life-threaten-
ing, require major surgery, or cause significant disability.
•• Infants with multiple minor defects (eg, syndactyly of toes 2 and 3, single transverse
palmar crease) should be thoroughly evaluated to exclude a major malformation.
•• Atypical morphogenesis can be classified into 4 categories of defects:
malformations, disruptions, deformations, and dysplasias.
——Malformations, such as limb hypoplasia, arise during organogenesis and are of
teratogenic or genetic origin.
——Disruptions, such as amniotic band sequence, occur later in gestation when
teratogenic, traumatic, or other factors interfere with normal fetal growth.
These are less likely to be inherited.
——Deformations, such as calcaneovalgus foot deformity, occur at the end of
gestation and are caused by intrauterine crowding or position.
——Dysplasias, such as achondroplasia, result from altered growth that occurs
before and after birth.
•• Developmental variations, which may resolve with time and seldom require
any treatment, should be differentiated from deformities. Examples discussed
elsewhere in this book include flatfoot (Chapter 52), in-toeing (Chapter 24),
out-toeing (Chapter 25), and genu valgum (knock knee) or genu varum (bowleg)
(Chapter 26, Angular Deformities).
——Temporary joint and muscle contractures can be caused by in utero
positioning. Full-term newborns have 20- to 30-degree flexion contractures at
the hip and knee that usually resolve by 6 months of age, and external rotation
contractures of the hip that resolve at walking age.
——Indications for orthopaedic referral for developmental variations typically
include persistence of condition beyond the expected age of correction. For
in-toeing and out-toeing as well as genu valgum and varum, variations typically
resolve around 7 to 8 years of age.
 Chapter 2: Atypical Musculoskeletal Growth and Motor Development 19

Atypical Motor Development

•• Difficulties with visuospatial information that guides gross motor actions can lead
to ineptitude at skills such as catching and throwing.
•• Some children have difficulty planning complex motor procedures needed for
tasks such as dancing, and others lack adequate proprioception and are impaired
with activities requiring balance and control of body movement.
•• Difficulties with fine motor skills, caused by impaired hand-eye coordination, can
lead to problems with rapid and precise hand movements and impair tasks such as
drawing, writing, or playing an instrument.
•• Limited competence in fundamental motor skills at an early age can negatively
affect future performance in physical and motor activities.
•• Developmental deviation is when children develop skills out of the usual sequence.
•• Developmental dissociation occurs when developmental spheres are achieved at
different rates.
——Children with cerebral palsy show motor delay but normal language
development.
——Children with autism show language delay but often achieve motor milestones
at a normal rate.
——Toe walking is often seen in children with autism, cerebral palsy, muscular
dystrophy, or other developmental delay.
•• Milestone regression, or loss of developmental skills, is a serious developmental
problem suggesting an active, ongoing neurologic or muscular condition.

EARLY DETECTION AND INTERVENTION

•• The goal of developmental surveillance and screening is to identify children
with developmental problems early to ensure they receive the benefits of early
intervention (EI).
•• Early detection of motor problems and EI can eliminate or minimize many
physical and related emotional problems.
——Interventions for motor disorders have been shown to be effective at 18 months
of age.
——There is strong evidence that EI can result in significant improvements in
cognitive and emotional development.
——Later interventions in children with more established disabilities show more
modest gains.
Developmental Surveillance
•• Developmental surveillance is the process of identifying children who may be at
risk of developmental delays. A good source of information on motor, sensory,
and other developmental milestones can be found at https://pathways.org.
•• Developmental surveillance should be incorporated into every well-child visit,
with additional developmental screening tests administered at the 9-, 18-, and 24-
or 30-month visits or any time concerns are raised by parents, clinicians, or others
involved in the care of the child.
•• Mild motor delays that were undetectable at 9-month screening may be more
apparent at 18 months, and by 30 months of age most motor delays may be
identified with screening instruments.
20 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

Table 2-1. Normal Ages When Primitive Reflexes Extinguish

Normal Age When ­Reflex

Reflex ­Extinguishes
Rooting 4 mo
Moro 4–6 mo
Tonic labyrinthine 4–6 mo
Galant 4–6 mo
Palmar grasp 5–6 mo
Asymmetric and symmetric tonic neck reflexes 6–7 mo
Foot placement (stepping) Before 12 mo
Babinski 12 mo

•• Parental concerns about development should be appropriately addressed, but lack

of parental concern does not necessarily indicate normal development.
•• Surveillance should continue throughout childhood, and developmental concerns
should be addressed at every pediatric health supervision visit for the first 5 years
(Table 2-1).
•• Children identified as at risk for delayed or disordered development should
receive further detailed diagnostic developmental evaluation, including a thorough
history, physical examination, vision and hearing assessment, family history,
prenatal and postnatal history, review of newborn metabolic screening and
growth charts, laboratory tests (eg, chromosome testing), and assessment of other
environmental and social risk factors.
——If a disorder is not identified, the child should be followed with more frequent
visits to re-evaluate the areas of concern.
•• An underlying etiology will be identified in approximately 25% of children
with delayed development, with higher rates (> 50%) in children with global
developmental delays and motor delays.
•• Observations made over a period are most informative, and developmental
screening tests should be used periodically.
Developmental Screening
•• Developmental screening is the administration of a brief standardized tool that aids
the identification of children at risk for a developmental disorder.
•• Pediatrician assessment of a child’s developmental status is more accurate with
the use of a standardized screening tool.
•• Many screening tools are available, but there is no universally accepted screening
tool appropriate for all populations and ages.
•• Sensitivity and specificity levels of 70% to 80% (moderate) are considered
acceptable for developmental screening tests.
•• Most tools can be completed by parents, scored by nonphysicians, and
interpreted by physicians. See Table 2-2 for a list of common developmental
screening tools.
 Chapter 2: Atypical Musculoskeletal Growth and Motor Development 21

