508 SECTION 18 • DISEASES OF THE BONE AND JOINTS reduced position Close monitoring of position is required to assure proper harness position Improper use is associated with nerve problems and avascular necrosis of hips REFERENCE Guille J, Pizzutillo P, MacEwen G: Developmental dysplasia of the hip from birth to six months J Am Acad Orthop Surg 2000;8:232–242 152 FRACTURES Denise T Ibrahim and John F Sarwark SALTER-HARRIS CLASSIFICATION OF PHYSEAL FRACTURES • Type I: Injury occurring through the physis (i.e., growth plate), does not extend into the metaphysis or epiphysis • Type II: Injury extends along the physis and exits through the metaphysis • Type III: Injury extends along the physis and exits through the epiphysis, these may also be intraarticular • Type IV: Injury extending from the metaphysis across the physis and into the epiphysis, usually intraarticular • Type V: Crushing injury to the physis from a compression force (Fig 152-1) • Descriptive terminology 1 Torus (buckle) fracture—mild fracture with plastic deformation of one or both cortices, minimal displacement 2 Greenstick fracture—cortex under tension fractures completely and the compression side undergoes plastic deformity and remains intact 3 Physeal (growth plate) injuries—describe using Salter-Harris classification (see above) FIG 152-1 Salter-Harris Classification SURGICAL EMERGENCIES OPEN FRACTURES • Often associated with high-energy trauma and multiple injuries • Classified by Gustillo and Anderson (1976), according to wound size and extent of soft tissue involvement: 1 Type I: Wound 1 cm, moderate soft tissue injury 3 Type III: Extensive soft tissue injury with possible neurovascular injury and severe wound contamination • Management 1 Advanced trauma life support (ATLS) primary survey first 2 Immediate IV antibiotics: First generation cephalosporin for type I; add aminoglycoside for types II and III; if “barnyard” involved add penicillin or metronidazole 3 Tetanus prophylaxis 4 Assess and document neurovascular status 5 Sterile dressing and splinting for comfort without definitive reduction 6 Operative treatment when stable DISLOCATIONS OF JOINT • Traumatic dislocation of a joint requires immediate reduction in a gentle, nontraumatic and controlled fashion • Many joint dislocations are managed by the emergency room physician Examples include nurse-maid elbow (radial head dislocation) in children and shoulder dislocations in adults being the most frequent • Traumatic hip dislocations should be discussed with an orthopedic surgeon for immediate reduction, occasionally requiring general anesthesia with muscle relaxation in the operating room NEUROVASCULAR COMPROMISE • Any injury or condition that presents with a change of neurovascular examination requires immediate attention CHAPTER 152 • FRACTURES • Compartment syndrome: A potentially devastating condition in which increased pressure within a fascial compartment of limb causes a destructive ischemia-edema cycle unyielding to autocompensation by the vascular system Identification and surgical release of the affected compartments is required Recognized by the six Ps: pain out of proportion to physical examination findings, increased pressure, pallor skin color, pulseless, paresthesias, and paresis Pain with passive stretch is one of the earlier signs Early recognition is critical Tight bandages or splints on an injured limb can cause increased pressure, thus caution needs to be practiced when attending to injured limbs There are nontraumatic but chronic presentations of compartment syndrome that can exist, such as exercise-induced MULTIPLE FRACTURES • Multiply injured patients should all be assessed by a multidisciplinary approach as outlined by ATLS protocol Once the patient is stabilized, orthopedic injuries are assessed in the secondary survey A child with multiple fractures is best treated with early stabilization of the fractures Depending on the fracture, surgery is required for fixation of certain fractures that would not require fixation in an isolated injury situation Surgery may be required for better mobilization 509 of the patient Morbidity and mortality with multiple fractures are not increased to the same magnitude as in adult situations INITIAL CARE OF FRACTURES • Examine and document the sensory, motor, and vascular status of the injured extremity, including joints above and below the injured region • Splinting techniques 1 Initial treatment of any limb injury should include a well-molded appropriate splint Cast padding (webril = cotton padding) is applied first in several layers thick with extra