PEDIATRIC ORTHOPEDIC AND MSK CONDITIONS

1. PEDIATRIC ORTHOPEDIC AND MSK CONDITIONS Unit 4: Part 1 Module 5

3. OUTLINE Limp Limb Pain Hip Problems Pediatric Fractures/dislocations Angular Anomalies of extremities Osteomyelitis/Septic Joint Juvenile Arthritis Bone tumours Many congenital and acquired mechanisms cam produce orthopedic problems specific to childhood Most Pediatric orthopedic problems involve the spine and lower extremities. Upper extremity abnormalities other than trauma are less frequent In utero positioning produces joint and muscle contractures and affects torsional and angular alignment of long bones, especially of the legs For example all newborns have a 20-30 degree hip and knee flexion contractures. There decrease to neutral by 4-6 months The newborn�s hip externally rotates in extension to 80-90 degrees and has limited internal rotation of 0-10 degrees The newborn fore foot appears adducted in relation to the hind foot, the heel may be inverted and the foot tends to be in eqquinus or pointed down at the ankle A child may be 3-4 years of age in some cases before the intrauterine effects completely resolve Neurologic maturation as marked by achievement of motor developmental milestones at regular intervals is important for normal musculoskeletal development. Any neurologic problems may secondarily affect MSK growth . Normal muscle function is necessary for normal skeletal growthMany congenital and acquired mechanisms cam produce orthopedic problems specific to childhood Most Pediatric orthopedic problems involve the spine and lower extremities. Upper extremity abnormalities other than trauma are less frequent In utero positioning produces joint and muscle contractures and affects torsional and angular alignment of long bones, especially of the legs For example all newborns have a 20-30 degree hip and knee flexion contractures. There decrease to neutral by 4-6 months The newborn�s hip externally rotates in extension to 80-90 degrees and has limited internal rotation of 0-10 degrees The newborn fore foot appears adducted in relation to the hind foot, the heel may be inverted and the foot tends to be in eqquinus or pointed down at the ankle A child may be 3-4 years of age in some cases before the intrauterine effects completely resolve Neurologic maturation as marked by achievement of motor developmental milestones at regular intervals is important for normal musculoskeletal development. Any neurologic problems may secondarily affect MSK growth . Normal muscle function is necessary for normal skeletal growth

4. MECHANISMS OF ORTHOPEDIC PROBLEMS Congenital - Teratogenic malformation- e.g spinal bifida - Disruption in growth - limb atrophy- varicella infection in utero - Deformation- leg compression in utero- Congenital Hip dysplasia - Dysplasia- abnormal cell growth or metabolism - osteogenesis imperfecta

5. MECHANISMS OF ORTHOPEDIC PROBLEMS Acquired - Infection - pyogenic spread- Septic arthritis - Inflammation-antigen-antibody reaction- Lupus, Juvenile RA - Trauma- mechanical forces-overuse- fractures, tendonitis - Tumour - primary or metastatic bone tumour- osteosarcoma Always keep in mind child abuse in trauma situations especially in the very young child < 2 yearsAlways keep in mind child abuse in trauma situations especially in the very young child < 2 years

6. DIFFERENTIAL DX. OF LIMPEarly Walker- ( 1-3 years old) Painful Limp - Septic joint - Osteomyelitis - Transient monoarticular synovitis - Occult trauma ( toddler;s fracture) - Intraverterbral discitis Gait disturbances including limp are common manifestations of orthopedic disorders. It can be hard sometimes to distinguish normal developmental maturational gait features from pathologic problems This complaint should always be taken seriously. A limp may arise from problems in joints, bones, ligaments or soft tissues. In diagnosing a limp, it is difficult to distinguish bone pain from muscle and joint pain. Younger children (toddlers) may refuse to bear weight. Severe illness involving bone, joint or muscle may present as a limp.Gait disturbances including limp are common manifestations of orthopedic disorders. It can be hard sometimes to distinguish normal developmental maturational gait features from pathologic problems This complaint should always be taken seriously. A limp may arise from problems in joints, bones, ligaments or soft tissues. In diagnosing a limp, it is difficult to distinguish bone pain from muscle and joint pain. Younger children (toddlers) may refuse to bear weight. Severe illness involving bone, joint or muscle may present as a limp.

7. DIFFERENTIAL DX. OF LIMPEarly Walker- ( 1-3 years old) Painless Limp - Congenital ( developmental) hip dysplasia) - Neuromuscualr disorder - Cerebral palsy - Lower extremity length inequality

8. DIFFERENTIAL DX. OF LIMPChild 3-10 Years Painful Limp - Septic joint - Osteomyelitis - Transient monoarticular synovitis - Trauma - Intravertebral discitis - Juvenile RA - Legge-Calve- Perthes disease

9. DIFFERENTIAL DX. OF LIMPChild 3-10 Years Painless Limp - Congenital ( developmental) hip dysplasia) - Neuromuscular disorder - Duchenne muscular dystrophy - Cerebral palsy - Lower extremity length inequality - Legge-Calve-Perthes disease

10. DIFFERENTIAL DX. OF LIMPAdolescent ( 11-18 years) Painful Limp - Septic joint - Osteomyelitis - Trauma - Rheumatological disorders - Slipped capital femoral epiphysis- acute/unstable

11. DIFFERENTIAL DX. OF LIMPAdolescent ( 11-18 years) Painless Limp - Slipped capital femoral epiphysis- chronic unstable - Neuromuscualr disorder - Leg length discrepancy - Developmental hip dysplasia - not repaired

12. ASSESSMENT OF LIMP IN CHILDREN HISTORY - Onset - acute, gradual - Qualify/quantify � CHLORIDEPEPPS neumonic - Trauma - Fever - Viral URTI in preceding week - Painful or painless - Ability to bear weight - Affect on mobility

13. ASSESSMENT OF LIMP IN CHILDREN PHYSICAL EXAM- Look for: - Heat, Swelling,Redness, bruising/discoloration - Rashes/lesions - Obvious deformity Tenderness, crepitus Pain on movement - Decrease in ability to bear weight - Decrease in active and passive range of motion Perform abdominal and general examinations if the cause is not evident on limb examination (e.g., incarcerated hernia may present as a limp) Perform abdominal and general examinations if the cause is not evident on limb examination (e.g., incarcerated hernia may present as a limp)

14. ASSESSMENT OF LIMP IN CHILDREN MANAGEMENT - Diagnose accurately - Treat underlying cause - Maintain a high index of concern about possible pathology - Consult with a physician - Immobilization may be required to rest the limb, reduce pain and prevent further damage - Analgesic

15. LIMB PAIN Often presents as an alteration of activity or gait or an unwillingness to bear weight or use a limb The affected joint may not be the one the child complains about Pain may be referred from disease of the hip joint to the knee, and the child presents with knee pain

16. LIMB PAIN DIFFERENTIAL DIAGNOSIS - Cellulitis (of the overlying areas only; no involvement of bones or joint spaces) - Septic arthritis (this is an emergency situation) - Transient viral arthritis - Juvenile rheumatoid arthritis - Transient toxic synovitis (commonly seen in the hip); related to previous URTI

