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

2. 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!

3. 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

4. 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)

5. 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

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

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

8. 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

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

10. FEET

11. 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

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

13. Calcaneovalgus V’s CVT

14. Congenital Talipes Equinovarus

15. 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

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

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

18. Severs: (Calcaneal apophysitis)
What is it:
Traction apophysitis of achilles insertion
Associated with rapid growth spurt
Who gets it:
Common 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

19. 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

20. Assessing hip rotation
Medial Rotation Hip
Lateral Rotation
Hip

22. Femoral antetorsion

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

24. Assessing tibial rotation

25. “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

26. Asymmetry

27. 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

28. Osgood-Schlatters What is it: Traction Apophysitis Who gets it:
Boys> Girls
Age: Boys 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

29. Hips

30. 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)

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

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

33. 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

34. DDH

35. 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

36. Slipped Upper Femoral Epiphysis
Presentation:
Girls 9-15
Boys (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

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

38. 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

39. Contact Details Email; lindawalsh@nhs.net
Telephone; or
Fax;
Address; Clinic 3, 7th Floor, North Tower, Royal London Hospital, Whitechapel E11
Referrals; Please complete letter with referral details. Referrals accepted via fax, and post.

40. Thank you!!!