Pediatric Orthopedic Trauma

Pediatric Orthopedic Trauma Frequency of Childhood Fractures Assistant Professor, Pediatric Orthopaedics Department of Orthopaedic Surgery; Univ of Missouri Frequency by Season Frequency by Time of Day More common during the summer. Children are out of school and exposed to more vigorous physical activities. The time of day when children are most active correlates with the peak time for fracture occurrence. 6:00pm 1

Specific Fracture Types Fractures Resulting from Accidental Trauma Playground 90% were upper extremity fractures from a fall off of monkey bars or climbing equipment Change of playground surfaces concrete / dirt / rubber => bark (impact-absorbing) Skateboarding Nature of skateboarding being high speed and extreme maneuvers causes high-energy trauma fractures Roller Skates & In-line Skates Most injuries involve elbow, forearm, wrist, and fingers; < 20% use protective gear Fractures Resulting from Accidental Trauma Trampoline 1/3 of injuries result from falling off the trampoline Skiing More than half of the injuries occur due to collisions with stationary objects; i.e. trees, poles, stakes Snowboarding Compared to skiers, snowboarders have 2-½ times as many fractures 2

Clavicle Injuries Midshaft Clavicle Fractures Newborn Occur from compression of the shoulders during delivery Children/Adolescents Result of a fall onto outstretch extremity or side of shoulder Direct blow 85% of clavicle fractures 8-15% of all peds fractures Distal Clavicle Fractures Distal Clavicle Fractures 10% of clavicle fractures Pseudodislocations of the AC joint Fracture thru distal physis Periosteal sleeve intact Double clavicle sign 3

Distal Clavicle Fractures Clavicle Fracture Treatment Children and adolescents Arm sling Figure-of-eight sling Surgical Indications Displaced / shortened Open fractures Neurovascular injury Cosmetic reasons Trade a bump for a scar Proximal Humerus Growth Patterns Upper Extremity Growth occurs away from the elbow Humeral growth 80% proximal 4

Extraordinary remodeling potential of the proximal humerus Treatment Accept any alignment if 2 yrs growth Sling Sling and Swathe Hanging cast 5

Humeral Shaft Fractures If the bones are in the same room it will heal Elbow Fractures Supracondylar fractures (70%) Lateral condylar fractures (15%) Medial epicondylar fractures Radial head/neck fractures Transphyseal Olecranon Pediatric Elbow Fractures 5-10% of all fractures in children Distinguishing fractures from the six normal secondary ossification centers Girls mature earlier than boys Supracondylar Fractures 70% of all elbow fractures in children Average age: 6 y/o Anatomic predisposition: Ligamentous laxity Metaphyseal remodeling Thin cortex 6

Classification Vascular Injury Type I nondisplaced or minimally displaced Type II angulation with posterior cortex intact Type III completely displaced Occurs 0.5-1% Brachial artery laceration/occlusion m/c: posterolateral displacement, open fx Rely on clinical exam: Pale, non-viable vs. pink, viable Radial pulse? Suspect vascular compromise => direct surgical exploration Neurologic Injury Occurs: 7% AIN easily overlooked; currently felt to be m/c Radial nerve felt to be m/c in past; posteromedial displacement Median nerve posterolateral displacement Ulnar nerve common; olecranon pin traction; med. perc. pin Type I Supracondylar Fractures Long arm cast 4-6 weeks Sling is recommended Parents should be instructed on elevation of the extremity to reduce swelling Fingers above the elbow Elbow above the heart 7

Type II & III Supracondylar Fractures Type II & III Supracondylar Fractures Closed reduction Percutaneous pinning Cast immobilization Lateral Condyle Fractures Radiographic Findings Second most common elbow injury in children AP radiograph may show little abnormality Oblique film very important! 8

