Pediatric Orthopedics - PowerPoint Presentation

Slide1

Pediatric Orthopedics

Llewellyn Mensah, MD

3/19/15Slide2

Outline

Common pediatric orthopedic problems

DMD

Club foot

DDH

Intoeing

Common hip conditions in pediatric and adolescent population

Transient

synovitis

SCFE

Legg Calve

Perthes

Osteochondroses

Osteochondritis

dessecans

Kohler’s

osteochondritis

Freiberg’s

osteochondrosis

Apophysitides

– scoliosis, traction

apophysitis

, Osgood

Schlatter’s

,

Sever’s

Benign nocturnal limb pain of childhood

Pediatric fracturesSlide3

Duchenne

Muscular Dystrophy

Caused by a defective gene located on the X chromosome responsible for the production of

dystrophin

(important muscle fiber membrane protein)

Clinical onset of weakness usually occurs between 2 and 3 years of age and most will present by 6 years of age

Affected children usually have varying degrees of mild cognitive impairment

Muscle weakness affects the proximal before the distal limb muscles

Features: cardiomyopathy and conduction abnormalities, bone fractures, scoliosis,

pseudohypertrophy

of the calf/quadriceps, lumbar

lordosis

, waddling gait, shortening of Achilles tendons, hypo- or

areflexiaSlide4

Duchenne

Muscular Dystrophy (DMD)Slide5

DMD

DMD

is

the most common fatal disease affecting children in the United

States

Patients with DMD are often confined to a wheelchair by age 12 years and die in their late teens or 20s from respiratory insufficiency or cardiomyopathy

Elevated levels of serum CK and EKG abnormalities are common

Muscle biopsy confirms the diagnosis if genetic studies are negativeSlide6

DMD

Treatment aims at preventing complications

Respiratory – volume recruitment / deep lung inflation, manual and mechanically assisted cough techniques, nocturnal ventilation, daytime ventilation, tracheostomy

Orthopedic interventions to prevent contractures,

nutritional and weight monitoring, dietary calcium and vitamin D supplementation, exercise to prevent disuse atrophy

For boys 5 years of age and older who are no longer gaining motor skills, or whose motor skills are declining –

glucocorticoids

(prednisone or

deflazacort

)

With LVEF < 55% or LV dilation – ACEI or Β blockerSlide7

Erb’s

palsySlide8

Erb’s

palsy

Paralysis of arm caused by injury to C5 – C6

Arises most commonly , but not exclusively, from shoulder dystocia during a difficult birth

Loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps and brachialis

The arm hangs by the side and is rotated medially; the forearm is extended and pronated and there is loss of shoulder abduction, elbow flexion and supination of the forearm (waiter’s tip).

Depending on severity, the paralysis can either resolve on its own over a period of months, or necessitate rehab /

surgery

Treatment: Daily PT; Serial exams for 3 – 6

mo

and surgical referral if still no improvementSlide9

Club footSlide10

Club foot

AKA

talipes

equinovarus

– foot is excessively plantar flexed, with the forefoot swung medially and the sole facing inward

Can be diagnosed in

utero by u/s;

Amniocentesis for karyotype if there are associated abnormalities (

syndromic

clubfoot)

Hereditary predisposition; 1:1000 live births; boys >

girls

For parents without clubfoot, the overall risk of recurrent isolated clubfoot depends upon the sex of the first affected child

2% after an affected male; 5% after an affected

female

If both a parent and a child are affected, then the recurrence risk is as high as 25% Slide11

Club foot: Types / Therapy

Classification

Congenital (most common): isolated anomaly; - Rx: Serial casting and bracing (

Ponseti

method) followed by heel cord release and night time bracing x 2

years if necessary

Syndromic

: associated with connective tissue, genetic, neuromuscular disorders. Rx: surgical correction at 9 – 12

mo

if needed

Positional: intrauterine crowding or breech position; - easily corrects to normal position with manipulationSlide12

