Pediatrics [ORTHOPEDICS]
Adult orthopedics has a great many diseases to learn and peds
ortho is no different. For pediatrics every disease has its own
unique presentation. Learning each constitutes strict
memorization but there’s only a few things to commit for each
disease. Keep in mind - if you’re studying for a test this makes for
a great extended matching set.
1) Hip Pathology
Knowing the age, presentation, and treatment will help build a
differential for “hip disease.”
i. Developmental Dysplasia of the hip
The hip is insufficiently deep so the femur head constantly
pops out. Diagnosed during the well-baby exam (newborn),
there’ll be a clear click sound on hip flexion (Barlow and
Ortolani). Confirm the diagnosis with an ultrasound at 4-6
weeks as there can be physiologic laxity initially around
time of birth which may resolve. Once diagnosed put the
child in a harness to keep the femur approximated to the join
as the joint grows out.
ii. Legg-Calve-Perthe Disease
When a child is around six years old they can suffer from
avascular necrosis of the hip. There’ll be an insidious onset
knee pain and an antalgic gait (spend less time on painful
leg). Diagnose by x-ray and then cast.
iii. Slipped Capital Femoral Epiphysis
An orthopedic emergency, it can occur in adolescents who
are either obese or in a growth spurt. They’ll complain of
hip or knee pain of sudden onset. Get a frog-leg position
x-ray to confirm. Surgery is required.
iv. Septic Hip
The differential of pediatric hip disease could be done by age
alone were it not for this. It shows up in any age (though
usually a toddler) during a febrile illness with complaints
of joint pain. Do an x-ray first then a joint aspiration with
Gram stain and culture. It needs to be drained and
antibiotics should be started.
v. Transient Synovitis
On the differential for septic hip. It’s synovial
inflammation up to 4 weeks after URI or GI viral illness.
Differentiate by lack of fever, no leukocytosis, and
decreased inflammatory markers (Kocher criteria - the more
you have, the higher risk of septic joint - see right). The Xray is normal. Treat supportively.
Dx
DDH
LCP
Age
Newborn
6
SCFE
13
Septic
Hip
Any
(Toddler)
Transient
Synovitis
Any
Dx
OsgoodSchlatter
Scoliosis
Osteogenic
Sarcoma
Ewing’s
Fractures
Patient
Clicky Hip
Insidious Onset
Antalgic Gait
Fat kid with
knee pain
(nontraumatic)
Joint pain
during febrile
illness
Joint pain after
viral illness
Patient
Teenage
athlete
Teenager
(usually girl)
Retinoblastoma
t(11:22)
Dx
U/S
XR
Tx
Harness
Cast
XR
Surgery
(frog-leg) (Urgent)
Aspirate
Drain and Abx
History
Supportive
Sxs
Knee pain with
swelling
Adam’s Test
Dx
Clinical
Tx
Support
XR
Brace.
Rods
Resection
XR
Sunburst
XR
Resection
Onion-skin
If a plate involved do open reduction and internal fixation
Non-weight bearing
ESR > 40
Fever > 38 °C
WBC > 12,000
Femur / Tib
pain
Mid-shaft pain
Kocher Criteria
1: not septic joint
2: not sure
3: 93% septic joint
4: 99% septic joint
2) Osgood-Schlatter Disease
Occurring in teenage athletes, it presents as a painful knee with
swelling over the tibial tubercle. The athlete has two options:
stop exercising (curative) or play through it. If they work
through, it there may be a palpable nodule. Otherwise, it causes
no permanent sequelae but it does hurt.
3) Scoliosis
A developmental disorder of the spine found in adolescents
(mainly females). Their thorax will tip to the side causing a
cosmetic deformity. More severe disease can cause respiratory
issues. Perform an Adam’s Test (patient bends forward,
asymmetric shoulders are diagnostic) and confirm with X-rays.
Treat by bracing with the goal of slowing progression (not
curing). Surgery with rod placement is reserved for severe cases.
© OnlineMedEd. http://www.onlinemeded.org
Pediatrics [ORTHOPEDICS]
4) Bone Tumors
In kids, 1o tumors cause low grade focal pain and may invade
locally. Have two in mind: osteogenic sarcoma presents with a
sunburst onion skin pattern typically at the distal femur. It’s
associated with retinoblastoma. The other is a Ewing’s sarcoma
found in the mid-shaft caused by t(11:22) translocation. The test
may show you an x-ray of the bone with the lesion, or they may
just say “sunburst” or “onion-skin.” An MRI is the best
radiographic test, and, as with most cancers, biopsy is the best
diagnostic step. Resection is treatment in both cases.
Osteogenic Sarcoma
Ewing’s
5) Special Considerations for Fractures
Fractures are the same as for adults except when it comes to the
growth plate. If the fracture involves the growth plate an ORIF
is needed to ensure the plate is realigned. Otherwise the kid will
grow up with one leg shorter than the other.
© OnlineMedEd. http://www.onlinemeded.org