21798765 Pediatric Orthopedics

8/14/2019 21798765 Pediatric Orthopedics

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Pediatric

Orthopedics: LowerExtremity Disorders

St. Francis UniversityPA Program

September 25, 2001

Todd Lang, MD

Family Practice


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What is Peds Ortho? Fundamentals of kids bones Many unusual congenital deformities Developmental (Congenital) Hip

dysplasia

MY Opinion: best done at a tertiarycare center unless very routine orspecially trained surgeon


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Goals Remember the foot anatomy!

Learn a few new words

See some interesting pictures

Generally describe disorders and

treatments

Create limited differentials

Use AAP guidelines for hip dysplasia


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Dorsal View


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Lateral View


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Medial View


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Varus Bent or twisted inward toward the

midline of the body

Bowlegged is varus def. of the knee Can be confusing because will

occasionally refer limb instead of body

I try to avoid this word, since there areother ways to speak

Orthopods love to use it


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Valgus Bent or twisted away from midline of

body or limb

Orthopods refer to knock-kneed asgenu valgum as is deformity of the

knee joint away form the body midline

Still a rotten set of words


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Equinus Like a horses foot

Refers to having plantarflexion due to

shortened heel cord

Leads to toe-toe gait not heel-toe


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Adduction Abduction Adduction moves it towards the

midline of the body or limb.

Think of ADDing it to the body Fingers adduct

Pronounce A D duct

Abduction moves it away Pronounce A B duct Doing the splits abducts hips.


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Arthrodesis Surgical stiffening (fusion) of a joint

Triple Arthrodesis: fusion of the

talonavicular, talocalcaneal,

calcaneocuboid joints to stabilize the

foot


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Osteotomy Simply means cutting a bone

Used throughout surgery


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In-Toeing=Pigeon Toed

Ddx:

Metatarsus adductus

Internal tibial torsion Internal hip rotation

Can be from contracture

Can be from excessive femoral anteversion

All are worsened by childhood positions Reverse tailor

Prone with internal rotation


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Diagnosing In-Toeing Compare position of patella to foot Check malleoli related to tibial tubercle with leg

over table edge Lie them prone and flex knee 90 degrees and

measure hip internal and external rotation (>30deg difference is abnl)

Examine the foot for hindfoot line meeting toes Examine foot for convex lateral

border/concave medial border


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Tx Tibial torsion No evidence that in-toeing causes

adult trouble

Treat with reassurance Avoid problem postures

Sit in chair

Sleep on side Resolves with growth and dev. Shoes, stretching not helpful


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Hip Contracture Tx Roller skating!

Avoid positions as above

Usually resolves by age 6

Occasionally surgery needed if not

better by age 8


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Metatarsus Adductus Cause of toeing in

Mild, moderate,

severe Imagine heel

bisector line

Normally bisects

toes 2&3

Helps grade

severity


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Metatarsus Adductus Bilateral in 50%

More common in

1st

born 10% of pts have

acetabular

dysplasia so

check the hips


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Treatment of Met Add Treatment is shoes or serial casting and

stretching to restore normal flexibility

Start early in life Most mild cases resolve spontaneously Use conservative tx before surgery Surgery for:

Pain Deformity

(Appearance)


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Metatarsus Adductus


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Surgery for Met Add After fail conservative tx

2-4 yr-Tarsometatarsal capsulotomiesCuts ligamentous joint capsule

4 yr-Multiple metatarsal osteotomies

Cuts bones


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Surgery for Met Add

Closing wedge

osteotomies at the

base (not head) ofthe metatarsals

Internal fixation

holds until healed


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Calcaneouvalgus feet From in utero foot on uterus wall

Dorsiflexed, forefoot abduction, heel

valgus Ass. w/ext tibial torsion

Normal plantar flexion


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Calcaneouvalgus feet Distinguish from:

Congenital vertical talus

Posteromedial tibial bowing

Paralyzed gastrocnemius

PE+AP/lat simulated wt bearing Xrays Usually requires no tx

Dorsiflexion resolves in 6 mo Tibial bowing resolves with 6-12 mo of

walking


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Flatfoot=Pes Planus Usually flexible: if not weight bearing,

looks like normal arch present

Variety of opinions on correctapproach to flexible flatfeet

Normal arch develops in later

childhood Many adults have some degree offlatfeetmost without sx


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Flexible Pes Planus This is among the most aggravating

condition for parents and grandparents

My brother couldnt go in toe the Warbecause he had flat feet Reassurance and reexamination Evaluate for other orthopedic problems Are they telling you he cant walk right or

that they thing his foot looks funny?


