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Paediatric Orthopaedic Problems

  

Management and referral of common orthopaedic problems in childhood


Paediatric Orthopaedic Department Ward 16 UHCW

There are four specialist paediatric orthopaedic surgeons who work at University Hospital Coventry & Warwickshire and satellite clinics. All surgery is performed at UHCW.

  • Giles Pattison – General, infant hip & foot, trauma
  • Steve Cooke – General, neuromuscular, trauma
  • Dan Westacott – General, infant hip & foot, child and adolescent hip, trauma
  • Chris Hill – General, neuromuscular, trauma

Referrals

Routine referrals for children with musculoskeletal surgical pathology should be made through the NHS eReferral Service.

Referrals for suspected hip dysplasia should be made urgently through the NHS eReferral Service via the dedicated Referral Assessment Service for this condition (Paediatric Orthopaedic (Hip Dysplaysia Referrals Only) RAS – Trauma & Orthopaedics – UHCW – RKB). This service can be found via:

Specialty: Children’s & Adolescent Services

Clinic Type: Orthopeadics

Referrals will be reviewed by a Clinician and an appointment will be allocated to the patient.

Other Urgent referrals should be made for dislocation in infancy, suspected bone tumour, or any other condition considered urgent by the GP

Urgent referrals marked as URGENT can be made by fax: 02476 967010 or email: uhc-tr.paedsortho@nhs.net

Our secretaries can be contacted by telephone:

Chloe Gallagher         02476 96 7030

Lesley Macaulay        02476 96 7011

Christina Cullivan       02476 96 6918

Immediate referrals to Children’s Emergency Department UHCW:  Suspected osteomyelitis, septic arthritis or slipped upper femoral epiphysis  

 

Developmental Dysplasia of the Hip (DDH, CDH, infantile hip dislocation)

Early recognition and urgent referral is important.The success rate of non-invasive treatments eg. Pavlik harness, falls quickly beyond seven weeks of age.

Ultrasound screening is currently offered to infants with first-degree family history, breech presentation, or clinical examination findings.

30-50% of DDH cases have no risk factor so accurate clinical examination is crucial. Ortolani’s and Barlow’s tests are technically difficult with low sensitivity so the following signs are very useful:

Galeazzi sign: a difference in the height of the knees when the child is supine, with the hips and knees flexed, and the soles of the feet on a firm surface

 

Reduced abduction: with the hips flexed up, a difference in the amount the knees can be pulled apart

Leg length discrepancy: a difference in the overall length of the legs

Asymmetric skin folds: when examined supine, 1 in 4 infants will have asymmetry of the thigh or groin creases. This finding is only relevant when looking at the gluteal fold with the child in ventral suspension

The older the child, the more important these signs become because after six months of age the dislocation may become fixed so Ortolani’s and Barlow’s tests will be falsely negative.

Reduced abduction is often the most sensitive sign of a late-presenting dislocated hip.

Knock knee ( Genu valgum) / Bow leg (Genu varum)

Variation in the frontal (coronal) plane alignment of the legs in children is part of their normal development but can be a source of great concern to parents. The normal changes in alignment are shown in the Selenius curve (the wide range of normal should also be noted):

 

The easiest way to monitor knee angle (using finger breadths or cms looking for change on sequential examinations, remembering the normal pattern ie increasing varus until two, then increasing valgus until four, then straightening):

  • Genu varum: measure the distance between the knees with the ankles touching (intercondylar distance)
  • Genu valgum: measure the distance between the ankles with the knees touching.

In summary:

  • legs bowed at birth
  • straight at two years
  • maximum knock-knee at four
  • correct to the slightly knock-kneed adult position by seven

Referral:

Physiotherapy or orthoses (insoles etc) of little or no benefit.

Referral is indicated for cases:

  • outside these parameters
  • rapidly changing
  • asymmetrical
  • painful
  • associated with a known metabolic or endocrine condition.

 

Leg Pain in Children

Bilateral leg pain in children that affects more than one site (hips, thighs, knees, calves, ankles or feet), in the absence of other symptoms or deformity, is rarely due to surgical pathology.

Vitamin D deficiency is a common and easily treatable cause of non-specific lower limb pain.

Referral:

If Vitamin D is normal, please consider referral to physiotherapy before a paediatric orthopaedic surgeon.

Back Pain in Teenagers / Adolescents

Recent studies have shown the prevalence of mechanical lower back pain in adolescents to equal that of the adult population.

In the absence of deformity, demonstrable neurological deficit or radiculopathy, or any other ‘red flags’ in history or examination, the first line, and often only, treatment is physiotherapy.

Referral:

Paediatric physiotherapy: see above

Paediatric orthopaedic surgeon: no symptom relief despite active engagement with physiotherapy, or with concerning clinical features, should be referred for further assessment and investigation.

In-toeing

There are three main causes of in-toeing in childhood :

  • increased femoral anteversion
  • internal tibial torsion
  • metatarsus adductus.

These are usually due to normal intra-uterine moulding and correct with growth.

Increased femoral anteversion

Most infants are born with a twist in the femur that slowly remodels with growth up to the age of 10. When this twist is present, gait is more efficient with the feet turned in most apparent between the ages of 3 and 6.

