Presentation is loading. Please wait.

Presentation is loading. Please wait.

Devin Peterson, MD, FRCSC, Dip Sport Med Associate Professor, McMaster University McMaster University Medical Centre David Braley Sport Medicine & Rehabilitation.

Similar presentations


Presentation on theme: "Devin Peterson, MD, FRCSC, Dip Sport Med Associate Professor, McMaster University McMaster University Medical Centre David Braley Sport Medicine & Rehabilitation."— Presentation transcript:

1 Devin Peterson, MD, FRCSC, Dip Sport Med Associate Professor, McMaster University McMaster University Medical Centre David Braley Sport Medicine & Rehabilitation Centre

2 Faculty/Presenter Disclosure Faculty: Devin Peterson Program: 51 st Annual Scientific Assembly Relationships with commercial interests: None

3 Disclosure of Commercial Support This program has received no financial support This program has received no in-kind support Potential for conflict(s) of interest: –None

4 Mitigating Potential Bias N/A

5 1. To assess and diagnose common causes of childhood limping 2. To understand the management principles of the limping child including timely referral

6  Smooth energy-efficient transfer of the body through space

7

8 Limp: “to walk with a halting or irregular step”  Funk & Wagnall's

9

10  Antalgic Gait: body’s effort to compensate for pain or instability in the stance-phase limb by minimizing the duration and magnitude of loading

11  Trendelenburg Gait: leaning of the head and trunk toward the lower extremity affected by the pathology  Pain  Weakness in the hip muscles

12

13 19 month old female referred because of limping

14  Fifth born  Normal delivery/presentation  Walking at 14 months  Always limped  No pain  Healthy  Negative Family history

15  Differential diagnosis  Top three: Hip dysplasia Neuromuscular disease Leg length discrepancy

16

17

18  Dislocated: the femoral head is not in contact with the acetabulum  Dislocatable the femoral head is within the acetabulum but can be forced out  Subluxed the femoral head is within the acetabulum but not in its proper position  Subluxable the femoral head can be moved beyond its physiologic limits within the acetabulum  Dysplastic although the femoral head is in the proper position the acetabulum or head are abnormally developed

19  History  Risk Factors Female Firstborn Breech Large baby Low amniotic fluid Family history

20  Physical  Associated Conditions o Foot deformity, Torticollis o Neuromuscular disorders o Syndromes  Hip Examination o Trendelenburg gait o Skin folds o Galeazzi sign o Abduction o Provocative maneuvers - Ortolani, Barlow

21  Imaging  Ultrasound < 6 months  X-ray

22

23  Treatment  URGENT REFERRAL  Pavlik Harness  Closed Reduction Safe Zone  Open reduction Extra-articular blocks Intra-articular blocks  Osteotomies Pelvic Femoral + Shortening

24  Most common cause of hip pain in childhood  3% childhood risk  Idiopathic  Frequently associated with concurrent or antecedent illness  Right hip = left hip  NEVER BILATERAL  2:1 male:female

25  History  Age varies (9 months to adolescence) Most between 3 and 8 years old  Unilateral hip pain Can present with knee or thigh pain  Limp vs non-weight bearing

26  Physical  May have a low grade temperature  Antalgic or Trendelenburg gait  Flexed and externally rotated position  Decreased ROM Especially abduction and internal rotation  Laboratory tests  Non-specific

27  Imaging  Radiographs usually normal  Ultrasound may show effusion  Diagnosis of exclusion

28  Treatment  URGENT REFERRAL Differential includes a septic joint  Self limiting disorder May have symptoms for up to 10 days or longer  Bed rest until full ROM, no pain, limp free Crutches for older patients  NSAIDS  Gradual return to activity

29

30  Self limiting hip disorder  Caused by ischemia and subsequent necrosis of the femoral head  Usually 4 to 8 years of age  Male to female ratio:  4-5 to 1  Usually unilateral (88%)  Age and lateral head involvement are the key to prognosis  8 years of age seems to be the watershed  <50% of lateral pillar involvement better prognosis

31  Unilateral Perthes:  septic arthritis  sickle cell disease  spondyloepiphyseal dysplasia tarda  Gaucher’s disease  Bilateral Perthes:  Hypothyroidism  Multiple epiphyseal dysplasia  spondyloepiphyseal dysplasia tarda  sickle cell disease

