Transcript Pediatric Orthopedics

Pediatric Orthopedics
Llewellyn Mensah, MD
3/19/15
Outline
 Common pediatric orthopedic problems
 DMD
 Club foot
 DDH
 Intoeing
 Common hip conditions in pediatric and adolescent population
 Transient synovitis
 SCFE
 Legg Calve Perthes
 Osteochondroses
 Osteochondritis dessecans
 Kohler’s osteochondritis
 Freiberg’s osteochondrosis
 Apophysitides – scoliosis, traction apophysitis, Osgood Schlatter’s, Sever’s
 Benign nocturnal limb pain of childhood
 Pediatric fractures
Duchenne Muscular Dystrophy
 Caused by a defective gene located on the X chromosome
responsible for the production of dystrophin (important muscle
fiber membrane protein)
 Clinical onset of weakness usually occurs between 2 and 3
years of age and most will present by 6 years of age
 Affected children usually have varying degrees of mild cognitive
impairment
 Muscle weakness affects the proximal before the distal limb
muscles
 Features: cardiomyopathy and conduction abnormalities, bone
fractures, scoliosis, pseudohypertrophy of the calf/quadriceps,
lumbar lordosis, waddling gait, shortening of Achilles tendons,
hypo- or areflexia
Duchenne Muscular Dystrophy (DMD)
DMD
 DMD is the most common fatal disease affecting children in
the United States
 Patients with DMD are often confined to a wheelchair by age
12 years and die in their late teens or 20s from respiratory
insufficiency or cardiomyopathy
 Elevated levels of serum CK and EKG abnormalities are
common
 Muscle biopsy confirms the diagnosis if genetic studies are
negative
DMD
 Treatment aims at preventing complications
 Respiratory – volume recruitment / deep lung inflation,
manual and mechanically assisted cough techniques,
nocturnal ventilation, daytime ventilation, tracheostomy
 Orthopedic interventions to prevent contractures, nutritional
and weight monitoring, dietary calcium and vitamin D
supplementation, exercise to prevent disuse atrophy
 For boys 5 years of age and older who are no longer gaining
motor skills, or whose motor skills are declining –
glucocorticoids (prednisone or deflazacort)
 With LVEF < 55% or LV dilation – ACEI or Β blocker
Erb’s palsy
Erb’s palsy
 Paralysis of arm caused by injury to C5 – C6
 Arises most commonly , but not exclusively, from shoulder
dystocia during a difficult birth
 Loss of sensation in the arm and paralysis and atrophy of the
deltoid, biceps and brachialis
 The arm hangs by the side and is rotated medially; the forearm
is extended and pronated and there is loss of shoulder
abduction, elbow flexion and supination of the forearm (waiter’s
tip).
 Depending on severity, the paralysis can either resolve on its
own over a period of months, or necessitate rehab / surgery
 Treatment: Daily PT; Serial exams for 3 – 6 mo and surgical
referral if still no improvement
Club foot
Club foot
 AKA talipes equinovarus – foot is excessively plantar flexed,
with the forefoot swung medially and the sole facing inward
 Can be diagnosed in utero by u/s; Amniocentesis for karyotype
if there are associated abnormalities (syndromic clubfoot)
 Hereditary predisposition; 1:1000 live births; boys > girls
 For parents without clubfoot, the overall risk of recurrent isolated
clubfoot depends upon the sex of the first affected child
 2% after an affected male; 5% after an affected female
 If both a parent and a child are affected, then the recurrence risk
is as high as 25%
Club foot: Types / Therapy
 Classification
 Congenital (most common): isolated anomaly; - Rx: Serial
casting and bracing (Ponseti method) followed by heel cord
release and night time bracing x 2 years if necessary
Syndromic: associated with connective tissue, genetic,
neuromuscular disorders. Rx: surgical correction at 9 – 12 mo if
needed
Positional: intrauterine crowding or breech position; - easily
corrects to normal position with manipulation
Developmental dysplasia of the hip
 Spectrum of conditions related to the development of the hip
in infants and young children – dislocation / dislocatability,
subluxation / subluxability, femoral head and acetabular
dysplasia
 Incidence is 1 – 2 per 1000 newborn infants
 Risk factors: female sex, breech presentation and other
conditions associated with limited fetal mobility, family history
 Hip exam should occur at birth and at every health
supervision visit until the child is walking normally (usually by
2 years of age).
