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

2. 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’…

3. Ipswich DDH

5. 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?

6. 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

7. 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 Sep;(119):6-10.

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

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

10. Normal lower limb development

11. 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

12. 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

13. In-toeing – Pigeon Toeing / Feet

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

15. 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

16. ‘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

18. 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

19. Curly toes

20. Syndactyly

21. 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

22. 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’

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

24. Osgood Schllaters

25. Sever’s

26. Iselin’s

27. ASIS

28. What not to miss…

29. 2 year old with short leg & a shoe raise? Waddling gait…

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

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

32. Growing pains & tired all the time

33. Leg pain, limping, fever, night pain

34. Free Px Resources

35. Thank you