Common Orthopedic Problems in Children

Common Orthopedic Problems in Children - Prof. Mamoun...

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Unformatted text preview: Prof. Mamoun Kremli , FRCS Consultant Pediatric Orthopedics College of Medicine & King Khaled University Hospital Common Orthopedic Problems in Children • Angular deformities of LL: – Bow legs. – Knock knees. • Rotational deformities of LL: – In-toeing. – Ex-toeing. • • • • Leg aches. CDH. Feet problems. Irritable hip. Angular LL Deformities of LL Angular Deformities Nomenclature Bow legs Knock knees Genu Varus Genu Valgus Angular Deformities Range of Normal Varies With Age • During first year : Lateral bowing of Tibiae • During second year : Bow legs (knees & tibiae) • Between 3 – 4 years : Knock knees Angular Deformities Evaluation Should differentiate between “physiologic” and “pathologic” deformities Angular Deformities Evaluation Physiologic Pathologic • Symmetrical • Asymmetrical • Mild – moderate • Severe • Regressive • Progressive • Generalized • Localized • Expected for age •Not expected for age Angular Deformities Causes Physiologic Pathologic • Normal – for age • Rickets • Exaggerated : • Endocrine disturbance - Overweight - Early wt. bearing - Use of walker? • Metabolic disease • Injury to Epiphys. Plate Infection / Trauma • Idiopathic Angular Deformities Evaluation Symmetrical deformity Angular Deformities Evaluation Asymmetrical Deformity Angular Deformities Evaluation Generalized deformity Angular Deformities Evaluation Localized deformity Blount’s Angular Deformities Evaluation Localized deformity Rickets Angular Deformities Evaluation Measure Angulation ( standing / supine ) in bow legs / genu varum Inter-condylar distance Angular Deformities Evaluation Measure Angulation ( standing / supine ) in knock knees /genu valgum Inter- malleolar distance Angular Deformities Evaluation Measure Angulation Use goneometer measures angles directly Angular Deformities Evaluation Investigations / Laboratory • Serum Calcium / Phosphorous ? • Serum Alkaline Phosphatase • Serum Creatinine / Urea – Renal function Angular Deformities Evaluation Investigations / Radiological X-ray when severe or possibly pathologic • Standing AP film – long film ( hips to ankles ) with patellae directed forwards • Look for diseases : – Rickets / Tibia vara (Blount’s) / Epiphyseal injury.. – Measure angles. Angular Deformities Evaluation Investigations / Radiological Medial Physeal Slope Femoral-Tibial Axis Angular Deformities When To Refer ? • Pathologic deformities: Asymmetrical. Localized. Progressive. Not expected for age. • Exaggerated physiologic deformities: Definition ? Angular Deformities Surgery Rotational LL Deformities In-toeing / Ex-toeing • Frequently seen. • Concerns parents. • Frequently prompts varieties of treatment. ( often un-necessary / incorrect ) Rotational Deformities • Level of affection : Femur Tibia Foot Rotational Deformities Femur Ante-version = more medial rotation Retro-version = more lateral rotation Rotational Deformities Normal Development • Femur : Ante-version : – 30 degrees at birth. – 10 degrees at maturity. • Tibia : Lateral rotation : – 5 degrees at birth. – 15 degrees at maturity. Rotational Deformities Normal Development Both Femur and Tibia laterally rotate with growth in children • Medial Tibial torsion and Femoral ante-version improve ( reduce ) with time. • Lateral Tibial torsion usually worsens with growth. Rotational Deformities Clinical Examination Rotational Profile • At which level is the rotational deformity? • How severe is the rotational deformity? • Four components: 1- Foot propagation angle. 