LOWER EXTREMITY PROBLEMS IN CHILDHOOD TIMOTHY J. FETE MD,MPH University of Missouri School of...
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Transcript of LOWER EXTREMITY PROBLEMS IN CHILDHOOD TIMOTHY J. FETE MD,MPH University of Missouri School of...
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