padding to bony prominences (elbow, heel, ankle, and so on) A posterior mold made of plaster or prefabricated fiberglass is then applied to splint the joints above and below the injured region in a neutral position It is held on with an ace bandage It is important to roll the ace bandage with mild stretch to allow for swelling and to avoid tight compression to the limb, which can cause iatrogenic skin sores or neurovascular compromise Neurovascular assessment must be performed and documented after a splint is applied to a child (Fig 152-2) FIG 152-2 Posterior mold splinting technique, starting with cotton padding (left), followed by posterior mold made of plaster, and lastly an ace wrap (right) Notice the 50% overlapping of each circumferential wrap 510 SECTION 18 • DISEASES OF THE BONE AND JOINTS COMMON PEDIATRIC FRACTURES UPPER EXTREMITY • Upper extremity radiographic anatomy 1 Two-thirds of occult elbow fractures present with a posterior fat pad sign If present with clinical symptoms it requires splinting 2 Contralateral comparison elbow radiographs are useful for diagnosis of pediatric elbow fractures with questionable features 3 Ossification centers appear in the following order: a Capitellum: 1–2 years old b Radial head: 3–4 years c Medial epicondyle: 5–6 years d Trochlea: 7–8 years e Olecranon: 10 years f Lateral epicondyle: 12 years • The above ages are approximate ages with females ossifying earlier than males Clavicle Fractures • Most are midclavicular, treated in a sling until nontender; exceptions to conservative management include open fractures, neurovascular compromise, or severe tenting of the skin Proximal Humerus Fractures • Excellent remodeling potential, mostly treated with a sling or coaptation splint (long-arm posterior mold which wraps around shoulder); rarely require surgery Supracondylar Humerus Fracture • Type I is undisplaced; type II displaced with posterior cortex hinging present, varus or valgus impaction; type III is completely displaced, no cortical contact (Gartland classification) • Most common elbow fracture in children and is associated with serious neurovascular compromise in 10% May lead to compartment syndromes and later “Volkmann ischemic contracture” (compartment syndrome) if not recognized Careful assessment of the anterior interosseus nerve motor function (median nerve branch, most commonly affected) by flexion of interphalangeal joint of the thumb and index finger, and also the radial and ulnar nerve sensory and motor function Initial splinting should not flex the elbow greater than 90° secondary to potentiating neurovascular compromise Radial Head Subluxation • “Nursemaid’s elbow.” Peak incidence 1–3 years old, secondary to pulling or traction on the forearm/wrist Child presents holding elbow by the side slightly flexed and pronated and will not supinate forearm Diagnosis is by history and physical Radiographs are normal Reduce radial head by applying pressure over the anterior radial head while flexing the elbow 90° followed by rotation of the forearm into full supination If child is moving elbow freely, immobilization is not required Monteggia Fractures • Radial head dislocation and ulnar fracture Anatomic relationship of the radial head and capitellum will line up in all radiographic views of the elbow Radius and Ulna Diaphyseal Fractures • “Both-Bone Forearm Fracture.” Described by location: distal third, middle third, or proximal third Remodeling potential in childhood with acceptable angulation ranging from 10 to 30° depending on age Acceptable malrotation remains controversial since it is thought that it does not remodel Long-arm splinting or casting is required Distal Radius Fractures • Most common pediatric upper extremity fracture Fall on outstretched arm is common mechanism If tender in supination and pronation, long-arm splinting or casting required Salter-Harris classification can be used for physeal injuries Excellent remodeling potential LOWER EXTREMITY Hip Fractures • Type I: Transphyseal (distinguished from slipped capital femoral epiphysis [SCFE] by younger age) severe trauma, more displaced acute separation of the physis • Type II: Transcervical or middle portion of the femoral neck • Type III: Cervicotrochanteric or at the base of the femoral neck • Type IV: Intertrochanteric or between the greater and lesser trochanter of the proximal femur • Avascular necrosis common in types I, II, and III and need immediate attention and reduction Slipped Capital Femoral Epiphysis (SCFE) • Displacement of the femoral head epiphysis on the metaphysis in a posterior-superior direction 1 