Table 2-2. Developmental Screening Tools

Testing Age
Tool Description Range
Parents’ Evaluation of Suitable for eliciting and addressing parental 0–8 y
Developmental Status concerns. Indicates when to refer, screen further,
(PEDS) or reassure (sensitivity 0.74, specificity 0.7–0.8).
Parents’ Evaluation Useful for periodic evaluation of milestones. One 0–8 y
of Developmental question per each domain: fine motor, gross
Status: Developmental motor, social-emotional, self-help, expressive
Milestones (PEDS:DM) language, receptive language, reading, and math
(sensitivity 0.83, specificity 0.84).
Early Screening Brief parent questionnaires based on milestones 3–6 y
Inventory (ESI) to screen for children who may need special
education. Has increased sensitivity to detect
subtle delays (sensitivity 0.92, specificity 0.80).
Ages and Stages At-home screening test used between health 4–48 mo
Questionnaire (ASQ) supervision visits to assess communication,
gross motor, fine motor, problem-solving, and
personal adaptive skills (sensitivity 0.70–0.90,
specificity 0.76–0.91).
Child Development 300 items that measure social, self-help, motor, 18 mo–6 y
Inventory (CDI) language, and general developmental skills.
Suitable for more in-depth evaluation (sensitivity
0.8–1.0, specificity 0.94–0.96).
Early Motor Pattern 15 items, administered by a physician to screen 6–12 mo
Profile (EMPP) for cerebral palsy by examining movement,
tone, and reflex development for ages 6–12 mo
(sensitivity 0.87–0.92, specificity 0.98).
Motor Quotient (MQ) Assesses 11 milestones per visit and uses 8–18 mo
a simple ratio quotient with gross motor
milestones to detect delayed motor
development (sensitivity 0.87, specificity 0.89).
Test of Infant Motor 42 items with picture references that assess Preterm
Performance (TIMP) motor tone, axis symmetry, and movement. infants > 34 wk
Administered by physician or physical/ post-conceptional
occupational therapist (sensitivity 0.92, age to 4 mo
specificity 0.76). adjusted age

Bibliography—Part 1
Abbassi V. Growth and normal puberty. Pediatrics. 1998;102(2 Pt 3):507–511
American Academy of Pediatrics Council on Children with Disabilities, AAP Section on
Developmental Behavioral Pediatrics, AAP Bright Futures Steering Committee, AAP Medical
Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying
infants and young children with developmental disorders in the medical home: an algorithm
22 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

for developmental surveillance and screening. Pediatrics. 2006;118(1):405–420. Reaffirmed

August 2014
Gerber RJ, Wilks T, Erdie-Lalena C. Developmental milestones: motor development. Pediatr Rev.
2010;31(7):267–276
Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC).
Use of World Health Organization and CDC growth charts for children aged 0-59 months in the
United States. MMWR Recomm Rep. 2010;59(RR-9):1–15
Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of
Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020
Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length
discrepancy. J Bone Joint Surg Am. 2000;82(10):1432–1446
Wrotniak BH, Epstein LH, Dorn JM, Jones KE, Kondilis VA. The relationship between motor
proficiency and physical activity in children. Pediatrics. 2006;118(6):e1758–e1765
Part 2: Musculoskeletal
Evaluation
TOPICS COVERED
3. History..................................................................................... 25
Mechanism of Injury
Pain
Deformity
Change in Function
Previous Management
Sports and Physical Activity History
Past Medical and Surgical History
Pregnancy and Birth History
Medications and Allergies
Diet
Growth and Developmental History
Social History
Family History
Review of Symptoms
4. Physical Examination................................................................. 33
General Principles of the Physical Examination
Inspection
Range of Motion
Muscle Tone
Muscle Strength
Muscle Flexibility
Reflexes
Sensation
Joint Stability
Palpation
Joint-Specific Evaluations
Lower Extremity Rotation and Alignment
Gait Evaluation
5. Musculoskeletal Imaging Studies.................................................. 63
Effective Radiation Doses
Radiography

23
 Computed Tomography
Magnetic Resonance Imaging
Ultrasonography
Nuclear Medicine
Dual Energy X-ray Absorptiometry
6. Laboratory Studies..................................................................... 75
 CHAPTER 3

History
•• Musculoskeletal issues may result from a wide range of possible etiologies
(Table 3-1).
•• History is an important aspect of the musculoskeletal evaluation and may alone
yield the diagnosis in 75% of cases.
•• The most common musculoskeletal issues are injury, pain, deformity, and change
in function.

Mechanism of Injury
•• Ask the child and family to provide a detailed account of how the injury occurred.
•• The mechanism of injury is very important—it may identify injured structures
and injury types.
——An inversion injury to the ankle commonly results in sprain of the lateral
­ligaments.
——A fall on an outstretched arm commonly results in a humerus or radius
­fracture.

