Lecture 15: Common Pediatric Orthopedic Conditions

What is scoliosis?

Structural, lateral, rotated curvature of the spine; Cobb angle ≥10° (<10° = spinal asymmetry)

What age range is “adolescent” scoliosis?

• Age ≥10 years at diagnosis

• Early-onset scoliosis (EOS) = onset before age 10

What does idiopathic mean?

Other causes have been ruled out: congenital (vertebral malformation), neuromuscular, syndromic

Scoliosis Etiology

• Probably a genetic component

  • Gene has not yet been identified

• Neuro pathoanatomy

  • Chiari 1 malformation, syrinx

• Abnormal paravertebral musculature

  • Denervation leads to thoracic scoliosis in animals

• Vertebral body growth asymmetry

  • Unsure if cause or effect

Scoliosis Natural History

• Early long term studies of scoliosis led to common misconception that all types of idiopathic scoliosis lead to disabling back pain and severe cardiopulmonary compromise

  • Studies included non-idiopathic causes of scoliosis and early onset scoliosis

• New studies have proven otherwise

Evaluation of Scoliosis Physical Exam

• Shoulder height

• Pelvic obliquity

• Trunk shift

• Waist asymmetry

• Adams forward bend test

Evaluation of Scoliosis Neuro Exam and Reflexes

• Neuro exam

  • Sensation

  • Motor

• LE Reflexes

  • Patellar Tendon: L2,3,4

  • Achilles Tendon: S1, S2

• Abdominal reflexes

  • T8-T12

• Foot deformity

Radiology of Scoliosis

• Standing spine radiographs

  • AP and Lat first assessment

  • PA subsequently

  • Must be able to see pelvis and proximal femur

    • Risser Sign, TRC, proximal femoral physis

      
      

• EOS

  • low dose radiation system, results in 3d imaging

AP Radiology Results of Scoliosis

• Curves

  • Right thoracic is normal

  • Left thoracic is abnormal

• Cobb angle

  • End vertebra to end vertebra

  • 5 degree variability

• Risser sign

  • growth sign (5 means done growing, 0 means a lot of growth to go)

• Tri-radiate cartilage

  • Growth measure

Sagittal Profile Radiology Results of Scoliosis

• • Hyperlordosis at apex

Who needs an MRI?

• A typical curves and/or symptoms

• Left curve

• Kyphosis

• Abnormal appearing curves

• Abnormal exam

• Headaches

• Rapid progression

• Progression despite bracing

• Early onset or juvenile

  • Neural axis abnormalities in ~20% of early onset (infantile/juvenile) curves; much less common in typical AIS

Treatment Determination Based on

• Decision making based on age/skeletal maturity + curve magnitude

• Chronological age, bone age, Risser sign, menarchal status all play a role

• Sanders Stage now most widely used

Sanders Stage

• Skeletal maturity scoring system that correlates more strongly with curve behavior than Risser sign or bone age

  • Uses hand x-ray

• Stage 3 – start of Adolescent Rapid stage (peak height velocity, Risser 0, open TRC)

• Curves >20 deg at Stage 2 and >30 deg at Stage 3 are at greatest risk for progression

Surgery recommended at _ degrees or more

50

• Curves followed for avg 40 years

• Curves <30 deg at maturity tended not to progress

• Curves between 50-75 degrees at skeletal maturity with thoracic apex progressed the most

• This is where the 50 deg threshold for surgery comes from

When to brace?

• Curve magnitude

  • 25-40 degrees

• Age

  • At least 2 years of growth remaining (13-14 boys, 11-12 girls)

  • Risser sign (0,1,2), menarchal status

• What type of brace?

