common pediatric orthopedic clinical problems saunders jones jr. md georgiaorthopedic@msn.com...

Common Pediatric Common Pediatric Orthopedic Clinical Orthopedic Clinical

ProblemsProblems

Saunders Jones Jr. MDSaunders Jones Jr. MDGeorgiaorthopedic@msn.com

sjones12@kennesaw.edu

Common Pediatric Orthopedic Common Pediatric Orthopedic ProblemsProblems

Metabolic Metabolic Developmental Developmental CongenitalCongenital TraumaticTraumatic InfectiousInfectious NeoplasticNeoplastic Neuromuscular Neuromuscular

Radiological “hole in the Radiological “hole in the bone”bone”

Fibrous cortical defectFibrous cortical defect Aneurysmal Bone cystAneurysmal Bone cyst ““bone island”bone island” Giant cell tumorGiant cell tumor Infection Infection Ewing’s SarcomaEwing’s Sarcoma EnchondromaEnchondroma

Fibrous cortical defect Fibrous cortical defect (Fibroxanthoma)(Fibroxanthoma)

Unicameral bone cystUnicameral bone cyst

Next to growth Next to growth plateplate

Active vs InactiveActive vs Inactive Falling leaf signFalling leaf sign

ABCABC Aneurysmal bone cysts Aneurysmal bone cysts

may occur in patients aged may occur in patients aged 10-30 years, with a peak 10-30 years, with a peak incidence in those aged 16 incidence in those aged 16 years.years.

About 75% of patients are About 75% of patients are younger than 20 years.younger than 20 years.

Four phases of pathogenesis are recognized, Four phases of pathogenesis are recognized, as follows:as follows:

Osteolytic initial phase Osteolytic initial phase Active growth phase, which is characterized Active growth phase, which is characterized

by rapid destruction of bone and a by rapid destruction of bone and a subperiosteal blow-out pattern subperiosteal blow-out pattern

Mature stage, also known as stage of Mature stage, also known as stage of stabilization, which is manifested by stabilization, which is manifested by formation of a distinct peripheral bony shell formation of a distinct peripheral bony shell and internal bony septae and trabeculae and internal bony septae and trabeculae that produce the classic soap-bubble that produce the classic soap-bubble appearance. appearance.

Healing phase with progressive calcification Healing phase with progressive calcification and ossification of the cyst and its eventual and ossification of the cyst and its eventual transformation into a dense bony mass with transformation into a dense bony mass with

an irregular structurean irregular structure..

ABCABC

Copyright © 2007 by the American Roentgen Ray Society

--6-year-old girl withEwing's sarcoma

Ewing's SarcomaEwing's Sarcoma

Incidence of EwingsIncidence of Ewings

EwingsEwings

Giant Cell tumorGiant Cell tumor

Not ped age groupNot ped age group

Osteochondromas or Multiple Osteochondromas or Multiple ExostosesExostoses

Cartilaginous cap covered by a bursaCartilaginous cap covered by a bursa Impinge on local structuresImpinge on local structures CT shows cap < 1cm in thicknessCT shows cap < 1cm in thickness Can be excised due to structural Can be excised due to structural

problemsproblems SMALL incidence (<1% per lesion) of SMALL incidence (<1% per lesion) of

transformation to Chondro sarcoma transformation to Chondro sarcoma (or Osteogenic less common)(or Osteogenic less common)

