Peds: MSK Conditions (DDH, Legg-Calvé-Perthes Disease, SCFE, Osgood-Shlatter), ITW, Clubfoot, Oncology

A condition of pathological hip instability

Developmental Dysplasia of the Hip

Which hip is most often involved in DDH?

L

What is the gold-standard imaging for DDH in young infants?

US

When do radiographs become useful for DDH?

Around 4-6 months, after femoral head ossification

What are the major clinical warning signs of DDH?

Limited hip abduction

Leg-length asymmetry

Asymmetric skin folds

Swaddling with legs extended and adducted

"Hip click" during passive ROM

Types of DDH: Subluxatable (Stable)

Femoral head partially displaced to rim of acetabulum

Slides laterally (but not out of socket)

Types of DDH: Dislocatable

Femoral head in socket

May displace completely outside the acetabular with manual pressure

Types of DDH: Dislocated

Femoral head completely out of hip socket

Deformity is significant

Avoid extreme or forceful _________, which may lead to dislocation

extension

T or F: Swaddling that restricts lower-extremity movementis associated with increased DDH risk

T

What is the most common intervention for infant DDH?

Pavlik harness

How does the Pavlik harness position the hips?

90-120° of flexion and 45-60° of abduction

What is the purpose of the Pavlik harness?

To stabilize/reduce the hip and promote normal acetabular development

What hip positions does the Pavlik harness avoid?

Extension and adduction

How long is the Pavlik harness typically worn after stabilization?

Full-time for at least 6 weeks after stabilization

Until what age is the Pavlik harness generally the primary treatment?

6-9 mths

What are contraindications to the Pavlik harness?

Significant muscle imbalance, significant contractures, or excessive ligament laxity

What conditions were given as examples of Pavlik harness contraindications?

Cerebral palsy and arthrogryposis

What is a major vascular complication of Pavlik harness treatment?

Avascular necrosis

What nerve complication can occur with Pavlik harness use?

Femoral nerve palsy

An infant has been diagnosed with hip dysplasia. Conservative treatment is being tried to avoid surgery. The child is wearing a hip positioning harness but is allowed to be out of the harness during physical therapy only. Which position should TOTALLY be avoided when out of the harness?

1. Hip flexion, adduction, and internal rotation

2. Hip extension, abduction, and external rotation

3. Hip flexion, abduction, and external rotation

4. Hip extension, adduction and internal rotation

4. Hip extension, adduction and internal rotation

What is commonly done for DDH detected after 9 months?

Closed reduction followed by a hip spica cast

When may open reduction be warranted?

In children over approximately 18 months when closed reduction fails

What may be performed before surgery for late DDH?

2-3 weeks of traction

Which hip movements should be avoided with DDH?

Internal rotation, extension, and adduction

Why should extension, adduction, and internal rotation be avoided?

They place the hip in a closed position and can promote femoral head displacement.

A condition involving avascular necrosis of the femoral head

Legg-Calvé-Perthes Disease

What is the most common age for Perthes disease?

5-7 years old

What is the cause of Perthes disease?

Multifactorial; the exact cause is not established

What environmental exposure is associated with increased Perthes risk?

Maternal smoking and second-hand smoke exposure

Which artery's flow may be disrupted in Perthes disease?

Medial femoral circumflex artery

What can happen to the femoral neck during Perthes disease?

It can become shortened with trochanteric overgrowth

What is a common gait finding in Perthes disease?

Trendelenburg

What typically aggravates Perthes pain?

Activity

What happens to hip ROM in Perthes disease?

Reduced

Which hip motions are usually most limited?

Abduction and internal rotation

What is the purpose of hip abduction in Perthes disease?

It seats the femoral head deeply in the acetabulum

Why is containment important?

It helps prevent further flattening and promotes remodeling

What are treatment options for Perthes disease?

Observation, ROM exercises, Petrie casts, braces, and surgery

What is often true when Perthes disease begins at age 6 or younger?

May be self-limiting and respond well to conservative treatment

What activities should be limited during painful phases?

Prolonged running and jumping

What types of strengthening are emphasized?

Hip abductors, extensors, and rotators

Displacement of the capital femoral epiphysis from the femoral neck through the physeal plate

Slipped Capital Femoral Epiphysis (SCFE)

In what direction does the femoral epiphysis typically slip?

Posteriorly relative to the femoral neck

What age is typical for SCFE?

10-16 years

What characterizes stable SCFE?

Mild-moderate hip, thigh, groin, or knee pain; the child can generally walk

What ROM limitations are common with stable SCFE?

Limited hip flexion, abduction, and internal rotation

What characterizes unstable SCFE?

Severe pain and inability to walk

What can happen to the hip during passive flexion with SCFE?