Lateral Condyle Fracture Treatment Recommendations > 2mm or unreliable Reduced percutaneous pin ORIF Avoid unnecessary dissection, especially posteriorly => AVN Use 2 divergent or widely-spaced pins Medial Epicondyle Fractures Average age: 9-12 y/o 4x boys > girls 3 rd m/c fracture; fuse by 15 y/o Mechanism: Acute avulsion by overpull of forearm flexor tendon or ulnar collateral ligament Chronic tension stress injuries (Little League elbow) Radiographic Findings Medial collateral ligament at base Entrapped epicondyle may be overlooked Entrapped medial epicondyle fracture of 11 year old - AP/LAT at time of injury CT Scan 5 weeks after injury shows entrapped med epicondyle 9

Medial Epicondyle Fractures Nondisplaced and minimally displaced fractures <5mm Immobilization in splint, 1-2 weeks Followed by early active range of motion exercises Open reduction and internal fixation Overhead athlete; fragment in the joint Radial Head/Neck Fractures Ossification starts ~ 4 years old Classification (Wilkins) I: valgus fractures II: fractures with elbow dislocation III: Monteggia variants Complications Stiffness *greatest with ORIF Synostosis AVN Physeal Closure/valgus *Due either to injury or treatment 10

Nursemaid s Elbow 11

Monteggia Fracture Before Treatment Monteggia Fracture After Treatment Shaft of Radius and Ulna Fracture 5-10% of children s fractures More common distally than proximally Closed treatment is usually successful, remodeling is significant, and malunion is uncommon 12

Distal Radius/Ulna Fractures Significant remodeling potential Well molded cast is key Short arm Nondisplaced fracture Long arm Requiring reduction Pin physeal fractures only if unstable Growth disturbance very rare Fractures of the Lower Extremities Hip Pelvic Femur Knee Tibial Spine Tibial Shaft Patellar Ankle Pediatric Hip Fractures <1% of all hip fractures 60% complication rate is much higher than the complication rate in adults AVN Coxa vara Premature physeal closure Leg length discrepancy 13

Blood Supply Changes over time At birth femoral head is supplied by vessels from the medial and lateral circumflex artery As the physis develops the metaphyseal blood supply diminishes and the lateral epiphyseal vessels supply the femoral head. Care then to avoid the pisiformis fossa and the posterior superior femoral neck. Pediatric Hip Fracture High energy injury If not given that history then look for pathologic fracture Fibrous dysplasia UCB Treatment Pediatric Hip Fractures Screw fixation 2-3 or hip screw and side plate Cross physis if necessary for stabilization Only 1mm of growth at the proximal physis per year! i.e. a 3 year old girl with 10 years of growth remaining will have a 1 cm LLD 14

Pediatric Hip Fracture Pelvic Avulsion Fracture Adolescent Playing in sports Powerful contraction of attached muscle Treatment: Rest Guarded wt. bearing w/ crutches Peds Femur Fractures -by age < 6 years: Fall 6-9 years: struck by vehicle 14-17 years: MVA (occupant) Falls and Child Abuse Major fracture- mechanism is questioned Actually is a valid mechanism! Fractures reported due to falls from bed or couch are abuse only in ~5% Hennrikus et al CORR 2003; 407:148 Inability to walk is a strong predictor of abuse (42% vs 3%) Schwend et al JPO 2000; 20:475-481 Hinton et al JBJS 1999; 81:500-507 15

Early Spica Early Spica -disadvantages No scars No implant Early discharge Good results - especially in young children - -relies on size, overgrowth, remodeling Hard to get around Difficult to manage polytrauma Who should we place in a spica cast?? Lighter weight patient Patients with home care arrangements Patients that require less time in cast When a tutor is not needed Who should we place in a spica cast?? New set of issues: Potty trained?? Attending day care, pre-k, or kindergarten?? Obese child Primary caregiver: Single parent? Two working parents? 16

5 y/o boy with pathologic femur fracture 17

Stabilizing Pediatric Femur Fractures Skin Traction Fractures about the Knee Ligamentous injuries are rare Stress views help sort out ligamentous versus physeal injury Distal femoral physeal injuries are more common than proximal tibial injuries r 18