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Tx: Flexible Pes Planus 0-3 years old: no treatment unless very

strong family hx of persistent flatfeet

3-9 years, no sx: explain to parents thatwe dont know what is best

No long term follow up studies for natural

history

No evidence that shoe modification alters foot

structure


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Tx: Flexible Pes Planus 3-9 y/o with sx related to FPP:

Arch support, special shoes

Custom orthosis, sturdy shoes

10-14 y/o no sx: no treatment

10-14 y/o with sx:

Molded orthosis, sturdy shoes

Verify that it corrects anatomy with Xray


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Tx: Flexible Pes Planus

Little role for muscles in maintainingthe archstrengthening not helpful

Surgery should only be done if:

Pain necessitates itnot cosmetics

Parents/pt will trade inversion/eversion for

relief of pain and disability

A version of arthrodesis usually done

Selection of the surgery is why there is

a peds ortho fellowship!


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Flexible Flatfeet Standing Xrays in both AP and lateral

planes, & nonstanding lateral oblique

views necessary to evaluate severity ofdeformity Shows the talocalcaneal divergence on

the dorsoplantar view and plantar flexion

of the talus on the lateral view. Whoopi!


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Clubfoot AKA Talipes Equinovarus

1/1000 incidence

50% with bilateral deformity

Do abnormal bones deform soft tissue?

Do abnormal soft tissues deform bone?


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Clubfoot Anterior view:

adduction and

supination offorefoot and

equinus of

hindfoot.


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Clubfoot

Posteriorview:inversion,plantar flexion,and internalrotation ofcalcaneus, aswell as cavus

deformity withtransverseplantar crease.
http://home.mdconsult.com/das/book/body/0/868/I1119.fig


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Evaluation of Clubfoot Roentgenograms

Nonambulatory child: anteroposterior and

stress dorsiflexion lateral of both feet. Ambulatory child: Add Anteroposterior

and lateral standing

Analyze various angles formed bybones to determine problems and

solutions


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Normal Foot Analysis Dorsiflexion

lateral view of

normal leftfoot.

Talocalcaneal

and

tibiocalcanealangles


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Clubfoot Treatment Initially nonoperative

Manipulation

Casting Repeat Q1-2 weeks

Works for some (15-80%!)

Surgery

Necessary for rigid deformities Releases ligaments to move bones


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Surgery Necessary for rigid deformities

Releases ligaments to move bones

Later, uses osteotomies to move bone

Later, uses arthrodesis to fuse bones


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Out-Toeing DDx:

Contracture

External femoral torsion (retroversion)

External tibial torsion

Calcaneovalgus

Flat feet


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Dx Out-Toeing Often ass with genu valgum deformity

May be worsened with prone sleeping

or wide diapers pad and walkers Examine patella and malleoli to

localize lesion


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Tx Out-Toeing Stretch if hip deformity

Avoid Aggravating positions

Observe and reassure, resolution

Surgery rarely needed


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Bowlegs=Genu varum

Normal in most pts

Spont resolution in 95% with walking

Converts to knock-knee, then resolves

age 4-7

stand with touching malleoli, measure

inter-femoral condylar distance


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Differential Ddx: rickets, Blounts Dz (tibia vara)

Radiographs help if severe bowing


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Blounts Dz=tibia vara Differential growth of upper medial

tibial epiphysis-maybe from abnl

pressure C/b unilateral (physiologic

bow=bilateral) More in obese Gets worse, not better Early recognition matters


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Forcesin utero

See why thisbends yourtibia?

Physiologicgenu varum

bowlegs

Resolves on6-12 mo. ofwalking


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Normal Tibiofemoral Angle Time bends your bones

Genu Valgum


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Genu Valgum

Knock-Knees Ddx: physiologic, asymmetric growth,

metabolic disorders, skeletal dysplasia,congenital abnormalities, neuromusculardisorders

Causes other than physiologic or post-traumatic are unusual.

Physiologic occurs from ages 3-5 andresolves from 5-8 years old.

History and physical should suggest causesbesides physiologic.


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Torsional Profile There are a series of angles that can be

calculated from the position of various bones& joints in relation to each other

These are relatively simple to calculate butnot simple to explain without a child

The angle or distorted differently for differentorthopedic disorders and changed somewhatthroughout growth and development.

These are pretty esoteric charts.


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Internal Femoral Torsion

This is the most common cause of in-toeing in children > 2 y/o age.

2:1 female to male ratio Related to generalized ligamentous

laxity

Treatment is usually observation. Correction usually occurs

spontaneously around school age.


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Limb Length

Discrepancy Makes an odd gait

Causes scoliosis

May cause back pain

Compensation may injure other joints


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Limb Length

Discrepancy 37% of the leg length comes from

distal femoral physis.

28% comes from proximal tibialphysis.

