Pediatric Orthopedic Conditions 2024 PDF

Pediatric Orthopedic Conditions PT 832 Pediatric Diagnosis and Management 2024 Ellen M. Godwin PT, PhD Outline - Pathology and Interventions for: Rotational Changes Issues effecting the lower extremity Limb deficiencies and amputations Spinal conditions Conditions effecti...

Pediatric Orthopedic Conditions PT 832 Pediatric Diagnosis and Management 2024 Ellen M. Godwin PT, PhD Outline - Pathology and Interventions for: Rotational Changes Issues effecting the lower extremity Limb deficiencies and amputations Spinal conditions Conditions effecting the whole body Musculoskeletal Assessment History Birth history Age when concerns were noted Family history Sleeping and sitting positions Postural Screen ROM Strength Lower Extremity Alignment Normal Developmental Changes Rotational Profile Rotational Changes: Rotational Profile, In-toeing Out toeing, Rotational Profile, Metatarsus Adductus Knee Alignment Foot progression angle, Hip rotation, Thigh/Foot Axis, Metatarsus adductus, Calcaneouvalgus, Knee Alignment  In-Toeing Differential dx: Metatarsus adductus Internal tibial torsion Internal hip rotation Can be from contracture Can be from excessive femoral anteversion Maybe worsened by childhood positions Reverse tailor or w-sitting Prone with internal rotation Dx Out-Toeing Foot: Calcaneovarus Tibia: External tibial torsion Hip: Contracture of external rotators May be worsened with prone sleeping or wide diapers pad and walkers Stahlei, LT. Pediatric Orthopedic Secrets 2nd edition. Rotational Profile Foot Progression Angle Degree of foot turn in relation to direction of walking (observe, paint on feet) based on the average number of steps (-) = intoeing (+) = out-toing 0 to – 10 mild intoeing, -20 to -30 moderate, more than -30 severe This includes all rotational segments Hip version, tibial torsion, forefoot position THUS cannot differentiate location of rotation IR / ER arc of rotation of hip Child in prone, knees flexed to 90o move both legs simultaneously Upper range of normal IR is 70o girls 60o boys, Normal arc of motion is 90o. Asymmetrical rotation is indication for further investigation of possible hip pathology Typical Progression: Foot Progression Angle Out-toeing which decreases over time Hip Rotation: Anteversion/Retroversion Measure in prone with neutral hip extension “Version” is the relationship between femoral neck and shaft Anteversion: Head of the femur is directed anteriorly Internal rotation In-toeing Retroversion: Head of the femur is directed posteriorly External rotation Out-toeing Typical Progression: Hip Rotation Infants: Anteversion + ER contractures (appears to be out-toeing) ER contractures resolve by 5-6 years and anteversion becomes more apparent Total Hip Rotation (ER + IR) Up to age 2: 120 Thereafter: 95-110 Rotational Profile Thigh foot angle Measures tibial rotation Estimate angle by comparing the axis of foot with axis of the thigh TFA rotates lateral with increasing age (-) or medial rotation normal in infants (-) if foot is medial to the thigh = medial tibial torsion Upper limit of (+) TFA = 30o If > = lateral tibial torsion Fore foot adductus Best observed in prone. Lateral border of foot should be straight, convex = metatarsus adductus Thigh-Foot Axis Measure of tibial torsion Long axis of foot vs. long axis of thigh Internal (-) External (+) Treatment required if natural resolution does not happen Tibial Transformers Dennis Browne Bar Derotation Strap Tibial Transformers For in-toeing due to internal tibial torsion Allow for unilateral correction Typical Progression: Thigh Foot Axis Infants: Internal (-30 to +20) Spontaneous de-rotation with growth and onset of walking  Normal heel bisector intersects between 2nd and 3rd toe Normal is on the right Metatarsus Adductus Characterized by adduction of the forefoot as related to the hind foot (kidney shaped foot) Related to intrauterine positioning Mild, flexible, full correction to neutral and beyond Moderate, correction only to neutral Mild and moderate usually resolve or use conservative management, serial casting, BeBax bootie Severe AKA metarsus varus, no correction usually requires referral to ortho and possible casting, bracing or surgery Calcaneovalgus Position Forefoot: curved laterally Full or excessive dorsiflexion ROM Treatment: none, resolves naturally Orthotics, UCBL, SMO Differential: Vertical talus foot is usually less mobile, X-Ray needed  The Lower