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Infants and Developmental Dysplasia of the Hip

Infants and Developmental Dysplasia of the Hip

by | Oct 7, 2021 | Research & Innovation

This article was originally published in the Pediatric Society of Greater Dallas newsletter. Committed to improving orthopedics care of pediatric patients in all settings, Scottish Rite for Children specialists are regular contributors to this publication for local pediatricians in North Texas.

Developmental dysplasia of the hip (DDH) is the most common orthopedic condition affecting newborns. The overall incidence has been estimated at approximately 1%. Dysplasia is a term that means poorly formed. It describes this condition well because one or both sides of the hip joint do not grow correctly as the child develops. In severe forms of DDH, the hip joint can be completely dislocated, meaning that there is no contact between the ball of the hip joint (femur) and the socket (acetabulum). 

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Screening for DDH
The American Academy of Pediatrics (AAP) published a clinical report on current standards for evaluating and treating DDH. With later recognition of the condition, the treatment becomes more complex and may even require surgery. In order to minimize missed cases of hip dysplasia, the AAP recommends that pediatricians periodically screen for DDH during routine office visits, from infancy until the child is walking. With effective screening, most cases are identified and managed during infancy, leading to complete correction of hip dysplasia and the development of normal hips.

Ann,-Hip.jpg

As a pediatric orthopedic surgeon, Corey S. Gill, M.D., M.A., cares for many children with DDH and has received several questions from referring providers about appropriate care. The most important things for pediatricians and other referring providers to understand about DDH include:

  • Perform a hip examination on every newborn and infant patient. Soft tissue clicks around the hip and knee are very common and do not generally indicate hip dysplasia. Similarly, asymmetric skin creases on the inner thigh do not usually mean there is a problem with the hip. Findings that are clearly abnormal and should lead to orthopedic referral include:
    • An unstable hip that “clunks” into or out of place. Hip stability is evaluated during the exam by performing the Barlow and Ortolani maneuvers. The Barlow test identifies a hip that is in place but can be easily dislocated with gentle pressure. The Ortolani test identifies a hip that is dislocated at rest, but can be placed back into the joint with positioning of the thigh.
    • Significantly decreased or asymmetric range of motion. This is especially important for abduction of the hips, which is moving the hips out to the side when lying down. Differences as small as 10 degrees compared to the normal side may indicate a significant problem.
    • A significant leg length difference, which may indicate a hip dislocation. Leg length difference is best evaluated with a Galeazzi test. This test is performed by flexing the hips to 90 degrees and checking to see if the knees are level.
    • In toddlers and older children, decreased hip abduction and a waddling gait, limp or unilateral toe walking may indicate hip dysplasia or dislocation.
  • Identify the risk factors that make hip dysplasia more likely. The two most important are family history of hip dysplasia and breech presentation (especially frank breech). Providers should have a low threshold for orthopedic referral in these patients. Other risk factors include female sex, first born child and oligohydramnios.
  • Understand the right time to refer a patient for DDH evaluation. In newborns with unstable hips on exam, a referral should be made immediately so treatment can start as soon as possible. In children with a normal exam but risk factors for DDH, an ultrasound should be obtained at approximately six weeks of age. Obtaining an ultrasound in children earlier than this often leads to a false positive diagnosis of DDH secondary to physiologic immaturity of the hip joint in the newborn.

Orthopedic Intervention

When infants do need orthopedic intervention for hip dysplasia, our first line of treatment is a Pavlik harness. This fabric and Velcro harness is generally worn for 23 hours per day for approximately six to eight weeks, but it is removable for bathing. The harness keeps the hips flexed and rotated in the correct position for normal development of the hip joint. After treatment with a Pavlik harness, we use physical exams, ultrasound and X-rays to monitor growth and confirm the hip joint is developing normally. Most infants with DDH require no further orthopedic treatment after wearing a Pavlik harness.

In some infants, especially those with severe hip dysplasia or a dislocation, Pavlik harness treatment may not be successful. Occasionally, a different type of hard plastic brace may be successful in correcting the hip dysplasia in these children. However, most children who do not respond to Pavlik harness treatment will ultimately require surgical intervention to prevent long term problems from hip dysplasia such as cartilage injury, limp, leg length difference and early arthritis. Depending on the severity of the hip dysplasia, surgical treatments may include:

  • Closed reduction – This involves repositioning the ball of the hip joint deeply into the socket when the child is asleep under anesthesia and then applying a body cast called a spica cast for a total of three to four months. During this procedure, we often inject a small amount of medical dye into the hip joint to confirm that the ball of the hip joint is appropriately positioned in the socket. This is called an arthrogram.
  • Open reduction – Sometimes the hip joint will not line up well with repositioning of the leg because there are tight tissues blocking the ball from sitting deeply in the socket. In these cases, an incision is made in front of the hip where the tight tendons, ligaments and soft tissues are moved out of the way. Afterwards, the lining of the hip joint is tightened with a strong suture to help hold the hip in position. This procedure is called a capsulorrhaphy.
  • Osteotomies – In older children (over age 1.5 – 2 years), soft tissue procedures alone are often not enough to ensure the hip joint is lined up well. In these cases, we often supplement the open reduction procedure by cutting the bone in a controlled way to help reorient the hip into the socket. This is called an osteotomy and can be performed on the ball side of the hip (femur osteotomy) or socket side of the hip (pelvic osteotomy). Metal implants are often used to hold the bone in the new position and are removed at a later date.

