Knock knees Intermalleolar distance Mechanical axis Measure both

Knock knees • Inter-malleolar distance • Mechanical axis • Measure both with tape measure • Consider rickets • Indications ? • Mechanical axis lateral to tibia • Anatomic axis > 15 degrees

Knock knees

Knock knees: management • Guided growth • V expensive plate • Cheaper screws

Vitamin D • Low Vitamin D is a potent cause of musculo-skeletal pain Measure D levelatinpaed children with aches and • 40%Vitamin of attendees orthop clinic painsor before referral either deficient insufficient • Normal > 50 nmol/L • Insufficient < 50 nmol/L • Deficient < 25 nmol/L

Infection

Septic arthritis v irritable hip • Decision trees common • • History of fever > 38 o Non weight bearing WCC > 12, 000 ESR > 40 Kocher et al. J Bone Joint Surg Am. 1999 Dec; 81(12): 1662 -70.

Decision analysis • • One predictor Two predictors Three predictors Four predictors 0. 2% 40% 93% 99%

Outcome Resolution

Outcome Tom Smith Arthritis Life long disability

DDH: Clinical detection

What tests; Neonates • Ortolani reduction clunk (1936) • “segno del scotto” • Barlow test (1966) • Le Damany (1912) • “signe de ressaut”

Ortolani

Barlow

Barlow: Examine each hip separately

What you’re feeling

When ? Old Guidelines • • • At birth (but many lax) In first 2/52 At 6 – 8 weeks (last chance for O/B+) At 3 months ? At 6 – 9 months (required by guidelines but ? useful) • 15 - 21 months

Current UK Screening Policy NIPE 2008 Age NIPE Do. H Healthy Child Programme Birth Examination 6 -10 weeks Examination 2 months Immunisation 3 months Immunisation 4 months Immunisation 1 year Examination and immunisation

Treatment requirement 100% 90% 80% 70% 60% Abduction bracing 50% Open reduction 40% 30% 20% 10% 0% <6 weeks 6 -10 weeks 3 -5 months 6 -9 months >10 months

Examination at 3 months • Instability unlikely • Limited abduction important • Asymmetric skin creases caused by Nestle • LLD difficult to judge • If in doubt USS at hip instability

Limited abduction

Clubfoot

Ponseti’s method

Ponseti’s method

Ponseti’s method

Ponseti’s method : Splintage • • Boots on bar External rotation splintage 70 degrees ER Full time 2 - 4 months Night 2 - 4 years

Ponseti’s method : Splintage

Leg Length Inequality • Use Galleazzi sign for measurement in infants • No need to refer small children unless gross discrepancy or concern about hips

Femoral deficiencies • Spectrum • Congenital short femur • PFFD • 1 in 50 -200, 000

Examine the hips in children with knee pain

What we’re doing • Central referral place “dummy clinic” • Website for advice and simple treatment • Leaflets • Videos • More advice and guidance • Send back referrals for normal variants