COMMON MSK CONDITIONS IN BABIES. Introduction to Paediatric Physiotherapy June 2017 By Linda Walsh

Transcription

1 COMMON MSK CONDITIONS IN BABIES Introduction to Paediatric Physiotherapy June 2017 By Linda Walsh

2 OBJECTIVES Overview of: Congenital Talipes Equinovarus (CTEV) Developmental Hip Dysplasia (DDH) Plagiocephaly/Torticollis Obstetric Brachial Plexus Palsy (OBPP)

3 "THE ART OF SIMPLICITY IS A PUZZLE OF COMPLEXITY" Douglas Horton

4 SYSTEMATIC APPROACH

5 SYSTEMATIC ASSESSMENT ORTHOPAEDIC S'S Stiffness Symmetry Skeletal Dysplasia Symptoms Systemic signs Look Move Feel Functional context "P (REMS) PAEDIATRIC REGIONAL EXAM OF MSK SYSTEM

6 CONGENITAL TALIPES EQUINOVARUS Aetiology Pathology Clinical assessment Pirani score Ponseti treatment

7 TYPES OF TALIPES

8 CTEV "CAVE" deformity Cavus Adduction (navicular) Varus (calcaneus) Equinus (percutaneous heel cord tenotomy)

9 "CAVE" DEFORMITY Cavus Adduction Varus Equinus

10 BACKGROUND 1:1000 live births Affects girls >boys 3-4% if FH on one side 30% chance if FH from both parents Bony deformity Increased pull of tibialis posterior, gastro-soleus and long toe flexors Muscles are smaller in size and shorter Thick and Taut ligaments

11 ASSESSMENT THE PIRANI SCORE: 6 CLINICAL SIGNS MIDFOOT SCORE HINDFOOT SCORE Curved lateral border Medial crease Position of the talar head Posterior Crease Rigid Equinus Empty Heel

12 PIRANI SCORE CURVED LATERAL BORDER

13 MEDIAL CREASE

14 LATERAL HEAD OF TALUS

15 POSTERIOR CREASE

16 RIGID EQUINUS

17 EMPTY HEEL

18 PONSETI TECHNIQUE Gold standard for treatment at all ages Foot is moved and stretched Plaster cast from toe to thigh Approx 6 casts Achilles tenotomy Boots and Bar until age 4-5

19 CTEV TREATMENT

20 PONSETI CASTING

21 TO MAINTAIN CORRECTION o Foot abduction brace o 3 months 23 hours o Night time and nap time (minimum hours) until the age of 4-5

22 OTHER DIFFERENTIALS.

23 METATARSUS ADDUCTUS Curved Lateral Border Medial crease Forefoot abduction ROM

24 CALCANEOVALGUS Normal hindfoot Rests in valgus Look at range of plantar flexion If restricted PF, ensure no empty heel Need to rule out vertical talus Rx=plantar flexion stretches with supination and inversion

25 CONGENITAL VERTICAL TALUS Very rare Hindfoot Valgus heel Empty heel Posterior crease Midfoot will present with rocker bottom

26 DESCRIBE THE FOOT

27 DESCRIBE THE FOOT

28 DESCRIBE THE FOOT

29 DEVELOPMENTAL HIP DYSPLASIA

30 DDH Aetiology Pathology Clinical assessment Ultrasound techniques XR assessment Treatment Case discussion

31 WHAT IS DDH A spectrum of conditions Can refer to subluxation or dislocation Can occur from conception, birth or subsequently Can affect osseous structures (acetabulum/prox femur) Can affect the labrum, capsule, soft tissues Most common orthopaedic disorder in new-borns

32 AETIOLOGY Dysplasia; 1 per 100 Dislocation; 1 per 1000 Bilateral in 20% of cases Genetic factors 12 times increased risk in 1st degree relatives Lower rates in African communities Packaging

33 DEVELOPMENT OF THE HIP 3rd trimester; the femoral head grows more rapidly than acetabular cartilage and so by birth the femoral head is less than 50% covered. Acetabular cartilage then develops faster than the femoral head, to allow more coverage.

