Practical Pediatrics

WASHINGTON – For patients who come to the office complaining of knee pain, Dr. William Phillips advises physicians to always check for the motion of the hips, a common source of knee pain in athletes with overuse injuries.

At a practical pediatrics meeting sponsored by the American Academy of Pediatrics, Dr. Phillips, chief of the orthopedic service and orthopedic surgery clinic at Texas Children’s Hospital, Houston, recommended the following test to check for hip rotation: While the child is lying supine, flex their hips up to 90 degrees and flex their knees up "and try to internally rotate their legs, which means take their feet out and point the kneecaps in." X-rays are not necessary in these cases, he added.

Dr. Phillips also emphasized the value of encouraging patients with knee pain to start doing isometric exercises, which can be taught in the office and can be done at home. With a few exceptions, "the cure-all exercise for virtually every type of knee pain ... is isometric quadriceps strengthening exercises."

Courtesy Texas Children's Hospital

Repetitive overuse injuries occur when "an excessive, repetitive load overwhelms the body’s normal repair processes." Such injuries account for the majority of sports injuries seen by pediatricians – a result of the trend toward earlier specialization in sports, more-intensive involvement starting at younger ages, and year-round participation in one sport. These injuries can be soft-tissue or bony injuries, said Dr. Phillips, professor of pediatrics at Baylor College of Medicine, Houston.

In any evaluation, the history is the most important element, he said. The physical exam can be helpful, but imaging studies are less useful. He recommended asking patients when they experience pain, such as during an athletic activity; whether it limits their performance; what they are able to do; and how long they have been experiencing the pain.

Another question is whether there have been recent changes in their activity or sports practices, said Dr. Phillips. He described three cheerleaders from the same squad who came to his office complaining of the same type of knee pain around the same time. The cause turned out to be a new drill they were doing in practice.

An x-ray may be considered in situations that include a history of acute swelling, obvious limb asymmetry, limited range of motion, and certainly, when the patient is unable to bear weight. An x-ray "is usually not needed when the condition is bilateral ... and clearly the same on both sides," he said. But he added that he always offers the family the option of getting an x-ray if the child has not improved after a certain amount of time.

Injuries to the extensor mechanisms are probably the most common overuse injuries. "And again, knee pain can be referred from the hip," Dr. Phillips pointed out. Every year, he sees junior high school football players who have twisted their knees in a game and have been limping, but have a normal knee exam and turn out to have a slipped lateral femoral epiphysis. "So be sure to check the hips," he said, noting that the range of motion should be symmetrical, with at least 20 or 30 degrees of internal rotation, "and the feet go out, the kneecaps go in."

The most common causes of knee pain in young athletes are extensor patellofemoral problems, characterized by pain with such activities as running or climbing stairs. Another activity that elicits this type of pain is rising up from a sitting position, which "jams" the patellofemoral joint, he said. In such cases, there tends to be tenderness under the patella. "Usually, if you push the patella a little bit laterally, they will have pain."

Management of patellofemoral problems includes activity as tolerated; ice and analgesics; isometric quadriceps strengthening; and quadriceps and hamstring stretching. A brace – the type with a neoprene sleeve with a hole cut out, not a metal brace – is also acceptable to use if the patient likes it, but it is not essential, Dr. Phillips said.

Physical therapy is not usually necessary. Instead, he recommends teaching children who present with knee pain the following fundamental exercise: While lying down, bend the unaffected leg and keep that foot flat on the floor, then lift the affected leg 6-12 inches off the table with the knee fully extended, toe pointed to the ceiling – keeping it up for 20 seconds, down for 10 seconds, and repeating this for one or two sets of 20 repetitions, depending on the child and other factors. They should avoid lifting both legs up off the ground at the same time, which can hurt their backs.

For weights, they can use a knapsack, even their mother’s purse, starting with 1 or 2 pounds (or no weights if they are very sore). "This will go a long way toward helping them mend," he said.

Dr. Phillips advises avoiding weight machines where they kick their legs out, which is like getting up from a sitting position; squats; or stair climbing. He tells families that patellofemoral problems wax and wane, and "very rarely" require surgery, and he encourages a lot of rehabilitation before considering a recommendation for any type of surgery.

Dr. Phillips said he had no relevant disclosures.

[email protected]

WASHINGTON – For patients who come to the office complaining of knee pain, Dr. William Phillips advises physicians to always check for the motion of the hips, a common source of knee pain in athletes with overuse injuries.

At a practical pediatrics meeting sponsored by the American Academy of Pediatrics, Dr. Phillips, chief of the orthopedic service and orthopedic surgery clinic at Texas Children’s Hospital, Houston, recommended the following test to check for hip rotation: While the child is lying supine, flex their hips up to 90 degrees and flex their knees up "and try to internally rotate their legs, which means take their feet out and point the kneecaps in." X-rays are not necessary in these cases, he added.

Dr. Phillips also emphasized the value of encouraging patients with knee pain to start doing isometric exercises, which can be taught in the office and can be done at home. With a few exceptions, "the cure-all exercise for virtually every type of knee pain ... is isometric quadriceps strengthening exercises."

Courtesy Texas Children's Hospital

Repetitive overuse injuries occur when "an excessive, repetitive load overwhelms the body’s normal repair processes." Such injuries account for the majority of sports injuries seen by pediatricians – a result of the trend toward earlier specialization in sports, more-intensive involvement starting at younger ages, and year-round participation in one sport. These injuries can be soft-tissue or bony injuries, said Dr. Phillips, professor of pediatrics at Baylor College of Medicine, Houston.

In any evaluation, the history is the most important element, he said. The physical exam can be helpful, but imaging studies are less useful. He recommended asking patients when they experience pain, such as during an athletic activity; whether it limits their performance; what they are able to do; and how long they have been experiencing the pain.

Another question is whether there have been recent changes in their activity or sports practices, said Dr. Phillips. He described three cheerleaders from the same squad who came to his office complaining of the same type of knee pain around the same time. The cause turned out to be a new drill they were doing in practice.

