1. Discuss some common pediatric problems seen in the clinic. Diagnosis Clinical examination (at birth and subsequent well-baby examinations)

Transcription

1 1 Pediatric Orthopaedics for Primary Care Providers 2 Disclosure Statement No conflicts related to this presentation 3 4 Goals 1. Discuss some common pediatric problems seen in the clinic 2. Examination techniques 3. Basics of treatment 5 Overview 1. DDH 2. Clubfoot 3. Gait abnormalities 4. Shape abnormalities 5. Fracture topics 6. Hip and knee problems 7. Tumors 6 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 7 Risk Factors 1st born Girls Family history Breech Metatarsus adductus/cmt Joint laxity 8 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)

2 Sustained dislocation may demonstrate decreased hip abduction or leg length discrepancy (unilateral) 9 Bilateral DDH 10 Ortolani Maneuver 11 Barlow Maneuver 12 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) 13 Treatment Early identification Pavlik harness 14 Try to prevent situations like these 15 Dysplasia Unfortunately, cases like these are going to be missed 16 Congenital Talipes Equinovarus Multifactorial etiology Incidence 1:1000 Bilaterality 50% 17 Components of Deformity Complex deformity Cavus Adductus Varus Equinus Affects bones, muscles, ligaments of the foot AND leg 18 Ponseti Technique Initiated 7-10 days after birth 2

3 18 5/19/2016 Initiated 7-10 days after birth Serial (weekly) manipulation and casting Percutaneous Achilles tenotomy Bracing to prevent recurrence Results in flexible/functional foot 19 Common Gait Abnormalities In-toeing Toe walking Limp 20 Intoeing 21 Metatarsus adductus Usually flexible deformity resulting from intrauterine crowding Observation/reassurance Most resolve by 1 year Rare need for casting/bracing 22 Internal Tibial Torsion 23 Femoral Anteversion 24 Hip Rotation Profile Examine in prone position Usually symmetric Total arc ~ Increased anteversion if > 70 degrees -- W sitters 25 Surgery Occasionally indicated for severe rotational abnormalities causing cosmetic and functional problems Rarely before age Miserable malalignment syndrome - increased femoral anteversion and external tibial torsion 3

4 Miserable malalignment syndrome - increased femoral anteversion and external tibial torsion 26 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 27 Limping Child Abnormal gait due to pain, weakness or deformity When did it start? Associated illness or injury? Sudden vs. gradual onset? 28 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 29 Limp Septic arthritis Osteomyelitis Fracture/trauma Hip problem (dysplasia, SCFE, Perthes disease) Toxic synovitis JRA Discitis Neuromuscular disorder Limb deformity Other 30 4

5 Other 30 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? 31 Septic Arthritis of the Hip Limited range of motion +/- fever Radiographs may be normal CBC/ESR/CRP Ultrasound/Aspiration 32 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 Perthes disease Shape Abnormalities Genu valgum Genu varum Flatfeet 35 Lower Extremity Alignment History/physical Always examine with patellae pointing forward Apparent genu varum may be normal valgus alignment with internal tibial torsion

6 35 5/19/2016 Apparent genu varum may be normal valgus alignment with internal tibial torsion 36 Normal Development 37 Genu Valgum Knock-knees Physiologic Pathologic Limb deficiency Bone dysplasias Nutritional/metabolic Post-traumatic/post-infectious Other 38 Cozen fracture 39 Genu varum Bowed legs Physiologic Pathologic Bone dysplasias Nutritional/metabolic Blount s disease (obesity) Post-traumatic/post-infectious Other 40 Blount s Disease Tibia vara Growth disorder of medial proximal tibial physis 41 Guided-Growth 42 Rickets 43 Flatfeet Surgery is often indicated Osteotomy Guided-growth 44 Flatfeet Many children (and almost all infants) have flexible flatfeet 6

7 44 5/19/2016 Generally does not require treatment Rigid flatfeet -- think tarsal coalition 45 Tarsal Coalition Fusions between tarsal bones which lead to loss of eversion and inversion Bone, cartilage, or fibrous fusions Calcaneonavicular - most common 46 Congenital Vertical Talus Severe, pathologic flatfoot Often associated with syndromes (50%) Leads to significant disability = surgical correction 47 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 48 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) 49 Remodelling Age Proximity to fast-growing physis Plane of motion 50 Forearm Fractures Greenstick v. complete 7

8 50 Forearm Fractures Greenstick v. complete Many benefit from reduction Few require surgery Best evaluated within 1 week 51 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 52 Posterior Fat Pad Sign Common outpatient scenario Fall on outstretched hand 53 Pain around elbow or limited use of arm 54 Posterior Fat Pad Sign Posterior fat pad sign = occult fracture of the elbow in 76% (supracondylar, proximal ulna/radius, lateral humeral condyle) 55 Treat like nondisplaced fracture -- 3 weeks in long arm cast 56 Toddler s Fracture Non-displaced or minimally displaced spiral or oblique tibia fracture Mechanism: low energy (playground slide), ambulatory children < 3 years RX: Casting 57 Imaging Rules Image joint above and below 58 Imaging Rules Need orthogonal views Can be difficult at the elbow when the patient is holding elbow flexed 59 8

9 58 5/19/2016 Can be difficult at the elbow when the patient is holding elbow flexed 59 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 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 Thigh/Knee Pain Thigh/Knee Pain Thigh/Knee Pain Think HIP pathology!!! 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 65 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

10 66 SCFE Usually obese (clumsy) kids May stumble or trip if using crutches or walker 67 Slipped Capital Femoral Epiphysis Not treated with observation 68 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 69 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 70 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 71 ~1 week followup Buckle fractures Non-displaced elbow fractures Concern for septic hip v. SCFE v. Perthes Painful or concerning tumors 72 Review Kids are not little adults Most conditions can be observed with expectant normalization 73 10

11 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) 73 Thank You Please fill out evaluations Topics for next year? 11