Table 3-1. Categories of Etiologies of Musculoskeletal Issues

Etiology Examples
Trauma
Acute Fracture, tendon rupture
Chronic Stress fracture, tendinopathy
Inflammation Juvenile idiopathic arthritis

Infection Osteomyelitis

Neoplasm
Malignant Osteosarcoma, leukemia
Benign Unicameral bone cyst, exostosis
Congenital abnormality Clubfoot, amniotic band syndrome

Neurodevelopmental disorder Cerebral palsy, hereditary motor and sensory neuropathy

Endocrine disorder X-linked hypophosphatemic rickets

Hematologic disorder Osteonecrosis

Genetic disorder Osteogenesis imperfecta, trisomy 21

25
26 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

•• If the trauma was not witnessed, knowing what type of activity the child was par-
ticipating in at the time of the suspected injury may suggest a mechanism.
•• Trauma is common in active children, but it may not always be the cause of the
symptoms.
•• When the mechanism does not match the symptoms, or when the timing of the
trauma does not coincide closely with the onset of symptoms, consider a coinci-
dental condition such as neoplasm or infection, or nonaccidental trauma.

Pain
•• Pain expression depends on the patient’s age.
——Neonates and infants usually refuse to move the painful area (pseudoparalysis)
and cry or are fussy.
——Children will avoid using the painful part, alter its function, or report pain.
They may be able to localize pain but are rarely able to characterize it.
——Adolescents will report pain and can localize and characterize it.
•• Pain location can be determined by asking the patient to point with one finger
“where you feel the pain,” or by asking the patient to indicate where they hurt on
a corresponding drawing of a human figure (Figure 3-1). Keep in mind that pain
may occur along dermatomal distributions or be referred from another site in
addition to occurring at areas of peripheral nerve innervation.

Figure 3-1. Human

­figure marked by
patient to indicate
location of pain.
 Chapter 3: History 27

•• Severity can be rated by using a numeric scale (1 to 10) or by using a pain face
scale such as the Wong-Baker FACES® Pain Rating Scale (Figure 3-2).
•• Quality (eg, sharp, dull, aching, throbbing, burning), onset, frequency, and dura-
tion can be assessed using open-ended questions and may reveal patterns sugges-
tive of potential pathologies.
•• Timing of pain and factors that aggravate or relieve the pain may assist in diagno-
sis and guide treatment.
——Mechanical causes worsen with activity.
——Inflammatory causes worsen after rest.
——Progression over time can indicate whether the condition is static, episodic,
improving, or worsening.
——Malignancies and infections frequently cause pain at rest, awaken children
from sleep, or both.
——Night pain relieved by nonsteroidal anti-inflammatory medication is classic for
osteoid osteoma.
•• Presence of associated symptoms may suggest involvement of specific systems
(Box 3-1).
•• Chronic pain is less common in children than in adults, but it still is a difficult
problem to diagnose and treat.

Figure 3-2. Wong-Baker FACES® Pain Rating Scale.

© 1983 Wong-Baker FACES Foundation. www.WongBakerFACES.org. Used with permission. Originally
published in Whaley & Wong’s Nursing Care of Infants and Children. © Elsevier Inc.

Box 3-1. Symptoms Suggestive of Specific System Involvement

Neurologic: Numbness, tingling, and weakness

Musculoskeletal: Mechanical symptoms of clicking, locking, or instability
Infectious or inflammatory: Redness, warmth, swelling, and stiffness
Vascular: Changes in skin color and temperature
Systemic etiology: Fever, fatigue, or involvement of other joints
28 Pediatric Orthopaedics and Sports Injuries: A Quick Reference Guide

Deformity
•• Variants of normal musculoskeletal development, such as knock-knee, flatfoot,
and in-toeing, are common and inconsequential. These should be differentiated
from significant congenital, developmental, and neuromuscular abnormalities
(eg, congenital vertical talus, Blount disease, cerebral palsy).
•• Determine the onset, progression over time, and any limitations.
——Normal variants have a predictable progression and usually resolve spontane-
ously.
——Pain or limitation in the child’s functional abilities or motor development is
concerning.

Change in Function
•• May be caused by pain, injury, deformity, or weakness and warrants further
­evaluation

Previous Management
•• Ask about the effects (beneficial and adverse) of prior treatments (eg, physical
therapy, braces, orthoses, anti-inflammatory medications).
——This may narrow the differential diagnosis and suggest treatments to continue,
discontinue, or modify.
•• Inquire about treatment duration and adherence as reasons for lack of effect.
Asking patients to demonstrate physical therapy exercises can help the clinician
understand adherence to and adequacy of a prescribed physical therapy regimen.

Sports and Physical Activity History

•• Questions to ask when taking the sports and physical activity history are listed in
Box 3-2.
•• Severity of symptoms may be estimated by the degree to which they limit the
child’s usual activities.
•• Overuse, overtraining, and burnout are underappreciated phenomena in children.
•• Sport-specific physical therapy and knowledge of important upcoming events help
with return-to-play.