An x-ray may be considered in situations that include a history of acute swelling, obvious limb asymmetry, limited range of motion, and certainly, when the patient is unable to bear weight. An x-ray "is usually not needed when the condition is bilateral ... and clearly the same on both sides," he said. But he added that he always offers the family the option of getting an x-ray if the child has not improved after a certain amount of time.

Injuries to the extensor mechanisms are probably the most common overuse injuries. "And again, knee pain can be referred from the hip," Dr. Phillips pointed out. Every year, he sees junior high school football players who have twisted their knees in a game and have been limping, but have a normal knee exam and turn out to have a slipped lateral femoral epiphysis. "So be sure to check the hips," he said, noting that the range of motion should be symmetrical, with at least 20 or 30 degrees of internal rotation, "and the feet go out, the kneecaps go in."

The most common causes of knee pain in young athletes are extensor patellofemoral problems, characterized by pain with such activities as running or climbing stairs. Another activity that elicits this type of pain is rising up from a sitting position, which "jams" the patellofemoral joint, he said. In such cases, there tends to be tenderness under the patella. "Usually, if you push the patella a little bit laterally, they will have pain."

Management of patellofemoral problems includes activity as tolerated; ice and analgesics; isometric quadriceps strengthening; and quadriceps and hamstring stretching. A brace – the type with a neoprene sleeve with a hole cut out, not a metal brace – is also acceptable to use if the patient likes it, but it is not essential, Dr. Phillips said.

Physical therapy is not usually necessary. Instead, he recommends teaching children who present with knee pain the following fundamental exercise: While lying down, bend the unaffected leg and keep that foot flat on the floor, then lift the affected leg 6-12 inches off the table with the knee fully extended, toe pointed to the ceiling – keeping it up for 20 seconds, down for 10 seconds, and repeating this for one or two sets of 20 repetitions, depending on the child and other factors. They should avoid lifting both legs up off the ground at the same time, which can hurt their backs.

For weights, they can use a knapsack, even their mother’s purse, starting with 1 or 2 pounds (or no weights if they are very sore). "This will go a long way toward helping them mend," he said.

Dr. Phillips advises avoiding weight machines where they kick their legs out, which is like getting up from a sitting position; squats; or stair climbing. He tells families that patellofemoral problems wax and wane, and "very rarely" require surgery, and he encourages a lot of rehabilitation before considering a recommendation for any type of surgery.

Dr. Phillips said he had no relevant disclosures.

[email protected]

WASHINGTON – For patients who come to the office complaining of knee pain, Dr. William Phillips advises physicians to always check for the motion of the hips, a common source of knee pain in athletes with overuse injuries.

At a practical pediatrics meeting sponsored by the American Academy of Pediatrics, Dr. Phillips, chief of the orthopedic service and orthopedic surgery clinic at Texas Children’s Hospital, Houston, recommended the following test to check for hip rotation: While the child is lying supine, flex their hips up to 90 degrees and flex their knees up "and try to internally rotate their legs, which means take their feet out and point the kneecaps in." X-rays are not necessary in these cases, he added.

Dr. Phillips also emphasized the value of encouraging patients with knee pain to start doing isometric exercises, which can be taught in the office and can be done at home. With a few exceptions, "the cure-all exercise for virtually every type of knee pain ... is isometric quadriceps strengthening exercises."

Courtesy Texas Children's Hospital

Repetitive overuse injuries occur when "an excessive, repetitive load overwhelms the body’s normal repair processes." Such injuries account for the majority of sports injuries seen by pediatricians – a result of the trend toward earlier specialization in sports, more-intensive involvement starting at younger ages, and year-round participation in one sport. These injuries can be soft-tissue or bony injuries, said Dr. Phillips, professor of pediatrics at Baylor College of Medicine, Houston.

In any evaluation, the history is the most important element, he said. The physical exam can be helpful, but imaging studies are less useful. He recommended asking patients when they experience pain, such as during an athletic activity; whether it limits their performance; what they are able to do; and how long they have been experiencing the pain.

Another question is whether there have been recent changes in their activity or sports practices, said Dr. Phillips. He described three cheerleaders from the same squad who came to his office complaining of the same type of knee pain around the same time. The cause turned out to be a new drill they were doing in practice.

An x-ray may be considered in situations that include a history of acute swelling, obvious limb asymmetry, limited range of motion, and certainly, when the patient is unable to bear weight. An x-ray "is usually not needed when the condition is bilateral ... and clearly the same on both sides," he said. But he added that he always offers the family the option of getting an x-ray if the child has not improved after a certain amount of time.

Injuries to the extensor mechanisms are probably the most common overuse injuries. "And again, knee pain can be referred from the hip," Dr. Phillips pointed out. Every year, he sees junior high school football players who have twisted their knees in a game and have been limping, but have a normal knee exam and turn out to have a slipped lateral femoral epiphysis. "So be sure to check the hips," he said, noting that the range of motion should be symmetrical, with at least 20 or 30 degrees of internal rotation, "and the feet go out, the kneecaps go in."

The most common causes of knee pain in young athletes are extensor patellofemoral problems, characterized by pain with such activities as running or climbing stairs. Another activity that elicits this type of pain is rising up from a sitting position, which "jams" the patellofemoral joint, he said. In such cases, there tends to be tenderness under the patella. "Usually, if you push the patella a little bit laterally, they will have pain."

Management of patellofemoral problems includes activity as tolerated; ice and analgesics; isometric quadriceps strengthening; and quadriceps and hamstring stretching. A brace – the type with a neoprene sleeve with a hole cut out, not a metal brace – is also acceptable to use if the patient likes it, but it is not essential, Dr. Phillips said.

Physical therapy is not usually necessary. Instead, he recommends teaching children who present with knee pain the following fundamental exercise: While lying down, bend the unaffected leg and keep that foot flat on the floor, then lift the affected leg 6-12 inches off the table with the knee fully extended, toe pointed to the ceiling – keeping it up for 20 seconds, down for 10 seconds, and repeating this for one or two sets of 20 repetitions, depending on the child and other factors. They should avoid lifting both legs up off the ground at the same time, which can hurt their backs.

For weights, they can use a knapsack, even their mother’s purse, starting with 1 or 2 pounds (or no weights if they are very sore). "This will go a long way toward helping them mend," he said.

