Common ped problem_2014

Common Pediatric
Disorders of the Lower Extremity
Dr.Bahaa Ali Kornah
Prof. Of Orthopedic
Al-Azhar University
Cairo -EgyptBahaa Ali Kornah. Cairo -Egypt

Common Pediatric
Bahaa Ali Kornah. Cairo -Egypt
• Common and often benign
• In-toeing
• Out-toeing
• Bowed legs
• Knock-knees
• Flat feet

Common Pediatric
• Pathologies
• Cerebral Palsy
• Hip dysplasia = DDH
• Legg-Calve-Perthes’s disease
• Slipped Capital Femoral Epiphysis
• Clubfoot

Systematic approach -
Where’s the source?
• Hip joint
• Thigh (femur)
• Knee joint
• Leg (tibia)
• Ankle joint
• Foot (tarsals and metatarsals)
X
X

Group pathologies by age
• Newborns and infants (< 1 yr)
• Toddlers (1-3 yr)
• Older children (4-10 yr)
• Pre-teens and teens (> 10 yrs)

Common Pediatric
• HIP DYSPLASIA
• DDH

Theories
• Mechanical (Breech)
• Maternal hormone induced
• Primary dysplasia
• Genetic -Ortolani- 70%

Common Pediatric

DDH detection
• Newborn nursery exam
– Galiazzi test
– Ortolani test
– Barlow test
– Good up to 2-3 mos of age
• Loss of abduction, pistoning

Clinical screening
Look for thigh
asymmetry
(Buttock crease)

Developmental
Dysplasia of the Hip
Leg length
inequality Galeazzi Sign

Diagnosis: Walking age
• Waddling gait
• Wide perineum
• Short lower extremity
• Hyperlordosis

DDH detection
• Ultrasound (dedicated center)
–Better at > 2 wks of age
–Dynamic exam
• Radiography
–Gold standard
–Best after 6-8 weeks of age

Developmental Dysplasia
of the Hip
Pavlik harness for
instability or dislocated
hip

Developmental Dysplasia of
the Hip

R hip after OR, fem short, pelvic osteotomy

Common Pediatric
• Rotational LL Deformities
•In-toeing
•Out-toeing

Rotational LL Deformities
• Frequently seen.
• Concerns parents.
• Frequently prompts varieties of
treatment.
( often un-necessary / incorrect )

Common Pediatric
• Systematic approach –
• Where’s the source?
• Level of affection :
Femur
Tibia
Foot

Rotational Deformities
Femur
Ante-version = more medial rotation
Retro-version = more lateral rotation

Normal Development
• Femur : Ante-version :
– 30 degrees at birth.
– 10 degrees at maturity.
• Tibia : Lateral rotation :
– 5 degrees at birth.
– 15 degrees at maturity.

Clinical Examination
Rotational Profile
• At which level is the rotational deformity?
• How severe is the rotational deformity?
• Four components:
1- Foot propagation angle.
2- Assess femoral rotational arc.
3- Assess tibial rotational arc.
4- Foot assessment.

Common Presentation
•Stands with knees medially rotated (kissing patellae).
•Sits in W position.
•Runs awkwardly (egg-beater).
Family History
Medial Femoral Torsion (Ante-version)

Femoral antetorsion
•Usually 3-5 yo girls
•Sits in the “W”
•“Kissing patellae”
•“Egg-beater” run
•Severe if > 90°
•Resolves with growth -
no association with osteoarthritis

Management
• Challenge : dealing effectively with family
• In-toeing : spontaneously corrects in vast
majority of children as LL externally rotates
with growth - Best Wait !

Management
Convince family that only observation is
appropriate
• < 1 % of femoral & tibial torsional deformities
fail to resolve and may require surgery in late
childhood.

Management
• Attempts to control child’s walking, sitting and
sleeping positions is impossible and ineffective cause
frustration and conflicts.
• Shoe wedges and inserts : ineffective.
• Bracing with twisters :ineffective - and limits activity.
• Night splints : better tolerated - ? Benefit.

When To Refer ?
• Severe & persistent deformity.
• Age > 8-10y.
• Causing a functional disability.
• Progressive.

Management
When Is Surgery Indicated ?
•In older child ( < 8 – 10 years ).
•Significant functional disability.

