Pediatric
Orthopedics
Dr. Otto Roob
PGY-1 Family Medicine
Sept. 2 2003
Orthopaedia
 Nicolas Andry Professor of Medicine in
Paris, 1741
 Orthos: straight or free from deformity
 Pais: child
...
Common orthopedic conditions
Surgical referral…immediately
 SCFE
 Acute Septic arthritis
Common orthopedic conditions
Refer or consult…eventually
 Scoliosis
 Back pain
Common orthopedic conditions
No referral…almost
 Medial tibial torsion
 Medial femoral torsion
 Idiopathic toe walking
...
 9 yrs-end of growth
 M>F
 Obesity in 50%
 Increased frequency with endocrine
disorders; hypothyroid, renal disease,
G...
 Unstable: sudden, severe pain with limp
 Stable: limp with variable medial knee
or anterior thigh pain
 36% will later...
Slipped Capital Femoral
Epiphysis
Management
 X-rays: AP, frog leg, lateral
 Mild slips: subtle changes on the frog
leg ...
Acute septic arthritis
 Pyogenic bacteria invade a synovial
joint
 Pediatric incidence has close
association with osteom...
Acute septic arthritis
infants
 May develop with few clinical
manifestations
 Tenderness
 “pseudoparalysis”
 Painful r...
Acute septic arthritis
older children
 Severe pain
 Protective muscle spasm
 Marked tenderness
 Fever
 Elevated WBC
...
Acute septic arthritis
Investigations
 C&S blood, urine plus every orifice
 X-ray
 Ultrasound
 Immediate needle aspira...
Acute septic arthritis
 Refer
 Empiric IV Abx.
 3RD
generation cephalosporin and
penicillinase resistant synthetic peni...
Scoliosis
 lateral curvature of the spine >10˚ by
Cobb method
 Idiopathic
 congenital
 Secondary
 Neuromuscular
 oth...
Idiopathic scoliosis
 Infantile (birth-3 years) 1%
 Juvenile (4-9 years) 12-21%
 Adolescent (10 years- end of growth) 8...
Adolescent idiopathic scoliosis
 Lateral curvature of spine with rotation in child
>11 yrs. with no obvious cause
 Most ...
Adolescent idiopathic scoliosis
screening and investigations
 Adam’s forward bend test
 Radiographic examination
 AP & ...
Adolescent idiopathic scoliosis
screening and investigations
 Must always first ask “what is the
underlying etiology?”
 ...
Adolescent idiopathic scoliosis
progression
 Risk factors
 Female gender
 Growth potential
 Curve magnitude
Adolescent idiopathic scoliosis
progression
curve Risser
0-1
Risser
2-4
<20˚ 22% chance
of
progressing
at least 5 ˚
1.6%
c...
Adolescent idiopathic scoliosis
treatment
curve˚ Risser grade X-ray/refer treatment
10-19 0-1 Q6 mon/no observe
10-19 2-4...
Pediatric back pain
7 warning signs
 Less than 5 years old
 Duration >4 weeks
 fever
 Night pain
 Postural shift or s...
Pediatric back pain
Investigations
 CBC, ESR
 Imaging
 Plain X-ray of spine first
 CT
 CT with bone scan
 MRI
Torsional problems
 Single most common reason for referral
 Intoeing
 Metatarsus adductus
 Medial tibial torsion
 Int...
Assessing Torsional Profile
 Foot progression angle
 Forefoot alignment
 Hip rotation
 Thigh foot angle
Normal values +/- 2 std. deviations
Metatarsus Adductus
 Excessive amount of adduction of the
metarsals relative to the long axis of the foot
 Most common c...
Metatarsus Adductus
 Assessed by
abduction of forefoot
to neutral position
 Metatarsus varus:
rigid deformity
Metatarsus Adductus
management
 Flexible MA: stretching 5X at each diaper
change
 Flexible MA beyond 8 mo old or Metatar...
Internal tibial torsion
 Very common cause of intoeing
 M=F, left>right
 90% of patients resolve by 8 yrs. Old
(level B...
