Paediatric Orthopaedic Conditions and Scoliosis PDF 2023

PHT2012 Orthopaedics Traumatology and Rheumatology Paediatric Orthopaedic Conditions and Scoliosis Dr. Rufina Lau 2023 Content Paediatric MSK Development MSK Examination Dysplasia/ Deformity Fractures 2 Scoliosis Paediatrics • Medical care of infants, children, adolescents and young adul...

PHT2012 Orthopaedics Traumatology and Rheumatology Paediatric Orthopaedic Conditions and Scoliosis Dr. Rufina Lau 2023 Content Paediatric MSK Development MSK Examination Dysplasia/ Deformity Fractures 2 Scoliosis Paediatrics • Medical care of infants, children, adolescents and young adults • Not miniature of adults • Growth and development – immature MSK system • Susceptible to abnormal forces and stresses 3 Common Paediatric Bone & Joint Disorders • Congenital and hereditary disorders • Growth-related disorders • Skeletal trauma - fractures • Inflammatory and infectious disorders • Cancer – osteosarcoma, Ewing’s sacroma 4 Musculoskeletal Development • Vulnerable to external influence at various stages • Dependent on the interplay of multiple factors including hormones, nutrition and mechanical forces • Prenatal: susceptible to morphologic abnormalities due to exposure to pharmacologic agents, position constraints and abnormal mechanical forces e.g. Torticollis and clubfeet may result from position constraints late in the pregnancy • Postnatal: fast rate of bone remodelling at 50% annually vs adult 5% annually 5 Musculoskeletal Development • Bone growth in • Length: endochondral ossification (also known as epiphyseal growth) • Diameter: appositional growth by compressive force • Increase weight bearing results in increased thickness and density of the shaft of long bones 6 Musculoskeletal Examination • History • Obtained from caregiver and the child • For juvenile and adolescents, questions regarding sexual maturation e.g. Tanner staging for male and females and onset of menarche to provide information related to bone age and development • Postural screen & observation • Posture, play, spontaneous movement and activity • Note asymmetries and difficulty with age-appropriate skills • ROM, muscle length and strength measurements 7 • Muscle tone, sensation and developmental skills • Standardized testing both criterion and norm-reference tools for evaluating developmental skills Musculoskeletal Examination • Limb alignment (rotational and angular) • Foot progression angle (A) • Hip rotation (B, lateral rotation; C medial rotation) • Thigh-foot angle (D) • Transmalleolar axis (E) • Configuration of the foot • Varus/ valgus posture 8 Leg Length Discrepancy • Shortening or overgrowth of one or more bones of the leg • Caused by • • • • • • Congenital conditions such as limb deficiencies or hemihypertrophy Infections Fractures that involve the physis (often asymmetric and also cause angular deformities) Neuromuscular disorders Tumours Trauma results in overgrowth and disease processes • Significant LLD >2cm can lead to cosmetic and functional issues • Less efficient gait and postural compensations of the leg, pelvis, and spine often develop • Postural compensations may not lead to a structural deformity • Functional compensatory mechanisms include toe walking or foot and ankle supination on the short side or vaulting, circumduction, persistent knee 9 flexion, or foot and ankle pronation on the longer side Management of LLD • Difference of 1 – 2 cm: A lift inside the shoe or a custom-fabricated external heel-sole • Greater than 2 – 2.5cm: • may suggest surgical treatment options • guided growth and growth restriction of the longer limb or lengthening of the shorter limb, or combined approaches • Devices: external fixators (unilateral or circular) and internal medullary lengtheners 10 Adapted from Hosny, 2020 Physiotherapy Management of LLD • Physiotherapy intensity varies during the latency, distraction, consolidation (fixator removal, healing and rehabilitation phase) • Immediately after surgery: gait-training activities and promoting early weight bearing if permitted (to facilitate bone growth), pin care to prevent infection (wrapped with gauze to provide soft tissue compression for reducing pain), stretching 11 Physiotherapy Management of LLD Distraction phase: • Frequent and focused on ROM (esp knee and ankle) and stretching along with corresponding strengthening activity • Maintaining the same ROM measurement over the duration of the distraction phase actually represents increased muscle and soft tissue length i.e. considered as successful ROM intervention