Pediatric Primary Care (109 page)

Source:
Courtesy of Miki Patterson.

I.  Complications.

1. Rare and related to surgical intervention.

J.  Education.

1.  Reassurance and handouts.

2.  Despite grandparents' (or older relatives'/caregivers’) insistence, braces are not effective. Studies show same improvement or correction through normal growth without braces.

3.  Many athletic children, adults have tibial torsion; does not result in any increased incidence of arthritis or interfere with activity.

XV. IN-TOEING: FEMORAL ANTEVERSION

A.  Etiology.

1.  Normal and appears when child begins walking, causing ligaments to get looser; thus hips are allowed more internal rotation, especially in children 2–6 years of age.

B.  Occurrence.

1.  Normal in 2- to 4-year olds, usually corrects spontaneously by 8 years of age.

C.  Clinical manifestations.

1.  In-toeing gait.

2.  Children tend to “W” sit pain free.

D.  Physical findings.

1.  Knees and toes point inward when standing.

2.  Able to internally rotate hips up to 90°.

E.  Diagnostic tests.

1.  None.

F.  Differential diagnosis.

1.  Tibial torsion, hip dysplasia.

G.  Treatment.

1.  Discourage “W” sitting.

2.  Observation unless functional deformity after 8 years old.

3.  Refer to orthopedist for unilateral, severe, or painful deformity.

4.  Surgical intervention with femoral derotational osteotomy.

H.  Follow up.

1.  Yearly if not progressive.

I.  Complications.

1.  None unless surgical intervention.

J.  Education.

1.  Normal, child will grow out of it. Braces or shoe modification are ineffective.

XVI. FOOT PROBLEMS: TALIPES EQUINOVARUS (CLUBBED FOOT)

A.  Rigid fixed foot deformity with inverted heel, forefoot adduction, and down-facing toes.

B.  Etiology.

1.  Unknown; possibly genetic, mechanical, chemical embryologic insults.

C.  Occurrence.

1.  Age: newborn.

2.  2:1 males to females.

3.  1.24 in 1000 live births.

4.  Increased incidence in families where parents/siblings have same disorder.

D.  Clinical manifestations.

1.  Tight Achilles tendon, joint capsule, medial ligaments.

2.  Short angulated talus, thin atrophic muscles.

E.  Physical findings.

1.  Small foot and calf, with rigid equinus deformed foot with heel in varus.

2.  Prominent crease in arch of foot.

3.  Adducted forefoot.

F.  Diagnostic tests.

1.  Clinical exam of newborn; radiographs are of little use.

G.  Differential diagnosis.

1.  “Positional clubbed foot,” arthrogryposis, spastic hemiplegia, calcaneovalgus.

H.  Treatment.

1.  Refer to orthopedist. Serial casting and surgical intervention may be necessary.

I.  Follow up.

1.  Per orthopedist.

2.  Treatment soon after birth: weekly visits for manipulation and casting by orthopedist experienced in this form of treatment.

3.  If rigid deformity, surgical intervention may be necessary; may entail heel cord and joint capsule releases and casting typically at 6 months of age.

4.  Casting or braces may be used for a period of time; follow up is ongoing because deformity may recur until about age 7 years.

J.  Complications.

1.  Progressive deformity, leg length discrepancy, surgical complications.

K.  Education.

1.  Affected foot will always be smaller but may function near normal after correction.

XVII. PES PLANUS: FLAT FOOT

A.  Etiology.

1.  Flexible normal (asymptomatic) genetic etiology or rigid (symptomatic) tarsal coalition (fusion of calcaneus with talus or navicular) common cause.

B.  Occurrence.

1.  Normal occurrence younger than 2 years of age due to medial fat pad. Rigid is rare.

C.  Clinical manifestations.

1.  Flat foot while standing; normal arch that returns while sitting and hanging over exam table is flexible pes planus.

2.  Bilateral.

3.  Hereditary expression.

4.  May cause some discomfort for older children.

D.  Physical findings.

1.  Loss of normal plantar arch while standing.

2.  Limited subtalar joint motion for rigid pes planus.

3.  Look at parents' feet!

E.  Diagnostic tests.

1.  If rigid: radiographs, three standing views of both feet, CT or MRI looking for coalition.

F.  Differential diagnosis.

1.  Overuse.

2.  Arthrogryposis.

3.  Neuromuscular condition.

4.  Arthritis.

5.  Infection.

6.  Trauma/fracture.

G.  Treatment.

1.  Refer rigid pes planus to orthopedist, orthotics may decrease symptoms of older child with flexible pes planus.

2.  Apply before sling.

H.  Follow up.

1.  May require further workup or referral if not pain free after 1 month.

I.  Complications.

1.  None known.

J.  Education.

1.  Proper shoe wear. Sneakers with built-in arch preferred.

XVIII.  NURSEMAID'S ELBOW: RADIAL HEAD SUBLUXATION

A.  Etiology.

1.  Traction along axis of extended pronated arm resulting in radial head subluxation with annular ligament displacement.

2.  Typically “pulling” child's hand/arm to prevent from falling or pulling away or swinging child by arms.

B.  Occurrence.

1.  Most common elbow injury of children age 1–4 years.

2.  Female > males.

3.  Left > right.

C.  Clinical manifestations.

1.  Will not use arm.

2.  Holds arm close to body with elbow slightly flexed and pronated (palm down).

D.  Physical findings.

1.  Restricted supination of elbow.

2.  Typically nontender or swollen; however, exhibits distress if tries moving elbow.

E.  Diagnostic tests.

1.  Radiographs AP and lateral of elbow if questionable success of reduction
(note:
many times these are reduced when arm is rotated to get lateral X-ray).

F.  Differential diagnosis.

1.  Fracture.

G.  Treatment.

1.  Reduction maneuver.

a.  Child in parent's lap.

b.  Flex child's elbow to 90° with gentle pressure of thumb over radial head.

c.  Fully or “hyper” pronate wrist then fully supínate wrist; typically click will be felt and child will stop resisting
(
Figure 30–11
).