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LOWER EXTREMITY PROBLEMS IN CHILDHOOD

LOWER EXTREMITY PROBLEMS IN CHILDHOOD. TIMOTHY J. FETE MD,MPH University of Missouri School of Medicine Department of Child Health. Developmental Dysplasia of the Hip-associations. First born Torticollis Metatarsus Adductus Internal Tibial Torsion Oligohydramnios Breech

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LOWER EXTREMITY PROBLEMS IN CHILDHOOD

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  1. LOWER EXTREMITY PROBLEMS IN CHILDHOOD TIMOTHY J. FETE MD,MPH University of Missouri School of Medicine Department of Child Health

  2. Developmental Dysplasia of the Hip-associations • First born • Torticollis • Metatarsus Adductus • Internal Tibial Torsion • Oligohydramnios • Breech • + Family History

  3. Developmental Dysplasia of the Hip • Ortolani Maneuver: Reduction • Barlow Maneuver: Dislocation • Increased joint laxity • Limitation of Abduction • Assymetric thigh skin folds • Galeazzi’s Sign • Leg Length Discrepancy

  4. DEVELOPOMENTAL DYSPLASIA OF THE HIP • Positive exams per 1000 newborns • All 11.5 • Boys 4.1 • Girls 19 • + Fam Hx Boys 6.4 • + Fam Hx Girls 32 • Breech Boys 29 • Breech Girls 133

  5. Developmental Dysplasia of the Hip • Plain films not particularly valuable until 4-6 months of age • Ultrasonagraphy most useful beyond four weeks of age (false + before) • US allows static and dynamic study

  6. DDH: Screening • 1. All Newborns to be screened at birth • 2. If + Ortolani or Barlow: refer to ortho, do not order US • 3. If equivocal, recheck at 2 weeks • 4. If equivocal at 2 weeks, refer or order US at 3-4 weeks • 5. Examine hips at all well visits until 18 months (late presentation)

  7. DDH: Screening • Perform US for: *Girls who are breech Consider US for: *Girls with positive family history *Boys who are breech

  8. DDH: Treatment • NOT Triple Diapers! • Pavlik Harness • Progressive Casting • Adductor Tenotomy • Open Reduction • If late, may require acetabular surgery

  9. INTOEING • Metatarsus Adductus • Internal Tibial Torsion • Femoral Anteversion

  10. METATARSUS ADDUCTUS • Heel Bisector *normal: between toes 2 and 3 *mild: 3rd toe *mod: 4th toe *severe: 5th toe • Rigidity *actively correctable: straighten with tickle *passively correctable: straighten with gentle pressure *fixed: unable to straighten

  11. METATARSUS ADDUCTUS: Treatment • Actively Correctable: no Rx • Passively Correctable *exercises *straight or reverse-last shoes • Fixed: serial casting • Look for DDH!

  12. INTERNAL TIBIAL TORSION • Thigh/foot angle • Relative position of medial and lateral malleoli • Most common cause of intoeing under 3 years of age • Universally resolves by 4-6 years • No treatment required

  13. MEDIAL FEMORAL TORSION FEMORAL ANTEVERSION • Most common form of intoeing greater than 3 years of age • Examine prone rotational profile • Most (85%) resolve spontaneously by 8-10 years • Possible athletic advantage • Femoral osteotomies if severe

  14. EXTERNAL TIBIAL TORSION • Normal adults + 10 degrees of external tibial torsion • No treatment necessary

  15. PES PLANUS (FLAT FEET) • Normal through age 7 years • 1/7 never develop arch • Flexible: foot regains arch when stand on toes • Treatment rarely necessary—only if painful (rare) • Rigid: still flat with toe-standing-rare-may be due to tarsal coalition, may require surgery

  16. SHOES • Adequate size • Soft/flexible • Flat/non-skid sole • Soft/porous upper • Inexpensive • Avoid odd shapes (cowboy shoes/high heels)

  17. CLUBFOOT • Metatarsus adductus + Equinus + Hindfoot varus • 1/1,000 live births • 50% bilateral • Male/female = 2.5/1 • Increase if + family history • + association with DDH • Serial casting (25+ % effective) • Surgery

  18. CAVUS FOOT • High arch, usually inherited, no Rx • Red flags: new-onset, unilateral, painful, progressive • Red flags may indicate: Friedrich ataxia, Charcot-Marie-Tooth, tethered spinal cord, intraspinal lesion

  19. BOWLEGS • Physiologic *internal rotation of tibia/retroversion of femur *generally resolved within 6 months of walking • Genu Varum—all children initially bowlegged until 2-3 years, no Rx required if persists: • Blount Disease * “undergrowth” of medial proximal tibia *early walkers, heavyset,girls, AfricanAmericans • Metabolic/Medical: rickets, renal,dwarfism • X-ray if painful, unilateral, greater than 2 years old

  20. KNOCK-KNEES • Genu Valgum • By 7 years most children reach typical adult mild genu valgum • No Rx required, well-tolerated

  21. Legg-Calve’-Perthes Disease • Avascular Necrosis of the Femoral Head • 4-8 years of age • Males/females = 4/1 • Bilateral in 10-18% • Short stature/delayed bone age • Insidious, often painless limp • Thigh/knee pain not uncommon • Decreased hip mobility on exam • Rx: physical therapy, bracing, ultimate surgery

  22. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) • Insidious pain or limp vs acute pain • Pain often thigh/knee • Early adolescence (13-15 males, 11-13 females • Often, not always, obese • African-Americans > Caucasians • 20% bilateral initially, 30% more in < 1 yr • Limp,Lateral rotation of foot,limited internal rotation at hip

  23. OSGOOD-SCHLATTER DISEASE • Painful enlargement of tibial tubercle at insertion of patellar tendon • Repetitive stress from quadriceps pull • X-rays generally not helpful • May have fragmentation of tibial tubercle • Generally resolves within 6-18 months • Rx: rest, hamstring and quad stretching prior to participation, ice afterward, NSAIDS only for acute pain (not to participate!) • Resolved permanently with skeletal maturity

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