Extremity Developmental Displasia of the Hip, Club Foot, Legg Calve Perthe’s Disease, Slipped Capital Femoral Epiphysis, Blount’s Disease, Leg Length Discrepancies Developmental Displasia of the Hip (DDH)  Developmental Dysplasia of the Hip Classification Criteria AKA Congenital Hip Disclocation General “looseness” or “instability” Normal: No instability of hip joint of the hip joint Wide range of severity Subluxatable: Femoral head within the acetabulum but can be partially displaced out Overall incidence 1 in 1000 live from under the acetabulum births Caucasian Race most common Dislocatable: Femoral head within the Rarely seen in African Americans acetabulum but can be fully dislocated using the Barlow maneuver May –be 10 x greater in Native Americans Subluxed: Femoral head rests partially 4 X in female than male out of the acetabulum but can be reduced 63% unilateral Dislocated: Femoral head is completely out of the acetabulum https://www.ncbi.nlm.nih.gov/books/NBK563157/accessed Developmental Dysplasia of the Hip: Risk Factors Mechanical Breech position in 3rd trimester: Most significant risk factor Small intrauterine space Intrauterine position Physiologic Hormones such as Estrogen and Relaxin effecting the female fetus Incidence 4 X greater in female than male Environmental Swaddling Positioning Carrying Developmental Dysplasia of the Hip: Evaluation Hip ROM: Limited abduction Asymmetry of thigh or gluteal folds Apparent shortening of femur/uneven knees (“Galeazzi Sign”) Hip “clicks” are usually insignificant Imaging Ultrasound: at 6 weeks ( repeat in 4 weeks in positive) X-ray at 4 months Ortolani and Barlow maneuvers The sensitivity of these maneuvers with experienced hands ranges from 87% to 97 %, and the specificity varies from 98% to 99 % Ortolani Maneuver Ortolani Maneuver Relocates the hip into the acetabulu m Barlow Test Barlow Test dislocates the hip over the posterior rim Developmental Dysplasia of the Hip: Intervention Goal: Relocate and preserve joint shape Infants (18 months: Open reduction and spica cast 18-8 years Surgical interventions may be required. Without Intervention AVN Femoral nerve palsy Erosion of the acetabular rim Functional Disability Hip Pain Accelerated osteoarthritis The Pavlik harness is set by the orthopedist or orthotist to hold hip in the “safe zone” Developmental dysplasia of the Hip Role of PT Prognosis Help in identification Approximately 90% of Educate parent neonatal hips with instability or mild Facilitate development dysplasia resolve while child is in spontaneously with orthoses/casts normal functional and Develop ROM and radiographic outcomes strength when out of A 95% reduction is orthoses achieved with the Pavlik Facilitation of Gait harness Leg Length Discrepancies: Surgical Intervention Lengthening the Shorter Leg Factors to consider: Soft tissue mobility Stability of joints above and below Physeal Distraction – the Illizarov Method Can also correct rotational deformities 1mm per day, ¼ mm 4 times per day Active participation in PT while device is in place Pain can be significant, extended Stopping Growth in the Longer Leg “Club Foot” Talipes Equinovarus: Examination 1 in 1000 live births Hypoplastic muscles Which persists over the lifespan Position Ankle: Plantarflexion Forefoot: Adduction + Pronation (Medially curved) Hindfoot: Varus Calcaneous: Small Talar Head: Small and flattened Cause – largely unclear Positional/Limited intrauterine space Associated with other disorders Spina Bifida and arthrogryposis Club Foot = Talpies EquinoVarus Goals of treatment to restore alignment, correct deformity to provide a mobile foot for normal function and weight bearing Treatment begins immediately with casting or splinting Ponsetti Method highly recommended with excellent results At times splinting is preferred over casting for removal of splint for exercise and massage to help keep foot mobility If mild Bebax bootie Surgical correction usually performed at about 6 mo. of age Goal is to repair the foot to prepare for standing and ambulation Usually require bracing / splinting after surgery to maintain correction Many children have residual weakness that can interfere with higher level gross motor skills and sports “Club Foot” Talipes Equinovarus: Intervention Ponseti Method: Serial Casting Talonavicular joint reduction Percutaneous Achilles tendon lengthening Goal: Mobile foot, restore alignment, allow for weight bearing and ambulation Serial