Common age is 11–13 years 2 Common in obese boys 3 Approximately 25% bilaterality 4 Etiology—multifactoral, obesity, trauma, endocrine disorder (usually present at younger age without obesity) 5 Clinical presentation—hip or groin pain, knee pain, limping or unable to bear weight, trauma 6 Physical examination—limping, loss of internal rotation, obligatory external rotation with hip flexion 7 Radiograph—AP view shows physeal widening and metaphyseal rarefaction Kline line (line along CHAPTER 153 • LIMPING CHILD superior neck contacts the epiphysis in a normal hip) and the frog-leg lateral are useful 8 Classified as stable or unstable Patients with stable slips can bear weight, and symptoms are mild and chronic Unstable slips have an abrupt onset of pain and patients are unable to bear weight 9 Treatment—immediate nonweightbearing followed by appropriate surgical treatment by an orthopedic surgeon Diaphyseal Femur Fractures • Transverse, oblique, spiral, comminuted General Comments on Treatment 1 Initially requires splinting in neutral position of comfort 2 Zero to six months can consider pavlik harness or “soft spica.” 3 Seven months to six years old spica cast 4 Seven years or more; multiple surgical options since unlikely casting would be tolerated Fractures About the Knee • Tibial spine fracture: Type I—minimally displaced, slight anterior elevation Type II—anterior third to 50% of avulsed fragment is elevated, beaklike appearance Type III—avulsed fragment completely elevated • Sleeve fracture: Patellar fracture where the patellar tendon avulses an osteocartilagenous fragment from distal pole of patella; requires operative repair Ankle Fractures in Juveniles and Adolescents • Salter-Harris classification can describe fractures • Juvenile Tillaux fracture: Avulsion fracture of the anterolateral distal tibia epiphysis, vertical SalterHarris III fracture due to external rotation force • Triplane ankle fracture: Coronal plane, axial plane, and sagittal plane fracture, ages 10–16 that patterns onset of physeal closure May require computed tomography (CT) evaluation Base of Fifth Metatarsal Fracture • Proximal apophyseal growth center is frequently misdiagnosed as a fracture It is evident radiographically at age 9 and unites by age 12–15 years If tender on examination, splinting with a posterior mold splint is required REFERENCE Herring JA: Fractures about the elbow, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics Philadelphia, PA, W.B Saunders, 2002 p 2139 153 511 LIMPING CHILD Denise T Ibrahim and John F Sarwark TRANSIENT SYNOVITIS • Synonyms are toxic synovitis, coxalgia fugax, acute transient epiphysitis • Unknown etiology, self-limiting inflammation of the hip, resolves spontaneously, usually 1 or 2 days nonambulatory followed by mild limp to resolution • May follow upper respiratory infections • Clinically present with acute onset of hip pain, limping or refusal to bear weight, hold leg in flexed position • Usually tolerate gentle range of motion as opposed to severe pain present with a septic joint • May have a low-grade fever, less likely • Occurs in males > females, average age of 6 years • Diagnosis: Made by exclusion • Radiographs are normal, white blood cell (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are normal to mildly elevated if respiratory infection also present • Ultrasound helpful to determine joint fluid or assist in aspiration if effusion present • Differential diagnosis: Septic arthritis, juvenile rheumatoid arthritis (JRA), fracture, Legg-Calvé-Perthes, osteomyelitis, slipped capital femoral epiphysis, leukemia, hemophilia, and sickle cell crisis • Treatment: Rest, nonsteroidal anti-inflammatory drug (NSAID), gait assistive devices, and observation until pain resolves If not improving, may need to reconsider other etiologies All symptoms should resolve within 2 weeks SEPTIC ARTHRITIS • Etiology: Hematogenous seeding or rarely local seeding from contiguous infection, postoperative or traumatic • Condition requires early treatment to prevent cartilage destruction and further infection spread • More common in males with increased frequency in 12,000 mm3 If all the factors are present then there is a 99% chance of septic arthritis; if three factors are present then 93% chance Monitoring CRP is helpful in treatment course Radiographs are usually normal, take 1–2 weeks for bone changes to be seen Joint aspiration required; assess Gram stain, aerobic and anaerobic cultures, cell count with leukocyte count; consider a serum and synovial glucose level Most common organisms are Staphylococcus aureus, followed