DDH: Clinical features
DDH: Clinical features
DDH
 Detect hip instability (“jerk” or “clunk”) using adduction and
posterior pressure to feel for dislocatability (Barlow’s) and
abduction and elevation to feel for reducibility (Ortolani’s).
 The American Academy of Pediatrics recommends
ultrasound screening at 6 weeks for breech females, breech
males (optional), and females with a positive family history of
developmental dysplasia of the hip.
 Infants and young children who have hip instability on exam
(at any age) be referred to an orthopedic surgeon for further
evaluation and management
DDH
 The goal of treatment: obtain and maintain concentric hip
reduction so femoral head and acetabulum can develop
normally to prevent osteoarthritis
 Pavlik harness achieves and maintains hip reduction in 95%
of infants treated during the first 6 months of life

DDH
 Spica casting / Reduction under anesthesia (closed or open)
is usually necessary for children who are older than 6 months
of age at the time of diagnosis or initiation of therapy
 Children who have been treated for DDH should be
monitored with regular hip radiographs until they are
skeletally mature to evaluate hip development and
complications or sequelae
In toeing
In toeing
 The most common causes of in – toeing in children are
metatarsus adductus, internal tibial torsion, and increased
femoral anteversion
 These rotational variations are related to intrauterine
molding and resolve spontaneously through normal growth
and development

Metatarsus adductus
 Metatarsus adductus is medial deviation of the forefoot on the hindfoot
 It is the most common cause of in toeing in infants younger than one year
of age
 Characterized by “kidney bean” or “C” shape foot; normal range of motion
of the ankle and subtalar joint
 It usually resolves spontaneously by 2 years of age
Internal tibial torsion
 Internal tibial torsion is internal (medial) rotation of the tibia n
relation to the transcondylar axis of the femur
 It is the most common cause of in toeing in children between
one and three to four years of age
 Characterized by a foot that points inward when the patella
faces forward
 Neutral or internal thigh – foot angle
 Internal tibial torsion usually resolves spontaneously by 5
years of age
TFA
Increased femoral anteversion
 Increased femoral anteversion is an increased angle of rotation
of the femoral neck in relation to the transcondylar axis of the
femur.
 It is the most common cause of in toeing in children older than 3
years of age.
 Characterized by
inward facing feet and patella during walking and standing
 “egg – beater” pattern during running
symmetrically increased internal rotation and decreased external
rotation of the hips
preference for sitting in the “W” position
 Tends to improve spontaneously by 11 years of age
“W position” in increased femoral
anteversion
In toeing
 Most children with rotational variations of the lower extremity
can be followed in the primary care office.
 Pathologic conditions that must be considered neuromuscular diseases eg cerebral palsy, disorders of the
hip eg DDH, lower leg deformities eg skewfoot, clubfoot
 The most important aspect of management of rotational
causes of in toeing is parental reassurance that most
“deformities” correct spontaneously and that, even in
persistent cases, adverse long term sequelae are rare
In toeing
 Non operative interventions eg shoe inserts, braces, twister
cables, casting are ineffective in the treatment of internal
tibial torsion and increased femoral anteversion.
 Indications for referral include
 rigid metatarsus adductus
 unilateral or asymmetric in toeing with findings suggestive of
cerebral palsy or developmental dysplasia / dislocation of the hip
cosmetically or functionally unacceptable in toeing due to internal
tibial torsion in a child older than 8 years
 cosmetically or functionally unacceptable in toeing due to
femoral anteversion in a child older than 11 years
in toeing that does not follow the expected clinical course
Transient synovitis
 Pain and limitation of motion in the hip without clear
precipitant (?post traumatic, allergic, infectious).
