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5/19/2016 18 5/19/2016 1 Pediatric Orthopaedics for Primary Care Providers 22 Disclosure Statement No conflicts related to this presentation 33 44 Goals 1. Discuss some common pediatric problems seen in the clinic 2. Examination techniques 3. Basics of treatment 55 Overview 1. DDH 2. Clubfoot 3. Gait abnormalities 4. Shape abnormalities 5. Fracture topics 6. Hip and knee problems 7. Tumors 66 Developmental Dysplasia of the Hip Spectrum of abnormal development of the hip May be congenital or develop during infancy or childhood Incidence ~ 1:1000 of infants 77 Risk Factors 1st born Girls Family history Breech Metatarsus adductus/CMT Joint laxity 88 Diagnosis Clinical examination (at birth and subsequent well-baby examinations) Clunks signify dislocating hip (Barlow sign) or relocating hip (Ortolani sign) Sustained dislocation may demonstrate decreased hip abduction or leg length discrepancy (unilateral) 9 10 1 11 5/19/2016 Sustained dislocation may demonstrate decreased hip abduction or leg length discrepancy (unilateral) 99 Bilateral DDH 1010 Ortolani Maneuver 1111 Barlow Maneuver 1212 Screening All newborns should have examination of the hip as part of routine exam Imaging is not recommended on a routine basis At risk babies should have ultrasound examination at 4-6 weeks of age (+/- AP pelvis radiograph at 6 months of age) 1313 Treatment Early identification Pavlik harness 1414 Try to prevent situations like these 1515 Dysplasia Unfortunately, cases like these are going to be missed 1616 Congenital Talipes Equinovarus Multifactorial etiology Incidence 1:1000 Bilaterality 50% 1717 Components of Deformity Complex deformity Cavus Adductus Varus Equinus Affects bones, muscles, ligaments of the foot AND leg 1818 Ponseti Technique Initiated 7-10 days after birth 2 5/19/2016 18 Initiated 7-10 days after birth Serial (weekly) manipulation and casting Percutaneous Achilles tenotomy Bracing to prevent recurrence Results in flexible/functional foot 1919 Common Gait “Abnormalities” In-toeing Toe walking Limp 2020 Intoeing 2121 Metatarsus adductus Usually flexible deformity resulting from intrauterine crowding Observation/reassurance Most resolve by 1 year Rare need for casting/bracing 2222 Internal Tibial Torsion 2323 Femoral Anteversion 2424 Hip Rotation Profile Examine in prone position Usually symmetric Total arc ~ 90-100 Increased anteversion if > 70 degrees -- “W sitters” 2525 Surgery Occasionally indicated for severe rotational abnormalities causing cosmetic and functional problems Rarely before age 8-10 Miserable malalignment syndrome - increased femoral anteversion and external tibial torsion 26 3 5/19/2016 Miserable malalignment syndrome - increased femoral anteversion and external tibial torsion 2626 Toe Walking Neurogenic vs. idiopathic/behavioral Can be associated with gastrocnemius contracture (Silfverskiöld test) Treat with observation Surgery may be required after age 8-10 if persistent and problematic 2727 Limping Child Abnormal gait due to pain, weakness or deformity When did it start? Associated illness or injury? Sudden vs. gradual onset? 2828 Limp Antalgic -- due to pain Try to determine location Labs (ESR, CRP), radiographs, bone scan Equinus -- possible neurologic cause Abductor lurch -- hip abductor weakness Hip deformity Neuromuscular problem Circumduction Limb length discrepancy Foot/ankle pain 2929 Limp Septic arthritis Osteomyelitis Fracture/trauma Hip problem (dysplasia, SCFE, Perthes disease) Toxic synovitis JRA Discitis Neuromuscular disorder Limb deformity Other 30 4 5/19/2016 Other 3030 Septic Arthritis Superficial joints -- effusion Hip is deep so effusion is not visible Needs prompt diagnosis and treatment -- delayed treatment can lead to joint destruction Staph/Strep most common organisms Acute hip pain/irritability -- think “Why is this not septic arthritis?” 3131 Septic Arthritis of the Hip Limited range of motion +/- fever Radiographs may be normal CBC/ESR/CRP Ultrasound/Aspiration 3232 Perthes disease 1:10000 Boys > girls Ages 4-8 Usually presents with antalgic gait but only mild pain Healing occurs over 2+ years and prognosis related to age and severity of collapse 3333 Perthes disease 3434 Shape Abnormalities Genu valgum Genu varum Flatfeet 3535 Lower Extremity Alignment History/physical Always examine with patellae pointing forward Apparent genu varum may be normal valgus alignment with internal tibial torsion 36 37 5 35 5/19/2016 Apparent genu varum may be normal valgus alignment with internal tibial torsion 3636 Normal Development 3737 Genu Valgum “Knock-knees” Physiologic Pathologic Limb deficiency Bone dysplasias Nutritional/metabolic Post-traumatic/post-infectious Other 3838 Cozen fracture 3939 Genu varum “Bowed legs” Physiologic Pathologic Bone dysplasias Nutritional/metabolic Blount’s disease (obesity) Post-traumatic/post-infectious Other 4040 