TULSA BONE & JOINT CHAPTER 24 SPECIAL CONCERNS OF THE PEDIATRIC PATIENT ROTATIONAL DEFORMITIES Intoeing – “pigeon toed”, common. Usually spontaneously corrects. Metatarsus adductus (packaging defect) – stretching and casting (associated with hip dysplasia. Talipes Equinovarus. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

CHAPTER 24 SPECIAL CONCERNS OF THE PEDIATRIC PATIENT (Cont’d.) TULSA BONE & JOINT CHAPTER 24 SPECIAL CONCERNS OF THE PEDIATRIC PATIENT (Cont’d.) Club Foot: Metatarsus adductus Equinus (foot flexion) Always check hips TONY JABBOUR, MD ORTHOPAEDIC SURGERY

ANGULAR DEFORMITIES Pathologic if unilateral, painful or asymmetric. TULSA BONE & JOINT ANGULAR DEFORMITIES Genu varum (bow legged) Genu valgum (knock-kneed) Normal Exam: 2-3 years old, bow legged. 3 years old, knock-kneed. 7 years old, slightly knock-kneed. Pathologic if unilateral, painful or asymmetric. Consider rickets (vitamin D), renal disease, dysplasias, (dwarfism) TONY JABBOUR, MD ORTHOPAEDIC SURGERY

ANGULAR DEFORMITIES (Cont’d) TULSA BONE & JOINT ANGULAR DEFORMITIES (Cont’d) INFANTILE BLOUNT’S DISEASE: Unknown etiology: Medial tibial physis ceases to function appropriately. Leads to relative overgrowth laterally. Genu varum. Black females. Large kids. Early walkers <11 months. Treatment – Surgery. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

FOOT DEFORMITIES CLUB FOOT: 1 in1,000 live births, half are bilateral. TULSA BONE & JOINT FOOT DEFORMITIES CLUB FOOT: 1 in1,000 live births, half are bilateral. 2.5x more common in males. Inheritance multi-factorial. Metatarsus adductus. Equinus and heel varus. Not packaging defect. Always screen for hip dysplasia. Treatment: Casting for 3 months, then surgery. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

FLAT FEET Pes Planus: Absent arch which reappears when up on tip toes. TULSA BONE & JOINT FLAT FEET Pes Planus: Absent arch which reappears when up on tip toes. Treatment: Reassure family. Rigid flat foot: Tarsal coalition (calcaneus, talus, navicular may fuse abnormally). Can cause decreased motion and increasing pain. Treatment: Surgery. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

HIP DISORDERS DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) TULSA BONE & JOINT HIP DISORDERS DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) Genetic and can arise during development. 1 in 1,000 live births. Female. First born. Breech position. Family history. Allis sign (abnormal skin folds). TONY JABBOUR, MD ORTHOPAEDIC SURGERY

HIP DISORDERS DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) (Cont’d.) TULSA BONE & JOINT HIP DISORDERS DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) (Cont’d.) Galeazzi sign (decreased height of affected knee). 2 provocative tests: Ortolani maneuver – relocates hip. Barlow maneuver – dislocates hip. X-rays not helpful until after age 4 months. Pelvis/hips not ossified at birth. Ultrasound better after 2 weeks of age. 5% are missed by ultrasound. Must repeat tests for 1 year. If untreated, leads to arthritis. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) TULSA BONE & JOINT SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Displacement or slipping of part of femoral head through growth plate. 11-13 years old for girls. 13-15 years old for boys. Related to hormonal disorders (chubby, short, hypogonadism). More common in Blacks. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Cont’d. TULSA BONE & JOINT SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Cont’d. Complaint of knee or hip pain (obturator nerve referral pain). Limp, painful internal rotation of hip. Treatment: Surgery (pinning). TONY JABBOUR, MD ORTHOPAEDIC SURGERY

LEGG-CALVE PERTHES DISEASE TULSA BONE & JOINT LEGG-CALVE PERTHES DISEASE Idiopathic necrosis of femoral head. Usually 4-8 year old males, small for age, active. Limited abduction and external rotation. Disease course takes 2 years. Treatment: Involves maintaining femoral head in socket. Usually unilateral. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

GROWTH PLATE FRACTURES TULSA BONE & JOINT GROWTH PLATE FRACTURES Unlike adults, children rarely injure ligaments because the physis is weaker. SALTER-HARRIS CLASSIFICATIONS: Type I: Fracture goes straight through growth plate. X-rays within normal limits. Type II: Fracture goes through physis and metaphysis. Most common. Good prognosis. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

GROWTH PLATE FRACTURES (Cont’d.) TULSA BONE & JOINT GROWTH PLATE FRACTURES (Cont’d.) Type III: Fracture goes through physis and epiphysis. Intraarticular. Will require surgery. If left untreated, leads to growth arrest. TYPE IV: Fracture goes through epiphysis, growth plate and metaphysis. Surgery. High complication of growth arrest. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