2- Assess femoral rotational arc. 3- Assess tibial rotational arc. 4- Foot assessment. Rotational Deformities Clinical Examination Rotational Profile 1- Foot propagation angle – Walking Normal Range: +10o _10o ? In Eastern Societies +25o _10o Rotational Deformities Clinical Examination Rotational Profile 2- Assess Femoral Rotational Arc Supine Extended Rotational Deformities Clinical Examination Rotational Profile 2- Assess Femoral Rotational Arc Supine flexed Rotational Deformities Clinical Examination Rotational Profile 3- Tibial Rotational Arc Thigh-foot angle in prone foot position is critical leave to fall into natural position Rotational Deformities Clinical Examination Rotational Profile 4- Foot assessment • • • • Metatarsus adductus Searching big toe Everted foot Flat foot Rotational Deformities Common Presentations Infants • Out-toeing : Normal • seen when infant positioned upright ( usually hips laterally rotate in-utero ) • Metatarsus adductus : • medial deviation of forefoot 90 % resolve spontaneously • casting if rigid or persists late in 1st year • Rotational Deformities Common Presentations Toddlers • In-toeing most common during second year. ( at beginning of walking ) • Causes : – medial tibial torsion. – metatarsus adductus. – abducted great toe. Rotational Deformities Common Presentations Toddlers - Medial Tibial Torsion • The commonest cause of in-toeing • Observational management is best • Avoid special shoes / splints / braces – unnecessary, ineffective, interferes with activity and cause psychological and behavioral problems. Rotational Deformities Common Presentations Toddler - Metatarsus Adductus • Serial casting is effective in this age-group • Usually correctable by casting up to 4 years Rotational Deformities Common Presentations Toddlers - Abducted Great Toe • Dynamic deformity • Over-pull of Abductor Hallucis Muscle during stance phase • Spontaneously resolve - no treatment Rotational Deformities Common Presentations Child • In-toeing : due to medial femoral torsion • Out-toeing : in late childhood lateral femoral / tibial torsion Rotational Deformities Common Presentations Child Medial Femoral Torsion • Usually: - starts at 3 - 5 years, - peaks at 4 – 6 years, - then resolves spontaneously. • Girls > boys. • Look at relatives - family history – normal. • Treatment usually not recommended. • If persists > 8 years and severe, may need surgery. Rotational Deformities Common Presentation Medial Femoral Torsion (Ante-version) • Stands with knees medially rotated (kissing patellae). • Sits in W position. • Runs awkwardly (egg-beater). Family History Rotational Deformities Common Presentations Child Lateral Tibial Torsion • Usually worsens. • May be associated with knee pain (patellar) specially if LTT is associated with MFT. ( knee medially rotated and ankle laterally rotated ) Rotational Deformities Common Presentations Child Medial Tibial Torsion • Less common than LTT in older child • May need surgery if : – persists > 8 year, – and causes functional disability Rotational Deformities Management • Challenge : dealing effectively with family • In-toeing : spontaneously corrects in vast majority of children as LL externally rotates with growth - Best Wait ! Rotational Deformities Management Convince family that only observation is appropriate • < 1 % of femoral & tibial torsional deformities fail to resolve and may require surgery in late childhood. Rotational Deformities Management • Attempts to control child’s walking, sitting and sleeping positions is impossible and ineffective cause frustration and conflicts. • She wedges and inserts : ineffective. • Bracing with twisters :ineffective - and limits activity. • Night splints : better tolerated - ? Benefit. Rotational Deformities Management Shoe wedges Ineffective Twister cables Ineffective Rotational Deformities When To Refer ? • • • • Severe & persistent deformity. Age > 8-10y. Causing a functional dysability. Progressive. Rotational Deformities Management When Is Surgery Indicated ? •In older child ( > 8 – 10 years ). •Significant functional disability. •Not prophylactic ! Leg Aches / Growing Pains Leg Aches / Growing Pains • Incidence : 15-30 % of children. • More In girls / At night / In LL. • Diagnosis is made by exclusion. Leg Aches / Growing Pains History • • • • • • Vague pain. Poorly localised. Bilateral. Nocturnal. Seldom