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INTRODUCTION

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This chapter is designed to alert the pediatric practitioner to common conditions that are frequently missed in primary care practice. These conditions are those in which an early diagnosis can prevent long-term future problems. Although they are mentioned elsewhere in this text, an awareness of the diagnostic features of these conditions gives primary care persons the ability to prevent the complications that occur as the disorders progress. Thus, they are specifically considered in this chapter.

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LOWER EXTREMITY “MISSES”

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Slipped Capital Femoral Epiphysis

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Slipped capital femoral epiphysis should be suspected when an obese teenager with an outturned foot limps into the office complaining of knee pain. Although hip and groin pain may be present, knee pain is quite common. Anteroposterior (AP) and frog-lateral radiographs of the pelvis show characteristic changes (Fig. 218-1A and B). The patient should be made weight-bearing immediately to avoid sudden, drastic slipping of the femoral head and referred urgently for surgical stabilization.

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Figure 218-1

A and B: Right slipped capital femoral epiphysis. Note the malposition of the femoral head on the metaphysis.

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Developmental Dislocation of the Hip

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The diagnosis of developmental dislocation of the hip is sometimes missed in pediatric practice. The examiner must try to feel the hip move in and out of the joint with delicate pressure over the knee and greater trochanter. Sometimes it is easy to feel it, and at other times, the finding is missed or not there at all. The exam is hard to teach because the babies with this finding are few. Consequently, the examiner must have a high index of suspicion based on the presence of known risk factors. Ultrasound examination and orthopedic referral are appropriate for babies with breech presentation, especially females, for those with a positive family history, for firstborn girls, and for any infant with abnormal exam findings. For further information, see Chapter 212.

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Adolescent Septic Knee

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Septic arthritis of the knee in adolescence can be subacute with subtle physical findings and grave consequences. Patients may present with mild pain and swelling, low-grade fever, and history of recent infection treated with antibiotics. Aspiration of joint fluid may show only moderate leukocytosis, and cultures may be negative, especially if antibiotics have been given. Joint lavage or drainage and appropriate antibiotic treatment, beginning with intravenous dosage and transitioning to oral medications after clinical response, are the treatments of choice. Failure to treat may result in serious loss of joint function. For further information, see Chapter 211.

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Cozen Fracture

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The Cozen fracture is a proximal tibia fracture with minimal displacement in a young child (Fig. 218-2A...

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