Transcript Pediatric Orthopedic Diseases

Pediatric Orthopedic Diseases
• Congenital
Categories
• Developmental
• Neuromuscular
• Metabolic
• Acquired : inflammatory
infection
trauma
tumor
Mechanisms
• Congenital.. Defect in the stage of embryogenesis.
• Developmental.. Defect in the stage of fetogenesis.
• Neuromuscular.. Upper or lower motor neuron
disease or different muscular pathologies.
• Metabolic .. Abnormality in different metabolic
lines in our bodies.
• Inflammatory..antigen antibody reactions
• Infections.. Pyogenic spread
• Trauma.. Mechanical forces….fractures
• Tumor..benign or malignant
General Problems
• Hip problems
• Angular deformities
• Foot problems
• Infections & Tumors
DDH
• Predisposing factors - 5 F’s
• Female
• Family Hx. in 20 % of cases
• Frank breech birth
• First born
• Left side involvement
• Physical Exam
- Limited abduction of flexed hip( < 50-60%)
- Legs unequal in length
- Asymmetric fat folds in thigh
- Limp in the walking age child
- Trendelenburg sign: lurching toward affected side
Clinical
The artful approach is the secret of the exam
Ortolani test
Limited Abduction
Abductor lurch or trendelenburg gait
• Diagnostic tests
• U/S in first few months to view cartilage
• X-ray after 3 months
Treatment
• 0-6 months - Pavlik harness to maintain abdution
and flexion
• 6-18 months- reduction under GA, hip spica cast for
2-3 months
• > 18 months- Open surgical reduction: pelvic and/or
femoral osteotomy
LEGG-CALVE-PERTHES DISEASE
• AVN of proximal femoral epiphysis -self
limiting disease
• Leads to abnormal growth of physis
followed by eventual remodeling of new
bone
• Etiology unknown
• More common in males 4:1 ratio
• History/Physical Exam
• Child 4-10 years
• Limping
• tenderness over anterior thigh
• Flexion contracture with decreased internal
rotation/abduction
Diagnostic tests
Diagnostic tests
• Treatment : Aim CONTAINMENT
• Physiotherapy
• Brace in flexion/abduction x 2-3 years
• Femoral or pelvic osteotomy
SLIPPED CAPITAL FEMORAL EPIPHYSIS
• Epidemiology
-
Occurs during maximal pubertal growth spurt
Males: age 13 to 15
Females: age 11 to 13
Most common adolescent hip disorder
Black race affected more often than white race
Unilateral involvement in 90% of cases
Child is often overweight
SLIPPED CAPITAL FEMORAL EPIPHYSIS

Symptoms /Signs
-
Hip pain or knee pain
Limp, decreased ROM
Hip held in abduction and external rotation
Markedly limited internal rotation
Management -Orthopedic Emergency!
Immediate hospitalization
and operative
fixation
COMMON ANGULAR AND ROTATIONAL
PEDIATRIC PROBLEMS
• Angular deformities of LL:
-Bow legs.
-Knock knees.
• Rotational deformities of LL:
-In-toeing.
-Ex-toeing.
Angular Deformities
Nomenclature
Bow Legs
Knock Knees
Genu Varus
Genu Valgus
Angular Deformities
Evaluation
Should differentiate between
physiologic and pathologic
deformities
Angular Deformities Evaluation
physiologic
pathologic
• Symmetrical
• Asymmetrical
• Mild – moderate
• Severe
• Progressive
• Progressive
• Generalized
• Localised
• Expected for age
• Not expected for age
Symmertrical Deformities
Asymmetrical Deformities
Genu Varus
Radiograph
Angular Deformities Causes
Physiologic
Pathologic
 Rickets
 Endocrinopathy
 Normal for age
 May be exaggerated ??? :
 Metabolic diseases
 Physeal plate injury :
a.
a. Overwieght
b. Early walking
Trauma
b. Infection
c.
Tumor
Idiopathic
Evaluation
• Investigations / Radiological
X-ray when severe or pathological
• Standing AP film
– long film ( hips to ankles ) with patellae directed forwards
• Look for diseases :
– Rickets / Tibia vara (Blount’s) / Epiphyseal injury..
– Measure angles.
Angular Deformities
when to refer ?!!!!!!
• If Pathological
• Exaggerated physiological
Treatment
Osteotomy & Fixation
Hemiepiphysiodesis
Rotational Deformities
• INTOEING
Causes
• Metatarsus Adductus
• Tibial Torsion
• High femoral Anteversion
Metatarsus Adductus
• A cause of intoeing in the
first year of life
• Rx :
stretching exercises
casting
surgery
Internal Tibial torsion
• A cause of intoeing
between 1 – 3 years of age
Thigh foot angle
(-10 )– (+ 30)
• Rx :
• May correct
spontaneously
If severe … surgery
High Femoral Anteversion
• After 3 years of age
Rx: spontaneous
improvment till 10 years of
age
NO functional impairment
Surgery not indicated
EXTOEING
• External tibial torsion
Doesnot correct
spontaneously
If severe …surgery
Foot Deformities
Calcaneovalgus
• Common condition
• Packeging disorder
• Benign
•
???LLD in the future
Donot forget systemic diseases
• Arthrogryposis with
foot deformity
SEPTIC ARTHRITIS
• Bacterial infection within a joint
• Serious medical emergency!
• Spread by direct extention , hematogenous( most
commonly), inoculation
• Organisms:
- 0-6 months- S.aureus, E.Coli
- 6-36 months- S.aureus, H.influenza
- > 36 months- S.aureus, Streptococci
• History/Physical Exam
- Severe pain
- Fever, chills
- Dehydration
- Lethargy
- Local redness, swelling, heat, tenderness
- Unable or unwilling to move joint - neonates get pseudoparalysis
- Joint held in flexion
• Diagnostic tests
- Blood and throat cultures
- Joint aspirate for cultures
- CBC, WBC,
- Bone scan (for hip involvement only, to assess for vascular
compromise to femoral head)
SEPTIC ARTHRITIS
• Admit
• Rest the limb
• IV fluids for dehydration
• Analgesia
• Incision & Drainage
• IV antibiotics