1 Limping Pediatric Diagnosis and Orthopedics: The Challenge of the Limping Child Suraj Achar, MD, FAAFP ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
42
Embed
Limping Pediatric Diagnosis and Orthopedics: The Challenge of … · 2020-06-16 · Limping Pediatric Diagnosis and Orthopedics: The Challenge of the Limping ... He is the editor
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Limping Pediatric Diagnosis and Orthopedics: The Challenge of the Limping Child
Suraj Achar, MD, FAAFP
ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
2
DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.
Suraj Achar, MD, FAAFP Professor, Department of Family Medicine and Public Health, Department of Orthopaedics, University of California, San Diego (UCSD); Professor, Department of Orthopedics, Rady Children’s Hospital, San Diego, California; Team Physician, UCSD Varsity Teams, San Diego Padres, San Diego Sockers, United States Olympic Training Center
Dr. Achar earned his medical degree from State University of New York (SUNY) Buffalo School of Medicine and Biomedical Sciences. He completed his residency and fellowship at the University of California, San Diego (UCSD). He is board-certified in family medicine and sports medicine, practicing at UCSD and Rady Children’s Hospital. His specialty topics include pediatric sports medicine and the legal aspects of medicine. At UCSD, Dr. Achar cares for a wide variety of patients, including professional and Olympic athletes. He is the editor of The 5-Minute Sports Medicine Consult and is consistently named a top doctor by the San Diego County Medical Society.
3
Learning Objectives1. Use an evidence-based, systematic approach to diagnosing children
with deviations from normal age-appropriate gait patterns.
2. Order or provide appropriate laboratory tests and imaging studies to confirm diagnosis, as suggested by the history and physical examination.
3. Coordinate referral and follow-up care with a pediatric orthopedic surgeon, or other sub-specialist, as indicated by confirmation of the diagnosis.
4. Counsel parents on developmental milestones to evaluate in their children.
Audience Engagement SystemStep 1 Step 2 Step 3
4
Epidemiology of the problemAdirim TA, Cheng TL, Overview of Injuries in
the young athlete. Sports Med 2003
• 27/51 million play team sports
– The hidden demographics of youth sports, ESPN July 2013
– Aspen Institute• > 1/3 injury doctor or nurse/year
trivial trauma that can cause this injury may often be unknown or overlooked by the caregiver Distal ½ of tibia43% of initial x-rays negativeUndisplaced & spiral
Misleading!Retrospective Study:
163 infants and children with osteo-myelitis of the long boneshistory of preceding blunt trauma was elicited in 1/3?
What is wrong with this image?
13
Physical Exam
• Temperature
• Gait Eval?
• + Joint exam
• Physical Bone survey
Active 10yo F: L knee pain 3‐4 months. Pain started with soccer, but has increased to pain with just walking around.
14
Swelling L knee ~ 2 weeks ago which has since resolved after ice & motrin. Mom has tried to back child off from activities, but pushing through & has continued most activities, but with less force.
No prior injury. No numbness, weakness or tingling. ROS: neg
10 y/o soccer player: shoe stuck?
• STRENGTH TESTING: 1/5 strength in knee flexion and extension
• SLJ?
• What to do?
15
Surgery vs non‐op?
Non Operative Complications• <ROM
• weakness due to prolonged immobilization
• Risk of OA
• Loss of terminal extension or persistent extension lag
• usually does not compromise function or the ability to return to sport.
• Nonunion is rare
Operative Complications• Infection
• failure of hardware (eg, wires breaking)
• < ROM
• Nonunion
• osteonecrosis
AES Question #3 - Laboratory Analysis:
• Which test is not as useful in the limping child workup
1. CBC
2. ESR
3. C-reactive protein• Days vs hours• ESR (mm/h) < Age (y) +10 (if female)
2
• Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med 1992; 21:1418.
Days post inflammatory response
CRP
ESR
16
Presidential Fitness Test
A Pill for all ills?
17
9 y/o Left knee pain x 2 months, No trauma, 1‐2 x day intermittent, no RxOnset: sitting for a long time and stands up “locking of knee”, also in middle of running
Exam limited flexion, negative Wilson test, X‐ray nl
12 y/o competitive
male Baseball player2
years of right thigh/knee
pain
• No trauma but had 9/10 non-radiating, “aching” and “punching” pain at night
• Sometimes also at baseball practice• Improved with ibuprofen (30min)
• PCP and Urgent care ibuprofen• PCP and diagnosed with growing pains
and then Osgood Schlatter disease after initial x-rays of hip and knee were negative for acute pathology
• Pain persisted over 2 years• He had no associated constitutional
symptoms
18
Inspection: Marked atrophy of right quadriceps and calf musculature when compared to left.
Palpation: Unremarkable
ROM: Unremarkable
Strength: ⅘ strength to extension of right knee
Exam
Imaging
19
Advanced Imaging
Rx & response
20
12 y/o female runner with heel pain
• Diffuse heel pain
• 2 months
• training
• PE:
• squeeze test
• Tight heel cord
Severʼs Disease‐ Traction ApophysitisAnalogous to Osgood‐Schlatterʼs Disease
21
Severʼs Disease
• History
• Occurs during peak growth spurt.
• Running and jumping sports, particularly soccer..
• Physical Exam
• + squeeze test & tight heel cords.
• X‐ray‐serve to r/o other pathology
Treatment & Prognosis
• P®ICE
• Heel lifts
• Stretching & strengthening exercises
• Acetaminophen/NSAIDS
• Symptoms resolve in 98%
• RTP 2 months
22
14 month old boy
• HPI:• R toes outward?
• PMHx & Birth Hx-wnl• Development Hx: wnl • Child began walking at age 12
months.
• PE
• Asymmetric skin-folds• Limited abduction L
What test can lead to diagnosis?
AP Pelvis
Broken Shentonʼs line
> Acetabular Angle
https://en.wikipedia.org/wiki/Hip_dysplasia
23
Developmental Dysplasia of the Hip (DDH)
• Definition• Spectrum of abnormalities
• Instability -> frank dislocation
• Acetabular malformations
• Before or after birth?
AES Question #4
Which of the following is not a risk factor for DDH?
1. Male sex
2. Breech presentation
3. Torticollis
4. 1st birth
5. Club foot
24
DDH: Incidence and Etiology?• Genetics vs Environment?
• North American Indians: 25‐50/1,000
• Chinese & Black Africans~0
• Hx: Japan: 3.5%‐>0.2%
• Papoose board
• Familial incidence ~ 20%
https://en.wikipedia.org/wiki/Papoose#/media/File:Edward_S._Curtis_Collection_People_007.jpgJapan: 3.5%->0.2% when cradle board was discouraged
What is the best test to identify developmental dysplasia of the hip in a 2-week-old newborn?
Ortolani & Barlow tests
Dynamic ultrasound
X‐ray studies
All of the above
25
Diagnosis DDH: 0-8w
• Ortolani
• BarlowClick vs Clunk?
Ultrasound
• Costly!/Training?
• Screening: • > 6 weeks c inconclusive
exam
• Confirm reduction/Monitor • (real time Ortolani/Barlow)