Multiple ExostosesMultiple Exostoses

Found in areas around growth plates Found in areas around growth plates Can occur in multiple locations or Can occur in multiple locations or

singularlysingularly Usually not NeoplasticUsually not Neoplastic Bone with cartilaginous cap Bone with cartilaginous cap Grows normally with growth of the Grows normally with growth of the

rest of the skeletonrest of the skeleton

OsteochondromasOsteochondromas

B9 B9 Cartilaginous capCartilaginous cap Impinges on local Impinges on local

structuresstructures

OsteochondromasOsteochondromas

Another viewAnother view

OsteochondromaOsteochondroma

OsteochondromaOsteochondroma

Osteochondroma Osteochondroma microscopicmicroscopic

OsteosarcomaOsteosarcoma

OsteosarcomaOsteosarcoma

Some bone Some bone

elementselements

EnchondromaEnchondroma

Non ossifying FibromaNon ossifying Fibroma

Metabolic Pediatric Metabolic Pediatric Category Category

RicketsRickets Osteogenesis ImperfectaOsteogenesis Imperfecta

RicketsRickets

Radiologic changes Radiologic changes in the growth platein the growth plate

Vitamin problemVitamin problem

Osteogenesis ImperfectaOsteogenesis Imperfecta

Twisty Bendy FeetTwisty Bendy Feet

Most common is metatarsus Most common is metatarsus adductusadductus

FPS fetal packaging syndromeFPS fetal packaging syndrome Normal rotation of feet in uteroNormal rotation of feet in utero Should respond to gentle massage Should respond to gentle massage

and SWNand SWN Shoes could be worn in reverse (r-l l-Shoes could be worn in reverse (r-l l-

r) if there is any “last” in the shoer) if there is any “last” in the shoe

Metatarsus adductus/clubfootMetatarsus adductus/clubfoot(tell tale medial crease)(tell tale medial crease)

Twisty Bendy FeetTwisty Bendy Feet

Clubfeet “talipes equino-varus”Clubfeet “talipes equino-varus” Metatarsus adductus, heel equinus and Metatarsus adductus, heel equinus and

varus and talus adductusvarus and talus adductus Tell tale crease on lat underneath Tell tale crease on lat underneath

malleolus malleolus Thinning and atrophy of lower leg Thinning and atrophy of lower leg Needs attention based on severity of Needs attention based on severity of

deformity, START TREATMENT AT BIRTH deformity, START TREATMENT AT BIRTH !!! Refer early!!! Refer early

Club feetClub feet

MetatarsalMetatarsal TalusTalus HindfootHindfoot Leg atrophyLeg atrophy

Endstage Club feetEndstage Club feet

Clubfoot castingClubfoot casting

In the nursery or In the nursery or soon as possiblesoon as possible

Club foot CastingClub foot Casting

Must go above the Must go above the knee to control knee to control rotationrotation

Plaster is the best Plaster is the best Soak off night Soak off night

beforebefore Manipulation and Manipulation and

then maintenance then maintenance of that correctionof that correction

Limited clinic TenotomyLimited clinic Tenotomy

NewNew

Twisty Bendy legs Twisty Bendy legs

Twisty Bendy LegsTwisty Bendy Legs

Internal Tibial TorsionInternal Tibial Torsion Normal adult rotation is 10-15 degrees Normal adult rotation is 10-15 degrees

externalexternal Normal unwinding of child's lower legsNormal unwinding of child's lower legs Not significantly affected by orthotics or Not significantly affected by orthotics or

treatment !!!treatment !!! Sight along tibial crest and look at Sight along tibial crest and look at

malleolimalleoli Reassure (look for other conditions)Reassure (look for other conditions)

Twisty Bendy LegsTwisty Bendy Legs

Bendy knees/legsBendy knees/legs 2-4-6 years2-4-6 years Genu varus / genu valgusGenu varus / genu valgus Normal variantsNormal variants Radiographs for Blount’s DiseaseRadiographs for Blount’s Disease VitaminsVitamins Orthotics (?)Orthotics (?)

Blount’s vs. NormalBlount’s vs. Normal

Twisty Bendy LegsTwisty Bendy Legs

Femoral anteversionFemoral anteversion Femur is turned in at the hip causing Femur is turned in at the hip causing

“pigeon towed gait”“pigeon towed gait” Sit on their feetSit on their feet SWNSWN EducationEducation Twister cables!!?!?!?!?Twister cables!!?!?!?!?