progress • Splinting • Strengthening exercises (+ electrical stimulation and hydrotherapy) • Tissue mobilization 12 Physiotherapy Management of LLD Consolidation phase: • Continue strengthening and tissue mobilization exercises • For children who have undergone internal lengthening, increasing weightbearing progression through gait training as well as other activities will be included in the PT program. • Once ossification has reached an appropriate level, a cast or controlled ankle motion (CAM) boot is placed following a tibial fixator removal, and a knee immobilizer is placed following a femoral fixator removal to protect the new bone during continued healing • HEP to promote continued allowable stretching and strengthening of nonimmobilized joints 13 Physiotherapy Management of LLD Rehabilitation phase: • May last up to 1 year • Aggressive stretching to achieve as much functional ROM as possible • Flex casting and dynamic splinting as a stretching adjunct to address knee flexion or extension and ankle plantar flexion contractures • ROM status often regresses, so PT should remain steadfast and utilize soft tissue mobilization techniques to maintain progress • Strengthening activities are progressed as muscles and soft tissue are further lengthened • Functional activities and gait normalization as bone healing progresses and muscle strength and ROM increase • Postural reactions and balance training as the body accommodates to the new limb length, limits of stability, base of support, and center of gravity 14 Legg–Calvé–Perthes Disease • Self-limiting disease of the hip initiated by avascular necrosis of femoral head • Caused by vascular abnormalities and dysfunction but precise cause of AVN unknown • Typically occurs between 3 – 13 years old • Affected more boys than girls (3-5:1) • Bilateral presentation is seen in 10-20% of children with the disease 15 Clinical Presentation of LCPD • Clinical presentation: • a limp and pain referred to the groin, thigh, or knee • Hip F, IR and Abd ROM limitations may develop • Hip flexion contracture & a Trendelenburg-type gait frequently observed • Muscle spasm of the hip adductors and iliopsoas • 4 defined stages • • • • 16 Necrosis (initial) Fragmentation Reossification Remodelling (healed) Adapted from https://perthesdisease.org/2016/09/08/getting-to-know-the-four-stages-of-perthes/ Management of LCPD • Aims: to relieve the symptoms of pain and muscle spasm, prevent or minimize femoral head deformity, contain the femoral head in the acetabulum while bone remodeling occurs, and restore ROM • Pain relief with anti-inflammatory medications and traction • Use of orthotic device such as a Petrie cast, Scottish-Rite orthosis, or A-Frame orthosis or surgical procedures such as a femoral or innominate osteotomy Petrie cast • Post-operative physiotherapy • restoration of hip ROM, muscular flexibility, and strength esp. hip extensors and abductors due to longterm immobility • gait training PWB → FWB 17 Scottish-Rite orthosis Torticollis • Latin word of “twisted neck” • Noted in the first 2-3/52 after birth • Unilateral shortening of sternocleidomastoid (SCM) muscle • a mass or fibrotic pseudotumor may be observed or palpable within the belly of the SCM muscle • Ipsilateral cervical SF towards and contralateral Rot away from the shortened SCM • May develop cranial and facial asymmetry cause by plagiocephaly (skull flattening) due to persistent asymmetric positioning of the head 18 Clinical Presentation of Torticollis 19 Clinical Groups of Torticollis • Aetiology unknown • Possible causative factors include intrauterine malposition and birth trauma • Occlusion of blood vessels with resultant anoxic injury to SCM may cause fibrotic changes • 3 clinical groups • Sternocleidomastoid tumour – definite mass or tumour is palpable within SCM muscle • Muscular torticollis – contracture of SCM muscle but no palpable mass • Positional torticollis – both contraction of SCM muscle and a palpable mass are absent but alteration in resting head position exists 20 Management of Tortillcolis • APTA Clinical Practice Guideline (2018) • Conservative management • Infants aged 12 months or under • Passive ROM and SCM stretching • Active cervical ROM exercise e.g. Rot to involved side • • • • • Visual tracking objects or respond to stimuli • Equilibrium and right reaction • Developmental play promoting UL weight bearing, weight shifting and reaching Encourage mid-position Tummy time Caregiver education Orthotic device e.g. Symmetry Through Active Remolding (STARband®) orthosis, the Dynamic