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
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First born
Torticollis
Metatarsus Adductus
Internal Tibial
Torsion
Oligohydramnios
Breech
+ Family History
Developmental Dysplasia of
the Hip
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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
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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
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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
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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
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Perform US for:
*Girls who are breech
Consider US for:
*Girls with positive family history
*Boys who are breech
DDH: Treatment
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NOT Triple Diapers!
Pavlik Harness
Progressive Casting
Adductor Tenotomy
Open Reduction
If late, may require acetabular surgery
INTOEING
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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
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METATARSUS ADDUCTUS:
Treatment
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Actively Correctable:
no Rx
Passively
Correctable
*exercises
*straight or
reverse-last shoes
Fixed: serial casting
Look for DDH!
INTERNAL TIBIAL TORSION
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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
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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
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Normal adults + 10 degrees of external
tibial torsion
No treatment necessary
PES PLANUS (FLAT FEET)
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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
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Adequate size
Soft/flexible
Flat/non-skid sole
Soft/porous upper
Inexpensive
Avoid odd shapes (cowboy shoes/high
heels)
CLUBFOOT
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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
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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
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KNOCK-KNEES
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Genu Valgum
By 7 years most children reach typical
adult mild genu valgum
No Rx required, well-tolerated
Legg-Calve’-Perthes Disease
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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)
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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
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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