Common Pediatric Orthopedic Clinical Problems

1. Common Pediatric Orthopedic Clinical Problems Saunders Jones Jr. MD Georgiaorthopedic@msn.com sjones12@kennesaw.edu

3. Radiological �hole in the bone� Fibrous cortical defect Aneurysmal Bone cyst �bone island� Giant cell tumor Infection Ewing�s Sarcoma Enchondroma

4. Fibrous cortical defect (Fibroxanthoma)

5. Unicameral bone cyst Next to growth plate Active vs Inactive Falling leaf sign

6. ABC Aneurysmal bone cysts may occur in patients aged 10-30 years, with a peak incidence in those aged 16 years. About 75% of patients are younger than 20 years. Four phases of pathogenesis are recognized, as follows: Osteolytic initial phase Active growth phase, which is characterized by rapid destruction of bone and a subperiosteal blow-out pattern Mature stage, also known as stage of stabilization, which is manifested by formation of a distinct peripheral bony shell and internal bony septae and trabeculae that produce the classic soap-bubble appearance. Healing phase with progressive calcification and ossification of the cyst and its eventual transformation into a dense bony mass with an irregular structure.

7. ABC

9. Ewing's Sarcoma

10. Incidence of Ewings

11. Ewings

12. Giant Cell tumor Not ped age group

13. Osteochondromas or Multiple Exostoses Cartilaginous cap covered by a bursa Impinge on local structures CT shows cap < 1cm in thickness Can be excised due to structural problems SMALL incidence (<1% per lesion) of transformation to Chondro sarcoma (or Osteogenic less common)

14. Multiple Exostoses Found in areas around growth plates Can occur in multiple locations or singularly Usually not Neoplastic Bone with cartilaginous cap Grows normally with growth of the rest of the skeleton

15. Osteochondromas B9 Cartilaginous cap Impinges on local structures

16. Osteochondromas Another view

17. Osteochondroma

18. Osteochondroma

19. Osteochondroma microscopic

20. Osteosarcoma

21. Osteosarcoma Some bone elements

22. Enchondroma

23. Non ossifying Fibroma

24. Metabolic Pediatric Category Rickets Osteogenesis Imperfecta

25. Rickets Radiologic changes in the growth plate Vitamin problem

26. Osteogenesis Imperfecta

28. Twisty Bendy Feet Most common is metatarsus adductus FPS fetal packaging syndrome Normal rotation of feet in utero Should respond to gentle massage and SWN Shoes could be worn in reverse (r-l l-r) if there is any �last� in the shoe

29. Metatarsus adductus/clubfoot(tell tale medial crease)

30. Twisty Bendy Feet Clubfeet �talipes equino-varus� Metatarsus adductus, heel equinus and varus and talus adductus Tell tale crease on lat underneath malleolus Thinning and atrophy of lower leg Needs attention based on severity of deformity, START TREATMENT AT BIRTH !!! Refer early

31. Club feet Metatarsal Talus Hindfoot Leg atrophy

32. Endstage Club feet

33. Clubfoot casting In the nursery or soon as possible

34. Club foot Casting Must go above the knee to control rotation Plaster is the best Soak off night before Manipulation and then maintenance of that correction

35. Limited clinic Tenotomy New

36. Twisty Bendy legs

37. Twisty Bendy Legs Internal Tibial Torsion Normal adult rotation is 10-15 degrees external Normal unwinding of child's lower legs Not significantly affected by orthotics or treatment !!! Sight along tibial crest and look at malleoli Reassure (look for other conditions)

38. Twisty Bendy Legs Bendy knees/legs 2-4-6 years Genu varus / genu valgus Normal variants Radiographs for Blount�s Disease Vitamins Orthotics (?)

39. Blount�s vs. Normal

40. Twisty Bendy Legs Femoral anteversion Femur is turned in at the hip causing �pigeon towed gait� Sit on their feet SWN Education Twister cables!!?!?!?!?

