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

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Presentation on theme: "LOWER EXTREMITY PROBLEMS IN CHILDHOOD TIMOTHY J. FETE MD,MPH University of Missouri School of Medicine Department of Child Health."— Presentation transcript:

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

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10 DEVELOPOMENTAL DYSPLASIA OF THE HIP Positive exams per 1000 newborns All11.5 Boys4.1 Girls19 + Fam Hx Boys6.4 + Fam Hx Girls 32 Breech Boys29 Breech Girls133

11 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

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15 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)

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

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

18 INTOEING Metatarsus Adductus Internal Tibial Torsion Femoral Anteversion

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

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

24 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

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26 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

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29 EXTERNAL TIBIAL TORSION Normal adults + 10 degrees of external tibial torsion No treatment necessary

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31 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

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

33 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

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35 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

36 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

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

39 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

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41 SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) Insidious pain or limp vs acute pain Pain often thigh/knee Early adolescence (13-15 males, 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

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43 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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