Pediatric Clinical Medicine Unit

Most pediatric concerns are

developmental/behavioral problems

Growth deviations

may be the earliest sign of underlying conditions (height, weight, BMI, head circumference)

• large shifts warrant further evaluation

  • crossing 2 major percentile lines or significant changes in velocity

Weight normals for children

• Loss of 5-10% in first 3 days of life

• return to birth weight between 7-10 days old

• gain 0.7 points a day for the first 3-4 months

• double birth weight in 4-5 months

• triple birth weight in 1 year

• quadruple birth weight in 2 years

Denver developmental test (Denver II)

screen from birth→ 6 years old to catch potential developmemental delays

Easy child

regular biologic functions, respond positively to stimuli, adaptable to change, mood is +

Difficult child

irregular biologic function, respond negatively to stimuli, poor adaptive to change, intense responses

Slow to warm child

Moderately regular biologic function, decreased activity level, slow adaptation, mildly intense reactions, negative overall mood

Colic

>3 hrs of crying >3 days/week for >3 weeks in healthy well-fed infants

• Tx: self-resolving, reassurance to the parents, some may try to change formula (not-proven to work)

Enuresis

Urinary incontinence when urinary continence is considered normal

• Primary: child never continent for prolonged period (MC in nocturnal)

• Secondary: incontinence after prolonged continence (6+ months)→ UTI MC

• Tx: counseling, enuresis alarms, desmopressin acetate (DDAVP) or Imipramine (TCAs)

Encopresis

Fecal incontinence when fecal continence considered normal; caused by retention of stool→ rectal wall stretched and increased stool water absorption

• Causes: diet, laxatives/enemas, anal fissures/rashes, constipation

• Tx: read to child on port, give child stool for feet, stool softener/fiber

Failure to thrive

Inadequate growth rate in young child; concerned if child falls into disproportionately low weight percentile

• Risks: hypothyroidism, chronic serious medical conditions, feeding difficulties

• Dx: Hx and observation

• S/S: frozen watchfulness, minimal smiling, quiet, resistance to being held, self-stimulation

• Tx: R/O inadequate caloric intake and if it doesn’t resolve, child must be hospitalized

  • Failure to gain weight means it is an organic cause (something else is wrong)

Pediatric respiratory assessment

CC/duration/associated symptoms/sick contacts, past history, growth/development, exposure to pets/smoke/daycare, family history of “triad”, medications, immunizations

• Vitals: higher HR, higher RR, low BP→ normalizes as patient ages around 12 years old

Upper respiratory infection (URI)

Acute nasal congestion and rhino sinusitis

• <10 days: viral and tx with supportive care (pain meds, humidification, saline nose drips)

• >10-14 days OR any edema, sinus tenderness, severe headache: need antibiotics

• Add nasal suctioning if the child cannot blow their own nose

Streptococcal pharyngitis (strep throat)

Group A beta hemolytic strep that is spread through droplets

• S/S: sore throat, fever, HA, malaise (some may present with GI upset), rhinorrhea and cough absent

  • PE: large tonsils, lymphadenopathy, petechiae on soft palate

• Dx: Rapid antigen tests ± throat culture

• Tx: Penicillin or Amoxicillin (severe allergy= macrolide), (mild allergy= cephalexin)

• Frequent/recurrent infection is a referral to Peds ENT (>7 in 1 yr or 5+ in 2 consecutive years)

PIGN- Post infectious glomerulonephritis

Cola color urine, edema, HTN

• Tx: ACE/ARB

• Most commonly caused by a previous Group A strep infection

Acute rheumatic fever

Inflammatory autoimmune condition weeks after an untreated or inadequately treated scarlet fever/strep infection; no longer actively contagious

• S/S: painful swollen jaunts, fever, fatigue, chest pain

• Tx: antibiotics and anti-inflammatories

Scarlet fever

Active bacterial infection releasing a toxin a few days after a strep infection

• S/S: red sandpaper rash, fever, strawberry tongue

• Tx: abx (penicillin or amoxicillin)

PANDAS

Pediatric autoimmune neuropsychiatric disorders associated with streptococcus

• S/S: sudden onset of OCD or tics or worsening of these after strep infection

Viral pharyngitis

Diffuse uniform redness and mild tonsil swelling

• Causes: common cold, flu

• S/S: painful swallowing with cold/flu symptoms (runny nose, sneeze, cough)