GROWTH PLATE FRACTURES (Cont’d.) TULSA BONE & JOINT GROWTH PLATE FRACTURES (Cont’d.) Type V: Rare injury. Compression injury or crush injury to the growth plate. Leads to growth arrest. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

NEUROMUSCULAR DISORDERS CEREBRAL PALSY TULSA BONE & JOINT NEUROMUSCULAR DISORDERS CEREBRAL PALSY Brain lesion which leads to non-progressive Neurologic condition. Perinatal. 3.5 per 1,000 live births. Classifications: Quadriplegic – all four extremities. Diplegic – lower extremities. Hemiplegic – one side of body. Spasticity: high muscle tone. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SPINA BIFIDA Describes variety of neural tube defects. TULSA BONE & JOINT SPINA BIFIDA Describes variety of neural tube defects. Severity depends on which level is affected. 1 in 1,000 live births. Meningocele: Vertebral arches unfused. Meningeal sac is visible. Myelomeningocele: Neural elements exposed without sac. Rachischisis: Neural elements exposed without sac. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SPINA BIFIDA (Cont’d.) Occurs in embryologic development. TULSA BONE & JOINT SPINA BIFIDA (Cont’d.) Occurs in embryologic development. Women must have Folate > 400 units per day. No hot baths or saunas during first trimester. Diagnosis by 16 weeks gestation with ultrasound. Amniocentesis confirms diagnosis (increased Alpha Feta protein). Treatment: Immediate closure of defect. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SPINA BIFIDA (Cont’d.) Thoracic level causes spine and hip problems. TULSA BONE & JOINT SPINA BIFIDA (Cont’d.) Thoracic level causes spine and hip problems. Lumbar and sacral levels cause knee and foot problems. L4 gives quadriceps which allows ambulation. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SCOLIOSIS Three-dimensional curvature of the spine. IDIOPATHIC: TULSA BONE & JOINT SCOLIOSIS Three-dimensional curvature of the spine. IDIOPATHIC: Detected around age 10-12. Only 10% severe enough to warrant surgery. “Forward bend test”. Rib hump on clinical exam. Less than 25 degrees – observe. 25-45 degrees – brace. Greater than 45 degrees – surgery (fusing spine). TONY JABBOUR, MD ORTHOPAEDIC SURGERY

SCOLIOSIS (Cont’d.) CONGENITAL: TULSA BONE & JOINT SCOLIOSIS (Cont’d.) CONGENITAL: Look at heart and kidney abnormalities. NEUROMUSCULAR: Cerebral palsy, spina bifida, muscular dystrophy, spinal cord injuries. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

CHILD ABUSE Non-accidental injuring of a child. TULSA BONE & JOINT CHILD ABUSE Non-accidental injuring of a child. Mandatory reporting laws for physicians in all 50 states. 1,000 deaths per year. Types of child abuse: Emotional. Medical neglect. Sexual. Physical. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

CHILD ABUSE (Cont’d.) PHYSICAL ABUSE TULSA BONE & JOINT CHILD ABUSE (Cont’d.) PHYSICAL ABUSE Multiple fractures with various stages of healing. Posterior rib fracture. Bilateral acute long bone fractures. Complex skull fracture. Long bone fracture in non-ambulatory children (spiral fracture of long bones no longer pathopneumonic for child abuse). Skeletal survey. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

INFECTION OSTEOMYELITIS : Infection of bone. TULSA BONE & JOINT INFECTION OSTEOMYELITIS : Infection of bone. Osteomyelitis generally spreads hematogenously. Dissemination of bacteria in blood stream. In children, structures of blood vessels of metaphysical region predisposes them to infection. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

INFECTION (Cont’d.) SUBPERIOSTEAL ABSCESS: TULSA BONE & JOINT INFECTION (Cont’d.) SUBPERIOSTEAL ABSCESS: Staph aureus – most common in all ages. Streptococcus – less than 4 years of age. E-coli – neonates. Sickle cell anemia – staph aureus, salmonella. Pseudomonas – stepping on a nail while wearing sneakers. Labs: CBC with differential, sed rate, CRP, blood cultures, x-rays and bone scan, aspiration. Treatment: Six weeks IV antibiotics, rarely surgery. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

INFECTION (Cont’d.) SEPTIC ARTHRITIS: Infection in joint. TULSA BONE & JOINT INFECTION (Cont’d.) SEPTIC ARTHRITIS: Infection in joint. Bacteria invade joint synovium. Usually sicker than patients with osteomyelitis. Treatment: Emergent surgical drainage. Differential diagnosis: Juvenile rheumatoid arthritis. TONY JABBOUR, MD ORTHOPAEDIC SURGERY

INFECTION (Cont’d.) TOXIC SYNOVITIS: Acute non-bacterial joint TULSA BONE & JOINT INFECTION (Cont’d.) TOXIC SYNOVITIS: Acute non-bacterial joint Inflammation. Self-limiting. Normal sed rate and C-reactive protein. No abnormal joint fluid. TONY JABBOUR, MD ORTHOPAEDIC SURGERY