Pediatric Orthopedics

Dr. Otto Roob

PGY-1 Family Medicine

Sept. 2 2003

Orthopaedia Nicolas Andry Professor of Medicine

in Paris, 1741 Orthos: straight or free from

deformity Pais: child One third of medical problems in

children are related to the musculoskeletal system.

Common orthopedic conditions Surgical referral…immediately

SCFE

Acute Septic arthritis

Common orthopedic conditions Refer or consult…eventually

Scoliosis

Back pain

Common orthopedic conditions No referral…almost

Medial tibial torsion Medial femoral torsion Idiopathic toe walking Bow legs in a toddler Knock-knees Osgood-Schlatter disease Transient hip synovitis

9 yrs-end of growth M>F Obesity in 50% Increased frequency with

endocrine disorders; hypothyroid, renal disease, GH:sex hormone imbalance

Slipped Capital Femoral Epiphysis

Unstable: sudden, severe pain with limp

Stable: limp with variable medial knee or anterior thigh pain

36% will later involve opposite side Restricted internal rotation,

abduction, flexion

Slipped Capital Femoral Epiphysis

Slipped Capital Femoral EpiphysisManagement

X-rays: AP, frog leg, lateral Mild slips: subtle changes on the

frog leg view only Complications: AVN, Chondrolysis,

osteoarthritis Immediate Referral– surgical pin or

screw placement

Acute septic arthritis Pyogenic bacteria invade a

synovial joint Pediatric incidence has close

association with osteomyelitis Most common joint: hip and elbow Most common organism: S. aureus Emergency

Acute septic arthritisinfants

May develop with few clinical manifestations

Tenderness “pseudoparalysis” Painful restriction Fever and WBC misleadingly slight

Acute septic arthritis older children

Severe pain Protective muscle spasm Marked tenderness Fever Elevated WBC Elevated ESR

Acute septic arthritisInvestigations

C&S blood, urine plus every orifice X-ray Ultrasound Immediate needle aspiration

Inspection of aspirate C&S Gram stain Crystals

Acute septic arthritis Refer Empiric IV Abx.

3RD generation cephalosporin and penicillinase resistant synthetic penicillin

Scoliosis lateral curvature of the spine >10˚

by Cobb method Idiopathic congenital Secondary Neuromuscular other

Idiopathic scoliosis Infantile (birth-3 years) 1% Juvenile (4-9 years) 12-21% Adolescent (10 years- end of growth)

80-90% 4 Forms

Lumbar Thoracolumbar Thoracic Combined lumbar and thoracic

Adolescent idiopathic scoliosis Lateral curvature of spine with rotation in

child >11 yrs. with no obvious cause Most common type Typically right thoracic curve Frequency: 1.9% to 3% Frequency: curves >30˚ 0.3% Family history in ~30% More severe forms more common in

females

Adolescent idiopathic scoliosisscreening and investigations

Adam’s forward bend test Radiographic examination

AP & lat full length spine while standing

MRI Useful if neurological deficits, neck

stiffness or headache

Adolescent idiopathic scoliosis screening and investigations

Must always first ask “what is the underlying etiology?” Back pain Head/neck pain Bowel/bladder function Weakness Examine extremities, remove shoes Family history

Adolescent idiopathic scoliosisprogression

Risk factors Female gender Growth potential Curve magnitude

Adolescent idiopathic scoliosisprogression

curve Risser 0-1

Risser2-4

<20˚ 22% chance of progressing at least 5 ˚

1.6% chance of progressing at least 5 ˚

20-29˚ 68% chance of progressing at least 5 ˚

28% chance of progressing at least 5 ˚

Risser 0: no ossification of ileac crest apophysis Risser 5: complete ossification

Adolescent idiopathic scoliosistreatment

curve˚ Risser grade

X-ray/refer treatment

10-19 0-1 Q6 mon/no observe

10-19 2-4 Q6 mon/no observe

20-29 0-1 Q6 mon/yes

Brace if>25˚

20-29 2-4 Q6 mon/yes

obs or brace

29-40 0-1 refer brace

29-40 2-4 refer brace

>40 0-4 refer surgery

Pediatric back pain7 warning signs

Less than 5 years old Duration >4 weeks fever Night pain Postural shift or splinting Limitation of motion Neurological abnormality

