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 1 st 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 DisorderCells/microLGlucose Trauma RBCs>>WBCs; <2000 WBCs Normal Reactive arthr 3-10,000 WBCs; mostly monos Normal JRA/inflamm 5-80,000; mostly neutrophils Normal/sl. low Septic arthritis >60,000 WBCs; >90% neutrophils Low to normal Lyme arthritis 15-100,000 WBCs; variable cell types Low to normal

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 1 st line: Anti-staph PCN, 1 st 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.