Casting with the Ponsetti Method: 5 weeks Week 1 Week 2 Week 3 Week 4 Week 5 Legg Calve Perthes Disease (LCPD) AVN of the ossific nucleus of the femoral head – medial circumflex artery Unknown cause More common in males Family History Blood clotting disorder HIV Small, active children 2nd hand smoke Lower SES Spontaneous resolution over 1-3 years Children diagnosed girls (5 x more in boys) Can develop between 3 and 13 years most commonly between 5 and 7 Progressive destruction of the femoral head most likely due to avascular necrosis. Presents with pain in groin, medial thigh or medial knee and limp, limited hip motion, in abduction and IR Rx with abduction braces or casts, PT and surgery PT to focus on strength, gait training with brace, ROM into abduction, extension, IR Legg Calve Perthes Disease (LCPD): Evaluation & Intervention Evaluation Limp (antalgic early) Trandelenberg gait (later) Limited abduction, internal rotation X-Ray: Subchondral fracture, femoral head collapse Pain: Groin, medial thigh, medial knee Intervention: WIDE RANGE – observation, casting, derotational osteotomy Legg-Calve Perthes Disease Scottish-Rite Orthosis Tecklin 5th Ed LCPD: non-operative Tx recommendations by NIH; Indicated for children with bone age less than 6 Activity restriction and protective weight-bearing are recommended until ossification is complete. The patient may still take part in physical therapy Literature does not support the use of orthotics, braces, or casts NSAIDs can be prescribed for comfort Referral to an experienced pediatric orthopedist is recommended Good outcomes reported in up https://www.ncbi.nlm.nih.gov/books/ to 60% of patients NBK513230/ Slipped Capital Femoral Epiphysis SCFE Most common hip pathology in Risk factors Include adolescents Incidence 2-11 per 100,000 Boys 2-3 more times than girls. Obesity African Americans and pacific islanders more frequently affected African American Male May be related to obesity, slow skeletal maturity, weakness of Family History growth plate Endocrine / Hormonal Occurs in relation to puberty hormonal changes may cause disorders weakening of growth plates Graded I, II, III based on displacement of femoral head Previous SCFE Slipped Capital Femoral Epiphysis SCFE  Slipped Capital Femoral Ephiphysis (SCFE) Types Acute: Significant trauma Acute on Chronic: Chronic slip, trauma makes it worse Chronic: Most common type Stable Child can still walk. limp that comes and goes. worse with activity and gets better with rest. can present with pain or stiffness in the hip, groin or knee. Unstable Child will not be able to put weight on the affected leg. Acute onset more painful Slipped Capital Femoral Ephiphysis (SCFE): Evaluation & Intervention Presentation Pain: Groin, medial thigh, medial knee Hip held in ER Hip moves passively into ER with hip flexion Intervention Pinning surgery Non weight bearing If untreated AVN Chondrolysis Osteoarthritis Slipped Capital Femoral Epiphysis Usually Rx with pinning surgery (in situ pin or screw placement PT to include gait training (NWB) with assistive device (axillary crutches) 1st PT encounter is often for pre-op NWB gait training NWB status will continue short term post-op Post recovery: strengthening, stretching, gait training, neuromuscular reeducation, balance, higher level gross motor skills, return to sports Blount’s Disease: Tibia Vara Is a growth disorder of the medial aspect of the proximal tibia including: the epiphysis, epiphyseal plate, and metaphysis X-ray findings include Thickening of medial tibial cortex Breaking of medial metaphysis Classified into 3 types depending on age of onset: Infantile: Less than 3 years of age Juvenile: 4-10 years Adolescent: 11 years or older Blount’ s Disease Blount’s Disease: Tibia Vara Child presents with bow- legged stance, which must be distinguished from normal physiologic varum Toddlers are often obese, early walkers and Often presents with lateral thrust of the knee in stance Need to rule out other disorders such as rickets, vitamin D deficiency or previous fracture Blount’s Disease: Tibia Vara Treatment can include: Orthotics and surgical intervention Orthotics: < 2-3 years of age, KAFO for 23 hours of 24 in a day with progressive correction of brace by orthotist, Blount’s Brace PT will include gait training with orthosis, strengthening, development of gross motor and play skills Surgery: More common after age 4, tibial osteotomies and more advanced reconstruction