Doernbecher Children’s Hospital Staying out of Trouble in ...

Staying out of Trouble in Outpatient Musculoskeletal Problems

PRESENTED BY: Scott Yang MD, Assistant Professor, Pediatric Orthopaedic Surgery Doernbecher Children’s Hospital, OHSU

Doernbecher Children’s HospitalOHSU

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No disclosures for this presentationOHSU

Physical examination – diagnostic tools to stay out of troubleOHSU

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Leg Lengths

• Leg Lengths

– Pelvic height with knees

locked out

– Then check sacro-

iliac dimples

Not scoliosis!

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Leg Lengths

• Femoral length

– Firm, flat surface!

• Tibial Length

Image credit: 1) MSK Key2) Dalton MSK

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Things not to miss on leg lengths

• Causes in infants/toddlers

– Hip dysplasia

– Hemihypertrophy / Vascular malformation

– Hemimelia / Femoral deficiencies

– Tumor Syndromes

Image Credit: Takata et al; J. Orthopaedic Surg

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Rotational Alignment

• “My child walks pigeon toed!”

• “Grandma wore special

shoes”OHSU

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Rotational Alignment

• Rotational alignment of the legs

• Reassure parents

• Most will resolve with time

• Watch for milestones & spasticity

Internal Rotation External Rotation Thigh Foot AngleOHSU

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Leg Alignment – Bow Legs

• Monitor with time until at minimum age 2

– Worsening past age 2

– Short stature < 10th percentile

– Asymmetry

– Rare DDx: Blount disease, Rickets, Skeletal Dysplasia

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Blount Disease Example

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The Hip

– Infant hip

• Barlow/Ortolani may

need multiple checks

• Click does not equal

hip dysplasia. A clunk

is very obvious.

• Stay out of trouble by

REFINING this

examination

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The Hip

• After ~5-6 weeks

– Barlow & Ortolani not reliable

– Gluteal fold differences NOT

very helpful

– Look instead for differences in

hip abduction, Galleazzi signOHSU

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The Hip

• Dislocated hips in older children

– Not painful

– Unilateral – Toe walking, Limited hip abduction

– Bilateral – Lumbar hyperlordosis, Waddling Gait

Image credits: Weinstein S; Lovell and Winters Pediatric Orthopaedics

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The Hip

• The most sensitive tests for hip pathology:

• Flexion & Internal Rotation

• Prone internal rotation

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The Foot

• Flexible flat foot

– Arch returns up on toes

– Not a problem, reassure

• Rigid flat foot

– Arch does not form when

up on toes

– Look for tarsal coalition

• Cavovarus Feet

– Typically problematic

– Look for neurologic

disorder

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The Spine

– Shoulder height

asymmetry common in

normal kids

– Look instead of rotational

difference on forward bend

– Pay attention to skin

– Lumbar hairy patch

– Café au lait spots

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The Spine

• If no rotational deformity on xray… may be something else

Image credits:

Children’s Hospital Los Angeles

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“My child’s legs hurt”

• Simple tests to rule out growing pains from real pathology

• Tumors hurt. Infection hurts. Stress fractures hurt.

– Look for clear physical findings

– Single leg hop / jump x 5

– Squat jump x 10

– Then go for a walk & jog to look for limpOHSU

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The Fresh NewbornOHSU

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The Newborn – not moving the arm

• Not moving the arm

– Problem can be anywhere from clavicle to

forearm!

• Trauma from birth

• Clavicle fracture

• Humerus shaft fracture

• Distal Humerus Physeal Fracture

• Brachial Plexus palsy

• If not any of above, think about infection!!

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The Newborn – Lower Extremities

• Calcaneovalgus foot

– Improves with time

• Congenital knee dislocation

– Refer very early

– Sometimes associated with syndromes

• Clubfoot

– Refer very early

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Skeletal Injury from Child AbuseOHSU

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Case ExampleHPI:

2 month old F brought in to PCP

for not moving left arm. Mother

unclear on traumatic event.

Conflicting history with Father.

Exam:

Guards left arm

Moves other limbs

spontaneously. No major

swelling or bruising

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Case Imaging & Diagnoses

Skeletal Survey:

1) Multiple healing rib fractures

2) Left acute humerus fracture

3) Left 1st metatarsal fracture

4) Right healing femur fracture

Multiple stages of healing!

Repeated abuse!

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Case Treatment

• Hospitalize, Report to Social Work/DHS ASAP

• Treat injuries as appropriate, remove from current

situation

Learning Point: Very young non mobile children (< 1 year old) cannot easily hurt themselves

If presenting with pain or extremity splinting, they need you to advocate for them to look for injury, for which you may find many.

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The Pediatric HipOHSU

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Hip Dysplasia

Image: International Hip Dysplasia Institute

Staying out of trouble = not missing the diagnosis

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Hip Dysplasia

• Perform stability examination

early!

