lower extremity problems in childhood timothy j. fete md,mph university of missouri school of...
TRANSCRIPT
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LOWER EXTREMITY PROBLEMS IN CHILDHOOD
TIMOTHY J. FETE MD,MPHUniversity of Missouri School of
MedicineDepartment of Child Health
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Developmental Dysplasia of the Hip-associations First born Torticollis Metatarsus
Adductus Internal Tibial
Torsion Oligohydramnios Breech + Family History
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Developmental Dysplasia of the Hip
Ortolani Maneuver: Reduction Barlow Maneuver: Dislocation Increased joint laxity Limitation of Abduction Assymetric thigh skin folds Galeazzi’s Sign Leg Length Discrepancy
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DEVELOPOMENTAL DYSPLASIA OF THE HIP Positive exams per 1000 newborns All 11.5 Boys 4.1 Girls 19 + Fam Hx Boys6.4 + Fam Hx Girls 32 Breech Boys 29 Breech Girls 133
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Developmental Dysplasia of the Hip
Plain films not particularly valuable until 4-6 months of age
Ultrasonagraphy most useful beyond four weeks of age (false + before)
US allows static and dynamic study
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DDH: Screening 1. All Newborns to be screened at
birth 2. If + Ortolani or Barlow: refer to
ortho, do not order US 3. If equivocal, recheck at 2 weeks 4. If equivocal at 2 weeks, refer or
order US at 3-4 weeks 5. Examine hips at all well visits until
18 months (late presentation)
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DDH: Screening
Perform US for: *Girls who are breech Consider US for: *Girls with positive family history *Boys who are breech
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DDH: Treatment
NOT Triple Diapers! Pavlik Harness Progressive Casting Adductor Tenotomy Open Reduction If late, may require acetabular
surgery
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INTOEING
Metatarsus Adductus Internal Tibial Torsion Femoral Anteversion
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METATARSUS ADDUCTUS Heel Bisector *normal: between toes 2 and 3 *mild: 3rd toe *mod: 4th toe *severe: 5th toe Rigidity *actively correctable: straighten with tickle *passively correctable: straighten with gentle
pressure *fixed: unable to straighten
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METATARSUS ADDUCTUS: Treatment Actively
Correctable: no Rx Passively
Correctable *exercises *straight or
reverse-last shoes Fixed: serial casting Look for DDH!
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INTERNAL TIBIAL TORSION
Thigh/foot angle Relative position of medial and
lateral malleoli Most common cause of intoeing
under 3 years of age Universally resolves by 4-6 years No treatment required
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MEDIAL FEMORAL TORSION FEMORAL ANTEVERSION
Most common form of intoeing greater than 3 years of age
Examine prone rotational profile Most (85%) resolve spontaneously
by 8-10 years Possible athletic advantage Femoral osteotomies if severe
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EXTERNAL TIBIAL TORSION
Normal adults + 10 degrees of external tibial torsion
No treatment necessary
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PES PLANUS (FLAT FEET) Normal through age 7 years 1/7 never develop arch Flexible: foot regains arch when stand
on toes Treatment rarely necessary—only if
painful (rare) Rigid: still flat with toe-standing-rare-
may be due to tarsal coalition, may require surgery
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SHOES
Adequate size Soft/flexible Flat/non-skid sole Soft/porous upper Inexpensive Avoid odd shapes (cowboy
shoes/high heels)
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CLUBFOOT Metatarsus adductus + Equinus +
Hindfoot varus 1/1,000 live births 50% bilateral Male/female = 2.5/1 Increase if + family history + association with DDH Serial casting (25+ % effective) Surgery
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CAVUS FOOT
High arch, usually inherited, no Rx Red flags: new-onset, unilateral,
painful, progressive Red flags may indicate: Friedrich
ataxia, Charcot-Marie-Tooth, tethered spinal cord, intraspinal lesion
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BOWLEGS Physiologic *internal rotation of tibia/retroversion of femur *generally resolved within 6 months of walking Genu Varum—all children initially bowlegged
until 2-3 years, no Rx required if persists: Blount Disease * “undergrowth” of medial proximal tibia *early walkers, heavyset,girls, AfricanAmericans Metabolic/Medical: rickets, renal,dwarfism X-ray if painful, unilateral, greater than 2 years
old
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KNOCK-KNEES
Genu Valgum By 7 years most children reach
typical adult mild genu valgum No Rx required, well-tolerated
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Legg-Calve’-Perthes Disease Avascular Necrosis of the Femoral Head 4-8 years of age Males/females = 4/1 Bilateral in 10-18% Short stature/delayed bone age Insidious, often painless limp Thigh/knee pain not uncommon Decreased hip mobility on exam Rx: physical therapy, bracing, ultimate surgery
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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Insidious pain or limp vs acute pain Pain often thigh/knee Early adolescence (13-15 males, 11-13
females Often, not always, obese African-Americans > Caucasians 20% bilateral initially, 30% more in < 1 yr Limp,Lateral rotation of foot,limited
internal rotation at hip
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OSGOOD-SCHLATTER DISEASE
Painful enlargement of tibial tubercle at insertion of patellar tendon
Repetitive stress from quadriceps pull X-rays generally not helpful May have fragmentation of tibial tubercle Generally resolves within 6-18 months Rx: rest, hamstring and quad stretching
prior to participation, ice afterward, NSAIDS only for acute pain (not to participate!)
Resolved permanently with skeletal maturity