procedures (external fixators) PT will include post-op recovery, ambulation training with fixator if allowed) gait training, strengthening, development of gross motor and play skills Limb Length Discrepency Cused by shortening or over growth of one or more bones of the leg Can be congenital (hemihypertrophy), or due to infection or fractures of pelvis, neuromuscluar disorders (CP), tumors and trauma Accurate measurement: Scanogram, use of block prefered as compared to tape measure Less than 2 cm not treated Surgery: Epiphysidesis = stop longer leg from growing Limb Lengthening techniques – Ilizarov or Wagner techniques Leg Length Discrepancies: Evaluation & Intervention Evaluation and Quantification Level pelvis with blocks under foot, measure blocks Tape measure ASIS to: medial malleolus, lateral mallelous, heel pad Umbilicus to heel pad Radiologic measurements - scannogram Intervention Conservative: Shoe lift Surgical: Mosly graph predicts growth, can help time Stop growth in the longer leg by damaging the growth plate Lengthen the shorter leg Scanogram Radioopaque measuring rule Three exposures Helps objectify bone measures  Wagner Method Tecklin Eds. 2 Ilizarov Method Tecklin Eds. 2 & 3 Limb Deficiencies and Amputations Congenital, Acquired Classification of errors of morphological development Spranger’s Classification Malformation: incomplete in Deformation: developed in full, development but the wrong shape Longitudinal deficiencies Rotational changes, LCPD, SCFE Cleft palate, atrial septal Can be corrected with bracing, defect taping, splinting, casting Disruption: cessation of Dysplasia: developed in full, but atypical differentiation development due to outside throughout force Effects a whole system Transverse deficiencies Osteogenesis imperfecta, Amniotic band syndrome arthrogryposis Congenital Limb Deficiencies Classified as Longitudinal or transverse Longitudinal = deficits along the long axis of the bone Absence of radius with resultant radial club hand Transverse = across long axis of bone Proximal femoral focal deficiency at varying levels Managed with surgical intervention and prosthetics Surgery can include tendon transfers, realignment, osteotomies, amputations, fusions, limb lengthenings Congenital Limb Deficiencies Most are from spontaneous mutations 20-30% of children effected have more than 1 limb involved Most transverse deficiencies are unilateral Tecklin (5th ed.) uses Radial club hand and Proximal femoral focal deficiencies as examples Radial Club Hand Congenital absence of the radius with resultant malposition of the hand………..Will require surgical correction Soon after birth splinting or serial casting is performed to stretch shortened tissues. PT includes stretching including elbow flexors Surgery (centralization of the hand) usually performed 6 months to 1 year. Goal is a stable wrist centralized on the distal ulna while maintaining function Splinting and PT continues post op Centralization of the hand may not be appropriate for older children and adolecents if the have accommodated to their hand position Transverse Deficiencies Proximal Femoral Focal Deficiency Congenital absence or hypoplasia of the proximal femur. Surgical intervention Acetabulum, femoral head, addresses unstable hip patella, tibia and fibula and leg length may be involved. discrepancies Severity graded A – D Often includes multiple Femoral head presence, procedures and shape Acetabulum presence, shape amputations Femur length Children with bilateral Joint presence, articulation involvement often do not undergo surgery Acquired Amputations 70-85% due to trauma 15-30% due to disease Ewing’s Sarcoma Osteosarcoma Acquired Amputations: Intervention Surgical Treatment Further amputation to revise residual limb Limb replantation Upper more successful than lower extremity Children achieve better functional outcomes than adults Phantom Sensations Increasing prevalence with age Not always pain Spinal Conditions Congenital Scoliosis, Neuromuscular Scoliosis, Idiopathic Scoliosis and Kyphosis Scoliosis: Evaluation Deviation of spinal axis Screening Shoulder and pelvic asymmetries Forward bend test Scoliometer Radiography Screening Assess asymmetries, in standing view from posterior, anterior, side Shoulder levels, Inferior angle of scapula Elbows when bent at 90 degrees Pelvic crests Forward bend test, view from posterior If you suspect a leg length discrepancy perform the above in sitting as well as