17. LIMB PAIN DIFFERENTIAL DIAGNOSIS (CONT�D) - Osteomyelitis - Trauma (e.g. hemarthrosis,fracture) - Post-immunization arthritis (especially after immunization for rubella) - Bleeding disorder (e.g., hemophilia) - Henoch-Sch�nlein purpura (look for abdominal pain and rash) - Muscle /ligament sprain or strain - Slipped capital femoral epiphysis

18. LIMB PAIN DIFFERENTIAL DIAGNOSIS (CONT�D) - Legge-Calv�-Perthes disease - Growing pains - Rickets - Malignant lesion - Rheumatic fever - Sickle cell - Kawasaki�s disease

19. GROWING PAINS DEFINITION An idiopathic symptom complex that affects 10% to 20% of school-age children Pain usually occurs in shins or thigh muscles Joint pain is rare The pain is intermittent, usually occurring at night, and lasts from 30 minutes to several hours CAUSE Unknown, although probably related to over-exertion and fatigue. Emotional factors may also play a role. CAUSE Unknown, although probably related to over-exertion and fatigue. Emotional factors may also play a role.

20. GROWING PAINS HISTORY - Usually non-articular - Calf or thighs usually involved - Deep aching, usually worse at night - May waken the child at night - May be relieved with massage, rubbing

21. GROWING PAINS PHYSICAL FINDINGS - No physical signs DIFFERENTIAL DIAGNOSIS - Acute infection or inflammation - Trauma COMPLICATIONS - None

22. GROWING PAINS MANAGEMENT - ? X-ray for reassurance if necessary - Reassure child and family of benign nature - Explain course of the condition and prognosis - Counsel parents or caregiver about appropriate home management with rest, heat and analgesia - Heating pad or moist hot packs prn may help

23. GROWING PAINS MANAGEMENT - Analgesic for pain (for children >6 years old): - acetaminophen (Tylenol), 325 mg, 1�2 tabs PO q6h prn - Reassess the child if attacks become more frequent or increase in severity - Referral to a physician if the diagnosis is unclear or the symptoms are worsening

24. OSGOOD-SCHLATTER DISEASE DEFINITION - Traction apophysitis of the tibial tubercle - Considered an overuse syndrome in which repetitive microtrauma causes partial avulsion of the patellar tendon at its insertion on the tibia - It occurs during the pubertal growth spurt - Lasts up to 18 months Risk Factors - Male gender - Active in sports (e.g., football, soccer) - Recent growth spurt

25. OSGOOD-SCHLATTER DISEASE HISTORY AND PHYSICAL FINDINGS - Knee pain around the tibial tuberosity - Swelling - Limp - Tenderness and prominence of the tibial tubercle - Symptoms increase with activity (e.g., running, jumping, going up and down stairs, kneeling) and are relieved by rest.

26. OSGOOD-SCHLATTER DISEASE DIFFERENTIAL DIAGNOSIS - Patellar tendinitis - Osteomyelitis - Knee sprain - Ligamentous strain - Patellar femoral syndrome - Osteosarcoma

27. OSGOOD-SCHLATTER DISEASE COMPLICATIONS - Detachment of cartilage fragments from the tibial tuberosity - Decrease in capacity for physical activity - Osteoarthritis DIAGNOSTIC TESTS - X-ray to rule out other conditions - X-ray shows enlarged and fragmented tibial tubercle

28. OSGOOD-SCHLATTER DISEASE MANAGEMENT - Reassure child and parents as to the benign cause and favorable prognosis - Rest the limb - Apply ice packs prn - Decrease activities that aggravate symptoms for short period - Physio- Quad/hamstring stretching exercises - Knee immobilization (e.g.), for sports

29. OSGOOD-SCHLATTER DISEASE Anti-inflammatory and analgesic: - Acetaminophen (Tylenol)325 mg, 1�2 tabs PO q6h prn for 7�10 day OR - Ibuprofen (Motrin), 200 mg, 1�2 tabs PO q6h prn for 7�10 days Follow up in 1�2 weeks Refer to a physician for evaluation if symptoms do not improve with conservative measures in 6�8 weeks The condition is usually self-limiting and resolves over several months. May last up to 18 months The condition becomes chronic in 5% to 15% of cases, with persistent tenderness, swelling and formation of ossicles, which may need surgical removal The condition is usually self-limiting and resolves over several months. May last up to 18 months The condition becomes chronic in 5% to 15% of cases, with persistent tenderness, swelling and formation of ossicles, which may need surgical removal

30. PATELLAR FEMORAL SYNDROME DEFINITION Osteochondritis involving the patella, resulting in knee pain and swelling It is considered an overuse syndrome not involving avascular necrosis or an inflammatory process, and as such it develops over a period of time Usually unilateral, but sometimes bilateral Onset during adolescence Most of those affected show a mild degree of patellar femoral misalignment, which, with activity, causes instability of the patella and gradual destruction of the patellar cartilage Risk Factors � Female gender � Physical activity Most of those affected show a mild degree of patellar femoral misalignment, which, with activity, causes instability of the patella and gradual destruction of the patellar cartilage Risk Factors � Female gender � Physical activity

31. PATELLAR FEMORAL SYNDROME Mechanism - Overuse syndrome in athletes**** - Sports involving running, jumping, or quick stops and turns (pivots) - Direct impact to patella - Degeneration of patella

32. PATELLAR FEMORAL SYNDROME Mechanism - Chondromalacia patellae - Patellar osteoarthritis - Anatomic variation, such as increased angle between femur and tibia (Q-angle; - Females more often have larger Q-angle) or shallow outer patellofemoral groove (patella prone to sublux or dislocate laterally)

33. PATELLAR FEMORAL SYNDROME HISTORY - Acute or chronic anterior knee pain and pain on underside of patella - Gradually progressive, general aching or grating pain - Sensation of the knee �giving out� and instability (reflex response to pain); child is unable to keep knee in flexed position for any length of time - Grinding, popping or clicking sound on knee flexion Provocative Factors � Going up or down stairs or going down hills � Running � Prolonged sitting with knee bentProvocative Factors � Going up or down stairs or going down hills � Running � Prolonged sitting with knee bent

34. PATELLAR FEMORAL SYNDROME PHYSICAL FINDINGS - No knee effusion - No decrease in range of motion - Tenderness of undersurface of medial or lateral patella - Grinding, popping or clicking sound on knee flexion, detected on manipulation of patella - Positive patellar inhibition test: child refuses to actively extend knee when patella is compressed against the femoral condyles; patella is displaced with knee extension

35. PATELLAR FEMORAL SYNDROME PHYSICAL FINDINGS ( cont�d) - Disuse atrophy of the quadriceps - Crepitation on range of motion of knee - Q-angle increased - Abnormal patellar alignment Apprehension Sign - Hold patella as child lies with knee in extension - Ask child to tense quadriceps muscle - Positive result: child experiences pain - Child may refuse to do the test in anticipation of pain

