Pediatric Lower Extremity Orthopedic Concerns Esther Tompkins, DO Ped’s PM&R

Pediatric Lower Extremity Pediatric Lower Extremity Orthopedic ConcernsOrthopedic Concerns

Esther Tompkins, DOEsther Tompkins, DO

Ped’s PM&RPed’s PM&R

In Toeing DeformitiesIn Toeing Deformities

Three possible causesThree possible causes

1. Metatarsus Adductus1. Metatarsus Adductus 2. Internal Tibia Torsion2. Internal Tibia Torsion 3. Femoral Anteversion3. Femoral Anteversion

Metatarsus AdductusMetatarsus Adductus

““Foot turning in” most common Foot turning in” most common orthopedic problem in children.orthopedic problem in children.

Forefoot in varus and hindfoot in Forefoot in varus and hindfoot in valgusvalgus

Unlike clubfoot in which the forefoot Unlike clubfoot in which the forefoot and hindfoot are both in fixed varus.and hindfoot are both in fixed varus.


Physical ExaminationPhysical Examination 1. Foot is curved like a “C” with 1. Foot is curved like a “C” with

toes point to the midline.toes point to the midline. 2. The toes can be brought up up 2. The toes can be brought up up

easily into neutral plantigrade easily into neutral plantigrade position, and the heel comes down position, and the heel comes down into neutral.into neutral.


Treatment Treatment 1. If, by stroking the lateral side of 1. If, by stroking the lateral side of

the foot it straighten out, it will the foot it straighten out, it will mostly resolve on it own, by age 3-mostly resolve on it own, by age 3-5 years of age.5 years of age.

2. Stretching and ROM exercises 2. Stretching and ROM exercises done by caregiver.done by caregiver.

3. Serial casting3. Serial casting

Internal Tibial TorsionInternal Tibial Torsion

Normally, the medial malleolus Normally, the medial malleolus should be 15° anterior to the should be 15° anterior to the transcondylar axis of the knee transcondylar axis of the knee joint.joint.

If the lateral malleolus in on the If the lateral malleolus in on the same plane or anterior to the same plane or anterior to the medial malleolus, this infers medial malleolus, this infers internal tibial torsion.internal tibial torsion.

Internal Tibial TorsionInternal Tibial Torsion

Refer to an Orthopedic DoctorRefer to an Orthopedic Doctor

As treatment is very controversial As treatment is very controversial if surgery or bracing is the best.if surgery or bracing is the best.

Femoral AnteversionFemoral Anteversion

Consider this only after you have Consider this only after you have rule out metatarsus adductus, and rule out metatarsus adductus, and internal tibial torsion.internal tibial torsion.

History of this child usually History of this child usually includes sitting in the reverse “W” includes sitting in the reverse “W” or “TV squat” position. or “TV squat” position.


Two type of “TV squat” positionTwo type of “TV squat” position• 1. Hip flexed to 90°, knee flexion to 1. Hip flexed to 90°, knee flexion to

130°, with 90° of external rotation of 130°, with 90° of external rotation of the legs and feet pointing out.the legs and feet pointing out.

• 2. Hip flexed to 90° and sitting on 2. Hip flexed to 90° and sitting on legs with feet turned in and adducted legs with feet turned in and adducted underneath their butt.underneath their butt.


Physical ExamPhysical Exam Normal exam is 40°-50° of IR & ERNormal exam is 40°-50° of IR & ER Abnormal exam with anteversion Abnormal exam with anteversion

IR 90° and limited ERIR 90° and limited ER ER >25° than gait is normalER >25° than gait is normal ER <15°-20° than gait is abnormalER <15°-20° than gait is abnormal


TreatmentTreatment

• 1. Taylor sitting position often only 1. Taylor sitting position often only treatment needed, and resolves by treatment needed, and resolves by 10-12 years of age.10-12 years of age.

• 2. Referral to Ortho if ER <15°-20° 2. Referral to Ortho if ER <15°-20° for treatment.for treatment.