 Relatively common (Cumulative lifetime risk of 3%)
 Typically occurs in children aged 3 to 8 years, with a mean
age at presentation of 6 years
 Male to female ratio is slightly greater than 2:1
 Symptoms affect both hips in as many as 5% of cases
 Even in symptomatically unilateral disease, ultrasound can
detect bilateral effusions in 25% of children
Transient synovitis
 Most children have had symptoms for less than a week at the
time of presentation and are generally well appearing
 Fever is typically absent or low grade
 Management is conservative and most children recover
quickly with just NSAIDs
 A small percentage may go on to develop Legg – Calve –
Perthes disease with avascular necrosis of the ipsilateral
femoral head
Slipped capital femoral epiphysis
 Displacement of the capital femoral epiphysis from the femoral
neck through the physeal plate
 Mean age of presentation is 12 years in girls and 13.5 years in
boys and obesity is a significant risk factor
 The classic presentation is that of non radiating, dull, aching
pain in the hip, groin, thigh or knee, with no history of preceding
trauma
 The pain is increased by physical activity and may be chronic or
intermittent
 There is limited internal rotation of the flexed hip on physical
exam
 Diagnosis is usually made on plain radiograph, which reveals
posterior displacement of the femoral epiphysis, like ice cream
slipping off a cone
Slipped capital femoral epiphysis
 The earliest plain radiographic changes are widening and
irregularity of the physis, with thinning of the proximal
epiphysis
Slipped capital femoral epiphysis
Slipped capital femoral epiphysis
 If the radiograph is normal but suspicion for early SCFE is high,
MRI may demonstrate widening of the physis with surrounding
edema
 All cases of SCFE should be referred for surgical evaluation
(avoid weight bearing until surgery)
 Approximately 30 to 60% of patients with unilateral SCFE at
presentation eventually have SCFE in the contralateral hip
 To prevent delay in diagnosis of the second slip, all patients with
unilateral involvement should be followed closely by an
orthopedic surgeon until after the child has finished growing
 The complications of SCFE include osteonecrosis of the femoral
head, femoro-acetabular impingement, and chondrolysis
Legg – Calve – Perthes Disease
 Syndrome of idiopathic osteonecrosis (avascular necrosis) of
the hip
 Typically presents as hip pain and / or limp of acute or
insidious onset in children between the ages of 3 and 12
years, with peak incidence at 5 to 7 years of age
 LCP is bilateral in 10 to 20% of patients; M:F of 4:1 or
greater, and African Americans are rarely affected
 May occur in association with underlying condition eg renal
failure, glucocorticoid use, SLE, HIV, Gaucher’s disease
Legg – Calve – Perthes Disease
 The etiology of LCP remains undefined – approx 10% are
familial and patients often lag behind their peers in bone age
and height
 There is insidious onset hip pain, with limping and activity
related pain
 Diagnosis of LCP demands a high index of suspicion and initial
radiographs are often normal
 Early in the course, bone scan shows decreased perfusion to
the femoral head, and MRI reveals marrow changes highly
suggestive of the diagnosis
 Later in the course, radiographs show fragmentation and then
healing of the femoral head, often with residual deformity
Legg – Calve – Perthes Disease
Legg – Calve – Perthes Disease
Legg – Calve – Perthes Disease
 Children diagnosed with LCP should be made non weight
bearing and referred to an experienced pediatric orthopedist for
management
 Treatment focuses on containing the femoral head within the