Internal tibial torsion
 Surgical treatment has high complication rate
 Compartment syndrome
 Peroneal nerve injury
 C...
Internal Femoral Rotation
 Excessive amount of medial version of the
relationship of the femoral neck to the distal
femur...
Excessive internal
femoral rotation
Internal Femoral Rotation
Management
 Reassure
 Assess hip ROM q 6 mo.
 Conditions supporting surgical
approach:
 >8 y...
External Femoral torsion
 Common in early infancy
 Intrauterine constriction
 May gradually improve during first year
o...
External tibial torsion
 Usually seen between 4-7 yrs old
 Right>left
 IFT with external tibial torsion, termed
miserab...
Angular variations
 Genu varum (bowlegs)
 birth to 2 yrs old
 Genu valgum (knock-knees)
 3 to 7 yrs old
Angular variations
 Most common reason is physiologic or
a normal developmental variation
 Managed by serial measurement...
Standard Intercondylar and Intermalleolar
values of 196 caucasian children
solid dots=mean value
circles= 2 std. deviations
Angular variations
warning signs
 Intercondylar or intermalleolar distance
beyond 2 standard deviations
 Height of child...
Idiopathic toe walking
 Walk with toe-toe gait pattern in the
absence of any known cause
 Diagnosis of exclusion
 Preva...
Idiopathic toe walking
 Etiology unclear
 Typically seen in children <4 yrs old
 Often associated with subtle
neurologi...
Idiopathic toe walking
management
 Examine child walking
 Stance phase
 Swing phase
 Neurological and musculoskeletal ...
Osgood-Schlatter
 Traumatic partial separation of the tibial
tuberosity epiphysis
 Microavulsions caused by repeated
tra...
Osgood-Schlatter
 Typically vague history of onset with
mild, intermittent signs
 Occasionally with extreme pain and
loc...
Osgood-Schlatter
Investigations
 Diagnosis is based on typical clinical
findings and plain lateral x-ray
 Lateral x-ray
...
Osgood-Schlatter
Treatment
 Benign, self-limiting
 RICE when acute
 Activities as tolerated
 Refer if older patient wi...
Transient Hip Synovitis
 Acute, self limiting inflammation of synovial
lining characterized by pain, stiffness and a
limp...
Transient Hip Synovitis
Presentation
 Classically present as acute unilateral
hip pain in 3-8 yr. old child
 Hip may be ...
Transient Hip Synovitis
Investigations
 Inspect hip and knee
 Vitals
 CBC, ESR, CRP
 X-ray AP, frog-view
 If clinical...
Transient Hip Synovitis
Investigations
Presence of any 2 criteria was 95% sensitive and 91% specific for septic arthritis
...
Transient Hip Synovitis
Investigations
 Predictive probability of septic arthritis =
97.3% when:
 T>37˚
 ESR>20 mm/h
 ...
Conclusion
It is important to understand the natural
progression of pediatric orthopedic
conditions. This allows for appro...
References
 Alessandro, Back pain in children- a common clinical problem in
children
www.vh.org/pediatric/provider/radiol...
References
 Sala et al, Idiopathic toe walking: a review, Dev Med Child
Neuro, 1999 41:846-848
 Salter, Textbook of diso...
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
PowerPoint Presentation - Pediatric_Orthopedics
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    Fibrous capsule stretches
  • PowerPoint Presentation - Pediatric_Orthopedics

    1. 1. Pediatric Orthopedics Dr. Otto Roob PGY-1 Family Medicine Sept. 2 2003
    2. 2. Orthopaedia  Nicolas Andry Professor of Medicine in Paris, 1741  Orthos: straight or free from deformity  Pais: child  One third of medical problems in children are related to the musculoskeletal system.
