PTRS 833 - Pediatric Orthopedics

Orthopedic Examination

- LE alignment in standing

- posture

- gait analysis

- ROM

- strength testing (MMT vs Functional)

- balance

- special tests

Skeletal alignment of newborn

genu varum

Skeletal alignment at 6 months

minimal genu varum

Skeletal alignment at 18 months (or ~6 mos after indep ambulation)

legs straight

Skeletal alignment at 2 1/2 years

genu valgum

Skeletal alignment for 4-6 years

legs straight with normal out toeing

Femoral Anteversion at birth

40-60 degrees

when is femoral anteversion usually done decreasing by?

8-10 / 8-12 years

femoral anteversion in adulthood?

10-15 degrees

measurement of femoral anteversion

Craigs test

treatment of excessive femoral anteversion

conservative

operative (usually not considered until 8-12 years)

"W" Sitting

- excessive anteversion

- delayed LE weightbearing / ambulation

Concerns with "W" sitting

- decreased trunk / core engagement

- limited rotational patterns

- decreased crossing of midline

when is genu varum present?

birth to 2 years

- if noted in children 2-6 years, consult with ortho MD

when is genu valgum present?

2-6 years typically

what direction does the tibia rotate with growth?

externally

tibia alignment at birth

5 degrees internally rotated

tibia alignment from 4-5 years

neutral

tibia alignment at 8 years old

up to 25 degrees external rotation

measurement of tibia rotation

- thigh foot angle

- transmalleolar angle

thigh foot angle measurement

- for tibia rotation

- measure in prone with knee flexed to 90 degrees

- subtalar neutral, then slightly dorsiflex to hold position

- measure angle: axis on heel, bisect thigh, bisect foot (2/3rd webspace)

normal thigh foot angle infant measurement

5 degrees internal

normal thigh foot angle measurement for 8 years

10 degrees external

what tibia rotational measurement is easier and more reliable?

thigh foot angle

Transmalleolar angle

- for tibia rotation

- recommended with abnormal foot limiting TFA

- measurement in prone with knee flexed to 90 degrees

subtalar neutral, then slightly dorsiflex to hold position

- measure angle: bisect medial and lateral malleoli, bisect thigh, and then make line perpendicular

normal transmalleolar angle in infancy

neutral to 10 degrees internal

normal transmalleolar angle with growth

externally rotates up to 15 degrees

normal foot alignment for ages < 6 years

pes planus

when does arch formation typically occur

between ages 2-6

when is arch formation matured by?

age 12

matatarsus adductus

front foot turned inwards

C-shape foot

- norms 8-14 degrees

- heel bisector method

ways to measure leg length discrepancy

- umbilicus to medial malleolus

- superior iliac crest to medial malleolus

- thigh leg technique

- standing on graduated blocks

best measurement technique for leg length discrepancy

superior iliac crest to medial malleolus

intervention for less than <2 cm of leg length discrepancy

no intervention vs heel wedge

intervention for more than >2 cm of leg length discrepancy

orthosis vs surgical correction

causes of in-toeing

femoral anteversion

internal tibial torsion

metatarsus adductus

most common cause for in-toeing in children ages 3-10 years old

femoral anteversion

- feet forward, patella turned medially

- typically resolves without intervention by 8-11 y/o

most common cause for in-toeing in children ages 2-4 years old

internal / medial tibial torsion

- patella forward, feet inward (bow legs)

most common cause for in-toeing in children < 1 years old

metatarsus adductus

causes of out-toeing

external tibial torsion

calcaneovalgus / pes planus

femoral retroversion

who does external tibial torsion causing out-toeing normally effect?

older children / young adolescents

who does calcaneovalgus / pes planus causing out-toeing normally effect?

early walkers

- compensatory (weakness, foot structure)

who does femoral retroversion causing out-toeing normally effect?

obese children

- may predispose child to SCFE

Foot progression angle

- angular difference between axis of the foot and line or progression of foot during gait

- in-toeing is negative value

- out-toeing is a positive value

- norms: -3 to +20

when is MMT initiated for strength testing?