36. PATELLAR FEMORAL SYNDROME DIFFERENTIAL DIAGNOSIS � Knee sprain � Ligamentous strain � Osgood-Schlatter disease COMPLICATIONS - Interference with daily activities DIAGNOSTIC TESTS - None

37. PATELLAR FEMORAL SYNDROME MANAGEMENT - Rest - Ice packs prn - Support bandage may provide some comfort (should be worn only while child is awake) - Exercises to Strengthen Quadriceps - Exercises to Stretch Lower Extremity - Rest; child can continue most activity, but for a short period in the acute stage (1-2 weeks), activities that require flexion of the knee should be limited - Ice packs prn - Support bandage may provide some comfort (should be worn only while child is awake) Exercises to Strengthen Quadriceps - Isometric progressive resistance exercises - Leg-sled press (45�) Exercises to Stretch Lower Extremity - Quadriceps stretches - Hamstring stretches - Iliotibial band stretches - Ankle stretches - Gastrocnemius muscle stretches - Soleus muscle stretches - Rest; child can continue most activity, but for a short period in the acute stage (1-2 weeks), activities that require flexion of the knee should be limited - Ice packs prn - Support bandage may provide some comfort (should be worn only while child is awake) Exercises to Strengthen Quadriceps - Isometric progressive resistance exercises - Leg-sled press (45�) Exercises to Stretch Lower Extremity - Quadriceps stretches - Hamstring stretches - Iliotibial band stretches - Ankle stretches - Gastrocnemius muscle stretches - Soleus muscle stretches

38. PATELLAR FEMORAL SYNDROME - Ant-inflammatory agents (NSAIDs) for short course (1�2 weeks): Ibuprofen (Motrin) 200 mg, 1�2 tabs PO tid OR Naproxen (Naprosyn) 125 mg, 1�2 tabs PO bid to tid - Reassess every 1�2 weeks during the acute stage. Ascertain adherence to exercise program, and provide support and encouragement.

39. PATELLAR FEMORAL SYNDROME Refer to an orthopedist for assessment if there is no improvement with conservative management after 6�8 weeks Surgical arthroscopy may be needed (in 5% to 10% of cases) to remove bony or cartilaginous fragments or to shave the underside of the patella

40. DEVELOPMENTAL HIP DYSPLASIA Failure of femoral head to rest in acetabulum of pelvis Due to ligamentous laxity and /or abnormal slope of acetabular roof Spectrum of clinical presentations: - dislocated femoral head completely out of acetabulum - dislocatable head in socket - head subluxes out of joint when provoked - dysplatic acetabulum more shallow and more vertical than normal Congenital torticollis and metatarsus adductus are also associated with DHD and the presence of either of these findings in a newborn necessitates a careful exam of the hips This condition is commonly seen in some First Nations communities, but is almost never seen in Inuit people This condition is best diagnosed before the child begins walking A check for congenital problems of the hip are a routine part of newborn and infant screening Congenital torticollis and metatarsus adductus are also associated with DHD and the presence of either of these findings in a newborn necessitates a careful exam of the hips This condition is commonly seen in some First Nations communities, but is almost never seen in Inuit people This condition is best diagnosed before the child begins walking A check for congenital problems of the hip are a routine part of newborn and infant screening

41. DEVELOPMENTAL HIP DYSPLASIA Predisposing factors - 5 F�s Female Family Hx. in 20 % of cases Frank breech birth First born Left side involvement Approx. 60 % of children with DHD are firstborn and 30-50% are in breech position gender ratio 2:1 female:male Approx. 60 % of children with DHD are firstborn and 30-50% are in breech position gender ratio 2:1 female:male

42. DEVELOPMENTAL HIP DYSPLASIA Physical Exam - Limited abduction of flexed hip( < 50-60%) - Legs unequal in length - Asymmetric fat folds in thigh - Extra skin folds on involved side - Limp in the walking age child - Trendelenburg sign: lurching toward affected side

43. DEVELOPMENTAL HIP DYSPLASIA Special Tests Barlow �s Ortalani�s Trendelenberg test/gait ( useful > 2 years)

44. DEVELOPMENTAL HIP DYSPLASIA Diagnostic tests U/S in first few months to view cartilage X-ray after 3 months

45. DEVELOPMENTAL HIP DYSPLASIA DIFFERENTIAL DIAGNOSIS - Congenital short femur - Synovial click - Congenital adduction contraction - Fixed dislocation in arthrogryposis COMPLICATIONS - Long-term disturbance of the gait if untreated - Osteoarthritis - Avascular necrosis Early detection is important. Hence, the hip exam is an essential part of newborn screening. In addition, infants should be screened several times during the first year of life, as the problem may not be evident at birth Educate about potential aggravating factors, such as use of tikanagan by first nation�s peopleEarly detection is important. Hence, the hip exam is an essential part of newborn screening. In addition, infants should be screened several times during the first year of life, as the problem may not be evident at birth Educate about potential aggravating factors, such as use of tikanagan by first nation�s people

46. DEVELOPMENTAL HIP DYSPLASIA Treatment 0-6 months - Pavlik harness to maintain abdution and flexion 6-18 months- reduction under GA, hip spica cast for 2-3 months > 18 months- Open surgical reduction: pelvic and/or femoral osteotomy

47. Source; http://www.ucsf.edu/orthopaedics/patientedu/img/ddh3.jpg The Pavlik harness directs the ball into the center of the socket. Force transmitted by the ball into the center of the socket influences the socket to form better, i.e. to become deeper and wider. An ultrasound test is obtained 1 week after placing the child into the Pavlik harness. Once it is documented that the ball is sitting in the socket, the harness is worn for 6 more weeks. At that point, a second ultrasound test is obtained. If the angles and ratios of the ball and socket are normal (compared with published standards), then the child is converted to 6 weeks of night-time harness wear. If the ball will not sit in the socket after 3 weeks of Pavlik harness, the harness is stopped and the child moves to the second phase of treatment. The overall success rate of Pavlik harness is ~ 90%, which means that ~10% of children with DDH go to the second phase of treatment. Source; http://www.ucsf.edu/orthopaedics/patientedu/img/ddh3.jpg The Pavlik harness directs the ball into the center of the socket. Force transmitted by the ball into the center of the socket influences the socket to form better, i.e. to become deeper and wider. An ultrasound test is obtained 1 week after placing the child into the Pavlik harness. Once it is documented that the ball is sitting in the socket, the harness is worn for 6 more weeks. At that point, a second ultrasound test is obtained. If the angles and ratios of the ball and socket are normal (compared with published standards), then the child is converted to 6 weeks of night-time harness wear. If the ball will not sit in the socket after 3 weeks of Pavlik harness, the harness is stopped and the child moves to the second phase of treatment. The overall success rate of Pavlik harness is ~ 90%, which means that ~10% of children with DDH go to the second phase of treatment.