Out-toeing (Less commonly seen)
Causes:
• External rotation contracture at the hip?
• Lateral tibial torsion?
• Flatfoot?
• Little hope of improvement over time, unless
it’s a result of flatfoot

Perthes Disease
• Peak age of onset 3-8yr
• Spontaneous osteonecrosis of the femoral head
• Follow with serial radiographs
• Prognosis depends on age of onset / severity
– > 6 yrs at onset, less than whole-head involvement do
better
• Rx- decrease synovitis and weight bearing

Perthes Disease

Slipped capital femoral
epiphysis

Slipped capital femoral
epiphysis
• Peak incidence in pre-teens, 50% obese (50% not!)
• Anterior thigh or knee pain
• Bilateral in cases of endocrinopathy or renal ds
• Dx - AP and frog pelvis * radiograph
• If present, immediate wheel chair and referral

SCFE

Slipped capital femoral epiphysis

Postoperative radiographs

Common Pediatric
•Knee

Knee angular deformities
• Genu varum - bowing
• Genu valgum - knock-knees
What’s normal?

•Maximum varus at birth
•Maximum valgus > 10°, ages 3 - 4 yrs
•At maturity, mean is ~ 6° anatomic valgus
Physiologic Genu valgum

Bowing or Genu varum
• Physiologic bowing
• Pathologic bowing
– Rickets
– Tibia vara
– Skeletal dysplasia

Vit-D deficient/resistant rickets

Bowing of tibia vara

Common Pediatric
• Management
• Brace
• Follow up
• Surgical

Knock- knees or Genu valgum
• Physiologic
• Pathologic

Physiologic valgus

Knock- knees
• Pathologic Genu valgum
– Rickets - later onset such as with renal
osteodystrophy, because the disease is active when
knock knees are the norm
– Skeletal dysplasia's
• Diastrophic dysplasia
• Morquio’s syndrome
• Ellis-van Creveld or chondroectodermal
dysplasia
• Spondyloepiphyseal and multiple epiphyseal
dysplasia's Bahaa Ali Kornah. Cairo -Egypt

Pathologies to consider - leg
•Angulation or bowing of the tibia
–Very unusual!
•Antero-lateral
?neurofibromatosis?
•Postero-medial ?leg length
difference?
•Antero-medial ?fibular deficiency?

Common Pediatric
• Bilateral Leg Windswept Deformity

Common Pediatric
•Foot

Clubfoot
• Incidence 1:1000
• Talipes equinovarus
• True congenital vs. positional
• Cavus, adductus, varus, equinus
• If present, examine hips carefully!

Clubfoot treatment
• Serial manipulations and casting
• Begin first week of life, if possible
• Perform weekly
• 90% of routine clubfoot respond

Calcaneovalgus foot
• Most common foot
deformity at birth
• Forefoot abducted,
ankle dorsiflexed - foot
lies on anterior leg
• Resolves spontaneously
• Associated with hip
dysplasia

Pes Cavus Cavovarus foot
• High arch = Cavus
• Heel in varus
• Often rigid
• Look to spinal cord or peripheral
nervous system

Etiology of Pes Cavus
• Neurological
• Congenital
• Iatrogenic
• Infection
• Idiopathic

Common Pediatric
• Flat foot
• is normal and common in infants,
partly due to "baby fat" which
masks the developing arch and
partly because the arch has not
yet fully developed.

Pathologies to consider: foot
Flatfoot
• All infants have it
• Most children have it
• More than 15% of adults have it

Flexible flatfoot
• Often resolves with growth
• Not affected by specific shoes, heel cups, or
UCBL inserts
• Not correlated with disability in military
populations
• May be protective against stress fractures

More foot pathologies to
consider
• Stiff or rigid metatarsus adductus
• Calcaneovalgus
• Cavovarus foot
• Spasmodic valgus foot

Summary:
Normal Development
• Femoral ante version: 30° at birth, only 10° at
maturity (= lateral rotation)
– Femoral antetorsion improves over time
• Tibial version: 0° at birth, 15° externally rotated at
maturity (= laterally rotation)
– Medial tibial torsion improves over time
• Growth: lateral rotation of both femur and tibia
– In-toeing decreases with growth

Summary
• Most toe-ing and bow-ing deformities are
benign >>>Resolution may take many years
• Use history and exam to rule-out the
pathologic causes
• Reassure for what appear to be non-
pathologic but extreme cases
– Check back for re-exam, 6-12 months
• Beware unilateral deformities and those
associated with pain
– Radiographs indicated

Who needs a referral for
toeing and bowing?
• Over three years of age with documented
progression of deformity
• Stiff metatarsus adductus
• Bowing
– below the 5th percentile for height
– marked asymmetry or lateral thrust with
ambulation
• Marked knock-knees or in-toeing in patients
over 8 years of age

Thank you for
your attention
bkornah@gmail.com
‫د‬/‫قرنة‬ ‫بهاء‬

Common ped problem_2014

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