by group A streptococci, Streptococcus pneumoniae, and Kingella kingae In neonates group B streptococci is important and Neisseria gonorrhoeae in neonate and sexually active adolescents is still seen Initial treatment: Culture and sensitivity are completed before any medications are administered, which includes the blood cultures and joint aspiration Surgical treatment is required After all the tests are completed empiric coverage for culture negative is done and includes an antistaphylococcal IV antibiotic and gram-negative coverage for all neonates and adolescents Length of time of antibiotic ranges from 3 to 6 weeks with conversion to oral antibiotics at treating physician’s discretion Prognosis: Related to timing of diagnosis, delayed diagnosis, and treatment contributes to a poorer prognosis LEGG-CALVÉ-PERTHES DISEASE • Osteonecrosis (i.e., avascular necrosis) of the femoral head with subchondral collapse; etiology is unknown • More common in males, ages 4–8 years • Ten percent incidence of bilaterality • History of a limp before onset of pain • Clinically range of motion decreases as pain increases, loss of internal rotation is first finding, antalgic gait, some have positive Trendelenberg sign • Diagnosis: Radiographs of the hip If negative, bone scan or magnetic resonance imaging (MRI) required • Differential diagnosis: Transient synovitis, septic arthritis, juvenile rheumatoid arthritis, fracture, osteomyelitis, slipped capital femoral epiphysis, leukemia, hemophilia, and sickle cell crisis • Four stages of the disease: (1) Early (synovitis), (2) fragmentation, (3) reossification, and (4) definitive • Treatment: Refer to orthopedic surgeon • • • • Usually present with swollen knee (most often affected), ankle, or fingers, minimal pain Seventy percent positive antinuclear antibody (ANA) and negative rheumatoid factor (RF) A quarter may have iritis Length of disease usually slightly over 2 years 2 Polyarticular JRA: Five or more small and large joint involvement in either young 1–3-year-olds or adolescent age, females greater than males 3 Systemic JRA: Present in 3–10-year-olds with febrile illness, severe myalgia, polyarthritis, erythematous macular rash, toxic, hepatosplenomegaly, and/or occasionally pericarditis Length of symptoms vary and some can be vary destructive to the joints Diagnosis: No definitive laboratory examination Clinical and laboratory tests to aid in the diagnosis A history of 6 months of arthritis for JRA for diagnosis Radiographs may show osteopenia around the joints, soft tissue capsular/synovial swelling, and/or narrowing of joint space Treatment: Multispecialty team approach including rheumatologists, ophthalmologists, orthopedists, and physical and occupational therapists REFERENCES Blyth MJ, Kincaid R, Craigen MA, Bennett GC: The changing epidemiology of acute and subacute haematogenous osteomyelitis in children J Bone Joint Surg Br 2001;83:99–102 Kocher MS, Zuralowski D, Kasser JR: Differentiating between septic arthritis and transient synovitis of the hip in children J Bone Joint Surg Am 1999;81:1662–1670 Schneider R, Passo MH: Juvenile rheumatoid arthritis Rheum Dis Clin North Am 2002 Aug;28(3):503–30 154 SPINE Denise T Ibrahim and John F Sarwark SCOLIOSIS JUVENILE RHEUMATOID ARTHRITIS (JRA) • Three main types: Idiopathic scoliosis make up 80% of cases while congenital and neuromuscular make up 15%; miscellaneous scoliosis 5% • Three main forms: 1 Pauciarticular JRA: Most common; more common in 2–4-year-old females, females greater than males CONGENITAL SCOLIOSIS • Failure of formation or segmentation of the developing spine, present but not always detected at birth CHAPTER 154 • SPINE • Rate of progression and severity is dependent on the type or types of anomaly within the vertebrae • A sporadic, not inherited condition • Anomalies include segmented hemivertebrae, wedged vertebrae, nonsegmented hemivertebrae unilateral or bilateral, unilateral nonsegmented bar, and/or nonsegmented vertebrae • Unsegmented bar has greatest progression potential • Klippel-Feil syndrome: Failure of segmentation in one or more levels in cervical vertebra • Evaluate all systems since associated anomalies common; i.e., other musculoskeletal anomalies, congenital heart anomalies, hypoplastic lungs, genitourinary abnormalities • Treatment: Depends on progression and pattern of scoliosis, careful observation until skeletal maturity, often require surgery at younger ages, and lesser curves when compared to idiopathic scoliosis NEUROMUSCULAR SCOLIOSIS • Classified as neuropathic (i.e., cerebral palsy, spinocerebellar