LOWER EXTREMITY PROBLEMS IN CHILDHOOD
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Transcript LOWER EXTREMITY PROBLEMS IN CHILDHOOD
LOWER EXTREMITY
PROBLEMS IN CHILDHOOD
TIMOTHY J. FETE MD,MPH
University of Missouri School of
Medicine
Department of Child Health
Developmental Dysplasia of
the Hip-associations
First born
Torticollis
Metatarsus Adductus
Internal Tibial
Torsion
Oligohydramnios
Breech
+ Family History
Developmental Dysplasia of
the Hip
Ortolani Maneuver: Reduction
Barlow Maneuver: Dislocation
Increased joint laxity
Limitation of Abduction
Assymetric thigh skin folds
Galeazzi’s Sign
Leg Length Discrepancy
DEVELOPOMENTAL
DYSPLASIA OF THE HIP
Positive exams per 1000 newborns
All
11.5
Boys
4.1
Girls
19
+ Fam Hx Boys
6.4
+ Fam Hx Girls
32
Breech Boys
29
Breech Girls
133
Developmental Dysplasia of
the Hip
Plain films not particularly valuable until
4-6 months of age
Ultrasonagraphy most useful beyond
four weeks of age (false + before)
US allows static and dynamic study
DDH: Screening
1. All Newborns to be screened at birth
2. If + Ortolani or Barlow: refer to
ortho, do not order US
3. If equivocal, recheck at 2 weeks
4. If equivocal at 2 weeks, refer or
order US at 3-4 weeks
5. Examine hips at all well visits until 18
months (late presentation)
DDH: Screening
Perform US for:
*Girls who are breech
Consider US for:
*Girls with positive family history
*Boys who are breech
DDH: Treatment
NOT Triple Diapers!
Pavlik Harness
Progressive Casting
Adductor Tenotomy
Open Reduction
If late, may require acetabular surgery
INTOEING
Metatarsus Adductus
Internal Tibial Torsion
Femoral Anteversion
METATARSUS ADDUCTUS
Heel Bisector
*normal: between toes 2 and 3
*mild: 3rd toe
*mod: 4th toe
*severe: 5th toe
Rigidity
*actively correctable: straighten with tickle
*passively correctable: straighten with gentle pressure
*fixed: unable to straighten
METATARSUS ADDUCTUS:
Treatment
Actively Correctable:
no Rx
Passively
Correctable
*exercises
*straight or
reverse-last shoes
Fixed: serial casting
Look for DDH!
INTERNAL TIBIAL TORSION
Thigh/foot angle
Relative position of medial and lateral
malleoli
Most common cause of intoeing under 3
years of age
Universally resolves by 4-6 years
No treatment required
MEDIAL FEMORAL TORSION
FEMORAL ANTEVERSION
Most common form of intoeing greater
than 3 years of age
Examine prone rotational profile
Most (85%) resolve spontaneously by
8-10 years
Possible athletic advantage
Femoral osteotomies if severe
EXTERNAL TIBIAL TORSION
Normal adults + 10 degrees of external
tibial torsion
No treatment necessary
PES PLANUS (FLAT FEET)
Normal through age 7 years
1/7 never develop arch
Flexible: foot regains arch when stand on
toes
Treatment rarely necessary—only if painful
(rare)
Rigid: still flat with toe-standing-rare-may be
due to tarsal coalition, may require surgery
SHOES
Adequate size
Soft/flexible
Flat/non-skid sole
Soft/porous upper
Inexpensive
Avoid odd shapes (cowboy shoes/high
heels)
CLUBFOOT
Metatarsus adductus + Equinus + Hindfoot
varus
1/1,000 live births
50% bilateral
Male/female = 2.5/1
Increase if + family history
+ association with DDH
Serial casting (25+ % effective)
Surgery
CAVUS FOOT
High arch, usually inherited, no Rx
Red flags: new-onset, unilateral,
painful, progressive
Red flags may indicate: Friedrich ataxia,
Charcot-Marie-Tooth, tethered spinal
cord, intraspinal lesion
BOWLEGS
Physiologic
*internal rotation of tibia/retroversion of femur
*generally resolved within 6 months of walking
Genu Varum—all children initially bowlegged until 2-3
years, no Rx required if persists:
Blount Disease
* “undergrowth” of medial proximal tibia
*early walkers, heavyset,girls, AfricanAmericans
Metabolic/Medical: rickets, renal,dwarfism
X-ray if painful, unilateral, greater than 2 years old
KNOCK-KNEES
Genu Valgum
By 7 years most children reach typical
adult mild genu valgum
No Rx required, well-tolerated
Legg-Calve’-Perthes Disease
Avascular Necrosis of the Femoral Head
4-8 years of age
Males/females = 4/1
Bilateral in 10-18%
Short stature/delayed bone age
Insidious, often painless limp
Thigh/knee pain not uncommon
Decreased hip mobility on exam
Rx: physical therapy, bracing, ultimate surgery
SLIPPED CAPITAL FEMORAL
EPIPHYSIS (SCFE)
Insidious pain or limp vs acute pain
Pain often thigh/knee
Early adolescence (13-15 males, 11-13
females
Often, not always, obese
African-Americans > Caucasians
20% bilateral initially, 30% more in < 1 yr
Limp,Lateral rotation of foot,limited internal
rotation at hip
OSGOOD-SCHLATTER DISEASE
Painful enlargement of tibial tubercle at
insertion of patellar tendon
Repetitive stress from quadriceps pull
X-rays generally not helpful
May have fragmentation of tibial tubercle
Generally resolves within 6-18 months
Rx: rest, hamstring and quad stretching prior
to participation, ice afterward, NSAIDS only
for acute pain (not to participate!)
Resolved permanently with skeletal maturity