Dr. Phillips advises avoiding weight machines where they kick their legs out, which is like getting up from a sitting position; squats; or stair climbing. He tells families that patellofemoral problems wax and wane, and "very rarely" require surgery, and he encourages a lot of rehabilitation before considering a recommendation for any type of surgery.

Dr. Phillips said he had no relevant disclosures.

[email protected]

WASHINGTON – Normal variations of the lower extremities in healthy children can be worrisome for parents, but they "virtually never" need to be treated in the first decade of life, Dr. William Phillips said.

These normal variations – which include intoeing and bowlegs – often lead to unnecessary referrals and treatments, said Dr. Phillips, chief of the orthopedic service and the orthopedic surgery clinic at Texas Children’s Hospital, Houston.

Courtesy Texas Children's Hospital

What is normal can vary with age, and usually resolves without any treatment, he said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Families can be reassured that it can take a few years, not months, for intoeing to improve. "The natural history of intoeing of any cause is that it gradually gets better," usually by age 8-10 years, he said, pointing out that 30% of 6-year-olds have intoeing, compared with less than 5% of adults. And only in rare cases is any treatment recommended, he said.

The Denis Browne bar (now used only for clubfoot) or special shoes are not effective; the only effective treatment is a derotation osteotomy, which he usually does not recommend, although he does perform this surgery for children with cerebral palsy.

The common causes of intoeing or out-toeing are metatarsus adductus, internal or external tibial torsion, or excessive femoral anteversion. Evaluating the torsional profile while the child is in a prone position makes it easier to identify these conditions; this includes looking at the lateral border of the foot, the thigh-foot angle, and hip rotation, said Dr. Phillips, who also is a professor of pediatrics at Baylor College of Medicine, Houston.

The lateral border of the foot is normally straight, but if it appears to be "bean-shaped," the child has metatarsus adductus, he noted. At the thigh-foot angle, most children have some external tibial torsion, but if the line from the second toe to the heel is pointing outward instead of inward, the child has internal tibial torsion.

A child with a normal exam with normal variations should be checked for short stature. If under the fifth percentile for age, he or she is more likely to have an underlying problem such as a skeletal dysplasia. It also helps to observe how the child stands, walks, and runs when barefoot and in shorts. Other factors that should be considered include family history and whether the child was full term or a breech delivery, as well as whether he or she is meeting developmental milestones and whether the intoeing is causing functional problems, Dr. Phillips added. Radiographs are not very helpful when evaluating children with intoeing.

Metatarsus adductus typically resolves spontaneously, and while it is occasionally treated with serial casting, this is not usually necessary, said Dr. Phillips, who has not recommended special shoes for these patients for many years.

Internal tibial torsion is seen in toddlers and also improves with time, although it often persists longer in children who have a tendency to sleep in a position similar to a fetal position, which delays remodeling, he said.

Children with external tibial torsion, which is much less common, tend to be awkward, clumsy runners. The only treatment for this is an osteotomy, which he usually does not recommend.

Excessive or increased femoral anteversion is most commonly seen in younger children, who present with an intoed gait that tends to get worse when they are tired; these children also tend to sit in a "W" position. Another sign of increased femoral anteversion is "kissing patellae" when a child lies down, Dr. Phillips said. There is no evidence that increased femoral anteversion increases the risk of osteoarthritis, although it can cause problems with the kneecap in a few cases – but not until adolescence, he added.

For children with intoeing, he recommends activities "where they can’t get very far if they turn their feet in all the way," such as roller and ice-skating, skiing, and ballet.

The wide range of normal variations of the lower extremities in children includes bowlegs and knock-knees, which are angular variations, Dr. Phillips said, pointing out that children at different ages have different alignments to their limbs. In the first year and a half, children tend to be bowlegged, followed by a "hyper–knock-kneed" phase, and, subsequently, their legs straighten out and they are mildly knock-kneed, he added.

But if a child is still bowlegged at age 3 years, however, he starts to investigate further.

He recommends radiographs for children with bowlegs or knock-knees when they are under the fifth percentile, because they are more likely to have a problem like skeletal dysplasia, and when there is a positive family history or they have an asymmetrical or worsening deformity. A special x-ray – a standing AP from the hips to the ankles – helps evaluate alignment as the child is standing with the kneecaps straight ahead.

While there are few pathologic torsional variations, there are some pathologic angular variations, Dr. Phillips pointed out. They include Blount’s disease, a growth disturbance of the medial proximal tibial epiphysis; metabolic bone disease, such as early renal failure or vitamin D–resistant rickets; and a posttraumatic deformity.

"What you ought to really be careful about is if the bowlegging is coming from below the knee," which can be a sign of congenital pseudoarthrosis of the tibia, he said.

Dr. Phillips had no disclosures.

[email protected]

WASHINGTON – Normal variations of the lower extremities in healthy children can be worrisome for parents, but they "virtually never" need to be treated in the first decade of life, Dr. William Phillips said.

These normal variations – which include intoeing and bowlegs – often lead to unnecessary referrals and treatments, said Dr. Phillips, chief of the orthopedic service and the orthopedic surgery clinic at Texas Children’s Hospital, Houston.

Courtesy Texas Children's Hospital

What is normal can vary with age, and usually resolves without any treatment, he said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Families can be reassured that it can take a few years, not months, for intoeing to improve. "The natural history of intoeing of any cause is that it gradually gets better," usually by age 8-10 years, he said, pointing out that 30% of 6-year-olds have intoeing, compared with less than 5% of adults. And only in rare cases is any treatment recommended, he said.

The Denis Browne bar (now used only for clubfoot) or special shoes are not effective; the only effective treatment is a derotation osteotomy, which he usually does not recommend, although he does perform this surgery for children with cerebral palsy.

The common causes of intoeing or out-toeing are metatarsus adductus, internal or external tibial torsion, or excessive femoral anteversion. Evaluating the torsional profile while the child is in a prone position makes it easier to identify these conditions; this includes looking at the lateral border of the foot, the thigh-foot angle, and hip rotation, said Dr. Phillips, who also is a professor of pediatrics at Baylor College of Medicine, Houston.