Femoral anteversionFemoral anteversion

Pes Planus “flat feet”Pes Planus “flat feet”

Common in infants and up to about 8 Common in infants and up to about 8 years of ageyears of age

Painful flat feet is different…tarsal Painful flat feet is different…tarsal coalition or other conditioncoalition or other condition

Some pes planus is genetic or racialSome pes planus is genetic or racial Look at mom’s feet!!!Look at mom’s feet!!!

Heel Pain in AdolescentHeel Pain in Adolescent

Sever’s DiseaseSever’s Disease Calcaneal apophysitisCalcaneal apophysitis X rays show “fractionation”X rays show “fractionation” Symptomatic tx with NSAIDsSymptomatic tx with NSAIDs Stretching Stretching Limitation of activity ?Limitation of activity ?

Sever’s DiseaseSever’s Disease

Xray of the Calcaneal Xray of the Calcaneal ApophysisApophysis

Stretch for Sever’s DiseaseStretch for Sever’s Disease

Knee Pain in AdolescentKnee Pain in Adolescent

Anterior tibial tubercle painAnterior tibial tubercle pain Osgood-Schlatter’s diseaseOsgood-Schlatter’s disease Tibial apophysitis Tibial apophysitis Rest stretching Ice NsaidsRest stretching Ice Nsaids Prominent tubercleProminent tubercle Hereditary tendenciesHereditary tendencies HIP PAIN MASQUERADES AS KNEE HIP PAIN MASQUERADES AS KNEE

PAIN !!!!! Always xray same side PAIN !!!!! Always xray same side hip!!!hip!!!

Anterior Knee painAnterior Knee pain

Adolescent FemaleAdolescent Female Increased valgus with tracking Increased valgus with tracking

problems problems Squatting and Indian style sittingSquatting and Indian style sitting Quad sets and NsaidsQuad sets and Nsaids VMO?VMO? Usually self limited Usually self limited Make sure nothing else going on…..Make sure nothing else going on…..

OSDx and Ant knee painOSDx and Ant knee pain

Osgood Schlatter'sOsgood Schlatter's

Osgood Schlatter’s DiseaseOsgood Schlatter’s Disease

Hip PainHip Pain

SCFE SCFE Transient synovitisTransient synovitis Hip pyarthrosisHip pyarthrosis LCPLCP

Slipped Capital Femoral Slipped Capital Femoral EpiphysisEpiphysis

SCFESCFE EndomorphicEndomorphic Androgenital Androgenital Onset anterior thigh painOnset anterior thigh pain Externally Rotated GaitExternally Rotated Gait Can be bilat Can be bilat Rx pin in situRx pin in situ

SCFESCFE

SCFESCFE

SCFESCFE

LCP Perthe’s DiseaseLCP Perthe’s Disease

Avascular necrosis of the proximal Avascular necrosis of the proximal femoral growth platefemoral growth plate

Collapse Collapse Maintain concentricity and Maintain concentricity and

“containment”“containment” Multiple bouts of Transient synovitisMultiple bouts of Transient synovitis

LCP initial and resorptive LCP initial and resorptive phasesphases

LCP resorptive and LCP resorptive and remodelingremodeling

Congenital Dislocated HipCongenital Dislocated Hip

Barlow'sBarlow's OrtilaniOrtilani Duration and Duration and

treatmenttreatment Age of child at Age of child at

discoverydiscovery Pavlick harnessPavlick harness Closed reduction Closed reduction