The easiest clue that the in-toeing originates from the femur is that the kneecaps point inwards as well.

Internal tibial torsion

Many children have an inwards twist in the tibia that corrects with growth up to age 6.

The tibia can be identified as the source of the in-toeing by examining the child lying prone with the knees bent to 90. The feet should point slightly outwards in relation to the thighs but will be parallel or point inwards in ITT.

Metatarsus adductus

Usually presents in the first year of birth. The lateral border of the foot is not straight. It is a benign condition that corrects by age 4 in 90% of cases.

Referral:

Referral is indicated in children over 8 years old whose quality of life is affected by tripping, pain or cosmesis of gait, and in asymmetrical or progressive deformities.

Longterm studies have shown that none of these conditions leads to long term pain, disability or joint degeneration in adulthood.

Link to in-toeing patient information

Hip Pain in Teenagers / Adolescents

Gluteal tendinopathy (previously known as trochanteric bursitis) is a common cause of hip pain in young people, particularly adolescent girls.

Features:

  • severe aching pain in the buttock, hip and lateral thigh linked to activity
  • will rub the outer side of the hip and thigh when asked to localise the pain
  • most tender just posterosuperior to the greater trochanter.
  • Sensation of hip “popping out” – external snapping hip and is caused by a tight iliotibial band rubbing over the greater trochanter.
  • an internal snapping hip can be caused by a tight psoas muscle and patients will point to the front of the hip as the source of pain.

Referral:

The majority of patients improve with physiotherapy

Referral to a paediatric orthopaedic surgeon is indicated in patients without symptom relief from physiotherapy, or with catching or locking symptoms.

Anterior Knee Pain in Children

Non-traumatic pain at the front of the knee is very common in children and adolescents.

Tenderness over the tibial tubercle suggests Osgood-Schlatter’s Disease. There is no treatment other than rest, ice, and analgesia. There is little evidence that physiotherapy alters the disease course, although some simple quadriceps and hamstring stretches may be beneficial. Suggest swimming rather than running and jumping sports. It will stop when the child stops growing.

Referral:

Patients with tenderness over the patellar tendon itself or around the patellofemoral joint may benefit from physiotherapy.

Those without relief of symptoms following active engagement with physiotherapy for three months can be referred to a paediatric orthopaedic surgeon.

Remember to ALWAYS examine the hip in any child or adolescent with knee pain.

Slipped Upper Femoral Epiphysis (SUFE) often presents with referred pain to the knee. The hip will show reduced internal rotation in flexion or even obligate external rotation

Flat Feet in Children

Painless flexible flat feet in children (and adults) are part of a normal spectrum and are not pathological.

Most children will develop an arch with growth but even if they do not, will have no pain or disability in adulthood.

Check that the foot is flexible. There should be some increase in the arch on Jack’s test (passive extension of the big toe) and the heel should swing from valgus to varus as the child goes up onto tiptoes (look from behind).

Referral:

Insoles do not affect the development of the arch but may help pain.

Referral is indicated for painful feet and those that are not flexible (although please also see the section ‘Leg Pain in Children’)

Link to flat feet in children patient information

Hypermobility Syndrome

Do not refer for Hypermobility Syndrome as there are rarely any surgically remedial features.

Referral:

Children who suffer musculoskeletal pains attributed to flexible joints may benefit from physiotherapy, occupational therapy or psychological support.

Refer to paediatric rheumatology if diagnostic uncertainty or severe chronic pain. Funding has recently been declined for a paediatric chronic pain service in the Midlands.

Bunions (hallux valgus) in Children

2% of 10 year olds have hallux valgus, increasing to 23% of those over 18.

Surgery is very rarely indicated before skeletal maturity due to the high recurrence rate and difficulty in predicting outcome when significant growth remains.

Referral:

Symptom relief can be achieved with corn pads over the bunion, 1st web space cushioned inserts, and wide-fitting shoes without heels.

Referral is indicated in those nearing skeletal maturity (16 for boys, 14 for girls or 18 months post-menarche) with pain that significantly impacts on quality of life.

Referral is appropriate prior to skeletal maturity in patients with underlying syndromes, cerebral palsy or deformity not centred at the 1st metatarsophalangeal joint.

Heel Pain in Children

There are a number of causes of heel pain in children – surgery is very rarely indicated.

Sever’s Disease – Pain on squeezing the bony part of the heel from each side between finger and thumb suggests Sever’s disease. This is a traction apophysitis, similar to Osgood Schlatter’s in the knee. It often occurs in sporty children during a growth spurt.

Treatment rest, ice and analgesia.

They should avoid all activities that cause pain until it has resolved (may be some months).

A simple heel wedge inside the shoe may be helpful.

Referral: Physiotherapy – If the foot cannot be stretched up to beyond 90 degrees with the shin (with the knee straight). X-ray does not help in the diagnosis of Sever’s Disease.

Achilles tendinopathy

Tenderness along the Achilles tendon or at its insertion onto the heel suggests tendinopathy that can benefit from physiotherapy.

Plantar fasciitis

Pain in the medial heel at the origin of the plantar fascia, worsened by passive extension of the toes, suggests fasciitis that can benefit from physiotherapy.

 

 

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