1. LOWER EXTREMITY PROBLEMS IN CHILDHOOD TIMOTHY J. FETE MD,MPH University of Missouri School of Medicine Department of Child Health

2. Developmental Dysplasia of the Hip-associations First born Torticollis Metatarsus Adductus Internal Tibial Torsion Oligohydramnios Breech + Family History

3. Developmental Dysplasia of the Hip Ortolani Maneuver: Reduction Barlow Maneuver: Dislocation Increased joint laxity Limitation of Abduction Assymetric thigh skin folds Galeazzi’s Sign Leg Length Discrepancy

10. DEVELOPOMENTAL DYSPLASIA OF THE HIP Positive exams per 1000 newborns All11.5 Boys4.1 Girls19 + Fam Hx Boys6.4 + Fam Hx Girls 32 Breech Boys29 Breech Girls133

11. Developmental Dysplasia of the Hip Plain films not particularly valuable until 4-6 months of age Ultrasonagraphy most useful beyond four weeks of age (false + before) US allows static and dynamic study

15. DDH: Screening 1. All Newborns to be screened at birth 2. If + Ortolani or Barlow: refer to ortho, do not order US 3. If equivocal, recheck at 2 weeks 4. If equivocal at 2 weeks, refer or order US at 3-4 weeks 5. Examine hips at all well visits until 18 months (late presentation)

16. DDH: Screening Perform US for: *Girls who are breech Consider US for: *Girls with positive family history *Boys who are breech

17. DDH: Treatment NOT Triple Diapers! Pavlik Harness Progressive Casting Adductor Tenotomy Open Reduction If late, may require acetabular surgery

18. INTOEING Metatarsus Adductus Internal Tibial Torsion Femoral Anteversion

20. METATARSUS ADDUCTUS Heel Bisector *normal: between toes 2 and 3 *mild: 3 rd toe *mod: 4 th toe *severe: 5 th toe Rigidity *actively correctable: straighten with tickle *passively correctable: straighten with gentle pressure *fixed: unable to straighten

23. METATARSUS ADDUCTUS: Treatment Actively Correctable: no Rx Passively Correctable *exercises *straight or reverse-last shoes Fixed: serial casting Look for DDH!

24. INTERNAL TIBIAL TORSION Thigh/foot angle Relative position of medial and lateral malleoli Most common cause of intoeing under 3 years of age Universally resolves by 4-6 years No treatment required

26. MEDIAL FEMORAL TORSION FEMORAL ANTEVERSION Most common form of intoeing greater than 3 years of age Examine prone rotational profile Most (85%) resolve spontaneously by 8-10 years Possible athletic advantage Femoral osteotomies if severe

29. EXTERNAL TIBIAL TORSION Normal adults + 10 degrees of external tibial torsion No treatment necessary

31. PES PLANUS (FLAT FEET) Normal through age 7 years 1/7 never develop arch Flexible: foot regains arch when stand on toes Treatment rarely necessary—only if painful (rare) Rigid: still flat with toe-standing-rare-may be due to tarsal coalition, may require surgery

32. SHOES Adequate size Soft/flexible Flat/non-skid sole Soft/porous upper Inexpensive Avoid odd shapes (cowboy shoes/high heels)

33. CLUBFOOT Metatarsus adductus + Equinus + Hindfoot varus 1/1,000 live births 50% bilateral Male/female = 2.5/1 Increase if + family history + association with DDH Serial casting (25+ % effective) Surgery

35. CAVUS FOOT High arch, usually inherited, no Rx Red flags: new-onset, unilateral, painful, progressive Red flags may indicate: Friedrich ataxia, Charcot-Marie-Tooth, tethered spinal cord, intraspinal lesion

36. BOWLEGS Physiologic *internal rotation of tibia/retroversion of femur *generally resolved within 6 months of walking Genu Varum—all children initially bowlegged until 2-3 years, no Rx required if persists: Blount Disease * “undergrowth” of medial proximal tibia *early walkers, heavyset,girls, AfricanAmericans Metabolic/Medical: rickets, renal,dwarfism X-ray if painful, unilateral, greater than 2 years old

38. KNOCK-KNEES Genu Valgum By 7 years most children reach typical adult mild genu valgum No Rx required, well-tolerated

39. Legg-Calve’-Perthes Disease Avascular Necrosis of the Femoral Head 4-8 years of age Males/females = 4/1 Bilateral in 10-18% Short stature/delayed bone age Insidious, often painless limp Thigh/knee pain not uncommon Decreased hip mobility on exam Rx: physical therapy, bracing, ultimate surgery

41. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Insidious pain or limp vs acute pain Pain often thigh/knee Early adolescence (13-15 males, 11-13 females Often, not always, obese African-Americans > Caucasians 20% bilateral initially, 30% more in < 1 yr Limp,Lateral rotation of foot,limited internal rotation at hip

43. OSGOOD-SCHLATTER DISEASE Painful enlargement of tibial tubercle at insertion of patellar tendon Repetitive stress from quadriceps pull X-rays generally not helpful May have fragmentation of tibial tubercle Generally resolves within 6-18 months Rx: rest, hamstring and quad stretching prior to participation, ice afterward, NSAIDS only for acute pain (not to participate!) Resolved permanently with skeletal maturity