The lateral border of the foot is normally straight, but if it appears to be "bean-shaped," the child has metatarsus adductus, he noted. At the thigh-foot angle, most children have some external tibial torsion, but if the line from the second toe to the heel is pointing outward instead of inward, the child has internal tibial torsion.

A child with a normal exam with normal variations should be checked for short stature. If under the fifth percentile for age, he or she is more likely to have an underlying problem such as a skeletal dysplasia. It also helps to observe how the child stands, walks, and runs when barefoot and in shorts. Other factors that should be considered include family history and whether the child was full term or a breech delivery, as well as whether he or she is meeting developmental milestones and whether the intoeing is causing functional problems, Dr. Phillips added. Radiographs are not very helpful when evaluating children with intoeing.

Metatarsus adductus typically resolves spontaneously, and while it is occasionally treated with serial casting, this is not usually necessary, said Dr. Phillips, who has not recommended special shoes for these patients for many years.

Internal tibial torsion is seen in toddlers and also improves with time, although it often persists longer in children who have a tendency to sleep in a position similar to a fetal position, which delays remodeling, he said.

Children with external tibial torsion, which is much less common, tend to be awkward, clumsy runners. The only treatment for this is an osteotomy, which he usually does not recommend.

Excessive or increased femoral anteversion is most commonly seen in younger children, who present with an intoed gait that tends to get worse when they are tired; these children also tend to sit in a "W" position. Another sign of increased femoral anteversion is "kissing patellae" when a child lies down, Dr. Phillips said. There is no evidence that increased femoral anteversion increases the risk of osteoarthritis, although it can cause problems with the kneecap in a few cases – but not until adolescence, he added.

For children with intoeing, he recommends activities "where they can’t get very far if they turn their feet in all the way," such as roller and ice-skating, skiing, and ballet.

The wide range of normal variations of the lower extremities in children includes bowlegs and knock-knees, which are angular variations, Dr. Phillips said, pointing out that children at different ages have different alignments to their limbs. In the first year and a half, children tend to be bowlegged, followed by a "hyper–knock-kneed" phase, and, subsequently, their legs straighten out and they are mildly knock-kneed, he added.

But if a child is still bowlegged at age 3 years, however, he starts to investigate further.

He recommends radiographs for children with bowlegs or knock-knees when they are under the fifth percentile, because they are more likely to have a problem like skeletal dysplasia, and when there is a positive family history or they have an asymmetrical or worsening deformity. A special x-ray – a standing AP from the hips to the ankles – helps evaluate alignment as the child is standing with the kneecaps straight ahead.

While there are few pathologic torsional variations, there are some pathologic angular variations, Dr. Phillips pointed out. They include Blount’s disease, a growth disturbance of the medial proximal tibial epiphysis; metabolic bone disease, such as early renal failure or vitamin D–resistant rickets; and a posttraumatic deformity.

"What you ought to really be careful about is if the bowlegging is coming from below the knee," which can be a sign of congenital pseudoarthrosis of the tibia, he said.

Dr. Phillips had no disclosures.

[email protected]

WASHINGTON – Normal variations of the lower extremities in healthy children can be worrisome for parents, but they "virtually never" need to be treated in the first decade of life, Dr. William Phillips said.

These normal variations – which include intoeing and bowlegs – often lead to unnecessary referrals and treatments, said Dr. Phillips, chief of the orthopedic service and the orthopedic surgery clinic at Texas Children’s Hospital, Houston.

Courtesy Texas Children's Hospital

What is normal can vary with age, and usually resolves without any treatment, he said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Families can be reassured that it can take a few years, not months, for intoeing to improve. "The natural history of intoeing of any cause is that it gradually gets better," usually by age 8-10 years, he said, pointing out that 30% of 6-year-olds have intoeing, compared with less than 5% of adults. And only in rare cases is any treatment recommended, he said.

The Denis Browne bar (now used only for clubfoot) or special shoes are not effective; the only effective treatment is a derotation osteotomy, which he usually does not recommend, although he does perform this surgery for children with cerebral palsy.

The common causes of intoeing or out-toeing are metatarsus adductus, internal or external tibial torsion, or excessive femoral anteversion. Evaluating the torsional profile while the child is in a prone position makes it easier to identify these conditions; this includes looking at the lateral border of the foot, the thigh-foot angle, and hip rotation, said Dr. Phillips, who also is a professor of pediatrics at Baylor College of Medicine, Houston.

The lateral border of the foot is normally straight, but if it appears to be "bean-shaped," the child has metatarsus adductus, he noted. At the thigh-foot angle, most children have some external tibial torsion, but if the line from the second toe to the heel is pointing outward instead of inward, the child has internal tibial torsion.

A child with a normal exam with normal variations should be checked for short stature. If under the fifth percentile for age, he or she is more likely to have an underlying problem such as a skeletal dysplasia. It also helps to observe how the child stands, walks, and runs when barefoot and in shorts. Other factors that should be considered include family history and whether the child was full term or a breech delivery, as well as whether he or she is meeting developmental milestones and whether the intoeing is causing functional problems, Dr. Phillips added. Radiographs are not very helpful when evaluating children with intoeing.

Metatarsus adductus typically resolves spontaneously, and while it is occasionally treated with serial casting, this is not usually necessary, said Dr. Phillips, who has not recommended special shoes for these patients for many years.

Internal tibial torsion is seen in toddlers and also improves with time, although it often persists longer in children who have a tendency to sleep in a position similar to a fetal position, which delays remodeling, he said.

Children with external tibial torsion, which is much less common, tend to be awkward, clumsy runners. The only treatment for this is an osteotomy, which he usually does not recommend.

Excessive or increased femoral anteversion is most commonly seen in younger children, who present with an intoed gait that tends to get worse when they are tired; these children also tend to sit in a "W" position. Another sign of increased femoral anteversion is "kissing patellae" when a child lies down, Dr. Phillips said. There is no evidence that increased femoral anteversion increases the risk of osteoarthritis, although it can cause problems with the kneecap in a few cases – but not until adolescence, he added.

For children with intoeing, he recommends activities "where they can’t get very far if they turn their feet in all the way," such as roller and ice-skating, skiing, and ballet.