  • TLSO

  • Night time bending brace (Providence, Charleston)

Conditions Effecting Brace failure

• Male patients

  • 74% of curves progressed >5 deg; 46% progressed to >50 deg or had PSF

  • Compliance rate 38%

• Obese patients

  • Curve progression to >45 deg in 45% of obese patients vs. 28% normal weight

  • 3.1 more likely to have unsuccessful result if obese

• Thoracic vs. Lumbar Curves

  • Rate of PSF or progression >50 deg 34% in thoracic curves vs. 15% in lumbar curves

• Risser stage

  • Rate of progression highest (70%) for Risser 0 with open TRC, especially if curve >30 deg (even with 18 hours of daily brace wear)

  • Risser 0, TRC open should wear brace 18 hours/day

  • Bracing should start with curves <30 if Risser 0, especially if TRC open

The “monitor” effect

• Patients who are given feedback about their compliance with brace wear, wear their brace more

• 13.8hrs/day vs. 10.8 hrs/day

• 25% who were counseled progressed to >50 deg or surgery vs. 36% who were not

Surgical Treatment Scoliosis

• When

  • Curve >50 degrees

• Why

  • Weinstein data about curve progression

  • Cosmesis

• Age

  • At least 10 yo

• Alternative

  • Vertebral body tethering: skeletally immature, curves 30–65°, failed bracing (FDA HDE 2019)

Early Bracing Through History

20 years ago

• SRS guidelines → brace curves 25-40° in order to stop progression to surgical magnitude

• Previous studies have shown that 33% of patients with curves 25-29º braced at Risser 0 and open TRC still go on to surgery (Karol, et al. JBJS 2016)

  
  

Now want to try to brace earlier so it doesnt get to that point

• Early brace treatment (curve <25º and open TRC) may reduce curve progression and the need for surgery

• Only 8% of patients with fulltime brace progressed to surgery vs. 33% in previous study of patients with curves 25-29º and open TRC

Early Bracing For Scoliosis

• Often results in curve improvement

• Decreases risk of curve progression

• Usually amenable to nighttime bracing

• Now treating younger patients with smaller curves

How has Dr. Meagan’s practice changed?

• Start bracing curves at 20°, especially in younger patients

• I will brace curves <20° when there is clinical deformity

• Mostly use nighttime braces for small curves; will change to full time if curve progression

Arthrogryposis

• Non-progressive congenital disorder of unknown etiology that presents with multiple rigid joints leading to stiffness and severe limitation in motion in all 4 limbs

  • NOT a specific diagnosis but a clinical finding

• 1:3000 births

  
  

Arthrogryposis Etiology

• Joint development is almost always normal during early embryogenesis

• Decreased fetal movements occurring as a result of fetal or maternal abnormalities

  • Lack of movement = extra connective tissue around the joint = contracture

Arthrogryposis Pathophysiology

• Due to failure of movement, joints that had initially formed with normal articular cartilage and joint space undergo changes

  • Joint capsules thickened

  • Fibrotic

  • Joint creases absent

  • Skin and subcutaneous tissue adherent to bone

  • Bursal areas poorly formed

Amyoplasia

• Amyoplasia (Classic Type of Arthrogryposis)

  • “No Muscle Growth”

  • Most common type

  • Comprises 1/3 of all cases

  • Usually Symmetric in limbs with trunk spared (84% symmetric involvement)

  • Normal intelligence

  • Incidence: 1 in 10,000 live births

Amyoplasia Symptoms

• Shoulders internally rotated and adducted

• Elbows extended

• Wrists flexed and ulnar deviated

• Fingers stiff

• Thumb in palm

• Hips may be dislocated

• Knees can be extended or flexed

• Equinovarus feet

Multidisciplinary Clinics for Amyoplasia

• Pediatric neurologist

• Pediatric orthopedic surgeon

• Hand orthopedic surgeon

• Geneticist

• Occupational therapist

• Physiotherapist

• Orthotic professionals

Goals of Treatment for Arthrogryposis

• Orthopaedic goals of treatment

• Independent ambulation

• Plantigrade standing and walking

• Increase active motion where muscle transfers are possible

• Reposition stiff joints for functional advantage

• Independent function of upper extremities for ADL

Treatment Arthrogryposis: Hip

• Typical deformity is flexion, abduction, and external rotation

• Hip Dislocations - Teratologic (14-42%)

• Also…

  • Hip Dysplasia (65%)

• Data and studies are sparse

• Early reduction of both unilateral and bilateral dislocations is typically recommended

  • Exception is when child demonstrates little active hip movement and ambulation is unlikely; positioning for sitting is more appropriate

