LOWER EXTREMITY PROBLEMS IN CHILDHOOD

TIMOTHY J. FETE MD,MPHUniversity of Missouri School of

MedicineDepartment of Child Health

Developmental Dysplasia of the Hip-associations First born Torticollis Metatarsus

Adductus Internal Tibial

Torsion Oligohydramnios Breech + Family History

Developmental Dysplasia of the Hip

Ortolani Maneuver: Reduction Barlow Maneuver: Dislocation Increased joint laxity Limitation of Abduction Assymetric thigh skin folds Galeazzi’s Sign Leg Length Discrepancy

DEVELOPOMENTAL DYSPLASIA OF THE HIP Positive exams per 1000 newborns All 11.5 Boys 4.1 Girls 19 + Fam Hx Boys6.4 + Fam Hx Girls 32 Breech Boys 29 Breech Girls 133

Developmental Dysplasia of the Hip

Plain films not particularly valuable until 4-6 months of age

Ultrasonagraphy most useful beyond four weeks of age (false + before)

US allows static and dynamic study

DDH: Screening 1. All Newborns to be screened at

birth 2. If + Ortolani or Barlow: refer to

ortho, do not order US 3. If equivocal, recheck at 2 weeks 4. If equivocal at 2 weeks, refer or

order US at 3-4 weeks 5. Examine hips at all well visits until

18 months (late presentation)

DDH: Screening

Perform US for: *Girls who are breech Consider US for: *Girls with positive family history *Boys who are breech

DDH: Treatment

NOT Triple Diapers! Pavlik Harness Progressive Casting Adductor Tenotomy Open Reduction If late, may require acetabular

surgery

INTOEING

Metatarsus Adductus Internal Tibial Torsion Femoral Anteversion

METATARSUS ADDUCTUS Heel Bisector *normal: between toes 2 and 3 *mild: 3rd toe *mod: 4th toe *severe: 5th toe Rigidity *actively correctable: straighten with tickle *passively correctable: straighten with gentle

pressure *fixed: unable to straighten

METATARSUS ADDUCTUS: Treatment Actively

Correctable: no Rx Passively

Correctable *exercises *straight or

reverse-last shoes Fixed: serial casting Look for DDH!

INTERNAL TIBIAL TORSION

Thigh/foot angle Relative position of medial and

lateral malleoli Most common cause of intoeing

under 3 years of age Universally resolves by 4-6 years No treatment required

MEDIAL FEMORAL TORSION FEMORAL ANTEVERSION

Most common form of intoeing greater than 3 years of age

Examine prone rotational profile Most (85%) resolve spontaneously

by 8-10 years Possible athletic advantage Femoral osteotomies if severe

EXTERNAL TIBIAL TORSION

Normal adults + 10 degrees of external tibial torsion

No treatment necessary

PES PLANUS (FLAT FEET) Normal through age 7 years 1/7 never develop arch Flexible: foot regains arch when stand

on toes Treatment rarely necessary—only if

painful (rare) Rigid: still flat with toe-standing-rare-

may be due to tarsal coalition, may require surgery

SHOES

Adequate size Soft/flexible Flat/non-skid sole Soft/porous upper Inexpensive Avoid odd shapes (cowboy

shoes/high heels)

CLUBFOOT Metatarsus adductus + Equinus +

Hindfoot varus 1/1,000 live births 50% bilateral Male/female = 2.5/1 Increase if + family history + association with DDH Serial casting (25+ % effective) Surgery

CAVUS FOOT

High arch, usually inherited, no Rx Red flags: new-onset, unilateral,

painful, progressive Red flags may indicate: Friedrich

ataxia, Charcot-Marie-Tooth, tethered spinal cord, intraspinal lesion

BOWLEGS Physiologic *internal rotation of tibia/retroversion of femur *generally resolved within 6 months of walking Genu Varum—all children initially bowlegged

until 2-3 years, no Rx required if persists: Blount Disease * “undergrowth” of medial proximal tibia *early walkers, heavyset,girls, AfricanAmericans Metabolic/Medical: rickets, renal,dwarfism X-ray if painful, unilateral, greater than 2 years

old

KNOCK-KNEES

Genu Valgum By 7 years most children reach

typical adult mild genu valgum No Rx required, well-tolerated

Legg-Calve’-Perthes Disease Avascular Necrosis of the Femoral Head 4-8 years of age Males/females = 4/1 Bilateral in 10-18% Short stature/delayed bone age Insidious, often painless limp Thigh/knee pain not uncommon Decreased hip mobility on exam Rx: physical therapy, bracing, ultimate surgery

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Insidious pain or limp vs acute pain Pain often thigh/knee Early adolescence (13-15 males, 11-13

females Often, not always, obese African-Americans > Caucasians 20% bilateral initially, 30% more in < 1 yr Limp,Lateral rotation of foot,limited

internal rotation at hip

OSGOOD-SCHLATTER DISEASE

Painful enlargement of tibial tubercle at insertion of patellar tendon

Repetitive stress from quadriceps pull X-rays generally not helpful May have fragmentation of tibial tubercle Generally resolves within 6-18 months Rx: rest, hamstring and quad stretching

prior to participation, ice afterward, NSAIDS only for acute pain (not to participate!)

Resolved permanently with skeletal maturity