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Common Pediatric Orthopedic Clinical Problems Saunders Jones Jr. MD

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Presentation on theme: "Common Pediatric Orthopedic Clinical Problems Saunders Jones Jr. MD"— Presentation transcript:

1 Common Pediatric Orthopedic Clinical Problems Saunders Jones Jr. MD

2 Common Pediatric Orthopedic Problems Metabolic Metabolic Developmental Developmental Congenital Congenital Traumatic Traumatic Infectious Infectious Neoplastic Neoplastic Neuromuscular Neuromuscular

3 Radiological hole in the bone Fibrous cortical defect Fibrous cortical defect Aneurysmal Bone cyst Aneurysmal Bone cyst bone island bone island Giant cell tumor Giant cell tumor Infection Infection Ewings Sarcoma Ewings Sarcoma Enchondroma Enchondroma

4 Fibrous cortical defect (Fibroxanthoma)

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

6 ABC Aneurysmal bone cysts may occur in patients aged years, with a peak incidence in those aged 16 years. Aneurysmal bone cysts may occur in patients aged years, with a peak incidence in those aged 16 years. About 75% of patients are younger than 20 years. About 75% of patients are younger than 20 years. Four phases of pathogenesis are recognized, as follows: Four phases of pathogenesis are recognized, as follows: Osteolytic initial phase Osteolytic initial phase Active growth phase, which is characterized by rapid destruction of bone and a subperiosteal blow-out pattern 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. 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. 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

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9 Ewing's Sarcoma

10 Incidence of Ewings

11 Ewings

12 Giant Cell tumor Not ped age group Not ped age group

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

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

15 Osteochondromas B9 B9 Cartilaginous cap Cartilaginous cap Impinges on local structures Impinges on local structures

16 Osteochondromas Another view Another view

17 Osteochondroma

18 Osteochondroma

19 Osteochondroma microscopic

20 Osteosarcoma

21 Osteosarcoma Some bone Some boneelements

22 Enchondroma

23 Non ossifying Fibroma

24 Metabolic Pediatric Category Rickets Rickets Osteogenesis Imperfecta Osteogenesis Imperfecta

25 Rickets Radiologic changes in the growth plate Radiologic changes in the growth plate Vitamin problem Vitamin problem

26 Osteogenesis Imperfecta

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28 Twisty Bendy Feet Most common is metatarsus adductus Most common is metatarsus adductus FPS fetal packaging syndrome FPS fetal packaging syndrome Normal rotation of feet in utero Normal rotation of feet in utero Should respond to gentle massage and SWN 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 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 Clubfeet talipes equino-varus Metatarsus adductus, heel equinus and varus and talus adductus Metatarsus adductus, heel equinus and varus and talus adductus Tell tale crease on lat underneath malleolus Tell tale crease on lat underneath malleolus Thinning and atrophy of lower leg Thinning and atrophy of lower leg Needs attention based on severity of deformity, START TREATMENT AT BIRTH !!! Refer early Needs attention based on severity of deformity, START TREATMENT AT BIRTH !!! Refer early

31 Club feet Metatarsal Metatarsal Talus Talus Hindfoot Hindfoot Leg atrophy Leg atrophy

32 Endstage Club feet

33 Clubfoot casting In the nursery or soon as possible In the nursery or soon as possible

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

35 Limited clinic Tenotomy New New

36 Twisty Bendy legs

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

38 Twisty Bendy Legs Bendy knees/legs Bendy knees/legs years years Genu varus / genu valgus Genu varus / genu valgus Normal variants Normal variants Radiographs for Blounts Disease Radiographs for Blounts Disease Vitamins Vitamins Orthotics (?) Orthotics (?)

39 Blounts vs. Normal

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

41 Femoral anteversion

42

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

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

45 Severs Disease

46 Xray of the Calcaneal Apophysis

47 Stretch for Severs Disease

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

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

50 OSDx and Ant knee pain

51 Osgood Schlatter's

52 Osgood Schlatters Disease

53 Hip Pain SCFE SCFE Transient synovitis Transient synovitis Hip pyarthrosis Hip pyarthrosis LCP LCP

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

55 SCFE

56 SCFE

57 SCFE

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

59 LCP initial and resorptive phases

60 LCP resorptive and remodeling

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

62 Congenital Dislocation

63 Congenital Hip Dislocation

64 Causes of Hip Pain in Children CDH 0-2 years 1:4 m:f 20%bilat LCP 4-8 years 5:1 m:f 10% bilat SCFE years 1.5:1 m:f %bilat

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

66

67 Risser sign

68 Risser Sign

69 Nursemaids Elbow

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71 Falls from a Height common in Children

72

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

74 Salter One

75

76 Salter 2

77 Salter 3

78 Salter 4

79 Salter 5

80

81

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

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87 Lines around the elbow

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89 Supracondylar fx minimal displacement

90 Displaced Supracondylar fx

91 Medial Epicondyle fx

92

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 Alignment has different criteria Overgrowth Overgrowth Maintenance of overall alignment most important Rotation, etc 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 Cerebral Palsy Spastic or Flaccid Spastic or Flaccid Birth injury Birth injury Perinatal cerebral anoxia Perinatal cerebral anoxia Hyperactive stretch receptors Hyperactive stretch receptors Contractures Contractures Releases, Transfers, Braces etc. Releases, Transfers, Braces etc.

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

106 ANY QUESTIONS??? Comments Comments Discussion Discussion

107 Thank you


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