PEDIATRIC DILEMMAS
From the annual Family Practice Refresher Course, sponsored by the David Geffen School of Medicine at the
University of California, Los Angeles
| Orthopedic Problems in Children —James D. Korb, MD, Director, Academic Affairs and Pediatric Residency
Program, Children’s Hospital of Orange County, Orange, California
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| Developmental dysplasia of hip (DDH): previously called congenital dislocation of hip; spectrum of disorders; incidence of
true dislocation 1 in 1000; risk factors—breech delivery; female sex; positive family history; other orthopedic abnormalities;
prognosis—20% of hip replacements in adult women due to unrecognized or poorly treated DDH; short term, child
has decreased range of motion and certain amount of limping
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 | Physical examination (PE): newborn to 4 mo of age— Ortalani and Barlow tests; >4 mo of age—most important finding
on PE limited abduction (if child cannot go 60° from vertical, suspect dislocated hip); other signs include asymmetric
thigh folds, leg length abnormality (eg, Galleazi’s sign), and waddling or Trendelenburg gait
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| Clinical diagnosis: ultrasonography (US)—effective in identifying dislocated and subluxable hips in children <4 to 6
mo of age; x-rays—extremely reliable in children by 3 to 4 mo of age; gold standard (ie, treatment continued until x-
rays normal) used to follow acetabular development and to rule out other orthopedic abnormalities; when to image—
not necessary if Ortalani or Barlow test positive (diagnostic for DDH); beyond neonatal period, consider in child with
suspicious signs, eg, limited abduction, leg length discrepancy; recommended (even if PE normal) if patient breech delivery
or female child with positive family history
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| Treatment: neonates and young infants—Pavlik harness; children 6 to 12 mo of age—traction; closed reduction with
US guidance; casting; children >12 mo of age—open reduction; rebuilding (angle of femur or acetabulum itself);
surgical release of adductors; key to treatment—if diagnosis missed until after walking age, outcome for hip will
never be normal; at every well-child visit during first year of life, hips must be checked carefully
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| Metatarsus adductus and varus: deviation of forefoot inward; positional defect; increased incidence seen in cases of intrauterine
crowding; key finding on PE whether forefoot flexible (adductus) or fixed (varus); use heel bisector to grade
degree of condition; treatment—if forefoot flexible, no treatment necessary (resolves spontaneously); if rigid, serial
casting required (usually started at 6-8 wk of age)
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| Calcaneovalgus foot: seen in newborns who were in tight intrauterine environment where foot pushed up against intrauterine
wall; on PE—foot dorsiflexed; heel in valgus when foot in this position; treatment—resolves spontaneously
(usually by 2 wk of age); look for DDH
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| Congenital muscular torticollis: typical case infant with slightly turned or tilted head; usually presents as mass in sternocleidomastoid
(SCM) muscle at 2 to 3 wk of age; can lead to flattening of occiput and some facial asymmetry; thought to
be secondary to intrauterine compartment syndrome; treatment—stretching (during first year of life) usually sufficient; if
condition still present after 18 mo of age, consider surgical release of SCM; caveat—if mass in neck not present, must
get x-ray to rule out congenital abnormalities of spine
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| In-toeing: diagnosis based on age, as conditions causing in-toeing tend to occur at specific ages and resolve with time (in
children ≤1 yr of age, metatarsus adductus; in children 1-3 yr of age, medial tibial torsion; in children ≥4 yr of age, medial
femoral torsion; problem is that children often develop all 3 conditions sequentially)
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| Medial tibial torsion: most common cause of in-toeing in children 1 to 3 yr of age; associated with other abnormalities
(eg, tibia vara); key to diagnosis—foot progression angle; thigh-foot angle; position of medial and lateral malleoli
(easiest way to diagnose in this age group); resolves completely without treatment
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| Medial femoral torsion: most severe at 4 to 6 yr of age, then improves slowly up to 8 to 10 yr of age; more common in
girls; tends to be bilateral (unlike tibial torsion, which can be unilateral or bilateral); findings on PE—knees point inward
when child stands; can sit in reverse tailor position; key to diagnosis—measure internal rotation of hip when
child prone; management—no treatment required in most cases; femoral derotational osteotomy reserved for significant
cosmetic problems in puberty
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| Bowlegs (genu varum): normal developmentally until 2 to 3 yr of age; exaggerated by medial tibial torsion; key finding
on PE whether bowing symmetric or asymmetric; can track bowing by measuring intercondylar distance or can measure
femorotibial angle; warning signs of pathologic bowing—not improving (or worsening) by 2 to 3 yr of age;
asymmetric; short stature; positive family history; history of trauma; pathologic causes—osteochondral dysplasias;
trauma to growth plate; rickets; tibia vara; in most cases, bowing physiologic and resolves without treatment
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| Tibia vara (Blount’s disease): medial aspect of tibial growth plate does not grow; as result, growth of lateral aspect of tibial
