doernbecher children’s hospital staying out of trouble in
TRANSCRIPT
Staying out of Trouble in Outpatient Musculoskeletal Problems
PRESENTED BY: Scott Yang MD, Assistant Professor, Pediatric Orthopaedic Surgery Doernbecher Children’s Hospital, OHSU
Doernbecher Children’s HospitalOHSU
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Leg Lengths
• Leg Lengths
– Pelvic height with knees
locked out
– Then check sacro-
iliac dimples
Not scoliosis!
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Leg Lengths
• Femoral length
– Firm, flat surface!
• Tibial Length
Image credit: 1) MSK Key2) Dalton MSK
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Things not to miss on leg lengths
• Causes in infants/toddlers
– Hip dysplasia
– Hemihypertrophy / Vascular malformation
– Hemimelia / Femoral deficiencies
– Tumor Syndromes
Image Credit: Takata et al; J. Orthopaedic Surg
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Rotational Alignment
• Rotational alignment of the legs
• Reassure parents
• Most will resolve with time
• Watch for milestones & spasticity
Internal Rotation External Rotation Thigh Foot AngleOHSU
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Leg Alignment – Bow Legs
• Monitor with time until at minimum age 2
– Worsening past age 2
– Short stature < 10th percentile
– Asymmetry
– Rare DDx: Blount disease, Rickets, Skeletal Dysplasia
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The Hip
– Infant hip
• Barlow/Ortolani may
need multiple checks
• Click does not equal
hip dysplasia. A clunk
is very obvious.
• Stay out of trouble by
REFINING this
examination
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The Hip
• After ~5-6 weeks
– Barlow & Ortolani not reliable
– Gluteal fold differences NOT
very helpful
– Look instead for differences in
hip abduction, Galleazzi signOHSU
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The Hip
• Dislocated hips in older children
– Not painful
– Unilateral – Toe walking, Limited hip abduction
– Bilateral – Lumbar hyperlordosis, Waddling Gait
Image credits: Weinstein S; Lovell and Winters Pediatric Orthopaedics
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The Hip
• The most sensitive tests for hip pathology:
• Flexion & Internal Rotation
• Prone internal rotation
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The Foot
• Flexible flat foot
– Arch returns up on toes
– Not a problem, reassure
• Rigid flat foot
– Arch does not form when
up on toes
– Look for tarsal coalition
• Cavovarus Feet
– Typically problematic
– Look for neurologic
disorder
OHSU
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The Spine
– Shoulder height
asymmetry common in
normal kids
– Look instead of rotational
difference on forward bend
– Pay attention to skin
– Lumbar hairy patch
– Café au lait spots
OHSU
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The Spine
• If no rotational deformity on xray… may be something else
Image credits:
Children’s Hospital Los Angeles
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“My child’s legs hurt”
• Simple tests to rule out growing pains from real pathology
• Tumors hurt. Infection hurts. Stress fractures hurt.
– Look for clear physical findings
– Single leg hop / jump x 5
– Squat jump x 10
– Then go for a walk & jog to look for limpOHSU
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The Newborn – not moving the arm
• Not moving the arm
– Problem can be anywhere from clavicle to
forearm!
• Trauma from birth
• Clavicle fracture
• Humerus shaft fracture
• Distal Humerus Physeal Fracture
• Brachial Plexus palsy
• If not any of above, think about infection!!
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The Newborn – Lower Extremities
• Calcaneovalgus foot
– Improves with time
• Congenital knee dislocation
– Refer very early
– Sometimes associated with syndromes
• Clubfoot
– Refer very early
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Case ExampleHPI:
2 month old F brought in to PCP
for not moving left arm. Mother
unclear on traumatic event.
Conflicting history with Father.
Exam:
Guards left arm
Moves other limbs
spontaneously. No major
swelling or bruising
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Case Imaging & Diagnoses
Skeletal Survey:
1) Multiple healing rib fractures
2) Left acute humerus fracture
3) Left 1st metatarsal fracture
4) Right healing femur fracture
Multiple stages of healing!
Repeated abuse!
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Case Treatment
• Hospitalize, Report to Social Work/DHS ASAP
• Treat injuries as appropriate, remove from current
situation
Learning Point: Very young non mobile children (< 1 year old) cannot easily hurt themselves
If presenting with pain or extremity splinting, they need you to advocate for them to look for injury, for which you may find many.
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Hip Dysplasia
Image: International Hip Dysplasia Institute
Staying out of trouble = not missing the diagnosis
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Hip Dysplasia
• Perform stability examination
early!
