Common Pediatric Orthopaedic Problems

1. Common Pediatric Orthopaedic Problems SelinaSilva, MD UNM Carrie Tingley Hospital

2. Common Problems • Intoeing/ Outoeing • Bowlegged/ knock-kneed • Flexible Flatfeet • Growing Pains • Septic Joints • Legg-Calve-Perthes • DDH • SCFE • Scoliosis • Back Pain

3. “my child is pigeon-toed!!” • 3 sources of intoeing • Femoral anteversion • Internal tibial torsion • Metatarsus adductus

4. Intoeing • 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 men • Often familial • Measure the amount of IR and ER of the hip • Greater than 70 degrees IR is considered severe

5. Intoeing • 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 normal

6. Intoeing • 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

7. Outoeing • 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

8. Evaluation of Femur

9. Evaluation of Tibia

10. Treatment • Toeing out usually corrected around the age of 7-10 if symptomatic • Toeing in often resolves near normal • Therefore give more time prior to offering surgical correction • 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

11. Pediatric Angular Alignment www.pulsetoday.uk.co www.orthopediatrics.com

12. “my child’s bowlegged!” • Physiologic between 1-3 • External rotation hip contractures • Internal tibial torsion

13. Rule Out Blount’s • Blounts: • Disturbance of proximal tibial physis • Often unilateral • Overweight child, early walker vs. obese adolescent

14. Rule Out Rickets • Familial • Radiographic changes not limited to medial tibial physis • Notice bowing of femurs

15. Knock-Knees • Physiologic between ages 3-6 • Worry if unilateral • Ankles rolling in correct when the knees correct

16. When for Surgery? • Early teens may consider hemiepiphysiodesis • Indications: Mechanical axis off and knee pain or patellar subluxation

17. Flexible Flatfeet • 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

18. Growing Pains • 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 • FLAGS: • Always same joint • Wakes them up in the middle of the night • Stop playing or doing sports because of pain

19. Septic Joint • 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

20. Developmental Hip Dysplasia • Risk Factors: • First born, female, breech, family history • Physical Exam: • Check Ortolani and Barlow • Asymetric Skin Creases • Check Galeazzi • Check for asymetric hip abduction

21. Developmental Hip Dysplasia • No Swaddling the legs, can still swaddle arms and get same effect • Ultrasound helpful after 1 mo of age • AP Pelvis at >4 months old • Can present at limb length discrepancy in walking child

22. Legg-Calve-Perthes • 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

23. Slipped Capital Femoral Epiphysis • Patient profile • Obese preteen • Often c/o knee pain • Affected leg may rotate outwards • Also seen with kids that have thyroid problems

24. Slipped Capital Femoral Epiphysis • 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 immediately

25. SCFE is always a surgical problem Hight risk of AVN, which occurred in this patient

26. Scoliosis • Forward bend test • Imbalance of shoulders or pelvis • Greater than 10 degree curve on Xray is scoliosis

27. 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 findings

28. Scoliosis • 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 pain

29. Back Pain • 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 stretches • If fail therapy, then get MRI or Bone Scan • If any neurologic findings get MRI