48. Step 1 The child is taken to the operating room, given a general anesthetic for full relaxation, and the hips are carefully examined. X-rays are taken to help see the bones of the hip-joint, and contrast dye may be injected into the hip-joint to help see the soft tissues (joint lining, muscles, ligaments and other structures that don't show up on X-ray). This is known as an arthrogram. If the hip is sufficiently stable, i.e. if the ball sits in the socket and does not fall out, the child is placed in a cast that extends from just below nipples to the ankle on the side of the DDH, and to the knee on the other side (a "1� limb spica"). This is known as a spica cast The spica cast is worn for 6 weeks, at which point the cast is removed in the operating room under general anesthesia and step 1 is repeated. If all is well, the child is placed back into another spica cast for 6 more weeks. At the conclusion of 12 weeks or 3 months, the spica cast is removed in clinic.Step 1 The child is taken to the operating room, given a general anesthetic for full relaxation, and the hips are carefully examined. X-rays are taken to help see the bones of the hip-joint, and contrast dye may be injected into the hip-joint to help see the soft tissues (joint lining, muscles, ligaments and other structures that don't show up on X-ray). This is known as an arthrogram. If the hip is sufficiently stable, i.e. if the ball sits in the socket and does not fall out, the child is placed in a cast that extends from just below nipples to the ankle on the side of the DDH, and to the knee on the other side (a "1� limb spica"). This is known as a spica cast The spica cast is worn for 6 weeks, at which point the cast is removed in the operating room under general anesthesia and step 1 is repeated. If all is well, the child is placed back into another spica cast for 6 more weeks. At the conclusion of 12 weeks or 3 months, the spica cast is removed in clinic.

49. LEGG-CALVE-PERTHES DISEASE AVN of proximal femoral epiphysis -self limiting disease Leads to abnormal growth of physis followed by eventual remodeling of new bone Etiology unknown More common in males 4:1 ratio Positive family Hx. Associated with low birth weight and abnormal pregnancy/L/D

50. LEGG-CALVE-PERTHES DISEASE History/Physical Exam Child 4-10 years Limping tenderness over anterior thigh Flexion contracture with decreased internal rotation/abduction

51. LEGG-CALVE-PERTHES DISEASE Diagnostic tests X-ray - may be negative early then characteristics of AVN (collapse of femoral head), subchondral fracture, metaphyseal cyst

52. LEGG-CALVE-PERTHES DISEASE Treatment Physio Brace in flexion/abduction x 2-3 years Femoral or pelvic osteotomy Prognosis better in < 5 year old, < 1/2 of head involved and abduction > 30 % 50% do well with conservative RX May be complicated by early onset osteoarthritis and decreased ROMPrognosis better in < 5 year old, < 1/2 of head involved and abduction > 30 % 50% do well with conservative RX May be complicated by early onset osteoarthritis and decreased ROM

53. SLIPPED CAPITAL FEMORAL EPIPHYSIS Epidemiology - Occurs during maximal pubertal growth spurt - Males: age 13 to 15 - Females: age 11 to 13 - Most common adolescent hip disorder - Incidence 1 to 4 per 100,000 - Black race affected more often than white race - Unilateral involvement in 90% of cases - Child is often overweight

54. SLIPPED CAPITAL FEMORAL EPIPHYSIS Pathophysiology Occurs before the epiphyseal plate closes Symptoms /Signs Hip pain or knee pain Limp, decreased ROM Hip held in abduction and external rotation - Markedly limited internal rotation Pain Duration, location, radiation Ability to bear weight Family history - Genetics may play a role because 5-7% incidence of familial involvement with a large variability in penetrance. Medical history - In patients younger than 10 years, a higher association exists for metabolic endocrine disorders (eg, hypothyroidism, panhypopituitarism, hypogonadal, renal osteodystrophy, growth hormone abnormalities). Bilaterality is more common in these younger patients. Chronicity Prodromal symptoms (eg, hip or knee pain, limp, decreased range of motion) for less than 3 weeks are termed acute. Patients with prodromal symptoms greater than 3 weeks are termed chronic. If a patient complains of symptoms greater than 3 weeks but presents with acute exacerbation of pain, limp, inability to bear weight, or decreased range of motion with or without an associated traumatic episode, the SCFE is categorized as acute on chronic. Determine if a traumatic episode occurred. If a patient complains of knee pain, always examine the hip because knee pain may be referred pain from the hip via the obturator nerve. Always examine and x-ray the contralateral hip to use as a comparison and to rule out coexisting bilateral disease. Determine the patient's gait pattern (eg, antalgic, Trendelenburg) and ability to bear weight. Active and passive range of motion of both hips and knees The lower extremity may rotate externally on gentle passive flexion of the hip when a SCFE is present. Note any lower extremity deformity, such as external rotation or shortening Pain Duration, location, radiation Ability to bear weight Family history - Genetics may play a role because 5-7% incidence of familial involvement with a large variability in penetrance. Medical history - In patients younger than 10 years, a higher association exists for metabolic endocrine disorders (eg, hypothyroidism, panhypopituitarism, hypogonadal, renal osteodystrophy, growth hormone abnormalities). Bilaterality is more common in these younger patients. Chronicity Prodromal symptoms (eg, hip or knee pain, limp, decreased range of motion) for less than 3 weeks are termed acute. Patients with prodromal symptoms greater than 3 weeks are termed chronic. If a patient complains of symptoms greater than 3 weeks but presents with acute exacerbation of pain, limp, inability to bear weight, or decreased range of motion with or without an associated traumatic episode, the SCFE is categorized as acute on chronic. Determine if a traumatic episode occurred. If a patient complains of knee pain, always examine the hip because knee pain may be referred pain from the hip via the obturator nerve. Always examine and x-ray the contralateral hip to use as a comparison and to rule out coexisting bilateral disease. Determine the patient's gait pattern (eg, antalgic, Trendelenburg) and ability to bear weight. Active and passive range of motion of both hips and knees The lower extremity may rotate externally on gentle passive flexion of the hip when a SCFE is present. Note any lower extremity deformity, such as external rotation or shortening

55. SLIPPED CAPITAL FEMORAL EPIPHYSIS Differentials DX: Legg-Calv�-Perthes disease Synovitis Septic joint Chronic developmental hip dysplasia Femoral injury AVN Femoral Hernia

56. SLIPPED CAPITAL FEMORAL EPIPHYSIS Radiology: Hip X-Ray (Compare sides) AP /lateral views of hips/pelvis - Widened epiphyseal plate - Displacement of femoral head In patients with atypical presentations (eg, bilateral involvement in a presenting patient aged younger than 10 years), rule out metabolic disorders (eg, panhypopituitarism, renal osteodystrophy, hypothyroidism, hypogonadism, growth hormone abnormalities), each with its own workup. Anteroposterior (AP) and lateral radiographs of the pelvis and bilateral hips Note any bony changes of the femoral neck and head because they may demonstrate chronic adaptive changes during alterations in hip biomechanics as the femoral head displaces. Determine the amount of head displacement off the femoral neck as a percentage to classify degree of slip Klein line: On the AP view of the hip, a line drawn along the superior border of the femoral neck should pass through a portion of the femoral head. If not, a SCFE is diagnosed In patients with atypical presentations (eg, bilateral involvement in a presenting patient aged younger than 10 years), rule out metabolic disorders (eg, panhypopituitarism, renal osteodystrophy, hypothyroidism, hypogonadism, growth hormone abnormalities), each with its own workup. Anteroposterior (AP) and lateral radiographs of the pelvis and bilateral hips Note any bony changes of the femoral neck and head because they may demonstrate chronic adaptive changes during alterations in hip biomechanics as the femoral head displaces. Determine the amount of head displacement off the femoral neck as a percentage to classify degree of slip Klein line: On the AP view of the hip, a line drawn along the superior border of the femoral neck should pass through a portion of the femoral head. If not, a SCFE is diagnosed