Developmental dysplasia of the

hip

Spectrum of conditions related to the development of the hip in infants and young children – dislocation /

dislocatability

, subluxation /

subluxability

, femoral head and

acetabular

dysplasia

Incidence is 1 – 2 per 1000 newborn infants

Risk factors: female sex, breech presentation and other conditions associated with limited fetal mobility, family history

Hip exam should occur at birth and at every health supervision visit until the child is walking normally (usually by 2 years of age).Slide13

DDH: Clinical featuresSlide14

DDH: Clinical featuresSlide15

DDH

Detect hip instability (“jerk” or “clunk”) using adduction and posterior pressure to feel for

dislocatability

(Barlow’s) and abduction and elevation to feel for reducibility (

Ortolani’s

).

The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech females, breech males (optional), and females with a positive family history of developmental dysplasia of the hip.

Infants and young children who have hip instability on exam (at any age) be referred to an orthopedic surgeon for further evaluation and managementSlide16

DDH

The goal of treatment: obtain and maintain concentric hip reduction so femoral head and acetabulum can develop normally to prevent osteoarthritis

Pavlik

harness achieves and maintains hip

reduction in 95

% of

infants treated during

the first 6

months

of

life

Slide17

DDH

Spica casting / Reduction

under anesthesia (closed or open) is usually necessary for children who are older than 6 months of age at the time of diagnosis or initiation of therapy

Children who have been treated for DDH should be monitored with regular hip radiographs until they are skeletally mature to evaluate hip development and complications or

sequelaeSlide18

In toeingSlide19

In toeing

The most common causes of in – toeing in children are metatarsus

adductus

, internal

tibial

torsion, and increased femoral

anteversion

These rotational variations are related to intrauterine molding and resolve spontaneously through normal growth and development

Slide20

Metatarsus

adductus

Metatarsus

adductus

is medial deviation of the forefoot on the

hindfoot

It is the most common cause of in toeing in infants younger than one year of age

C

haracterized by “kidney bean” or “C” shape foot; normal range of motion of the ankle and

subtalar

joint

It usually resolves spontaneously by 2 years of ageSlide21

Internal

tibial

torsion

Internal

tibial

torsion is internal (medial) rotation of the tibia n relation to the

transcondylar

axis of the femur

It is the most common cause of in toeing in children between one and three to four years of age

C

haracterized by a foot that points inward when the patella faces forward

N

eutral or internal thigh – foot angle

Internal

tibial

torsion usually resolves spontaneously by 5 years of ageSlide22

TFASlide23

Increased femoral

anteversion

Increased femoral

anteversion

is an increased angle of rotation of the femoral neck in relation to the

transcondylar

axis of the femur.

It is the most common cause of in toeing in children older than 3 years of age.

C

haracterized by

inward facing feet and patella during walking and standing

“egg – beater” pattern during running

symmetrically increased internal rotation and decreased external rotation of the hips

preference for sitting in the “W” position

Tends to improve spontaneously by 11 years of ageSlide24

“W position” in increased femoral

anteversionSlide25

In toeing

Most children with rotational variations of the lower extremity can be followed in the primary care office

.

Pathologic conditions that must be considered - neuromuscular diseases

eg

cerebral palsy, disorders of the hip

eg

DDH, lower leg deformities

eg

skewfoot

, clubfoot

The most important aspect of management of rotational causes of in toeing is parental reassurance that most “deformities” correct spontaneously and that, even in persistent cases, adverse long term

sequelae

are rareSlide26

In toeing

Non operative interventions

eg

shoe inserts, braces, twister cables, casting are ineffective in the treatment of internal

tibial

torsion and increased femoral

anteversion

.