    3. 3. Common orthopedic conditions Surgical referral…immediately  SCFE  Acute Septic arthritis
    4. 4. Common orthopedic conditions Refer or consult…eventually  Scoliosis  Back pain
    5. 5. Common orthopedic conditions No referral…almost  Medial tibial torsion  Medial femoral torsion  Idiopathic toe walking  Bow legs in a toddler  Knock-knees  Osgood-Schlatter disease  Transient hip synovitis
    6. 6.  9 yrs-end of growth  M>F  Obesity in 50%  Increased frequency with endocrine disorders; hypothyroid, renal disease, GH:sex hormone imbalance Slipped Capital Femoral Epiphysis
    7. 7.  Unstable: sudden, severe pain with limp  Stable: limp with variable medial knee or anterior thigh pain  36% will later involve opposite side  Restricted internal rotation, abduction, flexion Slipped Capital Femoral Epiphysis
    8. 8. Slipped Capital Femoral Epiphysis Management  X-rays: AP, frog leg, lateral  Mild slips: subtle changes on the frog leg view only  Complications: AVN, Chondrolysis, osteoarthritis  Immediate Referral– surgical pin or screw placement
    9. 9. Acute septic arthritis  Pyogenic bacteria invade a synovial joint  Pediatric incidence has close association with osteomyelitis  Most common joint: hip and elbow  Most common organism: S. aureus  Emergency
    10. 10. Acute septic arthritis infants  May develop with few clinical manifestations  Tenderness  “pseudoparalysis”  Painful restriction  Fever and WBC misleadingly slight
    11. 11. Acute septic arthritis older children  Severe pain  Protective muscle spasm  Marked tenderness  Fever  Elevated WBC  Elevated ESR
    12. 12. Acute septic arthritis Investigations  C&S blood, urine plus every orifice  X-ray  Ultrasound  Immediate needle aspiration  Inspection of aspirate  C&S  Gram stain  Crystals
    13. 13. Acute septic arthritis  Refer  Empiric IV Abx.  3RD generation cephalosporin and penicillinase resistant synthetic penicillin
    14. 14. Scoliosis  lateral curvature of the spine >10˚ by Cobb method  Idiopathic  congenital  Secondary  Neuromuscular  other
    15. 15. Idiopathic scoliosis  Infantile (birth-3 years) 1%  Juvenile (4-9 years) 12-21%  Adolescent (10 years- end of growth) 80-90%  4 Forms  Lumbar  Thoracolumbar  Thoracic  Combined lumbar and thoracic
    16. 16. Adolescent idiopathic scoliosis  Lateral curvature of spine with rotation in child >11 yrs. with no obvious cause  Most common type  Typically right thoracic curve  Frequency: 1.9% to 3%  Frequency: curves >30˚ 0.3%  Family history in ~30%  More severe forms more common in females
    17. 17. Adolescent idiopathic scoliosis screening and investigations  Adam’s forward bend test  Radiographic examination  AP & lat full length spine while standing  MRI  Useful if neurological deficits, neck stiffness or headache
    18. 18. Adolescent idiopathic scoliosis screening and investigations  Must always first ask “what is the underlying etiology?”  Back pain  Head/neck pain  Bowel/bladder function  Weakness  Examine extremities, remove shoes  Family history
    19. 19. Adolescent idiopathic scoliosis progression  Risk factors  Female gender  Growth potential  Curve magnitude
    20. 20. Adolescent idiopathic scoliosis progression curve Risser 0-1 Risser 2-4 <20˚ 22% chance of progressing at least 5 ˚ 1.6% chance of progressing at least 5 ˚ 20-29˚ 68% chance of progressing 28% chance of progressing Risser 0: no ossification of ileac crest apophysis Risser 5: complete ossification
    21. 21. Adolescent idiopathic scoliosis treatment curve˚ Risser grade X-ray/refer treatment 10-19 0-1 Q6 mon/no observe 10-19 2-4 Q6 mon/no observe 20-29 0-1 Q6 mon/yes Brace if>25˚ 20-29 2-4 Q6 mon/yes obs or brace 29-40 0-1 refer brace 29-40 2-4 refer brace >40 0-4 refer surgery
    22. 22. Pediatric back pain 7 warning signs  Less than 5 years old  Duration >4 weeks  fever  Night pain  Postural shift or splinting  Limitation of motion  Neurological abnormality