57. SLIPPED CAPITAL FEMORAL EPIPHYSIS Management -Orthopedic Emergency! - Immediate hospitalization and operative fixation - Severe chronic slipped capital femoral epiphyses - Requires osteotomies to realign and stabilize  At this time, internal fixation using central percutaneous pin fixation with one or more cannulated screws is the treatment of choice Bone-graft epiphysiodesis, in combination with internal fixation or casting, is advocated by some surgeons but has a high learning curve, high incidence of avascular necrosis and chondrolysis, poor initial fixation, prolonged operative time, increased intraoperative blood loss, and loss of epiphyseal position. Intracapsular osteotomy is considered an open reduction and internal fixation procedure with an unusually high rate of complications (20-30% incidence of avascular necrosis). It is not indicated as the primary procedure for SCFEs. Prophylactic treatment of the asymptomatic hip has been a controversial topic. Due to the high incidence of eventual bilateral involvement (up to 40-80%) and given that one hip already is affected, some have advocated routine prophylactic treatment of the contralateral hip at the initial time of surgery. At this time, internal fixation using central percutaneous pin fixation with one or more cannulated screws is the treatment of choice Bone-graft epiphysiodesis, in combination with internal fixation or casting, is advocated by some surgeons but has a high learning curve, high incidence of avascular necrosis and chondrolysis, poor initial fixation, prolonged operative time, increased intraoperative blood loss, and loss of epiphyseal position. Intracapsular osteotomy is considered an open reduction and internal fixation procedure with an unusually high rate of complications (20-30% incidence of avascular necrosis). It is not indicated as the primary procedure for SCFEs. Prophylactic treatment of the asymptomatic hip has been a controversial topic. Due to the high incidence of eventual bilateral involvement (up to 40-80%) and given that one hip already is affected, some have advocated routine prophylactic treatment of the contralateral hip at the initial time of surgery.

58. PEDIATRIC FRACTURES Greenstick fracture: - Incomplete angulated fracture of a long bone - Type seen most often in children - This type of # represents bone failure on the tension side of injury and compression or bend deformity on the opposite side Clavicle fracture is one of the most common types of fracture in children. The most serious bony injury of the upper limb is supracondylar fracture of the elbow. Fractures involving the epiphysis of a bone are serious, as they may damage the epiphyseal plate so much that growth is arrested Trauma is the most common cause. Occasionally, pre-existing pathologic conditions may predispose to fractures: Osteogenesis imperfecta Rickets Scurvy Bony cyst Malignant lesion In the case of a fracture in an infant or toddler, the possibility of abuse should be considered. Clavicle fracture is one of the most common types of fracture in children. The most serious bony injury of the upper limb is supracondylar fracture of the elbow. Fractures involving the epiphysis of a bone are serious, as they may damage the epiphyseal plate so much that growth is arrested Trauma is the most common cause. Occasionally, pre-existing pathologic conditions may predispose to fractures: Osteogenesis imperfecta Rickets Scurvy Bony cyst Malignant lesion In the case of a fracture in an infant or toddler, the possibility of abuse should be considered.

59. PEDIATRIC FRACTURES Buckle or torus fracture - Compression of bone produces a buckle - # typically occurs in the metaphysis area - especially distal radius Very stable #, healing 2-3 weeks - simple immobilization Bowing/bend fractures - bone bends but does not break

60. Bend/bowing # - www.googleimages.comBend/bowing # - www.googleimages.com

61. Greenstick # - www. Google images.comGreenstick # - www. Google images.com

62. Torus or buckle # - www.google.comTorus or buckle # - www.google.com

63. PEDIATRIC FRACTURES Epiphyseal fractures Fracture involving the growth plate

64. Salter fractures. S A L T E R: the fracture line is I - the Same as the growth plate, II - Above the growth plate, III - Lower than the growth plate, IV - Through the growth plate, and V - Epiphyseal crush: Remember! Salter fractures. S A L T E R: the fracture line is I - the Same as the growth plate, II - Above the growth plate, III - Lower than the growth plate, IV - Through the growth plate, and V - Epiphyseal crush: Remember!

65. SUPRACONDYLAR FRACTURE Supracondylar fractures are the most frequent elbow fracture in children, accounting for 50-60% of cases Most occur in children aged 3-10 years, with a peak incidence in those aged 5-8 years The fracture is located below the humeral shaft in the metaphysis The fracture is located below the humeral shaft in the metaphysis. In this region, the humerus flares out into medial and lateral columns that extend into the condyles. Between these columns, the humerus is relatively thin at the olecranon and coronoid fossae. This thinning is most pronounced during childhood, with the trabeculae less well developed than in adults. This difference likely accounts for the greater frequency of supracondylar fractures in children (Wilkins, 1991). The fracture is located below the humeral shaft in the metaphysis. In this region, the humerus flares out into medial and lateral columns that extend into the condyles. Between these columns, the humerus is relatively thin at the olecranon and coronoid fossae. This thinning is most pronounced during childhood, with the trabeculae less well developed than in adults. This difference likely accounts for the greater frequency of supracondylar fractures in children (Wilkins, 1991).

66. SUPRACONDYLAR FRACTURE Usually extension injuries due to a fall on an outstretched arm, with the proximal ulna transmitting force to the distal humerus Supracondylar fractures may be complete or incomplete and have a wide range of severity The usual classification defines supracondylar fractures as follows: Type 1 - Fractures with no displacement Type 2 - Fractures with mild displacement or angulation and an intact posterior cortex Type 3 - Fractures with displacement and complete cortical disruption Relative ligamentous laxity in childhood allows the elbow to hyperextend, and with hyperextension, the olecranon transmits the load into a bending force on the distal humerus in the supracondylar region. Most supracondylar fractures involve posterior displacement or angulation of the distal fragment. Often, medial displacement accompanies supracondylar fractures. The less common supracondylar fractures that occur with anterior displacement of the distal fragment are usually caused by a direct blow to the posterior aspect of the elbow such as that sustained with a fall onto the elbow. Relative ligamentous laxity in childhood allows the elbow to hyperextend, and with hyperextension, the olecranon transmits the load into a bending force on the distal humerus in the supracondylar region. Most supracondylar fractures involve posterior displacement or angulation of the distal fragment. Often, medial displacement accompanies supracondylar fractures. The less common supracondylar fractures that occur with anterior displacement of the distal fragment are usually caused by a direct blow to the posterior aspect of the elbow such as that sustained with a fall onto the elbow.

