Medicine Exam 5: Pediatrics Orthopedics

Lecture 3

Additional Topics

· Pes Planus (Flat Foot) · Pediatric Fractures · Pediatric Bone Tumors

An intoed gait can come from 3 areas

• Feet: metatarsus adductus - Tibias: medial tibial torsion - Femurs/hips: excessive femoral anteversion (medial femoral torsion)

Barlow and Ortolani Tests

• Barlow Test: Can you push femur “Below?” - Ortolani Test: Can you reduce (dislocated) hip with anterior force? • “Clunk” = Bad • “Click” = Usually Fine

Bone Tumors – Types

• Osteochondroma - Osteoid osteoma - Nonossifying fibroma - Osteosarcoma - Ewing sarcoma

Buckle Fractures

• “Like a soda can bent in on itself” - Heal reliably - Cast is for comfort - Very common, especially at distal radius

Clavicle Fractures

• Rarely require surgery - Exception: throwing arm in high-level athlete - Usually treated with sling or shoulder immobilizer - May remodel over time

Clubfoot

Speedy consultation with a serial casting practitioner is important. Early start can lead to best results.

Clubfoot – Clinical Findings

· This can occasionally be diagnosed in-utero. · This can now be successfully treated 95% of the time with serial casting (Ponsetti Method) and/or achilles tenotomy. · The affected leg may be globally small.

Clubfoot – Clinical Findings

• Occasionally diagnosed in-utero - Affected leg may be globally small

Clubfoot – Treatment

• Serial casting (Ponsetti Method) - Achilles tenotomy - 95% success rate - Speedy consultation with serial casting practitioner is important - Early start leads to best results

Clubfoot –Complication

· Walk on dorsum of foot or on ankles if not treated · Legs can be different lengths

Clubfoot –General

· Treat successful with serial casting · May also cut some achilles fibers · Stuck in plantarflexion

Congenital Muscular Torticollis – Clinical Findings

· Parents note that the baby often keeps one ear tilted to the ipsilateral shoulder and the chin to the contralateral shoulder. · Practitioner notes tightness in one of the sternocleidomastoid (SCM) muscles. · This can be associated with facial asymmetry and/or asymmetric flattening of head (plegiocephaly).

Congenital Muscular Torticollis – General

· Can be very subtle, decreased movement on one side · Cheeks, facial differences

Congenital Muscular Torticollis – Treatment

Physical Therapy = key - Parents stretch as taught by PT daily - PT not well-tolerated after a while - Cervical Collar: occasionally used, not necessarily effective - Surgical Release of Tight SCM: • Considered when PT plateau is reached and significant concern persists • Followed by weeks in a pinless halo

Developmental Dysplasia of the Hip – Clinical Findings

• Improper formation/development of hip joint (often acetabular dysplasia) - Risk factors: • Breech positioning • First born • Family history • Female - Screening controversy: • May resolve spontaneously • Treatment has risks • Cost vs benefit

Developmental Dysplasia of the Hip – Diagnostic Work-up

• Ultrasound of hips: helpful from 2 weeks to 6 months • Technique-dependent - Plain Radiographs (AP Pelvis): helpful from 6 months onward - Follow-up with specialist appropriate even with “normal” ultrasound

Developmental Dysplasia of the Hip – Screening

• Observe leg lengths, thigh fold symmetry - Galleazi Sign: apparent femoral length discrepancy - Barlow Test: push femur “below” - Ortolani Test: reduce dislocated hip with anterior force • “Clunk” = Bad • “Click” = Usually Fine

Developmental Dysplasia of the Hip – Treatment

• Pavlik harness: • Usually worn for 3 months • Usually successful - Closed reduction and casting - Open hip reduction and/or pelvic osteotomy

Developmental Dysplasia of the Hips

• Improper formation/development of the hip joint (often is dysplasia of the acetabulum)

Developmental Dysplasia of the Hips -- 4 Main Risk Factors

• Breech positioning (packaging issue) - First born (packaging issue) - Family history (genetics) - Female (some disagreement regarding reason)

Developmental Dysplasia of the Hips -- Diagnostic Studies

• Ultrasound of hips = key: helpful from 2 weeks through 6 months of age • Highly technique-dependent; best performed at facility that does many - Plain Radiographs (AP Pelvis): most helpful from 6 months onward (hips more ossified) - Follow-up with specialist appropriate even with “normal” ultrasound