Conclusion

Hip dysplasia is a common orthopedic condition in newborns that can lead to significant long-term consequences if left untreated. Certain risk factors such as family history of dysplasia and frank breech presentation greatly increase the risk of developing DDH. Pediatricians play a crucial role in examining infants, identifying those with risk factors and referring them to a pediatric orthopedic specialist when appropriate. When diagnosed in the first few months of life, noninvasive treatment with a harness or brace is highly successful and generally leads to the development of a normal hip. In some cases of severe hip dysplasia/dislocation or in cases of delayed diagnosis, surgical intervention is required to improve the long term prognosis of the hip joint.

Referral Tips 

A potential diagnosis of hip dysplasia can lead to significant anxiety for new parents. Understanding the best time to refer patients and initiate treatment helps to maximize treatment success and efficiency while minimizing parental stress and worry.

  • For infants with risk factors for DDH such as family history or breech presentation but a normal physical exam, an ultrasound should be obtained around six weeks of age. Ultrasounds performed earlier than this age result in a large number of false positives and potential unnecessary treatment in a harness.
  • There is no need to obtain an ultrasound prior to referral as we work closely with experienced ultrasound technologists who can perform the diagnostic hip ultrasound on the same day as an infant’s office visit.
  • In children with a clearly abnormal exam (unstable/dislocatable hip or asymmetric hip abduction) in the nursery or in routine office visits, immediate referral should be made so that treatment in a harness can be initiated as soon as possible. In these children, there is no need to wait until the child is 6 weeks of age for referral.
  • If only abnormal exam finding is a “hip click” or asymmetric thigh crease, referral and ultrasound should be deferred until 6 weeks of age given the relatively low prevalence of DDH in these children.
  • In premature infants still in the NICU with risk factors for DDH, it is generally OK to wait for referral until after the child is discharged to go home. If an examiner finds the hip to be unstable while still an inpatient, phone consultation with a pediatric orthopedic surgeon is available to answer questions or discuss the most appropriate time to see the patient.
  • If a family has an infant diagnosed with DDH, all future siblings of the child should be referred for screening, ultrasound at six weeks of age and strong consideration should be given for referral of older siblings for a hip radiograph. First degree relatives have more than a tenfold higher risk of DDH compared to controls.
Evaluating Adolescent Ankle Pain

Evaluating Adolescent Ankle Pain

by | Sep 2, 2021 | Sports Medicine

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by sports medicine physician Jacob C. Jones, M.D, RMSK.

You can watch the full lecture and download this summary.

The ankle is one of the most commonly injured body parts in children of all ages. An ankle sprain usually occurs when the ligaments, which support the three ankle bones, are stretched beyond their normal limits. This often occurs when the ankle is twisted or rolled inwards. When this happens, the ligaments can stretch or even tear. An evaluation by a pediatric orthopedic specialist can help to prevent potential complications. Usually X-rays are required to make a diagnosis and treatment will depend on multiple factors, including the specific type of injury and age of the patient.

Ankle Anatomy

Lateral Ankle
There are three major ligaments in the lateral ankle:

  • Anterior talofibular ligament (ATFL)
  • Calcaneofibular ligament (CFL)
  • Posterior talofibular ligament (PTFL)

Medial Ankle
The ligaments on the medial aspect are grouped together into a ligament complex called the deltoid ligament.

Posterior Ankle
The main area of concern here is the Achilles tendon which connects the calf muscles down to the calcaneus, or heel bone.

Anterior Ankle
There are two major areas to focus on in the anterior ankle:

  • The high ankle
    • Several ligaments in the upper part of the ankle are grouped together.
    • Ankle syndesmosis
      • These are the ligaments that connect the tibia to the fibula.
  • The low ankle
    • This is where the tibia and fibula interact with the main ankle bone (talus).
      • Tendons and other tissues coarse over the anterior portion of this joint

History
Knowing the patient’s history is vital for diagnosing the problem. There are two key things that physicians should ask when covering the patient’s history:

  1. Was there an injury?
  2. If there was an injury, can the patient recreate the injury?

Sometimes adolescents or younger populations have trouble verbalizing what happened to them, but they can demonstrate it with their injured ankle, their uninjured ankle or with their hands. This can help physicians determine what to focus on during the physical exam and help guide the diagnosis, evaluation and treatment.

Inspection

  1. Look at all aspects of the ankle to make sure that there are no breaks in the skin, bruising, swelling, erythema or deformity.
  2. Have the patient stand if they are able to do so. This gives a view of their overall alignment.
    • Look at the knees to see which way they are facing.
    • Assess for curvatures in their lower extremities, which may play a role in their pain or may have been a contributing factor to their actual injury.
  3. Have the patient turn around to look at them from the posterior aspect.
    • Look at their alignment from this view, paying particular attention to the lower aspect to see what their alignment looks like down low.
    • Check for any kind of curvature or angulation of their heel that may also contribute to their pain and injury.
    • Look at their arches to see if they are flat (pes planus) or if they have a high arch (cavovarus foot) that may be contributing to the pain that they are having or may have contributed to their injury.

Active Range of Motion
Testing a patient’s active range of motion shows how far they can move their joint on their own. Have the patient move their foot in circles one way and then the other. Then have them move in each particular plane, by dorsiflexing up, plantar flexing down, internally rotate or invert then have them externally rotate and move their toes as well.

