pediatrics exam 2

developmental assessment of young children (DAYC-2)

outcome used for children ages 0-6yrs old that scores based on observation, report, interview, or direct assessment of cognition, communication, social/emotion, physical development, and adaptive behavior

peabody developmental motor scales (PDMS-3)

outcome used top assess gross and fine motor sills of children under 6 yrs old with use of provided kit to score (website also provides interventions based on score)

what are the 3 subdomains of the gross motor domain of PDMS3?

body transport, body control, and object control (object control only done in 16mos+ ages)

what are the 2 subdomains of the fine motor domain of PDMS 3?

hand eye coordination and hand manipulation

bruininks oseretsky test of motor proficiency (BOT 2)

outcome tailored towards school services used for children 2-22 yrs old with a provided kit to perform and can be done in a short or complete form

what are the 4 composites of the BOT 2?

manual coordination, fine manual control, body coordination, and strength/agility

BOT 3

added 17 new items and an extended balance subtest, removed 2nd trial requirement, extended age range to 4-26yrs old

gross motor functional measure (GMFM)

outcome used to assess children from 5 mos - 6yrs old with cerebral palsy; has 88 and 66 versions

what are the 5 dimensions of the GMFM

lying/rolling, sitting, kneeling/crawling, standing, and walking/running/jumping

88 vs 66 version of the GMFM

88 version has additional tests allocated to the lying/rolling, sitting, and kneeling/crawling dimensions to include a wider range of motor disorders such as down syndrome, spina bifida, osteogenesis imperfecta, or muscular dystrophy while also allowing the use of an AD

what is the easiest position to breathe in for infants?

sidelying

what are the 3 directions of breathing

superior, lateral-costal, and diaphragmatic

presentation of typical infant breathing

shallow breaths with a high respiratory rate

signs of respiratory distress

grunting, nasal flaring, paradoxical breathing (seesaw pattern), and retractions

cystic fibrosis

genetic condition caused by CTFR protein defect leading to a dehydrated fluid layer and thick/sticky mucus

physiology of cystic fibrosis

CFTR protein typically moves chloride out and draws water in to maintain thin layer of fluid over airway cells; without this, liquid layer dries up/is dehydrated (ASL) and mucus coating becomes thick, dense, and sticky causing cilia to get stuck

methods of mucus clearance with cystic fibrosis

coughing, mucociliary escalator, and cephalad air flow bias (autogenic drainage)

autogenic drainage/cephalad air flow bias

1. blow all air out to decrease airway diameter and increase speed of air flow

2. small inhale and hold 3 seconds for collateral ventilation to open mucus blocked area

3. gently exhale

4. repeat with larger breaths and huff cough to clear secretions

sequence of cystic fibrosis treatment

1. bronchodilators

2. hypertonic saline

3. mucolytic

4. airway clearance

5. huff cough

6. antibiotics

7. steroids

huff cough

1. sitting upright, breath normally

2. medium sized inhale

3. hold

4. exhale with 2x the amount of force maintaining an open mouth

cycled huff cough

gradually increase inhale volume and exhalation force; more effective to move secretions from peripheral airways through squeezing effect

pulmonary cilia dyskinesia

structure and movement of cilia causes inability to coordinate and sweep mucus out

asthma

reactive airway disease causing wheezing and coughing

bronchopulmonary dysplasia (BPD)

diagnosed in infants born <32 weeks that still require supplemental O2 at 36 weeks OR infants born >32 weeks that still require supplemental O2 at 56 days postnatal

laryngomalacia

laryngeal tissue above the vocal cords softens causing the tissue to fall in towards airway with inspiration causing partial obstruction, noisy breathing, stridor on inspiration that worsens with exertion, and poor weight gain

mild vs moderate vs severe laryngomalacia

mild= inconsequential inspiratory stridor

moderate= stridor and feeding related symptoms

severe= requires surgery (supraglottoplasty or tracheostomy)

tracheomalacia

tracheal cartilage is floppy with widened supporting rings and decreased airway caliber causing tracheal collapse, expiratory stridor, wheezing, SOB, frequent infection, respiratory failure, and poor weight gain

congenital vs acquired tracheomalacia

congenital occurs at birth; acquired typically associated with intubation, trauma, infection, or polychondritis

treatment for mild vs moderate vs severe tracheomalacia

mild= humidified air

moderate= CPAP

severe= stent via tracheostomy

bronchomalacia

diminished cartilage support of smaller airways or weakened cartilage that collapses with exhalation causing expiratory wheezes, chronic cough, lower respiratory tract infections, apnea, and recurrent bronchitis/pneumonia

