OMISSION BE CHILLY in PÆDIATRIC ORTHOPÆDICS

Transcription

1 OMISSION BE CHILLY in PÆDIATRIC ORTHOPÆDICS Mohammad Diab, M.D. Chief, Pædiatric Orthopædics UCSF limping knee - acute - chronic foot - metatarsus adductus - flat torsion - knock knees - bow legs scoliosis back pain LIMPING CHILD LIMPING CHILD frequency frequency transient synovitis 3x transient synovitis 3x pyarthritis osteomyelitis trauma Legg-Calvé-Perthes x pyarthritis osteomyelitis trauma Legg-Calvé-Perthes x CENTRAL JOINT NWB 1 < 10% fever > 38.5 C 2 ~ 40% WBC > 12K 3 > 75% ESR > 40 mm/hr. 4 > 90 % rheumatoid arthritis rheumatoid arthritis CRP > 10 mg/l 87% NPV 50% PPV diskitis ½x diskitis ½x 1

2 LIMPING CHILD transient synovitis pyarthritis osteomyelitis trauma x Legg-Calvé-Perthes frequency 3x PERIPHERAL JOINT arthrocentesis TORSION adult rotational profile established by 8 yr. reassure, reassure, reassure: nothing alters natural history except osteotomy in-toeing spontaneously improves in-toeing may offer a functional advantage not exercises not inserts not braces etc. Jordan Elway Agassi rheumatoid arthritis diskitis ½x out-toeing does not improve, and may worsen out-toeing may be disadvantageous GENU VALGUM et VARUM GENU VALGUM et VARUM 30º yr. 15º bow-legs generalized focal symptomatic ugly knock-knees maximum genu 3 yr. + initiate R x of genu 3 yr. = refer genu 3 yr. maximum genu 3 yr. + spontaneous improvement till 8 yr. = refer genu 8 yr. 2

3 KNEE acute KNEE chronic history: mechanism significant? physical: effusion patellofemoral ligament instability röntgenogrammes yes fracture no effusion crutches + immobilizer crutches immobilizer for comfort OCD tendinitis refer within week 6 wk meniscal disease apophysitis LIMB LENGTH DISCREPANCY FOOT flat foot 20% United States population immature mature % 50% ob serve physeodesis shorten femur leng then sho rten ampu tation refer not abnormal maturity 3

4 FOOT arch not abnormal FOOT flat foot arch/heel 90% flexible rigid 10 - % 1 flat foot 75 + % 25 - % tarsal coalition 0.5 normal s tight heel cord c tight heel cord pain vertical talus 0 cavus 7 yr. obser vation orthotic oper ation <10% FOOT flat foot FOOT flat foot hindfoot valgus hindfoot varus no medial longitudinal arch arch restored standing on toes 4

5 FOOT metatarsus adductus FOOT metatarsus adductus flexible rigid < 5 yr. > 5 yr. cast > 99% observe osteotomy < 1% SCOLIOSIS types SCOLIOSIS types POSTURAL ST RUC TUR AL POSTURAL f rotation f supine IDIOPATHIC NEUROMUSCULAR CONGENITAL SYNDROMIC 5

6 SCOLIOSIS types SCOLIOSIS types ST RUC TUR AL ST RUC TUR AL IDIOPATHIC CONGENITAL unknown ætiology? vertebral anomaly SCOLIOSIS types SCOLIOSIS types ST RUC TUR AL ST RUC TUR AL NEUROMUSCULAR e.g. skeletal dysplasia SYNDROMIC cerebral palsy myelodysplasia 6

7 NATURAL HISTORY NATURAL HISTORY progression: magnitude α 1/maturity α curve progression post maturity: > 45º ⅔ average 28º cardiopulmonary D: thoracic > 90º > 30 < 10 yr fusion sitting/other care issues: appearance: back pain lumbar psychosocial impact [di Méglio A. Spine 31: , 2006] algorithm MANAGEMENT - risk test specific and sensitive, reproducible, easy to perform applied risk population cost:benefit ratio acceptable cost to patient = psychosocial effect of brace cost to society = financial during childhood = employment and medical care in adulthood assumption that early intervention alters natural history id est bracing effective [Wilson + Junger. Principles & Practice of Screening for Disease. WHO 1968] 7

8 test specific and sensitive, reproducible, easy to perform applied risk population cost:benefit ratio acceptable cost to patient = psychosocial effect of brace cost to society = financial during childhood = employment and medical care in adulthood assumption that early intervention alters natural history id est bracing effective angle of trunk rotation % referred/missed students (N = 1000) [Wilson + Junger. Principles & Practice of Screening for Disease. WHO 1968] [Bunnel WP. JBJS-A 1984] 7 normal variation rib hump 75% lumbar prominence 80% shoulder elevation 10 mm waist asymmetry 15 mm. lower limb length discrepancy 50% normal variation rib hump 75% lumbar prominence 80% shoulder elevation 10 mm waist asymmetry 15 mm. lower limb length discrepancy 50% [Vercauteren M. Spine 1982] [Vercauteren M. Spine 1982] 8