Neurovascular Check
Visually inspect and check the dorsal aspect of the midfoot and palpate for the dorsalis pedis pulse. The posterior tibialis pulse is located just posterior to the medial malleolus. Assess sensation on the distal aspect of the foot.

Palpation
Palpating helps to define the painful area and often guides next steps, such as X-rays. Pain may be apparent during the evaluation, however, asking questions throughout is recommended. To avoid missing any structures, this assessment should be consistent for any ankle injury. Start at the very top, just below the knee, and methodically work down.

  1. Palpate between the tibia and the fibula to see if there are potential injuries in that area.
  2. Palpate over the anterior aspect of the ankle
  3. Palpate over the medial malleolus and the deltoid ligament.
  4. Palpate the lateral malleolus, and then around it. Assess all three lateral ligaments: ATFL, CFL and PTFL
  5. Palpate all over the foot to make sure there isn’t any pain there.
  6. Palpate the posterior aspect. Squeeze on and around the Achilles tendon and move down to the calcaneus.

Special Tests
These special maneuvers help physicians in their evaluation of the patient’s ankle.

Anterior Drawer Test (ATFL Laxity)
This test attempts to separate the lower aspect of the ankle from the upper aspect of the ankle by moving the ankle anteriorly. The ATFL is being stressed with this test.

  1. Get a good firm grip on the lower leg with your non-dominant hand. You will be providing counter-traction with that hand and you don’t want it to move.
  2. With your dominant hand, cup the heel with a firm grip and try to move that ankle anteriorly without the foot flexing too much. While doing this, feel how much the ankle moves and look for an endpoint when the ATFL ligament becomes taught.
    • With an alternative method, you wrap the thumb of your dominant hand over the anterior aspect of the ankle. This can give more of a firm grip and more control while moving the ankle anteriorly.
  3. Always check the contralateral side to see what the patient’s baseline is. This comparison can tell you if the ligament is injured, and/or not functioning the way it should be.

Talar Tilt/Stress Inversion Test
This test stresses these lateral ankle ligaments. You can tilt the foot the other way to stress the medial ankle ligament.

  1. Get a firm grip of the lower leg to make sure that doesn’t move.
  2. With your other hand, get a full grip on the whole foot, not just the toes.
  3. Slowly tilt it in a clockwise motion on the left ankle.

Thompson Test (Achilles Tendon Injury)
This test is to evaluate for an Achilles tendon injury. When the calf muscles contract, it causes the Achilles tendon to pull that calcaneus upward which in turn, causes the foot to go plantar flex, or move downward a little bit. If there is no movement, you have a positive test. This could be because of a tear of the Achilles tendon.

  1. Have the patient lay prone on the exam table with both feet are dangling off the edge. Make sure the patient is relaxed and comfortable.
  2. Squeeze the calf muscle. As you squeeze the calf muscle, look to see if the foot plantar flexes.
  3. If it does plantar flex, it tells you the Achilles tendon which connects the calf muscle and the foot is intact.
  4. Always compare with the other leg.

Squeeze Test (High Ankle Injury)
The squeeze test evaluates for a high ankle injury and can be performed during the palpation assessment. When you squeeze the upper parts of the leg, the lower part of the leg to tries to spread apart. If there is an injury in this area, there will be more movement, or more commonly, more pain. Patients will point to this area to show where they are having pain.

  1. Squeeze at the upper aspect of the tibia and fibula. You are trying to squeeze those two bones together. Work your way down and squeeze in different areas.
  2. What you are looking for when you squeeze is if there is more movement in the distal aspect of the tibia and fibula, or more commonly, if they have pain in that area.

External Rotation Testing
This test is also for high ankle injuries. With external rotation, the talus is going to try to move apart the tibia and the fibula. And so if there is an injury to the high ankle, it is going to cause that part or that high ankle area to have some pain or to try to move apart.

  1. Make sure that you have a good grip on that lower extremity to keep it stable.
  2. With the palm of your other hand, externally rotate that patient’s foot while making sure the patient is relaxed. You are looking for pain and for a little bit more movement.

Resistive Range of Motion
Resistive range of motion testing assesses the patient’s strength.

  1. As the patient inverts, everts or externally rotates, plantar flexes and dorsiflexes, push against them to provide resistance and to test how strong they are.
  2. Compare to their other leg.

Gait Evaluation
Observe the patient walk down a hallway, not just in an exam room. Look for any type of limp or asymmetry. Make note of the patient’s alignment and their cadence. A conversation or other distraction can help them walk more naturally.

Double and Single Leg Toe Raise
A functional test like the double or single leg toe raise assesses the strength of the patient’s lower extremity and how their pain is in regards to their movement in a weight bearing position.

  1. Have the patient go up on their toes, starting with both feet at once to see if they are able to do this or not. This shows how strong they are and how confident they are on their ankles.
  2. Have the patient do several single-leg toe raises on each leg
    • If the patient can do this, it shows that their ankle is pretty strong and they can likely start getting ready to return to sport.
    • If the patient cannot do this, they are still too injured to return to sport.

Ankle X-rays
It is most common to order three views of the ankle after an ankle injury. Foot X-rays may be needed if the exam findings include midfoot or distal complaints. Standard three views of the ankle includes:

  1. Anterior/Posterior (or AP) – gives a good view of the anterior aspect of the joint.
  2. Mortise – this one is slightly angled from the AP which allows you to see the lateral malleolus at a different angle and lets you see the joint between the talus and the tibia and fibula well. You can also see the area of the high ankle without any bony overlap.
  3. Lateral – with this view you can see the posterior aspect of the ankle and the calcaneus very well.