growth plate forces leg to turn medially; more common in blacks, obese children, and those with positive family
history; presents in infants (typically bilateral symmetric disease with no pain) or in teenagers (usually unilateral and
painful; patients usually obese); diagnosis made on x-ray; treatment—in younger children, treated with braces; in
teenagers, almost always requires corrective surgery
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| Knock knees (genu valgum): normal developmentally in children 3 to 10 yr of age; exaggerated by genu recurvatum;
similar warning signs as with bowlegs; on PE—can measure distance between malleoli with child lying prone; x-rays
can identify abnormal femorotibial angle; in most cases, treatment not necessary
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| Transient synovitis of hip: typical case 2- to 6-yr-old who, upon awakening, refuses to walk; as day progresses, child improves
slightly, but still walks with limp; next morning, refuses to walk again; key to treatment is ensuring child does not
have septic arthritis; findings on PE—loss of internal rotation; decreased abduction; mild or moderate pain with hip
movement; no or low-grade fever; often symptoms of urinary tract infection (URI); laboratory studies (white blood cell
[WBC] count, elevated erythrocyte sedimentation rate [ESR]) helpful in ruling out septic arthritis; if unsure of diagnosis,
refer to orthopedist; treatment—bed rest; nonsteroidal anti-inflammatory drugs (NSAIDs); traction no longer thought
helpful; symptoms resolve in few days to weeks
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| Legg-Calve-Perthes disease: limp in child 4 to 8 yr of age Legg-Calve-Perthes disease until proven otherwise; idiopathic ischemia
and avascular necrosis of femoral head; usually occurs in boys (usually short in stature; rare in blacks); presents as
limp occurring for several weeks before child brought into office; in children outside age range, consider other nonidiopathic
causes of avascular necrosis; findings on PE—decreased internal rotation and eventually adduction; some pain with passive
rotation; positive Trendelenburg test; leg length discrepancy (in severe cases); x-ray findings—often lag behind clinical
findings; usually first finding small femoral head compacted from pressure; treatment—key is age when disease
develops (if <6 yr of age, outcome excellent, regardless of treatment; if 9-10 yr of age, treatment will never result in normal
hip); goal to restore range of motion and keep femoral head within acetabulum
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| Slipped capital femoral epiphysis (SCFE): displacement of femoral head secondary to abnormal growth plate; typically
seen in adolescents (limp in child 10-15 yr of age is SCFE until proven otherwise); patients typically obese; more common in
blacks than in whites, in boys than in girls; can present as mild hip, thigh, or knee pain with or without limp or as severe hip
pain after minor trauma; findings on PE—limp; pain on passive motion; leg length discrepancy; loss of internal rotation;
flexion causes increased external rotation; diagnosis—obtain anteroposterior (AP) and frog-leg lateral x-rays of both hips;
treatment—once diagnosed, treat as emergency; goal to prevent further slippage, rather than putting femoral head back into
place
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| Spondylolysis and spondylolisthesis: spondylolysis—stress fracture through pars interarticularis; spondylolisthesis—
fracture on both sides of pars interarticularis, resulting in forward displacement of vertebral body; probably most common
cause of chronic back pain in children; associated with activities that cause hyperextension; generally more severe
and symptomatic in girls; patients present with poorly described, nonspecific back pain; findings on PE—some tenderness
over L5-S1 area; tight hamstrings; may have mild lumbar scoliosis; normal neurologic examination; spondylolysis
best seen on oblique x-ray; treatment—if mild, decrease activity and give NSAIDs for pain control; if ineffective, consider
braces; in most cases, condition resolves; indications for surgical treatment—persistent pain; slip >50%; neurologic
symptoms
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| Growing pains: poorly localized pain in lower extremities; varies in location; usually not in joints, more in leg itself; never
looks abnormal (no redness or swelling); children usually totally normal next day; most important differential diagnosis
leukemia and osteoid osteoma
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| Failure to Thrive —Carol D. Berkowitz, MD, Professor of Pediatrics, David Geffen School of Medicine at the University
of California, Los Angeles; Executive Vice President, Harbor-UCLA Medical Center, Torrance, California
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| Introductory remarks: term “failure to thrive” (FTT) should be reserved for children not just physically small, but not doing
well globally (in addition to growth deficits, delayed developmentally and have deficits in interactional skills); while all children
with FTT small, not all small children have FTT; operational criteria for FTT—height or weight below 5th percentile;
deceleration in growth rate; body mass index (BMI) below 5th percentile; evidence-based population studies not effective in
identifying etiology; systematic, comprehensive, and focused approach (including full medical history and PE) required to establish
diagnosis and cause of growth impairment in most cases
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| Evaluation of birth history: key questions—was pregnancy planned; mother’s feelings about pregnancy; prenatal care;
maternal gravidity (repeated pregnancies at intervals of <18 mo may be associated with intrauterine growth restriction
[IUGR] due to placental insufficiency); previous fetal loss; problems during pregnancy; child’s gestational age; child’s