degeneration, spinal muscular atrophy) or myopathic (i.e., arthrogryposis, muscular dystrophy, hypotonia) • Progressive and more severe than idiopathic scoliosis • Long thoracolumbar curve patterns with greater pelvic obliquity • Assessment of pulmonary, cardiac, and nutritional status important in management of patients • Treatment is individualized taking into consideration functional goals, sitting balance, and pulmonary function IDIOPATHIC SCOLIOSIS • Subdivided according to patient age: (1) Infantile, infancy to 3 years of age; (2) juvenile, 4–9 years of age; and (3) adolescent, 10 years and up • Defined as a curvature of the spine 10° or higher with unknown etiology • Infantile males > females and adolescent females > male • Juvenile idiopathic scoliosis has highest progression rates • Clinically a painless condition; if pain present, evaluate for other causes and perform thorough workup • Assessment: Evaluate skin, symmetry of shoulder, waistline, limb lengths, rib prominence angle of trunk rotation (ATR) on forward bend test (Adam’s forward bend test), and neurovascular examination in prepubescent girls and boys • Most are right-sided thoracic curves Left-sided curves may indicate other etiologies that require further investigation • Natural history of progression is dependent on the degree of curvature before skeletal maturity 513 • Treatment: General guidelines include bracing for curves in the range of 25–45° and surgery for curves greater than 50° where progression likely SCHEUERMANN KYPHOSIS • Increased thoracic kyphosis on standing lateral radiograph over 40°, wedging of the anterior vertebrae of three contiguous vertebrae levels exceeding 5° at each level; Schmorl nodes; and radiographic finding of irregular end plates • Peak age is midteens; male predominance • Clinical presentation: Pain at thoracic apex; poor posture according to parents • Treatment: Mostly conservative with exercises, stretching or bracing Surgery rare and considered when >75° kyphosis and/or progression SPONDYLOLYSIS AND SPONDYLOLISTHESIS SPONDYLOLYSIS • Defined as a radiographic unilateral or bilateral defect in the pars interarticularis of the posterior elements of the vertebrae; 50% of patients are normal on radiographs—bone scan with single photon emission computed tomography (SPECT) images Oblique views may show posterior spine elements resembling a “Scottie dog.” A break at the neck indicates spondylolysis SPECT (bone scintography) more sensitive than radiographs • Most commonly L5 • A common etiology of lower back pain in juveniles and teens • Males have 50% greater incidence than females • Common in athletes that undergo repetitive hyperextension stress of the spine, i.e., gymnastics, wrestling, football linebackers, diving • Treatment: Mostly conservative Brace (LSO— lumbo-sacral-orthosis) for symptomatic patients failing conservative management; activity modification SPONDYLOLISTHESIS • The forward slippage of a vertebrae relative to the distal vertebrae most commonly L5 on S1 • Five subtypes: (1) Dysplastic, (2) isthmic (most common), (3) degenerative, (4) traumatic, and (5) pathologic • Dysplastic: Secondary to congenital anomalies of L5 and S1 articulation • Isthmic: Most common—secondary to acquired defect in pars interarticularis; females have higher rate 514 • • • • • SECTION 18 • DISEASES OF THE BONE AND JOINTS of progression of slippage with low overall rate of 5% or less Unlikely to progress after skeletal maturity Clinically: Rarely symptomatic, back pain is most common initial complaint Lumbar lordosis and/or lumbosacral flattening with buttock flattening, tight hamstrings is seen in advanced cases Grading system: Meyerding: Grade I—up to 25% slippage on lateral radiograph, grade II—26–50%, grade III—51–75%, grade IV—76–100%, and grade V—>100% (spondyloptosis) Imaging: Standing posteroanterior and lateral lumbosacral radiographs Treatment: Based on severity, pain, slip grade, skeletal maturity for conservative vs surgical treatment • If suspicious of pathologic limb alignment one assesses age of onset compared to normal development, progression of deformity (i.e., Blount disease) diet (i.e., Rickets), trauma (i.e., asymmetric physeal closure), growth percentile (i.e., skeletal dysplasia), and congenital anomalies • Examination: Assess gait, limb symmetry, intercondylar distance of knee for bowlegs or medial malleolar distance for knock-knees to document progression, and joint laxity Radiographs may indicate rickets when physeal changes or other metabolic causes are seen When severe or asymmetric, refer to pediatric orthopedic surgeon