The wide range of normal variations of the lower extremities in children includes bowlegs and knock-knees, which are angular variations, Dr. Phillips said, pointing out that children at different ages have different alignments to their limbs. In the first year and a half, children tend to be bowlegged, followed by a "hyper–knock-kneed" phase, and, subsequently, their legs straighten out and they are mildly knock-kneed, he added.

But if a child is still bowlegged at age 3 years, however, he starts to investigate further.

He recommends radiographs for children with bowlegs or knock-knees when they are under the fifth percentile, because they are more likely to have a problem like skeletal dysplasia, and when there is a positive family history or they have an asymmetrical or worsening deformity. A special x-ray – a standing AP from the hips to the ankles – helps evaluate alignment as the child is standing with the kneecaps straight ahead.

While there are few pathologic torsional variations, there are some pathologic angular variations, Dr. Phillips pointed out. They include Blount’s disease, a growth disturbance of the medial proximal tibial epiphysis; metabolic bone disease, such as early renal failure or vitamin D–resistant rickets; and a posttraumatic deformity.

"What you ought to really be careful about is if the bowlegging is coming from below the knee," which can be a sign of congenital pseudoarthrosis of the tibia, he said.

Dr. Phillips had no disclosures.

[email protected]

WASHINGTON – Community-acquired methicillin-resistant Staphylococcus aureus should be considered in the differential diagnosis of skin and soft tissue infections, as well as neonatal eye infections, Dr. Morven Edwards said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Dr. Edwards, an infectious disease specialist at Texas Children’s Hospital, Houston, said that unlike a decade ago, she now considers community-acquired MRSA as a possible cause "in almost any manifestation of a problem with the skin or soft tissue, even including those entities that we used to think were caused by other microorganisms."

For example, in the past, perianal dermatitis in a young infant "was essentially a pathognomonic presentation for group A strep infection," which did not even require a culture for an accurate diagnosis and appropriate treatment, said Dr. Edwards, who is a professor of pediatrics at Baylor College of Medicine, Houston.

She referred to a small retrospective study of children between the ages of 5 months and 12 years with perianal erythema, which found that the dominant culture results were MRSA and methicillin-sensitive S. aureus (MSSA), some streptococci, and some mixed infections. In the past, staphylococcal skin and soft tissue infections were considered uncommon among healthy term newborns discharged home, "unless it was just a very mild diaper dermatitis," she noted.

In a 2006 study of healthy term babies who returned to the hospital within a month of discharge to Texas Children’s Hospital’s emergency department, cases of MRSA peaked at 8-12 days after discharge. Almost all were skin and soft tissue infections (SSTIs), and some of the babies had mild, pustular skin disease and were treated as outpatients with topical therapy and/or oral antistaphylococcal medications. But almost 40% required admission for incision and drainage and parenteral antibiotic therapy.

Dr. Edwards referred to a case of an SSTI that started with a stubbed toe and progressed to a disseminated staphylococcal infection and endocarditis – illustrating that "even with an apparently limited minor staph infection, it always should go through our minds that this could be one that’s more serious."

The healthy teenage boy had stubbed his toe during a wrestling match, then developed fever, fatigue, and buttock and back pain, along with swelling and pain in the toe 4 days later. A fracture was diagnosed at an urgent care clinic, and he was sent home, but 9 days after the initial injury, symptoms persisted and he was admitted to the hospital for treatment with broad-spectrum antimicrobials, including clindamycin.

On the fourth day in the hospital, he had a fever of 104° F, "massive" facial swelling, bibasilar crackles, a systolic murmur, left lower quadrant pain, and a large parietal abscess seen on MRI. He had vegetations on the anterior leaflet of the mitral valve and multiple microemboli to the brain. The abscess was drained, and he had a vegetectomy, where vegetation was "peeled" off the leaflet, leaving the valve intact. After 6 weeks of intravenous antimicrobial treatment, he did well and was discharged.

"The lesson is that a seemingly innocuous SSTI always has the potential to disseminate," Dr. Edwards said, adding that while this is very uncommon, especially in a healthy child, "it’s always something to keep in mind."

Transmitted by direct contact, risk factors for community-acquired MRSA include chronic skin conditions, participation in sports teams that involve close contact with other players, and a history of such infections in family members, she noted.

In infants, MRSA infection also should be included in the differential diagnosis of ophthalmia neonatorum, Dr. Edwards said. She described the case of a healthy term 4-day-old baby who presented with eye swelling and purulent discharge, but no other systemic findings. The mother’s pregnancy had been uncomplicated; maternal tests were negative for group B streptococcus, chlamydia, and Neisseria gonorrhoea; and the baby had been discharged home by the second day after a normal vaginal birth.

The cause turned out to be community-acquired MRSA infection. "We need to consider this diagnosis with a higher index of suspicion in young infants now," she said, noting that the peak onset is at age 4-6 days, and it is characterized by a purulent discharge not likely to be a gonococcal infection. The baby was admitted to the hospital and treated with parenteral antimicrobial therapy.

Dr. Edwards disclosed that she is a consultant for and has received research funds from Novartis related to the development of a group B streptococcus vaccine.

[email protected]

WASHINGTON – Community-acquired methicillin-resistant Staphylococcus aureus should be considered in the differential diagnosis of skin and soft tissue infections, as well as neonatal eye infections, Dr. Morven Edwards said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Dr. Edwards, an infectious disease specialist at Texas Children’s Hospital, Houston, said that unlike a decade ago, she now considers community-acquired MRSA as a possible cause "in almost any manifestation of a problem with the skin or soft tissue, even including those entities that we used to think were caused by other microorganisms."

For example, in the past, perianal dermatitis in a young infant "was essentially a pathognomonic presentation for group A strep infection," which did not even require a culture for an accurate diagnosis and appropriate treatment, said Dr. Edwards, who is a professor of pediatrics at Baylor College of Medicine, Houston.

She referred to a small retrospective study of children between the ages of 5 months and 12 years with perianal erythema, which found that the dominant culture results were MRSA and methicillin-sensitive S. aureus (MSSA), some streptococci, and some mixed infections. In the past, staphylococcal skin and soft tissue infections were considered uncommon among healthy term newborns discharged home, "unless it was just a very mild diaper dermatitis," she noted.