acetabulum through the use of splints or occasionally surgery
 Almost all children do well in the short term; however long term
outcome depends on age of onset and degree of involvement of
the femoral head
 Children who are younger than 6 to 8 years years have a better
prognosis, perhaps because more time is permitted for femoral
remodeling and because before 8 years of age the acetabulum
is plastic and can mold to the deformed femoral head,
maintaining congruity
Osteochondritis dessicans of the knee
 Defined as osteonecrosis of subchondral bone
 Specifically, a localized lesion in which a segment of
subchondral bone and articular cartilage separates from the
underlying bone, leaving either a stable or unstable fragment
 Classified as juvenile (open physis) / adult (skeletally mature)
 The need for specialty referral primarily depends upon the
likelihood that the OCD lesion will not heal with nonoperative
therapy
Osteochondritis dessicans of the knee
 M > F, average age is 10-20 years, bilateral in 30-40%
 85% in medial epicondyle & 70% at posterolateral aspect
(LAME)
 Radiographs as initial test; MRI can demonstrate degree of
involvement
 Girls < 11 y & boys < 13 y usually do well without surgery if
fragment intact
Osteochondritis dessicans of the knee
Kohler’s osteochondrosis
 Ages 2–8 years
 Boys are 5x more commonly affected than girls
 Presents with limp and midfoot pain ± dorsal foot swelling
 Tender over the navicular, ± swelling/warmth
 Treat in a short leg cast for 8 weeks
Kohler’s osteochondrosis
Freiberg’s osteochondrosis
 Disordered ossification of the 2nd MT head
 Most common in adolescent girls in dance or ballet
 Causes: repetitive stress, trauma, disruption of blood supply
 Bilateral in < 10% of cases
 Pain, dorsal swelling; tenderness over the metatarsal head
 Treat with activity modification, analgesics, ice, metatarsal pads,
well-padded shoes
Freiberg’s osteochondrosis
Freiberg’s osteochondrosis
Idiopathic scoliosis
 Females more commonly affected
 •Prevalence of 0.5-3%
 •Infantile idiopathic scoliosis is most likely to spontaneously
resolve
 •Juvenile idiopathic scoliosis may be considered the most
malignant form of scoliosis due to high rates of progression
 •Adolescent idiopathic scoliosis is most common
Cobb angle measurement
Cobb angle measurement
Adolescent idiopathic scoliosis
 The goal of the treatment is a curve with a Cobb angle of 40°
or less at skeletal maturity
 Options for treatment include observation, bracing and
surgery
 Indications for referral to orthopedic surgeon may include
 angle of trunk rotation ≥ 7°
inability to obtain a Cobb angle
Cobb angle between 20 and 29° in premenarcheal girls or boys
aged 12 to 14 years
Cobb angle > 30° in any patient
progression of Cobb angle ≥ 5° in any patient
Adolescent idiopathic scoliosis
 Surgery for patients with Cobb angle ≥ 50° at the time of
presentation or later, regardless of the degree of skeletal
maturity
 Indications for bracing:
 Cobb angle 20 – 29° with substantial growth remaining and the
Cobb angle increases by ≥ 5% over a 3 to 6 month period
 Cobb angle 30 to 40° with substantial growth remaining
 If decision is taken for just observation (Cobb angle less thsn
20°), get radiographs every 6 to 9 months (only necessary if
patient is skeletally immature).
Traction apophysitis
 Insidious onset that results from injury or overuse of the
tendon and surrounding ossification centers
 Boys are more commonly affected and symptoms generally
appear between 10 to 14 years of age
 Often occurs at or after growth spurt
 Physical activity required
 Principles of rehab include ice, stretching, and modification to
activity (relative rest).