Developmental Dysplasia of the Hips -- Screening Controversy

• May resolve spontaneously - Thus, treating some patients who don’t need treatment - Treatment has risks - Costs vs benefits of screening Screening for hip dysplasia is not a standard requirement, because may resolve spontaneous but no know who will happen to Issue = if missed then issues with limb when walking

Developmental Dysplasia of the Hips -- Screening Exam

• Observe: leg lengths, thigh fold symmetry - Galleazi Sign: can show apparent femoral length discrepancy Barlow and Ortolani Tests = key

Developmental Dysplasia of the Hips -- Treatment Options

• Pavlik harness = key • Usually worn for 3 months • Usually successful, but is it spontaneous = no know - Closed reduction and casting - Open hip reduction and/or pelvic osteotomy

Epiphyseal Separations – General

• Pediatric bones have growth plates (physes) - Growth plate fractures = epiphyseal separations - 10–30% of pediatric fractures involve physis - 4% of physeal fractures result in physeal arrest - Most common site of arrest: distal tibia - Physeal arrest can lead to angular deformity or limb length discrepancy

Essential Bone Terms

• Diaphysis – long part of long bone - Metaphysis –the long-bone side adjacent to growth plate - Physis – growth plate - Epiphysis – adjacent to physis (often toward jointline)

Ewing Sarcoma – Clinical Findings & Prognosis

• Bone cancer in bone or soft tissue around bone - Often in long bones, but can present anywhere - Often affects localized muscle and other soft tissues. - Treatment depends on many factors (including location/size of lesion, metastasis), and can include chemotherapy with radiation and/or surgery. - 5-year survival: • Localized: 55–70% • Metastatic: 22–33%

Ewing Sarcoma – Clinical Findings & Prognosis

• Bone cancer in bone or soft tissue around bone - Often in long bones, but can present anywhere - Affects localized muscle and soft tissues - Treatment: chemotherapy with radiation and/or surgery - 5-year survival: • Localized: 55–70% • Metastatic: 22–33%

Excessive Femoral Anteversion – Clinical Findings

· In inward twist in the femurs. · Easily assessed by checking hip motion. · PE: significantly increased internal rotation of the hips. · Resolves spontaneously to a degree, may not resolve completely.

Excessive Femoral Anteversion – Diagnosis

Clinical, stablilze the pelvis and lay flat

Excessive Femoral Anteversion – Treatment

• Resolves spontaneously to a degree - May not resolve completely

Femoral Anteversion – Clinical Findings

• Inward twist in femurs - PE: significantly increased internal rotation of hips

Femoral Anteversion – Treatment

• Resolves spontaneously to a degree - May not resolve completely

Flatfoot – Treatment

• If painful, arch supports often help

Flatfoot (Pes Planus) – Clinical Findings

• Common condition - Usually asymptomatic - PE: assess arch with foot suspended or standing on toes • Arch present = flexible pes planus • Arch absent = rigid flatfoot (may require specialist follow-up)

Focused PE Topic – Tenderness

• Tenderness: So Simple. So Important. - Focal bony tenderness vs. more diffuse muscular tenderness vs. superficial tenderness at an abrasion. Knowledge of anatomy is key to making tenderness exam useful. - When on rotations… look this up if you have a chance.

Fracture Classification – Additional Types

· Comminuted fracture: produced by direct trauma, resulting in fracture into more than 2 pieces of bone. · Avulsion fracture: produced by forcible resisted contraction of a muscle that pulls off fragment of bone at muscle insertion. · Stress fracture (March fracture): caused by repetitive overuse that leads to microfractures in the bone. · Pathologic fracture: occurs at the site of bone weakened by tumor or osteoporosis.

Fracture Classification – Types

• Closed: does not fracture through skin - Open: soft tissue injury open to fracture (treat as infected wound) - Spiral: twisting/rotational force = Often caused by indirect force - Greenstick: occurs when bone is bent and fails on the side subjected to compression. Kids have more bone elasticity. - Torus (Buckle): caused by compression force on the long axis of the bone in children. (AKA “Buckle Fracture”)

General Pediatrics Universal Challenges/ Considerations – Abuse Considerations

• Must always consider abuse. - History: parent-coached responses - PE: Bruising patterns - Incidental fracture findings Fractures that don’t make sense when considering mechanism of injury reported - Leg fractures in infants? = ex. “I heard a snap when I was putting on his pants.” Hmm…

General Pediatrics Universal Challenges/ Considerations – Abuse Protocols

Know your facility’s protocol - SCAN Team (at CHOP) - Skeletal Survey (x-ray evaluation of entire body) - Social Work Team - Governmental Agency Even kids with disabilities can be abused - Patients with osteogenesis imperfecta and cerebral palsy deserve the same consideration.

