CHAPTER 24 SPECIAL CONCERNS OF THE PEDIATRIC PATIENT ROTATIONAL DEFORMITIES

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CHAPTER 24SPECIAL CONCERNS OF THE PEDIATRIC
PATIENTROTATIONAL DEFORMITIES

• Intoeing pigeon toed, common. Usually
  spontaneously corrects.
• Metatarsus adductus (packaging defect)
  stretching and casting (associated with hip
  dysplasia.
• Talipes Equinovarus.

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CHAPTER 24SPECIAL CONCERNS OF THE PEDIATRIC
PATIENT (Contd.)

• Club Foot
• Metatarsus adductus
• Equinus (foot flexion)
• Always check hips

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ANGULAR DEFORMITIES

• Genu varum (bow legged)
• Genu valgum (knock-kneed)
• Normal Exam
• 2-3 years old, bow legged.
• 3 years old, knock-kneed.
• 7 years old, slightly knock-kneed.
• Pathologic if unilateral, painful or asymmetric.
• Consider rickets (vitamin D), renal disease,
  dysplasias, (dwarfism)

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ANGULAR DEFORMITIES (Contd)

• INFANTILE BLOUNTS DISEASE Unknown etiology
• Medial tibial physis ceases to function
  appropriately.
• Leads to relative overgrowth laterally.
• Genu varum.
• Black females.
• Large kids.
• Early walkers lt11 months.
• Treatment Surgery.

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FOOT DEFORMITIES

• CLUB FOOT
• 1 in1,000 live births, half are bilateral.
• 2.5x more common in males.
• Inheritance multi-factorial.
• Metatarsus adductus.
• Equinus and heel varus.
• Not packaging defect.
• Always screen for hip dysplasia.
• Treatment Casting for 3 months, then surgery.

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FLAT FEET

• Pes Planus
• Absent arch which reappears when up on tip toes.
• Treatment Reassure family.
• Rigid flat foot
• Tarsal coalition (calcaneus, talus, navicular may
  fuse abnormally). Can cause decreased motion and
  increasing pain.
• Treatment Surgery.

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HIP DISORDERSDEVELOPMENTAL DYSPLASIA OF THE HIP
(DDH)

• Genetic and can arise during development.
• 1 in 1,000 live births.
• Female.
• First born.
• Breech position.
• Family history.
• Allis sign (abnormal skin folds).

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HIP DISORDERSDEVELOPMENTAL DYSPLASIA OF THE HIP
(DDH) (Contd.)

• Galeazzi sign (decreased height of affected
  knee).
• 2 provocative tests
• Ortolani maneuver relocates hip.
• Barlow maneuver dislocates hip.
• X-rays not helpful until after age 4 months.
  Pelvis/hips not ossified at birth.
• Ultrasound better after 2 weeks of age. 5 are
  missed by ultrasound. Must repeat tests for 1
  year.
• If untreated, leads to arthritis.

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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

• Displacement or slipping of part of femoral head
  through growth plate.
• 11-13 years old for girls.
• 13-15 years old for boys.
• Related to hormonal disorders (chubby, short,
  hypogonadism).
• More common in Blacks.

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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Contd.

• Complaint of knee or hip pain (obturator nerve
  referral pain).
• Limp, painful internal rotation of hip.
• Treatment Surgery (pinning).

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LEGG-CALVE PERTHES DISEASE

• Idiopathic necrosis of femoral head.
• Usually 4-8 year old males, small for age,
  active.
• Limited abduction and external rotation.
• Disease course takes 2 years.
• Treatment Involves maintaining femoral head in
  socket. Usually unilateral.

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GROWTH PLATE FRACTURES

• Unlike adults, children rarely injure ligaments
• because the physis is weaker.
• SALTER-HARRIS CLASSIFICATIONS
• Type I
• Fracture goes straight through growth plate.
• X-rays within normal limits.
• Type II
• Fracture goes through physis and metaphysis.
• Most common.
• Good prognosis.

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GROWTH PLATE FRACTURES (Contd.)