34 PATHOLOGY NEW BORN Poor ossification of acetabulum Femoral head can glide in and out of acetabulum Socket shallow with loss of supero-lateral acetabulum Poor restraint to postero-lateral dislocation

35 EXAMINATION Is the hip dislocated? If dislocated is it reducible? If not dislocated is it dislocatable? Is it an older child? General exam e.g Mm/skeletal dysplasia, foot abnormalities, Spinal dysraphism

36 CLINICAL EXAMINATION OF BABIES Barlow Test: Hips flexed Thigh adducted Push posterially in line with the shaft of femur(pistoling) Positive sign is femoral head dislocating posteriorly. Ortolani s test: Hips examined 1 at a time Flex hips and knees to 90 degrees Thigh abducted with adduction pressure on greater trochanter Positive sign is a palpable and audible clunk as the hip reduces.

37 ORTOLANI AND BARLOW

38

39 CLINICAL EXAM 100% specific but <60% sensitivity (Scandinavian countries) Accurate within the first few days of life Experience of clinicians

40 CLINICAL EXAMINATION THE OLDER CHILD Galleazi test Skin creases Range of motion Barlow test Ortolani test Gait- waddling Lordosis Reduced Abduction Toe walking (especially unilaterally)

41 ULTRASOUND METHODS Graf (Europe) Terjesen (RLH/Scandinavian) Harcke (States) Anatomy according to age; what is the maturation curve

42 X-RAY MEASUREMENT Hilgenreiner s Line femoral head below Perkin s Line femoral head medial Shenton s Line continuous Reverse Shenton s continuous

43 GOALS OF RX Reduction Retention Maturation

44 PAVLIK HARNESS RX < 6 months and reducible hip flexion 50 abd 6 Weeks 95% cases resolve > 6 months, failure rate = 50% Not for tetralogic / neuromuscular hips Complications AVN due extreme abduction Femoral nerve injury

45 OTHER TREATMENT OPTIONS 6 months 18 months?adductor tenotomy?traction?eua arthrogram Closed reduction 6 months 24 months / irreducible Failure of closed treatment Persistent subluxation Surgical approach

46 CASE DISCUSSION 9 month female Brought into A&E by mother Noticed not walking on left leg Noticed left leg shorter by 2cm Born at term, normal delivery and development 3 older children, first child had DDH Did not attend / have hip screening

47 TORTICOLLIS

48 TORTICOLLIS Descriptive term- neck rotation and side flexion Not a specific diagnosis but a sign of an underlying disorder Not always muscular in origin- exclude differentials! 3rd most common MSK condition of childhood Muscular torticollis incidence is 0.3-2% Males > females

49 BALLOCK AND SONG children with torticollis 18% had a non-muscular aetiology Of which 30% had Klippel-Feil anomalies Underlying neurological disorder in 51% (ocular 23%, OBPI 17%, CNS lesions 11% Inflammatory C1-C2 rotary subluxations Clavicle fracture Paroxysmal torticollis

50 CONGENITAL TORTICOLLIS Postural/Packaging Mechanical stresses Muscular (Sternocleidomastoid tightness +/- fibrosis) Unknown aetiology Sternocleidomastoid Tumour Benign soft fluid filled tumour 8-16mm/fibrotic thickening/haematoma, most apparent a few weeks after birth. Resolves approx 5-21 months after birth The type of torticollis is predictive of the time to resolution.