Thus, problems around the knee can

cause largest length discrepancies


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Bone Age Bone age is and important concept in

growth and development

It is based on a 1950 Atlas and iscalculated from a radiograph of the lefthand and wrist

This, coupled with growth chartspredicts remaining growth and helpspredict need for correction.


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LLD Diagnosis Not always simple because of

compensatory deformity

Scoliosis Contracture

Use both physical and radiographic

study


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Scanogram

Radioopaque

measuring rule

Threeexposures

Helps objectify

bone measures

LLD DDx


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LLD DDx Damage to the physis

Trauma Infection

Asymmetrical paralytic conditions poliomyelitis

or cerebral palsy Conditions that affect bone growth by

stimulating asymmetrical growth Tumors

juvenile rheumatoid arthritis postfracture hypervascularity.

Idiopathic unilateral hypoplasia/hyperplasia


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LLD Treatment

Tailored to condition and patient chars.

Lengthen one or shorten the other

Shoes/orthotics/prosthetics Surgery

Not simple because of continued growth

and interpersonal variability Final LLD of 1.5cm excellent outcome


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Surgery for LLD

Epiphysiodesis-artificial closure of the

growth plate

Shortening or lengthening of diaphysis Tightens or slackens the muscles

Allows continued epiphyseal growth

Each has own set of complications


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Dev. Hip Dysplasia

developmental hip dysplasia detected

in 1/5000 infants at 18 months.

High litigation area of medicine

This makes people order more things

in hopes that they will protect self

Does it work? No evidence that it

does.

Guidelines help defend you.

D Hi D l i


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Girl (newborn risk of 19/1000). + Fam Hx developmental hip dysplasia newborn

risk boys of 9.4/1000 and 44/1000 girls Breech presentation

newborn risk boys of 26/1000 and 120/1000 girls Breech may be ass. with later hip problems

Acetabular dysplasia-Xray at 6 months?

Consider screening test in the highest prevalence

groups

Dev. Hip Dysplasia

Risk Factors

C it l Hi D l i


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Hips must be examined at every well-babyvisit according to the schedule for well-babyexams.

If there is suspicion of Dev. Hip Dysplasia: Re-exam by other PCP

consultation with an orthopod,

US if infant < 5 months

Radiography if infant > 4 months Between 4-6 months of age, US and radiography

equally effective diagnostic imaging studies.

Congenital Hip Dysplasia

Follow Up Exams

AAP P ti G id li


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AAP Practice Guideline

Hip Dysplasia

All newborns are to be screened by

physical examination.

screening done by a properlytrained health care provider:

physician, pediatric NP, PA, or PT.

US all newborns not recommended


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Hip Dysplasia

If a + Ortolani or Barlow sign found at

newborn examination, refer to ortho

If results of birth physical are "equivocally"positive (i.e., soft click, mild asymmetry, but

neither an Ortolani nor a Barlow sign), then

follow-up exam by peds in 2 weeks

Peds should reexamine the hips at 2 weeksbefore refer to ortho or US

G


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Hip Dysplasia

If the results of newborn exam are + (i.e.,

presence of an Ortolani or a Barlow sign),

an US examination not recommended.

Treatment not influenced by US, but based

on exam.

If the results of the newborn exam +,

pelvis/hips radiograph not recommended use of triple diapers not recommended.


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Take Homes

If a kid has one skeletal problem, dont miss

the rest of their skeletal problems.

Many orthopedic diseases of childhoodresolve on their own.

It is your duty to be able to determine which

ones will not to resolve on their own.

Use your specialists for these diseases.

Use AAP guidelines for hip dysplasia.


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Take Homes

Recall basic anatomy of foot and ankle Understand and use words defined in this

lecture Be able to describe the basic deformity of

the above conditions Create a limited differential diagnosis for

genu valgum and varum, in-toeing andout-toeing.


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Bibliography Clinical practice guideline: early detection of

developmental dysplasia of the hip. Pediatrics 2000

Apr;105(4 Pt 1):896-905.

Canale: Campbell's Operative Orthopaedics, 9th ed.,Copyright 1998 Mosby, Inc.

Behrman: Nelson Textbook of Pediatrics, 16th ed.,

Copyright 2000 W. B. Saunders Company

http://www.medmedia.com/med.htm

Wheeless Textbook of Orthopaedics

http://www.foottalk.com/index.htm

Mercier, L. Practical Orthopedics, 5th Ed. Mosby 2000.
http://www.medmedia.com/med.htmhttp://www.foottalk.com/index.htmhttp://www.foottalk.com/index.htmhttp://www.medmedia.com/med.htmhttp://www.medmedia.com/med.htm

21798765 Pediatric Orthopedics

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