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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. 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 Epiphysis

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.

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.

Cozen Fracture

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 ...

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