• Identify risk factors
– Breech in 3rd trimester; Family
history
• If stable exam, but + history,
obtain ultrasound at 6 weeks
of age
Image: Weinstein et al, JBJS 2003
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• Treatment Principles
– Aggressiveness of treatment generally increases with age
Hip Dysplasia – Why Catch Early?
Image: Murphy & Kim, JAAOS 2016
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Hip Dysplasia – Case Example
• 4 year old autistic male with left sided toe walking and leg
length difference
– PCP attributed toe walking to sensory processing issues
Initial Presentation Surgery 2 years laterOHSU
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Perthes Disease
Legg-Calve-Perthes
disease
● Avascular necrosis
of the hip in
childhood (Age 3-9
typically)
● Unclear etiology
● Treatment is
supportive care,
sometimes surgery
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Perthes Disease – Case ExampleHPI:
5 year old male presents with
intermittent limping, and mild hip pain
for past 6 months. No fevers/malaise.
Able to jog with a limp
-Otherwise plays well, can go to school,
no malaise
PEX:
Well appearing
Slight trendelenburg limp
Difficulty running / jumping
Slightly decreased left hip abduction
range of motion
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Perthes Disease - Case Example
6 months later
Initial Presentation
Perthes is evolving process – one negative xray doesn’t
rule it out!!
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Slipped Capital Femoral Epiphsysis(SCFE)
• Proximal femoral
epiphysis is disrupted
from the metaphysis at
the growth plate
– Leads to 3D deformity of
the hip
– Can occur gradually over
time or associated with a
sudden event
Image: OrthoInfo.aaos.org
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SCFE Epidemiology
• Age 9-13
• 10.8/100,000 children
annually in USA
• Associated with obesity
– >50% of SCFE patients are
>95th percentile for weight
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SCFE Clinical Pearls
• Groin / thigh / knee pain
– 90% - Several weeks-months of
pain, insidious limp
– 10% - Sudden acute severe pain
without prodromal symptoms
• Range of motion
– Loss of hip internal rotation
– Excessive hip external rotation
Image: OrthoInfo.aaos.org
Learning Point: An overweight pre-teen / teen complaining of frequent knee painNeeds a thorough and TIMELY HIP exam
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SCFE Case Example
HPI:
13 year old M with 6 months right knee
pain. No trauma. Severe limp 2 weeks
ago, improved, but persistently painful
PEX:
BMI: 31
Normal right knee exam
Right hip: Limitation of flexion & internal
rotation compared to left side. ++ pain
with hip flexion & internal rotation Image Credit: AAOS
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SCFE Case Example
- Diagnosis: Slipped capital femoral epiphysis
- Resulting deformity = functional loss; early hip arthritis
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Examination of the Pediatric Spine
• Underlying diagnosis?
– Neuromuscular condition
• Look at feet / lower extremities
• Neurologic symptoms
– Congenital conditions
• History of heart / renal problems?
– Syndromes
• Marfan’s or connective tissue
disorder?
• Very sharp curvature
– After all other factors ruled out then
we think:
• Idiopathic
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Adolescent Idiopathic Scoliosis
• Diagnosis
– Curvature > 10 degrees in child
> 10 years old
– More common in females (Up
to 7:1) in larger curves
• Spine rotates around the
apex
– 3-D Deformity!
Image credits:
1) Yang et al, Posterior Thoracolumbar Fusion
Techniques for Adolescent Idiopathic Scoliosis, In:
Vaccardo et al, Operative Techniques in Spine Surgery
3rd Edution
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• Growth is the DRIVING
FORCE of deformity
– Control the curve before
major growth spurt
– Fastest growth is 6
months – 1 year prior to
menses
Adolescent Idiopathic Scoliosis
Image credits:
Little et al, JBJS 2000
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• Catch it early, ideally before
growth spurt
• Bracing
– Worn full time
– Bracing works!
