Common Orthopedic Problems Carolyn M. O’Donnell, MD, PGY-3 Developmental Dysplasia of the HIp • Abnormal development of the hip with 1.) Instability (joint dislocatability) and 2.) Dysplasia or abnormal shape of the acetabulum • Most hip instability resolves shortly after birth • Unresolved instability is often painless and not obvious since a dislocated hip may function well for many years • Unresolved, it can lead to pain (often knee pain), abnormal gait, functional disability and degenerative hip disease • These problems are preventable if it is caught and treated early DDH • Hip laxity and immature acetabula are common in the first few weeks of life • Approximately 90% of these infants will have stabilized by 2 months of age after time for further growth • After school age, the likelihood of spontaneous resolution is very low Hip Joint Clinical Features • The earlier DDH is detected, the easier and more successful the treatment • Presentations vary based on age • Newborn: hip instability • Infant: reduced abduction • Toddler: asymmetric gait • Adolescent: activity related pain • Adult: osteoarthritis Risk factors • • • • Breech presentation Female gender Family history Factors related to tight positioning in utero (can see associated torticollis and metatarsus adductus Risk factors • Girls with a breech presentation — 12 percent • Girls with a positive family history — 4.4 percent • Boys with a breech presentation — 2.6 percent • Girls — 1.9 percent • Boys with a positive family history — 0.9 percent In utero Torticollis Physical Exam • Hips should be checked at every visit until the child is walking normally • Exam technique uses adduction and posterior pressure to feel for dislocation and abduction and elevation to feel for reduction • Hip Instability: The sensation of dislocation or reduction is best described as a clunk or a jerk • Clicks and pops not associated with a palpable clunk are very common and not worrisome Exam • Examine each hip individually while the child is calm and not crying • Examine on a stable surface with the child supine and with hips flexed 90 degrees in neutral rotation Exam Galeazzi Test Exam • Galeazzi test: dislocated hip may be displaced posteriorly so the knee appears lower/shorter • Look for asymmetry in skin folds • Gait asymmetry • Bilateral DDH can be a challenge- look for widening of the perineum, symmetric limited abduction, and short thigh segments relative to the child's size. Once the child begins to walk, hyperlordosis and a waddling Trendelenburg gait can be seen Exam • • • • • Bilateral DDH: widening of the perineum symmetric limited abduction short thigh segments relative to the child's size. Once walking, hyperlordosis and a waddling Trendelenburg gait • By 3 months: hip often stabilizes and tests for instability are no longer very helpful Imaging • Ultrasound • Plain radiographs- limited value early on due to femoral heads cartilaginous and not ossified • Radiographs should be with hips flexed 20 to 30 degrees, or neutral if the child is older Radiograph Management • • • • • • If abnormal exam: Referral to orthopedic surgeon Imaging: Ultrasound if less than 5 months Radiograph if >4 months Breech females: screening is recommendedultrasound at 6 weeks or radiograph at 4 months. This is optional for lower risk groups. Treatment • Based on age • Abduction splints in younger kids (usually <6 months) • Closed reduction- goal is to reduce the hip, then keep it stabilized in spica cast • Open reduction If closed reduction is unsuccessful Often needed in kids >18 months • Risks vs benefits • Follow up is important; complications, failure Pavlik Harness Septic Joint • Infection and inflammation of usually sterile joint space • Typically affects large joints and joints of the lower extremity- knee, ankle and hip (approximately 80%) • Up to 10% in more than 1 joint • Predominant age: 2-6 years; adolescent • Males>Females Pathophysiology • • • • • • Bacterial entry: Hematogenous spread Direct inoculation Extension from adjacent infection (bone) Influx of inflammatory Cells Rapid destruction of cartilaginous structures by bacterial enzymes; may -> necrosis Etiologies • Viral- parvovirus, EBV, herpes, CMV, varicella, Hep B or C, mumps, rubella • Fungal- Candida albicans • Spirochete- Lyme (B. burgdorferi) • Tuberculosis • Bacterial • <5 years: S. aureus, Group B strep, HIB, gram negative bacteria • >5 years: S. aureus, Group A strep, N. gonorrhoeae Etiologies • Also Kingella kingae, salmonella, N. meningitidis • S. aureus most common outside of neonatal period • Sickle cell associated with salmonella • Immunocompromised: Mycoplasma, ureoplasma, or Aspergillus Neonates and Infants • Can be subtle • >1 joint • Microbiology: GBS, Gram negative bacilli such as E. Coli, S. aureus • Often presents with septicemia or fever without source • Subtle features: positional preference, decreased use, pain with handling, extremity swelling • Hip arthritis Children • • • • Fever and constitutional symptoms Pain with active and passive movement Limp/refusal to bear weight Joint related findings can be subtle: swelling, warmth • Hip/shoulder: often no external signs • Hip involvement may be referred (knee) • Sacroiliac may present similarly to appendicitis, neoplasm or UTI Symptoms • • • • • Do not wax and wane Can wake up at night with pain Worsens with time Specific joint symptoms: Pain- often exquisite tenderness through any range of motion • Warmth, erythema, swelling Evaluation • • • • • • Should be PROMPT NO DELAYS History and Physical Labs and imaging Joint aspiration/joint fluid analysis ASAP Risks vs. benefits- diagnosis vs seeding the joint if overlying cellulitis Evaluation • • • • • • History: ?direct inoculation ?rash- can implicate type of infection ?skin/soft tissue infections- source for bacteremia ?Recent antibiotic use- may attenuate symptoms ?recent illnesses/URIs- consider post-infectious synovitis • ?LMP- disseminated gonococcal in 1st 7d of menses • ?Exposures • ?Immunization Status Exam • • • • • Observation (use parents if young child) Soft tissue/skin exam Joint exam: swelling, redness, erythema, pain Active and passive range of motion Exam: eyes, skin, heart, lungs, abdomen, etc Labs • CBC/WBC- elevated but not sensitive or specific • ESR- elevated in 95% of cases • CRP- increased • Blood cultures- positive in 30-40% of cases Synovial Fluid Analysis Disorder Cells/microL Glucose Trauma RBCs>>WBCs; <2000 WBCs Normal Reactive arthr 3-10,000 WBCs; mostly monos Normal JRA/inflamm 5-80,000; mostly neutrophils Normal/sl. low Septic arthritis >60,000 WBCs; >90% neutrophils Low to normal Lyme arthritis 15-100,000 WBCs; variable cell types Low to normal Imaging • Radiography- may (or may not) show widening of the joint space +/- displacement of the normal fat pads • Ultrasound- can identify fluid in the joint space • CT scan • MRI • Bone scan Algorithm • • • • • Look for 4 or more of the following: ESR > 20 mm/h CRP > 1 mg/dL WBC > 11,000 cells/mL Joint space fluid apparent on radiograph Differential Diagnosis • • • • • • • • • • • • Osteomyelitits Deep cellulitits Abscess Septic bursitis Bacterial endocarditis Inflammatory/autoimmune arthritis Transient synovitis Acute rheumatic fever Trauma Legge-Calves-Perthes SCFE Tumor/Malignancy Treatment • IV antibiotics • 1st line: Anti-staph PCN, 1st generation cephalosporin • If MRSA in community, consider vanco or clinda • Sickle cell pts: add ceftriaxone • Duration of therapy depends on bacteria • Supportive care (sepsis, etc) • Drainage of infection- ASAP • Open surgical drainage/irrigation for hip and usually shoulder, inability to aspirate Complications • • • • Septic shock Death Joint destruction Limited range of motion which may be permanent • Growth disturbance if the epiphysis is involved.