Common Pediatric Orthopedic Clinical Problems

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Common Pediatric Orthopedic Clinical Problems

• Saunders Jones Jr. MD
• Georgiaorthopedic_at_msn.com
• sjones12_at_kennesaw.edu

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Common Pediatric Orthopedic Problems

• Metabolic
• Developmental
• Congenital
• Traumatic
• Infectious
• Neoplastic
• Neuromuscular

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Radiological hole in the bone

• Fibrous cortical defect
• Aneurysmal Bone cyst
• bone island
• Giant cell tumor
• Infection
• Ewings Sarcoma
• Enchondroma

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Unicameral bone cyst

• Next to growth plate
• Active vs Inactive
• Falling leaf sign

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Fibrous cortical defect (Fibroxanthoma)
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Ewing's Sarcoma
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Incidence of Ewings
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Osteochondromas or Multiple Exostoses

• Cartilaginous cap covered by a bursa
• Impinge on local structures
• CT shows cap lt 1cm in thickness
• Can be excised due to structural problems
• SMALL incidence (lt1 per lesion) of
  transformation to Chondro sarcoma (or Osteogenic
  less common)

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Multiple Exostoses

• Found in areas around growth plates
• Can occur in multiple locations or singularly
• Usually not Neoplastic
• Bone with cartilaginous cap
• Grows normally with growth of the rest of the
  skeleton

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Osteochondromas

• B9
• Cartilaginous cap
• Impinges on local structures

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Osteochondromas

• Another view

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Osteochondroma microscopic
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Osteosarcoma

• Some bone
• elements

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Rickets

• Radiologic changes in the growth plate
• Vitamin problem

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Twisty Bendy Feet

• Most common is metatarsus adductus
• FPS fetal packaging syndrome
• Normal rotation of feet in utero
• Should respond to gentle massage and SWN
• Shoes could be worn in reverse (r-l l-r) if there
  is any last in the shoe

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Metatarsus adductus/clubfoot(tell tale medial
crease)
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Twisty Bendy Feet

• Clubfeet talipes equino-varus
• Metatarsus adductus, heel equinus and varus and
  talus adductus
• Tell tale crease on lat underneath malleolus
• Thinning and atrophy of lower leg
• Needs attention based on severity of deformity,
  START TREATMENT AT BIRTH !!! Refer early

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Club feet

• Metatarsal
• Talus
• Hindfoot
• Leg atrophy

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Endstage Club feet
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Clubfoot casting

• In the nursery or soon as possible

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Club foot Casting

• Must go above the knee to control rotation
• Plaster is the best
• Soak off night before
• Manipulation and then maintenance of that
  correction

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Limited clinic Tenotomy

• New

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Twisty Bendy legs
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Twisty Bendy Legs

• Internal Tibial Torsion
• Normal adult rotation is 10-15 degrees external
• Normal unwinding of child's lower legs
• Not significantly affected by orthotics or
  treatment !!!
• Sight along tibial crest and look at malleoli
• Reassure (look for other conditions)

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Twisty Bendy Legs

• Bendy knees/legs
• 2-4-6 years
• Genu varus / genu valgus
• Normal variants
• Radiographs for Blounts Disease
• Vitamins
• Orthotics (?)

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Blounts vs. Normal
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Twisty Bendy Legs

• Femoral anteversion
• Femur is turned in at the hip causing pigeon
  towed gait
• Sit on their feet
• SWN
• Education
• Twister cables!!?!?!?!?

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Femoral anteversion
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Pes Planus flat feet

• Common in infants and up to about 8 years of age
• Painful flat feet is differenttarsal coalition
  or other condition
• Some pes planus is genetic or racial
• Look at moms feet!!!

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Heel Pain in Adolescent

• Severs Disease
• Calcaneal apophysitis
• X rays show fractionation
• Symptomatic tx with NSAIDs
• Stretching
• Limitation of activity ?

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Severs Disease
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Xray of the Calcaneal Apophysis
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Stretch for Severs Disease
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Knee Pain in Adolescent

• Anterior tibial tubercle pain
• Osgood-Schlatters disease
• Tibial apophysitis
• Rest stretching Ice Nsaids
• Prominent tubercle
• Hereditary tendencies
• HIP PAIN MASQUERADES AS KNEE PAIN !!!!! Always
  xray same side hip!!!

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Anterior Knee pain

• Adolescent Female
• Increased valgus with tracking problems
• Squatting and Indian style sitting
• Quad sets and Nsaids
• VMO?
• Usually self limited
• Make sure nothing else going on..

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OSDx and Ant knee pain
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Osgood Schlatter's
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Osgood Schlatters Disease
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Hip Pain

• SCFE
• Transient synovitis
• Hip pyarthrosis
• LCP

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Slipped Capital Femoral Epiphysis

• SCFE
• Endomorphic
• Androgenital
• Onset anterior thigh pain
• Externally Rotated Gait
• Can be bilat
• Rx pin in situ

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SCFE
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SCFE
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SCFE
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LCP Perthes Disease

• Avascular necrosis of the proximal femoral growth
  plate
• Collapse
• Maintain concentricity and containment
• Multiple bouts of Transient synovitis

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LCP initial and resorptive phases
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LCP resorptive and remodeling
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Congenital Dislocated Hip

• Barlow's
• Ortilani
• Duration and treatment
• Age of child at discovery
• Pavlick harness
• Closed reduction and casting

• Open Reduction
• Subtrochanteric osteotomy
• Acetabular osteotomy

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Congenital Dislocation
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Congenital Hip Dislocation
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Causes of Hip Pain in Children
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Idiopathic Adolescent Scoliosis

• Not a painful condition
• If there is painlook for another cause!
• OBJECTIVE OF TREATMENT
• To prevent deformity as adult
• Skeletal maturity
• Onset of menses, Risser sign
• Criteria for referral relates to progression
• Braces?Surgery runs the gamut

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Nursemaids Elbow
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Falls from a Height common in Children
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Epiphyseal Injuries only in kids!!!

• Salter classification
• Joint involvement
• Growth disturbance
• Thick periosteum

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Salter One
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Salter 2
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Salter 3
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Salter 4
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Salter 5
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Supracondylar elbow fractures

• Compartment syndrome because of vascular
  compromise
• Characteristic fx due to the shape of the
  supracondlyar region of the humerus
• balancing two canoes

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Lines around the elbow
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Supracondlyar fx minimal displacement
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Displaced Supracondylar fx
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Medial Epicondyle fx
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Lateral condyle Salter ?
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Supracondylar fx
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Radial Head fxs
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Displaced Lateral condyle Salter ?
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Radial Head Fx displaced epiphyseal.Salter ?
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Late Sequelae Cubitus varus
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Fracture Tx in Kids

• Alignment has different criteria
• Overgrowth
• Maintenance of overall alignment most important
  Rotation, etc

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Fracture Tx in Younger Kids (growth potential)
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Overall Alignment and Residual Growth
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Fracture Tx in Older Kids
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Fracture Tx in Even Older Kids
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Neuromuscular Category

• Cerebral Palsy
• Spastic or Flaccid
• Birth injury
• Perinatal cerebral anoxia
• Hyperactive stretch receptors
• Contractures
• Releases, Transfers, Braces etc.

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Infections

• Joints Pyarthrosis
• Infants and young children
• Endemic Otitis Media
• No good lab test
• X-rays normal
• Patho-anatomy growth plate vasculature
• Drain and decompress because of potential damage
  to cartilage
• May lead to Osteomyelitis

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ANY QUESTIONS???

• Comments
• Discussion

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Thank you