Orthotic Cranioplasty system (DOC band®) • Injection of botulinum toxin in conjunction with physiotherapy • Surgical release of SCM muscle 21 Righting exercises Tummy time Clubfoot TEV • Aka congenital talipes equinovarus • Complex deformity • CAVE: cavus (midfoot, high arch), adductus (forefoot adduction), varus (hindfoot varus and pronation), equinus (ankle plantar flexion) • Incidence 1-3:1000 live births, 50% bilateral involvement, male: female – 2:1 • Causative factors • intrauterine positioning or neuromuscular impairment such asspina bifida, myelomeningocele or arthrogryposis (decreased or absent fetal movement lead to prolonged abnormal fetal positioning) • A defect in mesenchymal cells forming the template for cartilaginous model of the hindfoot structures (dysplasia) → pathologic deformities of bony and cartilaginous structures and overall smaller appearance to involved foot and lower leg • Genetic and chromosomal abnormality 22 Management of Clubfoot • Aims: • To restore alignment and correct the deformity • To provide a mobile foot for normal function and weight bearing • Physiotherapy for mild postural clubfoot • Passive mobilisation, splinting, strapping and active correction with facilitation • Ponseti treatment method • Corrective phase (Weekly for 4-8 weeks) : serial casting with manipulation to correct the forefoot adduction and pronation and hindfoot varus along with percutaneous Achilles tenotomy to correct equinus. • Maintenance phase (for 4-5 years): long-term brace use to maintenance correction 23 Clubfoot stretches Developmental Dysplasia of the Hip • Hip anomalies in infants and young children resulting from abnormal growth and development of the joint • Screening of all newborn for signs of hip instability • 90% dislocatable hips can be stabilised by 9 week of age • Aetiology likely multifactorial - malposition and mechanical factors in utero such as a small intrauterine space, hormone-induced ligamentous laxity, genetics, and cultural or environmental factors • Risk factors include breech position, female gender, first-born child and a positive family history of DDH • Higher incidence of DDH with other congenital deformities such as torticollis or metatarsus adductus 24 Clinical Presentation of DDH • Types: Subluxatable, dislocatable, subluxed, or dislocated • Clinical Presentation: • Ortolani test and Barlow maneouvers (reliable before 2 months of age) • Asymmetry of thigh, gluteal or labial folds, limitation of or asymmetric hip abduction ROM (due to adductor longus shortening), apparent unequal femoral lengths (Galeazzi sign) • Positive Trendelenburg sign with unilateral involvement or waddling gait/ hyperlordosis with bilateral involvement for older children • Imaging: US (radiography less preferred and usually for children > 6 months) 25 US Features of DDH Adapted from https://leodonnan.com.au/the-stable-but-dysplastic-hip/ US Anatomy of Congenital Hip Dysplasia 26 (Kang & Koo, 2017) Ortolani’s Test • To detect the presence of a dislocated hip • Procedures: • Hips and knees 90F • Thumbs on the medial side of the knee and index fingers over the greater trochanters • Abduct hip smoothly and gently to 90 degree • +ve sign: palpable sensation or click sound of the femoral head slipping into the acetabulum (indicates dislocated but reducible hip) • Restriction of hip abduction – irreducible hips 27 Barlow’s Test • To identify unstable hip that lies in the reduced position but can passively dislocated – dislocatable • Procedures • Examine one hip at a time • Hip flexed and thigh adducted while pushing posteriorly in line of the shaft of femur causing femoral head to dislocate posteriorly from acetabulum • Palpable dislocation when femoral head slip out of acetabulum 28 Demo of Ortolani’s & Barlow’s Tests Management of DDH • Aims: • To return the femoral head to its normal relationship within the acetabulum • To maintain the alignment until the abnormal changes reverse • <6 months old: • Use of orthosis e.g. Pavlik harness (23-24h/day) to maintain hips in a flexed and abducted position until hip is stable • Possible complications include avascular necrosis of femoral head, femoral nerve palsy and inferior dislocation • Regular monitoring, caregiver education (e.g. positioning to facilitate prone skill), proper fit/ donning and doffing of the harness • > 6 months old: • Abduction orthosis or Closed reduction under anesthesia with application hip spica cast • Surgical intervention for child older than 12 months • May require femoral osteotomy or acetabular osteotomy to aid in