Pediatric Lower Extremity Orthopedic Concerns

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					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.

				
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