LECTURE 8: DEVELOPMENTAL ORTHOPAEDICS Paediatric MS History o Reason for referral o Past history Antenatal history Birth history (term? Premmy? Breech? Complications?). Medical history/investigations/tests o Developmental (milestones) o Family (siblings, parents etc.). o Social/educational/environmental Physical examination o To determine whether child s performance lies within expected normal range. o To determine need for intervention/investigation. o Context o Components Observation (gait, posture, interaction, functional activities). Musculoskeletal assessment Joint range of movement (active and passive) Muscle Strength Muscle Length Rotational Profile (see lecture) Palpation Paediatric Special Tests (eg Barlow and Ortolani tests, Leg Length Discrepancy= Galeazzi test **exam**). Neurodevelopmental assessment Age-appropriate gross motor and fine motor functional ability. Neurological status- Resting muscle tone, reflexes, clonus, tremor. Developmental posture and balance reactions. Sensorimotor responses and / or perception. Motor skill ability and coordination. Standardised Assessment tools. Developmental differences o Normal toddlers do not walk like small adults! o Toddlers legs are different from adult legs o Knee joints are closer to the ankles o Torsional problems are more obvious o Flat foot gait o Reduced foot clearance and arm swing. o Variable gait o Gait mature by 3.
o Mild foot drop, faster steps rather than larger steps to increase speed. o Flexed Rotated knee- Medial hamstrings rotates tibia medially on femur with knee flexion. o In-toeing causes; Metatarsus Adductus Internal Tibial Torsion Excessive femoral torsion- Angular difference between the femoral neck axis and the transcondylar axis of the knee. o Average Thigh foot angles: Infants: 5 internal torsion 3 yrs: 0 8 yrs: 10 external torsion Adults: 5-15 external torsion Prolonged or accentuated by W-sitting & prone sleeping. o Mx tibial torsion; Dennis-Browne boots & bar Strengthening o Internal rotation of 80-90 is evidence of mod severe femoral torsion. o Intoeing Mx; Presence of Muscle Tightness: Stretches Strengthening of hip external rotators Proprioceptive retraining Absence of tightness: Strengthening of hip external rotators Proprioceptive retraining Surgery K-Taping Fabifoam for ER of hips o Metatarsus Adductus is the most common cause of intoeing from birth to 1 year. o In toddlers, internal tibial torsion causes most intoeing. o Intoeing at 3-9 yrs usually attributable to increased femoral anteversion. o More severe intoeing suggests a combination. o Out-toeing External rotator contracture due to positioning (frog position). Increased base of support. Reduced balance New gait pattern Centre of Gravity higher than adults Valgus heels
External tibial torsion Management: Contracture management (positioning, handling, stretches & exercises) Footwear advice Proprioceptive taping Monitor Toe walking o Differential Diagnosis Charcot Marie Tooth Duchenne s Muscular Dystrophy Leg length discrepancies Cerebral Palsy (diplegia or hemiplegia) Developmental Dysplasia of the Hip o Thorough Hx and Ax Muscle lengths (soleus and gastrocs) Muscle strengths (imbalance at ankle) LL and pelvic stability Gait Assessment o Mx Presence of tightness: Serial casting Night splints Stretching & Exercises Surgery Absence of tightness: Proprioceptive retraining/taping Exercises Modified shoe Program Exercises for toe walking: Core strengthening: Planks, yoga trunk twists, prone strengthening to utilize core and gluts attempting to increase joint range. Bow legs/knock knees o Genu Valgum typically presents in 3-5 year olds, in a non-neurologically impaired population. o Usually symmetric and non-progressive. o Frequently associated with flat feet. o Measure the distance between the feet when the knees are together (should be <10cm). o Alternatively, measure femoral-tibial angle. o Only 1-2 / 100 will require treatment. o Assessment (WB & NWB):
Varus- Distance between medial femoral condyles. Valgus-Distance between medial malleoli o Genu varus Mx; Monitor Stability and strengthening activities o Genu valgus Mx; Monitor Orthotics Strengthening Exs Surgery (at ~ puberty) Flat feet o Causes; Flexible (collapses in WB/arch when NWB. Full ankle ROM) heel eversion pronated forefoot out-toed gait Can be developmentally appropriate in toddlers (ligaments lax, wide-based ER). Neurological Tarsal coalition Vertical talus Tight tendo achilles When there is evidence of collapse through the midfoot and the heel is in valgus we need to intervene. Decreased shock absorption stress on the mm & tendon structures = less stability Problems of anterior knee pain, LBP and foot pain commonly occur in the presence of chronic foot pronation of moderate to severe degree. Ax: Age (?developmentally appropriate) Passive extension of great toe at MTP joint Measurement of heel valgus Toe-walking Foot Posture Index (FPI) Footprint analysis Photographs Mx: - Some will resolve spontaneously with age (if it is a developmentally appropriate flat foot.) Stretches