General Pediatrics Universal Challenges/ Considerations – History

• Children can be very good or bad historians. - Some won’t even talk to you! - Can’t hurt to try: many 3 year-olds and patients with severe cerebral palsy have been excellent historians.

General Pediatrics Universal Challenges/ Considerations – Physical Exam

Teenagers – athletes might want to downplay injury in order to play sport. - Healthy skepticism sometimes needed. Adolescents – self consciousness. - Always gown appropriately. - Can make reflex evaluation challenging. Toddlers/infants often don’t want to be examined. - PE should be playful, when possible.

Genu Varum/Valgum – Clinical Findings

• Mild genu varum (“bow-legs”) normal from birth to 2–3 y/o - Mild genu valgum (“knock knees”) normal from 3–4 y/o (peak), resolving by 8 y/o

Greenstick Fractures – Classification

• Occurs when bone is bent and fails on side subjected to compression - Kids have more bone elasticity

Growth Plate (Physis) – Anatomy

• Cartilaginous area at end of long bones where longitudinal growth occurs - Between metaphysis and epiphysis - Cartilage transitions to bone at skeletal maturity = no further longitudinal growth Closure varies by individual and bone - Mostly closed between 12–18 years - Girls close earlier than boys

Growth Plate Fractures – Management

• Many treated with cast/immobilization - Significantly displaced fractures may require surgery - SH II: more likely to cause growth abnormality - SH III/IV: more likely to need surgery Many growth plate fractures require long-term x-ray follow-up to assess continuing growth. · May check contralateral physis · Check for Park-Harris lines parallel to physis = Can indicate physeal arrest/regrowth

Growth Plate Fractures – Management

• Many treated with cast/immobilization - Significantly displaced fractures may require surgery - Long-term x-ray follow-up often needed to assess growth - May check contralateral physis - Park-Harris lines parallel to physis can indicate physeal arrest/regrowth

Idiopathic Scoliosis – 45-50 degrees

Issue, can have a hard time with breathing in the future progress and worsen in 20s and beyond

Idiopathic Scoliosis – Clinical Findings

• Abnormal lateral curvature of the spine - Often noted on well-visit or school screening - Strong but unidentified genetic link - PE: • “Rib hump” or spinal/rib asymmetry on forward bending • Ensure leg lengths are approx. equal • Neuro: check reflexes (including abdominal) and strength - Usually a pain-free condition

Idiopathic Scoliosis – Diagnostic Work-up

• X-rays: • Cobb Angle used to assess severity · <10 degrees = spinal asymmetry (not scoliosis) · 25 degrees = consider bracing if patient has significant growth remaining · 45-50 degrees = consider surgery (usually spinal fusion), as this may continue to progress even when patient is finished growing

Idiopathic Scoliosis – workup

Use of a Scoliometer = ball bearing

Intoeing

common and is most often not a problem that requires intervention.

Intoeing – Additional Notes

• May occur in combination - Grandparents often most concerned - Some families’ overwhelming concern will want specialist referral, despite the best educational efforts of the PCP

Intoeing – Common Concerns

• “He walks with his feet turned in.” - “She’s very bow-legged.” - “My mother had to wear shoes attached to a bar for the same thing.” - “He’s clumsier than other kids his age and falls a lot.” - “It looks funny.”

Legg-Calvé-Perthes Disease – Clinical Findings

• Avascular necrosis of the femoral head - Age: 3–9 years - Male > Female - ~90% unilateral - Usually starts with a painless limp = gait difference - May look like a leg length discrepancy (LLD) - PE: limited abduction, internal rotation

Legg-Calvé-Perthes Disease – Etiology

Loss of blood supply to part of the femur at some point in development

Legg-Calvé-Perthes Disease – Pathogenesis & Clinical Findings

• Avascular necrosis of femoral head - Age: 3–9 years - Male > Female - ~10% bilateral - Usually starts with painless limp - May look like leg length discrepancy - PE: limited abduction, internal rotation

Legg-Calvé-Perthes Disease – Prognosis & Treatment

• Prognosis and treatment depend on age and extent of involvement

Legg-Calvé-Perthes Disease – Prognosis & Treatment

• Prognosis and Rx depend on age and extent of involvement Better = younger = more time to correct Treatment = avoid run and jump activities, limit high impact activities, some surgical could be attempted