In a 2006 study of healthy term babies who returned to the hospital within a month of discharge to Texas Children’s Hospital’s emergency department, cases of MRSA peaked at 8-12 days after discharge. Almost all were skin and soft tissue infections (SSTIs), and some of the babies had mild, pustular skin disease and were treated as outpatients with topical therapy and/or oral antistaphylococcal medications. But almost 40% required admission for incision and drainage and parenteral antibiotic therapy.

Dr. Edwards referred to a case of an SSTI that started with a stubbed toe and progressed to a disseminated staphylococcal infection and endocarditis – illustrating that "even with an apparently limited minor staph infection, it always should go through our minds that this could be one that’s more serious."

The healthy teenage boy had stubbed his toe during a wrestling match, then developed fever, fatigue, and buttock and back pain, along with swelling and pain in the toe 4 days later. A fracture was diagnosed at an urgent care clinic, and he was sent home, but 9 days after the initial injury, symptoms persisted and he was admitted to the hospital for treatment with broad-spectrum antimicrobials, including clindamycin.

On the fourth day in the hospital, he had a fever of 104° F, "massive" facial swelling, bibasilar crackles, a systolic murmur, left lower quadrant pain, and a large parietal abscess seen on MRI. He had vegetations on the anterior leaflet of the mitral valve and multiple microemboli to the brain. The abscess was drained, and he had a vegetectomy, where vegetation was "peeled" off the leaflet, leaving the valve intact. After 6 weeks of intravenous antimicrobial treatment, he did well and was discharged.

"The lesson is that a seemingly innocuous SSTI always has the potential to disseminate," Dr. Edwards said, adding that while this is very uncommon, especially in a healthy child, "it’s always something to keep in mind."

Transmitted by direct contact, risk factors for community-acquired MRSA include chronic skin conditions, participation in sports teams that involve close contact with other players, and a history of such infections in family members, she noted.

In infants, MRSA infection also should be included in the differential diagnosis of ophthalmia neonatorum, Dr. Edwards said. She described the case of a healthy term 4-day-old baby who presented with eye swelling and purulent discharge, but no other systemic findings. The mother’s pregnancy had been uncomplicated; maternal tests were negative for group B streptococcus, chlamydia, and Neisseria gonorrhoea; and the baby had been discharged home by the second day after a normal vaginal birth.

The cause turned out to be community-acquired MRSA infection. "We need to consider this diagnosis with a higher index of suspicion in young infants now," she said, noting that the peak onset is at age 4-6 days, and it is characterized by a purulent discharge not likely to be a gonococcal infection. The baby was admitted to the hospital and treated with parenteral antimicrobial therapy.

Dr. Edwards disclosed that she is a consultant for and has received research funds from Novartis related to the development of a group B streptococcus vaccine.

[email protected]

WASHINGTON – Community-acquired methicillin-resistant Staphylococcus aureus should be considered in the differential diagnosis of skin and soft tissue infections, as well as neonatal eye infections, Dr. Morven Edwards said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Dr. Edwards, an infectious disease specialist at Texas Children’s Hospital, Houston, said that unlike a decade ago, she now considers community-acquired MRSA as a possible cause "in almost any manifestation of a problem with the skin or soft tissue, even including those entities that we used to think were caused by other microorganisms."

For example, in the past, perianal dermatitis in a young infant "was essentially a pathognomonic presentation for group A strep infection," which did not even require a culture for an accurate diagnosis and appropriate treatment, said Dr. Edwards, who is a professor of pediatrics at Baylor College of Medicine, Houston.

She referred to a small retrospective study of children between the ages of 5 months and 12 years with perianal erythema, which found that the dominant culture results were MRSA and methicillin-sensitive S. aureus (MSSA), some streptococci, and some mixed infections. In the past, staphylococcal skin and soft tissue infections were considered uncommon among healthy term newborns discharged home, "unless it was just a very mild diaper dermatitis," she noted.

In a 2006 study of healthy term babies who returned to the hospital within a month of discharge to Texas Children’s Hospital’s emergency department, cases of MRSA peaked at 8-12 days after discharge. Almost all were skin and soft tissue infections (SSTIs), and some of the babies had mild, pustular skin disease and were treated as outpatients with topical therapy and/or oral antistaphylococcal medications. But almost 40% required admission for incision and drainage and parenteral antibiotic therapy.

Dr. Edwards referred to a case of an SSTI that started with a stubbed toe and progressed to a disseminated staphylococcal infection and endocarditis – illustrating that "even with an apparently limited minor staph infection, it always should go through our minds that this could be one that’s more serious."

The healthy teenage boy had stubbed his toe during a wrestling match, then developed fever, fatigue, and buttock and back pain, along with swelling and pain in the toe 4 days later. A fracture was diagnosed at an urgent care clinic, and he was sent home, but 9 days after the initial injury, symptoms persisted and he was admitted to the hospital for treatment with broad-spectrum antimicrobials, including clindamycin.

On the fourth day in the hospital, he had a fever of 104° F, "massive" facial swelling, bibasilar crackles, a systolic murmur, left lower quadrant pain, and a large parietal abscess seen on MRI. He had vegetations on the anterior leaflet of the mitral valve and multiple microemboli to the brain. The abscess was drained, and he had a vegetectomy, where vegetation was "peeled" off the leaflet, leaving the valve intact. After 6 weeks of intravenous antimicrobial treatment, he did well and was discharged.

"The lesson is that a seemingly innocuous SSTI always has the potential to disseminate," Dr. Edwards said, adding that while this is very uncommon, especially in a healthy child, "it’s always something to keep in mind."

Transmitted by direct contact, risk factors for community-acquired MRSA include chronic skin conditions, participation in sports teams that involve close contact with other players, and a history of such infections in family members, she noted.

In infants, MRSA infection also should be included in the differential diagnosis of ophthalmia neonatorum, Dr. Edwards said. She described the case of a healthy term 4-day-old baby who presented with eye swelling and purulent discharge, but no other systemic findings. The mother’s pregnancy had been uncomplicated; maternal tests were negative for group B streptococcus, chlamydia, and Neisseria gonorrhoea; and the baby had been discharged home by the second day after a normal vaginal birth.

