Common Orthopedic Problems

Carolyn M. O’Donnell, MD, PGY-3

Developmental Dysplasia of the HIp

• Abnormal development of the hip with1.) Instability (joint dislocatability) and2.) Dysplasia or abnormal shape of the acetabulum• Most hip instability resolves shortly after birth• Unresolved instability is often painless and not obvious

since a dislocated hip may function well for many years • Unresolved, it can lead to pain (often knee pain),

abnormal gait, functional disability and degenerative hip disease

• These problems are preventable if it is caught and treated early

DDH

• Hip laxity and immature acetabula are common in the first few weeks of life

• Approximately 90% of these infants will have stabilized by 2 months of age after time for further growth

• After school age, the likelihood of spontaneous resolution is very low

Hip Joint

Clinical Features

• The earlier DDH is detected, the easier and more successful the treatment

• Presentations vary based on age• Newborn: hip instability• Infant: reduced abduction• Toddler: asymmetric gait• Adolescent: activity related pain• Adult: osteoarthritis

Risk factors

• Breech presentation• Female gender• Family history• Factors related to tight positioning in utero

(can see associated torticollis and metatarsus adductus

Risk factors

• Girls with a breech presentation — 12 percent • Girls with a positive family history — 4.4

percent • Boys with a breech presentation — 2.6

percent • Girls — 1.9 percent • Boys with a positive family history — 0.9

percent

In utero

Torticollis

Physical Exam

• Hips should be checked at every visit until the child is walking normally

• Exam technique uses adduction and posterior pressure to feel for dislocation and abduction and elevation to feel for reduction

• Hip Instability: The sensation of dislocation or reduction is best described as a clunk or a jerk

• Clicks and pops not associated with a palpable clunk are very common and not worrisome

Exam

• Examine each hip individually while the child is calm and not crying

• Examine on a stable surface with the child supine and with hips flexed 90 degrees in neutral rotation

Exam

Galeazzi Test

Exam

• Galeazzi test: dislocated hip may be displaced posteriorly so the knee appears lower/shorter

• Look for asymmetry in skin folds• Gait asymmetry• Bilateral DDH can be a challenge- look for

widening of the perineum, symmetric limited abduction, and short thigh segments relative to the child's size. Once the child begins to walk, hyperlordosis and a waddling Trendelenburg gait can be seen

Exam

• Bilateral DDH: • widening of the perineum• symmetric limited abduction• short thigh segments relative to the child's size. • Once walking, hyperlordosis and a waddling

Trendelenburg gait• By 3 months: hip often stabilizes and tests for

instability are no longer very helpful

Imaging

• Ultrasound• Plain radiographs- limited value early on due

to femoral heads cartilaginous and not ossified

• Radiographs should be with hips flexed 20 to 30 degrees, or neutral if the child is older

Radiograph

Management

• If abnormal exam:• Referral to orthopedic surgeon• Imaging:• Ultrasound if less than 5 months• Radiograph if >4 months• Breech females: screening is recommended-

ultrasound at 6 weeks or radiograph at 4 months. This is optional for lower risk groups.

Treatment

• Based on age• Abduction splints in younger kids (usually <6

months)• Closed reduction- goal is to reduce the hip, then

keep it stabilized in spica cast• Open reduction If closed reduction is unsuccessful Often needed in kids >18 months• Risks vs benefits• Follow up is important; complications, failure

Pavlik Harness

Septic Joint

• Infection and inflammation of usually sterile joint space

• Typically affects large joints and joints of the lower extremity- knee, ankle and hip (approximately 80%)

• Up to 10% in more than 1 joint• Predominant age: 2-6 years; adolescent• Males>Females

Pathophysiology

• Bacterial entry:• Hematogenous spread• Direct inoculation• Extension from adjacent infection (bone)• Influx of inflammatory Cells• Rapid destruction of cartilaginous structures

by bacterial enzymes; may -> necrosis

Etiologies

• Viral- parvovirus, EBV, herpes, CMV, varicella, Hep B or C, mumps, rubella

• Fungal- Candida albicans• Spirochete- Lyme (B. burgdorferi)• Tuberculosis• Bacterial • <5 years: S. aureus, Group B strep, HIB, gram

negative bacteria• >5 years: S. aureus, Group A strep, N.

