Post on 26-Mar-2015
Common Pediatric Common Pediatric Orthopedic Clinical Orthopedic Clinical
ProblemsProblems
Saunders Jones Jr. MDSaunders Jones Jr. MDGeorgiaorthopedic@msn.com
sjones12@kennesaw.edu
Common Pediatric Orthopedic Common Pediatric Orthopedic ProblemsProblems
Metabolic Metabolic Developmental Developmental CongenitalCongenital TraumaticTraumatic InfectiousInfectious NeoplasticNeoplastic Neuromuscular Neuromuscular
Radiological “hole in the Radiological “hole in the bone”bone”
Fibrous cortical defectFibrous cortical defect Aneurysmal Bone cystAneurysmal Bone cyst ““bone island”bone island” Giant cell tumorGiant cell tumor Infection Infection Ewing’s SarcomaEwing’s Sarcoma EnchondromaEnchondroma
Fibrous cortical defect Fibrous cortical defect (Fibroxanthoma)(Fibroxanthoma)
Unicameral bone cystUnicameral bone cyst
Next to growth Next to growth plateplate
Active vs InactiveActive vs Inactive Falling leaf signFalling leaf sign
ABCABC Aneurysmal bone cysts Aneurysmal bone cysts
may occur in patients aged may occur in patients aged 10-30 years, with a peak 10-30 years, with a peak incidence in those aged 16 incidence in those aged 16 years.years.
About 75% of patients are About 75% of patients are younger than 20 years.younger than 20 years.
Four phases of pathogenesis are recognized, Four phases of pathogenesis are recognized, as follows:as follows:
Osteolytic initial phase Osteolytic initial phase Active growth phase, which is characterized Active growth phase, which is characterized
by rapid destruction of bone and a by rapid destruction of bone and a subperiosteal blow-out pattern subperiosteal blow-out pattern
Mature stage, also known as stage of Mature stage, also known as stage of stabilization, which is manifested by stabilization, which is manifested by formation of a distinct peripheral bony shell formation of a distinct peripheral bony shell and internal bony septae and trabeculae and internal bony septae and trabeculae that produce the classic soap-bubble that produce the classic soap-bubble appearance. appearance.
Healing phase with progressive calcification Healing phase with progressive calcification and ossification of the cyst and its eventual and ossification of the cyst and its eventual transformation into a dense bony mass with transformation into a dense bony mass with
an irregular structurean irregular structure..
ABCABC
Copyright © 2007 by the American Roentgen Ray Society
--6-year-old girl withEwing's sarcoma
Ewing's SarcomaEwing's Sarcoma
Incidence of EwingsIncidence of Ewings
EwingsEwings
Giant Cell tumorGiant Cell tumor
Not ped age groupNot ped age group
Osteochondromas or Multiple Osteochondromas or Multiple ExostosesExostoses
Cartilaginous cap covered by a bursaCartilaginous cap covered by a bursa Impinge on local structuresImpinge on local structures CT shows cap < 1cm in thicknessCT shows cap < 1cm in thickness Can be excised due to structural Can be excised due to structural
problemsproblems SMALL incidence (<1% per lesion) of SMALL incidence (<1% per lesion) of
transformation to Chondro sarcoma transformation to Chondro sarcoma (or Osteogenic less common)(or Osteogenic less common)
Multiple ExostosesMultiple Exostoses
Found in areas around growth plates Found in areas around growth plates Can occur in multiple locations or Can occur in multiple locations or
singularlysingularly Usually not NeoplasticUsually not Neoplastic Bone with cartilaginous cap Bone with cartilaginous cap Grows normally with growth of the Grows normally with growth of the
rest of the skeletonrest of the skeleton
OsteochondromasOsteochondromas