Knee Flexion Contractures Arthrogryposis

• Knee deformities occur frequently with an incidence between 38 – 85%

  • Flexion contractures are reported as more common

  • More disabling than extension contractures

• Only 50% of patients with knee flexion contractures became community ambulators

• 8 of 9 patients with knee extension contractures were community ambulators

Surgical Treatment of the Knees

• Flexion contracture

  • consider ambulatory potential and quad function

• Surgical options

  • Extensive soft tissue release

    • Posterolateral

    • Posteromedial

    • Anterior, including ACL/PCL

  • Femoral shortening

  • Extension osteotomy (in mature individuals)

  • Ilizarov

• Hyperextended knee

  • Completely dislocated unlikely to respond to nonoperative management

    • Surgical options

      • Anterior release of knee capsule and patella, V-Y plasty of quad

      • Femoral shortening

        • Advantageous in that weakening of the quad may be avoided

Typical Foot Deformities Arthrogryposis

• Clubfoot

  • High rate of recurrence (73%)

  • Avg 2.5 procedures per foot

• Equinocavus

  • Can be extremely rigid

  • Seems to have a lower tendency to relapse

• Vertical Talus

  • Low incidence (3-7%)

Arthrogryposis Foot Deformities Treatment Goals

Plantigrade foot for standing

Arthrogryposis Treatment: Clubfoot

• More severe and rigid than idiopathic clubfoot

• Was described as “Typically resistant to casting”

• Operative treatment

  • Extensive posterior medial release

  • Residual Adductus: lateral column shortening

  • Residual Equinovarus: Decancellation of talus (Verebelyi-Ogston procedure)

  • Talectomy

  • Ilizarov distraction

  • Salvage: Triple arthrodesis

Arthrogryposis Treatment: Congenital Vertical Talus

• Dobbs Method an option

• Can be very stiff

• Operative Treatment

  • Reduction of navicular on talus

    • Release Ant Tib Tendon

    • Release Tibionavicular and talonavicular ligaments

  • Lengthening of toe extensors

  • Release of equinus contracture after securing talonavicular reduction

Arthrogryposis Treatment: Scoliosis

• Incidence varies greatly 20-67%

• Neuromuscular type curve

  • Very stiff curves

• May result from pelvic obliquity

  • Correct hip contractures first

• Bracing not effective

  • May be used to delay surgery in young

    patients

• Surgical treatment for progressive curves

  • PSF

  • Instrumentation to Pelvis

Spina Bifida

• Spectrum of neural tube defects

• Incidental radiographic findings to significant central and peripheral nervous system dysfunction

  • Neurologically normal

    • Spina bifida occulta

    • Meningocele (may have mild deficits)

  • Neurologic deficit

    • Lipomeningocele

    • Myelomeningocele

    • Caudal regression

Spina Bifida Incidence

• 3.6 per 10,000 live births or 1 in every 2,758 live births

• Result of defect in neural tube closure that occurs by 26-28 days of life

• Risk factors

  • Folate deficiency – 400mcg folic acid daily

  • Maternal Hyperthermia

  • Maternal Diabetes

  • Valproic Acid

• Prenatal screen – maternal serum AFP

MOMS Trial

• In utero repair of myelomeningocele pioneered at Vanderbilt in 1997

• Management of Myelomeningocele Study

• 183 patients randomized to receive in utero repair vs. post-natal closure

  • Stopped early due to clear benefits of in utero repair

    • Decreased need for shunt

    • Improved level of impairment

  • Risk of pre-term birth

• School-age follow-up

  • More children walked independently (93% vs. 80%)

    • Benefit does not last as patient age

  • Fewer shunt placements (49% vs. 85%)

Spina Bifida Multidisciplinary Care

Spina Bifida Goals of Orthopedic Care

• Correct deformities in order to allow patients to maintain mobility / ambulation and independence for ADLs

• Monitor for spine balance and deformity, maintain stable posture for sitting / standing

• Monitor neurologic status, look for signs of neurological deterioration

Spina Bifida Assessment of Neuro-segmental Level

Spina Bifida Classification

Spina Bifida Thoracic Level Goals

• May ambulate with orthoses (RGO, HKAFO) as children, most transition to wheelchair full time