Conclusion
The ankle is a complex and highly mobile joint. Due to the demands of sports and activities, the ankle is a risk of injury and should be fully evaluated for bony and soft tissue injuries. Watch the 20-minute lecture which includes video demonstration of the ankle exam on a pediatric patient.

Common Causes of Adolescent Knee Pain

Common Causes of Adolescent Knee Pain

by | Aug 12, 2021 | Research & Innovation

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Philip L. Wilson, M.D.
 
You can watch the full lecture and download this summary.
 
Diagnosing common causes of adolescent knee pain can be confusing, but it can be simplified by looking at history and physical findings during the exam systematically. To narrow the list of common causes, symptoms are broken down in three ways:

  1. Acute vs. Chronic presentation
  2. Effusion vs. No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality

Below is a list of common knee conditions:

  • Sprain
  • Contusion
  • Stress Fracture
  • Apophysitis
  • Patellofemoral Dislocation
  • ACL Tear
  • Tibial Spine Fracture
  • Meniscal Pathology
  • Osteochondritis Dissecans

Conditions with an Acute Presentation
If the presentation is acute instead of chronic, the number of potential diagnoses becomes much smaller:

  1. Acute vs. Chronic presentation: Acute
    • Sprain
    • Contusion
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

By determining if there is an effusion, or a collection of fluid within the joint, the list of common diagnoses narrows even further:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
    • Sprain
    • Contusion

Then, the likely diagnosis can be determined by looking at where the patient’s pain is located:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: No Effusion
  3. Primarily a Pain Problem vs. Primarily a Motion Abnormality: Primarily a Pain Problem

If the patient has soft tissue swelling and pain around the joint with nothing focal, no bony tenderness and no effusion, it is most likely a sprain.

  • Treatment
    • Protect, Rest, Ice, Compression, Elevation (PRICE)
      • Sometimes an Ace wrap, a splint or a brace is used to immobilize and protect the joint
    • Early protected range of motion
      • Get the patients up and moving early
    • Restore strength

Patients do not need to be referred to Scottish Rite unless their pain lasts for more than three or four weeks.
 
If the patient has an acute problem with an effusion, different common causes of adolescent knee pain from the list are likely:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
    • Patellofemoral Dislocation
    • ACL Tear
    • Tibial Spine Fracture
    • Meniscal Pathology

To determine the cause, consider the motion associated with the injury to further narrow down the list of diagnoses:

  1. Acute vs. Chronic presentation: Acute
  2. Effusion vs. No Effusion: Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality
  • Patellofemoral Dislocation
    • Twist and valgus
    • “Knee dislocated”
  • ACL Tear
    • Twist and valgus
    • “Gave out” / “shifted”
  • Tibial Spine Fracture
    • Hyperflexion
  • Meniscal Pathology
    • Twisting event

Knee Injury and Effusion
How to tell if the patient has an effusion, not soft tissue swelling:

  • X-ray – side view image of the knee
    • Look at the kneecap as it is related to the thigh bone.
    • Look at the muscle coming off the kneecap
    • Look at the space between the kneecap and the femur
      • If there is a curvilinear density that is not the linear muscle, not the deep muscle or the fat pad, it is most likely an effusion.
  • Physical examination
    • Compare the patient’s knees
      • A knee with an effusion will look bulbous and will not have all the concavities around the patella of a normal knee
    • Push on the tissues around the knee
      • If the fluid can be moved from lateral to medial or if you can see a fluid wave, it is most likely an effusion
        • Soft tissue swelling cannot be moved around
X-ray of a knee

Knee Effusion – Patellar Dislocation
When a patient has a patellar dislocation, they relate an instability event where they knee “popped out of place.” There is also an effusion.

  • Diagnosis
    • Apprehension sign
      • While pushing down on the medial kneecap, the patient becomes apprehensive and will sometimes try to stop the exam because they think that their kneecap will become dislocated.
    • “J” sign
      • As the knee is flexed, the kneecap visibly jumps from out of the groove to back into place.
  • Treatment
    • PRICE
    • Physical therapy (PT)
    • Surgery

Refer patients to Scottish Rite for continued effusion or recurrent instability.

Knee Effusion – ACL Tear
When a patient describes twisting their knee and it giving out on them or shifting and they have an effusion, they most likely have an ACL tear. Their knee is unstable. There are four ligaments in the knee: the medial knee ligament and the lateral collateral ligament on each side, with the anterior cruciate ligament (ACL) on the front and the posterior cruciate ligament on the back. When the ACL is torn, the knee has more motion, so patients say that their knee slipped or gave out. The best way to check for a torn ACL is the Lachman test.

  1. The patient lies on their back with their legs out straight and their muscles relaxed, especially their hips and hamstring muscles.
  2. Bend the patient’s knee slowly and gently to about a 20-degree angle. Physicians may also rotate the patient’s leg so their knee points outward.
  3. Stabilize the patient’s thigh with one hand and gently move the tibia forward with the other hand.
    • If there is a great deal of of motion and instability, it is likely because the ACL is torn

Treatment

  • Surgery may be necessary to repair instability or an associated meniscal injury.

Refer any patients with a suspected ACL tear to Scottish Rite.

