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1 I have no relevant relationships/affiliations with any proprietary entity producing health care goods or services.

2 OCSA 2017 OMT For Extremity Disorders and Torticollis in Children Ava C. Stanczak, D.O., FACOP, CS Professor of Pediatrics LMU-DeBusk College of Osteopathic Medicine

3 GOALS AND OBJECTIVES 1. Identify ages when extremity disorders commonly occur. 2. Differentiate between acquired and congenital torticollis. 3. Formulate an osteopathic treatment plan for each disorder. 4. Discuss possible prevention for each disorder.

4 REFERENCES Atlas of Osteopathic Techniques; 2 nd edition; Nicholas and Nicholas;Lippincott, 2012, pages 327, ; (upper and lower extremities, torticollis) page 400 (pes planus) Cranial Osteopathy For Infants, Children and Adolescents; Sergueef, Elsevier, 2007 pages (torticollis)

5 DEFINITIONS Nursemaid Elbow - Dislocation of the radial head Little League Elbow Syndrome An overuse injury caused by repetitive throwing

6 Nursemaid Elbow

7 Frequency and Predilection This condition is most commonly seen in children aged 1 to 4 years. The condition is slightly more common in females than males. There is a predominance of left arm involvement in both males and females. Common scenarios include: - Being picked up (even gently) by the arm - having an arm pulled through a garment sleeve

8 PATHOPHYSIOLOGY In this disorder, the radial head slips under the annular ligament. The distal attachment of the annular ligament is weaker in children than adults, so it is more easily injured.

9 CLINICAL FINDINGS A child having this disorder presents with a sudden onset of decreased arm movement. There is no history of trauma, and the condition is usually unilateral. The child is usually quite anxious, and may appear to be screaming in pain, but actually is really more anxious than hurting. The child may carry their forearm flexed at degrees at the elbow, and they may be carrying their arm with the other hand.

10 CLINICAL FINDINGS Erythema and warmth are not present and there may be tenderness over the radial head. Circulation, sensation and motor activity are completely normal. The child will NOT extend, flex, pronate or supinate the arm. The history of being picked up or carried by the arm should always be asked. The arm must be assumed to be fractured until a careful exam is completed.

11 CLINICAL FINDINGS Note the angle at which the arm is held. Also, note the facial expression!

12 EVALUATION Radiographs are usually unnecessary, but certainly should be done if a fracture is suspected. When having a forearm radiograph, the technician doing the X-ray usually reduces the dislocation. No lab work is necessary unless erythema, swelling and/or fever accompany the disorder. The key to this diagnosis is a careful history and physical exam. Asking about being picked up by the arm is the most important piece of information. Remember, sometimes it s the siblings picking up the child.

13 TREATMENT Treatment consists of manipulation of the child s arm to return the annular ligament and radial head to their normal anatomical positions. A click felt during this manipulation has a positive predictive value in over 90% of cases. Even if a click is not felt or heard, observation of the child may reveal no further pain. It is important to know that some children will not use their arm AFTER successful reduction, until the next day.

14 TREATMENT Immobilize the elbow and palpate the radial head with one hand. With the other hand, apply axial pressure at the wrist, and supinate the forearm and flex the elbow.

15 FOLLOW UP One of the most important parts of management, is the education of parents regarding reoccurrence. Some literature states that if nursemaid elbow occurs more than twice, immobilization is necessary, however, no large studies exist to support this care. Counseling parents and caregivers regarding picking up a child by the arm is very useful in preventing reoccurrence. If the radiographic findings are normal, and the first attempt at reduction is not successful, another attempt (by another health care professional, if possible) is reasonable. No further radiographs are necessary after reduction. Persistent pain is inconsistent with the diagnosis of nursemaid elbow, and further evaluation is warranted in this case.

16 LITTLE LEAGUE ELBOW SYNDROME

17 FREQUENCY AND PREDILECTION About 4.8 million children play baseball and softball in the United States each year. Of this group, the incidence of Little League Elbow Syndrome (LLES) is 2-8% per year. In adolescence LLES is estimated to be 30-50% of ALL sports related injuries. Since many of these injuries are treated at home, it is impossible to have accurate numbers.

18 PATHOPHYSIOLOGY Valgus stress placed on the elbow during the throwing movement, results in tension on the medial epicondyle, medial epicondylar apophysis, the medial collateral ligament complex, and places increased pressure on the radial head, and the capitellum. During overuse, tissue breakdown exceeds tissue repair, resulting in ongoing micro-trauma.

19 BIOMECHANICS OF INJURY Observe the forearm action during throwing

20 CLINICAL SUBTYPES Little League Elbow Syndrome is actually a group of disorders that includes: - Medial epicondylar apophysitis - Osteochondrosis and osteochondritis of the capitellum - Deformation and osteochondrosis of the radial head - Olecranon apophysis - Hypertrophy of the ulna - Medial collateral ligament sprain Age is a determining factor with regard to injury subtype. In childhood, repeated microtrauma is the most likely cause. During adolescence, the ability to throw harder, results in increased valgus stress, which results in avulsion or nonunion of the medial epicondyle.