Box 3-2. Sports and Physical Activity History Questions

What physical activities (eg, sports, dance, music, drama) does the child enjoy?
Are the symptoms limiting participation in these activities?
What is the child’s position/role, level of competition, and hand/leg dominance?
How many hours per week are spent in practice and competition, and how many days’ rest
does the child have per week and per year?
What is the timeline for upcoming games, competitions, or tryouts?
Another random document with
no related content on Scribd:
absolutely refused to lend the book to Betty, who had taken
it without leave.

"Yes, I know all about that!" said my aunt.

"Betty told me herself, poor wretch, that you told her

you would not lend it to her; but can you deny that you
went away and left the book in her hands? Can you deny
that you were angry with her, and reproached her for telling
me of your private curtsying about London, and London fine
gallants, and other things that young maids should not
know, much less tell on? You are an adder and a viper—that
you are! And come of viper's brood—nasty, frog-eating
French!"

My mother rose. "With your leave, sister Corbet, we will

withdraw," said she, assuming the chatelaine, as she well
knew how. "I shall not justify my child till I hear from her all
the circumstances of this unlucky affair. Nephew Andrew, I
will thank you to order the pony."

"The pony—and for what?" asked my aunt, cooling

down, as she always did when my mother took this tone.

"That I may withdraw to my own house, since I am so

happy as to have one," replied my mother. "When this
matter is cleared up, sister Corbet, you shall have all proper
explanations and apologies. In the meantime, 'tis neither
for your dignity or mine that I should remain longer under a
roof where such language has been applied to me and
mine. I thank you from my heart for your hospitality, but I
can partake of it—no, not an hour longer."

My aunt, upon this, began to cry, and to retract what

she had said.
 "I did not mean you, sister d'Antin—and perhaps it was
not so bad; but you see she does not deny that she had the
book, and that Betty got it from her—and I know I am hasty
when I am roused; and the French do eat frogs, for you told
me yourself; and you said they were good—you know you
did, sister d'Antin. And Betty is artful, I confess; but that
does not make it right for Vevette to lend her bad books,
nor for Andrew to look at me so, as if—and I am sure I am
his own natural mother and not a stranger, and 'tis
unknown the trouble I had in rearing him, because he was a
May babe, and my mother said he would never be lucky."

"Mother and my aunt," said Andrew, in his grave,

commanding tones, "will you be so good as to let this
matter rest for to-night? It hath been made far too public
already. Aunt, if I have ever done you any service, I
beseech you to remain under my roof till to-morrow." (I
never heard Andrew say my roof before.)

"Yes, do," said my aunt, who had cooled rapidly, as

usual. "Indeed I regret that I was so hasty; and I will take
back all I said about vipers and adders."

My mother suffered herself to be prevailed upon so far

as to say she would remain till the time originally set, for
her departure. Then she withdrew to her room, and I
followed, like one going to execution. Once there she
addressed me in a tone which I had never heard from her
but once before, requiring me to give her a full account of
this transaction. I fell down on my knees before her, and
told her the whole story from beginning to end.

"How shall I believe you? You have already deceived

me," said she sadly.
 "Indeed, maman, I have now told you the truth," said I,
weeping. "I only read the first poem in the book, and then I
would go no farther. And I did not lend it to Betty. She took
it from the room when you called me to look at the china,
and I never could get it again, though I asked her for it ever
so many times. Oh, maman, do believe me!"

"Vevette," said she, laying her hand on my shoulder,

and looking me through and through as I knelt before her,
"as you hope ever to meet your father again, tell me the
truth. Have you any more of these books?"

"No, maman, not one."

"Have you ever had any of them since I forbade you

reading them?"

"Yes, maman, I had two or three that my Uncle Charles

sent to the tower, but the day before we went to the Supper
in the old grange I burned them, every one."

"And you have not read the rest of this book?"

"No, maman, only the first poem, in which there was no

harm. Betty wanted to read on, but I would not. Oh,
maman, do forgive me!"

"I forgive you, my child, but you have grieved me to the

heart," said my mother. "Go to your room, and pray for
forgiveness and cleansing. Do not leave it this night. By and
by, when I am rested, we will talk farther."

I retired to my own room, feeling as miserable as any

girl of my age ever felt in the world, mid that is saying
much, for the capacities of such girls for misery are very
great. It seemed to me as though I could never be happy
again. In all my little difficulties with my aunt and Betty
heretofore, Andrew had always been on my side; but now,
he too had turned against me. How plainly I could see the
look he gave me when he handed me that detestable book
—a look full of anger and grief. I knew that he hated lying
above all things. It was the only sin with which he seemed
to have no patience.

I had not told a lie in words, to be sure, but I had been

guilty of deception, and that was enough for him. Now that
I had lost him, or thought I had, I felt how dear he was to
me. I had lost his respect, and I felt sure that all comfort
was at an end between us, even though he should feel
bound to fulfil his contract. One thing I made up my mind to
—I would never be his wife if he showed the least
unwillingness to marry me. And then I remembered how
pleased he had been when I spoke of our living together on
a desert island, and for the first time I burst into tears.

I wept for a long time, thus lightening my heart a little,

and then taking up my Bible I tried to read myself into
some sort of quietness. I had just begun to breathe without
sobbing when smile one knocked at the door. I opened it,
with my heart throbbing at the thought that it might be
Andrew, and there stood Betty, her eyes cast down with
that affectation of meekness I knew so well, and carrying in
her hands a tray laden with good things.