5-10 years of age dependent on child's cognitive ability to follow directions for the test

functional strength testing in young kids requires...

observation of functional skills including the quality of movement patterns

documentation

- observations are key

- note quality of movement

- tie activities to your functional goals - this is not as obvious to a payer

- level of assist - remember it is based on their effort, not yours

Type 1 Salter Harris Fracture

- through the growth plate

- more common in younger children

- tx: immobilization, possible closed reduction

Type 2 Salter Harris Fracture

- through growth plate and metaphysis

- most common type (75%)

- tx: immobilization, possible closed reduction

Type 3 Salter Harris Fracture

- through growth plate and epiphysis

- more common in children > 10 y/o

- Tx: ORIF

Type 4 Salter Harris Fracture

- through all 3 elements

- occurs in all ages; may affect bone growth

- tx: ORIF

Type 5 Salter Harris Fracture

- crush injury of growth plate

- least common; often misdiagnosed

- tx: surgery or NWB

Slipped Capital Femoral Epiphysis

displacement of the femoral head relative to the femoral neck and shaft

- avg age of onset: 14 (males) and 12 (females)

- obesity is a major risk factor

- medical emergency

S&S of Slipped Capital Femoral Epiphysis

- pain in medial thigh, groin, knee

- ROM limited in hip flexion, abduction, and IR

- antalgic gait

- hip ER when asked to flex

Tx of Slipped Capital Femoral Epiphysis

surgical

- early detection is key!

Legg-Calve-Perthes "Disease"

avascular event affecting the capital epiphysis (head) of an immature femur (cause unknown)

- typical onset: 4-8 vs 4-10

- 3:1 boys > girls - more severe in girls

S&S of Legg-Calve-Perthes "Disease"

- gradual onset of trendelenberg gait

- localized pain in groin, anterior hip and/or greater trochanter

- referred pain to anteromedial thigh or knee

- impaired ROM with hip abduction and IR

Initial / Necrosis Stage of Healing in Legg-Calve-Perthes "Disease"

- several months

- blood supply to femoral head is disrupted and cells die

Fragmentation Stage of Healing in Legg-Calve-Perthes "Disease"

- 1-2 years

- body removes dead bone and replaces it with softer, weaker bone that is more susceptible to collapse

Reossification Stage of Healing in Legg-Calve-Perthes "Disease"

- years

- new, stronger bone develops and take the shape of the femoral head; typically the longest stage and may last a few years

Residual / Healed Stage of Healing in Legg-Calve-Perthes "Disease"

bone regrowth is complete and femoral head has reached its final stage

Legg-Calve-Perthes "Disease" Treatment

- ROM = hip abduction and IR

- Strengthening: focus on core and proximal stability

- Activity Modification: low impact, use of AD as needed

- Bracing / Casting: Petrie cast

- Surgery: osteotomy

Blount's Disease (Tibia Vara)

- progressive deformity of the tibia due to deceleration of the posteromedial proximal tibial epiphysis

- results in bow-legged presentation

- etiology unknown

Infantile Blount's Disease (Tibia Vara)

- more common, tibia only

- ages 2-4 y/o

- bilateral

Adolescent Blount's Disease (Tibia Vara)

- less common, tibia and femur

- > 10 y/o

- unilateral

- obesity = risk factor

Blount's Disease (Tibia Vara) Treatment

Bracing < 4 y/o

Surgical > 4 y/o

Clubfoot (Talipes Equinovarus) Position

forefoot adductus + hindfoot varus + ankle equinus

- inversion with plantarflexion

Clubfoot (Talipes Equinovarus)

idiopathic deformity of the tarsal bones due to genetics and/or environmental factors

Clubfoot (Talipes Equinovarus) treatment

- ponseti method (series of serial casting)

- surgical (tendon release)

