Orthopedic Disorders
Dr. Darawshe mohamad
Developmental Dysplasia of the Hip (DDH)
• refers to a spectrum of pathology in the development of the immature hip joint. Formerly called
congenital dislocation of the hip, DDH more accurately describes the variable presentation of the disorder,
encompassing mild dysplasia as well as frank dislocation.
• Family history, Female, Firstborn, Breech, Oligohydramnios, Multiple gestation, Large for
gestational age- LGA.
• Exam:-
– Barlow is most important examination; will dislocate an unstable hip; is easily felt (clunk
not a click)
– Ortolani—reduces a recently dislocated hip (most at 1–2 months of age), but after 2
months, usually not possible because of soft-tissue contractions.
• All infants with positive exams should immediately be referred to an orthopedic surgeon
• If equivocal, can repeat exam in 2 weeks and if equivocal then a dynamic U/S of the hips is
the best test (age <4 months) or hip x-ray (age >4 months)
• Treatment:
– Pavilk harness for 1–2 months
– Surgery, casting
• Complications: acetabular dysplasia, leg length discrepancy
Case
• A 5-year-old boy has developed progressive limping.
• At first painless, it now hurts to run and walk.
• The pain is in the anterior thigh.
• The pain is relieved by rest.
• Parents recall no trauma.
Legg-Calvé-Perthes Disease
• Idiopathic avascular necrosis of the capital femoral epiphysis in
immature.
• More in males; 20% bilateral; sometimes after trauma.
• * remember to check coagulation disorder/venus stasis.
• Presentation:
– Mild intermittent pain in anterior thigh with painless limp with restriction
of motion.
• Diagnosis:
– anterior/posterior and frog leg lateral x-ray shows compression, collapse
and deformity of femoral head.
• Treatment:
– Containment (femoral head within acetabulum) with orthoses or casting
– Bedrest
– Abduction
– surgical correction
Slipped Capital Femoral Epiphysis (SCFE)
• Most common adolescent hip disorder
• Either obese with delayed skeletal maturation, or thin with a recent growth spurt
• Can occur with an underlying endocrine disorder- hypothyroidism/ hypocalcemia/
hypopiyuitary disease.
• Clinical presentation
– Pre-slip stable; exam normal; mild limp external rotation
– Unstable slip; sudden-onset extreme pain; cannot stand or walk; 20%
complain of knee pain with decreased hip rotation on examination
• Complications:
– osteonecrosis (avascular necrosis) and chondrolysis (degeneration of cartilage)
• Diagnosis:
– AP and frog-leg lateral x-ray, earliest finding: widening of physis without
slippage (preslip); as slippage occurs, femoral neck rotates anteriorly while
head remains in acetabulum
• Treatment:
– open or closed reduction (pinning)
Transient Synovitis
• Viral; most 7–14 days after a nonspecific upper
respiratory infection; most at 3–8 years of age
• Clinical presentation:
– Acute mild pain with limp and mild restriction of
movement
– Pain in groin, anterior thigh, and knee
• Diagnosis:
– Small effusion (±)
– Slight increase in ESR
– Normal x-rays
– No to low-grade fever
– non-toxic-appearing
• Treatment:
– bedrest and NSAIDS
Osgood-Schlatter Disease
• Traction apophysitis of tibial tubercle
(overuse injury)
• Look for active adolescent (running,
jumping)
• Tenderness, increased prominence of
tubercle
•
• Treatment:
– rest, restriction of activities, knee
immobilization, isometric exercises
– NSAIDS.
• Complete resolution requires 12–24 months
Osteomyelitis:
– Bone infections in children are relatively common. Early recognition of osteomyelitis
in young patients is of critical importance; prompt institution of appropriate medical
and surgical therapy before extensive infection develops will minimize permanent
damage. The risk is greatest if the physis (the growth plate of bone) is damaged.
– S. aureus most common among all age groups, including newborns.
– Kingella kinge- K. kingae can be difficult to detect unless polymerase chain reaction
(PCR) testing is used.
– GAS\S.PNEUMONIA
– Pseudomonas—puncture wound
– Salmonella species and S. aureus are the two most common causes of osteomyelitis
in children with sickle cell disease.
– Neonates might exhibit pseudoparalysis or pain with movement of the affected
extremity, children are more likely to have pain, fever, and localizing signs such as
edema, erythema, and warmth. With involvement of the lower extremities, limp, or
refusal to walk is seen in approximately half of patients. Focal tenderness over a long
bone can be an important finding.
– Long bones are principally involved in osteomyelitis ; the femur and tibia are equally
affected and together constitute almost half of all cases.
– The diagnosis of osteomyelitis begins with clinical suspicion and requires appropriate
cultures and imaging studies. Blood cultures should be performed in all suspected
cases, CBC, ESR\crp. Initial plain film if diagnosis not obvious to exclude other causes
– MRI is more sensitive than CT or radionuclide imaging in acute osteomyelitis and is
the best radiographic imaging technique for identifying abscesses and for
differentiating between bone and soft tissue infection. Radionuclide imaging, an
alternative to MRI, may be useful if multiple foci are suspected
– Tx- Obtaining a blood culture before antibiotics are given is essential.
– Abx dipends on pathogen ‘ cover staph by 1 generation cephalosporin .
• Septic arthritis :-
septic arthritis in infants and children has the potential to damage to the synovium, adjacent cartilage, and bone, and cause
permanent disability.
- Staphylococcus aureus is the most common cause of bacterial arthritis in all age groups. GAS,
S.pneumoniae.
- In sexually active adolescents, gonococcus is a common cause of septic arthritis and tenosynovitis, usually
of small joints or as a monoarticular infection of a large joint.
- A microbial etiology is confirmed in approximately 65% of cases of septic arthritis.
- Most septic arthritides are monoarticular. The signs and symptoms of septic arthritis depend on the age of
the patient. Early signs and symptoms may be subtle, particularly in neonates. As with osteomyelitis,
neonates might exhibit pseudoparalysis or pain which limits voluntary movement of the affected extremity .
Older infants and children might have fever and pain, with localizing signs such as swelling, erythema, and
warmth of the affected joint. With involvement of joints of the pelvis and lower extremities, limp or refusal
to walk often occurs.
- Dx- CBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are generally elevated in
children with joint infections.
- Blood cultures should be performed in all cases of suspected septic arthritis but are positive in 20% or
fewer cases of proven or probable septic arthritis
- Synovial fluid analysis for cell count, differential, protein, and glucose has limited utility in diagnosing
infectious arthritis. Joint fluid white blood cell counts >50,000 cells/mm3 suggest bacterial infection as the
most likely etiology.
- Plain films can suggest the diagnosis of septic arthritis by showing: widening of the joint capsule, soft tissue
edema, and obliteration of normal fat lines, Ultrasonography is included with plain films in routine
evaluations because it is particularly helpful in detecting joint effusion and fluid collection in the soft tissue
and subperiosteal regions. Ultrasonography is highly sensitive in detecting joint effusion, MRI and CT can
confirm the presence of joint fluid in patients with suspected osteoarthritis infections but are not routinely
indicated. MRI is useful in evaluating for adjacent osteomyelitis or pyomyositis but is typically reserved for
cases when the index of suspicion for these conditions is high. Radionuclide imaging, although not routinely
indicated, is more sensitive than plain radiographs in providing supportive evidence of the diagnosis of
septic arthritis,
- Tx- cover anti staph 3-4 weeks . . Adjunct therapy with dexamethasone for 4 days with antibiotic therapy has
been shown to decrease the duration of fever and promote a more rapid decline in inflammatory markers.