Indications for referral include

rigid metatarsus

adductus

unilateral or asymmetric in toeing with findings suggestive of cerebral palsy or developmental dysplasia / dislocation of the hip

cosmetically or functionally unacceptable in toeing due to internal

tibial

torsion in a child older than 8 years

cosmetically or functionally unacceptable in toeing due to femoral

anteversion

in a child older than 11 years

in toeing that does not follow the expected clinical courseSlide27

Transient

synovitis

Pain and limitation of motion in the hip without clear precipitant (?post traumatic, allergic, infectious).

Relatively common (Cumulative lifetime risk of 3%)

Typically occurs in children aged 3 to 8 years, with a mean age at presentation of 6 years

Male to female ratio is slightly greater than 2:1

Symptoms affect both hips in as many as 5% of cases

Even in symptomatically unilateral disease, ultrasound can detect bilateral effusions in 25% of childrenSlide28

Transient

synovitis

Most children have had symptoms for less than a week at the time of presentation and are generally well appearing

Fever is typically absent or low grade

Management is conservative and most children recover quickly with just NSAIDs

A small percentage may go on to develop Legg – Calve –

Perthes

disease with avascular necrosis of the

ipsilateral

femoral headSlide29

Slipped capital femoral epiphysis

Displacement of the capital femoral epiphysis from the femoral neck through the

physeal

plate

Mean age of presentation is 12 years in girls and 13.5 years in boys and obesity is a significant risk factor

The classic presentation is that of non radiating, dull, aching pain in the hip, groin, thigh or knee, with no history of preceding trauma

The pain is increased by physical activity and may be chronic or intermittent

There is limited internal rotation of the flexed hip on

physical exam

Diagnosis is usually made on plain radiograph, which reveals posterior displacement of the femoral epiphysis, like ice cream slipping off a coneSlide30

Slipped

capital femoral epiphysis

The earliest plain radiographic changes are widening and irregularity of the

physis

, with thinning of the proximal epiphysisSlide31

Slipped

capital femoral epiphysisSlide32

Slipped

capital femoral epiphysis

If the radiograph is normal but suspicion for early SCFE is high, MRI may demonstrate widening of the

physis

with surrounding edema

All cases of SCFE should be referred for surgical evaluation (avoid weight bearing until surgery)

Approximately 30 to 60% of patients with unilateral SCFE at presentation eventually have SCFE in the contralateral hip

To prevent delay in diagnosis of the second slip, all patients with unilateral involvement should be followed closely by an orthopedic surgeon until after the child has finished growing

The complications of SCFE include osteonecrosis of the femoral head,

femoro-acetabular

impingement, and

chondrolysisSlide33

Legg – Calve –

Perthes

Disease

Syndrome of idiopathic osteonecrosis (avascular necrosis) of the hip

Typically presents as hip pain and / or limp of acute or insidious onset in children between the ages of 3 and 12 years, with peak incidence at 5 to 7 years of age

LCP is bilateral in 10 to 20% of patients; M:F of 4:1 or greater, and African Americans are rarely affected

May occur in association with underlying condition

eg

renal failure, glucocorticoid use, SLE, HIV,

Gaucher’s

diseaseSlide34

Legg – Calve –

Perthes

Disease

The etiology of LCP remains undefined –

approx

10% are familial and patients often lag behind their peers in bone age and height

There is insidious onset hip pain, with limping and activity related pain

Diagnosis of LCP demands a high index of suspicion and initial radiographs are often normal

Early in the course, bone scan shows decreased perfusion to the femoral head, and MRI reveals marrow changes highly suggestive of the diagnosis

Later in the course, radiographs show fragmentation and then healing of the femoral head, often with residual deformitySlide35

Legg

– Calve –

Perthes

DiseaseSlide36

Legg

– Calve –

Perthes

DiseaseSlide37

Legg

– Calve –

Perthes

Disease

Children diagnosed with LCP should be made non weight bearing and referred to an experienced pediatric orthopedist for management

Treatment focuses on containing the femoral head within the acetabulum through the use of splints or occasionally surgery

Almost all children do well in the short term; however long term outcome depends on age of onset and degree of involvement of the femoral head