Blount’s Disease Tibia vara Growth disorder of medial proximal tibial physis Surgery is often indicated Osteotomy Guided-growth 4141 Guided-Growth 4242 Rickets 4343 Flatfeet 4444 Flatfeet Many children (and almost all infants) have flexible flatfeet 6 44 5/19/2016 Generally does not require treatment Rigid flatfeet -- think tarsal coalition 4545 Tarsal Coalition Fusions between tarsal bones which lead to loss of eversion and inversion Bone, cartilage, or fibrous fusions Calcaneonavicular - most common 4646 Congenital Vertical Talus Severe, pathologic flatfoot Often associated with syndromes (50%) Leads to significant disability = surgical correction 4747 Surgery Severe flexible flatfeet -- pain, callus formation, usually older (heavier) children Hypermobile with contracted heel cord and secondary lateral column shortening Tarsal coalitions/rigid flatfeet often become symptomatic during early adolescence Congenital vertical talus 4848 Buckle Fractures Distal radius is most common site Need to make sure it is truly a buckle fracture, look at the growth plate No long term complications Usually immobilize for 2-3 weeks in short arm cast (comfort & protection) 4949 Remodelling Age Proximity to fast-growing physis Plane of motion 5050 Forearm Fractures Greenstick v. complete 7 5/19/2016 5050 Forearm Fractures Greenstick v. complete Many benefit from reduction Few require surgery Best evaluated within 1 week 5151 Pediatric Elbow Fractures Supracondylar humerus fractures Most common Lateral condyle fractures Medial epicondyle fractures Rare Little leaguer’s elbow Nondisplaced often non-operative Displaced often operative 5252 Posterior Fat Pad Sign Common outpatient scenario Fall on outstretched hand Pain around elbow or limited use of arm 5353 5454 Posterior Fat Pad Sign Posterior fat pad sign = occult fracture of the elbow in 76% (supracondylar, proximal ulna/radius, lateral humeral condyle) Treat like nondisplaced fracture -- 3 weeks in long arm cast 5555 5656 Toddler’s Fracture Non-displaced or minimally displaced spiral or oblique tibia fracture Mechanism: low energy (playground slide), ambulatory children < 3 years RX: Casting 5757 Imaging Rules Image joint above and below 5858 Imaging Rules Need orthogonal views Can be difficult at the elbow when the patient is holding elbow flexed 59 8 5/19/2016 58 Can be difficult at the elbow when the patient is holding elbow flexed 5959 Nursemaid’s Elbow “Pulled elbow” Subluxation of annular ligament Arm held in slight flexion and pronation Reduce by flexing elbow and supinating forearm If swelling/tenderness/bruising/history of fall on outstretched hand, think fracture and not “pulled elbow” 6060 Child Abuse Be vigilant No fracture pathognomonic Mechanism doesn’t make sense Multiple fractures (various stages of healing), corner fractures, bucket-handle fractures Rib fractures, scapula fractures, lateral clavicle fractures, skull fractures, humerus/femur fractures 6161 Thigh/Knee Pain 6262 Thigh/Knee Pain 6363 Thigh/Knee Pain Think HIP pathology!!! 6464 Slipped Capital Femoral Epiphysis (SCFE) Weakened upper femoral physis resulting in gradual slipping of the metaphysis on the epiphysis which leads to: Progressive deformity Pain Avascular necrosis Arthritis 6565 SCFE Most common adolescent hip disorder (boys 12-14, girls 10-12) Frequently delayed dx Order BILATERAL AP and frog leg laterals (50% bilateral) If unable to bear weight Make NWB Requires urgent stabilization 66 67 9 5/19/2016 6666 SCFE Usually obese (clumsy) kids May stumble or trip if using crutches or walker 6767 Slipped Capital Femoral Epiphysis Not treated with observation 6868 Osteochondroses Osgood-Schlatter disease = tibial tubercle Sinding-Larsen-Johansson syndrome = patella Severs = Calcaneus Localized tenderness Effusion = think intra-articular problem (structural vs. inflammatory) Self-limited May take 1-2 years for symptoms to resolve Stretching exercises and activity modification 6969 Tumors Most are benign and often incidental findings on xray Observation vs. surgery Malignancies do occur Primary bone tumors (osteosarcoma, Ewing sarcoma) Leukemia Metastatic disease (neuroblastoma) NIGHT PAIN 7070 Make NPO and Call Me Today Septic arthritis (especially hip) Complete forearm fractures Displaced elbow fractures Displaced lower extremity fractures SCFE, unable to bear weight 7171 ~1 week followup Buckle fractures Non-displaced elbow fractures Concern for septic hip v. SCFE v. Perthes Painful or concerning tumors 7272 Review Kids are not little adults Most “conditions” can be observed with expectant normalization 73 10 72 5/19/2016 Most “conditions” can be observed with expectant normalization Still requires vigilance - DDH, infection, SCFE, tumor, etc. (things that result in irreversible disability or death) 7373 Thank You Please fill out evaluations Topics for next year? 11 .
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