• Tx: supportive (hydration, gargling salt, pain management)

Peritonsillar abscess

complication of strep; infection penetrates the tonsillar capsule and involves surrounding tissues (cellulitis) and then evolves into a peritonsillar abscess (quinsy)

• S/S: severe sore throat, odynophasia, trismus (decrease opening of the jaw), medial deviation of palate/uvula, hot potato voice, drooling

• Dx: exam, aspiration bx, CT

• Tx: IV abx (amoxicillin, clindamycin, unasyn), PO (amoxicillin, clindamycin, augmentin)

Hand Foot and Mouth Disease

Coxsackie virus, enterovirus 71 can rarely cause encephalitis

• S/S: ulcers occur anywhere in the mouth, vesicles/pustules/papules may be found on palms/soles/interdigitale areas and buttocks, younger patients will be present on face and distal extremities

• Tx: supportive care- hydration and comfort (highly contagious)

Mononucleosis

EBV infection that is spread through saliva (sharing drinks and kissing)

• S/S: fever, tonsilar pharyngitis, lymphadenopathy, malaise, fatigue, splenomegaly, palatal petechiae, jaundice, rash

• Dx: lymphocytosis, mono-spot serologic testing (can be - in younger children), IgM/IgG (most definitive)

• Tx: supportive care (fluids, rest, Tylenol PRN), avoid contact sports (splenic rupture)

What antibiotic should patient’s with mono not be prescribed?

Amoxicillin (usually by accidental mistake for a strep infection)

• pt will erupt in a maculopapular rash

Allergic rhinitis

Strong association with asthma and family history of the triad

• Dx: clinical, based on s/s and usually pale pink-purple turbinates on exam

• Tx: Intranasal steroids, antihistamines, environmental control (some patients may qualify for allergy testing/shots)

Asthma patho

Chronic inflammatory disease of the airway, 70% will also have allergies, usually detected in childhood; airway inflammation also contributes to airflow limitation which includes- bronchoconstriction, edema, chronic mucus plugging, airway wall remodeling→ bronchial obstruction

Prior to participating in sports

asthma patients should used SABA and have inhaler on standby during play

Asthma

• S/S: cough, wheezing, SOB especially with exercise, chest pain/tightness, vomiting (may have history of eczema or allergies)

  • PE: can be normal, acute attack- wheezing, crackles, cough, exacerbation- respiratory distress, nasal flaring

• Dx: Hx of s/s, PFTs, metacholine provocation test or albuterol test, chest x-ray, immunoglobulins

• Tx: intermittent (low dose ICS PRN)→ severe persistent (medium dose ICS formoterol and a maintenance treatment)

PFTs in asthma

Obstructive pattern- FEV1/FVC ratio decreased

Apnea of prematurity

Premature <36 weeks that causes a central control problem or a upper airway obstruction

• S/S: apnea or bradycardia

Central apnea

Caused by Arnold chiari malformations that leads to an abnormal central control

• S/S: apnea

Breath holding spells

Blue after crying; prolonged expiratory apnea

• S/S: cyanosis, syncope

Cystic Fibrosis

Autosomal recessive genetic disease caused by mutations on chromosome 7, MC in caucasians; ducts and tubes get clogged by thick sticky mucus or other secretions; airways, sinuses, liver, pancreas, small intestines, reproductive tract, skin→ primarily lungs

• S/S: cough (productive), steatorrhea with fat droplets, DM, meconium ileum, constipation

• Dx: + sweat test (>30 examine further, >/= 60 + result)

• Tx: vest therapy, abx, corticosteroids, Ibuprofen/anti-inflammatory, Dornase Alfa

Bronchiectasis

Manifestation of disease→ obstructive pulmonary disease; manifestation of dilation and destruction of larger bronchi caused by chronic inflammation or infection (IRREVERSIBLE)

• Risks: CF, recurrent infection (H flu, P. aerugionosa, S. pneumo)

• S/S: chronic cough with purulent sputum, hemoptysis, pleuritic chest pain

• Dx: Hx, PE, X-ray (diminishes airway- tram tracks), high resolution CT

• Tx: CF= aerosolized amnioglycosides, copius sputum= macrolides

Brief resolved unexplained events (BRUE)