67. SUPRACONDYLAR FRACTURE

68. SUPRACONDYLAR FRACTURE

69. LATERAL CONDYLE FRACTURE Fractures of the lateral condyle are the second most frequent elbow fracture in children, accounting for approximately 15%. Lateral condyle fractures are seen most often in children aged 4-10 years Lateral condyle fractures have 2 primary mechanisms of injury. With a fall on an outstretched arm with the elbow extended and the forearm abducted, the radius transmits an axial load on the capitellum, causing the lateral condyle to fracture. More frequently, the fractures are the result of traction force Lateral condyle fractures have 2 primary mechanisms of injury. With a fall on an outstretched arm with the elbow extended and the forearm abducted, the radius transmits an axial load on the capitellum, causing the lateral condyle to fracture. More frequently, the fractures are the result of traction force

70. LATERAL CONDYLE FRACTURE Although controversy existed previously, lateral condyle fractures are currently considered to be Salter-Harris type IV fractures. The fracture line usually begins in the lateral aspect of the metaphysis and extends medially through the metaphysis and crosses the physis into the epiphysis . In most patients, the fracture involves only the cartilaginous portion of the distal humeral epiphysis; therefore, the epiphyseal component of the fracture is not seen on radiographs Stage I fractures are incomplete, with an intact cartilaginous hinge that may have some angulation but no true displacement. Stage II fractures are complete and have only a small amount of displacement of the distal fragment. With Stage III fractures, the distal fragment is significantly displaced, usually laterally and proximally, with instability of the elbow joint. In addition, traction from the common extensor muscles leads to rotation so that the cartilage-covered articular surface of the fractured lateral condyle is in contact with the metaphysis; this situation may result in malunion if not corrected Although controversy existed previously, lateral condyle fractures are currently considered to be Salter-Harris type IV fractures. The fracture line usually begins in the lateral aspect of the metaphysis and extends medially through the metaphysis and crosses the physis into the epiphysis . In most patients, the fracture involves only the cartilaginous portion of the distal humeral epiphysis; therefore, the epiphyseal component of the fracture is not seen on radiographs Stage I fractures are incomplete, with an intact cartilaginous hinge that may have some angulation but no true displacement. Stage II fractures are complete and have only a small amount of displacement of the distal fragment. With Stage III fractures, the distal fragment is significantly displaced, usually laterally and proximally, with instability of the elbow joint. In addition, traction from the common extensor muscles leads to rotation so that the cartilage-covered articular surface of the fractured lateral condyle is in contact with the metaphysis; this situation may result in malunion if not corrected

71. RADIAL HEAD SUBLUXATION Nursemaid's elbow occurs when the radius (one of the bones in the forearm) slips out of place from where it normally attaches to the elbow joint It is a common condition in children younger than 4 years of age It is also called pulled elbow, slipped elbow, or toddler elbow

72. RADIAL HEAD SUBLUXATION Symptoms may include: History of elbow pull/trauma Immediate pain in the injured arm Refusal or inability to move the injured arm Anxiety  A sudden pulling or traction on the hand or forearm causes nursemaid's elbow. This causes the radius to slip out of the ligament holding it into the elbow. It can occur when an infant rolls himself or herself over, from a fall or from pulling, or swinging a young child by the handA sudden pulling or traction on the hand or forearm causes nursemaid's elbow. This causes the radius to slip out of the ligament holding it into the elbow. It can occur when an infant rolls himself or herself over, from a fall or from pulling, or swinging a young child by the hand

73. RADIAL HEAD SUBLUXATION RX - Rapid firm supination and flexion of arm while applying pressure over radial head usually releases trapped tissues allowing for reduction of radial head - A click,or clunk is head or felt - Relief of pain is immediate and full mobility returns shortly if Rx is immediate after injury - Sling for 1 week to allow soft tissue healing

76. LOWER EXTREMITY PROBLEMS Common variations include: Rotational problems Intoeing Out-toeing Angular problems - Genu varum [bowlegs] - Genu valgum [knock-knees]

77. LOWER EXTREMITY PROBLEMS Meatatarsus varusMeatatarsus varus

78. LOWER EXTREMITY PROBLEMS

79. LOWER EXTREMITY PROBLEMS

80. LOWER EXTREMITY PROBLEMS

81. LOWER EXTREMITY PROBLEMS

82. LOWER EXTREMITY PROBLEMS History Taking - Chief complaint - Complete medical history Include maternal pregnancy, birth, and development. Questioning perinatal events and motor development may reveal a diagnosis of cerebral palsy - Duration of complaint and progression Parents often seek medical advice about lower extremity appearance in their children. In most cases, the complaint is a variation of normal growth and development, and the problem resolves without treatment as the child grows. Family history Lower extremity abnormalities frequently demonstrate a familial tendency. Knowing the parents' experience and attitudes toward similar problems may help with the discussion later. Why the concern? Know why the child is in your office or clinic. Is it gait or cosmesis? A toddler's gait and legs are different from those of an adult. Parental concern often stems from a lack of understanding regarding the maturation of the gait. Know exactly what concerns the parents in order to provide prognostic information History should clarify if the problem began at birth, or before or after walking. How has the problem changed during the past few months? Parents often seek medical advice about lower extremity appearance in their children. In most cases, the complaint is a variation of normal growth and development, and the problem resolves without treatment as the child grows. Family history Lower extremity abnormalities frequently demonstrate a familial tendency. Knowing the parents' experience and attitudes toward similar problems may help with the discussion later. Why the concern? Know why the child is in your office or clinic. Is it gait or cosmesis? A toddler's gait and legs are different from those of an adult. Parental concern often stems from a lack of understanding regarding the maturation of the gait. Know exactly what concerns the parents in order to provide prognostic information History should clarify if the problem began at birth, or before or after walking. How has the problem changed during the past few months?

83. LOWER EXTREMITY PROBLEMS Signs and symptoms Ask about pain, limping, tripping, and falling, sitting habits - Internal tibial torsion is commonly associated with sitting on the feet, while increased femoral anteversion is associated with sitting in a "W" position. - Aggravating factors - Torsional deformities become more apparent with fatigue

84. LOWER EXTREMITY PROBLEMS Physical examination Height and weight Extremities- signs of inflammation, deformity,muscle tone/bulk,power, ROM Trendelenberg sign/leg length discrepancy Spine - scoliosis Neurological exam Physical examination should include height/weight. Normal size for age makes pathologic conditions (e.g., hypophosphatemic rickets, metabolic bone disease) less likely The spine should be examined for scoliosis, hairy patches, or sinus openings. A neurologic examination should be done to rule out neuromuscular disorders The lower extremities should be examined for Trendelenburg's Sign and leg length discrepancy to rule out hip dysplasia.1,4,5 The range of motion of the hips, knees, and ankles should be determined. Evidence of joint laxity that mimics the appearance of a torsional/angular deformity should be checked. The majority of children less than three years of age will have all the findings. Therefore, these characteristics become more meaningful as children grow older. Presence or absence of flat feet should also be assessed Physical examination should include height/weight. Normal size for age makes pathologic conditions (e.g., hypophosphatemic rickets, metabolic bone disease) less likely The spine should be examined for scoliosis, hairy patches, or sinus openings. A neurologic examination should be done to rule out neuromuscular disorders The lower extremities should be examined for Trendelenburg's Sign and leg length discrepancy to rule out hip dysplasia.1,4,5 The range of motion of the hips, knees, and ankles should be determined. Evidence of joint laxity that mimics the appearance of a torsional/angular deformity should be checked. The majority of children less than three years of age will have all the findings. Therefore, these characteristics become more meaningful as children grow older. Presence or absence of flat feet should also be assessed