SH I Distal Femur Fractures Pin using 2 smooth k wires that X above the growth plate and are aimed anteriorly in the sagittal plane 10 degrees Concerns Vascular injury Equivalent to a knee dislocation Nerve injury Popliteal or peroneal Physeal Closure > 50% Tibial Spine Fractures Tibial Spine Fractures ACL pulls off the tibial spine (incompletely ossified) instead of the tendon rupturing Initially - plastic deformation in the ligament; which is hard to repair McKeever Classification 19

Tibial Tubercle Fracture Treatment of Tibial Tubercle Fracture 3 Types: Type 1: Fx through the ossification centre of the tuberosity Treatment: Casting Type 2: Fx w/comminution of the ossification centre Treatment: Surgical Management Type 3: Fx extending into the knee w/some displacement Treatment: Surgical Management Patellar Sleeve Fracture Patellar Sleeve Fracture Avulsion of cartilaginous inferior pole of the patella Diagnosis High riding patella Loss of knee extension Gap to palpation at the inferior pole 8-12 y/o children Sleeve: Articular cartilage, periosteum, and retinaculum Surgical treatment: > 3mm displacement Disrupted extensor mechanism 20

Patellar Sleeve Fracture Proximal Tibial Metaphyseal Fractures Cozen fracture Will grow into a valgus deformity (1yr) Overgrowth medially Tethering of fibula Expect spontaneous correction Tibial Shaft Fractures Tibial Shaft Fractures About 70% of tibial shaft fractures in children have an intact fibula Account for 4% to 5% of all pediatric fractures Occur most commonly in boys (3-4 and 15-16 y/o) Third most common long bone fracture in kids Treatment: Casting Pins and plaster External Fixator Flexible IM nails 21

Toddler Fracture 18-24 months old Trip and fall Refusal to bear weight External rotation injury Distal third spiral fracture Distal Tibia Physis Fractures Treated with closed reduction and long leg cast Displacement: Acceptable => younger ; anteroposterior plane Adolescent with valgus/varus angulation Cannulated screw or K-wire Periosteum / fibula => block reduction! Principles of Distal Tibial Growth Distal tibia ossific nucleus Appears => 2 3 y/o Fuses: Girls => 15 y/o Boys => 17 y/o Fuses central to medial and then lateral over 18 months! Distal fibula ossific nucleus Appear => 2 y/o Fused => 20 y/o Secondary ossification centers Tillaux Fractures Older adolescent Physis: Medial => closed; Lateral => open Fracture runs though the physis, across the epiphysis, and into the joint Fracture fragment => anterior due to the anterior tibiofibular ligament Internal rotation => reduction 22

Triplane Fractures Triplane Fracture Two-part or three-part fractures Fracture pattern: coronal, transverse, sagittal Closed reduction: Internal rotation; very difficult Triplane Fracture Triplane Fracture 23

Thank You!! 24

Evaluation and Management of Idiopathic Scoliosis Scoliosis Lateral curvature of the spine (coronal) Three dimensional: Sagital plane Vertebral rotation (axial plane) Assistant Professor, Pediatric Orthopaedics Department of Orthopaedic Surgery University of Missouri - Columbia True Scoliosis: Cobb angle > 10 Prevalence Faternal Twins 2% - 3% for curves >10 0.3% for curves >20 0.1% for curves >40 Female to male ratio: curves 11-20 (1.4:1) Curves > 20 (5:1) Males are much less likely to progress 57 degrees 30 degrees 1

Etiology Genetic component but most likely multifactorial Many other factors implicated but not proven: - Melatonin deficiency - Growth hormone - Asymmetric spinal growth - Increased platelet calmodulin - Vestibulo-ocular system dysfunction Adolescent idiopathic scoliosis. Monograph Series 28. Anterior spinal growth outpaces posterior spinal growth Etiology Genetic Testing for Idiopathic Scoliosis: Axial Biotech Scoliscore AIS Prognostic Test DNA-based testing» 53 genetic markers associated w/ severe curve progression (SNPs)» SCORE: 1-200» < 50 = low risk; > 180 = high risk Launched: 12/08 Dr. James Ogilvie chief investigator 2