• Identify risk factors

– Breech in 3rd trimester; Family

history

• If stable exam, but + history,

obtain ultrasound at 6 weeks

of age

Image: Weinstein et al, JBJS 2003

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• Treatment Principles

– Aggressiveness of treatment generally increases with age

Hip Dysplasia – Why Catch Early?

Image: Murphy & Kim, JAAOS 2016

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Hip Dysplasia – Case Example

• 4 year old autistic male with left sided toe walking and leg

length difference

– PCP attributed toe walking to sensory processing issues

Initial Presentation Surgery 2 years laterOHSU

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Perthes Disease

Legg-Calve-Perthes

disease

● Avascular necrosis

of the hip in

childhood (Age 3-9

typically)

● Unclear etiology

● Treatment is

supportive care,

sometimes surgery

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Perthes Disease – Case ExampleHPI:

5 year old male presents with

intermittent limping, and mild hip pain

for past 6 months. No fevers/malaise.

Able to jog with a limp

-Otherwise plays well, can go to school,

no malaise

PEX:

Well appearing

Slight trendelenburg limp

Difficulty running / jumping

Slightly decreased left hip abduction

range of motion

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Perthes Disease - Case Example

6 months later

Initial Presentation

Perthes is evolving process – one negative xray doesn’t

rule it out!!

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Slipped Capital Femoral Epiphsysis(SCFE)

• Proximal femoral

epiphysis is disrupted

from the metaphysis at

the growth plate

– Leads to 3D deformity of

the hip

– Can occur gradually over

time or associated with a

sudden event

Image: OrthoInfo.aaos.org

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SCFE Epidemiology

• Age 9-13

• 10.8/100,000 children

annually in USA

• Associated with obesity

– >50% of SCFE patients are

>95th percentile for weight

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SCFE Clinical Pearls

• Groin / thigh / knee pain

– 90% - Several weeks-months of

pain, insidious limp

– 10% - Sudden acute severe pain

without prodromal symptoms

• Range of motion

– Loss of hip internal rotation

– Excessive hip external rotation

Image: OrthoInfo.aaos.org

Learning Point: An overweight pre-teen / teen complaining of frequent knee painNeeds a thorough and TIMELY HIP exam

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SCFE Case Example

HPI:

13 year old M with 6 months right knee

pain. No trauma. Severe limp 2 weeks

ago, improved, but persistently painful

PEX:

BMI: 31

Normal right knee exam

Right hip: Limitation of flexion & internal

rotation compared to left side. ++ pain

with hip flexion & internal rotation Image Credit: AAOS

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SCFE Case Example

- Diagnosis: Slipped capital femoral epiphysis

- Resulting deformity = functional loss; early hip arthritis

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The SpineOHSU

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Examination of the Pediatric Spine

• Underlying diagnosis?

– Neuromuscular condition

• Look at feet / lower extremities

• Neurologic symptoms

– Congenital conditions

• History of heart / renal problems?

– Syndromes

• Marfan’s or connective tissue

disorder?

• Very sharp curvature

– After all other factors ruled out then

we think:

• Idiopathic

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Adolescent Idiopathic Scoliosis

• Diagnosis

– Curvature > 10 degrees in child

> 10 years old

– More common in females (Up

to 7:1) in larger curves

• Spine rotates around the

apex

– 3-D Deformity!

Image credits:

1) Yang et al, Posterior Thoracolumbar Fusion

Techniques for Adolescent Idiopathic Scoliosis, In:

Vaccardo et al, Operative Techniques in Spine Surgery

3rd Edution

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• Growth is the DRIVING

FORCE of deformity

– Control the curve before

major growth spurt

– Fastest growth is 6

months – 1 year prior to

menses

Adolescent Idiopathic Scoliosis

Image credits:

Little et al, JBJS 2000

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Progression can be fast during growth spurt

1 year…

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• Catch it early, ideally before

growth spurt

• Bracing

– Worn full time

– Bracing works!

• Randomized Trial

• Success rate 72% braced vs

48% unbraced (Weinstein et al, NEJM 2013)

Adolescent Idiopathic Scoliosis

Image credit:

http://cirrie.buffalo.edu/encyclopedia/en/article/49/

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The Adolescent AthleteOHSU

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The Adolescent Athlete

Sporting or activity demands

may lead to stress injuries

- Year-round sports

common

- More competition /

intensityImage Credit: LariatonlineOHSU

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The Adolescent Athlete

Always think about the growth plate in preteen/teen

- Child is rapidly growing in adolescence

- Skeletal growth plate is weakest part of the skeleton during

this timeOHSU

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Typical Case

HPI:

13 year old competitive soccer star

complains of activity related anterior

right > left knee pain

Worse with jumping or after soccer

practice

PEX:

- Tenderness along bilateral tibial

tubercle

- Pain with resisted knee extension,

pain with squat jumps

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Typical Case

Osgood Schlatter Disease

- Inflammation along tibial

apophysis due to

overuse

- Apophysitis: Traction

injury to growth plate

Treatment:

– Rest, Rest, RestImage Credit: NEJM

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Other cases

Other common areas of apophysitis:

Image Credits:

AAFP, NEJM

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The Acutely Limping ChildOHSU

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The Acutely Limping Child

– FIRST, rule out:

– Trauma

– (Fractures, growth plate injuries

including SCFE)

– Infection

– Can be from spine to foot!