Little league elbow
Little league elbow
 Descriptive term for a group of elbow problems related to the
stress of throwing in young athletes
 Throwing can cause medial symptoms as well as lateral and
posterior symptoms
 The medial symptoms are related to the repetitive valgus
distraction forces on the medial elbow
 Microtrauma from overuse or improper throwing mechanics
(opening up too soon so the throwing arm trails behind the trunk
rotation) can cause injury
 Clinical features: Progressive medial elbow pain, diminished
throwing effectiveness and decreased throwing distance
 Rx: Refrain from throwing for 3 to 6 weeks until pain free and
non tender then progressive return to throwing program
Ddx of heel pain in children
 Osgood – Schlatter disease
 Sever’s calcaneal apophysitis
 Plantar fasciitis
 Painful heel pad syndrome
 Calcaneal apophyseal fracture or calcaneal stress fracture
 Calcaneal osteomyelitis
 Bone tumors
 Unicameral (simple) bone cyst
 Spondyloarthropathy
 Tarsal tunnel syndrome (specifically medial calcaneal
branch)
Osgood – Schlatter’s disease
 An overuse injury caused by repetitive strain and chronic
avulsion of the secondary ossification center of the tibial
tubercle
 Occurs most frequently in participants of sports that involve
running and jumping and who have recently undergone a
rapid growth spurt
 The most common presenting complaint is anterior knee pain
that increases gradually over time
 The pain is exacerbated by direct trauma, kneeling, running,
jumping, squatting, climbing stairs, or walking uphill, and is
relieved by rest
Osgood – Schlatter’s disease
 Diagnosis is clinical – tenderness and soft tissue or bony
prominence of the tibial tubercle in a patient with an
otherwise normal examination (including ROM of the hip)
 Imaging is not necessary to confirm the diagnosis but may be
necessary to exclude other conditions in patients with
atypical complaints, such as
 pain at night
 rest – related pain
 acute onset of pain (especially after trauma)
 associated systemic complaints
 pain that is not directly over the tibial tubercle
 Usually a benign and self limited condition; symptoms
resolve once growth plate ossifies
Osgood – Schlatter disease
Osgood – Schlatter’s disease
 Therapy is conservative – ice, NSAIDs, activity continuation,
physical therapy
 Patients with persistent pain that alters their ability to participate
in sports for more than 3 months may benefit from injection of
hyperosmolar dextrose by a sports med specialist or orthopedic
surgeon
 Patients who have pain that persists after closure of the
proximal tibial growth plate and is related to bony or
cartilaginous ossicles may benefit from surgical excision
 Complications and sequelae of Osgood – Schlatter dz include
persistent prominence of the tibial tubercle
persistent pain (usually secondary to residual ossicle)
genu recurvatum
Sever’s calcaneal apophysitis
 Common cause of heel pain in young athletes, particularly those
who play soccer and basketball or participate in gymnastics or
track / running.
 The mean age of presentation is 8 to 12 years; boys are
affected more often than are girls; bilateral in 40 to 61% of
cases
 Inflammation of the calcaneal apophysis (growth plate at the
insertion of the Achilles tendon)
 The characteristic history is one of chronic heel pain related to
activity and insidious in onset
 Physical exam – decreased gastrocnemius – soleus flexibility;
approximately 25% of patients have a flat foot or rigid foot
alignment
Sever’s calcaneal apophysitis
 Heel pain may be reproduced by direct digital palpation over the
apophysis or the calcaneal compression test (hold affected heel
in palm with the fingers enveloping the upper portion of the heel
and then squeeze to compress the heel in the transverse plane)
 Radiographs are not required to make the diagnosis but should
be obtained to exclude other disorders if the presentation is
atypical
 Plain radiographs are usually normal early and may only show
sclerosis and widening of the growth plate; late findings –
calcaneal fragmentation
 MRI is more sensitive to identify stress related changes in the
calcaneal metaphysis and is only indicated in severe / chronic
cases or those that do not respond to routine management
Normal calcaneal radiograph in
symptomatic
Fragmentation demonstrated late
in symptomatic child
Sever’s disease: Treatment
 Decrease stress on the apophysis; daily icing for 20 minutes even after
