Pediatric Orthopaedics Emergencies _ Pitfalls - UNM Hospitals

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Pediatric Orthopaedics Emergencies _ Pitfalls - UNM Hospitals Powered By Docstoc
					    Selina Silva, MD
UNM Carrie Tingley Hospital
 Intoeing/ Outoeing
 Bowlegged/ knock-kneed
 Flexible Flatfeet
 Growing Pains
 Septic Joints
 Legg-Calve-Perthes
 Scoliosis
 Back Pain
    3 sources of
      Femoral
      Internal tibial
      Metatarsus
 Femoral Anteversion
   Normal is for children to be born with 30
      degrees and with growth this normalizes to 10
      degrees as an adult.
     Women have more femoral anteversion than
     Often familial
     Measure the amount of IR and ER of the hip
     Greater than 70 degrees IR is considered
 Internal Tibial Torsion
    Common for one leg to have more
     than the other
    Also externally rotates with growth to
     about 15 degrees as an adult
    Measure the thigh-foot angle
       5 degrees IR to 15 degrees ER is
 Metatarsus Adductus
   Most common congenital foot deformity
   Forefoot metatarsals are medially rotated on cuneiforms
   Hindfoot is normal
   Flexible and resolves on its own 85% of the time
 Deformity in femur or tibia

 Usually does not improve with
 growth or worsens

 Less tolerated and so treated
 surgically more often

 If asymmetric, need to rule out
 other problems
   SCFE
 Toeing out usually corrected around the age of 7-10 if
 Toeing in often resolves near normal
   Therefore give more time prior to offering surgical
   Correct severe cases, greater than 70 degrees
   Corrected in early teen years if symptomatic
 Forefoot adduction corrects 85% of the time on its own
   Start with passive stretching by parents
   Can do casting if not correcting
   If rigid and not correcting, osteotomies can be done
    around 5 yo

 Physiologic between 1-3
 External rotation hip contractures
 Internal tibial torsion
 Blounts:
   Disturbance of proximal tibial physis
   Often unilateral
   Overweight child, early walker vs. obese adolescent
 Familial
 Radiographic
  changes not limited
  to medial tibial
 Notice bowing of
 Physiologic between
  ages 3-6
 Worry if unilateral
 Ankles rolling in
  correct when the
  knees correct
 Early teens may

 Indications:
 Mechanical axis off
 and knee pain or
 patellar subluxation
 20% of the population,
    variant of normal
   When stand on toes there is
    an arch
   No treatment unless feet hurt
   Orthotics for symptoms
   Surgery for correction
 Usually bilateral lower extremities
 At night or first thing in the morning
 Goes away with massage/attention
 Treatment: Vitamin D3 and give 3-4 months of
  supplementation to really see results
   Always same joint
   Wakes them up in the middle of the night
   Stop playing or doing sports because of pain
 Painful, swollen joint
 Red and pain with axial load
 Aspirate joint and send for gram stain, cell count, and
  culture prior to antibiotics
 If septic, emergent incision and drainage is required
 Sometimes difficult to differentiate from cellulitis
 Risk Factors:
   First born, female, breech,
    family history
 Physical Exam:
   Check Ortolani and Barlow
   Asymetric Skin Creases
   Check Galeazzi
   Check for asymetric hip
 No Swaddling the legs,
  can still swaddle arms
  and get same effect
 Ultrasound helpful
  after 1 mo of age
 AP Pelvis at >4 months
 Can present at limb
  length discrepancy in
  walking child
 AVN of femoral head
 Ages 4-8, usually boys
 Pain and limp, no fevers, worse with more activity
 AP/Frog Pelvis xray for diagnosis and send to Ortho
 Patient profile
   Obese preteen
   Often c/o knee pain
   Affected leg may rotate
   Also seen with kids that
    have thyroid problems
 REAL danger is bone
  death of femoral head
 ALWAYS think of hips,
  when c/o knee pain
 Order AP Pelvis and Frog
  view Pelvis xrays
 If positive, put on
  crutches, TDWB and
  send to Peds Ortho/ER
                     SCFE is
                     always a

Hight risk of AVN,
which occurred in
this patient
 Forward bend test
 Imbalance of shoulders or pelvis
 Greater than 10 degree curve on
  Xray is scoliosis
 Sometimes presents as limb
 length inequality

 Most accurate is standing
 posterior view: PSIS “dimples”

 Get an MRI if thoracic curve is
 going to the left or neurologic
 Any patient with scoliosis we
    need to see and follow until they
    are 18 years of age
   We follow about every 6 months
    with Xrays
   Brace at about 25 degrees
   Surgery if rapidly progressing or
    greater than 50 degrees
   Scoliosis does not cause back
 Kids with or without scoliosis and that have back pain
 are initially treated with home exercise program
   We have handout for this
 If fail home exercise/stretching program will send to
 formal physical therapy
   1x per week, for 12 weeks
   Core strengthening, truncal stability and hamstring
 If fail therapy, then get MRI or Bone Scan
 If any neurologic findings get MRI

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