common childhood problems of the lower limb (cong. & dev.)

COMMON CHILDHOOD PROBLEMS OF THE LOWER LIMB (CONG. & DEV.)

Given Silishebo SishekanoMBChB IV

Orthopedics I tutorialFebruary 23, 2017(14h00-16h00)

TABLE OF CONTENT1. Principles of congenital development.2. Developmental Hyperplasia of the hip(DDH).3. Perthes disease.4. Recurrent dislocation of the patella.5. Congenital Talipes Equinovarus

(Club Foot)6. Syndactyl

1. PRINCIPLES OF CONGENITAL DEVELOPMENT.Many congenital conditions occur for no obvious reasons but;1. Genetic disturbances.2. Drugs3. Infections.4. Trauma.5. Anoxia.6. Compression inuteroare all factors known to cause maldevelopment if they occur at a time when development is critical.

2. DEVELOPMENTAL HYPERPLASIA OF THE HIP(DDH) It is the abnormal development of the hip resulting in dysplasia and dislocation.Pathology: Capsular laxity is the dominant feature in the unstable hip The tight fit between the femoral head and the acetabulum is lost The femoral head can be made to slide in and out of the acetabulum.

Risk factors: Female (Girls:Boys 8:1) Positive family history Environmental factors Position in utero (Breech)

DIAGNOSISDiagnosis is clinical limited abduction of the flexed

hip (<50-60°) 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 90° 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

positive test: palpable clunk is felt (not heard) if hip is reduced

Galeazzi’s sign knees at unequal heights when hips and

knees flexed dislocated hip on side of lower knee difficult test if child <1 yr Trendelenburg test and gait useful if

older (>2 yr)

INVESTIGATIONS U/S in first few months to view

cartilage Follow up radiograph after 3 mo X-ray signs (at 4-6 mo): false

acetabulum, acetabular index >25°, broken Shenton’s line, femoral

Neck above Hilgenreiner’s line, ossification centre outside of inner lower quadrant (quadrants formed by intersection of Hilgenreiner’s and Perkin’s line)

TREATMENT 0-6 mo: reduce hip using Pavlik

harness to maintain abduction and flexion

6-18 mo: reduction under GA, hip spica cast x 2-3 mo (if Pavlik harness fails)

>18 mo: open reduction; pelvic and/or femoral osteotomy

COMPLICATIONS Redislocation, inadequate

reduction, stiffness AVN of femoral head

3. PERTHES DISEASE. Ideopathic AVN of femoral head, presents

at 4-8 yr of age 12% bilateral, M>F = 5:1, 1/1,200

Associations Family history Low birth weight Abnormal pregnancy/delivery ADHD in 33% of cases, delayed bone age

in 89% Second-hand smoke exposure Asian, Inuit, Central European

Key features AVN of proximal femoral

epiphysis, abnormal growth of the physis.

Eventually remodelling of regenerated bone.

CLINICAL FEATURES Child with antalgic or

Trendelenburg gait ± pain Intermittent knee, hip, groin, or

thigh pain Flexion contracture (stiff hip):

decreased internal rotation and abduction of hip

Limb length discrepancy (late)

Investigations X-ray: AP pelvis, frog leg laterals May be negative early (if high

index of suspicion, move to bone scan or MRI)

Eventually, characteristic collapse of femoral head (diagnostic)

MANAGEMENT Goal: To preserve ROM and keep

femoral head contained in acetabulum.

Non-operative physiotherapy: ROM exercises brace in flexion and abduction x

2-3 yr (controversial)

Operative Femoral(varus) or pelvic

osteotomy (>8 yr of age or severe)

Prognosis better in males, <5 yr, <50% of femoral head involved, abduction >30°

60% of involved hips do not require operative intervention

Natural history is early onset OA and decreased ROM

4. RECURRENT DISLOCATION OF THE PATELLAAetiology:Congenital Ligament Laxity hypoplasia of lat. Femoral condyle Flattening of Intercondylar groove Patellar maldevelopment Primary muscle defect Genu valgum

Acquired Genu valgum Inequality of growth of condyle Weakness of Quads Contracture fibrosis

PRESENTATION More common in girls Often B/L Acute pain with knee stuck in flexionIn dislocated state: Visually obvious Tenderness SwellingBetween attack Patella alta Gen. lig. Laxity Apprehension test +ve

INVESTIGATIONSX-ray(skyline) Dislocation High-riding patella Other anatomical abnormalityMRICT-SCAN

MANAGEMENT Transplantation of patellar tendon

medially Near maturity: Transplant block of

bone bearing insertion of tendon more medially and distally Common comp: Osteoarthritis

Younger-Release vastus lateralis tightness with reefing of medial capsule.

4. CONGENITAL TALIPES EQUINOVARUS (CLUB FOOT) Muscle contractures resulting in

CAVE deformity Bony deformity: talar neck medial

and plantar deviated; varus calcaneus and rotated medially

Around talus; navicular and cuboid medially displaced

1-2/1,000 newborns, 50% bilateral, occurrence M>F, severity F>M

Etiology Intrinsic causes (neurologic,

muscular, or connective tissue diseases)

vs. extrinsic (intrauterine growth restriction), may be idiopathic, neurogenic, or syndrome-associated

Fixed deformity

EXAMINATIONPhysical examination Examine hips for associated DDH Examine knees for deformity Examine back for dysraphism

(unfused vertebral bodies)

X-ray

MANAGEMENT Largely non-operative via Ponseti

Technique (serial manipulation and casting)

Correct deformities in CAVE order Change strapping/cast -2wk Surgical release in refractory case

(rare)– delayed until 3-4 mo of age

3 yr recurrence rate = 5-10% Mild recurrence common; affected

foot is permanently smaller/stiffer than normal foot with calf

muscle atroph

5. SYNDACTYL Fusion of digits Relatively common Due to failure of separation of the

digits in uteroToes: Syndactyly of toes does not cause

functional limitations. Surgery to separate affected toes

is not advised.

THANK YOU FOR PAYING ATTENTION.