symptoms have began to improve
 Stretch gastrocnemius – soleus complex
 Use of heel cup or one fourth inch heel lift, and use of proper foot wear
 NSAIDs may be helpful for pain control during early management but
should not be used before exercise or to increase the amount of activity
the athlete can tolerate
 For the compliant patient whose symptoms fail to improve within 4 to 8
weeks, short term (3 to 4 weeks) short leg casting may help to resolve
painful symptoms related to stress associated bone changes
 Physical therapy and slow progressive return to activity are important to
recovery
Iselin’s disease
 Painful inflammatory condition of the apophysis (growth
plate) of the 5th metatarsal
 Seen in physically active boys and girls between the ages of
8 and 13 years of age
 Most common in those that participate in soccer, basketball
gymnastics and dance
 An overuse injury caused by repetitive pressure and/or
tension on the growth center at the base of the fifth
metatarsal
Iselin’s disease
Iselin’s disease
 Pain is most commonly found along the outer edge of the foot
and is worsened with activity and improved with rest
 A limp on the affected side may be present
 The child may walk on the inside of the affected foot
 The skin overlying the growth center may be swollen, red,
and/or painful to touch
 Diagnosis is primarily clinical
 Radiographs are usually not needed to diagnose the disease,
but they may prove useful in assessing for displacement of the
growth center and excluding other causes of foot pain
Iselin’s disease
 A short period of rest from aggravating activities to reduce
inflammation and allow release of pressure on the growth center
is recommended
 NSAIDs / Applying ice for 10 to 15 minutes every 2 to 3 hours is
helpful to reduce pain and swelling
 Tension on the growth plate can be relieved by gentle stretching
of the calf muscles
 Proper fitting shoes and/or arch support inserts are helpful in
decreasing pain
 If the individual fails a trial of stretching, rest, ice, and pain
medications, the affected limb may be immobilized with a
walking cast or boot
 Healing typically takes anywhere between 4-12 weeks
Benign nocturnal limb pain of
childhood (Growing pains)
 Bilateral lower extremity pain awakening a child at night (or from
naps) who is otherwise without any manifestation of
musculoskeletal problems
 Etiology is unknown; occurs in 15% of children; Affects 35% of
kids 4 to 6 years of age (may present up to age 19 years)
 Workup only indicated if child appears ill, complains of pain
during the day or with activity, or if pain worsens or persists
 Treatment is symptomatic and must include education and
reassurance;
 Warm baths, heat, massage, mild exercise / analgesics prior to
bed have been shown to be helpful
Fracture patterns in children
 Buckle (torus) fractures
 Plastic deformation
 Greenstick fracture
 Physeal (growth plate) fracture
 Apophyseal avulsion
Buckle (Torus) Fracture
Plastic deformation
Greenstick fracture
Physeal fractures –
Salter Harris classification
Board Review 1/7
 A 4-year-old male is brought to your office by his parents who
are concerned that he is increasingly “knock-kneed.” His
uncle required leg braces as a child, and the parents are
worried about long-term gait abnormalities. On examination,
the patient’s knees touch when he stands and there is a 15°
valgus angle at the knee. He walks with a stable gait. Which
one of the following should you do now?
 A) Refer to orthopedics for therapeutic osteotomy
 B) Refer to physical therapy for customized bracing
 C) Prescribe quadriceps-strengthening exercises
 D) Provide reassurance to the patient and his family
 ANSWER: D
 This case is consistent with physiologic genu valgus, and the
parents should be reassured. Toddlers under 2 years of age
typically have a varus angle at the knee (bowlegs). This
transitions to physiologic genu valgus, which gradually
normalizes by around 6 years of age. As this condition is
physiologic, therapies such as surgical intervention, special
bracing, and exercise programs are not indicated.
Board review 2/7
 A 2-week-old female is brought to the office for a well child
visit. The physical examination is completely normal except
for a clunking sensation and feeling of movement when
adducting the hip and applying posterior pressure. Which one
of the following would be the most appropriate next step?