    23. 23. Pediatric back pain Investigations  CBC, ESR  Imaging  Plain X-ray of spine first  CT  CT with bone scan  MRI
    24. 24. Torsional problems  Single most common reason for referral  Intoeing  Metatarsus adductus  Medial tibial torsion  Internal femoral torsion  Out-toeing (less common than intoeing)  External femoral torsion  External tibial torsion
    25. 25. Assessing Torsional Profile  Foot progression angle  Forefoot alignment  Hip rotation  Thigh foot angle
    26. 26. Normal values +/- 2 std. deviations
    27. 27. Metatarsus Adductus  Excessive amount of adduction of the metarsals relative to the long axis of the foot  Most common congenital foot deformity  1/1000 live births  F>M, left>right  Most likely cause: intrauterine restriction  85-90% resolve spontaneously by 1 yr. old (level B evidence)
    28. 28. Metatarsus Adductus  Assessed by abduction of forefoot to neutral position  Metatarsus varus: rigid deformity
    29. 29. Metatarsus Adductus management  Flexible MA: stretching 5X at each diaper change  Flexible MA beyond 8 mo old or Metatarsus varus: referral for casting  Biweekly casts, correction usually achieved in 3-4 casts  Extreme adduction of great toe: surgical release of abductor hallucis done between 6- 18 mo of age
    30. 30. Internal tibial torsion  Very common cause of intoeing  M=F, left>right  90% of patients resolve by 8 yrs. Old (level B evidence)  Avoiding prone sleeping and sitting on feet enhances resolution  Splints, shoe wedges, orthotics are ineffective
    31. 31. Internal tibial torsion  Surgical treatment has high complication rate  Compartment syndrome  Peroneal nerve injury  Conditions supporting surgical approach:  >8 yrs old  Thigh-foot angle >3 std. dev. from mean  family understands risks of surgery
    32. 32. Internal Femoral Rotation  Excessive amount of medial version of the relationship of the femoral neck to the distal femur  Family history, F>M  Children often sit in “W”  Usually diagnosed between age 3-6 yrs  Bracing, shoe inserts, therapy is ineffective  Gradual improvement in over 80% of patients (level B evidence)  not association with hip or knee arthritis
    33. 33. Excessive internal femoral rotation
    34. 34. Internal Femoral Rotation Management  Reassure  Assess hip ROM q 6 mo.  Conditions supporting surgical approach:  >8 yrs old  Deviation >3 std. dev. from mean  family understands risks of surgery
    35. 35. External Femoral torsion  Common in early infancy  Intrauterine constriction  May gradually improve during first year of walking  If no improvement at 2 to 3 yrs old referral indicated because of association with hip or knee arthritis in adults and SCFE in teenagers (Level C evidence)
    36. 36. External tibial torsion  Usually seen between 4-7 yrs old  Right>left  IFT with external tibial torsion, termed miserable malalignment (very rare) association with patellofemoral pain, subluxation or dislocation  Refer
    37. 37. Angular variations  Genu varum (bowlegs)  birth to 2 yrs old  Genu valgum (knock-knees)  3 to 7 yrs old
    38. 38. Angular variations  Most common reason is physiologic or a normal developmental variation  Managed by serial measurements of intercondylar/intermalleolar distance  Lack of resolution should alert to possibility of pathology
    39. 39. Standard Intercondylar and Intermalleolar values of 196 caucasian children solid dots=mean value circles= 2 std. deviations
    40. 40. Angular variations warning signs  Intercondylar or intermalleolar distance beyond 2 standard deviations  Height of child <25th percentile  Genu varum that has been progressing  Asymmetry of limb alignment  Persistence of physiologic varum or valgum beyond 7-8 yrs old
    41. 41. Idiopathic toe walking  Walk with toe-toe gait pattern in the absence of any known cause  Diagnosis of exclusion  Prevalence not well described  May have good ankle range of motion or more fixed contractures
    42. 42. Idiopathic toe walking  Etiology unclear  Typically seen in children <4 yrs old  Often associated with subtle neurological abnormalities such as speech and language delay
