Transcript Pediatric Orthopaedics: Emergencies & Pitfalls

Selina Silva, MD
UNM Carrie Tingley Hospital
 Intoeing/ Outoeing
 Bowlegged/ knock-kneed
 Flexible Flatfeet
 Growing Pains
 Septic Joints
 Legg-Calve-Perthes
 DDH
 SCFE
 Scoliosis
 Back Pain
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3 sources of
intoeing
 Femoral
anteversion
 Internal tibial
torsion
 Metatarsus
adductus
 Femoral Anteversion
 Normal is for children to be born with 30
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degrees and with growth this normalizes to 10
degrees as an adult.
Women have more femoral anteversion than
men
Often familial
Measure the amount of IR and ER of the hip
Greater than 70 degrees IR is considered
severe
 Internal Tibial Torsion
 Common for one leg to have more
than the other
 Also externally rotates with growth to
about 15 degrees as an adult
 Measure the thigh-foot angle
 5 degrees IR to 15 degrees ER is
normal
 Metatarsus Adductus
 Most common congenital foot deformity
 Forefoot metatarsals are medially rotated on cuneiforms
 Hindfoot is normal
 Flexible and resolves on its own 85% of the time
 Deformity in femur or tibia
 Usually does not improve with
growth or worsens
 Less tolerated and so treated
surgically more often
 If asymmetric, need to rule out
other problems
 SCFE
 Toeing out usually corrected around the age of 7-10 if
symptomatic
 Toeing in often resolves near normal
 Therefore give more time prior to offering surgical
correction
 Correct severe cases, greater than 70 degrees
 Corrected in early teen years if symptomatic
 Forefoot adduction corrects 85% of the time on its own
 Start with passive stretching by parents
 Can do casting if not correcting
 If rigid and not correcting, osteotomies can be done
around 5 yo
www.pulsetoday.uk.co
www.orthopediatrics.com
 Physiologic between 1-3
 External rotation hip contractures
 Internal tibial torsion
 Blounts:
 Disturbance of proximal tibial physis
 Often unilateral
 Overweight child, early walker vs. obese adolescent
 Familial
 Radiographic
changes not limited
to medial tibial
physis
 Notice bowing of
femurs
 Physiologic between
ages 3-6
 Worry if unilateral
 Ankles rolling in
correct when the
knees correct
 Early teens may
consider
hemiepiphysiodesis
 Indications:
Mechanical axis off
and knee pain or
patellar subluxation
 20% of the population,
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variant of normal
When stand on toes there is
an arch
No treatment unless feet hurt
Orthotics for symptoms
Surgery for correction
 Usually bilateral lower extremities
 At night or first thing in the morning
 Goes away with massage/attention
 Treatment: Vitamin D3 and give 3-4 months of
supplementation to really see results
 FLAGS:
 Always same joint
 Wakes them up in the middle of the night
 Stop playing or doing sports because of pain
 Painful, swollen joint
 Red and pain with axial load
 Aspirate joint and send for gram stain, cell count, and
culture prior to antibiotics
 If septic, emergent incision and drainage is required
 Sometimes difficult to differentiate from cellulitis
 Risk Factors:
 First born, female, breech,
family history
 Physical Exam:
 Check Ortolani and Barlow
 Asymetric Skin Creases
 Check Galeazzi
 Check for asymetric hip
abduction
 No Swaddling the legs,
can still swaddle arms
and get same effect
 Ultrasound helpful
after 1 mo of age
 AP Pelvis at >4 months
old
 Can present at limb
length discrepancy in
walking child
 AVN of femoral head
 Ages 4-8, usually boys
 Pain and limp, no fevers, worse with more activity
 AP/Frog Pelvis xray for diagnosis and send to Ortho
 Patient profile
 Obese preteen
 Often c/o knee pain
 Affected leg may rotate
outwards
 Also seen with kids that
have thyroid problems
 REAL danger is bone
death of femoral head
 ALWAYS think of hips,
when c/o knee pain
 Order AP Pelvis and Frog
view Pelvis xrays
 If positive, put on
crutches, TDWB and
send to Peds Ortho/ER
immediately
SCFE is
always a
surgical
problem
Hight risk of AVN,
which occurred in
this patient
 Forward bend test
 Imbalance of shoulders or pelvis
 Greater than 10 degree curve on
Xray is scoliosis
 Sometimes presents as limb
length inequality
 Most accurate is standing
posterior view: PSIS “dimples”
 Get an MRI if thoracic curve is
going to the left or neurologic
findings
 Any patient with scoliosis we
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need to see and follow until they
are 18 years of age
We follow about every 6 months
with Xrays
Brace at about 25 degrees
Surgery if rapidly progressing or
greater than 50 degrees
Scoliosis does not cause back
pain
 Kids with or without scoliosis and that have back pain
are initially treated with home exercise program
 We have handout for this
 If fail home exercise/stretching program will send to
formal physical therapy
 1x per week, for 12 weeks
 Core strengthening, truncal stability and hamstring
stretches
 If fail therapy, then get MRI or Bone Scan
 If any neurologic findings get MRI