Selected Pediatric Conditions

Contents

Type I Salter-Harris epiphyseal injury
Most common adolescent hip disorder, peak at pubertal growth spurt
Risk: male, obese, hypothyroid
Acute (sudden displacement) and chronic (insidious displacement) forms
Clinical features: bilateral involvement occurs in about 25%
- acute: sudden, severe pain with limp
- chronic: limp with medial knee or anterior thigh pain
- Whitman’s sign: with flexion there is an obligate external rotation of the hip
X-Rays: AP, frog-leg, lateral radiographs
- posterior and medial slip
- if mild slip, AP view may be normal or show slightly widened growth plate compared with opposite side

Formerly called congenital dysplasia of the hip (CDH)

Due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular roof

Spectrum of conditions

Painless, if painful suspect septic dislocation

Diagnosis is clinical

limited abduction of the flexed hip (<50-60o)
affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum
Barlow’s test (for dislocatable hip)
- flex hips and knees to 90o and grasp thigh
- fully adduct hips, push posteriorly to try to dislocate hips
Ortolani’s test (for dislocated hip)
- initial position as above but try to reduce hip with fingertips during abduction
- palpable clunk if reduction is a positive test (reduction is felt, not heard)
Galeazzi’s Sign
- knees at unequal heights when hips and knees flexed
- dislocated hip on side of lower knee
- difficult test if child <1 year
- Trendelenburg test and gait useful if older (>2 years)

Self-limited AVN of femoral head, presents at 4-10 years of age
Etiology unknown, 20% bilateral, males > females, 1/10,000
Associations: family history, low birth weight, abnormal pregnancy/delivery, history of trauma to affected hip

Key features

AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodeling of regenerated bone

Clinical features

X-Rays

Fixed deformity
3 parts to deformity
- talipes: talus is inverted and internally rotated
- equinus: ankle is plantar flexed
- varus: heel and forefoot are in varus (supinated)
May be idiopathic, neurogenic, or syndrome-associated
1-2/1,000 newborns, 50% bilateral, occurrence M>F, severity F>M

Treatment

Correct deformities in the following order (Ponseti Technique):
1. forefoot adduction, ankle inversion, equinus
  - change strapping/cast q1-2 weeks
2. surgical release in refractory case (50%)
  - delayed until 3-4 months of age
3 year recurrence rate = 5-10%
mild recurrence common; affected foot is permanently smaller/stiffer than normal foot with calf muscle atrophy

Clinical features

± back pain
1o curve where several vertebrae affected
2o curves above and below fixed 1o curve to try and maintain normal position of head and pelvis
asymmetric shoulder height when bent forward
Adam’s test: rib hump when bent forward
prominent scapulae, creased flank, asymmetric pelvis
associated posterior midline skin lesions in non-idiopathic scolioses
café-au-lait spots, dimples, neurofibromas
axillary freckling, hemangiomas, hair patches
associated pes cavus or leg atrophy
apparent leg length discrepancy

Treatment

based on degree of curvature
<20o: observe for changes
>20o or progressive: bracing (many types)
>40o, cosmetically unacceptable or respiratory problems: surgical correction (spinal fusion)

Attachments:

Clubfoot.jpg (image/jpeg)

Scolioses.jpg (image/jpeg)