Episode is frightening to the observer (apnea, color change, unresponsiveness, change in muscle tone/choking/gagging)

• Low risk patient: > 2 months old, brief episode that was self-limited and low risk for future events (EKG and testing for pertussis)

• Not low risk→ pt needs to be inpatient for cardiopulmonary monitoring

• Causes: infectious, GI (reflux), respiratory (airway abnormalities), neuro, CV (dysrhythmias), nonaccidental trauma, apnea of infancy

SIDS- Sudden infant death syndrome

Sudden death of an infant under 1 year of age the that remains unexplained after a thorough investigation including autopilot, exam of death scene and review of clinical hx; thought to be delayed maturation of respiratory or CV control or arousal mechanisms

• Risks: highest between 2-4 mo, lower significantly at >6 mo

  • sleeping in prone position, co-sleeping, smoking/drug use, crowded living conditions, low socioeconomic status, overheating, young parents, premature

• Cardiorespiratory monitors in premature infants with high risk of bradycardia or apnea are recommended (do not improve outcomes for all children)

Obstructive sleep apnea

Children of all ages, MC in children of preschool age (tonsils and adenoids largest)

• Causes: obesity, Down syndrome, prader-willi, neuromuscular disease, craniofacial abnormalities, obstruction

• S/S: snoring, disturbed sleep, daytime neurobehavioral problems, possible daytime sleepiness

  • ADHD with mid facial anomalies

• Dx: polysomnography

• Tx: tx allergies, sx tx if obstruction, possible CPAP

Pneumonia

• Risks: respiratory viruses (first dew years), daycare, cigarette smoking- MC d/t strep pneumo

• S/S: shaking chills, abrupt onset of high fever, cough, chest pain, mild URI, decreased appetite, rusty colored sputum, cyanosis, respiratory distress (more variable in younger pt)

  • PE: retractions, dullness to percussion, tubular breath sounds, rales, decreased tactile and vocal fremitus, decreased breath sounds

• Dx: leukocytosis, ABG (hypoxemia), bacteremia on culture, + sputum

• Tx: Abx (amoxicillin, doxycycline, macrolides)

Most pediatric pneumonia x-rays will clear in

2-3 months

Croup (laryngotracheobronchitis)

MC infection of the middle respiratory tract; MCC is parainfluenza or RSV

• Patho: mucosal edema and inflammation; airway resistance and increased work of breathing→ during inspiration walls of the subglottic space are drawn together producing stridor

• Risks: MC in 6mo-3yr, peaks in fall or early winter following common cold

• S/S: saddest onset of barking cough in early morning and gets better with air exposure (not usually too suck appearing)

• Dx: X-ray (steeple sign)

• Tx: PO/IM dexamethasone, steam inhalation or enhanced racemic EPI

Epiglottitis

Life threatening emergency

• Risks: 2-4 years old, strep pneumo/H. parainfluenzae/varicells zoster/HSV-1/staph

• S/S: sore throat, muffling or change in voice, difficulty speaking, high fever, dysphagia, drooling, respiratory distress, tropoding

• Dx: X-ray (thumbprint sign)

• Tx: endotracheal intubation and IV abx (ceftriaxone)

Foreign Body in Airway

Acute life treating or chronic, focus on ABCs (backblows/heimlich)

• Chronic: cough/.wheeze, recurrent pneumonia, lung abscess

• significant decrease of air entry on one side (looks like asthma)

• Dx: Hx and auscultation, Dx: chest x-ray, fluroscopy, bronchoscopy (if chest x-ray not dx)

  • AP and lateral of soft tissues of the neck inspiratory and expiratory

Pertussis

Bordetella pertussis, highly contagious via droplets; toxin mediated disease→ bacteria attach to the cilia of the respiratory epithelial cells and produce toxins that paralyze cilia that causes inflammation of the respiratory tract that interferes with the cleaning of pulmonary secretions

• S/S: high pitched “whooping”, cough-vomit syndrome

  • Infants appear with apnea or CNS damage

• Dx: clinical picture, WBC 15-20k, X-ray (segmental atelectasis or perihilar infiltrates- shaggy heart), PCR swab

Stages of pertussis

Most contagious during earliest stages- 2 weeks after cough begins (abx shorten this)