Pediatric back painInvestigations

CBC, ESR Imaging

Plain X-ray of spine first CT CT with bone scan MRI

Torsional problems Single most common reason for referral Intoeing

Metatarsus adductus Medial tibial torsion Internal femoral torsion

Out-toeing (less common than intoeing) External femoral torsion External tibial torsion

Assessing Torsional Profile Foot progression angle Forefoot alignment Hip rotation Thigh foot angle

Normal values +/- 2 std. deviations

Metatarsus Adductus Excessive amount of adduction of the

metarsals relative to the long axis of the foot

Most common congenital foot deformity 1/1000 live births F>M, left>right Most likely cause: intrauterine restriction 85-90% resolve spontaneously by 1 yr. old

(level B evidence)

Metatarsus Adductus Assessed by

abduction of forefoot to neutral position

Metatarsus varus: rigid deformity

Metatarsus Adductusmanagement

Flexible MA: stretching 5X at each diaper change

Flexible MA beyond 8 mo old or Metatarsus varus: referral for casting Biweekly casts, correction usually achieved

in 3-4 casts Extreme adduction of great toe: surgical

release of abductor hallucis done between 6-18 mo of age

Internal tibial torsion Very common cause of intoeing M=F, left>right 90% of patients resolve by 8 yrs.

Old (level B evidence) Avoiding prone sleeping and sitting

on feet enhances resolution Splints, shoe wedges, orthotics are

ineffective

Internal tibial torsion Surgical treatment has high

complication rate Compartment syndrome Peroneal nerve injury

Conditions supporting surgical approach: >8 yrs old Thigh-foot angle >3 std. dev. from mean family understands risks of surgery

Internal Femoral Rotation Excessive amount of medial version of

the relationship of the femoral neck to the distal femur

Family history, F>M Children often sit in “W” Usually diagnosed between age 3-6 yrs Bracing, shoe inserts, therapy is

ineffective Gradual improvement in over 80% of

patients (level B evidence) not association with hip or knee arthritis

Excessive internal femoral rotation

Internal Femoral RotationManagement

Reassure Assess hip ROM q 6 mo. Conditions supporting surgical

approach: >8 yrs old Deviation >3 std. dev. from mean family understands risks of surgery

External Femoral torsion Common in early infancy Intrauterine constriction May gradually improve during first

year of walking If no improvement at 2 to 3 yrs old

referral indicated because of association with hip or knee arthritis in adults and SCFE in teenagers (Level C evidence)

External tibial torsion Usually seen between 4-7 yrs old Right>left IFT with external tibial torsion,

termed miserable malalignment (very rare) association with patellofemoral pain, subluxation or dislocation

Refer

Angular variations Genu varum (bowlegs)

birth to 2 yrs old Genu valgum (knock-knees)

3 to 7 yrs old

Angular variations Most common reason is

physiologic or a normal developmental variation

Managed by serial measurements of intercondylar/intermalleolar distance

Lack of resolution should alert to possibility of pathology

Standard Intercondylar and Intermalleolar values of 196 caucasian childrensolid dots=mean valuecircles= 2 std. deviations

Angular variationswarning signs

Intercondylar or intermalleolar distance beyond 2 standard deviations

Height of child <25th percentile Genu varum that has been

progressing Asymmetry of limb alignment Persistence of physiologic varum or

valgum beyond 7-8 yrs old

Idiopathic toe walking Walk with toe-toe gait pattern in

the absence of any known cause Diagnosis of exclusion Prevalence not well described May have good ankle range of

motion or more fixed contractures

Idiopathic toe walking Etiology unclear Typically seen in children <4 yrs

old Often associated with subtle

neurological abnormalities such as speech and language delay

Idiopathic toe walkingmanagement

Examine child walking Stance phase Swing phase

Neurological and musculoskeletal exam

Passive stretching and observation If problem persists referral for

casting or bracing as child approaches school age

Osgood-Schlatter Traumatic partial separation of the

tibial tuberosity epiphysis Microavulsions caused by repeated

traction injury Localized pain, swelling,

tenderness over tibial tuberosity Ages 8-14 yrs (F) 10-15 yrs (M)