Idiopathic Scoliosis Types include: Infantile: 0 to 3 years of age Juvenile: 4 to 9 years of age Adolescent: 10 years of age to maturity Infantile Idiopathic Scoliosis Boys (3:2) Convex left curves (75%) Uncommon 1% in USA Associated with: Plagiocephaly (72%) DDH Postnatal positioning Resolves in 90% RVAD < 20 MRI for curves>20 Infantile Idiopathic Scoliosis Juvenile Idiopathic Scoliosis 4-9 year olds Neural axis anomalies (15-26%) MRI for curves > 20 More aggressive than AIS Rare spontaneous resolution 100% need for surgery for curves > 30 before puberty Charles et al. Spine, Vol 31 (17). 2006 Dobbs et al. JBJS, 84. 2002 3

School Screening Identify body asymmetry Forward bend test Value is often debated Referral rate: 3.4 30% Scoliometer False Negatives 5 degrees => 100% sensitive; 47% specific 7 degrees => 83% sensitive; 86% specific 4

Natural History Natural History Curves > 30 before maturity tend to progress Curves 50 at maturity tend to progress ~ 1 /year into adulthood Curves 80 : VC < 65% Skeletally Immature Age The younger you are the greater the risk of progression Curve Magnitude Larger curve => greater risk of progression Weinstein et al. JBJS 1981; 63: 702 Weinstein et al. JBJS 1983; 65: 447 Natural History Skeletally Immature Sex Females have a greater risk of progression Curves > 20 (5:1) Type of Curve Thoracic >>> Lumbar Double curves >>> Single curves Pulmonary Function Thoracic curves: Curves > 60 => 68% TLC (usually asymptomatic) Curves > 100 => 50% TLC (symptomatic) No correlation between: Thoracolumbar / Lumbar curves and pulmonary function 5

Back Pain and Scoliosis Present 23% at time of initial evaluation* 9% will have an identifiable cause* Identifiable causes: Spondylolysis Scheuermann s disease Disk, syrinx, or tumor Cutaneous lesions Gait Neuro exam, reflexes Limb length inequality Clinical Evaluation Extensive initial work up not indicated!!! *Ramirez et al. JBJS 1997; 79: 364 Clinical Evaluation Shoulder height Alignment Plumb line Trunk Shift Rotation Rib or scapula prominence Sagital deformity Radiographs Not indicated => minor curve Standing 36 PA film from T1-S1 Less XRT on breast tissue Lateral film curve looks abnormal or for preoperative purposes 6

Cobb Angle Are we skeletally mature?? Risser Sign Tanner Stage Peak height velocity Triradiate cartilage closure Menarchal age Tanner-Whitehouse stages Skeletal Maturity?? 14 y/o female 30 deg curve Just started menses Risser 4 7

King-Moe Classification No Treatment Curves <25 Immature patients (Risser 0-2): Follow up in 4 to 6 months Mature patients (Risser 4-5): Follow up not needed Curves 25 to 45 in (Risser 4-5) girls: Re-evaluate in 1 year Mainly a thoracic curve classification w/ no reference to sagittal balance Brace Indications Boston Brace Milwaukee Brace Curves 25-45 (Risser 0-1): Brace on initial evaluation Curves 25-30 (Risser 2-3): Brace if documented progression >5 Curves 30-45 (Risser 2-3): Brace on initial evaluation Brace treatment for curves >40 to 45 has a lower success rate 8

Boston Brace Boston Brace Introduced (1971) Low-profile brace Prefabricated Created from the full length x-rays Not effective: Curves above T7 Prevents progression Doesn t make better Charleston Brace (Night-time bending brace) Brace Regimen 23 hours per day is ideal - Recent SRS meta-analysis revealed dose dependent response (Rowe et al. J Bone & Joint Surg; 78: 1997) 16 to 23 hours may have some benefit (Green N. JBJS 1986; 68: 738) Continue until maturity: 2 years post-menarche Risser 4 in females, Risser 5 in males No significant gain in height Best for thoracolumbar and lumbar curves Not that effective in males (Karol. Spine 2001; 26: 2001) Katz et al. Spine 1997; 22: 1302 9

