CHAPTER 24 SPECIAL CONCERNS OF THE PEDIATRIC PATIENT ROTATIONAL DEFORMITIES Intoeing – “pigeon...
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Transcript of CHAPTER 24 SPECIAL CONCERNS OF THE PEDIATRIC PATIENT ROTATIONAL DEFORMITIES Intoeing – “pigeon...
CHAPTER 24SPECIAL CONCERNS OF THE PEDIATRIC PATIENTROTATIONAL DEFORMITIESIntoeing – “pigeon toed”, common.
Usually spontaneously corrects.Metatarsus adductus (packaging defect)
– stretching and casting (associated with hip dysplasia.
Talipes Equinovarus.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
CHAPTER 24SPECIAL CONCERNS OF THE PEDIATRIC PATIENT (Cont’d.)
Club Foot:Metatarsus adductusEquinus (foot flexion)Always check hips
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
ANGULAR DEFORMITIESGenu varum (bow legged)Genu valgum (knock-kneed)Normal Exam:
2-3 years old, bow legged. 3 years old, knock-kneed. 7 years old, slightly knock-kneed.
Pathologic if unilateral, painful or asymmetric.
Consider rickets (vitamin D), renal disease, dysplasias, (dwarfism)
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
ANGULAR DEFORMITIES (Cont’d)INFANTILE BLOUNT’S DISEASE: Unknown
etiology: Medial tibial physis ceases to function
appropriately. Leads to relative overgrowth laterally. Genu varum. Black females. Large kids. Early walkers <11 months. Treatment – Surgery.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
FOOT DEFORMITIESCLUB FOOT:1 in1,000 live births, half are bilateral.2.5x more common in males.Inheritance multi-factorial.Metatarsus adductus.Equinus and heel varus.Not packaging defect.Always screen for hip dysplasia.Treatment: Casting for 3 months, then
surgery.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
FLAT FEETPes Planus:Absent arch which reappears when up on tip
toes.Treatment: Reassure family.
Rigid flat foot:Tarsal coalition (calcaneus, talus, navicular
may fuse abnormally). Can cause decreased motion and increasing pain.
Treatment: Surgery.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
HIP DISORDERSDEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)Genetic and can arise during development.1 in 1,000 live births.Female.First born.Breech position.Family history.Allis sign (abnormal skin folds).
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
HIP DISORDERSDEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) (Cont’d.)Galeazzi sign (decreased height of affected knee).2 provocative tests:
Ortolani maneuver – relocates hip. Barlow maneuver – dislocates hip.
X-rays not helpful until after age 4 months. Pelvis/hips not ossified at birth.
Ultrasound better after 2 weeks of age. 5% are missed by ultrasound. Must repeat tests for 1 year.
If untreated, leads to arthritis.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)Displacement or slipping of part of femoral
head through growth plate.11-13 years old for girls.13-15 years old for boys.Related to hormonal disorders (chubby,
short, hypogonadism).More common in Blacks.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Cont’d.Complaint of knee or hip pain (obturator
nerve referral pain).
Limp, painful internal rotation of hip.
Treatment: Surgery (pinning).
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
LEGG-CALVE PERTHES DISEASEIdiopathic necrosis of femoral head.Usually 4-8 year old males, small for age,
active.Limited abduction and external rotation.Disease course takes 2 years.Treatment: Involves maintaining femoral
head in socket. Usually unilateral.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
GROWTH PLATE FRACTURESUnlike adults, children rarely injure ligamentsbecause the physis is weaker.SALTER-HARRIS CLASSIFICATIONS:Type I:
Fracture goes straight through growth plate. X-rays within normal limits.
Type II: Fracture goes through physis and metaphysis. Most common. Good prognosis.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
GROWTH PLATE FRACTURES (Cont’d.)Type III:
Fracture goes through physis and epiphysis. Intraarticular. Will require surgery. If left untreated, leads to growth arrest.