Knee Effusion – Tibial Spine Fracture
With a tibial spine fracture, the patent usually has a large effusion called a hemarthrosis, or blood in the joint, because of the fracture. These are usually caused by a flexion event like a fall from a bike or skiing or a twist in sport. This fracture will leave a fragment within the “notch” between the thigh bone and the shin bone. This is because instead of the ACL tearing in the middle of the rope, it pulls that piece of bone.
Treatment

  • Surgery
    • Put the piece of bone back in place
  • Casting
    • Moving the leg and putting it in a cast may work if it can be placed in a good position

Refer patients to Scottish Rite for immobilization or surgery.
Knee Effusion – Meniscal Tear

It the patient’s reports a twist or pop event and their effusion appears small while experiencing pain on the side of their joint, it is most likely a meniscal tear. Other things to look for to make the diagnosis are focal joint line pain, a loss of extension, a negative Lachman exam, no patellar apprehension, and nothing positive on their X-rays. An MRI may be needed to confirm the diagnosis. The effusion usually means that there is an internal derangement that needs to be treated with surgery.

Conditions with a Chronic Presentation
If the athlete’s injury is a chronic injury, a different set of diagnoses becomes likely:

  1. Acute vs. Chronic presentation: Chronic
  • Stress Fracture
    • Has been sore for a while
  • Apophysitis
    • Pain at the growth plate
  • Patellofemoral Dislocation
    • Pain around the kneecap
    • Not a specific injury
  • Osteochondritis Dissecans
    • An idiopathic osteonecrosis below the cartilage surface during development

These conditions generally do not have an effusion, and are all activity-related knee diagnoses.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Pain

To determine which condition it is, find out where the pain is located.

  • Stress Fracture
    • Focal distal femur or proximal tibia
    • Tender over a small area around a bone
  • Apophysitis
    • Focal distal patella or tibial tubercle
    • Focally tender
  • Patellofemoral Dislocation
    • Poorly localized / Not focally tender
    • “Horseshoe” sign
  • Osteochondritis Dissecans
    • Cannot localize
    • Deep within

Slipped Capital Femoral Epiphysis (SCFE)

ALWAYS CHECK THE HIP IN ADOLESCENTS WITH KNEE COMPLAINTS

When adolescents have activity related knee pain, often with no inciting event, and display symptoms including a limp, walking with their foot externally rotated and a limited range of motion (especially with internal rotation), it may be SCFE. SCFE is checked with a hip rotational exam. If the patient has equal symmetric range of motion, physicians can rule out SCFE and move on to other diagnoses.

Overuse Conditions – Stress Fracture
Stress fractures are an activity-related pain that often happens after periods of inactivity, like summer. They are associated with high activities like running. Patients are focally tender on their bone, but their knee joints are fine. An X-ray usually shows a stress fracture on their distal femur. The treatment for a stress fracture is forced rest until the patient is pain-free and a gradual return to sports.

Overuse Conditions – Apophysitis
Apophysitis is an activity-related condition with pain focal to only one place. The growth plate is going through a transition with a great deal of stress applied in that area with activities. The two main apophysitis to consider are Osgood-Schlatter Disease in which the patient’s pain is on the tibial tubercle, and Sinding-Larsen Johansson (SLJ) Syndrome in which the pain is on the inferior pole of the patella. The treatments for apophysitis are rest, anti-inflamitories, and quad stretching.

Patellofemoral Pain Syndrome
Unlike Osgood-Schlatter Disease and Sinding-Larsen Johansson (SLJ) Syndrome, the patient cannot pinpoint their pain with Patellofemoral pain syndrome. Patients motion all around the knee in what is called the “Horseshoe” sign. They do not have instability in their knee, but they do have pain around their kneecap. The cause of Patellofemoral pain syndrome is unknown, but it is believed to be related to an abnormal balance of the homeostasis of the muscle strength around the front of the knee. During the exam, physicians determine the “Q” angle, or the quadriceps angle. This is the angle between the quadriceps tendon and the patellar tendon. This angle provides useful information regarding the alignment of the knee joint. “Q” angles greater than 14° are vulnerable to patellar conditions. Physicians also look for poorly developed vastus medialis oblique muscle (VMO), a “J” sign, and pain with patellofemoral compression.

Treatment

  • Physical therapy
    • Quadriceps strengthening
    • Knee balance
    • Knee proprioceptive strengthening
  • 70% improved with physical therapy, regardless of associated interventions.

Osteochondritis Dissecans (OCD)
OCD is an idiopathic osteonecrosis below the cartilage surface during development. This can lead to cartilage surface cracks, instability and lesion on the joint. OCD can happen with or without trauma. In an X-ray, a radiolucent lesion is visible.

  • 2:1 Male to female
  • 33% Bilateral

The younger the patient is and the smaller they are, the more likely they are to heal. The location of lesion and the status of articular surface also play a factor in the patient’s healing potential.

Treatment

  • Forced rest
  • Unloader brace
  • Surgery if the patient is older or if the MRI reveals instability.

Meniscal Pathology
A meniscal pathology has a chronic presentation with no effusion, but a motion abnormality instead of pain.

  1. Acute vs. Chronic presentation: Chronic
  2. Effusion vs. No Effusion: No Effusion
  3. Pain vs. Motion Abnormality: Motion Abnormality

The patient says that their knee pops or snaps. They may also have a loss of extension and a limp. These are signs of a discoid meniscus.