Treatment Fixation devices Surgical - Skeletally immature w/ curves > 40-50 - Skeletally mature w/ curves > 50 * Exception may be well balanced curves - Use clinical judgment as well. Pedicle screws Hooks 13 y/o female Post-op 50 degrees 10

Selective thoracic fusion Originally recommended by King and Moe for type II curves (JBJS 1983; 65: 1302) Decompensation of the lumbar curve common due to failure to identify double major curves (Spine 1990; 15: 927) Current criteria (Spine 1992; 17: S274) 1) Thoracic/Lumbar Cobb ratio > 1.2 2) Thoracic/Lumbar AVT ratio > 1.2 3) Thoracic/Lumbar AVR ratio > 1.0 54 degrees; 40 degrees Selective thoracic fusion Anterior Spinal Fusion Anterior or Posterior? - Early enthusiasm for ASF * Saving fusion levels * ASF ideal for hypokyphosis - Enthusiasm diminishing w/ use of pedicle screw PSF T3-12 Potter et al. Spine 2005; 30: 1859 11

14 y/o female Post-op 57 degrees EOS Growing Rods 12

Thoracoscopic Surgery Limited Application Great exposure Decrease post-op pain Large learning curve Expensive / New Less long term effect on pulmonary function* Kishan et al. Spine 2007 Anterior Vertebral Body Stapling Nitinol Memory alloy staple Nickel Titanium Naval Ordinance Lab 50% Nickel, 50% Titanium Chilled: straight Body temperature: curved inward COLD Braun et al, Spine 2006;31:1314-1320 Early studies demonstrate equivalency when compared to bracing effectiveness in preventing curve progression (75%) Indications 6-10 years of age Juvenile idiopathic scoliosis Unable to tolerate bracing Scoliosis curves < 35 deg (thoracic); <40 deg (lumbar) WARM Surgical Technique Thoracoscopic assisted surgery Double lumen endotracheal tube Trial inserter to size staple and create pilot holes Insert chilled staple Anterior placement to prevent lordosis Post op chest tube No brace Release to full activities in 1 month Betz et al, Spine 2003;28:S255-S265 8 y/o female 34 degrees 13

Post-op Thank You 14

Rotational Deformities of the Lower Extremities AKA INTOEING AND OUTTOEING NORMAL DEVELOPMENT The tibia in a newborn is internally rotated and should gradually externally rotate as the child matures. It is a gradual process and should gradually externally rotate to around 10 degrees of external rotation by 8 years of age with a mean of 15 degrees at maturity. NORMAL DEVELOPMENT At birth, femoral anteversion is around 30 degrees and gradually decreases to around 10 degrees by maturity. Most newborns have an outtoeing exam. This is usually due to an external rotation contracture of the hip that should spontaneously resolve typically by the time they are standing or walking. 1

CAUSES 1. Tibial Torsion-toddler age to preschool 2. Femoral Anteversion-school age child to adolescence 3. Metatarsus Adductus-all ages but usually infant TIBIAL TORSION Cause can be attributed to genetic predisposition and/or possibly due to intrauterine molding. Tibial torsion is most commonly seen in the toddler age. It is usually noticed when the child begins to walk. twist in the shin FEMORAL ANTEVERSION 2

It is commonly seen in the older child. These children are frequently described as comfortably sitting in the W position twist in the hip METATARSUS ADDUCTUS Lateral border of the foot is curved instead of straight twist in the foot or sometimes referred to as 1/3 clubfoot - the forefoot turns in but not the hindfoot; no equinus About 1% of infants may have this May be due to intrauterine crowding Can be seen in association with Developmental Dysplasia of the hip (DDH) 3

EXAMINATION DIAGNOSIS This will include a rotational profile exam and an exam of the child s gait Rotational Profile exam includes: Foot exam, Thigh-foot angle, Hip exam, and foot progression angle. I also like to watch the child and how they ambulate and play in the exam room while I am obtaining their history. METATARSUS ADDUCTUS Foot exam- Examine the lateral border of the foot and check the heel bisector line. A normal heel bisector line falls in between the second and third toe. If it falls at the 3 rd toe then they have mild metatarsus adductus. If it falls at the 4 th toe, it is moderate and 5 th toe means it is severe. 4