IN-TOEING/OUT-TOEING REFERENCE Weinstein SL: Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes of treatment J Bone Joint Surg Am 2000;82:980–990 155 PHYSIOLOGIC DEVELOPMENT OF LOWER EXTREMITY ALIGNMENT Denise T Ibrahim and John F Sarwark NORMAL DEVELOPMENT OF LOWER EXTREMITIES • Birth: Increased bowlegs (genu varum) and internal tibiofemoral torsion • Eighteen months: Start to straighten lower limbs • Three to four years old: Increased knock-knees (genu valgum) • Seven years old: Straighten knock-knees to a normal average of 7° valgum (femoraltibial angle) GENU VALGUM (KNOCK-KNEES)/ GENU VARUM (BOWLEGS) • Important to understand normal development of lower extremity alignment to determine if physiologic type is present vs pathologic type • Most common pediatric orthopedic concern of parents for the toddler • Most are physiologic rather than pathologic • Femoral internal rotation (anteversion) or external rotation (retroversion), tibial internal rotation or external rotation, or foot development (i.e., metatarsal adductus, clubfoot) • Important to accept 2 SD from normal, in accordance with age, in any direction before considering alignment abnormal • Normally, femoral internal rotation decreases with age to near 10° at maturity and tibial external rotation increases with age as it is often internally rotated (i.e., appearance of in-toeing) foot progression angle slowly externally rotates during development up until ages 11–14 years • Examination of the entire extremity including torsional alignment is essential • Examination 1 If walking, assess heel-toe gait and foot progression angle (internal, neutral, external) 2 Persistent limping may require referral to orthopedic surgeon 3 Foot progression angle (long axis of foot angle compared to a central vertical line in the walking path) during walking changes with age Normal progression is external In-toeing disappears with age 4 Check hip rotation with child in prone position Knees flexed 90° and rotate femur internally and externally (Fig 155-1) In a younger child there is more internal rotation than external rotation of the hip 5 Check tibia torsion in prone position, thighs are parallel to each other with knees flexed and the long axis of the hindfoot and the long axis of the thigh form the thigh-foot angle (Fig 155-2) Intoeing is most notable after child begins to walk CHAPTER 155 • PHYSIOLOGIC DEVELOPMENT OF LOWER EXTREMITY ALIGNMENT FIG 155-1 515 Internal rotation of hips (above) and external rotation of hips (right) 6 In-toeing is a common concern of parents Education, reassurance, and observation are advised Surgery is rarely needed a Infants: Out-toeing commonly seen with infants secondary to external rotation intrauterine position of the hips Resolves with time and considered normal Often overlooked or misdiagnosed b Infants: In-toeing may be secondary to searching great toe or adducted toe This is a hyperactive adductor hallucis muscle as stance positioning begins in early toddler gait Usually resolves spontaneously Reassurance is recommended c Toddlers: In-toeing is a common complaint at 2 years of age due to internal tibial torsion Improves without treatment Bracing has no proven benefit d Child: In-toeing secondary to femoral anteversion at age greater than 3 years Excessive internal rotation of hips compared to external rotation is seen on examination If severe, orthopedic referral required PES PLANUS (FLATFOOT) FIG 155-2 Thigh foot angle to assess tibia rotation PHYSIOLOGIC FLATFEET • Many infants and children and is a pain-free condition 516 SECTION 18 • DISEASES OF THE BONE AND JOINTS • Infant: Lack arch secondary to excess subcutaneous fat and normal ligamentous laxity which improves once walking • No cause of disability • Often hereditary • Assessment: While standing foot appears flat, when standing on toes arch reappears showing it is flexible and not a fixed deformity • If fixed and not flexible on examination may need further workup • Arch supports not required if asymptomatic • Flatfeet with tight heel cord Assess dorsiflexion of foot and ankle with knee flexed and extended to determine whether contracture of soleus or gastrocsoleus complex, respectively are responsible for flatfeet PAINFUL OR RIGID FLATFEET • Consider referral to orthopedist if symptomatic or rigid to rule out pathology 1 Congenital anomalies include skewfoot or vertical talus, tarsal coalition (failure of separation of tarsal bones) 2 Most of the pathologic conditions are treated by conservative measures such as observation, inserts or casting, and physical therapy Surgery may be indicated