Children who are younger than 6 to 8 years years have a better prognosis, perhaps because more time is permitted for femoral remodeling and because before 8 years of age the acetabulum is plastic and can mold to the deformed femoral head, maintaining congruitySlide38

Osteochondritis

dessicans

of the knee

Defined as osteonecrosis of

subchondral

bone

S

pecifically, a localized lesion in which a segment of

subchondral

bone and articular cartilage separates from the underlying bone, leaving either a stable or unstable fragment

Classified as juvenile (open

physis

) / adult (skeletally mature)

The need for specialty referral primarily depends upon the likelihood that the OCD lesion will not heal with

nonoperative

therapySlide39

Osteochondritis

dessicans

of the knee

M > F, average age is 10-20 years, bilateral in 30-40%

85% in medial epicondyle & 70% at

posterolateral

aspect (LAME)

Radiographs as initial

test; MRI

can demonstrate degree of involvement

Girls <

11 y

& boys <

13 y

usually do well without surgery if fragment intactSlide40

Osteochondritis

dessicans

of the kneeSlide41

Kohler’s

osteochondrosis

Ages 2–8

years

Boys

are 5x more commonly affected than girls

Presents

with limp and

midfoot

pain ± dorsal foot swelling

Tender

over the

navicular

, ± swelling/warmth

Treat

in a short leg cast for 8 weeksSlide42

Kohler’s

osteochondrosisSlide43

Freiberg’s

osteochondrosis

Disordered ossification of the 2nd MT head

Most

common in adolescent girls in dance or ballet

Causes

: repetitive stress, trauma, disruption of blood

supply

Bilateral

in < 10% of cases

Pain,

dorsal swelling; tenderness over the metatarsal head

Treat

with activity modification, analgesics, ice, metatarsal pads, well-padded shoesSlide44

Freiberg’s

osteochondrosisSlide45

Freiberg’s

osteochondrosisSlide46

Idiopathic scoliosis

Females more commonly affected

•Prevalence of 0.5-3%

•

Infantile idiopathic scoliosis

is most likely to spontaneously resolve

•

Juvenile idiopathic scoliosis

may be considered the most malignant form of scoliosis due to high rates of progression

•

Adolescent idiopathic scoliosis

is most commonSlide47

Cobb

angle measurementSlide48

Cobb angle measurementSlide49

Adolescent idiopathic scoliosis

The goal of the treatment is a curve with a Cobb angle of 40° or less at skeletal maturity

Options for treatment include observation, bracing and surgery

Indications for referral to orthopedic surgeon may include

angle of trunk rotation ≥ 7°

inability to obtain a Cobb angle

Cobb angle between 20 and 29° in

premenarcheal

girls or boys aged 12 to 14 years

Cobb angle > 30° in any patient

progression of Cobb angle ≥ 5° in any patientSlide50

Adolescent

idiopathic scoliosis

Surgery for patients with Cobb angle ≥ 50° at the time of presentation or later, regardless of the degree of skeletal maturity

Indications for bracing:

Cobb angle 20 – 29° with substantial growth remaining and the Cobb angle increases by ≥ 5% over a 3 to 6 month period

Cobb angle 30 to 40° with substantial growth remaining

If decision is taken for just

observation (Cobb angle less

thsn

20°),

get radiographs every 6 to 9 months (only necessary if patient is skeletally immature).Slide51

Traction

apophysitis

Insidious onset that results from injury or overuse of the tendon and surrounding ossification centers

Boys are more commonly affected and symptoms generally appear between 10 to 14 years of age

Often occurs at or after growth spurt

Physical activity required

Principles of rehab include ice, stretching, and modification to activity (relative rest).Slide52

Little league elbowSlide53

Little league elbow

Descriptive term for a group of elbow problems related to the stress of throwing in young athletes

Throwing can cause medial symptoms as well as lateral and posterior symptoms

The medial symptoms are related to the repetitive valgus distraction forces on the medial elbow