primary vs secondary bronchomalacia

primary= congenital due to poor cartilage development

secondary= acquired due to compression by large blood vessel

treatment for mild vs moderate vs severe bronchomalacia

mild= may resolve on its own

moderate= CPAP

severe= stenting/splinting via tracheostomy

what type of curvature is more common with pediatric scoliosis

R thoracic curvature (if left curve or rigidity then further assessment warranted)

idiopathic scoliosis

most common with prognosis based on progression of curve, magnitude, risser sign, and age of diagnosis (early onset at 10yrs or later onset at puberty)

neuromuscular scoliosis

associated with systemic/chronic disease and has rapid progression due to lack of muscle fighting curve

congenital scoliosis

anomalous vertebral development in utero

cobb angle <20º

observe and recheck every 4-6 months; screen for nonidiopathic signs

cobb angle 20-40º

use of rigid orthoses, PSSE, adherence coaching, and activity

cobb angle 40-50º

brace or surgery (PT may be involved in prehab)

cobb angle >50º

spinal fusion with prehab and post op care

risser sign

radiographic grading of iliac apophysis ossification (lateral to medial) used to estimate skeletal maturity and remaining spinal growth to predict scoliosis progression risk

is a lower number or a higher number on the risser scale indicate immaturity

lower number indicates that the ileum is not ossified and therefore predicts more significant progression of scoliosis

nonsurgical intervention/bracing for scoliosis

bracing cuts progression to surgery with higher benefit with increased hours worn/day and greater outcome when used in cases of cobb 25-40º, risser 0-2, and later onset (10+ yrs old)

when can brace be removed for scoliosis

brace should be worn until skeletal maturity is reached

schroth intervention

additional certification for PT that includes an intensive stretching/strengthening program to reduce cobb angle and rotation angle with scoliosis

what precautions are used following spinal fusion in PT?

no loaded flexion or rotation early after

kyphosis

thoracic cobb angle of 45º (normal is 20-40º) that has unknown cause but most commonly arises with hemivertebrae

schauermann

structural kyphosis with 5º of wedging in 3 vertebrae

intervention for kyphosis based on degree

if 60º then observe, if 60-75º then brace if skeletally immature, if >75º then fusion

PT intervention for kyphosis

thoracic extension, core strength, scapular strength, hamstring stretching, pec stretching, bracing, and return to sport

lordosis

lumbar curve >60º (normal is 40-60º) that is common in toddlers and is usually observed or the underlying cause is treated (surgery is rare)

PT intervention for lordosis

hip flexor stretch, ab strengthening, glute strengthening, pelvic control

arthrogryposis multiplex congenita

non progressive condition where child has multiple congenital contractures in 2+ body areas at birth due to decreased fetal movement or akinesia due to atypical muscle fibrosis (not due to weakness)

amyoplasia arthrogryposis vs distal arthrogryposis type 1

amyoplasia is when all 4 limbs involved; distal only involves hands and feet

presentation of arthrogryposis multiplex congenita

- severe joint contractures

- clubfoot

- scoliosis

- decreased muscle strength/bulk

- congenital heart disease

- respiratory deficits

- abdominal hernia

- cognition is intact

intervention for arthrogryposis multiplex congenita

contracture release, ponseti casting for clubfoot, bracing, osteotomy, or spinal fusion

legg calve perthes disease

idiopathic avascular necrosis of the femoral head

presentation of legg calves perthes disease

- insidious limp

- hip pain or referred groin pain

- thigh/knee pain

- decreased hip ROM in abduction and IR

- pain worsens with activity and improves with rest

- thigh muscle atrophy

- leg length discrepancy

waldenstrom stages of legg calves perthes

stage 1= initial where sclerosis is present but epiphysis still intact

stage 2= fragmentation where priority is to contain femoral head

stage 3= reossification where new bone fills the head

stage 4= remodeling where final head shape is set

good vs poor prognosis of legg calves perthes

good prognosis if onset at 6yrs old, herring A or B, and if head shape is spherical/congruent; poor prognosis if onset at ≥8 yrs old, herring C, and if head is flat/extruded

treatment for legg calves perthes

aim is containment by keeping femoral head within acetabulum via abduction bracing (petrie cast), joint distraction, or femoral varus/pelvic osteotomy

PT intervention for legg calves perthes

- hip abd/IR ROM (measure every visit)

- hip abd/extn strengthening (low impact or isometrics)

