Transcript Pediatric Lower Extremity Orthopedic Concerns

Pediatric Lower Extremity
Orthopedic Concerns
Esther Tompkins, DO
Ped’s PM&R
In Toeing Deformities
 Three possible causes
 1.
Metatarsus Adductus
 2. Internal Tibia Torsion
 3. Femoral Anteversion
Metatarsus Adductus
 “Foot turning in”
most common orthopedic
problem in children.
 Forefoot in varus and hindfoot in valgus
 Unlike clubfoot in which the forefoot and
hindfoot are both in fixed varus.
Metatarsus Adductus
 Physical Examination
 1.
Foot is curved like a “C” with toes point to
the midline.
 2. The toes can be brought up up easily into
neutral plantigrade position, and the heel
comes down into neutral.
Metatarsus Adductus
 Treatment
 1.
If, by stroking the lateral side of the foot
it straighten out, it will mostly resolve on it
own, by age 3-5 years of age.
 2. Stretching and ROM exercises done by
caregiver.
 3. Serial casting
Internal Tibial Torsion
 Normally, the medial malleolus should be
15° anterior to the transcondylar axis of the
knee joint.
 If the lateral malleolus in on the same
plane or anterior to the medial malleolus,
this infers internal tibial torsion.
Internal Tibial Torsion
 Refer to an Orthopedic Doctor
 As treatment is very controversial if
surgery or bracing is the best.
Femoral Anteversion
 Consider this only after you have rule out
metatarsus adductus, and internal tibial
torsion.
 History of this child usually includes sitting
in the reverse “W” or “TV squat” position.
Femoral Anteversion
 Two type of “TV squat” position
• 1. Hip flexed to 90°, knee flexion to 130°, with
90° of external rotation of the legs and feet
pointing out.
• 2. Hip flexed to 90° and sitting on legs with feet
turned in and adducted underneath their butt.
Femoral Anteversion
 Physical Exam
 Normal exam is 40°-50° of IR & ER
 Abnormal exam with anteversion IR 90° and
limited ER
 ER >25° than gait is normal
 ER <15°-20° than gait is abnormal
Femoral Anteversion
 Treatment
• 1. Taylor sitting position often only treatment
needed, and resolves by 10-12 years of age.
• 2. Referral to Ortho if ER <15°-20° for treatment.
The Hip
 1.
CDH = Congenital dislocation of the Hip
or Developmental Dysplasia of the Hip
• May occur pre, post, or perinatally
• 1 out of 1000 live biths
The Hip - CDH con’t
 Characteristics:
•
•
•
•
1. Firstborn females
2. Breech delivery
3. Family history of CDH
4. Left side
The Hip - CDH con’t
 X-rays
• Standard films AP and frog-leg views of the
pelvis if > 7 months old
• US of hips for <7 months old as the ossific
centers have not developed in the capital
femoral epiphysis.
The Hip - CDH con’t
 Physical Exam
• 1. Ortolani test - flex hips to 90° and then
abducted maximally. A positive test is when
the head of the femur, which is dislocated
posteriorly, flips over the posterior acetabular
labrum or edge and head of femur goes back
into the true acetabulum. This produces a
palpable, not audible, “thunk,” “schlunk,” or
“clunk.” Not a “click”, which most often is from
the iliotibial band around the knee.
The Hip - CDH con’t
 2.
Barlow’s Test - With the infant’s pelvis
stabilized with one hand, place the other
hand so that thumb is over the lesser
trochanter. Flex the hip to 90°, then push
the femoral head posteriorly over the hip
joint. A positive test is movement of the
femoral head posterolaterally, which is
seen when there is acetabular/femoral
instability.
The Hip - CDH con’t
 3.
Allis or Galeazzi Sign - Lay the child in
supine and flex both hips to 90° with feet
flat on the exam table and look at the height
of the knees. The affected side will show a
marked shortening.
 4. Skin fold discrepancy will be noted at the
thigh and gluteal skin folds, with the
involved side having increase in folds.
The Hip - CDH con’t
 5.
Limitation of Abduction - With the child
in supine flex both hips to 90° then abduct
both legs at the same time. Both hips
should go equal distances into abduction.
If there is a differences between them them
the one that has limited movement is the
involved side.
Treatment of CDH
 Group I - Neonate to 6 weeks - positive
Ortolani and Barlow’s tests and skin fold
discrepancies. Also dislocated side can be
extended all the way down to the level of
the exam table, because it is lacking the
normal hip flexion tightness that newborn
have. Refer this child to Orthopedics for
treatment most likely with a Pavlik harness.
Treatment of CDH
 Group II - 6 weeks - 12 months - Hip
capsular and soft tissue have now
tightness up and the Ortolani test may not
be positive. Will see limited abduction in
this age and skin fold asymmetry. Again
referral to Ortho for treatment with Pavlik
harness, traction, adductor tenotomy, or
closed reduction.
Treatment of CDH
 Group III - 12 months - 3 years - Walking
with a painless limp. Galeazzi sign positive,
and limited abduction. X-rays positive by
this age. Again referral to Ortho for
possible treatment by arthrography,
traction, adductor tenotomy, open
reduction, and pelvic versus femoral
osteotomy.
Treatment of CDH
 Group IV - 3 years to skeletal maturity-
Same as group III and X-ray is positive.
Referral to Ortho for treatment. Usually
need to have surgery to corrected at this
age.
 FYI - Bilateral dislocations over 6 years old
and unilateral over 8 years old do better
left ALONE.
The Hip: Legg-Calvé-Perthes Disease
 Etiology is thought to be due to interruption
of the blood supply to the femoral head.
 Vague on set of pain in hip or knee.
 Male to female 5:1
 Between 3 to 10 years old
 Painful limp when synovitis is present and
then become a painless limp
 Family history 10%-20%
The Hip: Legg-Calvé-Perthes Disease

Physical Exam - Shows
• 1. Decrease ROM in hip abduction and internal
rotation.
• 2. Hip stiffness
• 3. Knee pain

X-rays: Four stages
• 1. Synovitis
• 2. Aseptic necrosis- increased joint space and small
femoral head
• 3. Fragmentation - increased bone density
• 4. Residual - increased bone density
The Hip: Legg-Calvé-Perthes Disease
 Treatment per Ortho
• 1. Aspiration to rule out septic arthritis
• 2. Russell’s traction until synovitis resolves.
• 3. Must kept femoral head in the acetabulum by
operative or non-operative means.
The Hip-Slipped Capital Femoral Epiphysis
 SCFE - More common in 10-16 year old male
especially those with obese and eunuchoid
body habitus.
 Present with hip or knee pain, with a limp.
 Pain often have been present for 3-9
months, and have been treated of other
things.
The Hip-Slipped Capital Femoral Epiphysis
 Physical Exam - Obese adolescent male
with short limb, and Trendelenberg gait.
The hip is often in extended and externally
rotated.
 Positive Log roll test which is decrease
internal or external rotation of the leg with
the hip and knee in extension.
The Hip-Slipped Capital Femoral Epiphysis
 X-ray - Shows “Ice cream falling off of the
cone” = Femoral head falling off of the
femoral shaft.
 Treatment STAT referral to Ortho when
found. Needs to be corrected quickly.