Microtrauma

from overuse or improper throwing mechanics (opening up too soon so the throwing arm trails behind the trunk rotation) can cause injury

Clinical features: Progressive medial elbow pain, diminished throwing effectiveness

and decreased throwing distance

Rx: Refrain from throwing for 3 to 6 weeks until pain free and non tender then progressive return to throwing programSlide54

Ddx

of heel pain in children

Osgood –

Schlatter

disease

Sever’s

calcaneal

apophysitis

Plantar fasciitis

Painful heel pad syndrome

Calcaneal

apophyseal

fracture or calcaneal stress fracture

Calcaneal osteomyelitis

Bone tumors

Unicameral (simple) bone cyst

Spondyloarthropathy

Tarsal tunnel syndrome (specifically medial calcaneal branch)Slide55

Osgood –

Schlatter’s

disease

An overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center of the

tibial

tubercle

Occurs most frequently in participants of sports that involve running and jumping and who have recently undergone a rapid growth spurt

The most common presenting complaint is anterior knee pain that increases gradually over time

The pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by restSlide56

Osgood

–

Schlatter’s

disease

Diagnosis is clinical – tenderness and soft tissue or bony prominence of the

tibial

tubercle in a patient with an otherwise normal examination (including ROM of the hip)

Imaging is not necessary to confirm the diagnosis but may be necessary to exclude other conditions in patients with atypical complaints, such as

pain at night

rest – related pain

acute onset of pain (especially after trauma)

associated systemic complaints

pain that is not directly over the

tibial

tubercle

Usually a benign and self limited condition; symptoms resolve once growth plate ossifiesSlide57

Osgood –

Schlatter

diseaseSlide58

Osgood

–

Schlatter’s

disease

Therapy is conservative – ice, NSAIDs, activity continuation, physical therapy

Patients with persistent pain that alters their ability to participate in sports for more than 3 months may benefit from injection of hyperosmolar dextrose by a sports med specialist or orthopedic surgeon

Patients who have pain that persists after closure of the proximal

tibial

growth plate and is related to bony or cartilaginous

ossicles

may benefit from surgical excision

Complications and

sequelae

of Osgood –

Schlatter

dz

include

persistent prominence of the

tibial

tubercle

persistent pain (usually secondary to residual

ossicle

)

genu

recurvatumSlide59

Sever’s

calcaneal

apophysitis

Common cause of heel pain in young athletes, particularly those who play soccer and basketball or participate in gymnastics or track / running.

The mean age of presentation is 8 to 12 years; boys are affected more often than are girls; bilateral in 40 to 61% of cases

Inflammation of the calcaneal

apophysis

(growth plate at the insertion of the Achilles tendon)

The characteristic history is one of chronic heel pain related to activity and insidious in onset

Physical exam – decreased gastrocnemius – soleus flexibility; approximately 25% of patients have a flat foot or rigid foot alignmentSlide60

Sever’s

calcaneal

apophysitis

Heel pain may be reproduced by direct digital palpation over the

apophysis

or the calcaneal compression test (hold affected heel in palm with the fingers enveloping the upper portion of the heel and then squeeze to compress the heel in the transverse plane)

Radiographs are not required to make the diagnosis but should be obtained to exclude other disorders if the presentation is atypical

Plain radiographs

are usually normal early and may only show

sclerosis and widening of the growth

plate; late findings – calcaneal fragmentation

MRI is more sensitive to identify stress related changes in the calcaneal metaphysis

and is only indicated in severe / chronic cases or

those that do not respond to routine managementSlide61

Normal calcaneal radiograph in symptomaticSlide62

Fragmentation demonstrated late in symptomatic childSlide63

Sever’s

disease: Treatment

Decrease stress on the

apophysis

; daily icing for 20 minutes even after symptoms have began to improve

Stretch gastrocnemius – soleus complex

Use of heel cup or one fourth inch heel lift, and use of proper foot wear

NSAIDs may be helpful for pain control during early management but should not be used before exercise or to increase the amount of activity the athlete can tolerate

