1. Common Pediatric Orthopaedic Problems
Selina Silva, MD
UNM Carrie Tingley Hospital

2. Common Problems Intoeing/ Outoeing Bowlegged/ knock-kneed
Flexible Flatfeet
Growing Pains
Septic Joints
Legg-Calve-Perthes
DDH
SCFE
Scoliosis
Back Pain

3. “my child is pigeon-toed!!”
3 sources of intoeing
Femoral anteversion
Internal tibial torsion
Metatarsus adductus

4. Intoeing Femoral Anteversion
Normal is for children to be born with 30 degrees and with growth this normalizes to 10 degrees as an adult.
Women have more femoral anteversion than men
Often familial
Measure the amount of IR and ER of the hip
Greater than 70 degrees IR is considered severe

5. Intoeing Internal Tibial Torsion
Common for one leg to have more than the other
Also externally rotates with growth to about 15 degrees as an adult
Measure the thigh-foot angle
5 degrees IR to 15 degrees ER is normal

6. Intoeing Metatarsus Adductus Most common congenital foot deformity
Forefoot metatarsals are medially rotated on cuneiforms
Hindfoot is normal
Flexible and resolves on its own 85% of the time

7. Outoeing Deformity in femur or tibia
Usually does not improve with growth or worsens
Less tolerated and so treated surgically more often
If asymmetric, need to rule out other problems
SCFE

8. Evaluation of Femur

9. Evaluation of Tibia

10. Treatment
Toeing out usually corrected around the age of 7-10 if symptomatic
Toeing in often resolves near normal
Therefore give more time prior to offering surgical correction
Correct severe cases, greater than 70 degrees
Corrected in early teen years if symptomatic
Forefoot adduction corrects 85% of the time on its own
Start with passive stretching by parents
Can do casting if not correcting
If rigid and not correcting, osteotomies can be done around 5 yo

11. Pediatric Angular Alignment

12. “my child’s bowlegged!”
Physiologic between 1-3
External rotation hip contractures
Internal tibial torsion

13. Rule Out Blount’s Blounts: Disturbance of proximal tibial physis
Often unilateral
Overweight child, early walker vs. obese adolescent

14. Rule Out Rickets Familial
Radiographic changes not limited to medial tibial physis
Notice bowing of femurs

15. Knock-Knees Physiologic between ages 3-6 Worry if unilateral
Ankles rolling in correct when the knees correct

16. When for Surgery? Early teens may consider hemiepiphysiodesis
Indications: Mechanical axis off and knee pain or patellar subluxation

17. Flexible Flatfeet 20% of the population, variant of normal
When stand on toes there is an arch
No treatment unless feet hurt
Orthotics for symptoms
Surgery for correction

18. Growing Pains Usually bilateral lower extremities
At night or first thing in the morning
Goes away with massage/attention
Treatment: Vitamin D3 and give 3-4 months of supplementation to really see results
FLAGS:
Always same joint
Wakes them up in the middle of the night
Stop playing or doing sports because of pain

19. Septic Joint Painful, swollen joint Red and pain with axial load
Aspirate joint and send for gram stain, cell count, and culture prior to antibiotics
If septic, emergent incision and drainage is required
Sometimes difficult to differentiate from cellulitis

20. Developmental Hip Dysplasia
Risk Factors:
First born, female, breech, family history
Physical Exam:
Check Ortolani and Barlow
Asymetric Skin Creases
Check Galeazzi
Check for asymetric hip abduction

21. Developmental Hip Dysplasia
No Swaddling the legs, can still swaddle arms and get same effect
Ultrasound helpful after 1 mo of age
AP Pelvis at >4 months old
Can present at limb length discrepancy in walking child

22. Legg-Calve-Perthes AVN of femoral head Ages 4-8, usually boys
Pain and limp, no fevers, worse with more activity
AP/Frog Pelvis xray for diagnosis and send to Ortho

23. Slipped Capital Femoral Epiphysis
Patient profile
Obese preteen
Often c/o knee pain
Affected leg may rotate outwards
Also seen with kids that have thyroid problems

24. Slipped Capital Femoral Epiphysis
REAL danger is bone death of femoral head
ALWAYS think of hips, when c/o knee pain
Order AP Pelvis and Frog view Pelvis xrays
If positive, put on crutches, TDWB and send to Peds Ortho/ER immediately

25. SCFE is always a surgical problem
Hight risk of AVN, which occurred in this patient

26. Scoliosis Forward bend test Imbalance of shoulders or pelvis
Greater than 10 degree curve on Xray is scoliosis

27. Scoliosis Sometimes presents as limb length inequality
Most accurate is standing posterior view: PSIS “dimples”
Get an MRI if thoracic curve is going to the left or neurologic findings

28. Scoliosis
Any patient with scoliosis we need to see and follow until they are 18 years of age
We follow about every 6 months with Xrays
Brace at about 25 degrees
Surgery if rapidly progressing or greater than 50 degrees
Scoliosis does not cause back pain

29. Back Pain
Kids with or without scoliosis and that have back pain are initially treated with home exercise program
We have handout for this
If fail home exercise/stretching program will send to formal physical therapy
1x per week, for 12 weeks
Core strengthening, truncal stability and hamstring stretches
If fail therapy, then get MRI or Bone Scan
If any neurologic findings get MRI