B9 B9 Cartilaginous capCartilaginous cap Impinges on local Impinges on local
structuresstructures
OsteochondromasOsteochondromas
Another viewAnother view
OsteochondromaOsteochondroma
OsteochondromaOsteochondroma
Osteochondroma Osteochondroma microscopicmicroscopic
OsteosarcomaOsteosarcoma
OsteosarcomaOsteosarcoma
Some bone Some bone
elementselements
EnchondromaEnchondroma
Non ossifying FibromaNon ossifying Fibroma
Metabolic Pediatric Metabolic Pediatric Category Category
RicketsRickets Osteogenesis ImperfectaOsteogenesis Imperfecta
RicketsRickets
Radiologic changes Radiologic changes in the growth platein the growth plate
Vitamin problemVitamin problem
Osteogenesis ImperfectaOsteogenesis Imperfecta
Twisty Bendy FeetTwisty Bendy Feet
Most common is metatarsus Most common is metatarsus adductusadductus
FPS fetal packaging syndromeFPS fetal packaging syndrome Normal rotation of feet in uteroNormal rotation of feet in utero Should respond to gentle massage Should respond to gentle massage
and SWNand SWN Shoes could be worn in reverse (r-l l-Shoes could be worn in reverse (r-l l-
r) if there is any “last” in the shoer) if there is any “last” in the shoe
Metatarsus adductus/clubfootMetatarsus adductus/clubfoot(tell tale medial crease)(tell tale medial crease)
Twisty Bendy FeetTwisty Bendy Feet
Clubfeet “talipes equino-varus”Clubfeet “talipes equino-varus” Metatarsus adductus, heel equinus and Metatarsus adductus, heel equinus and
varus and talus adductusvarus and talus adductus Tell tale crease on lat underneath Tell tale crease on lat underneath
malleolus malleolus Thinning and atrophy of lower leg Thinning and atrophy of lower leg Needs attention based on severity of Needs attention based on severity of
deformity, START TREATMENT AT BIRTH deformity, START TREATMENT AT BIRTH !!! Refer early!!! Refer early
Club feetClub feet
MetatarsalMetatarsal TalusTalus HindfootHindfoot Leg atrophyLeg atrophy
Endstage Club feetEndstage Club feet
Clubfoot castingClubfoot casting
In the nursery or In the nursery or soon as possiblesoon as possible
Club foot CastingClub foot Casting
Must go above the Must go above the knee to control knee to control rotationrotation
Plaster is the best Plaster is the best Soak off night Soak off night
beforebefore Manipulation and Manipulation and
then maintenance then maintenance of that correctionof that correction
Limited clinic TenotomyLimited clinic Tenotomy
NewNew
Twisty Bendy legs Twisty Bendy legs
Twisty Bendy LegsTwisty Bendy Legs
Internal Tibial TorsionInternal Tibial Torsion Normal adult rotation is 10-15 degrees Normal adult rotation is 10-15 degrees
externalexternal Normal unwinding of child's lower legsNormal unwinding of child's lower legs Not significantly affected by orthotics or Not significantly affected by orthotics or
treatment !!!treatment !!! Sight along tibial crest and look at Sight along tibial crest and look at
malleolimalleoli Reassure (look for other conditions)Reassure (look for other conditions)
Twisty Bendy LegsTwisty Bendy Legs
Bendy knees/legsBendy knees/legs 2-4-6 years2-4-6 years Genu varus / genu valgusGenu varus / genu valgus Normal variantsNormal variants Radiographs for Blount’s DiseaseRadiographs for Blount’s Disease VitaminsVitamins Orthotics (?)Orthotics (?)
Blount’s vs. NormalBlount’s vs. Normal
Twisty Bendy LegsTwisty Bendy Legs
Femoral anteversionFemoral anteversion Femur is turned in at the hip causing Femur is turned in at the hip causing
“pigeon towed gait”“pigeon towed gait” Sit on their feetSit on their feet SWNSWN EducationEducation Twister cables!!?!?!?!?Twister cables!!?!?!?!?