 A) Referral for orthopedic consultation
 B) Reassurance only, and follow-up in 2 weeks
 C) Triple diapering and follow-up in 2 weeks
 D) A radiograph of the pelvis
 ANSWER: A
 Developmental dysplasia of the hip encompasses both subluxation and
dislocation of the newborn hip, as well as anatomic abnormalities. It is
more common in firstborns, females, breech presentations,
oligohydramnios, and patients with a family history of developmental
dysplasia. Experts are divided as to whether hip subluxation can be
merely observed during the newborn period, but if there is any question
of a hip problem on examination by 2 weeks of age, the
recommendation is to refer to a specialist for further testing and
treatment. Studies show that these problems disappear by 1 week of
age in 60% of cases, and by 2 months of age in 90% of cases. Triple
diapering should not be used because it puts the hip joint in the wrong
position and may aggravate the problem. Plain radiographs may be
helpful after 4–6 months of age, but prior to that time the ossification
centers are too immature to be seen. Because the condition can be
difficult to diagnose, and can result in significant problems, the current
recommendation is to treat all children with developmental dysplasia of
the hip. Closed reduction and immobilization in a Pavlik harness, with
ultrasonography of the hip to ensure proper positioning, is the treatment
of choice until 6 months of age. The American Academy of Pediatrics
recommends ultrasound screening at 6 weeks for breech females,
breech males (optional), and females with a positive family history of
developmental dysplasia of the hip. Other countries have recommended
universal screening, but a review of the literature has not shown that the
benefits of early diagnosis through universal screening outweigh the
risks and potential problems of overtreating.
Board review 3/7
 A 7-year-old male is brought to your office after hurting his
hand when he fell on a wet kitchen floor. He is unable to
describe the mechanism of injury. On examination the
maximal point of tenderness is at the third
metacarpophalangeal joint, which also has some generalized
swelling but no ecchymosis. Range of motion is limited in this
joint due to pain. A radiograph of the hand is shown below:
 Which one of the following is the most likely diagnosis?
 A) Boxer’s fracture
 B) Greenstick fracture
 C) Salter-Harris type II fracture
 D) Spiral fracture
 E) No abnormality
Board review 4/7
 A 7-year-old female is brought to your office with a complaint of
right hip pain and a limp with an insidious onset. There is no
history of injury or repetitive use. Her vital signs are within
normal limits and she has no history of fever or chills or other
systemic symptoms. On examination you note that she cannot
fully abduct her hip and she winces with pain on internal
rotation. A FABER test is normal. Her right leg is 2 cm shorter
than the left. Plain films reveal flattening and sclerosis of the
proximal femur with joint space widening.






What is the most likely diagnosis in this patient?
A) Iliopsoas bursitis
B) Labral tear
C) Legg-Calvé-Perthes disease
D) Septic arthritis
E) Stress fracture
 ANSWER: C
 Legg-Calvé-Perthes disease results from interruption of the
blood supply to the still-growing femoral head. It occurs in
children 2–12 years of age and presents with hip pain and an
atraumatic limp. Common physical findings include leg-length
discrepancies, and limited abduction and internal rotation.
Radiographs reveal sclerosis of the proximal femur with joint
space widening. MRI confirms osteonecrosis. Septic arthritis
also causes atraumatic anterior hip pain but occurs in the
acutely ill, febrile patient. A CBC, erythrocyte sedimentation rate,
C-reactive protein level, and guided hip aspiration are
recommended if septic arthritis is suspected. A diagnosis of
stress fracture should be considered in patients with a history of
overuse and weight-bearing exercise. These patients have pain
that is worse with activity, and pain on active leg raising. MRI
can detect fractures not seen on plain films. Iliopsoas bursitis
presents with snapping or popping of the hip on extension from
a flexed position. Labral tears present with sharp anterior hip
pain at times, with radiation to the thigh or buttock. Usually
patients will have mechanical symptoms such as clicking with
activity. The FABER (flexion, abduction, external rotation) and
FADIR (flexion, adduction, internal rotation) impingement tests
are sensitive for labral tears.
Board review 5/7
 During a preparticipation examination of a 5-year-old male for
summer soccer camp, his mother states that he frequently
awakens during the night with complaints of cramping pain in
both legs, and that he seems to experience this after a day of
heavy physical activity. She says that she has never noticed
a definite limp. A physical examination of the hips, knees,
ankles, and leg musculature is entirely normal. Which one of
the following would be the most appropriate next step in the
evaluation and management of this patient?