- PT

Arthrogrypopsis Multiplex Congenita

- two or more joint contractures present at birth

- non-progressive

- mutations in > 400 genes have been identified as cause

- amyoplasia = most common

- shoulder IR, ADD; elbow EXT; forearm pronantion; wrist flex

Arthrogrypopsis Multiplex Congenita Treatment

- gentle ROM

- strengthening

- splinting / casting

- functional movement

Osteogenesis Imperfecta (OI) Symptoms

- factures easily

- bony deformities

- blue sclera

- loose joints

- muscle weakness

Osteogenesis Imperfecta (OI) Treatment

- avoid PROM in young children

- WB in proper alignment

- educate caregivers on positioning / handling

- strengthening

- aquatic therapy

- minimal impact

Congenital Muscular Torticollis (CMT)

"twisted neck" or wry neck

- shortening of the SCM

- named for side of the tilt (SCM involvement)

Presentation of torticollis

lateral flexion on ipsilateral side, rotation to the contralateral side

Postural CMT

positional preference

- non-muscular

- no significant ROM limitation

Muscular CMT

most common

- unilateral tightness of the SCM without fibrosis

Nodular / Fibrotic CMT

- palpable nodule (fibromatosis colli) or band in the SCM

- most severe, greatest ROM impairment

Other causes of CMT

- neurological

- skeletal

- GI

- occular

- integumentary

- cardiopulmonary

GI CMT presentation

- colic + reflux

- extended and rotated to right

CMT examination

- subjective hx - birth history, birth weight, multiple gestations, NICU, birth order

- PROM

- AROM

- palpation

- head shape and facial asymmetries

- gross motor skills

- trunk assessment

- screen for hip dysplasia, visual tracking

Cervical PROM assessment

- best practice = arthrodial protractor

- other options = photos, goni

- rotation = > 100 degrees (avg is 110)

- lateral flexion = > / = 65 degrees (avg = 70)

Cervical AROM assessment

- rotation = supine 0-3 months, sitting > 3 months

- lateral flexion = motor functional scale

Head-Righting

used to measure active lateral flexion

- photos

- motor functional scale

Motor Functional Scale

6 point scale to assess lateral flexion strength

- infants with CMT often have difference of 2-3 points

CMT Treatment

- stretching

- strengthening

- prone

- positioning

- gross motor skills

- referral to other providers

Passive stretching for CMT

- lateral flexion = football hold

- rotation = start in side lying, roll baby to supine while rolling head in rotated position

- trunk stretches

example of stretching for L tort

stretch right ear to shoulder, stretch left rotation

strengthening for CMT

- lateral tilts on ball

- active cervical rotation (watch for compensations)

- tummy time!

- cervical flexion

using prone position for treatment of CMT

- positions dependent on age

- work in varied angles (0-45 degrees)

- work in varied surfaces

- monitor for "chicken wing" on involved side

- avoid pelvic block > 5 mos

- symmetry in partial sidelying

Positioning with CMT

- avoid "containers" - carseat, etc

- sidelying is a great option

- prone

- with plagio - avoid weight on flattened side

- increase WB on opposite side when possible

- baby wearing

- high chair

Gross motor skills with CMT

- awareness of normal gross motor sequencing is crucial

- use for strengthening

- examples = rolling, transitions

- anticipate compensations in emerging skills

- symmetry!

CMT referral to other providers

- orthotic referral for helmet

- vision

- vestibular

- botox

- surgical - very uncommon

First choice interventions for CMT (CPG)

- neck / trunk PROM

- neck / trunk AROM

- development of symmetrical movement

- environmental adaptations

- parent / caregiver education

- no agreement on frequency, intensity

Prognosis for CMT interventions at < 3 months

full resolution

Prognosis for CMT interventions > 3 months

75% resoluation

CMT associated conditions

- plagiocephaly

- congenital hip dysplasia

- flexible scoliosis

Scaphocephaly

long, narrow head shape

- flattening on sides of head

- common in premies

Brachycephaly

flattening of posterior occiput

Plagiocephaly

asymmetric flattening of the posterior occiput

- coexisting impairment in 90% of infants with CMT

- argenta classification system

- TX = repositioning, address CMT, orthosis