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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AAP Practice Guideline
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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AAP Practice Guideline
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