Pediatric Lower Extremity Orthopedic Concerns

1. Pediatric Lower Extremity Orthopedic Concerns Esther Tompkins, DO Ped’s PM&R

2. In Toeing Deformities • Three possible causes • 1. Metatarsus Adductus • 2. Internal Tibia Torsion • 3. Femoral Anteversion

3. Metatarsus Adductus • “Foot turning in” most common orthopedic problem in children. • Forefoot in varus and hindfoot in valgus • Unlike clubfoot in which the forefoot and hindfoot are both in fixed varus.

4. Metatarsus Adductus • Physical Examination • 1. Foot is curved like a “C” with toes point to the midline. • 2. The toes can be brought up up easily into neutral plantigrade position, and the heel comes down into neutral.

5. Metatarsus Adductus • Treatment • 1. If, by stroking the lateral side of the foot it straighten out, it will mostly resolve on it own, by age 3-5 years of age. • 2. Stretching and ROM exercises done by caregiver. • 3. Serial casting

6. Internal Tibial Torsion • Normally, the medial malleolus should be 15° anterior to the transcondylar axis of the knee joint. • If the lateral malleolus in on the same plane or anterior to the medial malleolus, this infers internal tibial torsion.

7. Internal Tibial Torsion • Refer to an Orthopedic Doctor • As treatment is very controversial if surgery or bracing is the best.

8. Femoral Anteversion • Consider this only after you have rule out metatarsus adductus, and internal tibial torsion. • History of this child usually includes sitting in the reverse “W” or “TV squat” position.

9. Femoral Anteversion • Two type of “TV squat” position • 1. Hip flexed to 90°, knee flexion to 130°, with 90° of external rotation of the legs and feet pointing out. • 2. Hip flexed to 90° and sitting on legs with feet turned in and adducted underneath their butt.

10. Femoral Anteversion • Physical Exam • Normal exam is 40°-50° of IR & ER • Abnormal exam with anteversion IR 90° and limited ER • ER >25° than gait is normal • ER <15°-20° than gait is abnormal

11. Femoral Anteversion • Treatment • 1. Taylor sitting position often only treatment needed, and resolves by 10-12 years of age. • 2. Referral to Ortho if ER <15°-20° for treatment.

12. The Hip • 1. CDH = Congenital dislocation of the Hip or Developmental Dysplasia of the Hip • May occur pre, post, or perinatally • 1 out of 1000 live biths

13. The Hip - CDH con’t • Characteristics: • 1. Firstborn females • 2. Breech delivery • 3. Family history of CDH • 4. Left side

14. The Hip - CDH con’t • X-rays • Standard films AP and frog-leg views of the pelvis if > 7 months old • US of hips for <7 months old as the ossific centers have not developed in the capital femoral epiphysis.

15. The Hip - CDH con’t • Physical Exam • 1. Ortolani test - flex hips to 90° and then abducted maximally. A positive test is when the head of the femur, which is dislocated posteriorly, flips over the posterior acetabular labrum or edge and head of femur goes back into the true acetabulum. This produces a palpable, not audible, “thunk,” “schlunk,” or “clunk.” Not a “click”, which most often is from the iliotibial band around the knee.

16. The Hip - CDH con’t • 2. Barlow’s Test - With the infant’s pelvis stabilized with one hand, place the other hand so that thumb is over the lesser trochanter. Flex the hip to 90°, then push the femoral head posteriorly over the hip joint. A positive test is movement of the femoral head posterolaterally, which is seen when there is acetabular/femoral instability.

17. The Hip - CDH con’t • 3. Allis or Galeazzi Sign - Lay the child in supine and flex both hips to 90° with feet flat on the exam table and look at the height of the knees. The affected side will show a marked shortening. • 4. Skin fold discrepancy will be noted at the thigh and gluteal skin folds, with the involved side having increase in folds.

18. The Hip - CDH con’t • 5. Limitation of Abduction - With the child in supine flex both hips to 90° then abduct both legs at the same time. Both hips should go equal distances into abduction. If there is a differences between them them the one that has limited movement is the involved side.

19. Treatment of CDH • Group I - Neonate to 6 weeks - positive Ortolani and Barlow’s tests and skin fold discrepancies. Also dislocated side can be extended all the way down to the level of the exam table, because it is lacking the normal hip flexion tightness that newborn have. Refer this child to Orthopedics for treatment most likely with a Pavlik harness.

20. Treatment of CDH • Group II - 6 weeks - 12 months - Hip capsular and soft tissue have now tightness up and the Ortolani test may not be positive. Will see limited abduction in this age and skin fold asymmetry. Again referral to Ortho for treatment with Pavlik harness, traction, adductor tenotomy, or closed reduction.

21. Treatment of CDH • Group III - 12 months - 3 years - Walking with a painless limp. Galeazzi sign positive, and limited abduction. X-rays positive by this age. Again referral to Ortho for possible treatment by arthrography, traction, adductor tenotomy, open reduction, and pelvic versus femoral osteotomy.

22. Treatment of CDH • Group IV - 3 years to skeletal maturity- Same as group III and X-ray is positive. Referral to Ortho for treatment. Usually need to have surgery to corrected at this age. • FYI - Bilateral dislocations over 6 years old and unilateral over 8 years old do better left ALONE.

23. The Hip: Legg-Calvé-Perthes Disease • Etiology is thought to be due to interruption of the blood supply to the femoral head. • Vague on set of pain in hip or knee. • Male to female 5:1 • Between 3 to 10 years old • Painful limp when synovitis is present and then become a painless limp • Family history 10%-20%

24. The Hip: Legg-Calvé-Perthes Disease • Physical Exam - Shows • 1. Decrease ROM in hip abduction and internal rotation. • 2. Hip stiffness • 3. Knee pain • X-rays: Four stages • 1. Synovitis • 2. Aseptic necrosis- increased joint space and small femoral head • 3. Fragmentation - increased bone density • 4. Residual - increased bone density

25. The Hip: Legg-Calvé-Perthes Disease • Treatment per Ortho • 1. Aspiration to rule out septic arthritis • 2. Russell’s traction until synovitis resolves. • 3. Must kept femoral head in the acetabulum by operative or non-operative means.

26. The Hip-Slipped Capital Femoral Epiphysis • SCFE - More common in 10-16 year old male especially those with obese and eunuchoid body habitus. • Present with hip or knee pain, with a limp. • Pain often have been present for 3-9 months, and have been treated of other things.

27. The Hip-Slipped Capital Femoral Epiphysis • Physical Exam - Obese adolescent male with short limb, and Trendelenberg gait. The hip is often in extended and externally rotated. • Positive Log roll test which is decrease internal or external rotation of the leg with the hip and knee in extension.

28. The Hip-Slipped Capital Femoral Epiphysis • X-ray - Shows “Ice cream falling off of the cone” = Femoral head falling off of the femoral shaft. • Treatment STAT referral to Ortho when found. Needs to be corrected quickly.