Play/Exercises without footwear (e.g. on sand, picking up objects with feet). Pre- fabricated orthotics (Leap frog, Heel cups). Starting for one hour a day, increasing in 1 hour intervals up to 75% of the time Aiming for alignment without sacrificing mobility. Perthe s disease o Temporary loss of blood supply to the femoral head causing it to become soft and then collapse. o As disease progresses, the collapsed bone is reabsorbed and replaced by new bone formation. o Process can take between 1 and 4 years. o ~1 in 10 000 o Patients usually aged 3 10 years o Male : female ratio is 4:1 o Unilateral or bilateral o Presents with; A limp Minor pain Limitation of hip ROM (IR n & Abd n ) Diagnosis confirmed with x-ray o Mx; Femoral head containment Maintenance of hip ROM o Conservative Mx (if young or less severe) - Bed rest, traction, abduction orthosis/casts. o Surgical Mx (if older or more severe) - Pelvic or femoral osteotomy. o Physio Mx Bed exercises Musculoskeletal & functional assessments Rehabilitation program Gait retraining Exercise prescription Strengthening (esp. Hip abductors) Maintenance of hip ROM Hydrotherapy Monitoring LLD o The majority of children recover well with conservative management o Poorer prognosis with: Greater degree of femoral head involvement Girls compared with boys Children with onset over 6 yrs age o Osteoarthritis common in later life
Slipped capital femoral epiphysis (SCFE) o Displacement of the femoral neck from the capital femoral epiphysis which remains in the acetabulum. o More common in males, 11 15 yrs, who are usually overweight. o Bilateral in 25% o Insidious or traumatic onset. o Diagnosis confirmed with x-ray. o Presentation; Pain (knee +/- hip) Limp & possible Trendelenberg gait Hip adducted, externally rotated & 1-2cm shorter Reduced hip ROM (flex n, abd n, IR n ) o Conservative mx: Bed rest, traction. o Surgical mx: Manipulative reduction & single pin fixation, femoral osteotomy, or epiphyseodesis. o Physio Mx: Bed exercises Mobility retraining (TWB with crutches). Musculoskeletal & functional assessments. Gait retraining with gradual progression to FWB. Exercise prescription Strengthening (esp. Hip abductors) Maintenance of hip ROM Hydrotherapy Osgood-Schlatter s Disease o Inflammation or partial avulsion of the patellar tendon at its insertion into the tibial tubercle before this apophysis unites. o Gradual onset of pain o Swelling o Tender lump over tibial tubercle o Pain reproduced with resisted quads extension, stair climbing and jumping. o Rx- prevention of further irritation during healing process. o Conservative management: Rest (+/- immobilisation in a cast or splint), avoidance of exacerbating activities, taping, quadriceps strengthening, & graduated return to activity. o Surgical management: Open reduction in presence of displaced fragments. o Spontaneous recovery with time.
o Symptoms run a protracted course over several years before gradually settling once the apophysis is fully united. Juvenile idiopathic arthritis (JIA) o Also known as Juvenile Rheumatoid Arthritis (JRA) and Juvenile Chronic Arthritis (JCA). o Juvenile Idiopathic Arthritis is defined as definite arthritis of unknown etiology beginning before the age of 16 years and lasting for at least 6 weeks. o Disorder of the immune system resulting in inflammation in the joints and other body tissues. o Evidence suggests that onset occurs in a genetically predisposed host who encounters an external trigger (viral or bacterial). o Synovial joint inflammation including swelling, endrange joint pain, and stiffness. o Leads to villous hypertrophy, hyperplasia of the vascular endothelium, and intra-articular effusion. o Swelling and distention of the joint capsule result in protective muscle spasm, pain and stiffness. o Control joint inflammation using the most effective drug therapy with the least adverse effects. o Preserve joint mobility, integrity and function. o Promote independence and competence in necessary and desired activities. o Provide education and support to the child and family. o Consideration; Personal factors: Child s age Other health conditions Health habits Motivation and coping skills Environmental factors: Physical/social environment Access to appropriate medical/rehabilitation services o Outcome measures all favoured exercise therapy but none were statistically significant. o None of the studies reported negative effects of exercise therapy.
o Disease remission is defined as absence of arthritis while off medications for 2 or more yrs. o Oen et al (2002) examined 392 patients with JRA. 39% met remission criteria, 17% had inactive disease, and 41% continued to have active disease. o Significant no. of individuals have persistent active disease into adulthood with joint damage, reduced functional ability and disability (Duffy, 2005).