- load protection

- pool therapy

- progress only if pain allows

slipped capital femoral epiphysis (SCFE)

posterior and inferior slip of femoral epiphysis through the physis at the growth plate and is considered pediatric emergency

presentation of SCFE

adolescent males with high body weight (10-16yrs old) that have insidious onset of hip/groin/thigh/knee pain (knee trap), limp, positioned in hip ER, limited hip IR/flexion/abd, and pain worsens with activity/improves with rest

stable SCFE

most common form where child can bear weight and walk, has better prognosis, has no vascular interruption, and is treated via in situ fixation

unstable SCFE

cannot bear weight or walk even with crutches, risk of avascular necrosis, and requires urgent fixation (emergency)

southwick classification for SCFE

slip angle <30º= mild and treated by in situ screw fixation

slip angle 30-50º= moderate and treated by in situ screw fixation or assessed for osteoplasty

slip angle >50º= severe and treated via reduction, modified Dunn, or osteoplasty

treatment for SCFE

gold standard is in situ fixation but if severe/unstable then modified dunn to save blood supply; if there is still residual deformity then osteoplasty (may also have prophylactic done on other side if high risk)

sequence of PT POC

protected/progressive weight bearing --> gait training --> hip/trunk strength --> proprioception and balance --> full activity once pain free and full strength -> late return to sport (once physis closes)

types of fx unique to children

- buckle/torus: compression

- greenstick

- bowing: delayed ossification

- physeal: apophysial avulsion at growth plate

what are fx types seen at all ages?

transverse, oblique, spiral, and avulsion

salter harris fx

physeal fx treated via ORIF, casting, or surgery

salter harris fx type 1

least severe where transverse fx goes thru physis only (normal radiograph); treated via casting

salter harris fx type 2

involves physis and metaphysis (most common); treated via casting

salter harris fx type 3

involves physis, epiphysis, and possibly intra articular structures; treated via surgery

salter harris fx type 4

involves physis, metaphysis, and epiphysis having risk of growth arrest:; treated via surgery

salter harris fx type 5

physeal crush that is rare but has poor prognosis

acute complications of salter harris fx

compartment syndrome, neurovascular compromise, and fat embolism

chronic complications of salter harris fx

leg length discrepancy, pseudoarthritis, malunion, avascular necrosis, DVT/PE, refracture, or complex regional pain syndrome

highly specific fx associated with non accidental trauma

classic metaphyseal lesion, posterior rib fx, long bone fx (femur, tibia, humerus)

classic metaphyseal lesion

bucket handle or corner fx that occurs at end of long bones due to vigorous pulling, twisting, or bending of extremities

moderately specific fx associated with non accidental trauma

spiral fx of long bone (torsional force/limb twisting) and skull fx if under 18 months

limb deficiency

total/partial absence or different degrees of hypoplasia of skeletal limb structures that can be congenital or acquired (trauma, infection, tumor)

classifications of limb deficiency

transverse (missing below elbow), intercalary (missing radius/ulna), or longitudinal (missing fibula but not tibia)

sport related injury causes

- overuse accounts for 50%

- acute injuries caused by contact/pivoting

- lack of developmental maturity

- repetitive laoding

- shear stress (weakness of articular cartilage or osteochondritis)

patellofemoral pain treatment

treat with load reduction, activity modification, quad/hip strength, and gait training

osgood schlatter treatment

treat with relative rest, NSAIDs, and quad/hamstring loading

sever's disease treatment

treat with heel cup, activity modification, and calf/intrinsic foot loading

little league elbow treatment

treat by stopping throwing, relative rest, altering throw volume, scapular control, and interval return

brachial plexus birth injury

stretch to C5-T1 roots at delivery typically with shoulder dystocia, macrosomia, maternal diabetes, assisted delivery, or breech delivery

erbs palsy

roots c5-c6 injury causing waiter's tip deformity with shoulder add, IR, elbow extn, pronation, and wrist flexed

extended erbs palsy

c5-c7 injury causing same presentation as erbs but includes wrist/finger extension

klumpke's palsy

c8-t1 injury causing clawhand deformity with a weak hand, weak wrist flexors, and weak intrinsics; may also have horner's syndrome

global brachial plexus injury

c5-t1 injured causing flail arm and may have horner's syndrome if t1 is avulsed

outcome measures used for brachial plexus injury

AMS, toronto test score (determines surgical candidacy), and mallet classification

PT intervention for brachial plexus injury

- gentle PROM (especially shoulder ER) to prevent contracture

- promote active use

- task based play

- splinting

- supportive care early on

osteogenesis imperfecta

inherited connective tissue disorder due to mutation impacting type 1 collagen that is either quantitative (mild) or structural (severe) and causes bone fragility and recurrent fx

type 1 sillence classification for osteogenesis imperfecta

mild with few fx, normal stature, and minimal deformity

type 2 sillence classification for osteogenesis imperfecta

perinatal lethal that is severe and fatal within first weeks; baby has minimal in utero movement

type 3 sillence classification for osteogenesis imperfecta

progressive deforming that is severe with multiple fx, limited ambulation, short stature, and scoliosis