TCP Week 5 (Pediatric Ortho)

scoliosis

- Lateral deviation >10º, often w/ rotational component

- Usually convex to the R in thoracic spine

- Predominantly idiopathic (80%), classified by age (adolescent, juvenile, infantile)

scoliosis epidemiology

- 2-4% of US population has scoliosis

- M = F *but the F compression risk is higher

- 90% of cases will not require intervention

epiphysis

end of a long bone

scoliosis s/sx

CC: usually ASX

Frequently reported by caregiver, + screenings

- poor posture

- hips sticking out

- uneven shoulders

scoliosis PE

inspecting from behind patient for asymmetry at shoulders and hips

- Adams Forward Bend Test

- + Scoliometery

red flags of scoliosis

- L thoracic curve (spine is butting up against heart - not usually idiopathic)

- Leg length discrepancy (very progressed)

- Significant pain

scoliosis diagnostics

- X-ray: AP/Lat entire T/L spine

- Measure Cobb Angle (>10º = scoliosis)

- Riesser Sign (eval of bone age). More concerning if they're still growing.

MRI only if + neuro findings (or red flag sx)

scoliosis management

refer to ortho/spinal surgeon if >10º or progression on serial images, symptomatic

scoliosis management based on angle (

observation

*if skeletally mature, less concern it will worsen

scoliosis management based on angle (25-40º)

bracing (ONLY if skeletally immature, so younger pts)

brace worn up to 20 hrs/day

scoliosis management based on angle (40-50º)

surgery

arrests the curve progression

spondylolysis/listhesis continuum of disease

lysis: fracture of the pars interarticularis

lithesis: anterior subluxation

spondylolysis/listhesis pathophysiology of disease

lysis: repetitive stress -> stress/complete fx

listhesis: both pars fx -> anterior subluxation

Spondylolysis/lithesis epidemiology

6-7% of general population, 7-21% adolescent athletes

Risk factors: contact sports with repetitive hyperextension

L5 (80%), anterolithesis of L5 relative to S1

spondylolysis/listhesis history

CC: insidious lower back pain with activity

Generally, more pronounced with listhesis

Improves with rest

red flag of spondylolysis/listhesis

radicular pain/weakness

spondylolysis/listhesis PE

Limitations in lumbar flexion/extension

Potential step offs with listhesis

One-legged hyperextension/stork standing test:

- Patient stands on one leg and leans back

- No pain with flexion

spondylolysis diagnostics

No definitive gold standard (ombination of X-rays, CT scan, SPECT scan)

X-ray: AP/Lateral/Oblique

- Scottie Dog on oblique X-ray

spondylolisthesis diagnostic imaging

X-ray and CT

Classification based on anterior translation

classification of spondylolisthesis

Grade 1 - 0-25%

Grade 2 - 25-50%

Grade 3 - 50-75%

Grade 4 - 75-100%

Grade 5 - > 100% (spondyloptosis - complete anterior subluxation)

spondylolysis management

generally, observation, managed by PCP

surgical if fracture has failed observation, activity modification

spondylolisthesis management

establish care with pediatric spine or physiatry

Observation: Asymptomatic patients

PT/activity modification: Symptomatic, < grade 3

Bracing: Symptomatic, < grade 3 & failed PT

Operative: Symptomatic, > grade 3 or neuro deficits

developmental dysplasia of the hip

Abnormal relationship between proximal femur and acetabulum

Results in:

- dysplasia (shallow acetabulum)

- subluxation (partially displaced)

- dislocation of the hip

epidemiology of developmental dysplasia of the hip

most common orthopaedic disorder of newborns!

F > M, 6:1

More common in left hip (60%), bilateral (20%)

risk factors of developmental dysplasia of the hip

- first born

- female

- breech presentation

- family hx

developmental dysplasia of the hip history

More a PE finding than history finding

- Findings vary based on age & ambulatory status

- Several associated special tests and findings for dx

Picked up generally at well-infant check

Repeat testing until child is walking, especially in cases with risk factors

signs/maneuvers for developmental dysplasia of the hip (0-6 months)

Asymmetric Thigh Folds: From dislocated hip being displaced proximally

Galeazzi Sign: Differences in knee height level while supine

Ortolani Maneuver: Detects if hips are already dislocated, reduces hip

Barlow Maneuver: Detects if hips are unstable, dislocates hip

signs/maneuvers for developmental dysplasia of the hip (6 months-walking)