Femoral anteversionFemoral anteversion
Pes Planus “flat feet”Pes Planus “flat feet”
Common in infants and up to about 8 Common in infants and up to about 8 years of ageyears of age
Painful flat feet is different…tarsal Painful flat feet is different…tarsal coalition or other conditioncoalition or other condition
Some pes planus is genetic or racialSome pes planus is genetic or racial Look at mom’s feet!!!Look at mom’s feet!!!
Heel Pain in AdolescentHeel Pain in Adolescent
Sever’s DiseaseSever’s Disease Calcaneal apophysitisCalcaneal apophysitis X rays show “fractionation”X rays show “fractionation” Symptomatic tx with NSAIDsSymptomatic tx with NSAIDs Stretching Stretching Limitation of activity ?Limitation of activity ?
Sever’s DiseaseSever’s Disease
Xray of the Calcaneal Xray of the Calcaneal ApophysisApophysis
Stretch for Sever’s DiseaseStretch for Sever’s Disease
Knee Pain in AdolescentKnee Pain in Adolescent
Anterior tibial tubercle painAnterior tibial tubercle pain Osgood-Schlatter’s diseaseOsgood-Schlatter’s disease Tibial apophysitis Tibial apophysitis Rest stretching Ice NsaidsRest stretching Ice Nsaids Prominent tubercleProminent tubercle Hereditary tendenciesHereditary tendencies HIP PAIN MASQUERADES AS KNEE HIP PAIN MASQUERADES AS KNEE
PAIN !!!!! Always xray same side PAIN !!!!! Always xray same side hip!!!hip!!!
Anterior Knee painAnterior Knee pain
Adolescent FemaleAdolescent Female Increased valgus with tracking Increased valgus with tracking
problems problems Squatting and Indian style sittingSquatting and Indian style sitting Quad sets and NsaidsQuad sets and Nsaids VMO?VMO? Usually self limited Usually self limited Make sure nothing else going on…..Make sure nothing else going on…..
OSDx and Ant knee painOSDx and Ant knee pain
Osgood Schlatter'sOsgood Schlatter's
Osgood Schlatter’s DiseaseOsgood Schlatter’s Disease
Hip PainHip Pain
SCFE SCFE Transient synovitisTransient synovitis Hip pyarthrosisHip pyarthrosis LCPLCP
Slipped Capital Femoral Slipped Capital Femoral EpiphysisEpiphysis
SCFESCFE EndomorphicEndomorphic Androgenital Androgenital Onset anterior thigh painOnset anterior thigh pain Externally Rotated GaitExternally Rotated Gait Can be bilat Can be bilat Rx pin in situRx pin in situ
SCFESCFE
SCFESCFE
SCFESCFE
LCP Perthe’s DiseaseLCP Perthe’s Disease
Avascular necrosis of the proximal Avascular necrosis of the proximal femoral growth platefemoral growth plate
Collapse Collapse Maintain concentricity and Maintain concentricity and
“containment”“containment” Multiple bouts of Transient synovitisMultiple bouts of Transient synovitis
LCP initial and resorptive LCP initial and resorptive phasesphases
LCP resorptive and LCP resorptive and remodelingremodeling
Congenital Dislocated HipCongenital Dislocated Hip
Barlow'sBarlow's OrtilaniOrtilani Duration and Duration and
treatmenttreatment Age of child at Age of child at
discoverydiscovery Pavlick harnessPavlick harness Closed reduction Closed reduction
and castingand casting
Open ReductionOpen Reduction Subtrochanteric Subtrochanteric
osteotomyosteotomy Acetabular Acetabular
osteotomy osteotomy
Congenital DislocationCongenital Dislocation
Congenital Hip DislocationCongenital Hip Dislocation
Causes of Hip Pain in Causes of Hip Pain in ChildrenChildren
CDHCDH 0-2 years0-2 years 1:4 m:f1:4 m:f 20%bilat20%bilat
LCPLCP 4-8 years4-8 years 5:1 m:f5:1 m:f 10% bilat10% bilat
SCFESCFE 10-15 10-15 yearsyears
1.5:1 m:f1.5:1 m:f 25-25-40%bilat40%bilat
Idiopathic Adolescent Idiopathic Adolescent ScoliosisScoliosis
Not a painful conditionNot a painful condition If there is pain…look for another cause!If there is pain…look for another cause! OBJECTIVE OF TREATMENT:OBJECTIVE OF TREATMENT: To prevent deformity as adult To prevent deformity as adult Skeletal maturity Skeletal maturity Onset of menses, Risser signOnset of menses, Risser sign Criteria for referral relates to Criteria for referral relates to
progressionprogression BracesBracesSurgery runs the gamutSurgery runs the gamut
Risser signRisser sign
Risser SignRisser Sign
Nursemaids ElbowNursemaids Elbow
Nursemaids ElbowNursemaids Elbow
Falls from a Height common in Falls from a Height common in ChildrenChildren
Epiphyseal Injuries: only in Epiphyseal Injuries: only in kids!!!kids!!!