The HipThe Hip

1. CDH = Congenital dislocation of 1. CDH = Congenital dislocation of the Hip or Developmental the Hip or Developmental Dysplasia of the Hip Dysplasia of the Hip

• May occur pre, post, or perinatallyMay occur pre, post, or perinatally• 1 out of 1000 live biths1 out of 1000 live biths

The Hip - CDH con’tThe Hip - CDH con’t

Characteristics:Characteristics:

• 1. Firstborn females1. Firstborn females• 2. Breech delivery2. Breech delivery• 3. Family history of CDH3. Family history of CDH• 4. Left side4. Left side


X-rays X-rays • Standard films AP and frog-leg views Standard films AP and frog-leg views

of the pelvis if > 7 months oldof the pelvis if > 7 months old

• US of hips for <7 months old as the US of hips for <7 months old as the ossific centers have not developed in ossific centers have not developed in the capital femoral epiphysis.the capital femoral epiphysis.


Physical ExamPhysical Exam• 1. Ortolani test - flex hips to 90° and then 1. Ortolani test - flex hips to 90° and then

abducted maximally. A positive test is when abducted maximally. A positive test is when the head of the femur, which is dislocated the head of the femur, which is dislocated posteriorly, flips over the posterior posteriorly, flips over the posterior acetabular labrum or edge and head of acetabular labrum or edge and head of femur goes back into the true acetabulum. femur goes back into the true acetabulum. This produces a palpable, not audible, This produces a palpable, not audible, “thunk,” “schlunk,” or “clunk.” Not a “click”, “thunk,” “schlunk,” or “clunk.” Not a “click”, which most often is from the iliotibial band which most often is from the iliotibial band around the knee.around the knee.


2. Barlow’s Test - With the infant’s 2. Barlow’s Test - With the infant’s pelvis stabilized with one hand, place pelvis stabilized with one hand, place the other hand so that thumb is over the other hand so that thumb is over the lesser trochanter. Flex the hip to the lesser trochanter. Flex the hip to 90°, then push the femoral head 90°, then push the femoral head posteriorly over the hip joint. A positive posteriorly over the hip joint. A positive test is movement of the femoral head test is movement of the femoral head posterolaterally, which is seen when posterolaterally, which is seen when there is acetabular/femoral instability.there is acetabular/femoral instability.


3. Allis or Galeazzi Sign - Lay the child 3. Allis or Galeazzi Sign - Lay the child in supine and flex both hips to 90° with in supine and flex both hips to 90° with feet flat on the exam table and look at feet flat on the exam table and look at the height of the knees. The affected the height of the knees. The affected side will show a marked shortening.side will show a marked shortening.

4. Skin fold discrepancy will be noted 4. Skin fold discrepancy will be noted at the thigh and gluteal skin folds, with at the thigh and gluteal skin folds, with the involved side having increase in the involved side having increase in folds. folds.


5. Limitation of Abduction - With 5. Limitation of Abduction - With the child in supine flex both hips to the child in supine flex both hips to 90° then abduct both legs at the 90° then abduct both legs at the same time. Both hips should go same time. Both hips should go equal distances into abduction. If equal distances into abduction. If there is a differences between there is a differences between them them the one that has limited them them the one that has limited movement is the involved side. movement is the involved side.

Treatment of CDHTreatment of CDH

Group I - Neonate to 6 weeks - positive Group I - Neonate to 6 weeks - positive Ortolani and Barlow’s tests and skin Ortolani and Barlow’s tests and skin fold discrepancies. Also dislocated fold discrepancies. Also dislocated side can be extended all the way down side can be extended all the way down to the level of the exam table, because to the level of the exam table, because it is lacking the normal hip flexion it is lacking the normal hip flexion tightness that newborn have. Refer tightness that newborn have. Refer this child to Orthopedics for treatment this child to Orthopedics for treatment most likely with a Pavlik harness.most likely with a Pavlik harness.


Group II - 6 weeks - 12 months - Hip Group II - 6 weeks - 12 months - Hip capsular and soft tissue have now capsular and soft tissue have now tightness up and the Ortolani test tightness up and the Ortolani test may not be positive. Will see limited may not be positive. Will see limited abduction in this age and skin fold abduction in this age and skin fold asymmetry. Again referral to Ortho asymmetry. Again referral to Ortho for treatment with Pavlik harness, for treatment with Pavlik harness, traction, adductor tenotomy, or traction, adductor tenotomy, or closed reduction.closed reduction.


