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Knock knees

Knock knees. Inter- malleolar distance Mechanical axis Measure both with tape measure Consider rickets Indications ? Mechanical axis lateral to tibia Anatomic axis > 15 degrees. Knock knees. Knock knees: management. Guided growth V expensive plate Cheaper screws. Vitamin D.

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Knock knees

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  1. Knock knees • Inter-malleolar distance • Mechanical axis • Measure both with tape measure • Consider rickets • Indications ? • Mechanical axis lateral to tibia • Anatomic axis > 15 degrees

  2. Knock knees

  3. Knock knees: management • Guided growth • V expensive plate • Cheaper screws

  4. Vitamin D Measure Vitamin D level in children with aches and pains before referral Low Vitamin D is a potent cause of musculo-skeletal pain 40% of attendees at paedorthop clinic either deficient or insufficient Normal > 50 nmol/L Insufficient < 50 nmol/L Deficient < 25 nmol/L

  5. Infection

  6. Septic arthritis v irritable hip • Decision trees common • History of fever > 38o • Non weight bearing • WCC > 12,000 • ESR > 40 Kocher et al. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.

  7. Decision analysis • One predictor 0.2% • Two predictors 40% • Three predictors 93% • Four predictors 99%

  8. Outcome Resolution

  9. Outcome Tom Smith Arthritis Life long disability

  10. DDH: Clinical detection

  11. What tests; Neonates • Ortolani reduction clunk (1936) • “segno del scotto” • Barlow test (1966) • Le Damany (1912) • “signe de ressaut”

  12. Ortolani

  13. Barlow

  14. Barlow: Examine each hip separately

  15. What you’re feeling

  16. When ? Old Guidelines • At birth (but many lax) • In first 2/52 • At 6 – 8 weeks (last chance for O/B+) • At 3 months ? • At 6 – 9 months (required by guidelines but ? useful) • 15 - 21 months

  17. Current UK Screening PolicyNIPE 2008

  18. Treatment requirement

  19. Examination at 3 months • Instability unlikely • Limited abduction important • Asymmetric skin creases caused by Nestle • LLD difficult to judge • If in doubt USS at hip instability

  20. Limited abduction

  21. Clubfoot

  22. Ponseti’s method

  23. Ponseti’s method

  24. Ponseti’s method

  25. Ponseti’s method : Splintage • Boots on bar External rotation splintage • 70 degrees ER • Full time 2 - 4 months • Night 2 - 4 years

  26. Ponseti’s method : Splintage

  27. Leg Length Inequality • Use Galleazzi sign for measurement in infants • No need to refer small children unless gross discrepancy or concern about hips

  28. Femoral deficiencies • Spectrum • Congenital short femur • PFFD • 1 in 50-200,000

  29. Examine the hips in children with knee pain

  30. What we’re doing • Central referral place “dummy clinic” • Website for advice and simple treatment • Leaflets • Videos • More advice and guidance • Send back referrals for normal variants

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