for those failing conservative treatment MISCELLANEOUS FOOT DISORDERS • Talipes equinovarus (clubfoot): Congenital deformity of the foot with equinus, varus, adduction of forefoot, and internal rotation deformity Refer to pediatric orthopedist • Etiology: Extrinsic (molded) or intrinsic (genetic) Varying degrees of severity Can be associated with other conditions, i.e., arthrogryposis, torticollis, syndromes, and so on • Treatment: Goal is to correct deformity as soon after birth as possible with initial serial casting Casting techniques include the Ponseti (Iowa) method or Demeglio (French) method Surgical treatment may be required in cases where casting techniques incompletely correct the problem REFERENCE Tachdjian MO: The foot and leg In Tachdjian MO (ed): Pediatric Orthopaedics, 2nd ed Philadelphia, W.B Saunders, 1990 p 2810 156 SPORTS MEDICINE Denise T Ibrahim and John F Sarwark PREPARTICIPATION PHYSICAL EXAMINATION (PPE) • Goal: Detect conditions that may predispose athlete to injury or life-threatening risk • Timing: Four to six weeks before the season begins and repeated before each level of competition (i.e., junior high, high school, and college) Does not replace the yearly health supervision examination recommended by the American Academy of Pediatrics (www.aap.org) • History: Parent’s input important, and questions effectively screen for problems that may lead to sudden death The PPE task force forms and questions can be found in the Preparticipation Physical Examination by Smith DM, Kovan JR, Rich BSE, and Tanner SM and published by Mcgraw-Hill • Physical examination: Identify those who may need further evaluation or intervention 1 Cardiovascular examination: Peripheral pulses, heart murmur, and blood pressure 2 Musculoskeletal examination: Focus on previous injured areas or symptomatic areas Assess flexibility, range of motion, symmetry, atrophy or swelling, neurovascular status, joint stability, and nutritional status 3 Labs: None found to be effective in assymptomatic patients and none required unless specified by individual team or organization 4 Clearance—Again refer to the Preparticipation Physical Examination text for the most current recommendations and the Proceedings of the 26th Bethesda Conference on cardiovascular abnormalities for cardiac condition clearance 5 When families and/or patients disagree with recommendation, it is important to have a signed document from the parents acknowledging the discussion and recommendations HEAT-AND-COLD RELATED ILLNESSES • Thermoregulation differs in children at extremes of temperatures secondary to their surface area to mass ratio being higher than adults, less blood volume, sweat gland diminished sensitivity until teens and acclimatization • Heat illnesses 1 Exercise induced cramps: Produced by prolonged vigorous exercise, extreme sweating, fluid, and CHAPTER 156 • SPORTS MEDICINE electrolyte shifts If recurrent episodes, consider electrolyte evaluation and sodium food supplementation 2 Syncope: Loss of consciousness with core body temperature normal to slightly elevated after activity stops secondary to skin vasodilation, hypovolemia, and hypoperfusion Treatment: Move to cool location, rectal temperature to rule out heat stroke, check for injuries, and support with fluids 3 Exhaustion: Elevated core temperature rectally of 100.4–104°F causing mild confusion, dizziness, headache, nausea, chills, and collapse Treatment includes cooling, monitor rectal temperature, fluid replacement with cool liquids 4 Heatstroke: Medical emergency, imbalance of heat load with heat dissipation system Core temperature rectally is >104°F with abnormal mental status and tachycardia Treatment: Ambulance transport to hospital, fans, cool mist sprays, and immediate cool IV hydration enroute to ER, and sequential rectal temperatures Rule out arrhythmias with any collapse • Cold illnesses 1 Hypothermia: Core temperature decrease in mild cases 93–97°F, moderate is 86–93°F (stiffness, slow respirations, confusion, lethargy, decreased heart rate), and severe is 3 months • The disturbance causes marked distress or impairment in social, occupational, or other areas of functioning • Onset before18 years • The disturbance is not due to the direct physiologic effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington chorea, postviral encephalitis) CHRONIC MOTOR OR VOCAL TIC DISORDER (CT) • Same as for TS with the exception that there are single or multiple motor or vocal tics but not both TRANSIENT TIC DISORDER • Same as for CT with the exception that symptoms have been present for at least 1 month but