The cause turned out to be community-acquired MRSA infection. "We need to consider this diagnosis with a higher index of suspicion in young infants now," she said, noting that the peak onset is at age 4-6 days, and it is characterized by a purulent discharge not likely to be a gonococcal infection. The baby was admitted to the hospital and treated with parenteral antimicrobial therapy.

Dr. Edwards disclosed that she is a consultant for and has received research funds from Novartis related to the development of a group B streptococcus vaccine.

[email protected]

WASHINGTON – Community-acquired methicillin-resistant Staphylococcus aureus should be considered in the differential diagnosis of skin and soft tissue infections, as well as neonatal eye infections, Dr. Morven Edwards said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Dr. Edwards, an infectious disease specialist at Texas Children’s Hospital, Houston, said that unlike a decade ago, she now considers community-acquired MRSA as a possible cause "in almost any manifestation of a problem with the skin or soft tissue, even including those entities that we used to think were caused by other microorganisms."

For example, in the past, perianal dermatitis in a young infant "was essentially a pathognomonic presentation for group A strep infection," which did not even require a culture for an accurate diagnosis and appropriate treatment, said Dr. Edwards, who is a professor of pediatrics at Baylor College of Medicine, Houston.

She referred to a small retrospective study of children between the ages of 5 months and 12 years with perianal erythema, which found that the dominant culture results were MRSA and methicillin-sensitive S. aureus (MSSA), some streptococci, and some mixed infections. In the past, staphylococcal skin and soft tissue infections were considered uncommon among healthy term newborns discharged home, "unless it was just a very mild diaper dermatitis," she noted.

In a 2006 study of healthy term babies who returned to the hospital within a month of discharge to Texas Children’s Hospital’s emergency department, cases of MRSA peaked at 8-12 days after discharge. Almost all were skin and soft tissue infections (SSTIs), and some of the babies had mild, pustular skin disease and were treated as outpatients with topical therapy and/or oral antistaphylococcal medications. But almost 40% required admission for incision and drainage and parenteral antibiotic therapy.

Dr. Edwards referred to a case of an SSTI that started with a stubbed toe and progressed to a disseminated staphylococcal infection and endocarditis – illustrating that "even with an apparently limited minor staph infection, it always should go through our minds that this could be one that’s more serious."

The healthy teenage boy had stubbed his toe during a wrestling match, then developed fever, fatigue, and buttock and back pain, along with swelling and pain in the toe 4 days later. A fracture was diagnosed at an urgent care clinic, and he was sent home, but 9 days after the initial injury, symptoms persisted and he was admitted to the hospital for treatment with broad-spectrum antimicrobials, including clindamycin.

On the fourth day in the hospital, he had a fever of 104° F, "massive" facial swelling, bibasilar crackles, a systolic murmur, left lower quadrant pain, and a large parietal abscess seen on MRI. He had vegetations on the anterior leaflet of the mitral valve and multiple microemboli to the brain. The abscess was drained, and he had a vegetectomy, where vegetation was "peeled" off the leaflet, leaving the valve intact. After 6 weeks of intravenous antimicrobial treatment, he did well and was discharged.

"The lesson is that a seemingly innocuous SSTI always has the potential to disseminate," Dr. Edwards said, adding that while this is very uncommon, especially in a healthy child, "it’s always something to keep in mind."

Transmitted by direct contact, risk factors for community-acquired MRSA include chronic skin conditions, participation in sports teams that involve close contact with other players, and a history of such infections in family members, she noted.

In infants, MRSA infection also should be included in the differential diagnosis of ophthalmia neonatorum, Dr. Edwards said. She described the case of a healthy term 4-day-old baby who presented with eye swelling and purulent discharge, but no other systemic findings. The mother’s pregnancy had been uncomplicated; maternal tests were negative for group B streptococcus, chlamydia, and Neisseria gonorrhoea; and the baby had been discharged home by the second day after a normal vaginal birth.

The cause turned out to be community-acquired MRSA infection. "We need to consider this diagnosis with a higher index of suspicion in young infants now," she said, noting that the peak onset is at age 4-6 days, and it is characterized by a purulent discharge not likely to be a gonococcal infection. The baby was admitted to the hospital and treated with parenteral antimicrobial therapy.

Dr. Edwards disclosed that she is a consultant for and has received research funds from Novartis related to the development of a group B streptococcus vaccine.

[email protected]

WASHINGTON – Community-acquired methicillin-resistant Staphylococcus aureus should be considered in the differential diagnosis of skin and soft tissue infections, as well as neonatal eye infections, Dr. Morven Edwards said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Dr. Edwards, an infectious disease specialist at Texas Children’s Hospital, Houston, said that unlike a decade ago, she now considers community-acquired MRSA as a possible cause "in almost any manifestation of a problem with the skin or soft tissue, even including those entities that we used to think were caused by other microorganisms."

For example, in the past, perianal dermatitis in a young infant "was essentially a pathognomonic presentation for group A strep infection," which did not even require a culture for an accurate diagnosis and appropriate treatment, said Dr. Edwards, who is a professor of pediatrics at Baylor College of Medicine, Houston.

She referred to a small retrospective study of children between the ages of 5 months and 12 years with perianal erythema, which found that the dominant culture results were MRSA and methicillin-sensitive S. aureus (MSSA), some streptococci, and some mixed infections. In the past, staphylococcal skin and soft tissue infections were considered uncommon among healthy term newborns discharged home, "unless it was just a very mild diaper dermatitis," she noted.

In a 2006 study of healthy term babies who returned to the hospital within a month of discharge to Texas Children’s Hospital’s emergency department, cases of MRSA peaked at 8-12 days after discharge. Almost all were skin and soft tissue infections (SSTIs), and some of the babies had mild, pustular skin disease and were treated as outpatients with topical therapy and/or oral antistaphylococcal medications. But almost 40% required admission for incision and drainage and parenteral antibiotic therapy.

Dr. Edwards referred to a case of an SSTI that started with a stubbed toe and progressed to a disseminated staphylococcal infection and endocarditis – illustrating that "even with an apparently limited minor staph infection, it always should go through our minds that this could be one that’s more serious."