"I have brought you some supper," said she, in her

silver tones. "I thought perhaps you would not care to come
down."

"Oh, you did! You are very considerate," I said bitterly.

"You did not come at all to triumph in the mischief you have
made by your lies."
 "Why, Vevette," said she, in a tone of astonishment;
"what do you mean? I am sure I did not mean to do you
any harm, but only to relieve my own mind. I can't endure
to have secrets from my mother."

All at once Rosamond's ghost story darted into my

mind. When the devil puts such a weapon into the hand of a
person in a passion, that person is very apt to use it without
thought of consequences.

"Oh, you cannot! Then perhaps you have told your

mother of the pair of ghosts Rosamond saw disappear near
Torden's cottage, one of which had on a gray homespun
gown, and the other looked so much like young Mr. Lovel. I
think I will tell Mr. Dawson about these ghosts, that he may
keep a lookout for them, since he is so skilful in dealing with
that sort of gentry."

Betty turned white, or rather gray, for a moment, and

nearly let her tray fall. Then she recovered herself and said
quietly—

"I don't think I would tell any more tales if I were you.
You would not be likely to gain much credit just now. I came
to make friends with you."

"That is false!" I interrupted her. "You came to triumph

over me."

"I came to make friends with you," she continued

calmly; "but if you choose to treat me as an enemy, you can
do so. I pity you, Vevette, and I do not blame you as much
as I do those who have brought you up in such ways. Your
conduct just shows what that religion is worth of which we
have heard so much."
 In a quarrel, the person who has no conscience always
has an advantage over the person who has one. Betty had
certainly got the best of it in this case, notwithstanding the
stab I had given her. I shut the door in her face, and again
sat down to try to compose my thoughts, but I did not find
it so easy. Revenge is like the little book of the prophet, in
that though it may be sweet in the mouth it is very bitter of
digestion. I had struck a telling blow, it was true, but I had
gotten it back with interest, and the worst of it was that in
this instance Betty had some truth on her side. I was a
discredit to the parents who had brought me up, and the
religion in which I had been educated. I had brought shame
on my dear mother as well as myself.

Betty had indeed done me a cruel mischief, and that not

only in the trap she had so artfully laid for me, and into
which I had so foolishly walked, like a silly hare into a
springe, but in coming to enjoy her triumph as she had just
done; for that such was her motive I did not doubt then,
nor do I now. She had drawn toward her that anger which I
had hitherto directed toward myself, and roused in me a
spirit of anger and revenge. I felt as if I could have killed
her. In this state of mind, my mother found me when she
came in to talk to me later in the evening, nor did all her
expostulations avail to draw me out of it. I was ready to beg
her pardon in the very dust, and to make my submission to
my aunt, but I could not and would not forgive Betty; nay, I
would not even say I would try.

"Then you must yourself remain unforgiven, my poor

child," said my mother; "under the anger of that Heavenly
Father whom you have offended. Can you afford that? Will
you still further grieve that kind and tender Divine Friend
whom you have so deeply grieved already?"
 If I had spoken out the thought that was in my heart, I
should have said that I did not believe that Friend loved me
so very much, or he would not have suffered this trouble to
come upon me just when I was trying to be so very good;
but this I did not dare to say.

"I cannot help it, maman," I answered her at last. "I

never, never can forgive Betty for the part she has acted.
She has been ten times worse than I, and nobody seems to
blame her at all. You don't mind her coming here to triumph
over me—bringing me a tray forsooth as if I did not know
that she will never wait upon any one if she can help it. You
don't mind how much I am insulted!"

It showed how I was carried out of myself that I dared

speak so to my mother. I was scared when the words were
out of my mouth. But my mother was one who knew when
to reprove and punish and when to soothe and comfort. She
saw that I was almost beside myself with anger and
excitement—a mood, I must say, which was rare in me.

"We will talk no more to-night," said she. "You had

better try to calm yourself, and to sleep. My poor little maid,
I thought I was bringing you to a safe nest when I refused
to leave you in London. But there are temptations
everywhere, since there is no earthly state from which the
world, the flesh, and the devil can be kept out. Go to bed,
my Vevette, and remember, though thou canst not or wilt
not pray for thyself, thy mother is praying for thee."

With that she kissed me and returned to her own room.

I burst into fresh tears, and cried till I could cry no more,
and then, feeling my heart a little lightened, I was
preparing to undress when some one tapped softly at the
door, and a low voice said—
 "Vevette!"

"Who is there?" I asked.

"Rosamond," was the answer. "Please let me in. I have

brought you a cup of milk and some bread."

I could not resist the pleading tones, and I opened the

door. Rosamond had been crying as bitterly as myself, and
as she came into the room she set down her burden and
clasping me in her arms site kissed me and cried again. My
tears flowed too, but they were cool tears now, and
refreshed my burning eyes.

"Dear Rosamond, you won't turn against me, will you?"

said I.

"No indeed," she answered warmly, and then added, "Of

course you know I must think it was wrong for you to keep
the book, and to read ever so little, when you knew your
mother would not allow it. But every one does wrong
sometimes. If we were not sinners, the dear Lord would not
have needed to come down and die for us."