1. Catarrhal: insidious onset, lacrimation/sneezing/anorexia/malaise, hacking cough especially at night

2. Paroxysmal: burst of rapid consecutive coughs followed by deep high-pitch inspiratory whoops

3. Convalescent: 4 weeks after onset, decreased frequency of paroxysms

Bronchitis

Large airways (bronchi), bronchial inflammation→ mucus production

• Risks: viral-RSV, influenza, rhinovirus, COVID-19

• S/S: cough, low grade fever

• Tx: supportive

Bronchiolitis

Small airways (bronchioles), bronchiolar edema and mucus plugging

• Risks: Viral- RSV

• S/S: respiratory distress, wheezing, crackles

• Tx: supportive

Tx and prevention of Pertussis

• Prevent: DTaP immunization- diphtheria, tetanus, acellular pertusis

• Tx: Azithromycin, Clarithromycin, Erythromycin/Bactrim (not in neonates, >2+months)

• NO SCHOOL OR WORK UNTIL 5 DAYS OF ABX COMPLETED

• PEP (household, high risk individuals, people in contact with high risk individuals)- Azithromycin

RSV- Respiratory syncytial virus

Paramyxovirus; causes pneumonia, tracheobronchitis, bronchiolitis

• Risks: premature infants (bronchopulmonary dysplasia), males, <6 months, daycare, November-April

• S/S: nasal congestion/flaring, cough, tachypnea, labored breathing, dyspnea, cyanosis, wheezing, fever, “croupy” cough

• Dx: MC PCR, culture= gold standard, nasal washings ELISA or IFA

• Tx: hydration, humidification, venitilatory support

  • Passive immunity/prevention for compromised children: Palivizumab/Nirsevimab (monoclonal aby)

Tongue tie

Lingual frenulum (band under tongue) is too short/thick/tight; can be mild→ severe

• S/S: restricted movement, shape changes, feeding struggles in infants, speech challenges, poor oral hygiene

• Tx: Mild-=monitor, Severe= frenotomy (newborn), frenectomy (kids/adults)

Otitis Media

Usually after URI

• S/S: fever, pain, trouble feeding, tugging at ear

• Dx: mod/severe bulging of the TM (check for perforation)

• Tx: amoxicillin or augmentin

Otitis Externa

Painful edema and erythema of ear canal skin often with purulent exudate

• S/S: severe ear pain, recent swimming/instrumentation of the ear, itching in cancel, fullness, pain with manipulation

• Dx: inflamed swollen canal, tympanic membrane usually normal

• Tx: cipro/dexamethasone otic drops with pain control

Sinusitis

(Viral/Bacterial) Inflammatory conditions of sinuses in addition to nasal passages

• Viral- rhinorrhea, sneezing, sore throat

  • Tx: supportive, hydration, rest, analgesics

• Bacteria- pain and pressure over the sinuses, purulent drainage, >10 days w/o improvements

  • Tx: augmentin or doxy

Epistaxis

Bleeding from nasal mucosa; most are anterior from Kiesselbach plexus

1. Position- lean forward

2. Compression

3. Topical vasoconstrictor- Oxymetazoline

4. Cautery

Nasal FB

Child with unilateral foul-smelling discharge

• Dx: on visualization

• Tx: removal (forceps, balloon catheter, + pressure “Parent’s kiss”)

• BUTTON BATTERY EMERGENCY

Hyaline Membrane Disease

Infant respiratory distress syndrome (IRDS)

• Shortage of pulmonary surfactant that is supposed to keep small air sacs inflated

• Tx: Surfactant replacement, breathing support

Parotitis

Inflammation of parotid salivary gland causing swelling near jaw

• Risks: Virus (mumps, flu, EBV, CMV), bacteria (staph), dehydration, poor oral hygiene

• S/S: Viral (b/l or unilateral, fever, malaise, jaw pain), Bacterial (unilateral painful swelling, purulent drainage from Stenson duct, fever)

• Dx: viral testing, culture for bacteria

• Tx: viral (supportive), bacteria (Augmentin, Clindamycin)

Think social (pragmatic) communication disorder in patients that

have marked deficits of social communication but s/s don’t meet ASD

Social (pragmatic) communication disorder

Persistent difficulties in the social use of verbal and nonverbal communication as manifested by

