1. Pediatric Orthopedic Diseases

2. Categories Congenital Developmental Neuromuscular Metabolic Acquired : inflammatory infection trauma tumor

3. Mechanisms Congenital.. Defect in the stage of embryogenesis. Developmental.. Defect in the stage of fetogenesis. Neuromuscular.. Upper or lower motor neuron disease or different muscular pathologies. Metabolic.. Abnormality in different metabolic lines in our bodies.

4. Inflammatory..antigen antibody reactions Infections.. Pyogenic spread Trauma.. Mechanical forces….fractures Tumor..benign or malignant

5. General Problems Hip problems Angular deformities Foot problems Infections & Tumors

6. DDH Predisposing factors - 5 F’s Female Family Hx. in 20 % of cases Frank breech birth First born Left side involvement

7. Physical Exam -Limited abduction of flexed hip( < 50-60%) -Legs unequal in length -Asymmetric fat folds in thigh -Limp in the walking age child -Trendelenburg sign: lurching toward affected side

8. Clinical The artful approach is the secret of the exam Ortolani test Limited Abduction

9. Abductor lurch or trendelenburg gait

10. Diagnostic tests U/S in first few months to view cartilage X-ray after 3 months

12. Treatment 0-6 months - Pavlik harness to maintain abdution and flexion 6-18 months- reduction under GA, hip spica cast for 2-3 months > 18 months- Open surgical reduction: pelvic and/or femoral osteotomy

15. LEGG-CALVE-PERTHES DISEASE AVN of proximal femoral epiphysis -self limiting disease Leads to abnormal growth of physis followed by eventual remodeling of new bone Etiology unknown More common in males 4:1 ratio

16. History/Physical Exam Child 4-10 years Limping tenderness over anterior thigh Flexion contracture with decreased internal rotation/abduction

17. Diagnostic tests

18. Treatment : Aim CONTAINMENT Physiotherapy Brace in flexion/abduction x 2-3 years Femoral or pelvic osteotomy

19. SLIPPED CAPITAL FEMORAL EPIPHYSIS Epidemiology -Occurs during maximal pubertal growth spurt -Males: age 13 to 15 -Females: age 11 to 13 -Most common adolescent hip disorder -Black race affected more often than white race -Unilateral involvement in 90% of cases -Child is often overweight

20. SLIPPED CAPITAL FEMORAL EPIPHYSIS Symptoms /Signs -Hip pain or knee pain -Limp, decreased ROM -Hip held in abduction and external rotation -Markedly limited internal rotation

22. Management -Orthopedic Emergency! Immediate hospitalization and operative fixation

23. COMMON ANGULAR AND ROTATIONAL PEDIATRIC PROBLEMS Angular deformities of LL: -Bow legs. -Knock knees. Rotational deformities of LL: -In-toeing. -Ex-toeing.

24. Angular Deformities Nomenclature Bow Legs Genu Varus Knock Knees Genu Valgus

25. Angular Deformities Evaluation Should differentiate between physiologic and pathologic deformities

26. Angular Deformities Evaluation physiologic Symmetrical Mild – moderate Progressive Generalized Expected for age pathologic Asymmetrical Severe Progressive Localised Not expected for age

27. Symmertrical Deformities

28. Asymmetrical Deformities Genu VarusRadiograph

29. Angular Deformities Causes Physiologic Normal for age May be exaggerated ??? : a.Overwieght b.Early walking Pathologic Rickets Endocrinopathy Metabolic diseases Physeal plate injury : a.Trauma b.Infection c.Tumor Idiopathic

30. Evaluation Investigations / Radiological X-ray when severe or pathological Standing AP film – long film ( hips to ankles ) with patellae directed forwards Look for diseases : – Rickets / Tibia vara (Blount’s) / Epiphyseal injury.. – Measure angles.

31. Angular Deformities when to refer ?!!!!!! If Pathological Exaggerated physiological

32. Treatment Osteotomy & Fixation

33. Hemiepiphysiodesis

34. Rotational Deformities INTOEING Causes Metatarsus Adductus Tibial Torsion High femoral Anteversion

35. Metatarsus Adductus A cause of intoeing in the first year of life Rx : stretching exercises casting surgery

36. Internal Tibial torsion A cause of intoeing between 1 – 3 years of age Rx : May correct spontaneously If severe … surgery Thigh foot angle (-10 )– (+ 30)

37. High Femoral Anteversion After 3 years of age Rx: spontaneous improvment till 10 years of age NO functional impairment Surgery not indicated

38. EXTOEING External tibial torsion Doesnot correct spontaneously If severe …surgery

39. Foot Deformities

40. Calcaneovalgus Common condition Packeging disorder Benign ???LLD in the future

41. Donot forget systemic diseases Arthrogryposis with foot deformity

42. SEPTIC ARTHRITIS Bacterial infection within a joint Serious medical emergency! Spread by direct extention, hematogenous( most commonly), inoculation Organisms: -0-6 months- S.aureus, E.Coli -6-36 months- S.aureus, H.influenza -> 36 months- S.aureus, Streptococci

43. History/Physical Exam -Severe pain -Fever, chills -Dehydration -Lethargy -Local redness, swelling, heat, tenderness -Unable or unwilling to move joint - neonates get pseudoparalysis -Joint held in flexion

44. Diagnostic tests -Blood and throat cultures -Joint aspirate for cultures -CBC, WBC, -Bone scan (for hip involvement only, to assess for vascular compromise to femoral head)

45. SEPTIC ARTHRITIS Admit Rest the limb IV fluids for dehydration Analgesia Incision & Drainage IV antibiotics