birth weight; mother’s use of cigarettes, alcohol, and drugs
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| Exposure to tobacco, alcohol, and drugs: cigarettes associated with slight decrease in birth weight; alcohol abuse probably
number one cause of IUGR in low-birth-weight babies; in utero exposure to drugs (eg, cocaine, methamphetamine)
produces many harmful effects, but does not cause FTT
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| Prematurity: challenge to differentiate between healthy premature baby and child exhibiting IUGR; calculating ponderal
index and fetal/placental weight ratio useful for identifying growth restriction; generally, otherwise healthy premature
infants should have caught up in growth by 24 mo of age; if infant not caught up by appropriate age, suspect underlying
condition (most likely neurodevelopmental disability)
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| Previous medical history: evaluate—previous growth parameters; recurrent infections (suggest underlying immunologic
problem, eg, HIV infection); easy fatigability and sweating (suggests congenital heart disease); enuresis, daytime incontinence
(may be sign of urologic problems); chronic diarrhea (may indicate cystic fibrosis, gluten enteropathy, and parasitic infections)
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| Family history: can help distinguish between FTT and familial short stature
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| Physical examination: accurately weigh child (with clothes off) and measure height and head circumference; plot measurements;
calculate child’s BMI using weight (kg)/[height (m)]2 ; examine child for dysmorphic abnormalities, which
may be clue to underlying genetic syndrome
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| Suggestive findings on PE: cleft lip and palate—if feeding difficulties present, most often not mechanical and related to
cleft, but based on underlying neurologic disorder; assess bonding issues (mother of child with cleft may exhibit nonnurturing
behavior and emotional detachment); webbed neck—may be clue to presence of Turner’s syndrome (condition
seen in young girls; associated with very short stature)
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| Comments: just as child should be evaluated in relation to parental size, growth of child with underlying syndrome should
also be assessed using appropriate growth curves
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| Considerations in differential diagnosis of FTT: head—cataracts (consider inborn error of metabolism or in utero infection
such as toxoplasmosis, other agents [syphilis], rubella, cytomegalovirus, and herpes simplex virus [TORCH]); neurocutaneous
findings— rash (if present, determine whether allergic or infectious); amount of subcutaneous tissue; chest—is
this child with reactive airway disease who is receiving weekly courses of corticosteroid, eg, prednisone? is there evidence
of recurrent infection? (suggests cystic fibrosis); chronic lung disease associated with increased caloric expenditure;
heart—murmurs (any condition that can lead to congestive heart failure or cause pulmonary hypertension, eg, complex
atrial septal defects [ASDs], will lead to growth failure); otherwise, not associated with growth impairment; issue with congenital
heart disease whether FTT caused by heart lesion or by underlying genetic syndrome (eg, William’s syndrome);
abdomen—distention (masses); rectal prolapse (test for trichuriasis, cystic fibrosis; however, malnutrition itself leading
cause of rectal prolapse); genitourinary—undescended testes
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| Evaluation of interactional skills: does child make eye contact? does child react to stimuli like “funny sounds”? symptoms
of environmental deprivation classic and reproducible; for child with these symptoms, extensive work-up unnecessary
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| Laboratory work-up: should be focused; any suggestive findings on history or PE should be evaluated; otherwise, routine
health maintenance studies indicated
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| Bone age study: involves taking x-ray of child’s wrist to assess skeletal maturation; child’s bone age compared with his or
her height age (ie, age at which height at 50th percentile) and chronologic age; in normal child, bone, height, and chronologic
age equivalent; in child with familial short stature, bone and chronologic age equivalent, but height age delayed; in
child with constitutional delay, bone and height age lag equally behind chronologic age; if child’s bone age lags behind
height age and height age less than chronologic age, suspect endocrinopathy or severe and prolonged environmental deprivation
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Educational Objectives
| The goal of this activity is to review some of the orthopedic problems seen in infants and children and to offer a comprehensive
approach to the evaluation of failure to thrive (FTT). After hearing and assimilating this program, the clinician will be
better able to:
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| 1. Identify signs of developmental dysplasia of the hip (DDH) in neonates and very young children, establish a clinical
diagnosis, and select appropriate treatment for each age group.
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| 2. Describe common positional defects of the newborn foot, including metatarsus adductus and calcaneovalgus foot,
their signs on physical examination, and the recommended approach to management.
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| 3. Cite the common causes of in-toeing in infants and children, and effectively treat conditions such as medial tibial
torsion and medial femoral torsion.