Legg-Calvé-Perthes Disease – Workup

X ray difference

Medial Tibial Torsion – Clinical Findings

• Most common cause of intoeing - Slight twist in tibia bone - X-rays usually not helpful Most cases spontaneously resolve over time - May not improve completely but should not cause problems - Surgery not usually reasonable - Special shoes not proven effective

Medial Tibial Torsion – Diagnosis

Quick table top exam

Medial Tibial Torsion – Key Physical Exam Findings

Document: foot progression angle Document: thigh foot angle Key rule-out documentation: lateral borders of feet and hip ROM (hip ROM documentation relates to next topic)

Medial Tibial Torsion – Treatment

• Patient/family education Do not need big machines or contraptions, will resolve so reassure

Metatarsus Adductus – Clinical Findings

• Foot appears curved - Can affect one or both feet (commonly both) - PE: hold a straight-edge to lateral aspect of foot • Normal: foot lines up with ruler • Metatarsus Adductus: foot curves in near metatarsal bases - PE: assess flexibility of deformity

Metatarsus Adductus – Clinical Findings

• Foot appears curved - Can affect one or both feet (commonly both) - PE: hold a straight-edge to lateral aspect of foot • Normal: foot lines up with ruler • Metatarsus Adductus: foot curves in near metatarsal bases - PE: assess flexibility of deformity

Metatarsus Adductus – Treatment

· Most do well with gentle stretching taught to parents. · We often recommend putting shoes on opposite feet or order special shoes to stretch. · Most resolve with this intervention. · Surgery seldom required.

Metatarsus Adductus – Treatment

• Gentle stretching taught to parents - Shoes on opposite feet or special shoes to stretch - Most resolve with intervention - Surgery seldom required

Nonossifying Fibroma – Clinical Findings & Treatment

• Benign, non-aggressive tumor that consists mainly of fibrous tissue. - Common in femur or tibia - Less common in upper extremities - Usually asymptomatic - Often incidental finding - Treatment only needed if it causes or puts a patient at significantly increased risk for fracture. Weak spot in the bone = may lead to pathologic fracture = find it for first time In femoral neck = see a lot of force = reason to treat surgically even if benign

Nonossifying Fibroma – Clinical Findings & Treatment

• Benign, non-aggressive tumor of fibrous tissue - Common in femur or tibia - Less common in upper extremities - Usually asymptomatic - Often incidental finding - Treatment only if fracture risk is high

Nursemaid’s Elbow – Pathogenesis & Clinical Findings

• Radial head subluxation with annular ligament entrapment - Presents as child not using arm after the arm has been tugged forcefully. - May or may not seem painful

Nursemaid’s Elbow – Treatment

• Supination of forearm and flexion of elbow All done

Nursemaid’s Elbow – Treatment

• Supination of forearm and flexion of elbow

Osgood-Schlatter – Differential

• Tenderness at distal pole of patella may indicate Sinding-Larsen-Johansson condition (similar apophysitis with similar treatment)

Osgood-Schlatter Disease – Clinical Findings

• Presents as knee pain at tibial tubercles - Pain during/following activity during periods of rapid growth - Often bilateral pain - Unilateral complaints warrant x-ray

Osgood-Schlatter Disease – Clinical Findings

• Knee pain at tibial tubercles - Pain during/following activity during rapid growth - Often bilateral; unilateral pain warrants x-ray - PE: tenderness and bony prominence at tibial tubercle - Radiographs: may show fragmentation (microfractures) - History: insidious onset - Beware of acute injury/onset

Osgood-Schlatter Disease – Differential

· Localizing tenderness is always important · If patient has tenderness at the distal pole of the patella, they may more likely have Sinding-Larsen-Johansson condition (similar apophysitis condition with similar treatment).

Osgood-Schlatter Disease – Education

• Intermittent pain may last until skeletal maturity - This is a key educational point

Osgood-Schlatter Disease – Treatment & Prognosis

• Quadriceps stretching and rest are mainstays of treatment (not casting) - Activity level/sports return guided by symptoms: • Stop playing for the day if limping/pain • Take a week off if limping/pain 2 days in a row

Osgood-Schlatter Disease – Treatment & Prognosis

• Quadriceps stretching and rest - Not casting - Activity level guided by symptoms: • Stop playing if limping/pain • Take a week off if limping/pain 2 days in a row - Intermittent pain may last until skeletal maturity - Key educational point

Osgood-Schlatter Disease – Workup

· - Exam: tenderness and often bony prominence at tibial tubercle · Radiographs may show fragmentation at the tibial tubercle (microfractures) History should be positive for somewhat insidious onset. · Beware of acute injury/onset

