Selina Silva, MDUNM Carrie Tingley Hospital
Intoeing/ OutoeingBowlegged/ knock-kneedFlexible FlatfeetGrowing PainsSeptic JointsLegg-Calve-PerthesDDHSCFEScoliosisBack Pain
3 sources of intoeingFemoral
anteversionInternal
tibial torsionMetatarsus
adductus
Femoral AnteversionNormal is for children to be born with
30 degrees and with growth this normalizes to 10 degrees as an adult.
Women have more femoral anteversion than men
Often familialMeasure the amount of IR and ER of
the hipGreater than 70 degrees IR is
considered severe
Internal Tibial TorsionCommon for one leg to have
more than the otherAlso externally rotates with
growth to about 15 degrees as an adult
Measure the thigh-foot angle5 degrees IR to 15 degrees
ER is normal
Metatarsus AdductusMost common congenital foot deformityForefoot metatarsals are medially rotated on
cuneiformsHindfoot is normalFlexible and resolves on its own 85% of the
time
Deformity in femur or tibia
Usually does not improve with growth or worsens
Less tolerated and so treated surgically more often
If asymmetric, need to rule out other problemsSCFE
Toeing out usually corrected around the age of 7-10 if symptomatic
Toeing in often resolves near normalTherefore give more time prior to offering
surgical correctionCorrect severe cases, greater than 70 degreesCorrected in early teen years if symptomatic
Forefoot adduction corrects 85% of the time on its ownStart with passive stretching by parentsCan do casting if not correctingIf rigid and not correcting, osteotomies can be
done around 5 yo
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Physiologic between 1-3External rotation hip contracturesInternal tibial torsion
Blounts:Disturbance of proximal tibial physisOften unilateralOverweight child, early walker vs. obese adolescent
FamilialRadiographic
changes not limited to medial tibial physis
Notice bowing of femurs
Physiologic between ages 3-6
Worry if unilateralAnkles rolling in
correct when the knees correct
Early teens may consider hemiepiphysiodesis
Indications:
Mechanical axis off and knee pain or patellar subluxation
20% of the population, variant of normal
When stand on toes there is an arch
No treatment unless feet hurt
Orthotics for symptomsSurgery for correction
Usually bilateral lower extremitiesAt night or first thing in the morningGoes away with massage/attentionTreatment: Vitamin D3 and give 3-4 months
of supplementation to really see resultsFLAGS:
Always same jointWakes them up in the middle of the nightStop playing or doing sports because of pain
Painful, swollen jointRed and pain with axial loadAspirate joint and send for gram stain, cell count,
and culture prior to antibioticsIf septic, emergent incision and drainage is requiredSometimes difficult to differentiate from cellulitis
Risk Factors:First born, female,
breech, family historyPhysical Exam:
Check Ortolani and Barlow
Asymetric Skin CreasesCheck GaleazziCheck for asymetric
hip abduction
No Swaddling the legs, can still swaddle arms and get same effect
Ultrasound helpful after 1 mo of age
AP Pelvis at >4 months old
Can present at limb length discrepancy in walking child
AVN of femoral headAges 4-8, usually boysPain and limp, no fevers, worse with more activityAP/Frog Pelvis xray for diagnosis and send to Ortho
Patient profileObese preteenOften c/o knee painAffected leg may
rotate outwardsAlso seen with kids
that have thyroid problems
REAL danger is bone death of femoral head
ALWAYS think of hips, when c/o knee pain
Order AP Pelvis and Frog view Pelvis xrays
If positive, put on crutches, TDWB and send to Peds Ortho/ER immediately
Hight risk of AVN, which occurred in this patient
SCFE is always a surgical problem
Forward bend testImbalance of shoulders or pelvisGreater than 10 degree curve on
Xray is scoliosis
Sometimes presents as limb length inequality
Most accurate is standing posterior view: PSIS “dimples”
Get an MRI if thoracic curve is going to the left or neurologic findings
Any patient with scoliosis we need to see and follow until they are 18 years of age
We follow about every 6 months with Xrays
Brace at about 25 degreesSurgery if rapidly
progressing or greater than 50 degrees
Scoliosis does not cause back pain
Kids with or without scoliosis and that have back pain are initially treated with home exercise programWe have handout for this
If fail home exercise/stretching program will send to formal physical therapy1x per week, for 12 weeksCore strengthening, truncal stability and
hamstring stretchesIf fail therapy, then get MRI or Bone ScanIf any neurologic findings get MRI