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| 4. Recognize and manage important causes of pediatric limping such as transient synovitis of the hip, Legg-Calve-Perthes
disease, and slipped capital femoral epiphysis.
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| 5. Define the characteristics and components of the condition “failure to thrive,” and perform a systematic and comprehensive
evaluation of the child with suspected growth impairment.
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Discussed on This Program
Cocaine [Cocaine HCl, Cocaine Viscous]
Methamphetamine HCl (desoxyephedrine HCl) [Desoxyn, Desoxyn Gradumet]
Prednisone [Deltasone, Liquid Pred, Meticorten, Orasone, Panasol-S, Prednicen-M, Prednisone Intensol Concentrate,
Strerapred, Strerapred DS]
Suggested Reading
Argyle J: Approaches to detecting growth faltering in infancy and childhood. Ann Hum Biol 30:499, 2003; Bergman P,
Graham J: An approach to "failure to thrive" Aust Fam Physician 34:725, 2005; Boddy J et al: The developmental sequelae
of nonorganic failure to thrive. J Child Psychol Psychiatry 41:1003, 2000; Bogner E, Rafal RB: Failure to thrive.
Clin Pediatr (Phila) 44:185, 2005; Boswinkel J, Mamula P: Failure to thrive. Pediatr Case Rev 3:20, 2003; De Boeck
H, Vorlat P: Limping in childhood. Acta Orthop Belg 69:301, 2003; Do TT: Clinical and radiographic evaluation of
bowlegs. Curr Opin Pediatr 13:42, 2001; Eggert P, Viemann M: Physiological bowlegs or infantile Blount's disease.
Some new aspects on an old problem. Pediatr Radiol 26:349, 1996; Furdon SA, Donlon CR: Examination of the newborn
foot: positional and structural abnormalities. Adv Neonatal Care 2:248, 2002; Ganger R et al: Treatment options for
developmental dislocation of the hip after walking age. J Pediatr Orthop B 14:139, 2005; Hart ES et al: The newborn
foot: diagnosis and management of common conditions. Orthop Nurs 24:313, 2005; Herman MJ, Pizzutillo PD:
Spondylolysis and spondylolisthesis in the child and adolescent: a new classification. Clin Orthop Relat Res 434:46, 2005;
Hubbard AM: Imaging of pediatric hip disorders. Radiol Clin North Am 39:721, 2001; Jingushi S, Suenaga E: Slipped
capital femoral epiphysis: etiology and treatment. J Orthop Sci 9:214, 2004; Katz K et al: Below-knee plaster cast for the
treatment of metatarsus adductus. J Pediatr Orthop 19:49, 1999; Krugman SD, Dubowitz H: Failure to thrive. Am Fam
Physician 68:879, 2003; Leet AI, Skaggs DL: Evaluation of the acutely limping child. Am Fam Physician 61:1011,
2000; Leung AK, Lemay JF: The limping child. J Pediatr Health Care 18:219, 2004; Lincoln TL, Suen PW: Common
rotational variations in children. J Am Acad Orthop Surg 11:312, 2003; Listernick R: Accurate feeding history key to
failure to thrive. Pediatr Ann 33:161, 2004; McTimoney CA, Micheli LJ: Current evaluation and management of
spondylolysis and spondylolisthesis. Curr Sports Med Rep 2:41, 2003; Mooney JF 3rd, Podeszwa DA: The management
of slipped capital femoral epiphysis. J Bone Joint Surg Br 87:1024, 2005; Pandya AN, Boorman JG et al: Failure to
thrive in babies with cleft lip and palate. Br J Plast Surg 54:471, 2001; Sonmez K et al: Congenital muscular torticollis in
children. ORL J Otorhinolaryngol Relat Spec 67:344, 2005; Steward DK et al: Selection of growth parameters to define
failure to thrive. J Pediatr Nurs 18:52, 2003; Tatli B et al: Congenital muscular torticollis: evaluation and classification.
Pediatr Neurol 34:41, 2006; Vane AG et al: The diagnosis and management of neonatal hip instability: results of a clinical
and targeted ultrasound screening program. J Pediatr Orthop 25:292, 2005; Vitale MG, Skaggs DL: Developmental
dysplasia of the hip from six months to four years of age. J Am Acad Orthop Surg 9:401, 2001; Wall EJ: Practical primary
pediatric orthopedics. Nurs Clin North Am 35:95, 2000.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Korb and Berkowitz were recorded at the annual Family Practice Refresher Course, held May 31-June 4, 2005, in
Los Angeles, and sponsored by the David Geffen School of Medicine at the University of California, Los Angeles. The Audio-Digest
Foundation thanks Drs. Korb and Berkowitz and the David Geffen School of Medicine at UCLA for their cooperation
in the production of this program.
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