Osgood-Schlatter Typically vague history of onset

with mild, intermittent signs Occasionally with extreme pain

and localized tenderness Symptoms typically subside within

2 years and prognosis is excellent Occasionally some disability may

persist into adulthood

Osgood-SchlatterInvestigations

Diagnosis is based on typical clinical findings and plain lateral x-ray

Lateral x-ray Characteristic irregularity of apophysis

with separation from tibial tuberosity Fragmentation in later stages Patellar tendon ossicles

Ultrasound may be useful

Osgood-SchlatterTreatment

Benign, self-limiting RICE when acute Activities as tolerated Refer if older patient with

significant disability

Transient Hip Synovitis Acute, self limiting inflammation of

synovial lining characterized by pain, stiffness and a limp

Common, 0.4% -0.9% of pediatric visits to ED, M>F

Extrapolated lifetime risk 3% Etiology unclear

Viral Trauma allergic

Transient Hip SynovitisPresentation

Classically present as acute unilateral hip pain in 3-8 yr. old child

Hip may be in flexion and ext. rotation

Referred pain may be presenting c/o Occasionally associated with low

grade fever

Transient Hip SynovitisInvestigations

Inspect hip and knee Vitals CBC, ESR, CRP X-ray AP, frog-view If clinical suspicion of septic arthritis

Ultrasound If fluid then aspirate (GOLD STANDARD)

Transient Hip SynovitisInvestigations

Presence of any 2 criteria was 95% sensitive and 91% specific for septic arthritisEvaluation of 509 patients with irritable hip and limp, Taylor and Clark, 1994

Severe pain/spasm

Tenderness on palpation

T>38˚ ESR>20mm/hr

TransientSynovitis

11.5% 17.2% 7.9% 10.9%

Septic Hip

61.9% 85.7% 81% 90.5%

Transient Hip SynovitisInvestigations

Predictive probability of septic arthritis = 97.3% when: T>37˚ ESR>20 mm/h CRP>1.0 mg/dl Serum WBC> 11,000 cells/ml

mean age septic arthritis:5 yr 7mo N=27Mean age transient synovitis: 6 yr 7mo N=97 Jung, Row et al. 2003 retrospective study

Conclusion

It is important to understand the natural progression of pediatric orthopedic conditions. This allows for appropriate assurance, treatment or referral.

References Alessandro, Back pain in children- a common clinical

problem in children www.vh.org/pediatric/provider/radiology/BackPainInChildren/Diagnosis.html , 1996

Blankstein et al, Ultrasonography as a diagnostic modality in Osgood Schlatter disease. Arch Orthop Trauma Surg, 2001 121:356-539

Do T.T, Transient Synovitis as a cause of painful limps in children. Cur Op Ped, 2000 12:48-51

Lala, Wadel, MCCQE review notes. 19th ed. 2003 Toronto Notes Medical Publishing Inc.

Reamy et al, Adolescent Idiopathic Scoliosis: Review and Current Concepts. Am Fam Phys, 2001 64:111-116

References Sala et al, Idiopathic toe walking: a review, Dev Med

Child Neuro, 1999 41:846-848 Salter, Textbook of disorders and injuries of the

musculoskeletal system. 3rd ed. 1999 Lippincott Williams & Wilkins

Sass, Hassan, Lower extremity abnormalities in children. Am Fam Phys, 2003 68:461-468

Schewend, Geiger, Pediatric surgery for the primary care physician. Pediatr Clin N A, 1998 45:943-971

Taylor, Clark, Management of irritable hip: review of hospital admission policy. Arch Dis Child, 1994 71:59-63