Somehow these simple words did more to calm my

heart, and to show me my sin at the same time, than
anything had done before. The dear Lord had died for me,
and this was the way I had repaid him. He was ready to
forgive me, and yet I would not forgive Betty. I began to
see things in a new light.

"I know I was very wrong," said I, "and I am sorry—

indeed I am. But, Rosamond, it was not so bad. I did not
lend Betty the book: I told her she should not have it; but
maman called me, and when I came back, she was gone. I
have tried again and again to get it out of her hands, and
then I meant to burn it up. But what is the use of talking,
since nobody will believe me?"

"I believe you," said Rosamond; "I believe every word

you say. But don't you see that even, then, if you had gone
to your mother and laid the whole before her, all this would
not have happened? She might have been displeased, 'tis
true; but she would have forgiven you and got back the
book, and all would have ended well by this time."

"It is true," I answered. "I wish I had done as you say."

"I think the very most straightforward way is always the

best way, especially when one is dealing with one like—like
Betty," continued Rosamond. "There is nothing which
deceitful people understand so little as truth. But, Vevette,
if you are sorry, it will all come right in the end. Let us kneel
down and say the fifty-first Psalm together, and I am sure
you will feel better."

We did so, and then the dear maid repeated the thirty-
second Psalm. She was like the holy well at St. Wenna's,
which ran with a clear but small stream, while now and then
came a great rush of bright water, bubbling up through the
white pebbles and showing for a moment the crystal depth
below. I had always loved her from the first of our
acquaintance, but from that hour began a friendship which
will never end.

We kissed each other on our knees and then rose.

"Do eat a morsel," said Rosamond. "You have had no

supper, and you will be ill to-morrow."

I tried, in complaisance to her, but I could not manage

it.
 "I cannot eat," said I; "but oh, Rosamond, I am so
thirsty."

"I will bring you some cool water from the well in the
court," said she, and taking a jug, she was gone before I
could object. When she came back she looked startled.

"Do you know, Vevette, I am sure I saw that same

figure that I saw before near Torden's cottage with the
woman. It was just under the archway, as plain as could be
against the sky, and it slipped away just as before. Who or
what can it be?"

"Some one hanging about after one of the maids,

perhaps," said I, though I had my own thoughts upon the
matter. "Now you must not stay any longer or my aunt will
be angry and think I am corrupting you."

"Oh, no, she won't," answered Rosamond. "I asked her

if I might come, and she said yes, and wanted me to bring
you all kinds of nice things, but I thought you would not
care for them. I think she is very sorry she made such an
ado about the matter, now that it is over. Well, good-night,
dear Vevette; I hope you will sleep."

But I could not sleep, except feverishly and by

snatches, till after the birds began to sing in the morning.
Then indeed I had a good nap, and waked refreshed. I
washed and dressed, and went softly into my mother's
room. She was already up, and kneeling before the table,
on which lay, always open, her Bible, and the little worn
prayer-book she brought from France. She beckoned me to
kneel beside her, and we said our prayers together, as
usual. Then, as we rose, she drew me to her and kissed me.

"The evil spirit has gone out—is it not so?" said she,
looking into my face with a smile.
 "Yes, maman, I hope so," I answered. "I am very sorry
about the book, and I will try to forgive Betty."

"That is spoken well, my child; and now I must tell you

that I think you have been somewhat hardly dealt by in this
matter. Looking it over coolly, I can see that I did not make
enough allowance for indecision and embarrassment on
your part, after you received the book."

"Indeed and truly, maman, I meant to show you the

book, but I quite forgot it till we came here. Then when
Betty carried it off, I did not know what to do."

"There was but one thing to do, and that was to come
and tell me all about it," said my mother. "That would have
saved all the trouble."

"So Rosamond said. Oh, maman, she was so good last

night."

"She is a dear maid," said my mother; "by far the best

of the three."

"Better than Margaret?" said I, surprised, for I had

looked upon Meg as a pattern of all excellence.

"Yes, because she is truly humble-minded—a rare and

most precious quality. She is truly poor in spirit, while Meg,
with all her good qualities—but we will not discuss the faults
of others. Now, do you know what is to be done next?"

"I must go to my aunt and tell her that I am sorry," said

I, "but, maman, what shall I say? I cannot say that I am
sorry for lending Betty the book, for I did not lend it to her
—she took it."
 "Tell her just how it was, and say you are sorry for
bringing the book here. I will go with you, if it will make
matters easier."

We found my aunt in the still-room—luckily alone—

fussing over some peppermint she was distilling.

"Do see here, Margaret," said she, as we entered.

"What ails this peppermint? See how foul it runs."

"The still is too hot, I think," said my mother, examining

it; "and your peppermint is rather old. I should begin again,
and with some smaller shoots. But, sister, Vevette hath
something to say to you."

"About what?" asked my aunt absently, still busy with

the refractory still; and then, recollecting herself, "Oh,
about the book. Well, then, child, I forgive you, only don't
do it again. I know I was warm myself, and said too much,
but that is only my way. There, run, that's a good maid, and
cut me some nice lengths of the peppermint. You have more
sense about gathering of herbs, than any of the others—
only don't draggle your petticoats. Why, what ails the
child?" catching sight of my face. "She looks as if she had
had an illness."

"She has been very much distressed about this affair,"

said my mother; "and so have I; but I think if I were to
explain the matter to you as she has done to me—"

"Oh, let bygones be bygones," interrupted my aunt. "I

hate explanations; and, as I said, I was over-warm. Do you
want to cut the herbs, child? Do just as you please."