• Type III
• Fracture goes through physis and epiphysis.
• Intraarticular.
• Will require surgery.
• If left untreated, leads to growth arrest.
• TYPE IV
• Fracture goes through epiphysis, growth plate and
  metaphysis.
• Surgery.
• High complication of growth arrest.

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GROWTH PLATE FRACTURES (Contd.)

• Type V
• Rare injury.
• Compression injury or crush injury to the growth
  plate.
• Leads to growth arrest.

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NEUROMUSCULAR DISORDERSCEREBRAL PALSY

• Brain lesion which leads to non-progressive
• Neurologic condition.
• Perinatal.
• 3.5 per 1,000 live births.
• Classifications
• Quadriplegic all four extremities.
• Diplegic lower extremities.
• Hemiplegic one side of body.
• Spasticity high muscle tone.

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SPINA BIFIDA

• Describes variety of neural tube defects.
• Severity depends on which level is affected.
• 1 in 1,000 live births.
• Meningocele Vertebral arches unfused.
  Meningeal sac is visible.
• Myelomeningocele Neural elements exposed
  without sac.
• Rachischisis Neural elements exposed without
  sac.

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SPINA BIFIDA (Contd.)

• Occurs in embryologic development.
• Women must have Folate gt 400 units per day.
• No hot baths or saunas during first trimester.
• Diagnosis by 16 weeks gestation with ultrasound.
• Amniocentesis confirms diagnosis (increased Alpha
  Feta protein).
• Treatment Immediate closure of defect.

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SPINA BIFIDA (Contd.)

• Thoracic level causes spine and hip problems.
• Lumbar and sacral levels cause knee and foot
  problems.
• L4 gives quadriceps which allows ambulation.

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SCOLIOSIS

• Three-dimensional curvature of the spine.
• IDIOPATHIC
• Detected around age 10-12.
• Only 10 severe enough to warrant surgery.
• Forward bend test. Rib hump on clinical exam.
• Less than 25 degrees observe.
• 25-45 degrees brace.
• Greater than 45 degrees surgery (fusing spine).

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SCOLIOSIS (Contd.)

• CONGENITAL
• Look at heart and kidney abnormalities.
• NEUROMUSCULAR
• Cerebral palsy, spina bifida, muscular dystrophy,
  spinal cord injuries.

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CHILD ABUSE

• Non-accidental injuring of a child.
• Mandatory reporting laws for physicians in all 50
  states.
• 1,000 deaths per year.
• Types of child abuse
• Emotional.
• Medical neglect.
• Sexual.
• Physical.

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CHILD ABUSE (Contd.)

• PHYSICAL ABUSE
• Multiple fractures with various stages of
  healing.
• Posterior rib fracture.
• Bilateral acute long bone fractures.
• Complex skull fracture.
• Long bone fracture in non-ambulatory children
  (spiral fracture of long bones no longer
  pathopneumonic for child abuse).
• Skeletal survey.

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INFECTION

• OSTEOMYELITIS Infection of bone.
• Osteomyelitis generally spreads hematogenously.
  Dissemination of bacteria in blood stream.
• In children, structures of blood vessels of
  metaphysical region predisposes them to
  infection.

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INFECTION (Contd.)

• SUBPERIOSTEAL ABSCESS
• Staph aureus most common in all ages.
• Streptococcus less than 4 years of age.
• E-coli neonates.
• Sickle cell anemia staph aureus, salmonella.
• Pseudomonas stepping on a nail while wearing
  sneakers.
• Labs CBC with differential, sed rate, CRP,
  blood cultures, x-rays and bone scan, aspiration.
• Treatment Six weeks IV antibiotics, rarely
  surgery.

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INFECTION (Contd.)

• SEPTIC ARTHRITIS Infection in joint.
• Bacteria invade joint synovium.
• Usually sicker than patients with osteomyelitis.
• Treatment Emergent surgical drainage.
• Differential diagnosis Juvenile rheumatoid
  arthritis.

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INFECTION (Contd.)

• TOXIC SYNOVITIS Acute non-bacterial joint
• Inflammation.
• Self-limiting.
• Normal sed rate and C-reactive protein.
• No abnormal joint fluid.