The healthy teenage boy had stubbed his toe during a wrestling match, then developed fever, fatigue, and buttock and back pain, along with swelling and pain in the toe 4 days later. A fracture was diagnosed at an urgent care clinic, and he was sent home, but 9 days after the initial injury, symptoms persisted and he was admitted to the hospital for treatment with broad-spectrum antimicrobials, including clindamycin.

On the fourth day in the hospital, he had a fever of 104° F, "massive" facial swelling, bibasilar crackles, a systolic murmur, left lower quadrant pain, and a large parietal abscess seen on MRI. He had vegetations on the anterior leaflet of the mitral valve and multiple microemboli to the brain. The abscess was drained, and he had a vegetectomy, where vegetation was "peeled" off the leaflet, leaving the valve intact. After 6 weeks of intravenous antimicrobial treatment, he did well and was discharged.

"The lesson is that a seemingly innocuous SSTI always has the potential to disseminate," Dr. Edwards said, adding that while this is very uncommon, especially in a healthy child, "it’s always something to keep in mind."

Transmitted by direct contact, risk factors for community-acquired MRSA include chronic skin conditions, participation in sports teams that involve close contact with other players, and a history of such infections in family members, she noted.

In infants, MRSA infection also should be included in the differential diagnosis of ophthalmia neonatorum, Dr. Edwards said. She described the case of a healthy term 4-day-old baby who presented with eye swelling and purulent discharge, but no other systemic findings. The mother’s pregnancy had been uncomplicated; maternal tests were negative for group B streptococcus, chlamydia, and Neisseria gonorrhoea; and the baby had been discharged home by the second day after a normal vaginal birth.

The cause turned out to be community-acquired MRSA infection. "We need to consider this diagnosis with a higher index of suspicion in young infants now," she said, noting that the peak onset is at age 4-6 days, and it is characterized by a purulent discharge not likely to be a gonococcal infection. The baby was admitted to the hospital and treated with parenteral antimicrobial therapy.

Dr. Edwards disclosed that she is a consultant for and has received research funds from Novartis related to the development of a group B streptococcus vaccine.

[email protected]

WASHINGTON – Community-acquired methicillin-resistant Staphylococcus aureus should be considered in the differential diagnosis of skin and soft tissue infections, as well as neonatal eye infections, Dr. Morven Edwards said at a practical pediatrics meeting sponsored by the American Academy of Pediatrics.

Dr. Edwards, an infectious disease specialist at Texas Children’s Hospital, Houston, said that unlike a decade ago, she now considers community-acquired MRSA as a possible cause "in almost any manifestation of a problem with the skin or soft tissue, even including those entities that we used to think were caused by other microorganisms."

For example, in the past, perianal dermatitis in a young infant "was essentially a pathognomonic presentation for group A strep infection," which did not even require a culture for an accurate diagnosis and appropriate treatment, said Dr. Edwards, who is a professor of pediatrics at Baylor College of Medicine, Houston.

She referred to a small retrospective study of children between the ages of 5 months and 12 years with perianal erythema, which found that the dominant culture results were MRSA and methicillin-sensitive S. aureus (MSSA), some streptococci, and some mixed infections. In the past, staphylococcal skin and soft tissue infections were considered uncommon among healthy term newborns discharged home, "unless it was just a very mild diaper dermatitis," she noted.

In a 2006 study of healthy term babies who returned to the hospital within a month of discharge to Texas Children’s Hospital’s emergency department, cases of MRSA peaked at 8-12 days after discharge. Almost all were skin and soft tissue infections (SSTIs), and some of the babies had mild, pustular skin disease and were treated as outpatients with topical therapy and/or oral antistaphylococcal medications. But almost 40% required admission for incision and drainage and parenteral antibiotic therapy.

Dr. Edwards referred to a case of an SSTI that started with a stubbed toe and progressed to a disseminated staphylococcal infection and endocarditis – illustrating that "even with an apparently limited minor staph infection, it always should go through our minds that this could be one that’s more serious."

The healthy teenage boy had stubbed his toe during a wrestling match, then developed fever, fatigue, and buttock and back pain, along with swelling and pain in the toe 4 days later. A fracture was diagnosed at an urgent care clinic, and he was sent home, but 9 days after the initial injury, symptoms persisted and he was admitted to the hospital for treatment with broad-spectrum antimicrobials, including clindamycin.

On the fourth day in the hospital, he had a fever of 104° F, "massive" facial swelling, bibasilar crackles, a systolic murmur, left lower quadrant pain, and a large parietal abscess seen on MRI. He had vegetations on the anterior leaflet of the mitral valve and multiple microemboli to the brain. The abscess was drained, and he had a vegetectomy, where vegetation was "peeled" off the leaflet, leaving the valve intact. After 6 weeks of intravenous antimicrobial treatment, he did well and was discharged.

"The lesson is that a seemingly innocuous SSTI always has the potential to disseminate," Dr. Edwards said, adding that while this is very uncommon, especially in a healthy child, "it’s always something to keep in mind."

Transmitted by direct contact, risk factors for community-acquired MRSA include chronic skin conditions, participation in sports teams that involve close contact with other players, and a history of such infections in family members, she noted.

In infants, MRSA infection also should be included in the differential diagnosis of ophthalmia neonatorum, Dr. Edwards said. She described the case of a healthy term 4-day-old baby who presented with eye swelling and purulent discharge, but no other systemic findings. The mother’s pregnancy had been uncomplicated; maternal tests were negative for group B streptococcus, chlamydia, and Neisseria gonorrhoea; and the baby had been discharged home by the second day after a normal vaginal birth.

The cause turned out to be community-acquired MRSA infection. "We need to consider this diagnosis with a higher index of suspicion in young infants now," she said, noting that the peak onset is at age 4-6 days, and it is characterized by a purulent discharge not likely to be a gonococcal infection. The baby was admitted to the hospital and treated with parenteral antimicrobial therapy.

Dr. Edwards disclosed that she is a consultant for and has received research funds from Novartis related to the development of a group B streptococcus vaccine.

[email protected]