• Ability to transfer, use upper limb to power wheelchair

• Scoliosis

• Watch for hip and knee contractures, keep feet plantigrade for positioning in wheelchair

Spina Bifida Upper Lumbar Level Goals

• Household walkers with braces / forearm crutches, transition to wheelchair for longer distances

• Watch for hip and knee contractures, keep feet plantigrade

Spina Bifida Lower Lumbar Level Goals

• Community walkers

• Below knee orthoses (AFOs)

• May need forearm crutches / wheelchair for long distance

• Foot deformity common

Factors affecting the potential for ambulation Spina Bifida

1. Neurologic level

2. Hip deformity

3. Scoliosis

4. Foot and ankle deformity

5. Age – as kids get bigger and heavier their mobility changes

6. Obesity

Spina Bifida Neurologic level affecting ambulation

• Level of involvement:

  • L4 and below → mostly community walkers

  • L3 and above → non-functional walkers

• Muscle group strength

  • Quadriceps (knee extension) most important

    • 80% of patients with grade 4 or 5 strength – community or household walkers

    • 88% with grade 0-2 strength – non-functional walkers

  • Iliopsoas (hip flexor)

Spina Bifida Hip Deformity affecting ambulation

Status of hips (dislocated or located) does NOT correlate with ability to ambulate

Spina Bifida Obesity affecting ambulation

• 60%

• Increased risk with higher lesions

• Interferes with walking, transfers and self-esteem

Spina Bifida - Hips

• Subluxed / dislocated hips caused by muscle imbalance / paralysis around the hip joint

• Emotional and complicated topic:

  • If the hips remain dislocated, will my child be able to walk?

  • Won’t the hips hurt if they aren’t put back in the socket?

  • Our therapist is nervous to work with our child because his / her hips are dislocated

• What are the outcomes of hip reduction surgery?

  • 76 patients – showed that there was NOT an increase in ROM or ability to walk in children who had their hips reduced

    • No benefit in reduction of pain or need for bracing

  • 20 patients low-lumbar level spina bifida with hip dislocation on one side only – walking speed in children with dislocated hip was the same as those without

  • High rate of complications associated with hip reduction surgery

    • Loss of motion in 30%

    • Pathologic fracture in 17%

    • Decline in ambulatory ability in 36%

Bracing spina bifida

• Many children with spina bifida (except low sacral lesions) require some type of bracing:

  • Prevent deformity

  • Correct flexible deformities

  • Facilitate independent mobility

  • Protect insensate limb

Bracing spina bifida when to start

• When babies show interest in pulling to stand

  • May not require if intact ankle function

  • Started earlier if need to maintain alignment of foot / leg

• Bracing needs change over time

  
  

Common Orthopedic Conditions Spina Bifida

1. Hip

2. Knees

3. Rotational Deformities

4. Foot & Ankle

   1. Clubfoot

   2. Calcaneus / Calcaneovalgus

   3. Ankle Valgus

   4. Cavus / Varus / Cavovarus

5. Spine

   1. Abnormally formed vertebrae

   2. Complete or partial absence of sacrum

   3. Kyphosis

   4. Lordosis – usually due to hip flexion contracture

   5. Scoliosis

Common Orthopedic Conditions Spina Bifida - Hip and Knee

• Hip

  • Flexion Contracture

    • Can lead to pelvic tilt and compensation through the spine (excessive lordosis)

  • Dislocation

• Knee

  • Contractures – thoracic / high lumbar level

    • Flexion

      • If ambulatory and >20º of contracture, can interfere with brace fitting and ambulation

      • Non-ambulatory patients tolerate more of a contracture, but severe contracture can interfere with sitting and transferring

    • Extension

      • Maybe congenital or acquired

      • Makes sitting very difficult for non-ambulatory patient

Common Orthopedic Conditions Spina Bifida - Rotational Deformities

• Femoral anteversion

• Tibial torsion - more common in spina bifida patients

• Many rotational deformities improve over time

  • Not always true in patients with spina bifida due to abnormal gait and activity levels

Common Orthopedic Conditions Spina Bifida - Foot and Ankle

• Almost universal in patients with spina bifida

• Lead to problems with walking, brace fitting, shoe wear, skin breakdown / pressure sores