• Randomized Trial
• Success rate 72% braced vs
48% unbraced (Weinstein et al, NEJM 2013)
Adolescent Idiopathic Scoliosis
Image credit:
http://cirrie.buffalo.edu/encyclopedia/en/article/49/
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The Adolescent Athlete
Sporting or activity demands
may lead to stress injuries
- Year-round sports
common
- More competition /
intensityImage Credit: LariatonlineOHSU
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The Adolescent Athlete
Always think about the growth plate in preteen/teen
- Child is rapidly growing in adolescence
- Skeletal growth plate is weakest part of the skeleton during
this timeOHSU
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Typical Case
HPI:
13 year old competitive soccer star
complains of activity related anterior
right > left knee pain
Worse with jumping or after soccer
practice
PEX:
- Tenderness along bilateral tibial
tubercle
- Pain with resisted knee extension,
pain with squat jumps
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Typical Case
Osgood Schlatter Disease
- Inflammation along tibial
apophysis due to
overuse
- Apophysitis: Traction
injury to growth plate
Treatment:
– Rest, Rest, RestImage Credit: NEJM
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The Acutely Limping Child
– FIRST, rule out:
– Trauma
– (Fractures, growth plate injuries
including SCFE)
– Infection
– Can be from spine to foot!
– Tumor
Staying out of trouble =
don’t give up until you
find the causeOHSU
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Osteoarticular Infection
• Never miss this diagnosis
– Difficulty in anatomic location in
young children
• Rate: 80 / 100,000 children
• Most commonly: S Aureus
• Quickly evolving process
– Can lead to irreversible joint
destruction!
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Osteoarticular infection
• NOT mutually exclusive: Septic arthritis, osteomyelitis, myositis
Image credit: 1) DiPose et al; Radiographics2) Arnold et al; Infectious Disease Clinics of North America
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Infection Case Example
• 10 y/o F with right
knee pain after a
recent fall few days
ago, presents with
fevers and difficulty
ambulating
• Fevers thought to
be viral, sent home
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Infection Case Example
• Return to ED 2
weeks later,
worsening pain, still
can’t walk
• MRI with septic
arthritis /
osteomyelitis right
hip
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Septic Arthritis Hip
• Too late!!
• Hip with irreversible
damage
• Will require hip
replacement
Learning Point: Never send home limping
child systemic signs of infection. Previous
trauma history is common
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Tumor Case Example
HPI:
10 y/o M with 1 month left atraumatic knee pain. Hurts at rest,
wakes him at night, and painful every time he walks.
PEX:
Full range of motions left knee, no palpable masses
Antalgic gait, walks with clear limp
Learning Point: Persistent pain, frequent night pain, that is ALWAYS reproduceable, with limping = something is wrong!!
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Casting and Splinting
• Adequate padding at bone prominence (heel, anterior knee)– Kids show up to my office with heel sores frequently from outside splints
• No wrinkles / sharp points at the joints
– Once the cast or splint is set at the joint, do not move it anymore!
• A wet cast needs to be addressed within a day
Credit: UW Pediatric Orthopaedics
Staying out of
trouble = don’t cause
a heel sore
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Forearm Fractures
• Radius and ulna are intimately connected
– Do NOT miss the Monteggia Fracture – Dislocation
– Leads to chronic elbow pain due to missed radial head dislocation
– Draw a line from radius to capitellum. Should always intersect.
Ring et al, JAAOS 1998
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Forearm Fractures
• Can be even more subtle. Train your eyes
Image Credit: Royal Children’s Hospital Melbourne
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• Supracondylar humerus
fracture
– Most common elbow
fracture in children
– Can be very severe with
regards to loss of limb
function
Supracondylar Humerus Fractures
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Supracondylar Humerus Fractures
• If severely displaced injury:
• 10-20% risk of neurologic / vascular injury
• Risk of compartment syndrome
OHSU
Supracondylar Humerus Fractures
Image Credits:
1) Rowell PJ, Injry 1975
2) Aksakal et al, Acta Orthop Traumato Turc 2013
• Understanding anatomy helps clarify the riskOHSU
Lawn Mowers
• Common cause of open
fractures & amputations in
children
– 17,000 Children in 2010
• Most are
– A rider or bystander (70%)
– Under 5 years old (78%)
• High complication rate
– Infection
– Many require amputationLoder, JBJS-Am, 2004
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Lawn Mowers
• Tell your patients:
– Children < 14 should NOT operate power lawn mowers
– No riders other than the operator in a riding mower
– Secure lawn mowers in safe place, AWAY from children
– Caution with hills/slopes, especially when wet
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Trampolines
• AAOS Guidelines– No one under 6
– Always netted
– Always adult supervision
– One participant at a time
– Somersaults or high-risk maneuvers avoided
– Trampoline-jumping surface should be placed at ground level.
– Well padded bars
– Checked regularly
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Window Safety
• >5,000 falls from windows yearly– Age < 5 years old
– Serious head injuries / skeletal injuries
• No play near windows
• No furniture near by
• Install window stops / guards to limit opening to 4 inches
• Screens are not safety guards
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