alters activity. Long duration. Leg Aches / Growing Pains Examination • • • • • • General health is normal. No deformities. No joint stiffness. No tenderness. Normal gait. No limping. Leg Aches / Growing Pains Management • When atypical history or signs present on examination: – Imaging and lab. Studies. • If all negative : – Symptomatic treatment : • Heat / Analgesics. – Reassure family : • Benign. • Self-limiting. • Advise to re-evaluate if clinical features change. Leg Aches / Growing Pains Feature Growing Pain Serious Problem Often Usually not Pain localised No Often Pain bilateral Often Unusual Ulters activity No Often Cause limping No Sometimes General health Good May be ill History : Long duration From Stahili : Practice of Pediatric Orthopedics 2001 Leg Aches / Growing Pains Feature Growing Pain Serious Problem Tenderness No May show Guarding No May show Reduced rang of motion No May show CBC Normal ? Abnormal ESR Normal ? Abnormal Physical examination : Laboratory : From Stahili : Practice of Pediatric Orthopedics 2001 CDH / DDH Congenital Dislocation of Hip. Developmental Dysplasia of Hip. CDH Spectrum • Teratologic Hip : Fixed dislocation Often with other anomalies • Dislocated Hip : Completely out May or may not be reducible • Subluxated Hip : Only partially in • Unstable Hip : Femoral head can be dislocated • Acetabular Dysplasia : Shallow Acetabulum Head Subluxated or in place CDH Etiology & Risk Factors • Prenatal : – – – – – Positive family history (increases risk 10X) Primi-gravida Female (4-6 X > Males) Oligo-hydramnious Breech position (increases risk 5-10 X) • Postnatal : – – – – – Swaddling / Strapping ( ? Knees extended) Ligament Laxity Torticollis (CDH in 10-20 % cases) Cong. Knee recurvatum / dislocation Metatarsus adductus / calcaneo-valgus CDH Risk Factors When Risk Factors Are Present • The infant should be examined repeatedly • The hip should be imaged by – U/S – or X-ray CDH Clinical Examination CDH Neonatal Examination LOOK : • Asymmetric thigh folds – Posterior – anterior CDH Clinical Examination Look : • Shortening ( not in neonates ) - in supine - Galeazzy sign CDH Neonatal Examination MOVE : • Hip instability in early infancy • Limited hip abduction in flexion - later • (careful in bilateral) if <600 on both sides: request imaging CDH Neonatal Examination CDH Neonatal Examination Hip Flexion Deformity SPECIAL : • Loss of fixed flexion deformity of hips in early infancy. • Normally FFD: – newborn 28o – at 6 weeks 19o – at 6 months 7o Thomas Test Normal FFD CDH No FFD CDH Neonatal Examination Ortolani Barlow Feel Clunk Not hear click ! CDH Neonatal Examination Ortolani / Barlow clunk Ortolani Barlow CDH Neonatal Examination Ortolani Test Barlow Test CDH Clinical Examination • Hip clicks : - fine, short duration, high pitched sounds - common and benign – from soft tissues • Hip clunks : - sensation of the hip displacing over the acetabular margin • If in doubt : U/S in young infants single radiograph if > 2-3 months CDH Clinical Examination • Neonate (up to 2-3 months) : – Instability/ Ortolani-Barlow • Infant ( > 2-3 months) – Limited abduction – Shortening ( Galeazzi ) • Toddler : – Limited abduction – Shortening ( Galeazzi ) • Walker : – Trendelenburgh limpimg : CDH Ultrasound Screening • Early U/S screening not recommended • Delayed U/S screening : – Older than 3 weeks – Those at risk or suspicious by: • History • Clinical exam CDH Treatment • Birth to 6 months : – Pavlik harness or hip spica cast • 6 months – 12 months : – closed reduction UGA and hip spica casts • 12 months – 18 months : – possible closed / possible open reduction • Above 18 months : – open reduction and ? Acetabuloplasty • Above 2 years : – open reduction,acetabulplasty, and femoral osteotomy CDH Treatment • Method depends on Age • The earlier started, the easier the treatment & the better the results • Should be detected EARLY • UREGENT referral once an abnormality is detected. ...
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