Common Pediatric Orthopaedic Problems Selina Silva, MD UNM Carrie Tingley Hospital

Common Problems Intoeing/ Outoeing Bowlegged/ knock-kneed Flexible Flatfeet Growing Pains Septic Joints Legg-Calve-Perthes DDH SCFE Scoliosis Back Pain

“my child is pigeon-toed!!” 3 sources of intoeing Femoral anteversion Internal tibial torsion Metatarsus adductus

Intoeing Femoral Anteversion Normal is for children to be born with 30 degrees and with growth this normalizes to 10 degrees as an adult. Women have more femoral anteversion than men Often familial Measure the amount of IR and ER of the hip Greater than 70 degrees IR is considered severe

Intoeing Internal Tibial Torsion Common for one leg to have more than the other Also externally rotates with growth to about 15 degrees as an adult Measure the thigh-foot angle 5 degrees IR to 15 degrees ER is normal

Intoeing Metatarsus Adductus Most common congenital foot deformity Forefoot metatarsals are medially rotated on cuneiforms Hindfoot is normal Flexible and resolves on its own 85% of the time

Outoeing Deformity in femur or tibia Usually does not improve with growth or worsens Less tolerated and so treated surgically more often If asymmetric, need to rule out other problems SCFE

Evaluation of Femur

Evaluation of Tibia

Treatment Toeing out usually corrected around the age of 7-10 if symptomatic Toeing in often resolves near normal Therefore give more time prior to offering surgical correction Correct severe cases, greater than 70 degrees Corrected in early teen years if symptomatic Forefoot adduction corrects 85% of the time on its own Start with passive stretching by parents Can do casting if not correcting If rigid and not correcting, osteotomies can be done around 5 yo

Pediatric Angular Alignment www.pulsetoday.uk.co www.orthopediatrics.com

“my child’s bowlegged!” Physiologic between 1-3 External rotation hip contractures Internal tibial torsion

Rule Out Blount’s Blounts: Disturbance of proximal tibial physis Often unilateral Overweight child, early walker vs. obese adolescent

Rule Out Rickets Familial Radiographic changes not limited to medial tibial physis Notice bowing of femurs

Knock-Knees Physiologic between ages 3-6 Worry if unilateral Ankles rolling in correct when the knees correct

When for Surgery? Early teens may consider hemiepiphysiodesis Indications: Mechanical axis off and knee pain or patellar subluxation

Flexible Flatfeet 20% of the population, variant of normal When stand on toes there is an arch No treatment unless feet hurt Orthotics for symptoms Surgery for correction

Growing Pains Usually bilateral lower extremities At night or first thing in the morning Goes away with massage/attention Treatment: Vitamin D3 and give 3-4 months of supplementation to really see results FLAGS: Always same joint Wakes them up in the middle of the night Stop playing or doing sports because of pain

Septic Joint Painful, swollen joint Red and pain with axial load Aspirate joint and send for gram stain, cell count, and culture prior to antibiotics If septic, emergent incision and drainage is required Sometimes difficult to differentiate from cellulitis

Developmental Hip Dysplasia Risk Factors: First born, female, breech, family history Physical Exam: Check Ortolani and Barlow Asymetric Skin Creases Check Galeazzi Check for asymetric hip abduction

Developmental Hip Dysplasia No Swaddling the legs, can still swaddle arms and get same effect Ultrasound helpful after 1 mo of age AP Pelvis at >4 months old Can present at limb length discrepancy in walking child

Legg-Calve-Perthes AVN of femoral head Ages 4-8, usually boys Pain and limp, no fevers, worse with more activity AP/Frog Pelvis xray for diagnosis and send to Ortho

Slipped Capital Femoral Epiphysis Patient profile Obese preteen Often c/o knee pain Affected leg may rotate outwards Also seen with kids that have thyroid problems

Slipped Capital Femoral Epiphysis REAL danger is bone death of femoral head ALWAYS think of hips, when c/o knee pain Order AP Pelvis and Frog view Pelvis xrays If positive, put on crutches, TDWB and send to Peds Ortho/ER immediately

SCFE is always a surgical problem Hight risk of AVN, which occurred in this patient

Scoliosis Forward bend test Imbalance of shoulders or pelvis Greater than 10 degree curve on Xray is scoliosis

Scoliosis Sometimes presents as limb length inequality Most accurate is standing posterior view: PSIS “dimples” Get an MRI if thoracic curve is going to the left or neurologic findings

Scoliosis Any patient with scoliosis we need to see and follow until they are 18 years of age We follow about every 6 months with Xrays Brace at about 25 degrees Surgery if rapidly progressing or greater than 50 degrees Scoliosis does not cause back pain

Back Pain Kids with or without scoliosis and that have back pain are initially treated with home exercise program We have handout for this If fail home exercise/stretching program will send to formal physical therapy 1x per week, for 12 weeks Core strengthening, truncal stability and hamstring stretches If fail therapy, then get MRI or Bone Scan If any neurologic findings get MRI