• Goal for ambulatory patients is a flexible, braceable, plantigrade foot

• Goal for non-ambulatory patients is a foot that fits in braces and shoes and does not interfere with positioning in wheelchair

Common Orthopedic Conditions Spina Bifida - Clubfoot

• Most common deformity – 30-50%

• Rigid and resistant to treatment

• Initial treatment is similar to non-neuromuscular clubfeet – Ponseti method

  • Recurrence rate 70%

  • May require comprehensive release around 10-12 months

Common Orthopedic Conditions Spina Bifida - Calcaneus / Calcaneovalgus

• 17-35%

• Most common in low lumbar level

• Problems with gait, pressures sores from weight-bearing on hee

Common Orthopedic Conditions Spina Bifida - Ankle Valgus

• Caused by weakness of gastroc / soleus leading to abnormal gait pattern

  • Alters forces across the ankle joint

  • More stress on the lateral side → growth slows → medial side continues to grow normally

  • Valgus deformity of the ankle joint

Common Orthopedic Conditions Spina Bifida - Cavus / Varus / Cavovarus

• 8-17%

• Sacral level or lipomeningocele

• Elevated arch (cavus), hindfoot varus

• Can lead to pressure sores on lateral foot

Common Orthopedic Conditions Spina Bifida - Spine

Variety of deformities:

1. Abnormally formed vertebrae

2. Complete or partial absence of sacrum

3. Kyphosis

4. Lordosis – usually due to hip flexion contracture

5. Scoliosis

Spina Bifida Kyphosis

• 10%

• More common in thoracic level

• Progressive – caused by absence of the posterior elements of the spine along with weak muscles

• Sharp kyphotic deformity = gibbus

  • Can cause skin breakdown

• Not amenable to bracing → wheelchair modifications

• Surgical treatment for progressive deformity, skin breakdown

  • Removing some of the vertebrae and correcting the deformity with rods and screws

    
    

Spina Bifida Scoliosis

• 52-70% by age 6, as high as 100% for thoracic level

• Paralytic type curves – long “C” curve, pelvic obliquity

• Skin breakdown from uneven pressure when sitting

• Not amenable to standard bracing → wheel chair modifications

• Surgery for progressive deformity, pelvic tilt causing seating problems

  • Posterior spinal fusion

  • Significant risks

    • Decreased trunk flexibility/mobility (can affect ADLs – self-cathing, etc.)

    • Wound healing

    • Deep infection – 30-40%

Legg-Calvé-Perthes Disease Epidemiology

• Incidence = 1 in 1200

• Regional variability:

  • Low in South and East Asia

  • Higher in Northern Europe, USA and Canada.

• Male:Female = approximately 5 : 1

• Most common in ages 4-9

• Bilateral 10-15%

  • Usually asynchronous

  • If same stage, consider other diseases

Perthes Disease Pathophysiology

• blood supply of femoral head decreased

• bone becomes ischemic

• bone revascularizes

  • dead bone is resorbed

• 
  

Waldenström Classification

Classification system of Perthes Disease

1. Initial/Ischemic

2. Fragmentation

3. Reossification

4. Healed/Residual

Ischemic Stage of Perthes Disease

• Disruption of the blood supply to the femoral head

• Deep layer of the epiphyseal cartilage undergoes cell death

• There is increased mineral content (Sclerosis)

Revascularization/Resorption Stage of Perthes Disease

• Increased osteoclast activity leads to bone resorption.

• Mechanical strength of the femoral head decreases during revascularization.

• Mechanical loading can lead to femoral head deformation.

• Walking is 2.5X body weight and running is 4.5X body weight

Reossification Stage of Perthes Disease

• New bone formation occurs.

• There is remodeling of the femoral head with mixed osteoclastic and osteoblastic activity.

• Femoral head mechanical strength increases

Healed (Residual) Stage of Perthes Disease

Bone reformed but with deformity

Clinical Presentation of Perthes Disease

• Most often present with a limp.

