Review – Kaplan Pediatrics: Orthopedic Disorders

DISORDERS OF THE HIP

Developmental Dysplasia of the Hip (DDH)

General ligamental laxity

− Family history

Significantly more females
Firstborn
Breech
Oligohydramnios
Multiple gestation
Physical examination
- Barlow is most important examination; will dislocate an unstable hip; is easily felt (clunk not a click)
- Ortolani—reduces a recently dislocated hip (most at 1–2 months of age), but after 2 months, usually not possible because of soft-tissue contractions
Diagnosis–ALL (+) → refer immediately for orthopedic consult If unsure:

− Dynamic ultrasound of hips best test age <4 months

After 4 months, frog lateral x-ray

Treatment
- Pavilk harness for 1–2 months
- Surgery, casting
Complications—acetabular dysplasia, leg length discrepancy

Legg-Calvé-Perthes Disease

A 5-year-old boy has developed progressive limping. At first painless, it now hurts to run and walk. The pain is in the anterior thigh. The pain is relieved by rest. Parents recall no trauma.

Idiopathic avascular necrosis of the capital femoral epiphysis in immature, growing child
More in males; 20% bilateral; sometimes after trauma
Presentation—mild intermittent pain in anterior thigh with painless limp with restriction of motion

Diagnosis—anterior/posterior and frog leg lateral x-ray shows compression, collapse, and deformity of femoral head
Treatment
- Containment (femoral head within acetabulum) with orthoses or casting
- Bedrest
- Abduction stretching exercises
- If significant femoral deformity persists, surgical correction

Figure 17-1. MRI Demonstrating Legg-Calve-Perthes Disease

Slipped Capital Femoral Epiphysis (SCFE)

Most common adolescent hip disorder
Either obese with delayed skeletal maturation, or thin with a recent growth spurt
Can occur with an underlying endocrine disorder
Clinical presentation
- Pre-slip stable; exam normal; mild limp external rotation
- Unstable slip; sudden-onset extreme pain; cannot stand or walk; 20% complain of knee pain with decreased hip rotation on examination
Complications—osteonecrosis (avascular necrosis) and chondrolysis (degeneration of cartilage)
Diagnosis—AP and frog-leg lateral x-ray, earliest finding: widening of physis with- out slippage (preslip); as slippage occurs, femoral neck rotates anteriorly while head remains in acetabulum
Treatment—open or closed reduction (pinning)

Figure 17-2. X-ray of the Hips Demonstrating Slipped Capitol Femoral Epiphysis

Transient Synovitis

Viral; most 7–14 days after a nonspecific upper respiratory infection; most at 3–8 years of age
Clinical presentation
- Acute mild pain with limp and mild restriction of movement
- Pain in groin, anterior thigh, and knee
Diagnosis
- Small effusion (±)
- Slight increase in ESR

− Normal x-rays

No to low-grade fever; non-toxic-appearing

Treatment—bedrest and no weight-bearing until resolved (usually <1 week), then 1–2 weeks of limited activities

INTOEING

Metatarsus Adductus

Most common in firstborn (deformation)
Forefoot adducted from flexible to rigid
Treatment—primarily nonsurgical; serial plaster casts before 8 months of age; ortho- ses, corrective shoes; if still significant in a child age >4 years, may need surgery

Note

In talipes equinovarus, the patient’s heel can’t go flat on the exam surface (as opposed to metatarsus adductus, in which the heel can).

Talipes Equinovarus (Clubfoot)

A newborn is noted to have a foot that is stiff and slightly smaller than the other one. The affected foot is medially rotated and very stiff, with medial rotation of the heel.

Congenital, positional deformation, or associated with neuromuscular disease
Hindfoot equinus, hindfoot and midfoot varus, forefoot adduction (at talonavicular joint)
Treatment
- Complete correction should be achieved by 3 months (serial casting, splints, ortho- ses, corrective shoes); if not, then surgery

Internal Femoral Torsion (Femoral Anteversion)

Most common cause of intoeing ³2 years of age; entire leg rotated inwardly at hip during gait
Most are secondary to abnormal sitting habits (W-sitting).
Treatment—observation; takes 1–3 years to resolve; surgery only if significant at >10 years of age

Internal Tibial Torsion

Most common cause of intoeing <2 years of age (also because of in utero position- ing); often with metatarsus adductus
Measure prone thigh/foot angles
No treatment needed—resolves with normal growth and development; takes 6–12 months (is physiologic)

DISORDERS OF THE KNEE

Osgood-Schlatter Disease

Traction apophysitis of tibial tubercle (overuse injury)
Look for active adolescent (running, jumping)
Swelling, tenderness, increased prominence of tubercle
Treatment—rest, restriction of activities, knee immobilization, isometric exercises
Complete resolution requires 12–24 months

DISORDERS OF THE SPINE

Scoliosis

A 12-year-old girl is seen for routine physical examination. She voices no complaints. Examination is remarkable for asymmetry of the posterior chest wall on bending forward. One shoulder appears higher than the other when she stands up.

Most are idiopathic; rarely, hemivertebra
Others are congenital, with neuromuscular disorders, compensatory, or with intraspi- nal
Slightly more females than males; more likely to progress in females
Adolescent (>11 years) more common
Adams test bending forward at hips —almost all with >20-degree curvature are identified in school screening programs (but many false positives)
Diagnosis—x-ray is standard: posterior/anterior and lateral of entire spine gives great- est angle of curvature
Treatment—trial brace for immature patients with curves <30–45 degrees and surgery for those >45 degrees (permanent internal fixation rods)

DISORDERS OF THE UPPER LIMB

Nursemaid Elbow

When longitudinal traction causes radial head subluxation

• History of sudden traction or pulling on arm

Physical exam reveals a child who refuses to bend his/her arm at the elbow
Treatment—rotate hand and forearm to the supinated position with pressure of the radial head → reduction

OSTEOMYELITIS AND SEPTIC ARTHRITIS

Etiology

− Osteomyelitis:

aureus most common overall, in all
Pseudomonas—puncture wound
More Salmonella in sickle cell ( aureus still most common)

− Septic arthritis:

Almost all aureus
Most in young children; hematogenous; LE > UE and other parts of body

Presentation
- Pain with movement in infants
- Older—fever, pain, edema, erythema, warmth, limp, or refusal to walk (acute, toxic, high fever)