1. Deficits in using communication for social purposes such as greeting and sharing information appropriately

2. Impairment of the ability to change communication to match the context of the listener (speaking differently on the playground or the classroom)

3. Difficulty following rules for conversation and storytelling (taking turns or rephrasing when misunderstood)

4. Difficulties understanding things not explicitly stated

*Functional limitation in effective communications, social participation/relationships, academic achievement

*Onset early in childhood, may not fully manifest until social command exceeds limits

Tx using speech therapy

Autism Spectrum Disorder (ASD) defintion

1. Persistent deficits in social communication and interaction across multiple contexts

• deficits in social-emotional reciprocity, deficits in non-verbal communication, deficits in developing and maintaining relationships

2. restricted repetitive patterns of behavior, interests, or activities

• stereotyped or repetitive motor movements, inflexible adherence to routines, restricted fixated interests, hyper or hypo-reactivity

3. symptoms may be present in early developmental period→ may no fully manifest until demands exceed limitation or masked by learned strategies

ASD Classification

• Severity: based on social communication and impairments and restricted patterns of behavior

  • Level 1 (support), Level 2 (substantial support), Level 3 (very substantial support)

• With or without intellectual impairment, with or without language impairment, associated with medical, genetic, or environmental conditions

ASD s/s

Delayed attainment of social skill milestones, language impairment common, often seen with intellectual disorders, repetitive behaviors

• 9 months

  • - turning and eye contact,babling, vocals, waving, response to caregiver

  • + unusual sounds

• 12 months

  • + carry unusual comfort item, unusual attachment, repetitive behaviors

ASD Dx and Tx

• Dx: Autism screening (M-CHAT) @18 and 24 months→ if + neuropsychological referral

• Tx: multidisciplinary- speech, OT, audiologist, use of special education programs

Anxiety disorder

Excessive worry interfering with functions

• OCD (MC): worry alleviated by rigid and time consuming compulsions (counting, washing)

• Social anxiety: frequently troubling during adolescence interring with social relationships and self-esteem

• Tx: CBT, exposure therapy (OCD), SSRI (NO PAXIL)

Post Traumatic Stress Disorder (PTSD)

• Risks: significant trauma through abuse, neglect, abuse, illness, accident or other trauma

• S/S: arousal changes, avoidance and re-experiencing that can be persistent and debilitating, ± depression, SUD, risk taking behavior

• Tx: psychotherapy

Depression

School failure, poor relationships

• Tx: CBT+ SSRI

SSRIs in pediatric patients

can increase the risk of suicidal ideations

ADHD

• Inattention: fails to pay attention to details, difficulty organizing attention, avoid tasks requiring a lot of attention, loses things, easily distracted, not interested when being spoken to, forgetful

• Hyperactivity: fidget/squirm, run/climb, difficulty with leisure, on the go “driven by a motor”, talks excessive/blurts/interrupts, difficulty waiting turn

• Tx: Stimulatns- Methylphenidate (Ritalin), Adderall

  • Can significantly decrease appetite and slow growth velocity

Oppositional Defiant Disorder (ODD)

6+ months of symptoms: angry/irritable, argumentative/defiant, vindictiveness→ PRECURSOR TO CONDUCT DISORDER

• S/S: loses temper, argues with adults, refusal to comply, deliberately annoys, does not take responsibility for behaviors, sensitive/easily annoyed, angry, vindictive

• Tx: CBT, problem solving with parents

Conduct Disorder

Patter of behavior involving the violation of basic right of others or social norma or rules with at least 3 in the following year: aggression towards people and animals, destruction of property, deceitfulness, violation of rules→ risk of developing antisocial personality disorder in adulthood

• Tx: structure, rules, consistent enforcement, behavior, mood problem solving, therapy

  • Adjunct pharmacotherapy: antipsychotics, lithium, SSRIs

Disruptive Mood Dysregulation Disorder

Child with persistently irritated/angry mood, temper outbursts inconsistent with age for 12+ months with no more than 3 mo break in between episodes

• Tx: behavior therapy

Gender dysphoria

Psychological distress caused by a significant mismatch between a person's gender identity and their assigned sex at birth

• Pre-pubescent: family and personal therapy

• Pubescent: Leuprolide (block GHRH→ stop puberty)