    43. 43. Idiopathic toe walking management  Examine child walking  Stance phase  Swing phase  Neurological and musculoskeletal exam  Passive stretching and observation  If problem persists referral for casting or bracing as child approaches school age
    44. 44. Osgood-Schlatter  Traumatic partial separation of the tibial tuberosity epiphysis  Microavulsions caused by repeated traction injury  Localized pain, swelling, tenderness over tibial tuberosity  Ages 8-14 yrs (F) 10-15 yrs (M)
    45. 45. Osgood-Schlatter  Typically vague history of onset with mild, intermittent signs  Occasionally with extreme pain and localized tenderness  Symptoms typically subside within 2 years and prognosis is excellent  Occasionally some disability may persist into adulthood
    46. 46. Osgood-Schlatter Investigations  Diagnosis is based on typical clinical findings and plain lateral x-ray  Lateral x-ray  Characteristic irregularity of apophysis with separation from tibial tuberosity  Fragmentation in later stages  Patellar tendon ossicles  Ultrasound may be useful
    47. 47. Osgood-Schlatter Treatment  Benign, self-limiting  RICE when acute  Activities as tolerated  Refer if older patient with significant disability
    48. 48. Transient Hip Synovitis  Acute, self limiting inflammation of synovial lining characterized by pain, stiffness and a limp  Common, 0.4% -0.9% of pediatric visits to ED, M>F  Extrapolated lifetime risk 3%  Etiology unclear  Viral  Trauma  allergic
    49. 49. Transient Hip Synovitis Presentation  Classically present as acute unilateral hip pain in 3-8 yr. old child  Hip may be in flexion and ext. rotation  Referred pain may be presenting c/o  Occasionally associated with low grade fever
    50. 50. Transient Hip Synovitis Investigations  Inspect hip and knee  Vitals  CBC, ESR, CRP  X-ray AP, frog-view  If clinical suspicion of septic arthritis  Ultrasound  If fluid then aspirate (GOLD STANDARD)
    51. 51. Transient Hip Synovitis Investigations Presence of any 2 criteria was 95% sensitive and 91% specific for septic arthritis Evaluation of 509 patients with irritable hip and limp, Taylor and Clark, 1994 Severe pain/spasm Tenderness on palpation T>38˚ ESR >20mm/hr Transient Synovitis 11.5% 17.2% 7.9% 10.9% Septic Hip 61.9% 85.7% 81% 90.5%
    52. 52. Transient Hip Synovitis Investigations  Predictive probability of septic arthritis = 97.3% when:  T>37˚  ESR>20 mm/h  CRP>1.0 mg/dl  Serum WBC> 11,000 cells/ml mean age septic arthritis:5 yr 7mo N=27 Mean age transient synovitis: 6 yr 7mo N=97  Jung, Row et al. 2003 retrospective study
    53. 53. Conclusion It is important to understand the natural progression of pediatric orthopedic conditions. This allows for appropriate assurance, treatment or referral.
    54. 54. References  Alessandro, Back pain in children- a common clinical problem in children www.vh.org/pediatric/provider/radiology/BackPainInChildren/Diagno , 1996  Blankstein et al, Ultrasonography as a diagnostic modality in Osgood Schlatter disease. Arch Orthop Trauma Surg, 2001 121:356-539  Do T.T, Transient Synovitis as a cause of painful limps in children. Cur Op Ped, 2000 12:48-51  Lala, Wadel, MCCQE review notes. 19th ed. 2003 Toronto Notes Medical Publishing Inc.  Reamy et al, Adolescent Idiopathic Scoliosis: Review and Current Concepts. Am Fam Phys, 2001 64:111-116
    55. 55. References  Sala et al, Idiopathic toe walking: a review, Dev Med Child Neuro, 1999 41:846-848  Salter, Textbook of disorders and injuries of the musculoskeletal system. 3rd ed. 1999 Lippincott Williams & Wilkins  Sass, Hassan, Lower extremity abnormalities in children. Am Fam Phys, 2003 68:461-468  Schewend, Geiger, Pediatric surgery for the primary care physician. Pediatr Clin N A, 1998 45:943-971  Taylor, Clark, Management of irritable hip: review of hospital admission policy. Arch Dis Child, 1994 71:59-63
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