32  History  May be painless at first present with a limp only  symptoms occur with subchondral collapse/fracture  Can present with knee or thigh pain  Positive family history 1.6% – 20%  1% - 3% of patients with transient synovitis will develop Perthes

33  Physical  gait: Trendelenburg  decreased abduction/ internal hip rotation  thigh, calf, and buttock atrophy  LLD  Imaging  X-ray, bone scan, MRI

34  Treatment  TIMELY REFERRAL  Principles of treatment are maintenance of ROM & containment (good coverage of the head by the acetabulum) of the femoral head through the evolution of healing  May be obtained by non-operative means o relative rest o pain control o physiotherapy o traction o abduction splinting at night

35  Containable Hip  adductor release  Femoral varus/pelvic osteotomies  Non-Containable Hip  Hip/Late-presenting patient with deformity  Hinge abduction  Chiari/lateral shelf  Cheilectomy  Femoral abduction/extension osteotomy  OCD, non-operative, revascularization, removal, ORIF

36  First description: Young 1889  3-5% in general population have a larger than normal meniscus  Almost all in lateral, but reported in medial  20% bilateral and 10% associated with OCD of lateral femoral condyle

37  T HREE S EGMENTS Anterior horn Body Posterior horn Attached to tibial plateau, primarily through Coronary Ligament Attached to the capsule except at popliteal hiatus

38  Clinical Presentation  History: Asymptomatic “Snapping knee syndrome” Meniscal tear symptoms  Physical: Snapping knee with gait Meniscal signs

39  X-ray  Widened lateral joint space, squaring of lateral femoral condyle, cupping of lateral tibial plateau  MRI  Verify diagnosis and assess damage

40  Asymptomatic: observe  Symptomatic:  TIMELY REFERRAL UNLESS LOCKED KNEE THEN URGENT  Non-operative: restricted activity, bracing, physiotherapy  Operative: Partial meniscal “saucerization” Repair of tear

41

42

43  Apophysitis of the Hip and Pelvis  Sinding-Larsen-Johansson: inferior pole of patella  Osgood-Schlatter Disease: tibial tuberosity disturbance  Sever Disease: calcaneal apophysitis  Iselin Disease: apophysitis of the fifth metatarsal

44  Tibial tuberosity disturbance  Partial avulsion (microscopic fractures) of the ossification center and overlying hyaline cartilage  Epidemiology  10 – 15 years old  Boys > girls  > 10% of teenagers

45  History  Pain localized to tubercle  Worse with direct blows to the are and activity  Physical  Antalgic gait may be present  Prominent tubercle + local swelling  Tenderness localized to tubercle

46 Lovell and Winter’s Pediatric Orthopaedics 5 th edition

47  Treatment  Spontaneous resolution at maturity 20% may have pain with kneeling surgery for loose ossicles  Reassurance  Symptomatic treatment/activity modification NSAIDS, stretching, knee pads/braces, foot orthosis, casts  TIMELY REFERRAL

48

49  Acquired potentially reversible lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability  Juvenile and Adult forms Adult form is typically progressive and unremitting  May occur in almost any joint in upper or lower extremity Very common in the knee

50  15-29 per 100,000  May be bilateral in 25% of cases  Male: female ratio 5:3  >70% are in the classical area Posterolateral aspect of the medial femoral condyle

51  Idiopathic  Theories include: Genetics Inflammation Ischemia Ossification Repetitive trauma (stress reaction causing a stress fracture in the underlying subchondral bone)

52  History  Juvenile Poorly localized pain Exacerbated by exercise May present with symptoms of instability (swelling, stiffness, catching, locking) Limp  Physical  Antalgic gait  Effusion  Crepitus  Painful ROM  Quads atrophy  Maximum tenderness usually anteromedial knee  Wilson sign Pain with internal tibial rotation

53  X-rays AP Lateral Notch  MRI + gadolinium Lesion size Status of the cartilage and subchondral bone Bone edema and high signal zone beneath fragment Loose bodies  Technetium bone scan

54

55

56 Nonoperative Open physis = good prognosis? Activity modification Immobilization? Rehabilitation Local and systemic pain management Review every 3-6 months or sooner if symptoms worsening Repeat MRI every 6 months? TIMELY REFERRAL if no improvement or worsening, URGENT IF LOCKED KNEE