Hip may drift into ER

What are common chronic SCFE symptoms?

Aching groin/hip/thigh/knee pain and limp

What characterizes acute SCFE?

Severe hip pain, inability to walk, often following trauma

What is the primary treatment goal for SCFE?

Prevent further slippage

What is the most common surgical treatment?

In-situ screw fixation

In which children may prophylactic pinning be considered?

Girls under 10 and boys under 12

What is an early PT intervention after SCFE surgery?

Crutch-walking instruction

What are examples of early SCFE exercises?

Quad sets, ankle pumps, abduction/adduction slides, and heel slides

A teenager presents to the clinic with vague left hip and groin pain that worsens with weight-bearing. The PT's examination reveals limited and painful hip internal rotation, antalgic gait, and a weak gluteus medius. Based upon this clinical presentation, what is the MOST likely diagnosis?

1. Gluteus medius muscle strain

2. Oligoarticular juvenile rheumatoid arthritis (JRA)

3. Slipped capital femoral epiphysis (SCFE)

4. Legg-Calve-Perthes disease

3. Slipped capital femoral epiphysis (SCFE)

An adult completing in a community athletic event sustained a traumatic femoral neck fracture. What is a potential complication of this injury if it is not promptly identified and there is a subsequent delay in definitive treatment by an orthopedic surgeon?

1. Hip dysplasia

2. Legg-Calve-Perthes disease

3. Avascular necrosis of the femoral head

4. Slipped capital femoral epiphysis

3. Avascular necrosis of the femoral head

Traction apophysitis of the tibial tuberosity

Osgood-Schlatter Disease

When does Osgood-Schlatter disease commonly occur?

During adolescent growth spurts

Why does Osgood-Schlatter occur during growth spurts?

Bone grows faster than muscle, leaving the quadriceps relatively tight

What structure repeatedly pulls on the tibial tuberosity?

Quadriceps through the patellar tendon

What is the main symptom of Osgood-Schlatter disease?

Ant knee pain

What age range is typical for Osgood-Schlatter disease?

10-15 years

Which sex is more commonly affected?

Males

What happens to the tibial tuberosity lump during the active phase?

Tender

What happens to the lump after healing?

Hard, non-tender, and usually remains

What stretching is recommended?

Quad

What are the 5 attributes of normal walking?

Stability in stance

Foot clearance in swing

Prepositioning of foot for initial contact

Adequate step length

Conservation of energy

The angle between the line of progression and the line of the foot

Foot progression angle (FPA)

What does a positive FPA indicate?

Out-toeing

What does a negative FPA indicate?

In-toeing

T or F: Postural control and antigravity muscle strength are the prerequisites for independent walking

T

What are the major gait milestones from 9 months to 7 years?

9-11 mo: pre-walking

12 mo: first steps

18-24 mo: heel strike/arm swing emerge

2-3 yr: refinement

~3 yr: mature pattern

6-7 yr: adult time/distance values

What is the typical hip position during supported walking at 9-11 months?

Hip abduction, external rotation, and flexion

What is normal knee alignment at 9-11 months?

Genu varum (bowed legs)

What is the typical rearfoot position at 9-11 months?

Everted heel/calcaneal valgus

What a 12-month-old gait cycle looks like

Wide BOS and arms in high guard

Short steps with high cadence

Short single limb stance

When does heel strike emerge?

By 18 months

What knee motion emerges as heel strike develops?

Knee flexion during loading response

How does reciprocal arm swing develop between 18-24 months?

About 50-65% at 18 months and ~92% by 24 months

What happens to BOS between 18-24 months?

Begins to dec/narrow

What happens to genu varum around 18-24 months?

Resolves toward neutral alignment

What gait characteristics remain immature at 18-24 months?

Stance remains prolonged, cadence remains high, and the heel is still somewhat everted

What happens to hip and knee extension at 2-3 years?

Inc during stance

What happens to heel strike at 2-3 years?

Heel strike is established with knee flexion during loading response

When do the knees become relatively straight?

18-24 months

What knee alignment normally appears around age 3?

Genu valgum (knock-knee)

When is the gait pattern considered adult-like?

By 3 years

What are characteristics of the mature gait pattern around 3 years?

Smooth vigorous gait

Reciprocal arm swing

Well-developed heel strike

When is heel-to-toe gait consolidated?

3.5-4 years

When is reciprocal arm swing expected?

By 2 years

When do pediatric gait time and distance values reach adult values?

6-7 years

When does the heel reach a neutral position?

7 years

Where is the center of mass around 6-7 years?

L3 (S2 in adults)

What happens to single-limb stance from 1-7 years?

Inc

What happens to walking velocity with age?

Inc

What happens to cadence with age?

Dec

What happens to step-to-step variability?

Dec

What happens to step length?

Inc