Presentation on theme: "Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional Medical Center 5/01/06."— Presentation transcript:
1 Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional Medical Center 5/01/06
2 Objectives:1. Describe the commonly seen pediatric disorders involving gait, children's feet, and children's legs, including problems in normal development (and the ages at which these problems are commonly seen).
3 Objectives:2. Discuss the evaluation of common pediatric foot, gait, and leg disorders.3. Describe their optimal management.
4 Approach Learn the range of normal It’s huge “Normal” changes with growth and developmentBefore saying something is “normal”, rule out the pathologiesKnow the common pathologies“The eye sees what the mind knows”
5 Common and often benign orthopaedic concerns In-toeingOut-toeingBowed legsKnock-kneesFlat feet
6 Pathologies Cerebral Palsy Hip dysplasia Legg-Calve-Perthes’s disease Slipped Capital Femoral EpiphysisClubfoot
7 Systematic approach - Where’s the source? Hip jointThigh (femur)Knee jointLeg (tibia)Ankle jointFoot (tarsals and metatarsals)XX
8 Group pathologies by age Newborns and infants (< 1 yr)Toddlers (1-3 yr)Older children (4-10 yr)Pre-teens and teens (> 10 yrs)
9 Is in-toeing a problem? Not painful in and of itself Not associated with early arthritisCan be associated with knee pain and patellofemoral problemsMay be a cosmetic problemWhy does this patient in-toe?
10 History What is the specific concern? Who is concerned? When does it manifest?Duration?Improving or worsening?
11 Evaluation Medical History Family History Screening examination Developmental delay(s)?Precipitating event/birth complication?Family HistoryScreening examinationSpasticity?Asymmetry?Rotational Profile
12 Rotational Profile Gait: determine foot progression angles Assess hip rotationAssess tibial rotationDetermine the alignment of the foot Gait = f [(BRAIN) + (hip & femur) + (leg & foot) + (knee + ankle)]
23 Is the hip rotation normal? Within two standard deviations of the mean?Symmetric?Painless?Without spasticity? What is the cause of the increased medial (or lateral) rotation?
24 Causes of excess rotation Soft tissues vs. bony anatomyHip joint - soft tissue contracturesNewborns have an posterior capsular contracture, producing excessive lateral rotation of the hipsFemoral antetorsion - bony anatomyproduces excessive medial rotation at the hip
25 What is femoral anteversion? Left footLeft footLeft footExcessive anteversion equals antetorsionAnteversionFemoral antetorsion produces intoeing
26 Femoral antetorsion Usually 3-5 yo girls Sits in the “W” “Kissing patellae”“Egg-beater” runSevere if > 90°Resolves with growth - no association with osteoarthritis
40 Toeing and bowing: Determining the source Excessive medial rotation of hips?Does he have it? NO on antetorsion, but YES on excessive medial rotationInternally rotated thigh-foot angle = internal tibial torsion? NoCurved foot = metatarsus adductus? No
41 In SummaryFemoral antetorsion produces excessive medial rotation at the hip which leads to in-toeingMedial tibial torsion is a twist to the leg, pointing the foot inwardsMetatarsus adductus curves the foot inwardsA searching or abducted great toe produces in-toeing
42 A five year old girl presents with knock-knees and intoeing A five year old girl presents with knock-knees and intoeing. You should obtain a rotational profile and…refer to orthopaedics for bracing or surgeryhave the child put her shoes on the opposite feet and recheck her in a yearjust recheck her in a yearobtain an AP pelvis radiograph and full length lower extremity films to look for hip dysplasia
