Common Orthopedic Problems
Carolyn M. O’Donnell, MD, PGY-3
Developmental Dysplasia of the HIp
• Abnormal development of the hip with
1.) Instability (joint dislocatability) and
2.) 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
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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
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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
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If abnormal exam:
Referral to orthopedic surgeon
Imaging:
Ultrasound if less than 5 months
Radiograph if >4 months
Breech females: screening is recommendedultrasound 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
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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
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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
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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
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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
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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
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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
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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
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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
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Septic shock
Death
Joint destruction
Limited range of motion which may be
permanent
• Growth disturbance if the epiphysis is
involved.