Children’s Orthopaedics Common Lower limb Problems By Linda Walsh COOP Practitioner

Objectives Introduction to COOP Overview of common children’s orthopaedic conditions Overview of optimal management of these conditions What not to miss! When and How to Refer Top tips summary with a focus on lower limbs and gait Each condition is a whole topic in and of itself!

What is COOP?? Children’s Orthopaedic Outreach Project Charity Funded 3 year project Now Substantive Posts 2 Extended Scope Physiotherapists 2 Strands of the Service General MSK COOP Neuromuscular COOP Linda Walsh Lucy Llewellyn Stanton

COOP Objectives Enable more efficient use of consultant clinic time Introduce outreach work in paediatric orthopaedics To establish care pathways, protocols/guidelines To use our care pathways, protocols/guidelines and standardised assessments to enable participation in research, development of national guidelines and prospective databases. (virtual, SKYPE, Telephone)

COOP Clinics Now offer Physiotherapy Led Face to Face Screening and Follow up clinics To note; these clinics run alongside consultant led clinics Now running SKYPE clinics Now running Telephone clinics Run weekly outreach clinic at Newham hospital Run neuromuscular outreach clinics in special schools Offer a point of contact/liaison for queries between community and orthopaedics

PAEDIATRIC Assessment And Treatment “Consistency is more valuable than talent” Have a consistent approach-complete a thorough history and a thorough examination Tenacity

Basic Premise Assessment Is presentation normal? Will the presentation get better? Is there any advice/Rx/intervention that can help? Evidence??

Distinguishing what is NOrmal Normal variants Normal gait Normal motor milestones Normal range of motion Variations related to families, race, age Pediatric REMS, Foster 2008 Intro-Look-Feel- Move- Ax function, Foster 2011

Symmetry Symptoms Stiffness Systemic Disease Skeletal Dysplasia The 5 Orthopaedic S’s Symmetry Symptoms Stiffness Systemic Disease Skeletal Dysplasia

FEET

Metatarsus Adductus Calcaneo-Valgus CTEV Curly toes Flat Foot Common COnditions Metatarsus Adductus Calcaneo-Valgus CTEV Curly toes Flat Foot Tarsal Coalition Pes Cavus Severs

FooT - Assessment Met adductus; normally improves once child is steady on feet and with stretches.

Calcaneovalgus V’s CVT

Congenital Talipes Equinovarus

Flat Feet Clinical ax: Establish if fixed or flexible (90%) Look for medial arch on tiptoes Look for medial arch with big toe extension (Jacks test) Check ROM Need to rule out: Tarsal coalition CVT Neuromuscular disorder What to do next: UCBL for painful flat feet Ortho referral for fixed flat feet

flexible flat foot.......toe-standing test

Curly Toes Do nothing as most correct. If anything needs doing – not until the age of 4 years

Severs: (Calcaneal apophysitis) What is it: Traction apophysitis of achilles insertion Associated with rapid growth spurt Who gets it: Common 7-10. Boys> Girls. Pain with activity. Sporty children Clinical Ax: Tenderness over the Calcaneus Tight hamstrings and gastro-soleus complex What to do next: Physiotherapy for advice, stretching, strengthening, pain management Natural progression: Related to growth……..self limiting. Need advice regarding mx. 18

In-toeing gait Clinical assessment: Check symmetry Femoral anteversion/Medial tibial torsion/Metatarsus adducutus Natural progression: Femoral anteversion; normally self limiting by 8 years Out toeing: Femoral retroversion

Assessing hip rotation Medial Rotation Hip Lateral Rotation Hip

Femoral antetorsion

Assessing tibial torsion: Thigh-foot angle Transmalleolar axis Determine axes Measure angles

Assessing tibial rotation

“Genu valgum Squinting patella/Knock knees” Who gets it: Normal from 2 – 7 Clinical assessment: Symmetry Range of motion Intermalleolar distance (<8) What to rule out: JIA, Asymmetry, Torsional problem, trauma

Asymmetry

Genu Varum “Bow legs” Normal up to 18mths/2 Clinical assessment: Check symmmetry Intercondylar distance with feet together What to rule out: Rickets, osteogenesis imperfecta, blounts disease, post trauma

Osgood-Schlatters What is it: Traction Apophysitis Who gets it: Boys> Girls Age: Boys 13-14 Girls 11-12 Sporty, worse with activity Clinical assessment: Pain with palpation of tibial tuberosity Pain with resisted knee extension Often associated with muscle tightness! XR not necessary as clinical diagnosis. In cases of excessive pain and swelling XR ?BONY TUMOR? Rare but this is a site for possible osteogenic sarcoma in 10-30yrs 28

Hips

Complete hip ax for all children complaining of knee pain. The hip NB children are poor locators of pain, and hip pain is often referred to the knee! Complete hip ax for all children complaining of knee pain. Transient Synovitis Perthes Slipped Upper (Capitol) Femoral Epiphysis (SUFE) Traction Apophysitis (ASIS)

ABNORMAL HIP MOTION THINGS TO WATCH OUT FOR DDH PERTHES DISEASE SCFE

Pathologies to consider Infants and toddlers Hip dysplasia Neuromuscular disease -Cerebral palsy Toddlers Legg-Calve-Perthes disease Pre-teens Slipped Capital femoral epiphysis

DDH detection Newborn 6 week check Loss of abduction Galeazzi test Ortolani test Barlow test Useful up to 2-3 months of age Loss of abduction Risk factors; Breach positioning, Family history, Positional Talipes/MTA, Oligohydramnios

DDH

Perthes Osteochondrosis of femoral head Typically 4-10 yrs & unilateral ♂ ›♀ Clinical assessment: Limp, low grade ache thigh, groin, knee Abd + IR Density & flattening of femoral head Prognosis depends on age of onset /severity Rx- decrease synovitis and weight bearing

Slipped Upper Femoral Epiphysis Presentation: Girls 9-15 Boys 11-18 (Perthes 4-10) Most common with rapid growth and in the obese Assessment Limited internal rotation or resting in external rotation with flexion What is it: Unstable growth plate fracture Most common hip disorder in adolescents What to do: Send to A and E

Toe Walking Neurological immaturity, thus normal variant in young children Autism and behavioural abnormalities Congenital short TA Cerebral palsy BEWARE UNILATERAL TOE-WALKER

TOP TIPS: Assess!!! Remember the 5 S’s Symmetry Stiffness Symptoms Skeletal Dysplasia Systemic Illness Exclude Potential Worrying Pathology If in doubt, liaise with colleague and complete referrals

Contact Details Email; lindawalsh@nhs.net Linda.walsh@bartshealth.nhs.uk COOP@bartshealth.nhs.uk Telephone; 0203 594 6960 or 0203 594 1504 Fax; 0207 377 7302 Address; Clinic 3, 7th Floor, North Tower, Royal London Hospital, Whitechapel E11 Referrals; Please complete letter with referral details. Referrals accepted via fax, email and post.

Thank you!!!