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Common Pediatric Orthopedic Clinical Problems

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Cartilaginous cap covered by a bursa. Impinge on local structures ... Tell tale crease on lat underneath malleolus. Thinning and atrophy of lower leg ... – PowerPoint PPT presentation

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Title: Common Pediatric Orthopedic Clinical Problems


1
Common Pediatric Orthopedic Clinical Problems
  • Saunders Jones Jr. MD
  • Georgiaorthopedic_at_msn.com
  • sjones12_at_kennesaw.edu

2
Common Pediatric Orthopedic Problems
  • Metabolic
  • Developmental
  • Congenital
  • Traumatic
  • Infectious
  • Neoplastic
  • Neuromuscular

3
Radiological hole in the bone
  • Fibrous cortical defect
  • Aneurysmal Bone cyst
  • bone island
  • Giant cell tumor
  • Infection
  • Ewings Sarcoma
  • Enchondroma

4
Unicameral bone cyst
  • Next to growth plate
  • Active vs Inactive
  • Falling leaf sign

5
Fibrous cortical defect (Fibroxanthoma)
6
Ewing's Sarcoma
7
Incidence of Ewings
8
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)

9
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

10
Osteochondromas
  • B9
  • Cartilaginous cap
  • Impinges on local structures

11
Osteochondromas
  • Another view

12
Osteochondroma microscopic
13
Osteosarcoma
  • Some bone
  • elements

14
Rickets
  • Radiologic changes in the growth plate
  • Vitamin problem

15
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

16
Metatarsus adductus/clubfoot(tell tale medial
crease)
17
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

18
Club feet
  • Metatarsal
  • Talus
  • Hindfoot
  • Leg atrophy

19
Endstage Club feet
20
Clubfoot casting
  • In the nursery or soon as possible

21
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

22
Limited clinic Tenotomy
  • New

23
Twisty Bendy legs
24
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)

25
Twisty Bendy Legs
  • Bendy knees/legs
  • 2-4-6 years
  • Genu varus / genu valgus
  • Normal variants
  • Radiographs for Blounts Disease
  • Vitamins
  • Orthotics (?)

26
Blounts vs. Normal
27
Twisty Bendy Legs
  • Femoral anteversion
  • Femur is turned in at the hip causing pigeon
    towed gait
  • Sit on their feet
  • SWN
  • Education
  • Twister cables!!?!?!?!?

28
Femoral anteversion
29
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30
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!!!

31
Heel Pain in Adolescent
  • Severs Disease
  • Calcaneal apophysitis
  • X rays show fractionation
  • Symptomatic tx with NSAIDs
  • Stretching
  • Limitation of activity ?

32
Severs Disease
33
Xray of the Calcaneal Apophysis
34
Stretch for Severs Disease
35
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!!!

36
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..

37
OSDx and Ant knee pain
38
Osgood Schlatter's
39
Osgood Schlatters Disease
40
Hip Pain
  • SCFE
  • Transient synovitis
  • Hip pyarthrosis
  • LCP

41
Slipped Capital Femoral Epiphysis
  • SCFE
  • Endomorphic
  • Androgenital
  • Onset anterior thigh pain
  • Externally Rotated Gait
  • Can be bilat
  • Rx pin in situ

42
SCFE
43
SCFE
44
SCFE
45
LCP Perthes Disease
  • Avascular necrosis of the proximal femoral growth
    plate
  • Collapse
  • Maintain concentricity and containment
  • Multiple bouts of Transient synovitis

46
LCP initial and resorptive phases
47
LCP resorptive and remodeling
48
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

49
Congenital Dislocation
50
Congenital Hip Dislocation
51
Causes of Hip Pain in Children
52
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

53
Nursemaids Elbow
54
Falls from a Height common in Children
55
Epiphyseal Injuries only in kids!!!
  • Salter classification
  • Joint involvement
  • Growth disturbance
  • Thick periosteum

56
Salter One
57
Salter 2
58
Salter 3
59
Salter 4
60
Salter 5
61
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62
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

63
Lines around the elbow
64
Supracondlyar fx minimal displacement
65
Displaced Supracondylar fx
66
Medial Epicondyle fx
67
Lateral condyle Salter ?
68
Supracondylar fx
69
Radial Head fxs
70
Displaced Lateral condyle Salter ?
71
Radial Head Fx displaced epiphyseal.Salter ?
72
Late Sequelae Cubitus varus
73
Fracture Tx in Kids
  • Alignment has different criteria
  • Overgrowth
  • Maintenance of overall alignment most important
    Rotation, etc

74
Fracture Tx in Younger Kids (growth potential)
75
Overall Alignment and Residual Growth
76
Fracture Tx in Older Kids
77
Fracture Tx in Even Older Kids
78
Neuromuscular Category
  • Cerebral Palsy
  • Spastic or Flaccid
  • Birth injury
  • Perinatal cerebral anoxia
  • Hyperactive stretch receptors
  • Contractures
  • Releases, Transfers, Braces etc.

79
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

80
ANY QUESTIONS???
  • Comments
  • Discussion

81
Thank you
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