Selina Silva, MDUNM Carrie Tingley Hospital

Intoeing/ OutoeingBowlegged/ knock-kneedFlexible FlatfeetGrowing PainsSeptic JointsLegg-Calve-PerthesDDHSCFEScoliosisBack Pain

3 sources of intoeingFemoral

anteversionInternal

tibial torsionMetatarsus

adductus

Femoral AnteversionNormal is for children to be born with

30 degrees and with growth this normalizes to 10 degrees as an adult.

Women have more femoral anteversion than men

Often familialMeasure the amount of IR and ER of

the hipGreater than 70 degrees IR is

considered severe

Internal Tibial TorsionCommon for one leg to have

more than the otherAlso externally rotates with

growth to about 15 degrees as an adult

Measure the thigh-foot angle5 degrees IR to 15 degrees

ER is normal

Metatarsus AdductusMost common congenital foot deformityForefoot metatarsals are medially rotated on

cuneiformsHindfoot is normalFlexible and resolves on its own 85% of the

time

Deformity in femur or tibia

Usually does not improve with growth or worsens

Less tolerated and so treated surgically more often

If asymmetric, need to rule out other problemsSCFE

Toeing out usually corrected around the age of 7-10 if symptomatic

Toeing in often resolves near normalTherefore give more time prior to offering

surgical correctionCorrect severe cases, greater than 70 degreesCorrected in early teen years if symptomatic

Forefoot adduction corrects 85% of the time on its ownStart with passive stretching by parentsCan do casting if not correctingIf rigid and not correcting, osteotomies can be

done around 5 yo

www.pulsetoday.uk.co

www.orthopediatrics.com

Physiologic between 1-3External rotation hip contracturesInternal tibial torsion

Blounts:Disturbance of proximal tibial physisOften unilateralOverweight child, early walker vs. obese adolescent

FamilialRadiographic

changes not limited to medial tibial physis

Notice bowing of femurs

Physiologic between ages 3-6

Worry if unilateralAnkles rolling in

correct when the knees correct

Early teens may consider hemiepiphysiodesis

Indications:

Mechanical axis off and knee pain or patellar subluxation

20% of the population, variant of normal

When stand on toes there is an arch

No treatment unless feet hurt

Orthotics for symptomsSurgery for correction

Usually bilateral lower extremitiesAt night or first thing in the morningGoes away with massage/attentionTreatment: Vitamin D3 and give 3-4 months

of supplementation to really see resultsFLAGS:

Always same jointWakes them up in the middle of the nightStop playing or doing sports because of pain

Painful, swollen jointRed and pain with axial loadAspirate joint and send for gram stain, cell count,

and culture prior to antibioticsIf septic, emergent incision and drainage is requiredSometimes difficult to differentiate from cellulitis

Risk Factors:First born, female,

breech, family historyPhysical Exam:

Check Ortolani and Barlow

Asymetric Skin CreasesCheck GaleazziCheck for asymetric

hip abduction

No Swaddling the legs, can still swaddle arms and get same effect

Ultrasound helpful after 1 mo of age

AP Pelvis at >4 months old

Can present at limb length discrepancy in walking child

AVN of femoral headAges 4-8, usually boysPain and limp, no fevers, worse with more activityAP/Frog Pelvis xray for diagnosis and send to Ortho

Patient profileObese preteenOften c/o knee painAffected leg may

rotate outwardsAlso seen with kids

that have thyroid problems

REAL danger is bone death of femoral head

ALWAYS think of hips, when c/o knee pain

Order AP Pelvis and Frog view Pelvis xrays

If positive, put on crutches, TDWB and send to Peds Ortho/ER immediately

Hight risk of AVN, which occurred in this patient

SCFE is always a surgical problem

Forward bend testImbalance of shoulders or pelvisGreater than 10 degree curve on

Xray is scoliosis

Sometimes presents as limb length inequality

Most accurate is standing posterior view: PSIS “dimples”

Get an MRI if thoracic curve is going to the left or neurologic findings

Any patient with scoliosis we need to see and follow until they are 18 years of age

We follow about every 6 months with Xrays

Brace at about 25 degreesSurgery if rapidly

progressing or greater than 50 degrees

Scoliosis does not cause back pain

Kids with or without scoliosis and that have back pain are initially treated with home exercise programWe have handout for this

If fail home exercise/stretching program will send to formal physical therapy1x per week, for 12 weeksCore strengthening, truncal stability and

hamstring stretchesIf fail therapy, then get MRI or Bone ScanIf any neurologic findings get MRI