43 How to treat intoeing? Shoe wedges? No. Twister cables? No. Observation? Yes.
44 Pathologies to consider “Why is there an abnormal range of motion of the hip?” Infants and toddlersHip dysplasiaNeuromuscular disease -Cerebral palsyToddlersLegg-Calve-Perthes diseasePre-teensSlipped Capital femoral epiphysis
46 The most likely diagnosis is… cerebral palsyarthrogryposisPerthe’s diseaseseptic arthritis of the hiphip dysplasia
47 Arthrogryposis Congenital contractures Arthrogryposis multiplex congenita1/3000 birthsAmyoplasia = 1/2 of casesDue to fetal akinesiaMay includeradial head dislocationsHip dislocationsKnee dislocationsClubfootRx order - reduce the knee, then treat the feet, then the hips
48 Arthrogryposis Amyoplasia Classic arthrogryposis Muscle replaced by fibrous tissueMultiple congenital contractures60% with all limbs affected,Lower only in 25%Upper only in 15%Normal IQSurgery changes the range of the arc of motion, not the total arc itself
49 The most likely diagnosis is… cerebral palsyarthrogryposisPerthe’s diseaseseptic arthritis of the hiphip dysplasia
53 Developmental dysplasia of the hip (DDH) Incidencedislocation 1:1000neonatal hip instability 1:100Increased risks for first-born, girls, breech positioning, family historyL>R
54 DDH detection Newborn nursery exam Loss of abduction, pistoning Galiazzi testOrtolani testBarlow testGood up to 2-3 mos of ageLoss of abduction, pistoningPavlik harness for instability or dislocated hip
55 DDH detection Ultrasound (dedicated center) Radiography Better at > 2 wks of ageDynamic examRadiographyGold standardBest after 6-8 weeks of age
56 Rx for dysplasia -REFER Pavlik for both dysplastic and dislocated hipsNever exceed about four weeks of Pavlik treatment for a persistently dislocated hipUnstable hips deserve a referral to orthopaedicsAbduction orthoses may help correct hip dysplasia in the older child
57 Hip dysplasia Early treatment enables quick resolution Delayed treatment risks a poor result/multiple surgeriesOver-treatment is generally benign for the located hip
60 Cerebral palsy Mild developmental delays? Mild spasticity or increased tone?Asymmetry of motion, tone, reflexes?You may be the first to make the diagnosis
61 Perthes ds Peak age of onset 3-8yr Spontaneous osteonecrosis of the femoral headFollow with serial radiographsPrognosis depends on age of onset / severity< 6 yrs at onset, less than whole-head involvement do betterRx- decrease synovitis and weight bearing
64 Slipped capital femoral epiphysis Peak incidence in pre-teens, 50% obese (50% not!)Anterior thigh or knee painBilateral in cases of endocrinopathy or renal dsDx - AP and frog pelvis * radiographIf present, immediate wheel chair and referral
75 Physiologic genu valgum Maximum varus at birthMaximum valgus > 10°, ages yrsAt maturity, mean is ~ 6° anatomic valgus
76 Knock- knees Pathologic genu valgum Skeletal dysplasias Rickets - later onset such as with renal osteodystrophy, because the disease is active when knock knees are the normSkeletal dysplasiasDiastrophic dysplasiaMorquio’s syndromeEllis-van Creveld or chondroectodermal dysplasiaSpondyloepiphyseal and multiple epiphyseal dysplasias
77 Pathologies to consider - leg Angulation or bowing of the tibiaVery unusual!Antero-lateral ?neurofibromatosis?Postero-medial ?leg length difference?Antero-medial ?fibular deficiency?
78 Pathologies to consider: foot FlatfootAll infants have itMost children have itMore than 15% of adults have it
79 Flexible flatfoot Often resolves with growth Not affected by specific shoes, heel cups, or UCBL insertsNot correlated with disability in military populationsMay be protective against stress fractures
80 More foot pathologies to consider Stiff or rigid metatarsus adductusClubfootCalcaneovalgusCavovarus foot
82 Clubfoot treatment Serial manipulations and casting Begin first week of life, if possiblePerform weekly90% of routine clubfoot respond
83 Calcaneovalgus foot Most common foot deformity at birth Forefoot abducted, ankle dorsiflexed - foot lies on anterior legResolves spontaneouslyAssociated with hip dysplasia
84 Cavovarus foot High arch = cavus Heel in varus Often rigid Look to spinal cord or peripheral nervous system
85 Out-toeing (Less commonly seen) Causes:External rotation contracture at the hip?Lateral tibial torsion?Flatfoot?Little hope of improvement over time, unless it’s a result of flatfoot
86 Summary: Normal Development Femoral anteversion: 30° at birth, only 10° at maturity (= lateral rotation)Femoral antetorsion improves over timeTibial version: 0° at birth, 15° externally rotated at maturity (= laterally rotation)Medial tibial torsion improves over timeGrowth: lateral rotation of both femur and tibiaIn-toeing decreases with growth
87 Summary Most toe-ing and bow-ing deformities are benign Resolution may take many yearsUse history and exam to rule-out the pathologic causesReassure for what appear to be non-pathologic but extreme casesCheck back for re-exam, 6-12 monthsBeware unilateral deformities and those associated with painRadiographs indicated
88 Who needs a referral for toeing and bowing? Over three years of age with documented progression of deformityStiff metatarsus adductusBowingbelow the 5th percentile for heightmarked asymmetry or lateral thrust with ambulationMarked knock-knees or in-toeing in patients over 8 years of age
89 Who needs a referral? A newborn with a hip click? A newborn with a hip clunk?A ten year old girl with marked out-toeing on the side of groin pain?A newborn with flat feet?
90 References:Herring, JA: Tachdjian’s Pediatric Orthpaedics, WB Saunders, Philadelphia, 2002.Staheli, LT: Fundamentals of Pediatric Orthopedics, Raven Press, New York, 1992.Staheli, LT: Practice of Pediatric Orthopedics, Lippincott, 2002.Tolo, VT: “In-toeing and Out-toeing,” Lovell and Winter’s Pediatric Orthopaedics, 4th ed., Morrissey and Weinstein, eds., Lippincott-Raven, Philadelphia, 1996.Wenger, DA and M Rang: The Art and Practice of Pediatric Orthopaedics, Raven, New York, 1993.