Paediatric Orthopaedics in General Practice Mr Graeme S. Carlile Consultant Paediatric Orthopaedic Surgeon The Ipswich Hospital

Learning objectives Overview of common paediatric orthopaedic conditions presenting to a General Practitioner Asymmetrical creases & DDH Knock knees, bow legs, in-toeing Kids feet & orthotics? Toe walking Leg pains… Teenage pain, the apophysities What not to miss… Parents want ‘referral to the specialist’…

Ipswich DDH

Asymmetric creases in DDH Often ‘picked up’ by health visitor Can be thigh, groin or buttock Normal in a third child, no DDH Abnormal in two thirds! Considerable work load for GP & secondary services Where do you draw the line?

Asymmetric creases in DDH Abnormal clinical examination Leg length discrepancy (Galeazzi) Limited abduction Clinical instability – Ortalani +VE = Ultrasound scan Absolute Risk Factors Family Hx DDH Breech GP’s can refer directly for USS

Ortolani’s Sign v Barlow Palpable sensation of provoking the femoral head into subluxation, dislocation or reduction, ie: INSTABILITY NOT an AUDIBLE “click” Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res. 1976 Sep;(119):6-10.

Defensive medicine? Clarke NM et al. Twenty years experience of selective secondary screening for CDH. Arch Dis Child. 2012 May;97(5):423-9.

Knock knees, bow legs & in-toeing Extremely common Cause considerable parental anxiety Variations around normal growth & development; normal variants Rarely pathological, examine hips Should be symmetrical Often noticed by nursery / relative Attributed to falling / tripping

Normal lower limb development

Genu Valgum – Knock knees Bilateral genu valgum Commonly physiologic Rarely rickets or skeletal dysplasias Unilateral genu valgum Considered pathological Previous physeal injury / growth disturbance Refer Significant deformity Interference with gait Pain Unilateral

Genu Varum – Bow legs Bilateral genu varum Refer – as previous Commonly physiologic below 2 yrs Unilateral pathological Rickets Blouts disease - children on 95th centile for weight - early walkers - unilateral or bilateral - Afro-Caribbean predominance - Bimodal: infantile & adolescent forms Refer – as previous

In-toeing – Pigeon Toeing / Feet

Flat feet Flexible & correctable or not? Medial arch reconstitutes on tip toe stance Flexible – normal, no Rx Rigid flat foot = referral Symptomatic? Orthotics…

Flat feet & orthotics Temptation to prescribe due to parental pressure… Prospective RCT, 129 Px’s, 3 year follow up; Wearing inserts does NOT influence the flexible flat foot Evidence based medicine: Orthotics will not change the shape of the foot long term Orthotics do not influence growth & development The foot shape only changes when the orthotic is used

‘Limited’ indications Symptomatic flat foot – as a trial Symptomatic +/or rigid flat foot Practical Considerations Compliance child / parent Rapidly growing foot = frequent changes Cost & inconvenience

Cavovarus Feet – High Arches Hindfoot – varus Midfoot – cavus Forefoot – plantarflexion & lesser toe clawing Deformity always pathologic in children DD: HSMN, spinal dysraphism, muscular dystrophies, CP, Freidreich’s, polio, other neuro Full neurologic workup: CK, MRI brain & whole spine, neurology opinion, possibly nerve conduction studies Please refer

Curly toes

Syndactyly

Toe walkers Very common under 5 Majority are habitual toe walkers Can they / have they ever got their heels onto the ground? Majority have & can Those that cannot, ?neuro cause CK to r/o muscular dystrophy Consider a paeds neuro opinion Rx; non op, casting, strecthing, surgery

Leg pains Often around the time of a ‘growth spurt’ Bilateral & symmetrical pain distribution Long standing over months Other issues at home / school Red flags – waking with night pain, weight loss, Bloods – FBC, ESR, CRP, bone profile Radiograph – joint, whole bone If both normal, reassurance. Avoid term ‘growing pains’

Teenage pain V.common around adolescent growth spurt Girls LB stop growing @ 14 years 7 months Boys LB stop growing @ 16 years Traction apohysitis Growth plate under tension Often sporty kids Self limting, treat symptoms No surgery LB = long bone

Osgood Schllaters

Sever’s

Iselin’s

ASIS

What not to miss…

2 year old with short leg & a shoe raise? Waddling gait…

Hyperactive 8 yr old M, with hip pain, limps occasionally

Overweight 12 yr old with knee pain. Knee XR’s normal…

Growing pains & tired all the time

Leg pain, limping, fever, night pain

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