The foot should also be checked for flexibility This will classify the foot as either actively correctable, passively correctable, or rigid. Actively correctable feet straighten out when the lateral border of the child s foot is stroked by the examiner s finger. This causes the muscles of the foot to contract correcting the foot shape to neutral position The passively correctable foot straightens with gentle manipulation. The rigid foot does not. Also in the metatarsus adductus foot the space between the first and second toe may appear wide, especially when standing. The ankle joint and heel alignment are normal TIBIAL TORSION Check the Thigh-foot angle The thigh-foot angle will help determine the degree of tibial torsion and if it is internally or externally rotated. Let the foot fall in its natural position when assessing this. While walking, these children s knees tend to point out but the feet point in. Occasional tripping may be reported with this condition. 5

FEMORAL ANTEVERSION/RETROVERSION Check internal and external rotation of the hips Make sure the pelvis is stabilized during this exam so that the exam is more accurate. It may take two people perform this. I utilize the parents help as needed. Internal rotation close to 90 degrees and external rotation less than 15 degrees is abnormal. IN GENERAL When these kids walk, their knees and feet may look like they point in (anteversion). They may also kick their feet out to the side when running. Check the foot progression angle while walking 6

This is the angle between the long axis of the foot and a line of the forward direction of gait. The foot progression angle is a summation of the rotational alignment of the leg. The remainder of the exam then attempts to identify the level of the rotation. I also try to do a thorough hip exam and examine the spine for any scoliosis or defects. This is also a good time to look for any neurological issues/diseases. The neonatal and developmental history will assist in this. TREATMENT GENERAL TREATMENT Educate, educate, educate.. Observation and explanation to the family that it may take several years to improve/resolve. Bracing is cumbersome and has no value. If there is still functional or cosmetic concern then surgery may be an option after the child is older, >10 years. 7

TREATMENT FOR METATARSUS ADDUCTUS Study published in the Journal of Pediatric Orthopaedics July-August 1996 that looked at 100 high school students and the relationship between sprinting ability and intoeing. The findings suggested that a low-normal TFA and intoeing while sprinting may correlate with enhanced sprinting ability. I use this article to help educate the parents and hopefully reduce some of their anxiety The actively correctable foot does not require treatment and tends to correct spontaneously in the first 2 years of life. Reassurance and education for the family is important. The passively correctable foot may or may not respond to stretching exercises. Observation vs. stretching vs. casting is controversial. The rigid foot may be treated with serial casting. This tends to be more effective in the infant age. If indicated, it may also be treated surgically in the older child. ROTATIONAL MALALIGNMENT SYNDROME ADDITIONAL INFORMATION This usually includes external tibial torsion and femoral anteversion (internal rotation). It can cause patellofemoral tracking issues and pain. It is also more likely to require operative intervention. 8

ANY CONCERNS-REFER TO PEDS ORTHO THANKS! Kelly Scott,MSN,RN, FNP-BC Nurse Practitioner in Pediatric Orthopaedics, University of Missouri REFERENCES Orthopaedic Surgery Essentials. (2004). Pediatrics. Philadelphia: Lippincott Williams and Wilkins. Staheli, L. T. (2006). Practice of Pediatric Orthopedics. Seattle: Lippincott Williams and Wilkins. Texas Scottish Rite Hospital for Children. (2008). Tachdjian's Pediatric Orthopaedics 4th ed. Philadelphia: Saunders. Fuchs,R & Staheli, L. Sprinting and Intoeing. Journal of Pediatric Orthopaedics: July/August 1996, pp.489-491. 9

History When, gradual or abrupt, where, how frequent? Was there an injury associated with it? Worsening with time? Severity? Interference with play/sports** Who s concerned: parent, grandparent, neighbor, therapist? Weight loss? Physical Palpation ROM & Flexibility Gait * Antalgic (Fracture) * Trendelenburg (DDH, LCP, SCFE) * Proximal Muscle weakness (DMD) * Spastic Gait (CP) * Short limb gait (LLD) 1

