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

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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.

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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).

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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.

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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).

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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.

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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.

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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.

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GROWTH PLATE FRACTURES (Cont’d.)Type V:

Rare injury.Compression injury or crush injury to the growth plate.

Leads to growth arrest.

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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.

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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).

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SCOLIOSIS (Cont’d.)

CONGENITAL:Look at heart and kidney abnormalities.

NEUROMUSCULAR:Cerebral palsy, spina bifida, muscular

dystrophy, spinal cord injuries.

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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.

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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.

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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.

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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