Ossification Center of the Elbow

Several present

Osteochondroma – Clinical Findings & Treatment

• Most common non-cancerous (benign) bone tumor - Hard mass of cartilage and bone near physes - Most patients have only one tumor - May grow as patient grows - Treatment only if tumor causes problems

Osteochondroma – Clinical Findings & Treatment

• Most common non-cancerous (benign) bone tumor - Hard mass of cartilage and bone - often presents near physes - Most patients have only one tumor - May grow as patient grows - Treatment only if tumor causes problems May develop more as get older, may need minor surgery to remove if issue here grow

Osteoid Osteoma – Clinical Findings & Treatment

• Benign, small tumor - Usually in legs (femur), less often in hand or lower spine - Can be painful - In younger patients, may cause deformity or abnormal growth - Often presents in teenage years and young adulthood - Cause unknown - Treatment often radioablation

Osteoid Osteoma – Clinical Findings & Treatment

• Benign, small tumor - Usually in legs (especially femur), less often in hand or lower spine - Can be painful - In younger patients, may cause deformity or abnormal growth - Often presents in teenage years and young adulthood - Cause unknown - Treatment often radioablation

Osteosarcoma – Clinical Findings & Prognosis

• Most common bone cancer in children and young adults - Often presents in the long bones, though it can also present in pelvis, jaw, spine, or other areas. - Treatment depends on many factors (including location/size of lesion, metastasis), and can include chemotherapy and/or surgery. - 5-year survival: • Localized: 60–80% • Metastatic: 15–30%

Osteosarcoma – Clinical Findings & Prognosis

• Most common bone cancer in children and young adults - Often in long bones; also pelvis, jaw, spine - Treatment: chemotherapy and/or surgery - 5-year survival: • Localized: 60–80% • Metastatic: 15–30%

Pediatric Elbow

• Can appear mysterious on x-ray - Review anatomy/development - Look for fat pad signs (“sail signs”) - PE guides treatment when x-ray inconclusive

Pediatric Fracture Notes

· Angulation/Displacement: the closer the fracture is to a growth plate, the greater amount of deformity is acceptable. · The “remodeling” process helps us to allow fracture deformity in kids that would require surgery in an adult.

Pediatric Fractures – Epidemiology

1/3 of children fracture a bone - 10–30% involve physis - Most common: fingers and distal radius 4% of physeal fractures result in physeal arrest - Most common site of arrest: distal tibia - Physeal arrest can lead to angular deformity or limb length discrepancy

Pediatric Fractures – General Features

• Pediatric bones have growth plates (physes) = add some complexity to their fracture evaluation - More malleable bones/unique fracture patterns: • Buckle fracture • Greenstick/plastic deformation - Thick periosteum and robust healing response = Can heal displaced/angulated fractures

Pediatric Orthopedics Screenings

Lead to diagnosis - PE elements checked at well-visits to screen for orthopedic problems: • Hip exam for Developmental Dysplasia of the Hips (recent controversy) • Spine: Examine for Scoliosis • Joints: Assess for deficits in Range of Motion • Asymmetry • Congenital Deformities

Pediatric X-rays – Developmental Changes

• Further development leads to more ossified structures on x-ray - Examples shown: newborn, 3 years, 13 years, 18 years

Pes Planus – Physical exam

· PE: For symptomatic flat feet, assess that arch is present with foot suspended or when standing on toes. · If so, this is typical flatfoot and is described as flexible pes planus. · If not, this is an unusual rigid flatfoot which can be caused be a few different conditions and may require specialist follow up.

Pes Planus – Treatment

• If painful, arch supports often help

Pes Planus (Flat Foot) – Clinical Findings

• Common condition - Usually asymptomatic, no require treatment

Physiologic Genu Varum/Valgum – Clinical Findings

Physiologic genu varum/valgum “Don’t worry… it’s normal” · Mild genu varum (“bow-legs”) can be normal from birth to 2-3 y/o. = early walkers, air between knees · Mild genu valgum (“knock knees”) can be normal from 3-4 y/o (peak), resolving by 8 y/o. = kindergarten, gum holding knees together Normal processes to learn to walk

Physis – Clinical Notes

• Appears as dark line on x-rays (so do fractures) - Knowledge of normal anatomy is key to distinguish - Some growth plates can be palpated in skinny patients (e.g., radius, fibula) Susceptible to fractures - Can interrupt normal growth - “Loaf of bread” analogy helps patients understand