51 ASSESSMENT Subjective acute onset, unwell child, trauma Head shape analysis (80-90% have plagiocephaly) Facial asymmetries Resting/preferential postures & assessment of symmetry Neck skin folds Passive Neck ROM Active Neck Rom Visual eye tracking and eye movements Head control Lateral Head Righting on the contralateral side (strength) General neurodevelopment screen i.e. milestones, movements, tone etc Upper limb dominance Spine/skeletal alignment Palpation SCM tumour (USS) Other lumps! Hip Ax

52 RED FLAGS Ocular Motor Asymmetry (nystagmus, strabismus) Palpable Masses Asymmetrical head positioning due to abnormal muscle tone, muscle tone imbalance, absence of SCM contracture Palpable skeletal Anomalies or asymmetries (congenital scoliosis) Delayed development and integration of primitive reflexes Presence of pathological reflexes (clonus, tremors) Absence of Movement of any extremity Presence of any hand or leg dominance

53 TREATMENT Neck PROM/stretches: Formally e.g. every nappy change Informally: carrying, prone, positioning, feeding etc Neck AROM Visual attraction Asymmetric handling to activate weak muscles Use head righting reactions Prone Positioning Correlates with AIMs Facilitate development of symmetrical normal movement & milestones e.g. midline play, reaching, rolling, avoidance of functional neglect Environmental adaptations: position of cot, play gym etc. Educate about plagiocephaly

54 PROGNOSIS Variable, Dependent on age, severity, type and compliance (Cheng et al., 2001) Physio before < month of age = 98% success rate in 2.5 months Intervention > 1 month up to 3 months = 89% success rate in 6 months of physio Physio at >6 months to 12 months = 10 months & less success (20% success rate)petronic et al., (2010) Boys had longer treatment duration < 3 months= 100% (Demirbilek et al % after 3 months Tatli et al. (2006) 94% resolve if treated before 24 weeks Watemberg et al. (2016). At age 2 years, 78% had no evidence of torticollis; ; 3.3% had torticollis of the same severity as at diagnosis; 18.3% had improved.

55 PHYSIO IS GREAT!!:-) Ryu et al. (2016) Physiotherapy was the only factor influencing complete resolution Only patient age correlated with non-resolution Ohman, Nilsson and Beckung (2010) Resolution was quicker with a physiotherapy-administered stretching programme v parent-administered stretching programme 0.9. months v 3.0 months to achieve good ROM 2.5 months v 4.5 months to achieve symmetrical head position

56 PLAGIOCEPHALY

57 NORMAL NEONATAL HEADS

58 PROGRESSION OF HEAD SHAPE A period of rapid head growth Reflective of brain growth Plagiocephaly at birth is not predictive for plagiocephaly at 7 weeks.

59 DEFORMATIONAL MOULDING

60 OBSERVATIONAL AX Parallelogram shaped skull Flattening of R or L side occiput Ipsilateral frontal bossing Facial asymmetries Orbital bulging Ipsilateral ear displacement anteriorly Mandibular/maxillary deformation

61 OBSERVATION

62 PREVALENCE Approx 5% pre back to sleep 20-30% now Cranial asymmetries 13% singletons 56% of twins 67-90% if have CMT

63 RISK FACTORS Restrictive uterine environment Big baby, big head, mulitparity, small maternal pelvis, malformed uterus, increased uterine/abdo tone, oligohydramnious/polyhydramnious, breech presentation, primiparity CMT Advanced maternal age Developmental delay Back to Sleep /lack of prone play/equipment - car seats Prematurity. In last 10 weeks of pregnancy, calvarial bones stiffness increases 5 to 10 fold

64 DIFFERENTIALS Plagiocephaly vs brachcephaly vs scaphycephaly vs craniosynostosis Craniosynostosis: Premature fusion of one of more cranial sutures Single or multiple suture fusions

65 BRACHYCEPHALY & SCAPHYCEPHALY

66 TREATMENT Counterpositioning (Active repositioning to reduce preference) Facilitate active head turn e.g. through feeding, positioning, handling Environmental adaptation Facilitate normal symmetrical development & milestones Tummy time (Back to Sleep). Helmet???