Discoid Meniscus

  • Discoid meniscus is a congenital malformation of the meniscus
    • Affects approximately 1:100 children
  • Mechanical symptoms in childhood with no trauma history
    • Snapping in the knee usually occurs between the ages of 2 to 6.
  • Palpable / audible “snap” at lateral joint line during exam
  • Visible bulge at lateral joint line

As children get older, the discoid meniscus presents like a regular meniscal tear. The treatment for this condition is arthroscopic surgery if the patient is symptomatic.

Refer patients to Scottish Rite for mechanical symptoms or loss of motion.

Adolescent Hip Dysplasia and Other Causes of Hip Pain

Adolescent Hip Dysplasia and Other Causes of Hip Pain

by | Aug 6, 2021 | Hip Disorders

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon William Z. Morris, M.D.

You can watch the full lecture and download this summary.

In hip dysplasia, the acetabulum (or hip socket) is shallow and doesn’t adequately cover the femoral head. Developmental dysplasia of the hip (DDH) occurs in approximately 1% of newborn children, and it is associated with four risk factors:

  • Female
  • Firstborn
  • Feet first (breech)
  • Family history

Hip dysplasia is relatively more commonly diagnosed in skeletally mature adolescents, affecting around 3% to 5% of the asymptomatic population. Cross-sectional studies have shown that female sex and a family history of dysplasia remain risk factors in adolescents.

There has been growing attention to the treatment of hip dysplasia as there is an association between hip dysplasia and the development of early osteoarthritis. In 1939, Gunnar Wiberg first described hip dysplasia and objectively measured it using what is now called the lateral center edge angle, to describe how well the socket (acetabulum) covers the ball (femoral head). On an AP (anterior posterior) pelvis X-ray, the angle is created by a vertical line through the center of the femoral head and a line from the center of the femoral head to the lateral border of the acetabular fossa. A larger angle reflects greater hip coverage, and a smaller angle reflects less coverage, commonly seen in a dysplastic hip.

Wiberg followed patients with dysplasia for up to 30 years and found that all of the patients with hip dysplasia eventually developed osteoarthritis. The smaller their center edge angle was (reflecting greater hip dysplasia), the faster they developed osteoarthritis.

Development of Osteoarthritis in Dysplastic Hips
The development of early osteoarthritis is suspected to occur due to a couple mechanical reasons. The most important factor is that:

Pressure = Force / Unit Area
In the hip, pressure on the joint surfaces depends on the total surface area of the femoral head in contact with the socket. A well-covered femoral head distributes weight-bearing forces across a larger surface area, reducing the pressure on each unit of cartilage. In contrast, a dysplastic acetabulum offers less surface area which increases the pressure on the cartilage contributing to earlier hip degeneration. In addition to the smaller weightbearing surface, the acetabulum is also more obliquely oriented. Therefore, compressive forces are less and shearing forces are greatly increased. This increased shear force may also contribute to cartilage degeneration.

Symptoms of Adolescent Hip Dysplasia
There are many different causes of hip pain in an adolescent patient and combining clues from the history and physical exam is essential to determine the underlying problem. The location of a patient’s pain can help determine the underlying etiology. Intra-articular pain of the hip usually presents as anterior groin pain, often due to a cartilage injury, a tear in the labrum (the ring of cartilage at the periphery of the socket) or inflammation of one of the hip flexors called the Iliopsoas tendon. Lateral hip pain that locates over the greater trochanter (the bony prominence on the lateral aspect of the thigh) probably reflects trochanteric bursitis or inflammation of the bursa overlying that region. Pain or soreness after activity above the greater trochanter where hip abductors like the gluteus medius are located may signal hip abductor fatigue, which is common with hip dysplasia. Pain over the iliac crest where the abdominal musculature attaches could reflect some inflammation of that apophysis, of the anterior superior iliac spine (ASIS) where the sartorius attaches, or of the anterior inferior iliac spine (AIIS) where the rectus tendon attaches.

Additional Factors to Consider when Discussing Hip Joint Symptoms

  • Pain
    • Duration
    • Aggravating factors
      • Squatting, stairs, low chairs
    • Alleviating factors
  • Mechanical symptoms
    • Locking, popping, catching, snapping
  • Neurological symptoms (which may suggest spinal pathology)
    • Radiating pain, paresthesias

Physical Exam

  • Pain Assessment
    • Palpation can reproduce symptoms and help to localize the pain.
  • Strength Testing
  • Range of Motion
    • Limited internal rotation (IR) can indicate hip impingement or a more acute concern, slipped capital femoral epiphysis (SCFE)

Special Tests

Straight Leg Raise Test
A straight leg raise is a passive test that helps to distinguish between hip and spine pathology and is performed by flexing the hip with an extended knee in a supine position. If this maneuver reproduces the patient’s pain that radiates distally, the problem may be related to nerve compression in the spine rather than a problem in the hip.

Trendelenburg Test
The hip abductors (e.g. gluteus medius) are typically weaker when patients come in with pain, so it can be targeted in physical therapy. The Trendelenburg sign is a quick physical examination used to assess for hip abductor weakness.
The patient stands on one leg (stance leg) and bends the other knee about 90°. Observe for evidence of hip abductor (i.e. gluteus medius) weakness which includes:

  • Pelvis drop contralateral to the stance leg.
  • Trunk lean/shift toward the stance leg.