85. LOWER EXTREMITY PROBLEMS Torsional profile is a composite of measurements of the lower extremities and includes: foot progression angle forefoot alignment hip rotation thigh-foot angle Foot Progression Angle. Also known as gait angle, this is the angle made by the foot with respect to a straight line plotted in the direction the child is walking. The child's feet can be dusted with chalk prior to walking on a long strip of paper toward his or her parents.The angle can then be measured. A plus sign denotes an out-toeing angle, and a minus sign denotes an intoeing angle. Foot progression angle can be normal in children with combined torsional deformity (e.g., medial femoral torsion compensated by lateral tibial torsion) Forefoot Alignment. Metatarsus adductus exists if the sole of the foot is adducted (deviates medially) and if the lateral border is "C" shaped. Hip Rotation. The range of internal and external rotation of the hips should be measured with the child prone and knees flexed to 90 degrees. Internal rotation is determined by fully abducting the legs. External rotation is determined by fully adducting the legs. The degrees of internal and external rotation are generally equal, about 45 degrees. In children with excess femoral anteversion, the femoral neck axis is rotated anteriorly in relation to the frontal plane of the femoral condyles. The internal rotation will far exceed external rotation, while the opposite is true in femoral retroversion. Thigh-Foot Angle. The angle between the axis of the foot and the axis of the thigh should be measured with the child prone and knees flexed to 90 degrees. Intoeing angles are given negative values while out-toeing angles are given positive values. The angle describes the degree of tibial torsion. Each leg should be measured because the problem may be unilateral or the legs may differ in degree of torsion. Normally, the foot axis out-toes 10 degrees relative to the thigh axis. If the foot turns in relative to the thigh axis, the child has internal tibial torsion. Foot Progression Angle. Also known as gait angle, this is the angle made by the foot with respect to a straight line plotted in the direction the child is walking. The child's feet can be dusted with chalk prior to walking on a long strip of paper toward his or her parents.The angle can then be measured. A plus sign denotes an out-toeing angle, and a minus sign denotes an intoeing angle. Foot progression angle can be normal in children with combined torsional deformity (e.g., medial femoral torsion compensated by lateral tibial torsion) Forefoot Alignment. Metatarsus adductus exists if the sole of the foot is adducted (deviates medially) and if the lateral border is "C" shaped. Hip Rotation. The range of internal and external rotation of the hips should be measured with the child prone and knees flexed to 90 degrees. Internal rotation is determined by fully abducting the legs. External rotation is determined by fully adducting the legs. The degrees of internal and external rotation are generally equal, about 45 degrees. In children with excess femoral anteversion, the femoral neck axis is rotated anteriorly in relation to the frontal plane of the femoral condyles. The internal rotation will far exceed external rotation, while the opposite is true in femoral retroversion. Thigh-Foot Angle. The angle between the axis of the foot and the axis of the thigh should be measured with the child prone and knees flexed to 90 degrees. Intoeing angles are given negative values while out-toeing angles are given positive values. The angle describes the degree of tibial torsion. Each leg should be measured because the problem may be unilateral or the legs may differ in degree of torsion. Normally, the foot axis out-toes 10 degrees relative to the thigh axis. If the foot turns in relative to the thigh axis, the child has internal tibial torsion.

87. IN-TOEING Definition - Inward pointing of toes Causes - Metatarsus varus: adduction of forefoot on hindfoot (lateral border of foot is curved instead of straight); presents in infancy Tibial torsion: in-turning of entire foot (medial twisting of tibia); presents in early childhood Femoral anteversion: in-turning of leg (medial twisting at hip); presents in early childhood If mild, may resolve on its own; if extreme, treatment is required If mild, may resolve on its own; if extreme, treatment is required

88. MARTARSUS VARUS Forefoot is turned medially on the hindfoot. Ankle joint has normal dorsiflexion and plantar flexion. Physiologic metatarsus varus can lead to adduction of forefoot past midline (no treatment needed). Forefoot is turned medially on the hindfoot. Ankle joint has normal dorsiflexion and plantar flexion. Physiologic metatarsus varus can lead to adduction of forefoot past midline (no treatment needed).

89. TIBIAL TORSION Measured by angle between foot and thigh with ankle and knee positioned at 90�. The foot normally rotates externally with age (about 2� at about 1 year of age, about 20� at 15 years of age). In tibial torsion, this angle is smaller. Measured by angle between foot and thigh with ankle and knee positioned at 90�. The foot normally rotates externally with age (about 2� at about 1 year of age, about 20� at 15 years of age). In tibial torsion, this angle is smaller.

90. FEMORAL ANTEVERSION Decreased external rotation of the hip; if external rotation is less than 20�, in-toeing may result.

91. IN-TOEING History - May be associated with stumbling - Sleeping with feet tucked underneath legs (tibial torsion) - Sitting in the W-position, with knees together and feet spread laterally (femoral anteversion)

92. IN-TOEING Management Metatarsus Varus - Usually requires no treatment if the condition is mild. Reassure the parents or caregiver and follow up closely. Tibial Torsion Discuss with a physician Advise change in sleeping position Increased Femoral Anteversion Change sitting position to tailor position Most children require no other intervention COMPLICATIONS ���� Gait difficulties if left unattended Monitoring and Follow-Up Monitor gait every 3 or 4 months. COMPLICATIONS ���� Gait difficulties if left unattended Monitoring and Follow-Up Monitor gait every 3 or 4 months.

93. MALIGNANT BONE TUMOURS Ewing�s Osteosarcoma

94. EWINGS SARCOMA Small, round-cell sarcoma of mesenchyme of medullary bone Age 5 - 20 yrs - peak age 10-20 yrs Most lethal of all bone tumors Long bones , but could be any Periosteal reaction (moth eaten, onion-skin ) Present with fever, increased WBC, ESR,anemia and mass

95. OSTEOSARCOMA Classic osteosarcoma presents as a painful, hard, fixed, poorly defined swelling Deep, aching pain which occurs more often at night than during the day Hx. Of trauma often Pathologic fracture is uncommon Serum levels of alkaline phosphatase are elevated

96. OSTEOSARCOMA Age: 10-20 ( 60%) Sex: M > F Site: There is a predilection for the metaphyses of the large, long bones in adolescents, and it is most common in the distal femur, the proximal tibia, the proximal humerus, and the distal radius in that order It is, occasionally, multicentric Classic osteosarcoma demonstrates aggressive, rapid growth with a high risk of local, "skip" metastases and early, pulmonary metastasis. Classic osteosarcoma demonstrates aggressive, rapid growth with a high risk of local, "skip" metastases and early, pulmonary metastasis.