9 test specific and sensitive, reproducible, easy to perform applied risk population assumption that early intervention alters natural history id est bracing effective cost:benefit ratio acceptable cost to patient = psychosocial effect of brace cost to society = financial during childhood = employment and medical care in adulthood began 1962 in U.S.A. Scoliosis Research Society guidelines [ SRS or 14 yr. abandoned in Great Britain abandoned in Canada [Wilson + Junger. Principles & Practice of Screening for Disease. WHO 1968] 4% referred (92/2242) 0.2% treated (5/2242) (3 TLSO, 2 fusion) [Yawn BP. JAMA 1999] - risk if you don t believe in bracing, then <0.1% need treatment test specific and sensitive, reproducible, easy to perform applied risk population cost:benefit ratio acceptable cost to patient = psychosocial effect of brace cost to society = financial during childhood = employment and medical care in adulthood assumption that early intervention alters natural history id est bracing effective [Wilson + Junger. Principles & Practice of Screening for Disease. WHO 1968] 9

10 screening [Bunnel WP. Spine 1993] 4,800 fusions $168,000, % referred 10% (0.3%) brace 10% (0.03%) fusion $221,000,000 test specific and sensitive, reproducible, easy to perform applied risk population cost:benefit ratio acceptable cost to patient = psychosocial effect of brace cost to society = financial during childhood = employment and medical care in adulthood assumption that early intervention alters natural history id est bracing effective [Wilson + Junger. Principles & Practice of Screening for Disease. WHO 1968] BRACING BRACING wear full-time: > 20 hr./day - risk standard of care Milwaukee Boston 80% no further R x Milwaukee introduced as postoperative brace poorly tolerated: compliance 66% [Blount WP. JBJS-A 1958] Boston advantage: no collar disadvantage: T6 [Hall JE. Prosthet Orthot Int 1975] [Winter RB. Spine 1985; Emans JB. Spine 1985; Rowe DE. JBJS 1997; Nachemson AL. JBJS 1995] 10

11 BRACING BRACING contraindication curve > 40º apex > T6 thoracic lordosis obesity non-idiopathic too mature (e.g. post-menarche) Milwaukee Boston failure 10 yr. correction in brace < 50% brace signature worse outcomes if operation BRACING BRACING - risk - risk compliance 60-75%? efficacy no brace = surgery 28% (43/153) brace = surgery 23.5% [Diraimondo CV. JPO 1988 Bowen RJ. Spine 2004] [Weinstein S. Spine 2007; Goldberg CJ. Spine 2001; Dickson RA. JBJS-A 1999] 11

12 MANAGEMENT AIS refer curve > 25º associated sign on PE: neural change cutaneous stigma - risk SIGNIFICANT pain: nocturnal constant focal increasing short duration (< 3 mo) the problem in adults 80% of adults experience back pain most common cause of back pain is idiopathic the most common identifiable problem is degenerative disc disease the problem in children, per tradition back pain in children is rare in 85%, there is an identifiable and treatable cause [Hensinger RM. In The Pediatric Spine. New York, Thieme, 41-60, 1985] [King HA. Pediatr Clin N Am 33: , 1986] 12

13 diskitis osteomyelitis syrinx disc disease tethered cord tumor infection arthritis neuropathy deformity bone blood neural rheumatoid osteoid osteoma aneurysmal bone cyst eosinophilic granuloma ALL astrocytoma ankylosing spondylitis Scheüermann scoliosis? ependymoma nerve sheath tumor back pain in children is a diagnostic black box trauma slipped vertebral apophysis spondylolysis the problem in children, per tradition the problem in children, per tradition back pain in children is rare in 85%, there is an identifiable and treatable cause 11-33% of children complain of back pain [Balaque F. Scand J Rehab Med 20: , 1988] [Olsen TL. Am J Public Health 82: , 1992] most common cause of back pain is idiopathic [Feldman DS. JPO 2000] overuse syndrome child small adult child small adult 13

14 the problem in children, per tradition stress fracture of pars interarticularis vertebral body in 85%, there is an identifiable and treatable cause superior articular process most common identifiable cause of back pain is spondylolysis [Fredrickson BE. JBJS 66-A: , 1984] transverse process SP 5% by 5 yr. inferior articular process sacrum anterior posterior pain pain idiopathic 78% scintigramme N = 217 age 2-17 yr. f/u 1-7 yr. scintigramme N = 217 age 2-17 yr. f/u 1-7 yr. identifiable cause 22% identifiable cause 22% 7% spondylolysis tumor other 11% tumor other 6% [Feldman DS. JPO 2000] 4% infection arthritis neuropathy deformity [Feldman DS. JPO 2000] 4% 10% infection neuropathy 14

15 constant C associated sx/s A nocturnal N < 3 mo. D increasing I 90% non-emergent & non-threatening 10% worrisome focal F summary more common and less troublesome than once believed H&P H & P follow-up C.A.N.D.I.F. FIN judicious use of tests 15