Asymmetric Thigh Folds: From dislocated hip being displaced proximally

Galeazzi Sign: Differences in knee height level while supine

Asymmetric Passive Hip Abduction: Limited abduction on dislocated side

signs/maneuvers for developmental dysplasia of the hip (walking)

- Leg length discrepancies

- Painless Limp

- Asymmetric Abduction

- Hyperlordosis

ortolani and barlow maneuvers

developmental dysplasia of the hip diagnostics

Limited screening usage here, again mostly on PE

Ultrasound: < 6 months with positive Barlow or Ortolani

X-ray: > 6 months

developmental dysplasia of the hip management

Refer if positive Barlow and/or Ortolani

Early treatment yields best results; treatment based on age

developmental dysplasia of the hip management (0-6 months)

- Pavlik Harness (90% successful)

- Flex 100°, Abduct to 50°

- Re-eval in three weeks by U/S

- Duration of 3 months

developmental dysplasia of the hip management (6-12 months)

- Closed Reduction under anesthesia (80% successful)

- Followed by a spica cast

- Duration of 2-4 months

developmental dysplasia of the hip management (12-24 months)

- Failed conservative measures

- Require big, invasive surgeries

- But rarely needed

Legg-Calve-Perthes

Idiopathic avascular necrosis (causes bone to shrink) of the proximal femoral epiphysis

*blood supply to femoral head is lost*

Disruption -> Revascularization -> Resorption -> Collapse

Legg-Calve-Perthes epidemiology

Rare: 1/10,000 children, 7 years old (+ 5 yrs)

Generally unilateral (90%)

M > F

possible connection to coagulopathies

Legg-Calve-Perthes history

CC: painless limp

- In children it can be an aching discomfort

- Refers to thigh or knee

Legg-Calve-Perthes PE

- Atrophy on affected side

- Limited range of motion, loss of INTERNAL ROTATION

- Flexion contracture 0-30º

- Leg Length Discrepancy is LATE FINDING

Legg-Calve-Perthes diagnostics

Multimodal, but X-ray first

On XRAY: Crescent Sign (subchondral fx) = avascular necrosis

If positive --> bone scan/MRI to confirm

Legg-Calve-Perthes management (

Refer to pediatric orthopedics

Slipped Capital Femoral Epiphysis (SCFE)

Common condition of the proximal femoral physis (growth plate)

Slippage of the metaphysis relative to the epiphysis, main cause of premature OA in young adults

During periods of rapid growth (10-16 yrs old)

Slipped Capital Femoral Epiphysis (SCFE) epidemiology

Most common disorder affecting adolescent hip!

- 10/100,000 adolescents

- M > F, BMI 25-30, mostly unilateral (60-70%)

- More common in Pacific Island, Black, and Hispanic populations

Slipped Capital Femoral Epiphysis (SCFE) history

CC: Vague hip, groin, thigh, knee pain

- Can be atraumatic (more common)

- Can be traumatic after a fall or while playing sports

- Primary caregiver notices a limp

Slipped Capital Femoral Epiphysis (SCFE) PE

Antalgic gait, externally rotated foot at rest, leg length discrepancy (shorter)

Loss of hip IR, abduction, flexion,

Drehmann Sign (when flexing hip, it will ER)

Slipped Capital Femoral Epiphysis (SCFE) diagnostics

X-Ray: AP, Lateral, and frog-leg of BOTH hips

S-Sign: on frog-leg, sharp discontinuity of the normal S shape of femoral head and neck

MRI can pick up pre-slip conditions (edema)

Slipped Capital Femoral Epiphysis (SCFE) management

- REFER, REFER, REFER

- Success dependent upon prompt referral

- Always operative, >90% successful

**Consider prophylactic contralateral treatment in

femoral torsion

Rotation deformity of femoral head in acetabulum (anteversion or retroversion)

Part of the process that causes in-toeing

Thought to be related to intrauterine position

femoral torsion epidemiology

- Minimal prevalence data since it's a mostly benign and transient condition

- F > M , 2:1

- Associated with DDH, metatarsus adductus, congenital muscle torticollis

femoral torsion history

CC: no pain, often just a primary caregiver concern

Should not cause ambulatory issues, but may cause tripping during running activities

Often more pronounced later in the day

femoral torsion PE

Bilateral, asymmetry is a red flag!!