relocating the femoral head • Casting, regaining ROM, strengthening, gait training after operation 29 Anatomy of Paediatric Long Bone 1. Epiphysis: end of a long bone with associated joint cartilage 2. Physis (growth plate): hyaline cartilage plate to permits growth of solid bone after birth and before reaching maturity, translucent(dark) in X-ray 3. Metaphysis: wide area below physis, closest to the diaphysis/ shaft 4. Diaphysis: midshaft 30 Adapted from https://radiologykey.com/pediatric-skeletal-trauma-2/ Bone Healing in Children • Rapid healing rate • Strong and active periosteum which much more osteogenic • Fast bone remodelling and physeal plate growth • Spontaneous correction • Bone healing timeframe for fracture shaft of femour • • • • 31 At birth: 3 weeks 8 years old: 8 weeks 12 years old: 12 weeks 20 years old: 20 weeks Buckle/ Torus Fracture • Common in children between 5-10 years of age due to the elasticity of the bone • Incomplete fracture • Caused by compressive force • Broken at one side and buckled outward at cortex on the other without fully breaking • Usually involving distal radial or tibia metaphysis • Management: self-limiting, manipulation if angulation is severe, cast/ splint for rest/ immobilization 32 Radiographic features of Torus Fracture • Distinct fracture lines are not seen • Subtle deformity or buckle of the cortex • Angulation is the only diagnostic clue in some cases 33 Adapted from https://radiopaedia.org/articles/torus-fracture-1 Greenstick fracture • Usually seen in young children <10 years old • Incomplete unicortical fracture commonly at mid-diaphyseal region • Force to side of the bone • Broken at one side and bent at the other 34 Radiographic features of Greenstick Fracture • Usually mid-diaphyseal • Occur in tandem with angulation • Incomplete fracture, with cortical breach of only one side of the bone 35 Adapted from https://radiopaedia.org/articles/greenstick-fracture Epiphyseal Fracture • Common and up to 15% - 30% of fractures in children • Calcifying cartilage – weakest zone • Blood supply enter from epiphyseal surface • Loss of blood supply to epiphysis will result in necrosis and cessation of bone growth • Salter-Harris Classification Adapted from https://www.rch.org.au/fractureeducation/growth_plate_injuries/Physeal_growth_plate_injuries/ o Type I - S – straight across (incidence 6%) o Type II - A – above (75%) o Type III - L – lower or beLow (8%) o Type IV - T – two or through (10%) o Type V - ER – erasure of grow plate or cRush (1%) 36 o Type VI – avulsion: displacement of the perichondral ring (added by Rang, 1969) Type ? Challenges in Diagnosis & Treatment for Epiphyseal Fractures • Cooperation during examination • Radiation protection for children • X-ray appearance • Epiphysis may be mistaken as fracture line • Comparison between two limbs required • Reduction • • • • 37 Gentleness Best to reduce on the day of injury Method e.g. Type I & II managed mostly by casting Period e.g. Double the time for Type IV epiphyses fracture Complications of Paediatric Fractures • Similar to adult – malunion, nonunion, neurological complications • Physical plate injury may affect growth • Osteomyelitis tends to be more extensive • Joint stiffness is less common • Fat embolism, pulmonary embolism and accident necrosis are rarer • Less tolerant to major blood loss • Average blood volume ~75ml per kg body weight • 500ml blood loss in a 20 kg child vs 60kg adult? 38 PT Management for Paediatric Fractures • Early mobilisation • Prevent joint stiffness • Gait training • Prevent complications and deformities during bone growth 39 Scoliosis • A complex, three-dimensional structural deformity of the spine characterized by lateral curvature in the front plane, vertebral rotation in transverse plane and possible abnormal alignment in the sagittal plane • Classified based on • aetiology: congenital, neuromuscular, neural, iatrogenic, idiopathic (unknown origin, 80% of cases) etc • age of onset: infantile (0-2 years old), juvenile (3 – 9 years old), adolescent (10-17 years old) and adult (≥ 18 years old) • curve severity: low (up to 20˚), moderate (21˚-35˚), moderate to severe (36˚- 40˚), severe to very severe (41˚-55˚) and very severe (≥56˚) • curve type: cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, Lenke system, Rigo system 40 Schematic illustrations of the curve types of The Lenke Classification (Adapted from Lenke et al, 2001) 41 The Rigo Classification The three-curve scoliosis pattern described by The Rigo Classification using clinical and radiological criteria (Adapted from Rigo et al, 2010). 