For the compliant patient whose symptoms fail to improve within 4 to 8 weeks, short term (3 to 4 weeks) short leg casting may help to resolve painful symptoms related to stress associated bone changes

Physical therapy and slow progressive return to activity are important to recoverySlide64

Iselin’s disease

P

ainful

inflammatory condition of the

apophysis

(growth plate) of the 5th

metatarsal

S

een

in physically active boys and girls between the ages of 8 and 13 years of

age

M

ost

common in those that participate in soccer, basketball gymnastics and

dance

A

n

overuse injury caused by repetitive pressure and/or tension on the growth center at the base of the fifth

metatarsalSlide65

Iselin’s diseaseSlide66

Iselin’s disease

Pain

is most commonly found along the outer edge of the foot and is worsened with activity and improved with

rest

A

limp on the affected side may be

present

The

child may walk on the inside of the affected

foot

The

skin overlying the growth center may be swollen, red, and/or painful to

touch

Diagnosis is primarily clinical

Radiographs

are usually not needed to diagnose the disease, but they may prove useful in assessing for displacement of the growth center and excluding other causes of foot painSlide67

Iselin’s disease

A short period of rest from

aggravating activities

to reduce inflammation and allow release of pressure on the growth center is

recommended

NSAIDs / Applying

ice for 10 to 15 minutes every 2 to 3 hours is helpful to reduce pain and

swelling

Tension on the growth plate can be relieved by

gentle stretching of the

calf

muscles

Proper fitting

shoes

and/or arch support inserts

are helpful

in decreasing

pain

If the individual fails a trial of stretching, rest, ice, and pain medications, the affected limb may be immobilized with a walking cast or

boot

Healing typically takes anywhere between 4-12 weeksSlide68

Benign nocturnal limb pain of childhood (Growing pains)

Bilateral lower extremity pain awakening a child at night (or from naps) who is otherwise without any manifestation of musculoskeletal problems

Etiology

is unknown; occurs in 15% of children;

Affects 35% of kids 4 to 6 years of age (may present up to age 19 years

)

Workup only indicated if child appears ill, complains of pain during the day or with activity, or if pain worsens or persists

Treatment is symptomatic and must include education and reassurance;

W

arm baths, heat, massage, mild exercise / analgesics prior to bed have been shown to be helpfulSlide69

Fracture patterns in children

Buckle (torus) fractures

Plastic deformation

Greenstick fracture

Physeal

(growth plate) fracture

Apophyseal

avulsionSlide70

Buckle (Torus) FractureSlide71

Plastic deformationSlide72

Greenstick fractureSlide73

Physeal

fractures – Salter Harris classificationSlide74

Board Review 1/7

A 4-year-old male is brought to your office by his parents who are concerned that he

is increasingly

“knock-kneed.” His uncle required leg braces as a child, and the parents

are worried

about long-term gait abnormalities. On examination, the patient’s knees touch when

he stands

and there is a 15° valgus angle at the knee. He walks with a stable

gait. Which

one of the following should you do now

?

A) Refer to orthopedics for therapeutic osteotomy

B) Refer to physical therapy for customized bracing

C) Prescribe quadriceps-strengthening exercises

D) Provide reassurance to the patient and his familySlide75

ANSWER:

D

This case is consistent with physiologic genu valgus, and the parents should be reassured. Toddlers

under 2

years of age typically have a

varus

angle at the knee (bowlegs). This transitions to physiologic

genu valgus

, which gradually normalizes by around 6 years of age. As this condition is physiologic,

therapies such

as surgical intervention, special bracing, and exercise programs are not indicated.Slide76

Board review 2/7

A 2-week-old female is brought to the office for a well child visit. The physical examination

is completely

normal except for a clunking sensation and feeling of movement when adducting

the hip

and applying posterior

pressure. Which

one of the following would be the most appropriate next step

?