67 PROGNOSIS R.E PLAGIOCEPHALY Complete correction in 77% of conservative treatment (Steinbrenner et al 2015) Risk factors for failure: poor compliance, older babies, prolonged torticollis, developmental delay, initial severity Criteria for correction: diagonal difference of less than 5mm and/or cranial ratio of less than 0.85 by 18 months. Complete correction in 94% with helmet therapy Recommendation: Favour conservative Rx as a first choice if there are minimal risk factors Dependent on age, severity, compliance, & presence of torticollis

68 OBSTETRIC BRACHIAL PLEXUS PALSY ( B I RTH RELATED B RAC H I A L P L E X U S PA L S Y)

69 OBPP OBJECTIVES Aetiology Pathology Clinical assessment Treatment

70 WHAT IS BRBPP Umbrella term Refers to injury noted in the perinatal period to all or a portion of the brachial plexus 2 main risk factors: Birth Weight and Breech presentation Injuries affecting the upper brachial plexus are classically termed Erb palsies Injuries associated with the lower plexus are traditionally termed Klumpke palsies.

71 AETIOLOGY Always a Tearing Force Large babies (more than 4kg) Possible forceps or ventouse assistance Upper plexus injury, most commonly to the C5 and C6, and occasionally to the C7 roots, but never the lower nerve roots. Small babies (less than 3kg) Breech presentation-requiring excessive extension of the head & manipulation of the hand and arm which exerts traction on both the upper and lower roots. This may cause rupture or avulsion of any, or all of the roots

72 Associated with a 100-fold increased risk of brachial plexus injury SHOULDER DYSTOCIA

73 OBPP Incidence varies from 0.42 per 1000 live births (Evans-Jones, 2003) to per 1000 live births (Pondaag et al, 2004). Occasionally bilateral + Prognostic factor; Rapid return of motor function Various assessment tools and classification systems Narrakas classification Mallet classification Assisting Hand Assessment Toronto score Gilbert Raimondi assessment tools

74 THE BRACHIAL PLEXUS

75 TYPES OF INJURY Avulsion ; nerve is torn from where it attaches to the spinal cord Rupture is when the nerve is torn A neuroma forms when torn nerve fibres have attempted to re-grow and heal themselves, but scar tissue has grown in and around the injury Axonotmesis occurs when nerve fibres are ruptured, but the nerve covering is intact - recovery by nerve growth takes time (1mm per day); Neuropraxis occurs when the nerve has been damaged but is intact - nerve fibres recover on their own and recovery should occur within 3 months.

76 NERVE INJURY

77 AIMS OF PHYSIOTHERAPY To maintain full and equal passive range of movement in all joints and full soft tissue length in the upper limb To encourage active movements and improve strength and endurance against gravity To be aware of any sensory deficit and advise appropriately To introduce developmental activities at an age appropriate time To advise and educate parents on appropriate management.

78 APCP REFERRAL PATHWAY WITHIN FIRST 24 HOURS FOLLOWING BIRTH ASSESS: Does the baby move both arms equally? Observe spontaneous movements in supine and side-lying Compare left and right sides Assess for Horner s sign. If abnormalities observed.. BEFORE DISCHARGE FROM HOSPITAL: X-ray of humerus or clavicle if fractured, arrange pain relief and orthopaedic follow-up Check for phrenic nerve palsy Physiotherapy referral for initial advice re. handling and positioning; Refer to paediatric physiotherapy.

79 WITHIN 1 WEEK OF RECEIVING REFERRAL Complete baseline assessment using Toronto scoring Check passive range of movement Check parent handling and teach stretches Provide information on Erbs Palsy Group Arrange follow-up at 8 weeks or sooner

80 BY 8 WEEK REVIEW Refer for specialist opinion if Toronto score <3.5 If there is FULL RECOVERY; Discharge INCOMPLETE RECOVERY; Continue to monitor active and passive range of movement Monitor and advise on child s development Refer to Occupational Therapy & Community Paediatrician if appropriate Advice to school if required Direct intervention if surgery planned. Goals should focus on minimizing bony deformities and joint contracture, while optimising functional outcomes.

81 EXERCISES

82 POSITIONING

83 "CONSISTENCY IS MORE VALUABLE THAN TALENT"

84 QUERIES???