gonorrhoeae

Etiologies

• Also Kingella kingae, salmonella, N. meningitidis

• S. aureus most common outside of neonatal period

• Sickle cell associated with salmonella• Immunocompromised: Mycoplasma,

ureoplasma, or Aspergillus

Neonates and Infants

• Can be subtle• >1 joint• Microbiology: GBS, Gram negative bacilli such as

E. Coli, S. aureus• Often presents with septicemia or fever without

source• Subtle features: positional preference, decreased

use, pain with handling, extremity swelling• Hip arthritis

Children

• Fever and constitutional symptoms• Pain with active and passive movement• Limp/refusal to bear weight• Joint related findings can be subtle: swelling,

warmth• Hip/shoulder: often no external signs• Hip involvement may be referred (knee)• Sacroiliac may present similarly to appendicitis,

neoplasm or UTI

Symptoms

• Do not wax and wane• Can wake up at night with pain• Worsens with time• Specific joint symptoms:• Pain- often exquisite tenderness through any

range of motion• Warmth, erythema, swelling

Evaluation

• Should be PROMPT• NO DELAYS• History and Physical• Labs and imaging• Joint aspiration/joint fluid analysis ASAP• Risks vs. benefits- diagnosis vs seeding the

joint if overlying cellulitis

Evaluation

• History: • ?direct inoculation• ?rash- can implicate type of infection• ?skin/soft tissue infections- source for bacteremia• ?Recent antibiotic use- may attenuate symptoms• ?recent illnesses/URIs- consider post-infectious

synovitis• ?LMP- disseminated gonococcal in 1st 7d of menses• ?Exposures• ?Immunization Status

Exam

• Observation (use parents if young child)• Soft tissue/skin exam• Joint exam: swelling, redness, erythema, pain• Active and passive range of motion• Exam: eyes, skin, heart, lungs, abdomen, etc

Labs

• CBC/WBC- elevated but not sensitive or specific

• ESR- elevated in 95% of cases• CRP- increased• Blood cultures- positive in 30-40% of cases

Synovial Fluid Analysis

Disorder Cells/microL Glucose

Trauma RBCs>>WBCs;<2000 WBCs

Normal

Reactive arthr 3-10,000 WBCs; mostly monos

Normal

JRA/inflamm 5-80,000; mostly neutrophils

Normal/sl. low

Septic arthritis >60,000 WBCs;>90% neutrophils

Low to normal

Lyme arthritis 15-100,000 WBCs; variable cell types

Low to normal

Imaging

• Radiography- may (or may not) show widening of the joint space +/- displacement of the normal fat pads

• Ultrasound- can identify fluid in the joint space

• CT scan• MRI• Bone scan

Algorithm

• Look for 4 or more of the following:• ESR > 20 mm/h• CRP > 1 mg/dL• WBC > 11,000 cells/mL• Joint space fluid apparent on radiograph

Differential Diagnosis• Osteomyelitits• Deep cellulitits• Abscess• Septic bursitis• Bacterial endocarditis• Inflammatory/autoimmune arthritis• Transient synovitis• Acute rheumatic fever• Trauma• Legge-Calves-Perthes• SCFE• Tumor/Malignancy

Treatment

• IV antibiotics• 1st line: Anti-staph PCN, 1st generation

cephalosporin• If MRSA in community, consider vanco or clinda• Sickle cell pts: add ceftriaxone• Duration of therapy depends on bacteria • Supportive care (sepsis, etc)• Drainage of infection- ASAP• Open surgical drainage/irrigation for hip and

usually shoulder, inability to aspirate

Complications

• Septic shock• Death• Joint destruction• Limited range of motion which may be

permanent• Growth disturbance if the epiphysis is

involved.