57 Operative Indications Lesions not responding to nonoperative management Unstable lesions? Detached lesions

58

59 Tarsal coalition is an abnormal connection between some of the tarsal bones  May be painful  Can be associated with increased ankle sprains

60  Gait  Antalgic  Flexibility  Toe standing  Sitting/supine  Subtalar ROM

61 Flexible Flatfoot  Arch returns with sitting or tiptoe standing  Normal subtalar and midtarsal motion

62 Tarsal Coalition  Arch may not return with sitting or tiptoe standing  May be painful to move or palpate subtalar joint or other tarsal bones  Subtalar motion often decreased

63  Normal in flexible flatfoot  Oblique views and Harris view may help view a coalition  May need an MRI or CT to make diagnosis

64  Tarsal Coalition  TIMELY REFERRAL  Rest/activity modification  Antiinflammatories  Physiotherapy?  Orthotics  Casts  Surgery: resection or fusion

65

66  The slip normally occurs during adolescent growth phase  Mechanical or systemic factors may be present  Commonly obese  Endocrinopathies (eg. 1 o & 2 o hypothyroidism, panhypopituitarism, GH, hypogonadal conditions, & renal osteodystrophy

67  Male > female  Left > right  Bilateral involvement may occur  Second slip presents within 18 months in 88%

68  History  Chronic and/or acute  Limp  May present with knee or thigh pain instead of hip/groin pain

69  Physical  Gait: Trendelenburg  Shortened/external rotation  Decreased abduction/internal hip rotation  Passive flexion leads to thigh abduction and external rotation  Imaging  X-ray, CT, MRI

70 X-rays  Physeal plate widening & irregularity  Decrease in epiphyseal height  Blanch sign of Steel  Crescent-shaped area of increased density in the proximal femoral neck  Femoral metaphysis appears laterally displaced  Klein’s line  Southwick angles

71  Imaging  Frog-leg lateral avoid in acute situation  Cross-table lateral

72 Treatment - Acute  EMERGENT REFERRAL  Immediate bed rest  Insertion of one or more screws  in situ fixation  Designed to fuse the epiphysis on the metaphysis to prevent further slipping Prophylactic Pinning  Known metabolic/endocrine disorders?  Inability to follow-up

73

74  Stress Fractures in Skeletally Immature Patients  Walker et. al.: JPO 1996  34 stress fractures  Tibia (47%), fibula, femur, radius, humerus, MT

75  History  Pain often associated with an increase in activity  Be wary of female triad  Physical  Antalgic gait may be present  Tenderness localized

76  Radiographs  Rapid bony response may be present  Bone Scan  Helpful in questionable situations  Treatment (depends on causative factors)  URGENT REFERRAL  Modification of activities  Immobilization

77

78

79  History  Pain Night pain History of trauma may delay diagnosis Osteoid Osteoma pain relieved by NSAIDs  Constitutional Symptoms Fever, night sweats, anorexia, weight loss eg. Ewing sarcoma  Soft tissue mass may not be symptomatic

80  Physical Exam  Gait disturbance  Muscle atrophy  Neurovascular exam  Range of motion  Mass Size, tenderness, pulsation, mobility, bruits, tenderness, erythema, consistency  Lymph nodes

81  Investigations  Bloodwork CBC, ESR, CRP, serum alkaline phosphatase, serum and urine calcium & phosphorus, LDH  Imaging X-ray Bone Scan CT/MRI

82  Management  Referral Urgency dependent on tumor type

83

84  History  Pain Refusal to bear weight Limping  Recent illness Decreased immunity eg. chickenpox  Trauma

85  Physical Exam  Temperature  Antalgic gait  Disuse of a part  Erythema/swelling  Tenderness  Decreased ROM

86  Laboratory tests  CBC WBC  CRP  ESR  Blood cultures  Aspirates (Gram stain, Culture)  Imaging  X-rays  Ultrasound  Bone Scan  CT  MRI

87  Treatment  EMERGENT REFERRAL  Stop tissue destruction ASAP Decrease bacterial load and irrigation of the joint  Identify the Organism  Select appropriate antibiotic

88


Download ppt "Devin Peterson, MD, FRCSC, Dip Sport Med Associate Professor, McMaster University McMaster University Medical Centre David Braley Sport Medicine & Rehabilitation."

Similar presentations


Ads by Google