common childhood problems of the lower limb (cong. & dev.)
TRANSCRIPT
COMMON CHILDHOOD PROBLEMS OF THE LOWER LIMB (CONG. & DEV.)
Given Silishebo SishekanoMBChB IV
Orthopedics I tutorialFebruary 23, 2017(14h00-16h00)
TABLE OF CONTENT1. Principles of congenital development.2. Developmental Hyperplasia of the hip(DDH).3. Perthes disease.4. Recurrent dislocation of the patella.5. Congenital Talipes Equinovarus
(Club Foot)6. Syndactyl
1. PRINCIPLES OF CONGENITAL DEVELOPMENT.Many congenital conditions occur for no obvious reasons but;1. Genetic disturbances.2. Drugs3. Infections.4. Trauma.5. Anoxia.6. Compression inuteroare all factors known to cause maldevelopment if they occur at a time when development is critical.
2. DEVELOPMENTAL HYPERPLASIA OF THE HIP(DDH) It is the abnormal development of the hip resulting in dysplasia and dislocation.Pathology: Capsular laxity is the dominant feature in the unstable hip The tight fit between the femoral head and the acetabulum is lost The femoral head can be made to slide in and out of the acetabulum.
Risk factors: Female (Girls:Boys 8:1) Positive family history Environmental factors Position in utero (Breech)
DIAGNOSISDiagnosis is clinical limited abduction of the flexed
hip (<50-60°) affected leg shortening results in
asymmetry in skin folds and gluteal muscles, wide perineum.
Barlow’s test (for dislocatable hip) flex hips and knees to 90° and
grasp thigh fully adduct hips, push posteriorly
to try to dislocate hips
Ortolani’s test (for dislocated hip) initial position as above but try to
reduce hip with fingertips during abduction
positive test: palpable clunk is felt (not heard) if hip is reduced
Galeazzi’s sign knees at unequal heights when hips and
knees flexed dislocated hip on side of lower knee difficult test if child <1 yr Trendelenburg test and gait useful if
older (>2 yr)
INVESTIGATIONS U/S in first few months to view
cartilage Follow up radiograph after 3 mo X-ray signs (at 4-6 mo): false
acetabulum, acetabular index >25°, broken Shenton’s line, femoral
Neck above Hilgenreiner’s line, ossification centre outside of inner lower quadrant (quadrants formed by intersection of Hilgenreiner’s and Perkin’s line)
TREATMENT 0-6 mo: reduce hip using Pavlik
harness to maintain abduction and flexion
6-18 mo: reduction under GA, hip spica cast x 2-3 mo (if Pavlik harness fails)
>18 mo: open reduction; pelvic and/or femoral osteotomy
COMPLICATIONS Redislocation, inadequate
reduction, stiffness AVN of femoral head
3. PERTHES DISEASE. Ideopathic AVN of femoral head, presents
at 4-8 yr of age 12% bilateral, M>F = 5:1, 1/1,200
Associations Family history Low birth weight Abnormal pregnancy/delivery ADHD in 33% of cases, delayed bone age
in 89% Second-hand smoke exposure Asian, Inuit, Central European
Key features AVN of proximal femoral
epiphysis, abnormal growth of the physis.
Eventually remodelling of regenerated bone.
CLINICAL FEATURES Child with antalgic or
Trendelenburg gait ± pain Intermittent knee, hip, groin, or
thigh pain Flexion contracture (stiff hip):
decreased internal rotation and abduction of hip
Limb length discrepancy (late)
Investigations X-ray: AP pelvis, frog leg laterals May be negative early (if high
index of suspicion, move to bone scan or MRI)
Eventually, characteristic collapse of femoral head (diagnostic)
MANAGEMENT Goal: To preserve ROM and keep
femoral head contained in acetabulum.
Non-operative physiotherapy: ROM exercises brace in flexion and abduction x
2-3 yr (controversial)
Operative Femoral(varus) or pelvic
osteotomy (>8 yr of age or severe)
Prognosis better in males, <5 yr, <50% of femoral head involved, abduction >30°
60% of involved hips do not require operative intervention
Natural history is early onset OA and decreased ROM
4. RECURRENT DISLOCATION OF THE PATELLAAetiology:Congenital Ligament Laxity hypoplasia of lat. Femoral condyle Flattening of Intercondylar groove Patellar maldevelopment Primary muscle defect Genu valgum
Acquired Genu valgum Inequality of growth of condyle Weakness of Quads Contracture fibrosis
PRESENTATION More common in girls Often B/L Acute pain with knee stuck in flexionIn dislocated state: Visually obvious Tenderness SwellingBetween attack Patella alta Gen. lig. Laxity Apprehension test +ve
INVESTIGATIONSX-ray(skyline) Dislocation High-riding patella Other anatomical abnormalityMRICT-SCAN
MANAGEMENT Transplantation of patellar tendon
medially Near maturity: Transplant block of
bone bearing insertion of tendon more medially and distally Common comp: Osteoarthritis
Younger-Release vastus lateralis tightness with reefing of medial capsule.
4. CONGENITAL TALIPES EQUINOVARUS (CLUB FOOT) Muscle contractures resulting in
CAVE deformity Bony deformity: talar neck medial
and plantar deviated; varus calcaneus and rotated medially
Around talus; navicular and cuboid medially displaced
1-2/1,000 newborns, 50% bilateral, occurrence M>F, severity F>M
Etiology Intrinsic causes (neurologic,
muscular, or connective tissue diseases)
vs. extrinsic (intrauterine growth restriction), may be idiopathic, neurogenic, or syndrome-associated
Fixed deformity
EXAMINATIONPhysical examination Examine hips for associated DDH Examine knees for deformity Examine back for dysraphism
(unfused vertebral bodies)
X-ray
MANAGEMENT Largely non-operative via Ponseti
Technique (serial manipulation and casting)
Correct deformities in CAVE order Change strapping/cast -2wk Surgical release in refractory case
(rare)– delayed until 3-4 mo of age
3 yr recurrence rate = 5-10% Mild recurrence common; affected
foot is permanently smaller/stiffer than normal foot with calf
muscle atroph
5. SYNDACTYL Fusion of digits Relatively common Due to failure of separation of the
digits in uteroToes: Syndactyly of toes does not cause
functional limitations. Surgery to separate affected toes
is not advised.
THANK YOU FOR PAYING ATTENTION.