"Yes, aunt, I shall like it," I answered, glad of an excuse

to get into the fresh air. I was at once pleased and vexed
that my aunt should make so little of the matter. I went
down to the peppermint-bed which grew under the shade of
a yew hedge, and was busy choosing out the very best
shoots when I heard voices on the other side of the hedge.
"I shall never ask her to help in the school again—never!"
said Margaret. "I could not forgive myself, if she should
corrupt the children."

"If it had been anything else," said Andrew, in a voice of

deep dejection; "anything but deception."

"To read such a wicked book, too," said Margaret.

"How do you know it was so very wicked, after all?"

asked Rosamond.

"Oh, I looked at it last night as it lay on the table," said

Margaret, quite sedately.

"If I knew it was so wicked, I would not have looked at

it at all," said Rosamond. "And you know she said she only
read the first poem, in which there was no harm."

"Yes, but who can ever believe her? I know I shall never
trust her again. When I have found any one out once, there
is the end of it with me."

"According to your own account you are just as bad as

Vevette," said Rosamond; "that is, if you don't tell lies every
day."

"Rosamond, what do you mean?" said Margaret, in a

voice of amazement that almost made me laugh aloud. "I
as bad as Vevette?"

"According to your own showing," returned Rosamond,

in the same matter-of-fact way. "Don't you say every day of
your life that you have done the things you ought not to
have done, and left undone the things you ought to have
done—that there is no health in you, and you are a
miserable sinner? I don't know what Vevette could say of
herself worse than that."

"Rosamond, you are very pert," said Meg, and I could

tell by her voice that she was offended. "Of course one says
those things because they are in the prayers of the church,
and the Bible says we are all sinners; but I should like to
know wherein I fail in my duty. Do I ever tell lies, or read
bad books, or miss my church or sacrament? Don't I—"
Here she stopped, in a little confusion as it seemed,
thinking, I fancy, that it was not quite seemly thus to blazon
her good deeds, however highly she might rate them.

"Then if you never do wrong or omit to do good, why do

you say you do?" persisted Rosamond. "Is that telling the
truth? Take care, sister! It was the publican who went down
to his house justified, rather than the man who thanked
God he was not as other men."

"You are very impertinent to lecture your elder sister in

this way," returned Margaret. "I shall speak to my mother;"
and she walked away.

"I believe you are in the right, Rosamond," said Andrew.

"We have been too hard on the poor child. If it were
anything but deception!"

"I do not read in Scripture that one sin is worse than

another," returned Rosamond. "The Bible saith not so, but
that he that offendeth in one point is guilty of all. Besides—"

I did not care to hear more. Indeed I had not heard so

much, only the yew walk was my way to the house, and I
had been waiting hoping they would pass on. I now rose up,
and passing through the archway I went on my way, giving
a kind good-morning to Rosamond and curtsying to Andrew
in passing. He would have spoken, I believe, but I did not
give him the chance. When I entered the still-room I heard
my aunt say, in a tone of some annoyance—

"Well, well, sister, we will let the matter rest. It is

natural you should justify your own daughter as far as you
can. I have told the young ones to say no more, and to
treat their cousin kindly. So here she comes. Well, you have
got a little color, child, in the fresh air. Yes, that is very nice.
You are one who can mind what you are about, and will
make a good housewife for all that is come and gone. There
is a piece of gingerbread for you, and you had better take a
cup of cream for your breakfast; you look but poorly. I
think, sister, I will give Vevette the small still, and then she
will not forget what she has learned."

CHAPTER XIV.
 A WEDDING.

I THINK Margaret really did try to meet me as usual,

but of course she did not succeed. She had been vexed at
Rosamond for having so much the best of it in their little
argument, and I fancy too she found her usual self-
complacency a little disturbed; so she was very stately.
Andrew did not say much, but he was kind, and would have
liked to help me to everything on the table.

Betty was demure and silent, with eyes cast down,

though I fancied I now and then caught her regarding me
with some anxiety. I suppose she would have liked to find
out how much I did know, or whether I knew anything. In
good sooth I did not know anything, but I must needs own
that my suspicions were strong, and grew stronger the
more I considered the matter.

In the beginning of our acquaintance Betty had been

much disposed to make a confidante of me, and she herself
had told me that Mr. Lovel had been a suitor for her hand,
but that her mother had rejected him because he was a
spendthrift, and had no good character in other respects,
besides being a total unbeliever—a fashion just then much
affected by a certain class of men who wished to appear
strong-minded and learned at small cost. I could see that
Betty was well enough disposed toward him—indeed she
said so.

And our first breach came from my saying I wondered

she could think of such a person for a husband. I expressed
myself pretty warmly on the subject, at which she was very
much vexed, and said some sharp things in her turn.
However, we made up the quarrel, but when Betty began to
talk of him again—I, with a degree of prudence rather to be
wondered at, positively refused to hear, telling her that
since her mother and brother were opposed to the match,
and with such good reason, she ought not to allow her
thoughts to dwell upon the subject, but to conquer her
regard for Mr. Lovel, if she had any. This little lecture
completed the breach between us, and from that time Betty
never lost a chance of vexing and injuring me, though she
managed her matters with such adroitness that even
Andrew did not see through them, and I began to wonder in
myself whether I was not growing touchy and ill-natured.

