Pediatric disorders

Legg-Calvé-Perthes disease

An idiopathic avascular necrosis/osteonecrosis of the femoral epiphysis, usually affects 4 to 10 year olds, more common in boys. Children usually present with a limp or pain in the hip, thigh or knee. Examination of the knee is normal but there is limited and painful rotation and abduction of the ipsilateral hip. Trendelenburg test may be positive. It is often associated with coagulopathies like thrombophilia. Diagnosis is confirmed by MRI. Treatment is typically observation in children less than 8 years of age, and femoral and/or pelvic osteotomy in children greater than 8 years of age.

Slipped Capital Femoral Epiphysis (SCFE)

This condition is characterized by slipping of the metaphysis in relation to the epiphysis. Usually affects 11 to 14 year olds, is more common in obese children and boys and is bilateral in 20–40%. Adolescents usually present with a limp and may have hip, groin or knee pain. The knee exam is normal. The hip is often preferentially held in abduction and external rotation. Trendelenburg may be positive. X ray will show that the Klein’s line does not intersect the outer part of the femoral head. Treatment is by percutaneous pin fixation.

Developmental or Congenital Hip dysplasia

Developmental disorder with shallow acetabulum. Subluxation or dislocation of the hip follows. More common in girls, firstborns, breech presentations, family history and oligohydramnios. Limping, waddling, uneven skin folds in inguinal area, uneven lengths of lower limbs. On the physical exam the Ortolani and Barlow maneuvers may be positive. For the Ortolani maneuver, the contralateral hip is held still while the thigh of the hip being tested is abducted and gently pulled anteriorly. Palpable and sometimes audible “clunk” is a positive test. The Barlow maneuver is performed by adducting the hip while pushing the thigh posteriorly. If the hip goes out of the socket, it is called “dislocatable” and the test is termed “positive.” Diagnosis is confirmed by ultrasound until the age of 4 months and by radiographs after that. Treat in <6 month olds with Pavlik harness; >6 month olds with closed reduction or open surgery.

Osgood-Schlatter disease

It is a traction apophysitis or osteochondrosis of the tibial tubercle seen in physically active adolescents. It is more common in boys. It presents with anterior knee pain, enlargement and tenderness of the tibial tubercle. X ray shows fragmentation of the tibial tubercle. Treatment is conservative with NSAIDs, rest, knee strapping and quadriceps stretching. In severe or persistent cases, ossicle excision is required.