standing Scoliosis: Evaluation Quantification Risser Sign Skeletal Maturity Graded 0-5 Based on ossification of iliac crest Cobb Angle Severity of Curvature End vertebrae are cephalic and caudal with most tilt Intersection of lines perpendicular to end vertebrae >10o is diagnostic Scoliosis: Evaluation Descriptors Direction of curve: Convex side Magnitude: with Cobb Angle Flexibility: Structural Cannot be corrected Vertebrae rotate towards the convex side  Rib hump Non-Structural Corrects with sidebend towards the convex side Usually non-progressive Bending x-rays help determine of structural or not Types of Scoliosis Congenital Neuromuscular Idiopathic Congenital Scoliosis Caused by anomalous vertebral development Error in segmentation Error in formation May have a rotational component Kyphoscoliosis Lordoscoliosis Many become stable and do not progress Congenital Scoliosis – Failure in Formation May (A, B, E) or may not (C, D) cause scoliosis Always includes one or more “mis-shapen” vertebrae B C D E A Congenital Scoliosis – Failure in Segmentation En Bloc (A) Typically does not cause scoliosis Unilateral bar without growth plate (B) A B Bar opposite scoliotic side Limited growth Neuromuscular Scoliosis Long, C type curves, may become S curves with compensation Develop at a young age Tend to be progressive Most associated with SCI in young children, SMA or MD Treatment Orthotics (TLSO) Custom seating Surgery Neuromuscular Scoliosis - Severe Ben: Pre-op and post-op Ben: Pre-op and post-op Idiopathic Scoliosis Lateral curvature of unknown cause Most common form in children Infantile, Juvenile or Adolescent Adolescent Idiopathic Scoliosis (AIS) 80% of all idiopathic scoliosis cases 3.6:1 Female: Male ratio 5:1 with curves > 20o 1.4:1 with curves < 10o Performance Decreased high level balance activities Decreased lung capacity on the convex side, increased on the concave Adolescent Idiopathic Scoliosis Progression is defined as a change of > 5o on two consecutive exams Increased risk for progression Younger age/lower Risser sign at dx Double curve patterns  Curvature Females Adolescent Idiopathic Scoliosis: Intervention, Non-Surgical Candidates Idiopathic curves 20o Exercise goals Maintain or improve trunk and pelvic strength Improve lateral flexion and trunk shift ROM Stretching: Pectorals and lower extremities Increase lung capacity and volume Exercise alone has not been shown to prevent progression, even with high patient compliance  Schroth Method The Schroth Method is a nonsurgical option for scoliosis treatment. It uses exercises customized for each patient to return the curved spine to a more natural position. The goal of Schroth exercises is to de-rotate, elongate and stabilize the spine in a three- dimensional plane. This is achieved through physical therapy that focuses on: Restoring muscular symmetry and alignment of posture Breathing into the concave side of the body Teaching postural awareness This approach to scoliosis treatment was developed by Katharina Schroth and further popularized by her daughter Christa. Born in Germany in late 1800s, Katharina Schroth had scoliosis that was unsuccessfully treated with bracing. She developed her own breathing technique and exercises to manage her scoliosis.  Schroth Method Muscular Symmetry: The changes in the curvature of your spine also affect the muscles in your back. On one side of the back the muscles may weaken and waste away. On the other side, the muscles may be overworked and prominent. Schroth exercises are designed to address both problems, aiming to achieve muscular symmetry. Rotational Angular Breathing: Breathing is an important part of the Schroth Method. The method uses a special breathing technique called rotational angular breathing. The idea is to rotate the spine with breathing to help reshape the rib cage and surrounding soft tissue. Awareness of Your Posture: Katharina Schroth relied heavily on mirrors in her original practice. Mirrors helped her patients develop awareness of their posture. Being aware of the position of your spine is the first step to correcting it. Postural awareness is especially important when it comes to activities of daily living. If you have scoliosis, you will always need to be mindful of the positions that may make it worse. Schroth Method Most patients see visible improvement in the degree of their spine curvature after completing a Schroth program. The length of the program may vary, but