Apprehension Test
Another test to further evaluate for dysplasia is the apprehension test:

  1. The patient lays in a lateral position
  2. Abduct the patient’s leg 30° away from midline
  3. Flex the patient’s knee 90°
  4. Gradually extend the hip

Patients who have an anterior uncovering of the socket from dysplasia will feel pain or a sensation of apprehension, which suggests that there may be some instability or dysplasia.

Femoroacetabular Impingement Test
Hip impingement should also be tested:

  1. Flex the hip to 90°
  2. Abduct the hip, bringing it towards midline
  3. Internally rotate the hip

This test attempts to reproduce hip impingement where the femoral head or neck collides against the socket. If this causes pain, there may be a cartilage injury such as a labral tear. An MRI is recommended to evaluate intra-articular soft tissues.

Slipped Capital Femoral Epiphysis – A condition not to be missed
Slipped capital femoral epiphysis (SCFE) is an adolescent disorder in which the growth plate is damaged and the femoral head epiphysis moves, or slips, with respect to the rest of the femur. Diagnosis in a timely manner is essential to prevent further injury to the hip.

Consider SCFE if these signs are present:

  • limp
  • walk with their foot externally rotated
  • have limited range of motion, especially with internal rotation

Obligate external rotation is nearly pathognomonic for slipped capital femoral epiphysis, so if the patient can’t flex their hip straight up without turning their leg into an externally rotated position to accommodate further flexion, an anterior-posterior and frog pelvis film is recommended to ensure slipped capital femoral epiphysis hasn’t been missed. Immediate non-weight bearing with a wheelchair and urgent referral to pediatric orthopedics or an emergency room is recommended for this condition.

Radiographic Evaluation
A radiographic evaluation is important for a definitive dysplasia diagnosis. The AP pelvis film is a workhorse tool for the evaluation of hip coverage. It is taken standing to allow assessment of the patient’s hip coverage in their functional position using the lateral center edge angle (LCEA). A hip with an LCEA less than 25° is considered dysplastic.
Imaging also allows an assessment of the inclination of the socket. By drawing a line between the medial and lateral edges of the roof of the socket and measuring the angle between that line and a horizontal line, physicians can determine the acetabular inclination. The more inclined the socket is, the more dysplastic.

Treatments
Treatment for dysplasia begins with nonoperative options, which include:

  • Physical therapy
  • Activity modifications
  • Non-steroidal anti-inflammatory drugs (NSAID)

When nonoperative treatments don’t work, and patients continue to have radiographic dysplasia and pain, including abductor fatigue pain above the greater trochanter or anterior intra-articular groin pain, they are treated surgically with a periacetabular osteotomy (PAO). This specialized procedure is done in patients who are approaching skeletal maturity or are already skeletally mature. Several cuts are made around the socket of the acetabulum to mobilize the socket. The socket is then reoriented to better cover the femoral head.

Outcomes
For patients with symptomatic hip dysplasia, the PAO has been shown to be successful in improving patients’ function, getting them back to their activities/sports, and preventing early hip replacement. In patients with hip pain and clinical or radiographic evidence of acetabular dysplasia, please consider a referral to Scottish Rite for Children for discussion of the condition and shared decision-making in the plan for management.

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Ten Most Common Orthopedic Conditions Seen in the NICU

Ten Most Common Orthopedic Conditions Seen in the NICU

by | Jul 14, 2021 | Spotlight

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Amy L. McIntosh, M.D.

Watch the full lecture or download this summary.

Newborn care, particularly in the neonatal intensive care unit (NICU) requires the consultation of many pediatric specialists. Scottish Rite for Children pediatric orthopedic surgeon Amy L. McIntosh, M.D., frequently consults in the NICU, and in a lecture for pediatricians and other health care providers, she summarized the ten most common conditions she evaluates in newborns.

Pseudoparalysis
A baby with pseudoparalysis typically presents with one arm laying or hanging limply. In many cases, the hand of the affected limb moves normally and the baby can successfully grasp and release the fingers and thumb.

A mechanical injury, typically during birth, causes the apparent paralysis. These factors may contribute to pseudoparalysis:

  • Vaginal delivery
  • Large baby
    • Delivery converted from vaginal to C-section due to the size of the baby
  • Maternal diabetes
  • Forceps-assisted delivery

The most common causes for pseudoparalysis are:

Fracture to the clavicle or humerus
Though alarming to the parents, these causes of pseudoparalysis typically have excellent outcomes. Treatment is focused on immobilizing the arm and keeping the child comfortable, and follow-up care is minimal. In fact, repeating X-rays in follow-up is unnecessary and not recommended.

The treatment instructions are simple. Put the baby in a long-sleeved onesie and safety pin the sleeve to the torso of the onesie for two weeks. This is the easiest way to immobilize the arm. Tylenol may be given to the baby for any pain.

Injury to the Brachial Plexus
The brachial plexus provides motor control in the arm and fingers. Stretching or tearing of a portion of these nerves can cause true paralysis. The child’s wrist and fingers are held in flexion, and there is no active extension with them. When diagnosed, a pediatric hand specialist will often recommend occupational therapy to teach the parents arm, wrist and finger exercises. Observation for nerve recovery and continued care with a pediatric orthopedic hand/upper extremity specialist is highly recommended.