• Limp worse with activity

• Insidious onset of groin pain (sometimes thigh, buttock, knee, back pain)

• Stiffness

• Self-limited activity

Signs of Perthes Disease

• Antalgic gait and Trendelenburg gait (active phase)

• Reduced hip motion during initial and early fragmentation stage

• Variable presentation in late stages

• Loss of extreme range of motion to adduction and flexion contractures

Lateral Pillar (The Herring Lateral Pillar Classification)

Classification of predicted outcome of Perthes Disease

Treatment Perthes Disease

• Treatment options are controversial

• Non-operative

  • NWB

  • Casting (Petrie)

  • Bracing

  • Traction

• Operative

  • Femoral varus osteotomy

  • Salter Osteotomy

  • Combined

  • Hip joint distraction

  • Epiphyseal drilling

  • Greater trochanter epiphysiodesis

• Hip Preservation

  • Hip arthroscopy

  • Surgical hip dislocation with osteochondroplasty

  • Greater trochanter distalization

  • PAO for secondary dysplasia

  • Valgus Osteotomy

  • Head Reduction Osteotomy

Perthes Disease Summary

• Perthes disease involves a process of femoral head avascular necrosis with revascularization, resorption, reossification and remodeling.

• Age of onset, lateral pillar classification and amount of femoral head involvement are associated with prognosis.

  • younger it happens better they heal

• Interventions are directed towards femoral head containment to improve femoral head remodeling

• Children <6 years old should be managed non-operatively.

• Operative management can be beneficial for older patient.

• Containment procedures during early stages may improve hip sphericity at skeletal maturity

Developmental Dysplasia of the hip

• Shallow socket and/or under-covered femoral head

• Malformation of anatomic structures that have developed normally during the embryologic period

• Broad spectrum of disease ranging from physiologic immaturity to subluxation to frank dislocation

Epidemiology DDH Incidence

• 15% with sonographic findings at birth

• 1-2% with hip dysplasia

• 0.1% with frank hip dislocation

• Referral rates 4-5% of births either due to risk factors or abnormal exam

• 4-5:1000 treated for dysplasia

Epidemiology DDH Risk Factors

• Female (8 in 10 cases)

• First born (6 in 10 cases)

• Family Hx (12x relative risk)

• Feet First/Breech (2-27% with dysplasia)

• Environmental Factors

  • tight swaddling

Physical Exam DDH - Outcomes

1. Normal

2. Instability but not full dislocation (“subluxatable”)

3. Dislocatable reduced but dislocatable (“Barlow positive”)

4. Dislocated but reducible (“Ortolani positive”)

5. Fixed and dislocated (“stable, but dislocated”)

Physical Exam of DDH

• The physical findings are a spectrum, which vary with the severity of the pathology and the age of the child

  • Asymmetric thigh fold

  • Limited abduction

  • Positive Galeazzi

  • Pistoning

  • Trendelenburg gait

Dislocatable Hip (Barlow Positive)

• Reduced in the resting position

• Dislocatable with the Barlow maneuver

• May stabilize spontaneously or with treatment

• May convert to dislocated without treatment

Dislocated But Reducible Hip (Ortolani Positive)

• Dislocated in the resting position

• Reduces with abduction and anteriorly directed force on trochanter

• This will be lost, usually by 6-8 weeks of age

• Will not resolve without treatment

Dislocated And NON-Reducible Hip

• Dislocated and NON-reducible in the resting position:

  • Asymmetric thigh fold

  • Limited abduction

  • Positive Galeazzi

  • Pistoning

  • Trendelenburg gait

Late Presenting Dislocation

• Swayback deformity

• Trendelenburg gait

  • Contralateral hemipelvis drop

  • Lean towards dislocated hip

Imaging DDH

• Ultrasound

  • Obtained 6-8 weeks of age unless clinical instability

  • Reduces false positive rate

  • Selective, not universal, screening: breech, family history, or abnormal exam (AAOS)