Check hip motion while prone:

- IR usually > 70º (nl 20º-60º)

- ER usually < 20º (nl 30º-60º)

Craig's test: assessing trochanteric prominence. >15º is anteversion.

femoral torsion diagnostics

Usually not required

If unilateral or progressive bilateral + failed conservative treatment, and surgery being considered (rare) then CT or MRI

femoral torsion management

Largely SELF-LIMITING (grow out of it)

Managed by PCP

PT can help with hip and core strengthening

Rare: formal ortho work up if continues > 10 years old, causes ambulatory issues

Genu Varum/Valgum

Varum: bowleg

Valgum: knock-knee

genu varum/valgum epidemiology

Anatomic variations over the first decade

Varus -> Neutral -> Valgum

genu varum/valgum Hx and PE

CC: Generally asymptomatic. If older anterior knee pain, worse with running

History: Rickets, trauma, fractures, neoplasms

Varum: medial malleoli touching, knees deviate from midline

Valgum: medial aspect of knee touching, malleoli deviate from midline

genu varum/valgum Dx

Generally, not needed

X-ray if >6 cm varum/valgum and not following typical progression

Image should be from hip to the ankle

If unilateral, then MRI

genu varum/valgum management

Reassurance, observation

Refer:

• Unilateral

• Varum beyond age 2

• Valgum beyond age 12

Surgery only if > 12, failed PT, gait disturbances (RARE)

Osgood-Schlatter

Osteochondrosis (abnormal overgrowth) of tibial tubercle

Apophysitis (inflammation) of growth plate

Fragmentation of tibial tubercle

Osgood-Schlatter epidemiology

- During adolescence

- Common in athletes (jumping, running sports)

- M > F

Osgood-Schlatter Hx

CC: generalized anterior knee pain, worse with activity

- Swelling and pain at tibial tubercle

- During phases of rapid growth

Osgood-Schlatter PE

- Thick, indurated patellar tendon (palpable)

- Prominent tibial tubercle

- Pain with resisted knee extension

Osgood-Schlatter Dx

X-ray: AP/Lateral, looking for irregularity, fragmentation of the tubercle, ossicles within the tendon

MRI: pre-surgical planning

Osgood-Schlatter management

Self-limiting, usually resolves when patient reaches skeletal maturity

Mostly controlled by PCP

Activity modification, NSAIDs, PT

Rarely surgery

ACL

ACL prevents torsion and anterior translation of the knee

One of the primary stabilizers of the knee

Adjacent to the PCL in the intercondylar notch

ACL tear epidemiology

- 400,000 injuries a year

- F > M, 4:1

- Secondary to non-contact or contact

- High risk: soccer, basketball, skiing, football

ACL tear history

CC: pop after quick cut or traumatic injury

- Generally, discomfort, not necessarily pain

- Progressive swelling, instability

- After a few days can walk straight

ACL tear PE

General apprehension with movement

Limited ROM due to swelling

Tests:

• Anterior Drawer Test

• + Lachman (most sensitive) (how far can you pull tibia forward pushing femur down)

• + Pivot shift

ACL tear diagnostics

X-ray: AP/Lateral, Segond fracture (pathognomonic for ACL)

MRI: Necessary to confirm dx, kissing contusion

ACL tear management

- Refer to orthopaedics

- Non operative if > 40, low demand

Operative

- Reconstruction: using grafts (allograft vs autograft)

- Repair: emerging approach

pes planus

AKA flat feet

Loss of medial longitudinal arch of the foot, heel valgus deformity

Arch region of foot touches the ground

pes planus epidemiology

- Relatively common, 20-30%

- Normal developmental profile, arch develops around 10 yrs old

- Flexible... flat only when wt bearing (95%)

- Rigid... flat even if non wt bearing

pes planus history

CC: mostly asymptomatic

- Reported excessive valgus of the hindfoot

- Outersole wear pattern

pes planus PE

Severe pronation, can see bunion

Gait analysis... shoes on and off

Achilles alignment, angulated rather than vertical

pes planus dx

X-ray: Must be weight-bearing

pes planus management

Managed by PCP, non-operative

Physical therapy

Orthotics (supportive, gradual introduction)

Rarely surgery (failed all conservative options or if rigid form w no arch at all)

metatarsus adductus

Generally, self-limiting that condition that causes the forefoot to turn inwards

Visible at birth

Flexible or rigid

metatarsus adductus epidemiology

MC foot deformity!

