Pediatric Orthopedic Diseases

Categories• Congenital

• Developmental

• Neuromuscular

• Metabolic

• Acquired : inflammatory

infection

trauma

tumor

Mechanisms• Congenital.. Defect in the stage of

embryogenesis.

• Developmental.. Defect in the stage of

fetogenesis.

• Neuromuscular.. Upper or lower motor neuron

disease or different muscular pathologies.

• Metabolic .. Abnormality in different metabolic

lines in our bodies.

• Inflammatory..antigen antibody

reactions

• Infections.. Pyogenic spread

• Trauma.. Mechanical

forces….fractures

• Tumor..benign or malignant

General Problems

• Hip problems

• Angular deformities

• Foot problems

• Infections & Tumors

DDH• Predisposing factors - 5 F’s

• Female

• Family Hx. in 20 % of cases

• Frank breech birth

• First born

• Left side involvement

• Physical Exam

- Limited abduction of flexed hip( < 50-60%)

- Legs unequal in length

- Asymmetric fat folds in thigh

- Limp in the walking age child

- Trendelenburg sign: lurching toward affected

side

Clinical The artful approach is the secret of the exam

Ortolani test Limited Abduction

Abductor lurch or trendelenburg gait

• Diagnostic tests

• U/S in first few months to view

cartilage

• X-ray after 3 months

Treatment

• 0-6 months - Pavlik harness to maintain

abdution and flexion

• 6-18 months- reduction under GA, hip spica

cast for 2-3 months

• > 18 months- Open surgical reduction:

pelvic and/or femoral osteotomy

LEGG-CALVE-PERTHES DISEASE• AVN of proximal femoral epiphysis -

self limiting disease• Leads to abnormal growth of physis

followed by eventual remodeling of new bone

• Etiology unknown• More common in males 4:1 ratio

• History/Physical Exam

• Child 4-10 years

• Limping

• tenderness over anterior thigh

• Flexion contracture with decreased internal

rotation/abduction

Diagnostic tests

Diagnostic tests

• Treatment : Aim CONTAINMENT

• Physiotherapy

• Brace in flexion/abduction x 2-3 years

• Femoral or pelvic osteotomy

SLIPPED CAPITAL FEMORAL EPIPHYSIS

• Epidemiology

- Occurs during maximal pubertal growth spurt

- Males: age 13 to 15- Females: age 11 to 13 - Most common adolescent hip disorder - Black race affected more often than white

race - Unilateral involvement in 90% of cases - Child is often overweight

SLIPPED CAPITAL FEMORAL EPIPHYSIS

Symptoms /Signs

-Hip pain or knee pain-Limp, decreased ROM-Hip held in abduction and external rotation - Markedly limited internal rotation

Management -Orthopedic Emergency!

Immediate

hospitalization

and operative

fixation

COMMON ANGULAR AND ROTATIONAL PEDIATRIC PROBLEMS

• Angular deformities of LL:-Bow legs.-Knock knees.

• Rotational deformities of LL:-In-toeing.-Ex-toeing.

Angular DeformitiesNomenclature

Bow Legs

Genu Varus

Knock Knees

Genu Valgus

Angular DeformitiesEvaluation

Should differentiate between

physiologic and pathologicdeformities

Angular Deformities Evaluation

physiologic

• Symmetrical

• Mild – moderate

• Progressive

• Generalized

• Expected for age

pathologic

• Asymmetrical

• Severe

• Progressive

• Localised

• Not expected for age

Symmertrical Deformities

Asymmetrical DeformitiesGenu Varus Radiograph

Angular Deformities CausesPhysiologic

Normal for age

May be

exaggerated ??? :

a.Overwieght

b.Early walking

Pathologic

Rickets

Endocrinopathy

Metabolic diseases

Physeal plate injury :

a.Trauma

b. Infection

c. Tumor

Idiopathic

Evaluation• Investigations / Radiological

X-ray when severe or pathological

• Standing AP film

– long film ( hips to ankles ) with patellae directed

forwards

• Look for diseases :

– Rickets / Tibia vara (Blount’s) / Epiphyseal injury..

– Measure angles.

Angular Deformitieswhen to refer ?!!!!!!

• If Pathological

• Exaggerated physiological

TreatmentOsteotomy &

Fixation

Hemiepiphysiodesis

Rotational Deformities

• INTOEING

Causes

• Metatarsus Adductus

• Tibial Torsion

• High femoral Anteversion

Metatarsus Adductus• A cause of intoeing in

the first year of life

• Rx :

stretching exercises

casting

surgery

Internal Tibial torsion• A cause of intoeing

between 1 – 3 years of

age

• Rx :

• May correct

spontaneously

If severe … surgery

Thigh foot angle (-10 )– (+ 30)

High Femoral Anteversion• After 3 years of age

Rx: spontaneous

improvment till 10

years of age

NO functional

impairment

Surgery not indicated

EXTOEING

• External tibial torsion

Doesnot correct

spontaneously

If severe …surgery

Foot Deformities

Calcaneovalgus

• Common condition

• Packeging disorder

• Benign

• ???LLD in the

future

Donot forget systemic diseases

• Arthrogryposis

with foot deformity

SEPTIC ARTHRITIS

• Bacterial infection within a joint

• Serious medical emergency!

• Spread by direct extention , hematogenous(

most commonly), inoculation

• Organisms:- 0-6 months- S.aureus, E.Coli

- 6-36 months- S.aureus, H.influenza

- > 36 months- S.aureus, Streptococci

• History/Physical Exam- Severe pain

- Fever, chills

- Dehydration

- Lethargy

- Local redness, swelling, heat, tenderness

- Unable or unwilling to move joint - neonates get

pseudoparalysis

- Joint held in flexion

• Diagnostic tests

- Blood and throat cultures

- Joint aspirate for cultures

- CBC, WBC,

- Bone scan (for hip involvement only, to assess

for vascular compromise to femoral head)

SEPTIC ARTHRITIS

• Admit

• Rest the limb

• IV fluids for dehydration

• Analgesia

• Incision & Drainage

• IV antibiotics