 A) Reassurance, with no activity restrictions or treatment
 B) Recommending that he not participate in running sports
 C) Plain films of both hips and knees
 D) Serum electrolyte levels
 E) Referral to a pediatric orthopedist
 ANSWER: A
 Benign nocturnal limb pains of childhood (growing pains)
occur in as many as one-third of children, most often
between 4 and 6 years of age. The etiology is unknown, but
the course does not parallel pubescent growth, as would be
expected if bone growth were the source of the pain. Pain
often awakens the child within hours of falling asleep
following an active day. It is generally localized around the
knees, most often in the shins and calves, but also may affect
the thighs and the upper extremities. A characteristic history
coupled with a normal physical examination will confirm the
diagnosis. Reassurance that no additional tests or treatments
are necessary and that the condition is self-limiting is the
most appropriate response.
Board review 6/7
 A 3-year-old male is carried into the office by his mother.
Yesterday evening he began complaining of pain around his
right hip. Today he has a temperature of 37.6°C (99.7°F),
cries when bearing weight on his right leg, and will not allow
the leg to be moved in any direction. A radiograph of the hip
is normal. Which one of the following would be most
appropriate at this time?
 A) A CBC and an erythrocyte sedimentation rate
 B) A serum antinuclear antibody level
 C) Ultrasonography of the hip
 D) MRI of the hip
 E) In-office aspiration of the hip
 ANSWER: A
 This presentation is typical of either transient synovitis or
septic arthritis of the hip. Because the conditions have very
different treatment regimens and outcomes, it is important to
differentiate the two. It is recommended that after plain films,
the first studies to be performed should be a CBC and an
erythrocyte sedimentation rate (ESR). Studies have shown
that septic arthritis should be considered highly likely in a
child who has a fever >38.7°C (101.7°F), refuses to bear
weight on the affected leg, has a WBC count >12,000
cells/mm3, and has an ESR >40 mm/hr. If several or all of
these conditions exist, aspiration of the hip guided by
ultrasonography or fluoroscopy should be performed by an
experienced practitioner. MRI may be helpful when the
diagnosis is unclear based on the initial evaluation, or if other
etiologies need to be excluded.
Board review 7/7
 A 13-year-old male presents with a 3-week history of left lower
thigh and knee pain. There is no history of a specific injury, and
his past medical history is negative. He has had no fevers, night
sweats, or weight loss, and the pain does not awaken him at
night. He tried out for his school’s basketball team but had to
quit because of the pain, which was worse when he tried to run.
Which one of the following physical examination findings would
be pathognomonic for slipped capital femoral epiphysis?
 A) Excessive forward passive motion of the tibia with the knee
flexed
 B) Lateral displacement of the patella with active knee flexion
 C) Limited internal rotation of the flexed hip
 D) Reduced hip abduction with the hip flexed
 E) An inability to extend the hip past the neutral position
 ANSWER: C
 Slipped capital femoral epiphysis (SCFE) typically occurs in
young adolescents during the growth spurt, when the femoral
head is displaced posteriorly through the growth plate.
Physical activity, obesity, and male sex are predisposing
factors for the development of this condition. There is pain
with physical activity, most commonly in the upper thigh
anteriorly, but one-third of patients present with referred
lower thigh or knee pain, which can make accurate and
timely diagnosis more difficult. The hallmark of SCFE on
examination is limited internal rotation of the hip. Specific to
SCFE is the even greater limitation of internal rotation when
the hip is flexed to 90°. No other pediatric condition has this
physical finding, which makes the maneuver very useful in
children with lower extremity pain. Orthopedic consultation is
advised if SCFE is suspected. Hip extension and abduction
are also limited in SCFE, but these findings are nonspecific.
Displacement of the patella is not associated with SCFE.