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LOWER EXTREMITY PROBLEMS IN CHILDHOOD. TIMOTHY J. FETE MD,MPH University of Missouri School of Medicine Department of Child Health. Developmental Dysplasia of the Hip-associations. First born Torticollis Metatarsus Adductus Internal Tibial Torsion Oligohydramnios Breech

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lower extremity problems in childhood

LOWER EXTREMITY PROBLEMS IN CHILDHOOD

TIMOTHY J. FETE MD,MPH

University of Missouri School of Medicine

Department of Child Health

developmental dysplasia of the hip associations
Developmental Dysplasia of the Hip-associations
  • First born
  • Torticollis
  • Metatarsus Adductus
  • Internal Tibial Torsion
  • Oligohydramnios
  • Breech
  • + Family History
developmental dysplasia of the hip
Developmental Dysplasia of the Hip
  • Ortolani Maneuver: Reduction
  • Barlow Maneuver: Dislocation
  • Increased joint laxity
  • Limitation of Abduction
  • Assymetric thigh skin folds
  • Galeazzi’s Sign
  • Leg Length Discrepancy
developomental dysplasia of the hip
DEVELOPOMENTAL DYSPLASIA OF THE HIP
  • Positive exams per 1000 newborns
  • All 11.5
  • Boys 4.1
  • Girls 19
  • + Fam Hx Boys 6.4
  • + Fam Hx Girls 32
  • Breech Boys 29
  • Breech Girls 133
developmental dysplasia of the hip11
Developmental Dysplasia of the Hip
  • Plain films not particularly valuable until 4-6 months of age
  • Ultrasonagraphy most useful beyond four weeks of age (false + before)
  • US allows static and dynamic study
ddh screening
DDH: Screening
  • 1. All Newborns to be screened at birth
  • 2. If + Ortolani or Barlow: refer to ortho, do not order US
  • 3. If equivocal, recheck at 2 weeks
  • 4. If equivocal at 2 weeks, refer or order US at 3-4 weeks
  • 5. Examine hips at all well visits until 18 months (late presentation)
ddh screening16
DDH: Screening
  • Perform US for:

*Girls who are breech

Consider US for:

*Girls with positive family history

*Boys who are breech

ddh treatment
DDH: Treatment
  • NOT Triple Diapers!
  • Pavlik Harness
  • Progressive Casting
  • Adductor Tenotomy
  • Open Reduction
  • If late, may require acetabular surgery
intoeing
INTOEING
  • Metatarsus Adductus
  • Internal Tibial Torsion
  • Femoral Anteversion
metatarsus adductus
METATARSUS ADDUCTUS
  • Heel Bisector

*normal: between toes 2 and 3

*mild: 3rd toe

*mod: 4th toe

*severe: 5th toe

  • Rigidity

*actively correctable: straighten with tickle

*passively correctable: straighten with gentle pressure

*fixed: unable to straighten

metatarsus adductus treatment
METATARSUS ADDUCTUS: Treatment
  • Actively Correctable: no Rx
  • Passively Correctable

*exercises

*straight or reverse-last shoes

  • Fixed: serial casting
  • Look for DDH!
internal tibial torsion
INTERNAL TIBIAL TORSION
  • Thigh/foot angle
  • Relative position of medial and lateral malleoli
  • Most common cause of intoeing under 3 years of age
  • Universally resolves by 4-6 years
  • No treatment required
medial femoral torsion femoral anteversion
MEDIAL FEMORAL TORSION FEMORAL ANTEVERSION
  • Most common form of intoeing greater than 3 years of age
  • Examine prone rotational profile
  • Most (85%) resolve spontaneously by 8-10 years
  • Possible athletic advantage
  • Femoral osteotomies if severe
external tibial torsion
EXTERNAL TIBIAL TORSION
  • Normal adults + 10 degrees of external tibial torsion
  • No treatment necessary
pes planus flat feet
PES PLANUS (FLAT FEET)
  • Normal through age 7 years
  • 1/7 never develop arch
  • Flexible: foot regains arch when stand on toes
  • Treatment rarely necessary—only if painful (rare)
  • Rigid: still flat with toe-standing-rare-may be due to tarsal coalition, may require surgery
shoes
SHOES
  • Adequate size
  • Soft/flexible
  • Flat/non-skid sole
  • Soft/porous upper
  • Inexpensive
  • Avoid odd shapes (cowboy shoes/high heels)
clubfoot
CLUBFOOT
  • Metatarsus adductus + Equinus + Hindfoot varus
  • 1/1,000 live births
  • 50% bilateral
  • Male/female = 2.5/1
  • Increase if + family history
  • + association with DDH
  • Serial casting (25+ % effective)
  • Surgery
cavus foot
CAVUS FOOT
  • High arch, usually inherited, no Rx
  • Red flags: new-onset, unilateral, painful, progressive
  • Red flags may indicate: Friedrich ataxia, Charcot-Marie-Tooth, tethered spinal cord, intraspinal lesion
bowlegs
BOWLEGS
  • Physiologic

*internal rotation of tibia/retroversion of femur

*generally resolved within 6 months of walking

  • Genu Varum—all children initially bowlegged until 2-3 years, no Rx required if persists:
  • Blount Disease

* “undergrowth” of medial proximal tibia

*early walkers, heavyset,girls, AfricanAmericans

  • Metabolic/Medical: rickets, renal,dwarfism
  • X-ray if painful, unilateral, greater than 2 years old
knock knees
KNOCK-KNEES
  • Genu Valgum
  • By 7 years most children reach typical adult mild genu valgum
  • No Rx required, well-tolerated
legg calve perthes disease
Legg-Calve’-Perthes Disease
  • Avascular Necrosis of the Femoral Head
  • 4-8 years of age
  • Males/females = 4/1
  • Bilateral in 10-18%
  • Short stature/delayed bone age
  • Insidious, often painless limp
  • Thigh/knee pain not uncommon
  • Decreased hip mobility on exam
  • Rx: physical therapy, bracing, ultimate surgery
slipped capital femoral epiphysis scfe
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
  • Insidious pain or limp vs acute pain
  • Pain often thigh/knee
  • Early adolescence (13-15 males, 11-13 females
  • Often, not always, obese
  • African-Americans > Caucasians
  • 20% bilateral initially, 30% more in < 1 yr
  • Limp,Lateral rotation of foot,limited internal rotation at hip
osgood schlatter disease
OSGOOD-SCHLATTER DISEASE
  • Painful enlargement of tibial tubercle at insertion of patellar tendon
  • Repetitive stress from quadriceps pull
  • X-rays generally not helpful
  • May have fragmentation of tibial tubercle
  • Generally resolves within 6-18 months
  • Rx: rest, hamstring and quad stretching prior to participation, ice afterward, NSAIDS only for acute pain (not to participate!)
  • Resolved permanently with skeletal maturity