Group III - 12 months - 3 years - Group III - 12 months - 3 years - Walking with a painless limp. Walking with a painless limp. Galeazzi sign positive, and limited Galeazzi sign positive, and limited abduction. X-rays positive by this abduction. X-rays positive by this age. Again referral to Ortho for age. Again referral to Ortho for possible treatment by arthrography, possible treatment by arthrography, traction, adductor tenotomy, open traction, adductor tenotomy, open reduction, and pelvic versus femoral reduction, and pelvic versus femoral osteotomy.osteotomy.


Group IV - 3 years to skeletal Group IV - 3 years to skeletal maturity- Same as group III and X-maturity- Same as group III and X-ray is positive. Referral to Ortho for ray is positive. Referral to Ortho for treatment. Usually need to have treatment. Usually need to have surgery to corrected at this age.surgery to corrected at this age.

FYI - Bilateral dislocations over 6 FYI - Bilateral dislocations over 6 years old and unilateral over 8 years old and unilateral over 8 years old do better left ALONE.years old do better left ALONE.

The Hip: Legg-Calvé-Perthes The Hip: Legg-Calvé-Perthes DiseaseDisease

Etiology is thought to be due to Etiology is thought to be due to interruption of the blood supply to the interruption of the blood supply to the femoral head.femoral head.

Vague on set of pain in hip or knee. Vague on set of pain in hip or knee. Male to female 5:1Male to female 5:1 Between 3 to 10 years oldBetween 3 to 10 years old Painful limp when synovitis is present and Painful limp when synovitis is present and

then become a painless limp then become a painless limp Family history 10%-20%Family history 10%-20%


Physical Exam - Shows Physical Exam - Shows • 1. Decrease ROM in hip abduction and internal 1. Decrease ROM in hip abduction and internal

rotation.rotation.• 2. Hip stiffness2. Hip stiffness• 3. Knee pain3. Knee pain

X-rays: Four stagesX-rays: Four stages• 1. Synovitis1. Synovitis• 2. Aseptic necrosis- increased joint space and small 2. Aseptic necrosis- increased joint space and small

femoral headfemoral head• 3. Fragmentation - increased bone density3. Fragmentation - increased bone density• 4. Residual - increased bone density4. Residual - increased bone density


Treatment per OrthoTreatment per Ortho• 1. Aspiration to rule out septic 1. Aspiration to rule out septic

arthritisarthritis• 2. Russell’s traction until synovitis 2. Russell’s traction until synovitis

resolves.resolves.• 3. Must kept femoral head in the 3. Must kept femoral head in the

acetabulum by operative or non-acetabulum by operative or non-operative means.operative means.

The Hip-Slipped Capital Femoral The Hip-Slipped Capital Femoral EpiphysisEpiphysis

SCFE - More common in 10-16 year SCFE - More common in 10-16 year old male especially those with old male especially those with obese and eunuchoid body habitus.obese and eunuchoid body habitus.

Present with hip or knee pain, with Present with hip or knee pain, with a limp.a limp.

Pain often have been present for 3-Pain often have been present for 3-9 months, and have been treated of 9 months, and have been treated of other things.other things.


Physical Exam - Obese adolescent Physical Exam - Obese adolescent male with short limb, and male with short limb, and Trendelenberg gait. The hip is often Trendelenberg gait. The hip is often in extended and externally rotated.in extended and externally rotated.

Positive Log roll test which is Positive Log roll test which is decrease internal or external decrease internal or external rotation of the leg with the hip and rotation of the leg with the hip and knee in extension. knee in extension.


X-ray - Shows “Ice cream falling off X-ray - Shows “Ice cream falling off of the cone” = Femoral head of the cone” = Femoral head falling off of the femoral shaft.falling off of the femoral shaft.

Treatment STAT referral to Ortho Treatment STAT referral to Ortho when found. Needs to be when found. Needs to be corrected quickly.corrected quickly.

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Pediatric Lower Extremity Orthopedic Concerns Esther Tompkins, DO Ped’s PM&R