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. 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.
Slipped Capital Femoral
One should suspect this diagnosis when an obese teenager with
an outturned foot limps into the office complaining of knee pain.
Knee pain is most common, but some have hip or groin pain as well.
Anteroposterior (AP) and frog-lateral radiographs of the pelvis
show characteristic changes (Fig. 221-1).
The patient should not weight-bear until after surgical stabilization
to avoid sudden, drastic slipping of the femoral head.1 For
further information, see Chapter 215.
Figure 221-1.Graphic Jump Location
Slipped capital femoral epiphysis. Note the malposition
of the femoral head on the metaphysis.
DDH (Developmental Dislocation
of the Hip)
The diagnosis of DDH 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 this, 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 with
abnormal exam findings.2 For further information,
see Chapter 215.
Adolescent Septic Knee
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 often a history
of a respiratory infection treated with antibiotics. The 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 orals after clinical response are the treatments
of choice. Failure to treat may result in serious loss of joint
function.3 For further information, see Chapter 234.
The Cozen fracture is a proximal tibial fracture with slight
displacement in a young child (Fig. 221-2A).
As the fracture heals, the leg grows fairly rapidly into a valgus
or knock-knee alignment (Fig. 221-2B). The
parent returns alarmed 3 or 4 months after the cast is removed,
wondering what happened. Fortunately, most of these spontaneously
correct, and ...