Pediatric Movement Patterns and Mechanics

Pediatric Orthopedic Conditions

• Covered conditions include rotational changes, lower extremity issues, limb deficiencies/amputations, spinal conditions, and whole-body conditions.

• Musculoskeletal assessment includes history (birth, age of concern, family history, sleeping/sitting positions), postural screen, range of motion (ROM), strength, lower extremity alignment, and normal developmental changes/rotational profile.

Rotational Changes

• Rotational profile, in-toeing/out-toeing, metatarsus adductus, and knee alignment are examined.

• Differential diagnoses for in-toeing include metatarsus adductus, internal tibial torsion, internal hip rotation, contracture, and excessive femoral anteversion. In-toeing may be worsened by childhood positions like reverse tailor or W-sitting, and prone with internal rotation.

• Differential diagnoses for out-toeing include calcaneovarus, external tibial torsion, contracture of external rotators. Out-toeing may be worsened by prone sleeping or wide diapers/walkers.

• Rotational profile assessment includes foot progression angle, examination in prone position, thigh foot angle, medial/lateral rotation, and forefoot adductus.

Thigh-Foot Axis

• Measuring tibial torsion involves examining the long axis of the foot versus the long axis of the thigh (internal (-) or external (+)).

• Treatment is needed if natural resolution doesn't occur. Treatment options include tibial transformers, Dennis Browne bar, or a derotation strap.

• Infants typically have internal tibial torsion (-30 to +20), with spontaneous de-rotation as they learn to walk.

Metatarsus Adductus

• Characterized by adduction of the forefoot relative to the hindfoot (kidney-shaped foot).

• Associated with intrauterine positioning.

• Mild cases resolve with conservative care.

• Moderate cases might require serial casting, BeBax bootie.

• Severe cases require orthotic referral and possible casting, bracing, or surgery.

Calcaneovalgus

• Forefoot is curved laterally.
• Full or excessive dorsiflexion ROM is present.
• Typically resolves naturally, but orthotics might be used.
• Possible diagnosis of vertical talus, requiring X-ray.

Developmental Displasia of the Hip (DDH)

• Incidence is approximately 1 in 1000 live births.
• Common in Caucasians, less common in African Americans.
• 63% of cases are unilateral.
• Classification includes: normal, subluxatable, dislocatable, subluxed, dislocated.
• Risk factors: common with breech position in the third trimester and in smaller intrauterine spaces.
• Physiological factors include hormone influence in females (estrogen and relaxin).
• Environmental factors include swaddling, positioning, and carrying.
• Evaluation includes examination of hip ROM, asymmetry of thigh/gluteal folds, apparent shortening of femur/uneven knees (Galeazzi sign), and "clicks." Imaging with ultrasound at 6 weeks (repeat at 4 weeks if positive), X-ray at 4 months. Ortolani and Barlow maneuvers are used.
• Intervention in infants utilizes Pavlik Harness. Older children may require closed reduction and abduction orthoses or surgical interventions, including open reduction with spica cast.

Leg Length Discrepancies

• Lengthening the shorter leg may be considered in surgical interventions.
• Factors to consider are soft tissue mobility and stability of joints.
• Physeal distraction (Ilizarov method) involves 1mm per day correction, with ½ mm 4 times per day.

Club Foot (Talipes Equinovarus)

• Occurs in approximately 1 in 1000 live births, and persists over the child's lifespan.
• Hypoplastic muscles are present.
• Positional/limited intrauterine space can be a contributing cause.
• Associated with other disorders, such as spina bifida and arthrogryposis.
• Treatment typically involves Ponsetti Method (serial casting). Goals include correct deformity for weight bearing and normalized function of the foot. Surgical intervention is usually utilized at about 6 months of age.

Legg-Calve-Perthes Disease (LCPD)

• Avascular necrosis of the femoral head.
• More common in males.
• Family history, blood clotting disorders, HIV, small active children, and exposure to secondhand smoke are risk factors.
• Spontaneous resolution is possible over 1–3 years. Early diagnosis is more favorable.
• Common presentation is limp (antalgic early), Trandelenberg gait, limited abduction, and internal rotation.
• X-ray shows subchondral fracture and femoral head collapse.
• Intervention options include observation, casting, and derotational osteotomy.

Slipped Capital Femoral Epiphysis (SCFE)

• Most common hip condition among adolescents.
• Higher incidence in boys (2-3 times more than girls).
• Possible risk factors are obesity, slow skeletal maturity and growth plate weakness.
• Graded I, II, or III based on femoral head displacement.
• The presentation includes pain in groin, medial thigh, and medial knee.
• Treatment usually includes pinning surgery, followed by non-weight bearing. Untreated cases may lead to avascular necrosis, chondrolysis, and osteoarthritis.

Blount's Disease (Tibia Vara)

• A growth disorder of the medial aspect of the proximal tibia.
• X-ray shows thickening of the medial tibial cortex and breaking of the medial metaphysis.
• Classified into three types based on onset (infantile, juvenile, and adolescent).
• Children often have bowed legs and a lateral thrust of the knee during stance.
• Treatment includes orthotics (KAFO, Blount's brace) for cases among younger children but is often more advanced reconstruction (surgical intervention).

Limb Deficiencies and Amputations

• These may be congenital or acquired.
• Causes include spontaneous mutations, trauma, medical issues such as bone diseases.
• Treatment is often based on surgical revision or replantation, depending on the site/type of amputation.

Spinal Conditions

• Congenital scoliosis, neuromuscular scoliosis, and idiopathic scoliosis are examined.
• Evaluation typically includes assessing spinal axis deviation and screening for shoulder/pelvic symmetries (forward bend test, scoliometer) and radiology.
• Quantification assesses components like Risser sign (skeletal maturity) and Cobb angle (curvature severity). Assessing curves for structural or non-structural features.

Other Orthopedic Conditions

• Arthrogryposis Multiplex Congenita (AMC) is a nonprogressive condition present at birth.
• Osteogenesis Imperfecta (OI) is a connective tissue disorder, resulting in a multitude of presentations (bowed long bones, fractures due to minimal trauma).
• Treatment is often a balance between conservative means, and surgical intervention if needed. Specialized physical therapy is necessary for long-term management and care.

This quiz explores important concepts in pediatric movement patterns, including asymmetrical rotation and the foot progression angle in children. Learn about the characteristics of anteversion of the femur and how external rotation contractures resolve. Test your knowledge on these critical aspects of children's movement mechanics.