typically includes between five and 20 sessions sessions typically last from 45 minutes to an hour. Schroth-specific breathing complements the bracing as children are taught to breathe within their custom brace. Adolescent Idiopathic Scoliosis: Intervention, Orthotic Management Indications: Skeletally immature (Risser Sign 0-2) Curve from 25-45o Impact of orthotic management decreases as size of curve increases. Boston Milwaukee Charleston UNYQ Align Brace Prototype 3D printed  Permanent collection at Cooper Lightweight, low profile and breathable Hewitt As effective as rigid TLSO in a pilot  Available Summer 2017 study Bluetooth communication of wear  @unyqalignscoliosis schedule Adolescent Idiopathic Scoliosis: Intervention, Orthotic Management Continues until curve is no longer controlled or skeletal maturity is reached Exercise should still be performed while wearing the brace 12 months to wean from brace May progress a small amount after brace is discontinued Treatment is “successful” if curve is no more than 5o different from when brace was discontinued Adolescent Idiopathic Scoliosis: Intervention, Surgical For curves >40o Goals of surgical intervention Halt progression Prevent complications Achieve maximal correction Balanced trunk Solid fusion Posterior approach is most common More advanced curves may include both anterior and posterior approach Adolescent Idiopathic Scoliosis: Intervention, Surgical Bone graft packed into disk spaces and facet joints Metal stabilization “rods” Harrington Does not allow sagittal plane correction Rarely used Flattened lumbar lordosis Luque Prevents loss of lumbar lordosis Risk of neurological damage Cotrel-Dubousset Adolescent Idiopathic Scoliosis: Intervention, Post-Op Care Orthosis for 9-12 months – until fusion is “solid” on radiographs Average hospital stay: 5-7 days Role of PT Precautions lifted gradually over 1 year by MD No trunk rotation No lifting >5 lbs. Donning/doffing prosthesis – to be done in bed Encourage functional mobility, isometrics Other Orthopedic Conditions Arthrogryposis Multiplex Congenita, Osteogenesis Imperfecta Arthrogryposis Multiplex Congenita (AMC) Present at birth, non-progressive Unknown etiology Hallmarks of the disease Joint contractures in 2 or more body areas Lack of muscle development/weakness Featureless, cylindrical extremities Fibrosis Decreased DTRs Most children effected are bright and motivated Majority of cases are not genetically based Arthrogryposis Multiplex Congenita (AMC): Presentation: Flexed and dislocated hips Abducted and externally rotated hips Extended knees Flexed knees Equinovarus Equinovarus Internally rotated shoulders Internally rotated shoulders Flexed elbows Extended elbows Flexed and ulnarly deviated Flexed and ulnarly deviated wrists wrists Arthrogryposis Multiplex Congenita (AMC): Intervention Well timed surgical intervention Club foot repair when standing Debate over surgically reducing dislocated hips Knee flexion contracture when ambulating Shoulders are rarely addressed surgically Arthrogryposis Multiplex Congenita (AMC): Intervention Physical Therapy Positioning Splinting Stretching Normalizing development Balance Skills With aging Pain management Wheelchair training Osteogenesis Imperfecta Inherited connective tissue disorder – many different mutations Wide variability in manifestations Bowing of long bones Spinal deformities Recurrent fractures with minimal trauma May also exhibit Blue sclera Dental deformities Hearing loss Growth deficiency Easy bruising Excessive sweating O I : Application of the ICF Model Pathophysiology Cellular level abnormality of connective tissue Multiple fractures resulting in Impairments malalignment short stature Slow labored gait limits ability to keep up with peers Activity Limitations Not able to attend day care, unable to go out to play at recess Participation Restrictions Parental fears, teacher fears, unable to access environment due to short stature ( sink heights, light switches) Environmental Factors Osteogenesis Imperfecta: Intervention Goal: Prevent deformities Limit immobilization Fracture Scoliosis usually not managed with brace Internal fixation with IM rods and/or spinal fusion Disuse Immobilizati Fracture risk decreases by Osteoporosi s on puberty in most patients Osteogenesis Imperfecta: Intervention Strengthening ( gentle – functional ) Environmental adaptation Caregiver education Encouraging independence and social integration