15.11.2 Skeletal Conditions Flashcards
Rotational variations
- Vary widely (varies until age of 5 -> mature gait)
- Generally not pathological
- Foot position during walking relative to the body’s line of movement during the gait cycle
- Torsion➡️internal/ external / neutral
➡️version of the bones
➡️capsular pliability
➡️muscle control
Rotational variation Assessment
Static
- Available range of rotational motion
- Prone position
Dynamic
- Effect of various torsional
- Child should be able to walk alone Shoes and barefoot
- Foot and knee position should be observed over several cycles of gait.
Thigh foot angle
- Degree of tibial torsion
- Foot deformities may contribute to rotational abnormalities
- The average TFA: (only understand there is a big variation in children)
➡️5 degrees internal in infants (range, -30 to +20 degrees)
➡️10 degrees external by 8 years of age (range, -5 to +30 degrees) - TFA changes very little after 12 years of age
Rotational profile
- Foot progression angle
- Static rotation
- Thigh foot angle
- Abnormal rotational profiles➡️2 standard deviations
- According to Staheli’s criteria
Differential diagnosis
In-toeing
- Metatarsus adductus
- Internal tibial torsion
- Excessive femoral anteversion
- Children sit in W position (normal until 10 years; after this it won’t heal on its own)
Out-toeing
- femur or tibia turned outwards
- External rotation contracture of the hip (intra-uterine position) -18-24 month
- External femoral torsion Excessive ext tibial torsion
- Pes Planus
- Calcaneovalgus foot
- SCFE (sudden onset especially in older children) -> separation between femoral head and neck at growth plate
Genovarum (Don’t need to know all the names, only know what it is)
- Physiologic bowing
- Blounts disease
- Metabolic bone disease
➡️X linked Hypophosphatemic (XLH) rickets
➡️Nutritional rickets
Skeletal dysplasia
➡️Achondroplasia
➡️Pseudoachondroplasia
➡️Metaphyseal chondrodysplasia (Schmid’s or McKusick’s type)
- Neoplastic disease (rare)
- Trauma (sequelae)
- Infection(sequelae)
Alignment variations
- Natural history is gradual normalization➡️by 6 to 7 years of age
- 99% resolve spontaneously
- Tibia torsion surgically addressed after age 8
- Femoral anteversion addressed after age 10
Straight at 8 - Alignment should be straight at age of eight (Slide 11)
Physiological bowing
- At birth: 10 to 15 degrees of varus
- 10 degrees of bilateral femoral-tibial varus noted after the age of 18 months.
- Associated internal tibial torsion
- Early walkers
Clinical features
- A family history is common
- Bilateral, it may be asymmetric
- Very agile walkers
- NO Dynamic varus/ lateral thrust should be noted➡️characteristic of pathological bowing
Role of X-rays
- NOT before 18 months of age
- > 18 months- essential part of the evaluation
- Specifically Indicated:
➡️pronounced deformities (clinical femoral-tibial angle >20°) ➡️lateral thrust is observed
➡️short stature (below fifth percentile)
➡️metabolic bone disease is suspected
- Distribution of bowing deformity is noted
- Physiologicbowing throughout the distal femur, proximal tibia and distal tibia.
- Early Blount diseaseproximal tibia
Genu Valgum
- can be physiological
- 3-4 years of age children have up to 20 degrees of genu valgum
- Genu valgum rarely worsens after age 7
- After age 7 valgus should not be worse than 12 degrees
Unilateral genu valgum
- Physeal injury from trauma, infection, or vascular insult
- Tibia fractures
- Benign tumors
Bilateral genu valgum
- Physiologic
- Renal rickets
- Skeletal dysplasia
Packaging disorders
Torticollis
Genu recurvatum
If you see one, you should check for the other one
Torticollis
- Present at birth
- Head is tilted towards the affected side but the chin away from the affected side
- Shortened Sternocleidomastoid muscle
- Breastfeed/ feed and carry the child to encourage stretching of the affected side
- Physiotherapy referral for stretching.
- If not resolved by the age of 1, will need surgery.
Genu recurvatum
- Present at birth
- Spectrum of disease
- Breech babies
- Associated with syndromes
- Resolves with time
- Management is splinting
- Refer at 6 weeks of age to assess and ultrasound the hips for DDH
- If flexion <30 degrees achieved, need soft tissue releases
Tibial bowing
- All need to be referred to the Orthopaedics.
-
Anterolateral bowing is most likely to be caused by
Neurofibromatosis. - AnteroMedial bowing is most likely due to hemiMelia.
- Posterolateral bowing resolves with time but needs to be followed up.
Common hip pathology
DDH - developmental dysplasia of the hip
DDH
- First born
- Female
- breech
- family history
- positive ortolani and barlow
- refer for ultrasound at 6 weeks (no X-ray because bone is not calcified yet, see better on ultrasound)
Late presenter
- Leg length discrepancy
- Waddling gait if bilateral
- These need x rays and referral for surgery!
Perthes
- 4-8 years
- Boys
- AVN (idiopathic) of femoral head which remodels
- Must exclude TB (and other causes of AVN)
- Please always do CRP and ESR
RF for poor prognosis
- Female
- Older than 8 years on presentation
- Stiff hip
SUFE
Teen with knee pain who is not sporty
- Knee pain in adolescents
- Usually 12-14 years but as early as 8!
- Overweight usually
- Strict non-weight bearing
- Semi-urgent referral to Ortho
- VULA!
- patient is told not to walk and need to be referred so that head can be pinned
