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Pediatrics (week 9): Orthopedics


growing pains
are not really due to growing
idiopathic
tx with anything

osteomyelitis
usudt staph or strep
begins with bacteremia, hematogenous spread to bone
mb dt bone infx first
mc in femur or tib
sudden onset of unilat pain, refusal to bear weight
fever, pt tenderness, mb swelling
if somebody needs a blood culture she refers to hospital
complic: dmg to growth plate, septic arthritis, pathol fx
tx: iv abx

SEPTIC ARTHRITIS
2:1 male to female
mc age 2-6 and in adolescence
kid looks ill
joint hurts when moved no matter where to
high WBC's, over 100K
joint culture is definitive

JRA
chronic idiopathic synovial infx
min 6 wks in kid under 16
pauciartiular under 6 joints, type 1 girls under 6 ana pos, type 2 HLA b27 pos
polyarticular
tx: refer

LYME
disease du jour: finally getting recognized
more out there than realized
hx of tick bite
50-80% of kids get ticks
erythema migrans bullseye rash
Dr Rafferty says all ticks she has sent in from this area are pos for spirochete
presentation variable

OSTEOCHONDROSIS

OSGOOD SCHLATTER = pain in tib tubercle
parents usu dx it from dr google

SLIPPED CAPITAL FEMORAL EPIPHYSIS
xray ap and frog leg
mc in adolescents
painful limp and lost rom in hip, can't int rot
tx: surgery

TUMORS
unremitting bone pain
leukemia, lymphoma

SHIN SPLINTS
post unaccustomed exercise
tx: stretching, gentle consistent exercise

CHONDROMALACIA PATELLAE
worse with prolonged flexion


NORMAL ODDITIES
bow legs prominent at 6mo, usu straighten by age 2 or 2.5
both tibia and femur
wide stance when learning to walk
externally rotated at the hip, 10 degrees no prob, 30 degrees or assymmetrical
toeing-in: knock knees common by 3-4 years
pes planus or flat feet, rarely needs tx, have pt stand on tippy toes to see arch, fat pad may conceal
gait-affecting issues: toe-walk is normal
a. if the kid can do a normal heel-toe walk there is no neuromuscular disease
b. can be associated with increased extensor tone in lower extremities

II. Anatomic Problems
A. club feet/ foot
1. can be unilateral or bilateral
2. refer to ped ortho within 2 weeks of birth
3. treatments vary from stretching/ casts/ braces to surgery
B. Scoliosis
1. Abnormal lateral curve of the spine.
a. 10% of kids will have some scoliosis
b. monitor to ensure that curvature is not progressing
c. screening in schools common
C. Congenital hip dislocation
1. check for this routinely on well-child checks on infants (“hip click” test)
2. Ortalani maneuver: flex the thighs to right angle and fully abduct
a. feel a “clunk” as the hip moves back into acetabulum if the hip is dislocated

III. Limb Pain
A. Trauma
1. most common cause of limb pain in children
2. ddx soft-tissue injury from fracture/ subluxation
a. some kids have hyperextensible extremities
b. overuse problems common
c. consider child abuse
B. growing pains/ idiopathic leg pain
1. Can be related to exercise, recent viral illness/ fever/ flu
2. typically anterior shins, feet/ ankles, wrists, thighs
3. generally resolve in a few days with or without tx
4. sxs: typically worse at night, bilateral, intermittent with no systemic signs or local signs of inflammation or bruising.
C. Infection/ inflammation
1. osteomyelitis
a. localized bone infection.
b. usually begins as bacteremia with hematogenous spread to bone
c. femur and tibia
d. sudden-onset of unilateral bone pain with fever
e. PE: fever, point-tenderness on affected limb, eventual swelling, erythema, heat at site of infection
f. labs: elevated WBC count, high ESR. Blood culture
g. complications: damage to growth plate, septic arthritis, fracture of weakened bone
2. arthritis
a. septic arthritis
i. inflammation of an infected joint
ii. 2:1 male: female; most common ages 2-6 and again in adolescents
iii. fever; warm, swollen joint; child appears ill; decreased ROM
iv. Labs: WBC count, joint culture

JRA
chronic idiopathic synovial inflammation
affects at least one joint for minimum of 6 weeks
pauciarticular: fewer than 5 joints
Type I: in girls, usually under 6 yrs, mc, ana pos
type II: in boys, adolescents
polyarticular: 5 or more joints, any age
if suspected, refer to rheumatologist

LYME DZ
very common and gaining on the differential
HX: tick bite
rash (erythema chronicum migrans)

MISC
Osteochondroses
Osgood-Schlatter (apophysitis of tibial tubercle)
Leg-Calvé-Perthes (femoral head)
localized tenderness and pain is the rule
slipped capital femoral epiphysis in adolescents, painful limp with loss of ROM

TUMORS
bone pain often unremitting or worse at night

SHIN SPLINTS
localized and have hx of unaccustomed exercise

CHONDROMALACIA PATELLAE
localized knee pain
creptius is the rule

LIMP
hx? gait? with and without shoes.
palpate, look for infx, check rom, compare sides
etio: mc: trauma, fx, inflammation, lupus, henoch schoenlien purpura, infection

NURSEMAID'S ELBOW
dislocation of the radial head from annular ligament
and head gets trapped btw other ligaments
very common in small children
will happen repeatedly once it happens
history usually significant--parents yank on arm: longitudinal pull while the elbow is pronated
sx: kid won’t use the arm but not that painful
parents think they dislocated a shoulder (more painful)
easy to reduce: their palm to shoulder (my hand on their elbow and wrist)

SHOULDER DISLOCATION
more common in teens than young children, athletes
sx: painful
tx: reduce

TRAUMA/INJURIES
while many parents will go straight to the ER, some will come to you or call you
hx? visible bone deformity? can bear weight? rom? joint above joint below? sleep ok?
consider xray
arm over head to assess for clavicle fx
tx: send the child to ER if suspect fx or if swelling developed in less than 30 minutes
avoid weight bearing or use of part
if you think it is not a fracture: RICE, analgesics
give clear prognosis
offer PE or sports excuse for older children

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