and castingand casting

Open ReductionOpen Reduction Subtrochanteric Subtrochanteric

osteotomyosteotomy Acetabular Acetabular

osteotomy osteotomy

Congenital DislocationCongenital Dislocation

Congenital Hip DislocationCongenital Hip Dislocation

Causes of Hip Pain in Causes of Hip Pain in ChildrenChildren

CDHCDH 0-2 years0-2 years 1:4 m:f1:4 m:f 20%bilat20%bilat

LCPLCP 4-8 years4-8 years 5:1 m:f5:1 m:f 10% bilat10% bilat

SCFESCFE 10-15 10-15 yearsyears

1.5:1 m:f1.5:1 m:f 25-25-40%bilat40%bilat

Idiopathic Adolescent Idiopathic Adolescent ScoliosisScoliosis

Not a painful conditionNot a painful condition If there is pain…look for another cause!If there is pain…look for another cause! OBJECTIVE OF TREATMENT:OBJECTIVE OF TREATMENT: To prevent deformity as adult To prevent deformity as adult Skeletal maturity Skeletal maturity Onset of menses, Risser signOnset of menses, Risser sign Criteria for referral relates to Criteria for referral relates to

progressionprogression BracesBracesSurgery runs the gamutSurgery runs the gamut

Risser signRisser sign

Risser SignRisser Sign

Nursemaids ElbowNursemaids Elbow

Nursemaids ElbowNursemaids Elbow

Falls from a Height common in Falls from a Height common in ChildrenChildren

Epiphyseal Injuries: only in Epiphyseal Injuries: only in kids!!!kids!!!

Salter classificationSalter classification Joint involvementJoint involvement Growth disturbanceGrowth disturbance Thick periosteumThick periosteum

Salter OneSalter One

Salter 2Salter 2

Salter 3Salter 3

Salter 4Salter 4

Salter 5Salter 5

Supracondylar elbow Supracondylar elbow fracturesfractures

Compartment syndrome because of Compartment syndrome because of vascular compromisevascular compromise

Characteristic fx due to the shape of Characteristic fx due to the shape of the supracondlyar region of the the supracondlyar region of the humerushumerus

““balancing two canoes”balancing two canoes”

Lines around the elbowLines around the elbow

Supracondylar fx minimal Supracondylar fx minimal displacementdisplacement

Displaced Supracondylar fxDisplaced Supracondylar fx

Medial Epicondyle fxMedial Epicondyle fx

Lateral condyle Salter #?Lateral condyle Salter #?

Supracondylar fxSupracondylar fx

Radial Head fxsRadial Head fxs

Displaced Lateral condyle Displaced Lateral condyle Salter #?Salter #?

Radial Head Fx displaced Radial Head Fx displaced epiphyseal….Salter# ?epiphyseal….Salter# ?

Late Sequelae Cubitus varusLate Sequelae Cubitus varus

Fracture Tx in KidsFracture Tx in Kids

Alignment has Alignment has different criteriadifferent criteria

OvergrowthOvergrowth Maintenance of Maintenance of

overall alignment overall alignment most important most important Rotation, etcRotation, etc

Fracture Tx in Younger Kids Fracture Tx in Younger Kids (growth potential)(growth potential)

Overall Alignment and Residual Overall Alignment and Residual GrowthGrowth

Fracture Tx in Older KidsFracture Tx in Older Kids

Fracture Tx in Even Older Fracture Tx in Even Older Kids Kids

Neuromuscular CategoryNeuromuscular Category

Cerebral PalsyCerebral Palsy Spastic or FlaccidSpastic or Flaccid Birth injuryBirth injury Perinatal cerebral anoxiaPerinatal cerebral anoxia Hyperactive stretch receptorsHyperactive stretch receptors Contractures Contractures Releases, Transfers, Braces etc.Releases, Transfers, Braces etc.

InfectionsInfections

Joints PyarthrosisJoints Pyarthrosis Infants and young children Infants and young children Endemic Otitis MediaEndemic Otitis Media No good lab test No good lab test X-rays normalX-rays normal Patho-anatomy growth plate vasculaturePatho-anatomy growth plate vasculature Drain and decompress because of Drain and decompress because of

potential damage to cartilagepotential damage to cartilage May lead to OsteomyelitisMay lead to Osteomyelitis

ANY QUESTIONS???ANY QUESTIONS???

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