A) Referral for orthopedic consultation

B) Reassurance only, and follow-up in 2 weeks

C) Triple diapering and follow-up in 2 weeks

D) A radiograph of the pelvisSlide77

ANSWER:

A

Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip,

as well

as anatomic abnormalities. It is more common in firstborns, females, breech presentations

,

oligohydramnios

, and patients with a family history of developmental

dysplasia. Experts

are divided as to whether hip subluxation can be merely observed during the newborn period,

but if

there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to

refer to

a specialist for further testing and treatment. Studies show that these problems disappear by 1 week

of age

in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used

because it

puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be

helpful after

4–6 months of age, but prior to that time the ossification centers are too immature to be

seen. Because

the condition can be difficult to diagnose, and can result in significant problems, the

current recommendation

is to treat all children with developmental dysplasia of the hip. Closed reduction

and immobilization

in a

Pavlik

harness, with ultrasonography of the hip to ensure proper positioning, is

the treatment

of choice until 6 months of age. The American Academy of Pediatrics recommends

ultrasound screening

at 6 weeks for breech females, breech males (optional), and females with a positive

family history

of developmental dysplasia of the hip. Other countries have recommended universal screening,

but a

review of the literature has not shown that the benefits of early diagnosis through universal

screening outweigh

the risks and potential problems of

overtreating

.Slide78

Board review 3/7

A 7-year-old male is brought to your office after hurting his hand when he fell on a wet

kitchen floor

. He is unable to describe the mechanism of injury. On examination the maximal point

of tenderness

is at the third

metacarpophalangeal

joint, which also has some generalized

swelling but

no ecchymosis. Range of motion is limited in this joint due to pain. A radiograph of the

hand is

shown

below:Slide79

Which one of the following is the most likely diagnosis

?

A) Boxer’s fracture

B) Greenstick fracture

C) Salter-Harris type II fracture

D) Spiral fracture

E) No abnormalitySlide80

Board review 4/7

A 7-year-old female is brought to your office with a complaint of right hip pain and a limp

with an

insidious onset. There is no history of injury or repetitive use. Her vital signs are

within normal

limits and she has no history of fever or chills or other systemic symptoms.

On examination

you note that she cannot fully abduct her hip and she winces with pain on

internal rotation

. A FABER test is normal. Her right leg is 2

cm

shorter than the left. Plain

films reveal

flattening and sclerosis of the proximal femur with joint space widening

.

What is the most likely diagnosis in this patient?

A)

Iliopsoas

bursitis

B)

Labral

tear

C) Legg-

Calvé

-

Perthes

disease

D) Septic arthritis

E) Stress fractureSlide81

ANSWER:

C

Legg-

Calvé

-

Perthes

disease results from interruption of the blood supply to the still-growing femoral

head. It

occurs in children 2–12 years of age and presents with hip pain and an

atraumatic

limp.

Common physical

findings include leg-length discrepancies, and limited abduction and internal rotation.

Radiographs reveal

sclerosis of the proximal femur with joint space widening. MRI confirms

osteonecrosis. Septic

arthritis also causes

atraumatic

anterior hip pain but occurs in the acutely ill, febrile patient. A CBC

, erythrocyte

sedimentation rate, C-reactive protein level, and guided hip aspiration are recommended

if septic

arthritis is suspected. A diagnosis of stress fracture should be considered in patients with a

history of

overuse and weight-bearing exercise. These patients have pain that is worse with activity, and pain

on active

leg raising. MRI can detect fractures not seen on plain

films.

Iliopsoas

bursitis presents with snapping or popping of the hip on extension from a flexed position.