42 Right thoracic curve Left lumbar curve Double major curves Adolescent Idiopathic Scoliosis (AIS) • Complex three-dimensional spinal deformity • Predominantly occurs in females during peri-pubertal growth spurt • Prevalence • 1-4% globally (Cheng et al, 2015) • 4.7% with curve ≥10° in Hong Kong (Fong et al, 2015) • Girl-to-boy ratio of 2.2:1 for curves ≥10˚, 3.6:1 for curves ≥20˚, 5.5:1 ≥40˚ • Indefinite etiopathogenesis • Untreated or improperly treated AIS, the curve may deteriorate leading to functional disabilities and morbidities in the severe curves in adulthood 46 AIS: A Multifactorial Condition Genetic Skeletal growth Bone density and qualities 47 Body composition Hormonal & metabolic Biomechanics Central nervous system Respiratory system Environmental & lifestyle Abnormal Bone Density and Qualities in AIS Deranged bone qualities Lower areal BMD • Osteopenia which persists to early adulthood (Cheng et al, 2000 & • • 2006) • ↓ Cortical bone area & vBMD ↓ Trabecular number & separation (Yu et al, 2014 & 2016) ↓ Stiffness, failure load & apparent modulus (Cheuk et al, 2015) aBMD & cortical vBMD identified as prognostic factors for curve progression Normal 48 AIS Osteopenic AIS (Hung et al, 2005 & Yip et al, 2016) Abnormal body composition & muscle dysfunction in AIS • Lower skeletal mass, body fat mass and body mass index (BMI) associated with curve progression in AIS (Ramirez et al, 2013; Clark et al, 2014 & Tam et al, 2016) • Larger muscle volume (Jiang et al., 2016) and increase muscle activity at convex (Stetkarova et al., 2016) → secondary adaptation to ↑ load demand and related to curve progression 49 Genetic & Hormonal Factors in AIS Hormones related to muscle deficits & dysfunction Leptin Melatonin Ghrelin Calmoulin (Lowe et al, 2002;Qiu et al, 2007; Girardo et al, 2011; Zhong et al, 2013;Sales de Gauzy et al, 2015; Yu et al, 2018; Favero et al, 2019 &Liu et al, 2019) Gene loci related to muscle/ soft tissue LBX1 BNC2 Fibrillin and collagen genes (Londono et al, 2014; Ogura et al, 2016; Cheung et al, 2003 & Tang et al, 2021) Primary bone disease or primary soft tissue anomalies? (Tang et al, 2021) 50 Biomechanical Factors in AIS • Imbalance skeletal growth and soft tissue maturation altered mechanical loading exert to the spine • Upright bipedal posture with spinal curvatures predisposed an imbalance shearing forces in thoracic and lumbar regions (Smit, 2002 & Kouwenhoven et al, 2007) • Low bone density and low muscle mass reduced skeletal loading exerting to the spine (Mehlman et al, 1997 & Smit, 2020) 51 Screening and Diagnosis of AIS in Hong Kong • School screening programme • Uses Adam’s forward bending test (FBT), scoliometer measurement of angle of trunk rotation (ATR) to assess students in grade 5, 7 and 9 (mostly 10, 12 and 14 years of age) • ATR > 5˚ or obvious signs of trunk or shoulder asymmetry, further assessed by Moiré topography SRS Scoliosis Screening Exam 52 Adam’s Forward Bending Test • Useful in detecting rotational deformity • For initial screening of scoliosis is often done • Assess the angulation of rib hump during forward bending • Angle of trunk rotation (ATR) measured with a scoliometer 53 Moiré Topography • Useful in assessing rotational deformity • 3-D description of the shape of the back • Straight spine: Moiré shadow pattern is equal on both halves of the back • Structural scoliosis: asymmetry pattern (indicating rotational deformity) , the pattern differs more with increasing deformity 54 Cobb Method • Useful in measuring lateral deviation • Cobb angle is commonly measured in coronal plane (y-axis) by drawing a line that is parallel with the angle of the top border of the upper vertebra and the bottom of the lower vertebra involved in the curve • The angle formed by the intersection of these two lines is the Cobb angle 55 (Adapted from Cheng et al, 2015 & Lee et al, 2018) Management of AIS • • • • Close observation (Cobb angle <20˚) Bracing (Cobb angle >20˚) Physiotherapy Scoliosis- Specific Exercises (PSSE) Surgical intervention (Cobb angle >50˚) Treatment strategies based on remaining growth potential: • Radiological method (assess skeletal maturity or bone age): Risser sign, Sanders Classification System, Thumb Ossification Composite Index etc • Anthropometric parameters: change in body height, arm span • Biological milestones: status of puberty, onset of menarche (period) • Degree/ location of curvature • Gender 56 Bracing Treatment for AIS • For patient with immature skeleton and high risk of curve progression • Aims • to prevent curve progression reaching surgical threshold • To restore normal contours and alignment of the spine by means of external forces • Most common to have rigid bracing (thoracolumbosacral orthosis) made of thermoplastic material (from elastic to very rigid materials) • HK: 20h/ day (best up to 23h/ day) until skeletally mature • Monitor brace compliance with sensor (e.g. thermal sensor) 57 Type of Bracing (Adapted from Dunn et al, Screening for Adolescent Idiopathic Scoliosis: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Jan. (Evidence Synthesis, No. 156.) Table 1, Types of Braces for AIS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493369/table/ch1.t1/ ) 58 Charleston Skeletal Maturity • Risser’s Sign ≥ 4 and fused distal radius growth plate • TOCI ≥ 8 (ossified sesamoid bone and fused phalangeal epiphysis) • < 1cm change in standing height in the past 6 months and • > 2 year post-menarche Possible Complications with Bracing • Unable to correct 3-D deformities (newer design try to improve 3-D correction) • May worsen thoracic hypokyphosis • Muscle wasting • Stiffness • Pressure sore • Allergy • Psychological self-esteem • Esophagitis from increase intra-abdominal pressure • Poor compliance Physiotherapy Scoliosis Specific Exercise (PSSE) • Early active intervention • Endorsed by SOSORT observation, PSSE and bracing as interventions for managing AIS during growth • Different approaches or “schools” aims to treat 3-D scoliosis by realigning the spine, rib cage, and shoulders and pelvis to “normal” anatomical postures • Self-correction of curve and stabilization in correction • Evidence supported the use of PSSE to treat mild-to-moderate curves e.g. reduce Cobb and rotational angle, improve strength and vital capacity in AIS and prevent surgery in majority of patients in combination with braces • Requires expert training e.g. Schroth Method, Barcelona Scoliosis Physical Therapy School (BSPTS), Scientific Exercise Approach to Scoliosis (SEAS) etc 61 Surgical Intervention • Cobb angle >50 ˚ • Aims to prevent severe curve progression • Spinal fusion • Instrumental surgical intervention (e.g. vertebral body tethering) • use of implant rods to straighten and stabilize the curve • Complications and morbidities • Loss of motion at the fused spinal segments • Back pain • Gastrointestinal complications • Neurological complications • Pulmonary dysfunction • Infection • Surgical failure 62 Key References & Further Reading • Spearing, Pelletier, E. S., & Drnach, M. (2022). Tecklin's pediatric physical therapy (6th edition). Wolters Kluwer. • Dysplasia/ deformities: • Galloway, A. M., van-Hille, T., Perry, D. C., Holton, C., Mason, L., Richards, S., ... & Comer, C. (2020). A systematic review of the non-surgical treatment of Perthes’ disease. Bone & joint open, 1(12), 720-730. • Hosny, G.A. Limb lengthening history, evolution, complications and current concepts. J Orthop Traumatol 21, 3 (2020). https://doi.org/10.1186/s10195-019-0541-3 • Yagdiran A, Zarghooni K, Semler JO, Eysel P. Hip Pain in Children. Dtsch Arztebl Int. 2020 Jan 31;117(5):72-82. doi: 10.3238/arztebl.2020.0072. PMID: 32070474; PMCID: PMC7054595. • Paediatric fractures: • Gimigliano F, Liguori S, Moretti A, Toro G, Rauch A, Negrini S, Iolascon G; Technical Working Group. A systematic review of Clinical Practice Guidelines for the management of fractures in children to develop the WHO's Package of Interventions for Rehabilitation. Eur J Phys Rehabil Med. 2022 Apr;58(2):236-241. doi: 10.23736/S1973-9087.21.06916-1. Epub 2021 Jul 12. PMID: 34247473. • Congenital muscular torticollis: • Kaplan SL, Coulter C, Sargent B. Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy. Pediatr Phys Ther. 2018 Oct;30(4):240-290. doi: 10.1097/PEP.0000000000000544. PMID: 30277962; PMCID: PMC8568067. • Scoliosis: • Weinstein, S.L., et al., Adolescent idiopathic scoliosis. The Lancet, 2008. 371(9623): p. 1527-1537. • Cheng, J.C., et al., Adolescent idiopathic scoliosis. Nat Rev Dis Primers, 2015. 1: p. 15030. • Smit, T.H., Adolescent idiopathic scoliosis: The mechanobiology of differential growth. JOR Spine, 2020. 3(4): p. e1115. • Berdishevsky, H., Lebel, V.A., Bettany-Saltikov, J. et al. Physiotherapy scoliosis-specific exercises – a comprehensive review of seven major schools. Scoliosis 11, 20 (2016). https://doi.org/10.1186/s13013-016-0076-9 • Negrini, S., Donzelli, S., Aulisa, A.G. et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic 63 scoliosis during growth. Scoliosis 13, 3 (2018). https://doi.org/10.1186/s13013-017-0145-8