Transient Synovitis Septic Arthritis Developmental Dyplasia of the Hip (DDH) Legg Calve Perthes Disease Osteomylitis Slipped Capital Femoral Epiphysis (SCFE) Inflammatory Synovitis Common cause of limping Seen most often in children 3 8 y/o Often a history of precursor viral illness Hip most often affected They may have pain, stiffness, altered weight bearing Labs usually normal (CBC, CRP, Sed rate) Treat with rest, observation, and NSAIDS (scheduled ibuprofen) Improvement usually dramatic Signs and symptoms usually resolve over several days with the average duration being 10 days 2

Urgent medical management due to the potential for significant joint destruction Possible history of precursor mild trauma or concurrent infection/illness Usually febrile systemic illness The child usually holds the affected extremity immobile May have swelling of the joint, redness, warmth and tenderness to palpation More ill appearing than transient synovitis Labs elevated (check CBC, Sed rate, CRP and blood cultures) Treatment: Plain xrays, Admit to hospital, Ultrasound, joint aspiration to identify causative organism, antibiotics, low threshold for I &D if suspicious Kocher criteria 1) Temp >38.5 2) Refusal to bear weight 3) WBC > 12K 4) ESR > 40 1 present 3% (9%) 2 present 40% (35%) 3 present 93% (72%) 4 present 99% (93%) Kocher et al. JBJS 1999; 81: 1622 Kocher et al. JBJS 2004; 86: 1629 History: Family history, breech, torticollis, foot deformities Abnormal gait pattern: Trendelenburg gait weakened abductor muscles Other PE findings: Shortened extremity, asymmetrical thigh folds, limited abduction, Klisic test, hyperlordotic Radiograph: order AP, Frog lateral pelvis, US in infant < 6mo Acetabular dysplasia, subluxation, dislocation 3

Treatment ranges from Pavlik harness to surgery. Refer to ortho Hip disorder that causes collapse of the femoral head May have a history of trauma Most prevalent in children 4 12 y/o with boys > girls Pain may be in hip, groin, or referred to thigh or knee Often present with a limp that is exacerbated by physical activities and alleviated by rest Hip range of motion is stiff 4

X ray: AP and Frog lateral of the pelvis Treatment varies from rest to surgical treatement Refer to Ortho Classic history: Minor trauma Doing well for 1 3 days Increasing pain, swelling, not using extremity Occurs in the metaphysis Most common sites: Distal humerus, distal radius, proximal femur, distal femur, proximal tibia Acute produces local pain, swelling, warmth, erythema and tenderness, may have systemic symptoms CRP and ESR usually elevated, check blood cultures too Order x rays A bone scan may help localize the site of involvement if this is unclear A MRI may be helpful to localize any abscess Subacute An infection with duration longer than 2 3 weeks Often residual of acute osteo that has been contained but not eradicated May have local swelling, warmth and tenderness May present with a limp X ray changes: (7 14 days) Periosteal reaction, periosteal elevation (abscess) 5

Chronic osteomylitis untreated acute osteo Treatment for Osteomylitis Refer to ortho, aspiration or drainage of abscess, medical management if no abscess Displacement between the proximal femoral epiphysis and metaphysis Common adolescent hip disorder Can be acute or gradual Typically seen in boys 12 15 y/o or girls 10 13 y/o with boys > girls Present with pain usually in the hip, groin, thigh or knee Risk factors: Overweight, African American race, underlying endocrine disorders Always think of the hip if they are presenting with knee pain Decreased internal hip rotation May have an outtoeing gait on the affected side Risk of contralateral involvement 20 60% X ray: Order AP and Frog lateral Pelvis Treatment: Surgery and possible prophylactic fixation of the other side if necessary 6

Juvenile Rheumatoid Arthritis Cerebral Palsy Muscular Dystrophy Fractures/ Injuries Leg Length Discrepancy Leukemia/Neoplasms Discitis /Back Pain Tarsal Coalition Kelly Scott, RN, MSN, FNP BC Nurse Practitioner Pediatric Orthopaedics University of Missouri 7