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Paediatric Orthopaedic Problems Age 0 – ≤15 years

  

Management and referral of common orthopaedic problems in childhood Age 0 - ≤15 years


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 & adolescent hip, deformity, trauma
  • Chris Hill – General, neuromuscular, trauma

Referrals

Inclusion criteria: Age 0 – ≤15 years

Exclusion criteria: Age ≥16 years refer to adult service

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 (0-12 Months) – Trauma & Orthopaedics – UHCW – RKB]. This service can be found via:

Specialty: Children’s & Adolescent Services

Clinic Type: Orthopaedics

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

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

Please email URGENT referrals to the Paediatric Orthopaedic team at Paedsortho@uhcw.nhs.uk  using the preferred email form attached

Our secretaries can be contacted by telephone at  02476 967011 or 02476 966918

Immediate referrals to Children’s Emergency Department at 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 as part of NIPE 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. Leg or foot pains at night in a child who plays happily during the day is consistent with growing pains and does not need assessment in secondary care.

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.

Scoliosis in Children

Assessment in secondary care is advised for any child with a suspected scoliosis who is still growing.

Clinical signs suggestive of scoliosis include:

  • Asymmetry in shoulder height, arm-flank distance or flank creases.
  • Prominence of the ribs on one side when touching the toes is often the most apparent sign (Adam’s forward bend test).

Urgent Referral:

Urgent referral is advised:

  • Prompt referral is advised in children under 11 due to the risk of progression.
  • Those with neurological symptoms /signs or non-mechanical or night pain that interrupts sleep should be referred urgently.

Routine Referral:

Children with suspected scoliosis should otherwise be referred on a routine basis via NHS E-referral.

A standing AP of the whole spine, including iliac crests, can be useful prior to referral as in many cases we can reassure in mild cases or redirect in severe cases.

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.

Neck and shoulder pain is common in inactive adolescents with a hunched posture.

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.

ALWAYS CONSIDER SUFE IN AN ADOLESCENT WITH KNEE OR HIP PAIN. The most reliable clinical sign is a restriction in internal rotation and abduction, even obligate external rotation (the shin turns inwards as the hip is flexed).

Suspected SUFE should be referred immediately to the on-call orthopaedic registrar at UHCW.

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 (the shin turns inwards as the hip is flexed).

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 inwards 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

Please do not refer to paediatric orthopaedics for joint laxity or Hypermobility Syndrome as there are no surgical treatments for these conditions.

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 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.

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.

Children with more than two years growth remaining (boys under 14 or pre-menarchal girls) may be suitable for guided growth.

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.

If acute, a few weeks of avoiding all activities that cause pain can help. 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.

 

Syndactyly of the toes

Partial simple (not bony) syndactyly of the 2nd and 3rd toes is common and is rarely associated with any underlying condition or syndrome. It has no functional impact and does not cause pain. The decision to operate is cosmetic. Surgery is technically challenging and prone to complications so we advise waiting until the child is old enough to contribute to the decision-making process. If the child is keen for intervention, referral to plastics is best.

 

 

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