Labral

tears

present with sharp anterior hip pain at times, with radiation to the thigh or buttock. Usually

patients will

have mechanical symptoms such as clicking with activity. The FABER (flexion, abduction,

external rotation

) and FADIR (flexion, adduction, internal rotation) impingement tests are sensitive for

labral

tears.Slide82

Board review 5/7

During a

preparticipation

examination of a 5-year-old male for summer soccer camp, his

mother states

that he frequently awakens during the night with complaints of cramping pain in both legs

, and

that he seems to experience this after a day of heavy physical activity. She says that she

has never

noticed a definite limp. A physical examination of the hips, knees, ankles, and

leg musculature

is entirely

normal. Which

one of the following would be the most appropriate next step in the evaluation

and management

of this patient

?

A) Reassurance, with no activity restrictions or treatment

B) Recommending that he not participate in running sports

C) Plain films of both hips and knees

D) Serum electrolyte levels

E) Referral to a pediatric orthopedistSlide83

ANSWER:

A

Benign nocturnal limb pains of childhood (growing pains) occur in as many as one-third of children,

most often

between 4 and 6 years of age. The etiology is unknown, but the course does not parallel

pubescent growth

, as would be expected if bone growth were the source of the pain. Pain often awakens the

child within

hours of falling asleep following an active day. It is generally localized around the knees, most

often in

the shins and calves, but also may affect the thighs and the upper extremities. A characteristic

history coupled

with a normal physical examination will confirm the diagnosis. Reassurance that no additional

tests or

treatments are necessary and that the condition is self-limiting is the most appropriate response.Slide84

Board review 6/7

A 3-year-old male is carried into the office by his mother. Yesterday evening he

began complaining

of pain around his right hip. Today he has a temperature of 37.6°C (99.7°F),

cries when

bearing weight on his right leg, and will not allow the leg to be moved in any

direction. A

radiograph of the hip is

normal. Which

one of the following would be most appropriate at this time

?

A) A CBC and an erythrocyte sedimentation rate

B) A serum antinuclear antibody level

C) Ultrasonography of the hip

D) MRI of the hip

E) In-office aspiration of the hipSlide85

ANSWER:

A

This presentation is typical of either transient

synovitis

or septic arthritis of the hip. Because the

conditions have

very different treatment regimens and outcomes, it is important to differentiate the two. It

is recommended

that after plain films, the first studies to be performed should be a CBC and an

erythrocyte sedimentation

rate (ESR). Studies have shown that septic arthritis should be considered highly likely in

a child

who has a fever >38.7°C (101.7°F), refuses to bear weight on the affected leg, has a WBC

count >

12,000 cells/mm3, and has an ESR >40 mm/hr. If several or all of these conditions exist,

aspiration of

the hip guided by ultrasonography or fluoroscopy should be performed by an experienced

practitioner. MRI

may be helpful when the diagnosis is unclear based on the initial evaluation, or if other

etiologies need

to be excluded.Slide86

Board review 7/7

A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There

is no

history of a specific injury, and his past medical history is negative. He has had no fevers

, night

sweats, or weight loss, and the pain does not awaken him at night. He tried out for

his school’s

basketball team but had to quit because of the pain, which was worse when he tried

to run. Which

one of the following physical examination findings would be pathognomonic for

slipped capital

femoral epiphysis

?

A) Excessive forward passive motion of the tibia with the knee flexed

B) Lateral displacement of the patella with active knee flexion

C) Limited internal rotation of the flexed hip

D) Reduced hip abduction with the hip flexed

E) An inability to extend the hip past the neutral positionSlide87

ANSWER:

C

Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the growth spurt

, when

the femoral head is displaced posteriorly through the growth plate. Physical activity, obesity,

and male

sex are predisposing factors for the development of this condition. There is pain with

physical activity

, most commonly in the upper thigh anteriorly, but one-third of patients present with referred

lower thigh

or knee pain, which can make accurate and timely diagnosis more

difficult. The

hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the

even greater

limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has

this physical

finding, which makes the maneuver very useful in children with lower extremity pain.

Orthopedic consultation

is advised if SCFE is

suspected. Hip

extension and abduction are also limited in SCFE, but these findings are nonspecific.

Displacement of

the patella is not associated with SCFE.