Substance Use Disorders In Children

The younger initiated, higher risk of serious health complications and adult SUD

• high risk of school underachievement, delinquency, teenage pregnancy, depression

• Tx: therapy, psychotherapy, low dose antidepressants, inpatient and outpatient clinics

Anorexia Nervosa

Refusal to maintain body weight at or above a minimally normal weight for age and height OR failure to make expected weight gain during period of growth

• Risks: 12-15 yo, 17-21 yo, females, first degree relativesS/S: intense fear of gaining weight/being fat, denial of low body weight, starvation, fear of eating in public, bradycardia, hypothermia, lanugo, emaciation, thinks losing weight is good self discipline

• Screen: screening tools, use family members (pt will come in complaining of related symptoms- hair loss, muscle weakness)

• Tx: Hospitalize early to avoid cortical gray matter loss, CBT+Psychotherapy

Bulimia Nervosa

Recurrent episodes of binge eating; characterized by binge eating followed by recurrent compensatory behavior (vomiting, laxative, diuretics, enemas, meds, fasting, exercise)

• Purging: self induced vomiting, misuse of laxatives or diuretics

• Non-purging: fasting or excesive exercise

• Risks: preoccupation with being skinny, sports, abuse

• Dx: vomit (metabolic alkalosis), laxatives (metabolic acidosis)

• Tx: CBT and Prozac, bright light therapy→ no hospitalization pt not emaciated

Complications of anorexia

Amenia, impaired renal function, arrhythmia, HoTN, dental decay

Complications of bulimia nervosa

esophageal tears, seizures, orthostatic HoTN, gastric rupture

In utero positioning

Joint and muscle contractures affects torsional and angular alignment of long bones, 20-30 degrees of hip and knee flexion contractures that will resolve on its own in 4-6 months

Newborn foot (normal)

Tucked under, forefoot adducted (deviated inward), heel inverted, foot pointed down

• normal if the later border can be moved straight, the heel is slightly everted and foot can be dorsiflexed

Metatarsus adductus

Forefoot turned in, MC genetic foot deformity; inward turning of forefoot, hindfoot not affected→ foot can be manually straightened

• Tx: Mild= passive stretching, Severe= serial bracing/casting

Clubfoot (congenital talipes equinovarus)

True structural defect, cannot manually straighten

1. Midfoot directed downward

2. Hindfoot turns inward (varus)

3. Forefoot curls toward heel (adduct)

• Risks: genetic predisposition, males, unilateral or bilateral

• Tx: serial casting 8-12 weeks→ surgery if casting is not effective (TX occurs shortly after birth)

Common lower extremity disorders

• Angular: bow legged (varus), knock kneed (valgus)

• Rotational: femoral or tibial in-toeing or out-toeing

In-toeing: femoral anteversion (rotational)

• Risks: MCC of intoeing in kids >/+ 2, girls, congenital, acquired from sitting

• S/S: “kissing patella” appearance, feet turned inward, sit in the “w” position, external rotation 0-10 degrees, change in alignment between hip and knee

• Dx: X-rays not necessary→ clinical diagnosis

• Tx: observation, PT, correct sitting position

In-toeing: internal tibial torsion

• Risks: MCC intoeing in kids <2 yo, in utero positioning

• Normal in the first 24 months of life, patella will be in neutral position

• Tx: usually spontaneous correction, >2 yrs w/o improvement= Denis Browne splint (nighttime orthotic), PT

Out-Toeing External tibial torsion

Less common than in-toeing

• Risks: in utero positioning

• Tx: spontaneous resolution, if persists refer to ortho (more refractory to conservative treatment)

Out-toeing femoral retroversion

Knees are NOT in neutral position; monitor for SCFE in adolescence

• Tx: refer to orate surgeon if persists

Genu Varum (bow legged)

With standing and walking→ will correct spontaneously between 6-12 months

• 15 degrees→ 10 degrees in 1 yo→ 2 yo straight legs

• Tx: refer to ortho in 2-3 years without improvement

Tibia Vara (Blount Disease)

MC pathologic disorder causing progressive genu varum; abnormal growth of medial aspect of proximal tibial epiphysis and leads to a progressive varus able below the knee in any age growing child (80% bilateral, unilateral is very pathological)→ growth suppression from increased compressive forces along the medial aspect of the knee and leads to lower extremity length inequality