97. OSTEOSARCOMA This Stage II-B, classic osteosarcoma of the distal femur presented as a. The mass had been steadily enlarging since it was first appreciatedThis Stage II-B, classic osteosarcoma of the distal femur presented as a. The mass had been steadily enlarging since it was first appreciated

98. BONE TUMOURS IMAGING STUDIES Isotope Scan Angiography CT Scan MRI Angiography of an osteosarcoma shows hypervascularity. The MRI shows a low-intensity signal and best demonstrates the intramedullary extent, "skips", extent of the soft-tissue component, and epiphyseal or intra-articular involvement Survival rates are good when the lesion is responsive to chemotherapy and adequately managed surgically. Of the lesions, 90 percent present as Stage II-B with 5 percent Stage II-A and 5 percent Stage III. Angiography of an osteosarcoma shows hypervascularity. The MRI shows a low-intensity signal and best demonstrates the intramedullary extent, "skips", extent of the soft-tissue component, and epiphyseal or intra-articular involvement Survival rates are good when the lesion is responsive to chemotherapy and adequately managed surgically. Of the lesions, 90 percent present as Stage II-B with 5 percent Stage II-A and 5 percent Stage III.

99. BONE TUMOURS TREATMENT Surgical Radiation Chemotherapy In classic osteosarcoma, a wide, en bloc excision is indicated if the patient is responsive to preoperative chemotherapy, but radical resection or amputation are necessary if the patient is unresponsive Radiation Therapy Radiation therapy may be useful to augment inadequate, surgical margins in selected situations. Chemotherapy A high percentage of lesions respond to chemotherapy which is useful to suppress and treat metastases. Chemotherapy is responsible for a dramatic increase in survival rates and marked increase in the percentage of patients treated by limb salvage rather than amputationIn classic osteosarcoma, a wide, en bloc excision is indicated if the patient is responsive to preoperative chemotherapy, but radical resection or amputation are necessary if the patient is unresponsive Radiation Therapy Radiation therapy may be useful to augment inadequate, surgical margins in selected situations. Chemotherapy A high percentage of lesions respond to chemotherapy which is useful to suppress and treat metastases. Chemotherapy is responsible for a dramatic increase in survival rates and marked increase in the percentage of patients treated by limb salvage rather than amputation

100. OSTEOMYELITIS Etiology/ Pathophysiology Bacterial , viral or fungal invasion of bone or marrow results in infection Approximately 50% of cases occur in preschool aged children affecting tibia or femur More common in males, African Americans and the immunocompromised

101. OSTEOMYELITIS Staphylococcus aureus is the most common pathogen, followed by Streptococcus pneumoniae and Streptococcus pyogenes Gram-negative bacteria and group B streptococci frequently are seen in newborns Pseudomonas aeruginosa often is associated with osteomyelitis following penetrating wounds of the foot

102. OSTEOMYELITIS Immunocompromised children are prone to infection with a variety of fungi and bacteria Salmonella is an important cause of osteomyelitis in children with sickle cell disease and other hemoglobinopathies

103. OSTEOMYELITIS Clinical Presentation - Fever Bone pain � not a prominent feature Swelling Redness Guarding the affected body part Inability to support weight Asymmetric movement of extremities are often early signs in newborns and young infants

104. OSTEOMYELITIS Clinical Presentation �continued - Point tenderness over the affected area of bone - Draining sinus and bone deformity - rare in acute disease - When present, these symptoms suggest subacute or chronic infection. - Movements of the adjoining joint may be restricted due to joint involvement or associated soft tissue inflammation.

105. OSTEOMYELITIS Diagnostic investigations - Blood, bone, and joint aspirate cultures WBC ESR Plain X-ray films Bone scan MRI

106. OSTEOMYELITIS Differential Diagnosis Septic arthritis ( if near joint) Bone tumour � e.g Ewing�s sarcoma Cellulitis Fractures Subsutaneous abscess

107. OSTEOMYELITIS Management - Consult with an orthopedic surgeon and infectious disease specialist Bed rest Protect limb from further injury IV � antibiotics for 4-8 weeks The usual choice is an antistaphylococcal antibiotic e.g vancomycin, clindamycin Complications Septicemia ( more likely in children) Extension of infection to adjacent joint ( septic joint) Retarded bone growth due to damage to epiphyseal growth plate Chronic oesteomylitis IV antibiotics (continued_ - Vancomycin is used as an alternative to clindamycin for empiric therapy in patients living in communities where there is a higher incidence of penicillin resistant S pneumoniae or community-acquired methicillin-resistant S aureus.( MRSA) Complications Septicemia ( more likely in children) Extension of infection to adjacent joint ( septic joint) Retarded bone growth due to damage to epiphyseal growth plate Chronic oesteomylitis IV antibiotics (continued_ - Vancomycin is used as an alternative to clindamycin for empiric therapy in patients living in communities where there is a higher incidence of penicillin resistant S pneumoniae or community-acquired methicillin-resistant S aureus.( MRSA)

108. OSTEOMYELITIS Surgery - Surgical aspiration may be necessary if symptoms fail to respond quickly to antibiotics or if X-rays reveal periosteal lifting or abscess - If bone necrosis occurs surgical debridement of necrotic area may be needed � more common with chronic osteomylitis Follow Up � outpatient Follow up weekly with CBC, ESR 5-10% have recurrence despite adequate Rx Recurrence may lead to chronic osteomylitis Follow Up � outpatient Follow up weekly with CBC, ESR 5-10% have recurrence despite adequate Rx Recurrence may lead to chronic osteomylitis

109. SEPTIC ARTHRITIS Bacterial infection within a joint Serious medical emergency! Spread by direct extention , hematogenous( most commonly), inoculation Organisms: - 0-6 months- S.aureus, E.Coli - 6-36 months- S.aureus, H.influenza - > 36 months- S.aureus, Streptococci

110. SEPTIC ARTHRITIS History/Physical Exam Severe pain Fever, chills Dehydration Lethargy Local redness, swelling, heat, tenderness Unable or unwilling to move joint - neonates get pseudoparalysis Joint held in flexion

111. SEPTIC ARTHRITIS Diagnostic tests Blood and throat cultures Joint aspirate for cultures CBC, WBC, Bone scan (for hip involvement only, to assess for vascular compromise to femoral head)

112. SEPTIC ARTHRITIS Admit Limb at rest IV fliuds for dehydration IV antibiotics Analgesia Surgical aspiration/debridement Complications: septic dislocation, AVN of femoral head( pressure of pus), epiphyseal and cartilage destruction, osteomyelitisComplications: septic dislocation, AVN of femoral head( pressure of pus), epiphyseal and cartilage destruction, osteomyelitis