Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI

5. GU

6. Orthopedics

Common Orthopedic Findings

1. Metatarsus Varus: The most common cause of intoeing in the first year of life
Cause: in utero positioning; left more than right
Intervention rarely necessary: 90% spontaneously resolve
            -subluxation of tarsometatarsal joints: requires surgery
            -fixed position of forefoot: requires serial casting
Other treatments for milder metatarsus varus: reversing shoes; Thomas heels
When refer and why:
refer immediately for fixed unmoving forefoot requiring surgery.
refer by 6 months of age for casting.

2. Tibial Torsion: Most common cause of intoeing in second year of life
Cause: in utero positioning: left more than right
Intervention: almost never necessary
When refer to orthopedist: almost never

3. Femoral Anteversion: Peaks during 3-6 years of age as cause of intoeing
Intervention: almost never necessary
Natural History: spontaneously resolves by 7-8 years of age
When refer to orthopedist: almost never 

4. Flat Feet - Pes Planus: Lack of the longitudinal arch; seen in almost all children up to the age of 2 years when fat pad disappears; persists in 155 of adults.
Intervention: almost never necessary
Treatment: arch supports if a lot of pain

SUMMARY: Corrective shoes are a misnomer.  They are rarely indicated in children for intoeing or for flat feet.

5.  Bowlegs - Genu Varum: May have to differentiate between physiologic bowing and medical reasons for this--such as Rickets, trauma, infection, achondroplasia, Blount’s disease.
Intervention for physiologic bowlegs: none

6. Knock-knees: Again a physiologic pattern with self-correction occurring between 4 and 10 years of age.  No need for treatment.

Other Common Orthopedic Problems:

7. Ganglion cysts: Arise from tendon sheaths: most commonly seen around wrists.  Can be quite painful.
Treatment: prefer to observe with no treatment, because treatments are often not helpful:

1. injection of steroids: good short-term relief, but often recur
2. surgery: because hard to get around, hard to get entire ganglion out.

8. Baker cyst (Popliteal cyst): Seen behind the Popliteal fossa; can be painful, but often picked up on routine physical examinations.  They arise from the capsule or the tendon sheaths.  No treatment usually indicated since they resolve in 1-2 years.  Same problems with surgery as ganglion cysts.  May need to try and transilluminate, or do ultrasound to confirm the diagnosis.

9. Osgood-Schlater's Disease: Inflammation of the tibial tubercle (traction apophysitis) produces painful swelling over that area.  Can be bilateral (25-50%).  Seen mostly in teenagers.  Can be helped by NSAIDS, but self-limited.  Goes away usually by 15 years of age.

10. Nursemaid s Elbow: (subluxation of the radial head) - seen mostly < 4 years of age.  Occurs after traction of the hand with elbow extended and forearm pronated.  Child holds arm flexed with forearm pronated and refuses to move it.  Any motion is painful to the child.  Treatment is by supination with arm in 90-degree flexion.  A click is felt or heard, and the child has immediate relief.  Once this occurs it is likely to recur: parents should be instructed on how to reduce a nursemaid s elbow.  The earlier you treat this, the better.  If a child waits for 24 hours after subluxating the radial head, it will be hard to reduce.

11. Trauma to fingers and toes: X-rays are important to rule out growth plate involvement.  If there is involvement of growth plates, orthopedists should treat the child.  If not, splinting or taping should occur.  Most pediatric orthopedists now recommend taping fingers and toes together rather than using splints.

12. Sprained ankles: nature of pain does not distinguish between ligamentous and bony injuries. Hearing snapping sound can occur with either.  X-rays are important to distinguish these.  If X-ray negative, may still need to immobilize.  If instability present, refer to orthopedist.

13. Injured knees: very difficult to evaluate.  If swelling is within the joint, usually need to refer to orthopedist.  Usually cartilage problems will be painful with internal and external rotation of the knee; ligament problems with medial and lateral movement.  When in doubt, refer.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004