Developmental Dysplasia of the Hip (DDH)
Developmental dysplasia of the hip (DDH) is an orthopedic condition in which the hip joint is unstable or has a shallow socket. There are several risk factors to consider at the beginning of the consultation including:

  • Firstborn
  • Female
  • Family history of hip dysplasia
  • Breech delivery
  • Significantly low amount of amniotic fluid

During the exam, a Barlow maneuver will replicate the hip dislocation, and an Ortolani maneuver moves the femoral head back into the socket. To visualize the condition of the joint surfaces and shape, ultrasound is used to aid in treatment planning. The treatment for DDH is to position the hips in a “frog leg” posture for 23 hours / day using a Pavlik harness for a period of 6-12 weeks. The earlier treatment begins, the better the outcome. Though treatment is typically successful, annual observation by the pediatric orthopedic specialist is recommended until the patient is 18 years old.

Clubfoot
Clubfoot is a congenital disorder in which the foot is severely turned inward and pointed downward. Clubfoot is often associated with other syndromes, including arthrogryposis and amniotic band syndrome. The majority of clubfeet are easily seen on the prenatal ultrasound that is done at 20-26 weeks gestation. During the prenatal consult, Scottish Rite pediatric orthopedic surgeons explain what clubfoot is and its treatment. The Ponseti method is a series of weekly casts that gently move the foot into the correct position. If the baby is going to be in the NICU for six weeks or more, the entire Ponseti method can be completed in the NICU. Otherwise, treatment can begin after discharge from the NICU.

Amniotic band syndrome (Streeter’s dysplasia)
Amniotic band syndrome is a condition where amniotic bands formed in utero constrict fingers, limbs and other body parts. When clubfoot is related to amniotic band syndrome, it is called Streeter’s dysplasia. Sometimes the constriction from amniotic bands requires the limb to be amputated. To establish a relationship and initiate a prosthetic tolerance program and plan, the pediatric orthopedist collaborates with pediatric prosthetists. At a developmentally appropriate time, a custom prosthesis is created to assist the child in meeting normal developmental milestones on time.

NOT Amniotic band syndrome or compartment syndrome –> Limb Ischemia with dry gangrene and auto-amputation
In extremely rare occasions when intrauterine fetoscopic laser surgery is done to treat twin-to-twin transfusion syndrome (TTTS), a loss of blood supply to the developing extremities may cause ischemia and necrosis of a limb or limbs. In these cases, a pediatric orthopedic surgeon monitors and supports efforts to prevent infection while awaiting an autoamputation to occur. Establishing an early connection with a pediatric prosthetist ensures timely training and care to protect normal developmental progression.

Polydactyly / Syndactyly
Polydactyly is a hereditary condition that causes supernumerary (excess) fingers and/or toes, typically on the medial or lateral side. Syndactyly is a condition that causes two or more digits to be fused together. With preaxial polydactyly, the thumb or great toe (first digit, or medial-sided) is duplicated, which can be associated with tibial dysplasia or a tibial hemimelia. It is important to get X-rays of the tibia, fibula and foot to fully assess for tibial dysplasia. With postaxial polydactyly, the fifth, most lateral digit is duplicated. Postaxial polydactyly is never associated with tibial hemimelia, and it is much easier to treat surgically. Surgery is typically offered at 6 months of age or greater. Referral to a pediatric orthopedic surgeon for a thorough evaluation and discussion of treatment considerations is highly recommended.

Congenital knee dislocation
Congenital knee dislocation (CKD) is often associated with other syndromes, so a genetic consult is indicated. These babies are usually born Frank breech, and some may have required a Cesarean delivery. The knee or knees present in a hyperextended position. Ultrasound should be used to rule out hip dislocations, since the knee and hip are often both affected. CKD is treated with serial casting. A series of long leg plaster casts will slowly reduce the knee joint into a more normal position. Once the knee can be flexed to 90 degrees, a Pavlik harness is used to maintain knee flexion. Treatment can be completed during the NICU stay or as outpatient procedures after discharge.

Calcaneovalgus foot
Unlike a clubfoot, with a calcaneovalgus foot, the calcaneus is dramatically everted and flexed, sometimes the top of the foot is almost touching the tibia. This condition is usually caused by intrauterine positioning. With appropriate stretching, the foot position gradually improves in the first 4 to 6 weeks of life.

There is an association between calcaneovalgus feet and posteromedial bowing of the tibia. When an X-ray of the tibia reveals or confirms a posteromedial bow, the child is very likely to have a leg length discrepancy of 2-5 centimeters. These children should be referred to a pediatric orthopedic specialist with experience in limb reconstruction to monitor, and if needed, address the leg length discrepancy caused by the tibia bowing prior to skeletal maturity.

Spinal dysraphism
Spinal dysraphism is a reference to congenital abnormalities in the vertebrae, spinal cord and/or nerve roots. These signs are commonly associated with underlying spinal abnormality:

  • Hairy patch on the midline of the back
  • Central, sacral dimple
  • Abnormal fat distribution in the lumbosacral area

These cutaneous manifestations are all significant hints that the underlying spinal cord or vertebrae did not form normally. An MRI of the spine is required to determine the exact nature of the spinal dysraphism. Possible definitive diagnoses include tethered cord, abnormal development of the spinal cord, lipomeningocele or spina bifida. Referral to a pediatric orthopedic specialist with experience in neurological and spine conditions is highly recommended. The child will need ongoing evaluation and intervention to maximize function with spine and limb deformities with growth.

Addressing positioning, postural and orthopedic concerns may not be a top priority in the early days, but consulting a pediatric orthopedic specialist should be considered as soon as the need is identified. A collaborative approach to prioritizing care with treatment plans and accurate information is beneficial for treatment outcomes and reassuring to the family.