Salter classificationSalter classification Joint involvementJoint involvement Growth disturbanceGrowth disturbance Thick periosteumThick periosteum
Salter OneSalter One
Salter 2Salter 2
Salter 3Salter 3
Salter 4Salter 4
Salter 5Salter 5
Supracondylar elbow Supracondylar elbow fracturesfractures
Compartment syndrome because of Compartment syndrome because of vascular compromisevascular compromise
Characteristic fx due to the shape of Characteristic fx due to the shape of the supracondlyar region of the the supracondlyar region of the humerushumerus
““balancing two canoes”balancing two canoes”
Lines around the elbowLines around the elbow
Supracondylar fx minimal Supracondylar fx minimal displacementdisplacement
Displaced Supracondylar fxDisplaced Supracondylar fx
Medial Epicondyle fxMedial Epicondyle fx
Lateral condyle Salter #?Lateral condyle Salter #?
Supracondylar fxSupracondylar fx
Radial Head fxsRadial Head fxs
Displaced Lateral condyle Displaced Lateral condyle Salter #?Salter #?
Radial Head Fx displaced Radial Head Fx displaced epiphyseal….Salter# ?epiphyseal….Salter# ?
Late Sequelae Cubitus varusLate Sequelae Cubitus varus
Fracture Tx in KidsFracture Tx in Kids
Alignment has Alignment has different criteriadifferent criteria
OvergrowthOvergrowth Maintenance of Maintenance of
overall alignment overall alignment most important most important Rotation, etcRotation, etc
Fracture Tx in Younger Kids Fracture Tx in Younger Kids (growth potential)(growth potential)
Overall Alignment and Residual Overall Alignment and Residual GrowthGrowth
Fracture Tx in Older KidsFracture Tx in Older Kids
Fracture Tx in Even Older Fracture Tx in Even Older Kids Kids
Neuromuscular CategoryNeuromuscular Category
Cerebral PalsyCerebral Palsy Spastic or FlaccidSpastic or Flaccid Birth injuryBirth injury Perinatal cerebral anoxiaPerinatal cerebral anoxia Hyperactive stretch receptorsHyperactive stretch receptors Contractures Contractures Releases, Transfers, Braces etc.Releases, Transfers, Braces etc.
InfectionsInfections
Joints PyarthrosisJoints Pyarthrosis Infants and young children Infants and young children Endemic Otitis MediaEndemic Otitis Media No good lab test No good lab test X-rays normalX-rays normal Patho-anatomy growth plate vasculaturePatho-anatomy growth plate vasculature Drain and decompress because of Drain and decompress because of
potential damage to cartilagepotential damage to cartilage May lead to OsteomyelitisMay lead to Osteomyelitis
ANY QUESTIONS???ANY QUESTIONS???
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