41. Femoral anteversion

43. Pes Planus �flat feet� Common in infants and up to about 8 years of age Painful flat feet is different�tarsal coalition or other condition Some pes planus is genetic or racial Look at mom�s feet!!!

44. Heel Pain in Adolescent Sever�s Disease Calcaneal apophysitis X rays show �fractionation� Symptomatic tx with NSAIDs Stretching Limitation of activity ?

45. Sever�s Disease

46. Xray of the Calcaneal Apophysis

47. Stretch for Sever�s Disease

48. Knee Pain in Adolescent Anterior tibial tubercle pain Osgood-Schlatter�s disease Tibial apophysitis Rest stretching Ice Nsaids Prominent tubercle Hereditary tendencies HIP PAIN MASQUERADES AS KNEE PAIN !!!!! Always xray same side hip!!!

49. Anterior Knee pain Adolescent Female Increased valgus with tracking problems Squatting and Indian style sitting Quad sets and Nsaids VMO? Usually self limited Make sure nothing else going on�..

50. OSDx and Ant knee pain

51. Osgood Schlatter's

52. Osgood Schlatter�s Disease

53. Hip Pain SCFE Transient synovitis Hip pyarthrosis LCP

54. Slipped Capital Femoral Epiphysis SCFE Endomorphic Androgenital Onset anterior thigh pain Externally Rotated Gait Can be bilat Rx pin in situ

55. SCFE

56. SCFE

57. SCFE

58. LCP Perthe�s Disease Avascular necrosis of the proximal femoral growth plate Collapse Maintain concentricity and �containment� Multiple bouts of Transient synovitis

59. LCP initial and resorptive phases

60. LCP resorptive and remodeling

61. Congenital Dislocated Hip Barlow's Ortilani Duration and treatment Age of child at discovery Pavlick harness Closed reduction and casting Open Reduction Subtrochanteric osteotomy Acetabular osteotomy

62. Congenital Dislocation

63. Congenital Hip Dislocation

64. Causes of Hip Pain in Children

65. Idiopathic Adolescent Scoliosis Not a painful condition If there is pain�look for another cause! OBJECTIVE OF TREATMENT: To prevent deformity as adult Skeletal maturity Onset of menses, Risser sign Criteria for referral relates to progression Braces?Surgery runs the gamut

67. Risser sign

68. Risser Sign

69. Nursemaids Elbow

70. Nursemaids Elbow

71. Falls from a Height common in Children

73. Epiphyseal Injuries: only in kids!!! Salter classification Joint involvement Growth disturbance Thick periosteum

74. Salter One

76. Salter 2

77. Salter 3

78. Salter 4

79. Salter 5

82. Supracondylar elbow fractures Compartment syndrome because of vascular compromise Characteristic fx due to the shape of the supracondlyar region of the humerus �balancing two canoes�

87. Lines around the elbow

89. Supracondylar fx minimal displacement

90. Displaced Supracondylar fx

91. Medial Epicondyle fx

93. Lateral condyle Salter #?

94. Supracondylar fx

95. Radial Head fxs

96. Displaced Lateral condyle Salter #?

97. Radial Head Fx displaced epiphyseal�.Salter# ?

98. Late Sequelae Cubitus varus

99. Fracture Tx in Kids Alignment has different criteria Overgrowth Maintenance of overall alignment most important Rotation, etc

100. Fracture Tx in Younger Kids (growth potential)

101. Overall Alignment and Residual Growth

102. Fracture Tx in Older Kids

103. Fracture Tx in Even Older Kids

104. Neuromuscular Category Cerebral Palsy Spastic or Flaccid Birth injury Perinatal cerebral anoxia Hyperactive stretch receptors Contractures Releases, Transfers, Braces etc.

105. Infections Joints Pyarthrosis Infants and young children Endemic Otitis Media No good lab test X-rays normal Patho-anatomy growth plate vasculature Drain and decompress because of potential damage to cartilage May lead to Osteomyelitis

106. ANY QUESTIONS??? Comments Discussion

107. Thank you