TYPE IV: Fracture goes through epiphysis, growth plate and
metaphysis. Surgery. High complication of growth arrest.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
GROWTH PLATE FRACTURES (Cont’d.)Type V:
Rare injury.Compression injury or crush injury to the growth plate.
Leads to growth arrest.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
NEUROMUSCULAR DISORDERSCEREBRAL PALSY
Brain lesion which leads to non-progressive Neurologic condition.Perinatal.3.5 per 1,000 live births.Classifications:Quadriplegic – all four extremities.Diplegic – lower extremities.Hemiplegic – one side of body.Spasticity: high muscle tone.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SPINA BIFIDADescribes variety of neural tube defects.Severity depends on which level is affected.1 in 1,000 live births.Meningocele: Vertebral arches unfused.
Meningeal sac is visible. Myelomeningocele: Neural elements
exposed without sac.Rachischisis: Neural elements exposed
without sac.TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SPINA BIFIDA (Cont’d.)Occurs in embryologic development.Women must have Folate > 400 units per
day.No hot baths or saunas during first trimester.Diagnosis by 16 weeks gestation with
ultrasound.Amniocentesis confirms diagnosis (increased
Alpha Feta protein).Treatment: Immediate closure of defect.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SPINA BIFIDA (Cont’d.)
Thoracic level causes spine and hip problems.Lumbar and sacral levels cause knee and foot
problems.L4 gives quadriceps which allows
ambulation.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SCOLIOSISThree-dimensional curvature of the spine.IDIOPATHIC:Detected around age 10-12.Only 10% severe enough to warrant surgery.“Forward bend test”. Rib hump on clinical
exam.Less than 25 degrees – observe.25-45 degrees – brace.Greater than 45 degrees – surgery (fusing
spine).
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
SCOLIOSIS (Cont’d.)
CONGENITAL:Look at heart and kidney abnormalities.
NEUROMUSCULAR:Cerebral palsy, spina bifida, muscular
dystrophy, spinal cord injuries.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
CHILD ABUSENon-accidental injuring of a child.Mandatory reporting laws for physicians in
all 50 states.1,000 deaths per year.Types of child abuse:
Emotional. Medical neglect. Sexual. Physical.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
CHILD ABUSE (Cont’d.)PHYSICAL ABUSEMultiple fractures with various stages of
healing.Posterior rib fracture.Bilateral acute long bone fractures.Complex skull fracture.Long bone fracture in non-ambulatory
children (spiral fracture of long bones no longer pathopneumonic for child abuse).
Skeletal survey.TONY JABBOUR, MD ORTHOPAEDIC SURGERY
INFECTIONOSTEOMYELITIS : Infection of bone.
Osteomyelitis generally spreads hematogenously. Dissemination of bacteria in blood stream.
In children, structures of blood vessels of metaphysical region predisposes them to infection.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
INFECTION (Cont’d.)SUBPERIOSTEAL ABSCESS:Staph aureus – most common in all ages.Streptococcus – less than 4 years of age.E-coli – neonates.Sickle cell anemia – staph aureus, salmonella.Pseudomonas – stepping on a nail while wearing
sneakers.Labs: CBC with differential, sed rate, CRP,
blood cultures, x-rays and bone scan, aspiration.Treatment: Six weeks IV antibiotics, rarely
surgery.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY
INFECTION (Cont’d.)
SEPTIC ARTHRITIS: Infection in joint.
Bacteria invade joint synovium.Usually sicker than patients with
osteomyelitis.Treatment: Emergent surgical drainage.Differential diagnosis: Juvenile rheumatoid
arthritis.TONY JABBOUR, MD ORTHOPAEDIC SURGERY
INFECTION (Cont’d.)TOXIC SYNOVITIS: Acute non-bacterial joint Inflammation.
Self-limiting.Normal sed rate and C-reactive protein.No abnormal joint fluid.
TONY JABBOUR, MD ORTHOPAEDIC SURGERY