• X-ray – AP Pelvis

  • Can replace ultrasound from ~4 months of age

  • Sufficient ossification

Treatment DDH

• Pavlik Harness – 0-6 months

  • Maintains hip flexion/abduction to allow for remodeling

• Hip Abduction brace

  • Second line treatment

• Closed or open reduction and spica cast

Prevention DDH

• Healthy Hip Swaddling

  • Avoid forced hip extension

  • Allow hips to flex and abduct

• Sleep sacks

• Baby carriers

Clubfoot Etiology

• Congenital dysplasia of all musculoskeletal tissues distal to the knee

• 1-2 in 1000 live births

  • Higher in Hawaiians, Polynesians and Māori

• 2:1 M:F ratio

• Bilateral 50%

• 4 classes of clubfoot

  • Postural

  • Idiopathic

  • Neurogenic

  • Syndromic

Club Foot Associated Conditions

1. Arthrogryposis

2. Diastrophic dysplasia

3. Amniotic bands

4. Freeman-Sheldon syndrome

5. Prune Belly

6. Möbius syndrome

7. Spina bifida

8. Down syndrome

9. Larsen’s syndrome

10. Tibial/fibular hemimelia

Initial Evaluation Club Foot

• Distinguish from “postural” clubfoot

  • flexible will correct back on its own

• Evaluate for associated anomalies/neuromuscular conditions

• Determine the initial severity

Dimeglio Score

• Way of grading club foot

• 4 components: equinus, varus, derotation of the calcaneo-forefoot block, adduction of forefoot

• Assessed in terms of reducibility

• 4-point scale:

  • 90-45° = 4

  • 45-20° = 3

  • 0-20° = 2

  • 0- -20° = 1

  • < -20° = 0

• 4 “bonus points

  • Posterior crease

  • Medial crease

  • Cavus

  • Muscle condition

Components of club foot

• equinus

  • sagittal plane

• varus

  • frontal plane

• derotation of the calcaneo-forefoot block

  • horizontal plane

• adduction of forefoot

  • horizontal plane

Dimeglio Score Grades

• Four categories of feet based on score

  • Grade 1 – 0-5, benign, 20%

  • Grade 2 – 6-10, moderate, 33%

  • Grade 3 – 11-15, severe, 35%

  • Grade 4 – 16-20, very severe, 12%

Ponseti Method of Treating Club Foot

• Casting

  • Foot manipulated gently for 1-3 minutes

  • Long leg plaster cast is applied and kept in place for 5-7 days

  • Knee in 90° of flexion

  • 5-6 cast changes

  • Percutaneous TAL if needed (85%)

  • Thumb is positioned over the lateral aspect of the talar head and fingers correct the forefoot

• Abduction Orthosis

  • Feet placed shoulder width apart, 70° abduction/external rotation, 5-10° dorsiflexion

  • Worn 23 hrs/day for ~3 months, then nights and naps until age 4–5

French Method of Treating Club Foot

• Introduced to North America by Dimeglio in 1996

• Daily physical therapy sessions to stretch and relax medial tissues with gradual manipulation

• Taping applied to maintain passive motion

• 30 min/foot, daily by PT x 3months, then by parents at home, continued until walking

• CPM machine

Ponseti vs French Method Study

• 267 feet treated with Ponseti Method; 119 treated with French Physiotherapy Method

• Initial correction obtained in 95% of patients in both groups

• Perc TAL – 73% in Ponseti, 32% in French

• Recurrence – 37% in Ponseti, 29% in French

• Trend toward improved results using the Ponseti Method at 2 years, but not significant

Cerebral Palsy

• Brain injury in period of early brain growth (<2yo)

• Disordered motion, sensation, perception, cognition, communication and behavior

• Epilepsy

• Secondary MSK problems

Cerebral Palsy Epidemiology

• Most common cause of chronic physical disability in children

• 2-3/1000

• Causes:

  • Prematurity (main)

  • Intrauterine infection, hemorrhage, thromboembolism/stroke

  • Hypoxia

  • Brain malformations

• Primary lesion in the brain – non-progressive/static encephalopathy

• Progressive secondary MSK consequences

  
  

Cerebral Palsy Classification - Topography

• Unilateral

  • Monoplegia

  • Hemiplegia (30%)

    • UE>LE

    • Focus on hand and foot

• Bilateral

  • Diplegia (50%)

    • LE>UE

    • Focus on legs/walking

  • Triplegia

  • Quadriplegia (20%)

    • Focus on seating, hips, spine