Common Orthopedic Problems

1. Common Orthopedic Problems Carolyn M. O’Donnell, MD, PGY-3

2. Developmental Dysplasia of the HIp • Abnormal development of the hip with 1.) Instability (joint dislocatability) and 2.) Dysplasia or abnormal shape of the acetabulum • Most hip instability resolves shortly after birth • Unresolved instability is often painless and not obvious since a dislocated hip may function well for many years • Unresolved, it can lead to pain (often knee pain), abnormal gait, functional disability and degenerative hip disease • These problems are preventable if it is caught and treated early

3. DDH • Hip laxity and immature acetabula are common in the first few weeks of life • Approximately 90% of these infants will have stabilized by 2 months of age after time for further growth • After school age, the likelihood of spontaneous resolution is very low

4. Hip Joint

5. Clinical Features • The earlier DDH is detected, the easier and more successful the treatment • Presentations vary based on age • Newborn: hip instability • Infant: reduced abduction • Toddler: asymmetric gait • Adolescent: activity related pain • Adult: osteoarthritis

6. Risk factors • Breech presentation • Female gender • Family history • Factors related to tight positioning in utero (can see associated torticollis and metatarsus adductus

7. Risk factors • Girls with a breech presentation — 12 percent • Girls with a positive family history — 4.4 percent • Boys with a breech presentation — 2.6 percent • Girls — 1.9 percent • Boys with a positive family history — 0.9 percent

8. In utero

9. Torticollis

10. Physical Exam • Hips should be checked at every visit until the child is walking normally • Exam technique uses adduction and posterior pressure to feel for dislocation and abduction and elevation to feel for reduction • Hip Instability: The sensation of dislocation or reduction is best described as a clunk or a jerk • Clicks and pops not associated with a palpable clunk are very common and not worrisome

11. Exam • Examine each hip individually while the child is calm and not crying • Examine on a stable surface with the child supine and with hips flexed 90 degrees in neutral rotation

12. Exam

13. Galeazzi Test

14. Exam • Galeazzi test: dislocated hip may be displaced posteriorly so the knee appears lower/shorter • Look for asymmetry in skin folds • Gait asymmetry • Bilateral DDH can be a challenge- look for widening of the perineum, symmetric limited abduction, and short thigh segments relative to the child's size. Once the child begins to walk, hyperlordosis and a waddling Trendelenburg gait can be seen

15. Exam • Bilateral DDH: • widening of the perineum • symmetric limited abduction • short thigh segments relative to the child's size. • Once walking, hyperlordosis and a waddling Trendelenburg gait • By 3 months: hip often stabilizes and tests for instability are no longer very helpful

16. Imaging • Ultrasound • Plain radiographs- limited value early on due to femoral heads cartilaginous and not ossified • Radiographs should be with hips flexed 20 to 30 degrees, or neutral if the child is older

17. Radiograph

18. Management • If abnormal exam: • Referral to orthopedic surgeon • Imaging: • Ultrasound if less than 5 months • Radiograph if >4 months • Breech females: screening is recommended- ultrasound at 6 weeks or radiograph at 4 months. This is optional for lower risk groups.

19. Treatment • Based on age • Abduction splints in younger kids (usually <6 months) • Closed reduction- goal is to reduce the hip, then keep it stabilized in spica cast • Open reduction If closed reduction is unsuccessful Often needed in kids >18 months • Risks vs benefits • Follow up is important; complications, failure

20. Pavlik Harness

21. Septic Joint • Infection and inflammation of usually sterile joint space • Typically affects large joints and joints of the lower extremity- knee, ankle and hip (approximately 80%) • Up to 10% in more than 1 joint • Predominant age: 2-6 years; adolescent • Males>Females

22. Pathophysiology • Bacterial entry: • Hematogenous spread • Direct inoculation • Extension from adjacent infection (bone) • Influx of inflammatory Cells • Rapid destruction of cartilaginous structures by bacterial enzymes; may -> necrosis

23. Etiologies • Viral- parvovirus, EBV, herpes, CMV, varicella, Hep B or C, mumps, rubella • Fungal- Candida albicans • Spirochete- Lyme (B. burgdorferi) • Tuberculosis • Bacterial • <5 years: S. aureus, Group B strep, HIB, gram negative bacteria • >5 years: S. aureus, Group A strep, N. gonorrhoeae

24. Etiologies • Also Kingella kingae, salmonella, N. meningitidis • S. aureus most common outside of neonatal period • Sickle cell associated with salmonella • Immunocompromised: Mycoplasma, ureoplasma, or Aspergillus

25. Neonates and Infants • Can be subtle • >1 joint • Microbiology: GBS, Gram negative bacilli such as E. Coli, S. aureus • Often presents with septicemia or fever without source • Subtle features: positional preference, decreased use, pain with handling, extremity swelling • Hip arthritis

26. Children • Fever and constitutional symptoms • Pain with active and passive movement • Limp/refusal to bear weight • Joint related findings can be subtle: swelling, warmth • Hip/shoulder: often no external signs • Hip involvement may be referred (knee) • Sacroiliac may present similarly to appendicitis, neoplasm or UTI

27. Symptoms • Do not wax and wane • Can wake up at night with pain • Worsens with time • Specific joint symptoms: • Pain- often exquisite tenderness through any range of motion • Warmth, erythema, swelling

28. Evaluation • Should be PROMPT • NO DELAYS • History and Physical • Labs and imaging • Joint aspiration/joint fluid analysis ASAP • Risks vs. benefits- diagnosis vs seeding the joint if overlying cellulitis

29. Evaluation • History: • ?direct inoculation • ?rash- can implicate type of infection • ?skin/soft tissue infections- source for bacteremia • ?Recent antibiotic use- may attenuate symptoms • ?recent illnesses/URIs- consider post-infectious synovitis • ?LMP- disseminated gonococcal in 1st 7d of menses • ?Exposures • ?Immunization Status

30. Exam • Observation (use parents if young child) • Soft tissue/skin exam • Joint exam: swelling, redness, erythema, pain • Active and passive range of motion • Exam: eyes, skin, heart, lungs, abdomen, etc

31. Labs • CBC/WBC- elevated but not sensitive or specific • ESR- elevated in 95% of cases • CRP- increased • Blood cultures- positive in 30-40% of cases

32. Synovial Fluid Analysis

33. Imaging • Radiography- may (or may not) show widening of the joint space +/- displacement of the normal fat pads • Ultrasound- can identify fluid in the joint space • CT scan • MRI • Bone scan

34. Algorithm • Look for 4 or more of the following: • ESR > 20 mm/h • CRP > 1 mg/dL • WBC > 11,000 cells/mL • Joint space fluid apparent on radiograph

35. Differential Diagnosis • Osteomyelitits • Deep cellulitits • Abscess • Septic bursitis • Bacterial endocarditis • Inflammatory/autoimmune arthritis • Transient synovitis • Acute rheumatic fever • Trauma • Legge-Calves-Perthes • SCFE • Tumor/Malignancy

36. Treatment • IV antibiotics • 1st line: Anti-staph PCN, 1st generation cephalosporin • If MRSA in community, consider vanco or clinda • Sickle cell pts: add ceftriaxone • Duration of therapy depends on bacteria • Supportive care (sepsis, etc) • Drainage of infection- ASAP • Open surgical drainage/irrigation for hip and usually shoulder, inability to aspirate

37. Complications • Septic shock • Death • Joint destruction • Limited range of motion which may be permanent • Growth disturbance if the epiphysis is involved.