– Tumor

Staying out of trouble =

don’t give up until you

find the causeOHSU

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Osteoarticular Infection

• Never miss this diagnosis

– Difficulty in anatomic location in

young children

• Rate: 80 / 100,000 children

• Most commonly: S Aureus

• Quickly evolving process

– Can lead to irreversible joint

destruction!

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Osteoarticular infection

• NOT mutually exclusive: Septic arthritis, osteomyelitis, myositis

Image credit: 1) DiPose et al; Radiographics2) Arnold et al; Infectious Disease Clinics of North America

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Infection Case Example

• 10 y/o F with right

knee pain after a

recent fall few days

ago, presents with

fevers and difficulty

ambulating

• Fevers thought to

be viral, sent home

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Infection Case Example

• Return to ED 2

weeks later,

worsening pain, still

can’t walk

• MRI with septic

arthritis /

osteomyelitis right

hip

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Septic Arthritis Hip

• Too late!!

• Hip with irreversible

damage

• Will require hip

replacement

Learning Point: Never send home limping

child systemic signs of infection. Previous

trauma history is common

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Hip Pain in the Child

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Tumor Case Example

HPI:

10 y/o M with 1 month left atraumatic knee pain. Hurts at rest,

wakes him at night, and painful every time he walks.

PEX:

Full range of motions left knee, no palpable masses

Antalgic gait, walks with clear limp

Learning Point: Persistent pain, frequent night pain, that is ALWAYS reproduceable, with limping = something is wrong!!

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Tumor Case Example

Further workup & biopsy = Cancer

Osteosarcoma

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Fractures / Injuries: Casting & SplintingOHSU

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Casting and Splinting

• Adequate padding at bone prominence (heel, anterior knee)– Kids show up to my office with heel sores frequently from outside splints

• No wrinkles / sharp points at the joints

– Once the cast or splint is set at the joint, do not move it anymore!

• A wet cast needs to be addressed within a day

Credit: UW Pediatric Orthopaedics

Staying out of

trouble = don’t cause

a heel sore

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Fractures / Injuries: Do NOT miss these injuriesOHSU

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Forearm Fractures

• Most forearm fractures in children heal well….but

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Forearm Fractures

• Radius and ulna are intimately connected

– Do NOT miss the Monteggia Fracture – Dislocation

– Leads to chronic elbow pain due to missed radial head dislocation

– Draw a line from radius to capitellum. Should always intersect.

Ring et al, JAAOS 1998

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Forearm Fractures

• Can be even more subtle. Train your eyes

Image Credit: Royal Children’s Hospital Melbourne

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• Supracondylar humerus

fracture

– Most common elbow

fracture in children

– Can be very severe with

regards to loss of limb

function

Supracondylar Humerus Fractures

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Supracondylar Humerus Fractures

• If severely displaced injury:

• 10-20% risk of neurologic / vascular injury

• Risk of compartment syndrome

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Supracondylar Humerus Fractures

Image Credits:

1) Rowell PJ, Injry 1975

2) Aksakal et al, Acta Orthop Traumato Turc 2013

• Understanding anatomy helps clarify the riskOHSU

Be on alert if you see this!!

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AVOID THIS!

• Do NOT send home

• Send to ED ASAP (Surgery typically same day)OHSU

Fractures / Injuries: Preventative Guidance

Please help prevent catastrophiesOHSU

Lawn Mowers

• Common cause of open

fractures & amputations in

children

– 17,000 Children in 2010

• Most are

– A rider or bystander (70%)

– Under 5 years old (78%)

• High complication rate

– Infection

– Many require amputationLoder, JBJS-Am, 2004

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Lawn Mowers

• Tell your patients:

– Children < 14 should NOT operate power lawn mowers

– No riders other than the operator in a riding mower

– Secure lawn mowers in safe place, AWAY from children

– Caution with hills/slopes, especially when wet

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Trampolines

• AAOS Guidelines– No one under 6

– Always netted

– Always adult supervision

– One participant at a time

– Somersaults or high-risk maneuvers avoided

– Trampoline-jumping surface should be placed at ground level.

– Well padded bars

– Checked regularly

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Window Safety

• >5,000 falls from windows yearly– Age < 5 years old

– Serious head injuries / skeletal injuries

• No play near windows

• No furniture near by

• Install window stops / guards to limit opening to 4 inches

• Screens are not safety guards

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Thank YouOHSU