As soon as breakfast was over, my mother and myself

retired to our apartment, to finish our preparations for the
removal to the Well House. They were not many, for most of
our goods were sent thither already, and the house having
been kept in such nice order, there was but little to do. My
aunt, on her part, was busy among her storerooms and
presses, and we presently saw old Matt driving the laden
donkey before him, and carrying as many baskets as would
have loaded another.

We meant to have gone away directly after breakfast,

but aunt was most earnest with us to stay to dinner and
partake of the feast which had been put in hand before the
unlucky business of the book. So, though I at least was
impatient to be gone, we consented to remain. What a feast
it was, to be sure! What jellies and creams and tarts and
pies of every sort and kind! (The Cornish folk are famous
for pies, and 'tis said that the devil never dared to come
into Cornwall lest they should take a fancy to "a devilly pie."
This, however, is not true. He is just as busy in Cornwall as
anywhere else.)

We all parted good friends, and I forced myself to bid a

civil adieu to Betty. Aunt Amy was careful to put into each
of our hands a package of cakes and comfits, that we might
not enter our new home empty-handed and thus bring
scarcity upon it. Andrew walked at my mother's bridle-rein,
as usual, and Rosamond and I walked together. Simon and
Jeanne had preceded us.

When we reached the house-door, Andrew assisted my

mother to alight, and then he and Rosamond took a kind
leave of us. He saluted me as usual, but there was a change
in his manner toward me which I felt bitterly enough,
though I had too much maidenly pride to show it. Then they
returned home, and we entered our new house together.
Dinah and Jeanne were in the hall to welcome us, and had
made a cheerful little fire upon the hearth of our sitting-
room, for though the summer was in its prime, the evening
was cool, and a little mist was drifting up from the sea.

"The place seems home-like, does it not, my Vevette?"

said my mother. "I must say I am not sorry to be in my own
house once more. Ah, if your father were but here!"

"He is in a better home than this, maman," I ventured

to say.

"True, my child, and we will not wish to call him back

again. We shall go to him, but he will not return to us."

She kissed me, and we stood a moment in silence. Then

my mother roused herself and proposed that we should go
through the house.

We found everything in beautiful order, and had

occasion at every step to admire my aunt's generosity and
Andrew's thoughtfulness.

There was abundance of fine linen and of blankets and

everything in the housekeeping line that could be needed.
Dinah displayed with delight the service of real china, and
the silver salts, and the dredgers for pepper and spices, and
the pots upon pots of preserves and honey which my aunt
had provided.

My room opened from my mother's, and contained the

old French cabinet I had so much admired, and also a little
clock, which I knew had been one of Rosamond's chief
treasures. From Meg, and marked with her name, was a
pretty coverlet of silk patchwork—a kind of work very
fashionable at that time, and in which Meg excelled, as she
did in most things. From Betty there was a worked cushion,
which I am afraid I was spiteful enough to throw into the
darkest corner of the closet. From Andrew I had some
beautiful china and the loveliest little work-table that could
be, besides a case with doors, which being opened I found
to contain a portrait of himself, which I suppose he had had
painted in London. It was beautifully done, and looked at
me with his very eyes and expression—a kind of smiling
gravity.

The kitchens and offices were filled up with every

convenience, and we found Jeanne quite in ecstasies over
her little dairy and her two line cows—one a long-horned
Devon, the other a comical little black Welsh cow with no
horns at all.

"Ah, madame, had I but a Normandy brass jar for

milking in, I should be quite happy," said the good woman.
"To think what beautiful milk-jars I had, and how they are
all fallen into the hands of the Philistines, as it were!"

"Ah, my poor Jeanne, if it were only the milk-jars that

had fallen into the hands of the Philistines!" said old Simon.
"But we must be thankful that we have been so kindly dealt
by in this strange land. Will madame come to the stable and
look at the horses?"

"Horses! What horses?" asked my mother, in surprise.

"The two saddle horses, madame, and the pony for

mamselle, and the donkey. Indeed they are nice creatures.
Monsieur Corbet recommended the gray for madame's
riding, and the pony is as pretty and gentle a creature for a
young lady as I ever saw. Monsieur has been training it for
this fortnight."

Of course we must go to see them, and I was in

ecstasies over my pony, but my mother looked a little
grave.

"Andrew overloads us with benefits," said she. "I must

talk with him about these same horses. The obligation is
almost too great. But never mind, my Vevette; enjoy your
pretty Blanche. See how she stoops her head to be petted!"

We returned to the house to find supper served, and

Dinah, who had stepped easily enough into the place of
waiting-gentlewoman, standing behind my mother's chair.
We had been a little afraid Jeanne's feelings might be
wounded by this arrangement, but she fell into it more than
contentedly. She was born a cook, and her delight in having
such a neat kitchen to rule in her own way overcame every
other consideration. Simon had had great pleasure in
putting to rights the rather overgrown garden, which was
now a picture of neatness, and he declared he could easily
take care both of that and the garden at the Court till such
time as Andrew could suit himself with a gardener.

The next day was mine at the school, but I did not go
thither, being resolved, after all I had heard, never to set
foot therein till Margaret came and asked me. With the help