21 CLINICAL FINDINGS Children and adolescents may present with or without pain. Depending on the subtype, limitation of elbow extension may occur. Some persons having LLES will not have pain unless activity is present. Younger children tend to have swelling and a constant, dull aching pain that worsens with activity. Decreased range of motion is uncommon, and should cause a search for another etiology.

22 EVALUATION A careful physical examination of the elbow should include the following: - evaluate loss of motion, muscle atrophy, and asymmetry, and look at the carrying angle - palpate both epicondyles and the radial head - check the ulnar nerve in flexion and extension - check the stability of the ligaments - don t forget to completely examine the neck, shoulders, wrist and hand - completely check the nerve and circulatory function

23 TREATMENT Treatment of these injuries is multifaceted, and includes prevention. The patient SHOULD NOT PLAY SPORTS WITH A PART THAT HURTS!!! The most common cause of reinjury, and the need for surgery, is returning to play too quickly. Rest, ice, mild analgesics, and osteopathic manual medicine are the indicated. Parents, patients, and coaches should be educated about the problem so that full recovery can occur.

24 TREATMENT Osteopathic techniques useful in treating this syndrome include: - myofascial release, using the long axis or transverse approach - muscle energy, if joint not too painful - lymphatic pump for swelling Avoid high velocity techniques at the onset of the disorder, as they may cause increased swelling during the acute phase of the disorder. Muscle energy Lymphatic pump

25 PREVENTION AND FOLLOW UP This can be accomplished by education of parents, players, and coaches. Make sure adequate warm-up time is provided before play, AT EACH GAME AND AT PRACTICE. Emphasis should be placed on CORRECT throwing techniques during games and practice. Rest periods should also be mandatory during games and practice. A new rule in Little League limits pitchers to 6 innings per week during a game. Most cases of LLES resolve over time with rest and conservative management. Osteoarthritis is a potential long-term complication. Problems affecting the articular surfaces have the worse longterm outcome.

26 KNEE PAIN IN CHILDREN

27

28 Iliotibial Band Syndrome This is a friction syndrome and is the most common cause of chronic lateral knee pain. It is one of the overuse syndromes common in runners, cyclists and tennis players.

29 TREATMENT Self-treatment

30 PES PLANUS

31 Pes Planus and Plantar Fasciitis Flat feet are normal until about age 5 years. Evaluation of a child s feet should be a part of each health maintenance examination.

32 Pes Planus Evaluation Observation of a child s gait during the health maintenance exam and having the child stand in front of the provider can help identify this problem. If the area under the arch cannot accommodate an index finger, consider pes planus. Children present commonly with hip And knee pain. Plantar fasciitis is an inflammatory condition resulting from pes planus.

33 Pes Planus Treatment This treatment is effective for plantar discomfort associated with pes planus. The knee is flexed and passively extended and the ankle is plantar flexed with supination of the forefoot. Thumbs are directed toward the medial border of the cuboid bone and a high velocity, low amplitude thrust is applied at the end of range of motion.

34 Pes Planus Treatment To prevent chronic pain in pes planus, proper fitting shoes with arch support are recommended. Separate orthotics also are useful, but tend to be forgotten. Children with very small feet may need a custom orthotic but the ones available in sporting goods store work just as well IF they are worn.

35 TORTICOLLIS

36 Torticollis is a common term for conditions of head and neck dystonia and can be congenital or acquired. The condition results in a fixed posturing of the head and neck that may be rotated, flexed or extended. Congenital torticollis is caused by the contracture of the sternocleidomastoid muscle on the affected side. It is thought to be the result of positioning in utero and is more common in first pregnancies and those with decreased amniotic fluid. Acquired torticollis or wry neck is the result of minor trauma, sleeping position and stress. It is frequently seen days to weeks after motor vehicle accidents. While self-limited, it is very painful and attention.

37 CLINICAL FINDINGS Note the left facial asymmetry from congenital torticollis. This is frequently worsened by preferred sleeping position.

38 Acquired torticollis The most common cause of acquired torticollis in children is injury or inflammation of the sternocleidomastoid. Acute infections are the second leading cause and usually present with fever and other symptoms.

39 TREATMENT - NEWBORN Passive side-bending Stretching away from affected side Stretching

40 TREATMENT OLDER CHILDREN Sternocleidomastoid muscle stretching should be done before attempting other techniques. Muscle energy can be used in children old enough to follow instructions. Have child turn their head into your hand.

41 TREATMENT-OLDER CHILDREN Place fingertips in the suboccipital area, and move toward the cranium. Move the entire muscle mass with the entire finger, until the restriction is felt to release. The motion is cephalad and lateral.

42 Let s Practice!