1. Knock knees Inter-malleolar distance Mechanical axis Consider rickets
Measure both with tape measure
Consider rickets
Indications ?
Mechanical axis lateral to tibia
Anatomic axis > 15 degrees

2. Knock knees

3. Knock knees: management
Guided growth
V expensive plate
Cheaper screws

4. Vitamin D Low Vitamin D is a potent cause of musculo-skeletal pain
40% of attendees at paed orthop clinic either deficient or insufficient
Normal > 50 nmol/L
Insufficient < 50 nmol/L
Deficient < 25 nmol/L
Measure Vitamin D level in children with aches and pains before referral

5. Infection

6. Septic arthritis v irritable hip
Decision trees common
History of fever > 38o
Non weight bearing
WCC > 12,000
ESR > 40
Kocher et al. J Bone Joint Surg Am Dec;81(12):

7. Decision analysis One predictor 0.2% Two predictors 40%
Three predictors 93%
Four predictors 99%

8. Outcome
Resolution

9. Outcome
Tom Smith Arthritis
Life long disability

10. DDH: Clinical detection

11. What tests; Neonates Ortolani reduction clunk (1936)
“segno del scotto”
Barlow test (1966)
Le Damany (1912)
“signe de ressaut”

12. Ortolani

13. Barlow

14. Barlow: Examine each hip separately

15. What you’re feeling

16. When ? Old Guidelines At birth (but many lax) In first 2/52
At 6 – 8 weeks (last chance for O/B+)
At 3 months ?
At 6 – 9 months (required by guidelines but ? useful)
months

17. Current UK Screening Policy NIPE 2008
Age
NIPE
DoH Healthy Child Programme
Birth
Examination
6-10 weeks
2 months
Immunisation
3 months
4 months
1 year
Examination and immunisation

18. Treatment requirement

19. Examination at 3 months Instability unlikely
Limited abduction important
Asymmetric skin creases caused by Nestle
LLD difficult to judge
If in doubt USS at hip instability

20. Limited abduction

21. Clubfoot

22. Ponseti’s method

23. Ponseti’s method

24. Ponseti’s method

25. Ponseti’s method : Splintage
Boots on bar External rotation splintage
70 degrees ER
Full time months
Night years

26. Ponseti’s method : Splintage

27. Leg Length Inequality Use Galleazzi sign for measurement in infants
No need to refer small children unless gross discrepancy or concern about hips

28. Femoral deficiencies Spectrum 1 in 50-200,000 Congenital short femur
PFFD
1 in ,000

32. Examine the hips in children with knee pain

33. What we’re doing Central referral place “dummy clinic”
Website for advice and simple treatment
Leaflets
Videos
More advice and guidance
Send back referrals for normal variants