Bilateral in about 50%

Associated with DDH (15-20%)

Risk: family history, breech presentation, sleeping position of baby

metatarsus adductus Hx

CC: mostly asymptomatic

Primary care-giver will report in-toeing

Usually reported within the first year of life

metatarsus adductus PE

Diagnosable on inspection

Flexible: can be corrected manually versus rigid which is non-correctable

Normal heel bisector line should fall between 2nd and 3rd toe

metatarsus adductus diagnostics

Not needed

X-ray: only if older or rigid form

metatarsus adductus management

Managed by PCP

90% will resolve by age 4

• If child can actively correct = no treatment

• If child can be passively corrected = serial stretching by parents

Rarely operative (if persists > 4 years old)

tarsal coalition

Congenital connection of two or more tarsal bones

Calcaneus/navicular or calcaneus/talus

Progresses, starts cartilaginous but will ossify with age

tarsal coalition epidemiology

Rare, only 2% of general population

Frequently bilateral

Autosomal dominant inheritance pattern

tarsal coalition Hx

CC: mostly asymptomatic

Brought in by primary caregiver

Foot pain and stiffness develops during adolescence, as lesion ossifies

tarsal coalition PE

Pes planus, forefoot abduction

Limited subtalar range of motion

Hindfoot remains valgus upon toe-standing

tarsal coalition Dx

X-ray

Calcaneovavicular coalition - "anteater sign" (elongated anterior process of calc)

Talocalcaneal coalition - "talar beaking" (superior projection of distal talus)

tarsal coalition management

Refer to foot and ankle specialist

Treatment based on severity of pain and deformity

Conservative - orthotics, casting, 30% success

Operative - if failed conservative

Congenital Talipes Equinovarus

(Club Foot)

Contracture of the medial tendons of the foot with subsequent deformity of Achilles, ankle, hindfoot, and midfoot

Characterized by fixed ankle plantar flexion, inversion of subtalar joint, medial subluxation of talonavicular joint

Congenital Talipes Equinovarus

(Club Foot) epidemiology

Rare, 1 in 1,000 births

M > F, 2:1

Bilateral in 50%

Associated with neural-tube defects

Congenital Talipes Equinovarus

(Club Foot) history

CC: pain and callus formation along lateral border of foot

Brought in by primary caregiver

Congenital Talipes Equinovarus

(Club Foot) PE

Clinical diagnosis

Inverted, plantar flexed heel with supinated midfoot

*This is a rigid deformity, cannot be corrected passively

Congenital Talipes Equinovarus

(Club Foot) Dx

X-ray

Loss of the normal angle between talus and calcaneus, results in parallel relationship

U/S can detect in utero

Congenital Talipes Equinovarus

(Club Foot) management

Refer immediately! Treatment should start at birth

*Passive manipulation: Ponseti method (90% success)

Operative if failed/relapse conservative

nursemaid elbow intro and epidemiology

Subluxation of radial head, followed by entrapment of the annular ligament

Common injury in young children (birth - 6 years old)

Results from sudden pull on arm usually by a taller individual!

nursemaid elbow Hx and PE

CC: sudden pain and loss of function

Child will hold arm slightly flexed and pronated

No focal pain or tenderness to palpation

nursemaid elbow Dx

* Not needed if history of traction injury, child is 6 years or younger, consistent clinic exam

Normally straight to tx... X-rays or Ultrasound can be helpful if needed or to confirm diagnosis if needed

nursemaid elbow management

Closed reduction, but confirm no fracture first

- Supination-flexion method

- Hyperpronation method

Should be immediate resolution of pain and normal ROM

salter harris fractures

Series of fractures that impact the physis (growth plate)

Disruption through trauma can lead to chronic complications (e.g. growth arrest)

classification of salter-harris fractures

I: Separation through physis

II: Fracture through portion of physis that extended through metaphysis

III: Fracture through portion of physis that extended through epiphysis and into joint

IV: Fracture across metaphysis, physis, and epiphysis

V: Crush injury to physis

**SALTER to remember (see image)