• Dx: B/l x-rays of lower extremities

• Tx: <3 yo= orthoses, >4= sx- osteotomy of tibia and fibula

Genu valgum (knock knee)

• Risks: often spontaneous overcorrection for natural gene varum, between 3-4 and resolves between 5-8

• Tx: rarely needed, refer ortho

Gait

• Toddler (12-18 mo): hesitant and inconsistent, broad based with fast cadence, flat footed

• 2 years: high speed and step length, diminished cadence

• 3-7 yo: developing normal adult gait

Painful (acute onset) limping

trauma, infection (septic arthritis, osteomyelitis), acquired disorders (tumor, rickets)

• stance phase and stride length shorted and kids will try to not stand on painful limb (antalgic gait)

Painless limping

neuromuscular disorder (CP)- check hip drop- Trendelenberg, foot drop, muscle tone, muscle weakness

Toe-walking

Common in early walkers and common to grow out of

• If persists- leg length discrepancy, cerebral palsy, congenital contracture of muscle (may need a tendon release surgery)

Hip disorders

Blood supply to the femoral head is unique- blood vessels enter epiphysis peripherally which makes it vulnerable to damage: septic arthritis, trauma, vascular insult, avascular necrosis

Types of developmental dysplasia of the hip

• Typical: neurologically normal infant (MC)

• Teratologic: underlying neuromuscular disorder or syndrome is present (ex. CP)

Developmental dysplasia of the hip (DDH)

Abnormal development or dislocation of the hip

• Risks

  • Physiological: + family hx, general laxity of ligaments, pelvic ligament relaxation d/t maternal estrogen, female predominance

  • Mechanical: primigravida, breech baby, oligohydramnios, postnatal positioning

• Complications: Avascular necrosis- caused by occlusion of vessels which leads to abnormal growth and development

Dx of developmental dysplasia of the hip

• Barlow test- attempt to dislocate untstbale hip, Ortolani test (use in 1-2 mo)- reduce

• PE: limitation of hip abduction, asymmetric thigh skin folds, shortening of extremity (Galeazzi sign)

  • Older kids if not dx: limping, waddling (b/l), increased lumbar lordosis, toe-walking, in-toeing

• < 3 mo: b/l hip USN

• > 3 mo: XRAY (AP and frog leg positioning), USN can also be used

Tx developmental dysplasia of the hip

Refer to ortho→ goal= keep femoral head in reduction and let ligaments tighten

• Neonates: 2-3 diapers

• 1-6 mo: Pavlik harness (hip flexion >90 degree with gentle abduction)

• Fail tx: closed reduction with hip spica cast (in human position)

Transient Monoarticular Synovitis

Inflammation of the synovium MC in the hip joint

• Risks: recent viral infection, average 6 yo

• S/S: painful limp, acute onset of pain in the groin/anterior thigh/knee, mild restriction of ROM (esp abduction and internal rotation)

• Dx: X-ray (normal), aspiration (normal, may help relieve pressure)

  • want to exclude septic arthritis or osteomyelitis

• Tx: bed rest, NSAIDs, non-weight bearing or low activity

Legg-Calve-Perthes Disease

Idiopathic avascular necrosis of capital femoral epiphysis (CFE), caused by interruption of blood supply→ self limiting and increase risk of OA

• Risks: 3-12 yo, MC in males

• S/S: painless limp, mild pain of hip/groin/thigh/knee may be present

• Dx: X-ray (AP and frog legged)

• Tx: refer ortho, PT, bracing/surgical fixation if necessary

Slipped Capital femoral epiphysis (SCFE)

• Risks: MC adolescent hip disorder, obese with delayed skeletal development (low sex hormones), tall and thin after recent growth spurt (high GH)

• Changing rate of of cartilage in physis and rate of skeletal growth

• Slippage: mechanical factors or obesity- high shear force across weak growth plate

Slipped Capital femoral epiphysis (SCFE) Dx and Tx

• Dx: X-ray (AP and frog legged)- early+ wide physis without slippage, slip= cause varus retroverted head and neck

  • PE: lack of internal rotation and increased external rotation

• Tx: refer ortho for surgical intervention