Berkowitz’s – Section VIII: Orthopedic Disorders

Developmental Dysplasia of the Hip

David P. Zamorano, MD; Andrew K. Battenberg, MD; and Steven Donohoe, BS
CASE STUDY
A 4-month-old girl is seen for her routine health maintenance visit. She is doing well and has no complaints. The results of the entire examination are within normal limits except for limited external rotation and abduction of the left hip, which is approximately 45 degrees, in comparison to that of the right hip, which is almost 90 degrees.
Questions
1. What factors are responsible for normal growth and development of the hip joint?
2. What specific physical maneuvers help in the evaluation of infants with decreased range of motion of the hip?
3. What are the clinical findings of hip dislocation during and after the neonatal period?
4. What are some of the conditions often seen in conjunction with hip dysplasia that may be noted on physical examination?
5. What is the appropriate diagnostic workup of infants with suspected hip dysplasia?

Intoeing and Out-toeing: Rotational Problems of the Lower Extremity

David P. Zamorano, MD; Andrew K. Battenberg, MD; and Steven Donohoe, BS
CASE STUDY
A 3-year-old girl is brought to the office. Her mother is concerned because beginning a few months ago, her daughter’s feet appeared to “turn in” when she walked. The girl has never walked like this before, and she has no history of trauma, fever, pain, or swelling in the joints. The physical examination is within normal limits except for the intoeing gait.
Questions
1. How can observation of children’s gait help determine the etiology of their intoeing and out-toeing (rotational problems)?
2. What are the common causes of intoeing and out-toeing?
3. Does evaluation of intoeing and out-toeing require any laboratory or radiologic studies?
4. What is the natural history of most rotational problems?

Angular Deformities of the Lower Extremity: Bowlegs and Knock-knees

Carol D. Berkowitz, MD; Andrew K. Battenberg, MD; and Nima Eftekhary, MD
CASE STUDY
During the routine health maintenance examination of a 2-year-old, you observe moderate to severe bilateral bowing of both legs. The child’s mother reports that her son began walking at 10 months. She has not noticed problems with his gait and says he does not trip or fall excessively. On examination, the boy’s weight is greater than the 95th percentile for age, but otherwise he appears to be a healthy African American child.
Questions
1. What types of angular deformities affect children’s lower extremities?
2. How does children’s age help determine whether they have physiological or pathologic angular deformities?
3. What clinical measurements can help distinguish physiological from pathologic angular deformities?
4. To what extent are radiographs used in the routine assessment of angular deformities?

Orthopedic Injuries and Growing Pains

Sara T. Stewart, MD
CASE STUDY
A 6-year-old boy has a 1-week history of leg pains. He wakes up at night and cries because his legs hurt, yet during the day he is fine, with no pain or movement limitations. He has no history of trauma, fever, or joint swelling. The family history is negative for rheumatic or collagenvascular disease. The boy’s height and weight are at the 50th percentile for age, he is afebrile, and the physical examination is unremarkable.
Questions
1. What is the differential diagnosis of leg pains in school-aged children?
2. What laboratory or radiographic studies are appropriate for children with leg pains?
3. How do musculoskeletal injuries in children differ from those in adults (eg, type of injury sustained, location of injury)?
4. How does one decide the extent of the diagnostic workup in a child with extremity pain?
5. What physiological factors cause musculoskeletal injury patterns to change with age?

Sports-Related Acute Injuries

Monica Sifuentes, MD; Andrew K. Battenberg, MD; and Steven Donohoe, BS
CASE STUDY
A 15-year-old female basketball player complains of 6 months of intermittent pain in her left knee. Occasionally the knee gives out while she is playing ball. The teen denies any associated swelling or erythema over the joint. She is able to walk with no problem and reports no history of direct trauma to the area. She is otherwise healthy. On physical examination, she is a well-developed, well-nourished teenaged girl in no acute distress. The examination is normal except for mild pain to direct palpation of the left patella. No swelling, erythema, or effusion of the knee joint is evident, and the left hip, knee, and ankle have full range of motion. The back is straight.
Questions
1. What are some of the most common orthopedic complaints in adolescent patients, and why do they occur in this age group?
2. What is the pathophysiology of overuse syndromes?
3. What is the purpose of the preparticipation physical evaluation?
4. What conditions disqualify adolescents from participation in competitive sports?
5. What are the current recommendations for the treatment and rehabilitation of acute soft tissue injuries?

Evaluation of Limp

Andrea Fang, MD, and Marianne Gausche-Hill, MD
CASE STUDY
A 6-year-old boy who has a 2-day history of right knee pain and limp is brought to the office. No history of knee trauma, swelling, redness, or associated fever is present. The medical history is unremarkable. The boy is afebrile, and his height and weight are at the 10th percentile for age. Examination of the right leg reveals decreased abduction and internal rotation of the hip; the knee is normal. The boy limps when he walks and favors his right leg.
Questions
1. What is the differential diagnosis of painful and painless limp in children?
2. What is the differential diagnosis of knee pain in children?
3. What laboratory and radiographic tests are indicated in the evaluation of children with limp?
4. What is the appropriate management of children with suspected infectious causes of limp?

Musculoskeletal Disorders of the Neck and Back

Carol D. Berkowitz, MD; Andrew K. Battenberg, MD; and Nima Eftekhary, BS
CASE STUDY
A 4-week-old boy is brought to the office by his mother, who complains that her son always holds his head tilted to the right. She reports that he has held it in this position for about 1 week and prefers to look mainly to the left. The infant is the 8-lb, 8-oz product of a term gestation born via forceps extraction, and he had no complications in the neonatal period. He is feeding well on breast milk and has no history of fever, upper respiratory symptoms, vomiting, or diarrhea. On examination, the head is tilted toward the right side with limited lateral rotation to the right and
decreased lateral side bending to the left. Except for the presence of a small mass palpable on the right side of the neck, the examination is within normal limits.
Questions
1. What laboratory or radiologic studies are indicated in infants with torticollis?
2. What is the differential diagnosis of torticollis in infants?
3. What are some of the common musculoskeletal abnormalities that may be seen in association with torticollis?
4. What are other common musculoskeletal problems in children and adolescents?
5. What is the current recommended management of children and adolescents with idiopathic scoliosis?