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OPP IV Exam 2 > 3-25 Osteopathic Approach to LE Problems in Children > Flashcards

3-25 Osteopathic Approach to LE Problems in Children Flashcards

1
Q

What are the growth centers that appear in children, and what ages do they appear?

A

Femoral Condyle: 39 wks fetal age

Tibial Plateau: Birth

Femoral head: 4 months

Greater Trochanter: 4-6 yrs

Iliac Crest: 11-14 years

Ischial Tub: 13-15 yrs

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2
Q

At what ages and locations do growth centers close in children/adolescents?

A

Greater Trochanter: 16-17 years

Ischial Tub: 16-18 yrs

Femoral head: 16-18 years

Femoral Condyle: 16-19 years

Tibial Plateau: 16-19 years

Iliac Crest: 20 years

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3
Q

Pictured is an example of an adult gait cycle. Do children automatically have a similar gait cycle? What must be integrated in order to have an adult gait, and at what age does this happen?

A

Gait must evolve from the learned integration of the visual, vestibular, and somatosensory (proprioceptive) systems

Children do not develop an adult gait until they are 5-6 yo.

Evolution of childhood gait includes High-guard gait, low-guard gait then followed by the adult gait. Persistence of high- or low- guard gait is a sign of pathology and needs to be followed up.

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4
Q

What are some common orthopedic problems of the LE? (Name 6-7)

A
  • Hip Dysplasia
  • Legg- Calvé Perthes Disease
  • Slipped Capital Femoral Epiphysis
  • Osgood-Schlatter Disease
  • Intoeing - Metatarsus Adductus
  • Pes Planus (rigid vs. functional)
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5
Q

How do you evaluate the LE first?

A

•Static visual inspection

•Line and shape of legs:

Genu valgum/varus (minimal varus is normal in children <2)

Muscular tone and power

•Symmetry and shape of joints and folds:

Gluteal and popliteal folds

•The weight bearing foot:

Flat feet normal in children until ~3y/o

Look at lateral curve of foot

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6
Q

What do you look for in gait evaluation in the LE?

A
  • In-toeing
  • Out-toeing
  • Arm swing - High guard-> middle guard->low guard

normal adult gait mechanics not achieved until 5-6 y/o

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7
Q

What are you looking for in palpating/observing ROM, joints, and mm?

A

•Range of motion-global active and passive

  • SIJ, Hip, knee, ankle, foot
  • Quality and quantity

•Joint evaluation

•Warmth, effusion, skin color

•Muscles

•Tone, activity, firing patterns

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8
Q

When evaluating an X-ray of the pelvis/LE, what should you look for?

A

•Presence and shape of 3 innominate bones:

  • Cortical lines
  • Density

•Growth centers:

  • Bilateral presence according to age
  • Growth plates
  • Presence and symmetry

•Special tests according to site

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9
Q

What orthopedic pathologies can affect the hip in children? (3)

A
  • Congenital dysplasia of the hip (DDH)
  • Legg-Calve Perthes Disease
  • Slipped Capital Femoral Epiphysis (SCFE)
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10
Q

What are some SSXs of developmental dysplasia of the hip?

A
  • asymptomatic,
  • decreased ROM hip; diffificulty w/ diaper change; delayed crawling, standing, walking; gait asymmetry
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11
Q

How is developmental dysplasia of the hip Dx’ed?

A

Diagnosed at birth, DDH will reduce and stabilize with a brace (or double diapers!)

Open reduction is needed in some later diagnoses.

  • Exam:
  • Ortalani and Barlow
  • Requires XR if positive or high suspicion

•Early detection before 6mo old-best outcome

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12
Q

What are some DDXs for developmental dysplasia of the hip?

A
  • CP; other neurologic disorder
  • Congenital coxa vara (decreased abduction with decreased femoral neck-shaft angle)
  • Fracture
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13
Q

What is the etiology of developmental dysplasia of the hip?

A

utero rigid dislocation, perinatal hip dislocation, or ligament laxity or neuromuscular issues from CP or meningomyelocyle

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14
Q

What is the consequences of developmental dysplasia of the hip continuing into adulthood?

A

The result of missed DDH diagnosis as a child is a misshapen acetabulum in the adult. Note the flattened superior border of the right acetabulum above.

This sets the joint up for mechanical and orthopedic problems, including arthritis, during adult life. So, included in your differential diagnosis for the adult with early hip problems should include DDH.

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15
Q

What is Legg-Calve-Perthes Disease? What ages does it affect?

A
  • A form of aseptic necrosis of femoral head
  • 2-12 years old
  • Usually 4-8 years
  • Boys: Girls 4:1
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16
Q

What SSXs does Legg-Calve-Perthes Disease/LCPD preesnt with?

A
  • Aching groin or proximal thigh
  • Worse at the end of the day
  • Antalgic gait
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17
Q

What are the XR findings of LCPD?

A

•X-ray: narrowed and irregular epiphysis

Note the mottled appearance of the left femoral head as a result of avascular necrosis. The right is also affected (note the misshapen femoral head) though not as affected as the right.

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18
Q

Why does SCFE happen? What are the ages and risk factors?

A
  • Orientation of physis changes in adolescence (horizontal to more oblique)
  • Increased body size is a risk factor
  • Ages 10-16
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19
Q

What are the SSXs of SCFE?

A
  • Pain and antalgic gait
  • sudden onset or insidious
  • Decreased physical activity
  • Bilateral in 40-50% of patients
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20
Q

What does SCFE look like on XR?

A

Note the “fallen ice cream scoop” look of the right femoral head (epiphysis). This is the epiphysis literally slipping off the femoral neck.

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21
Q

What causes Osgood-Schlatter Disease?

A
  • Repetitive, tensile forces on developing tibial tubercle.
  • May occur after getting kicked in soccer
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22
Q

Who is affected by OSD?

A
  • Most common pediatric overuse syndrome
  • May be benign, self-limiting
  • Girls: 8-13 yo Boys: 10-15 yo
  • May occur after getting kicked in soccer
  • 20% of all young athletes
  • 20% of cases are bilateral
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23
Q

What is the presentation of OSD?

A
  • Pain over tibial tubercle with activity, especially eccentric contraction of quadriceps.
  • Tenderness and swelling over tubercle.
  • Type I - soft tissue swelling only
  • Type II – Xray evidence of fragmentation
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24
Q

What’s this?

A

Osgood-Schlatter Disease, Type II

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25
Q

What’s this?

A

Metatarsus adductus

26
Q

What should you do if parents present with concern about their child’s intoeing?

A

Parents often present to the office concerned about their children intoeing. It is important to determine the location of the internally rotated lower extremity-it can occur at the hip, the knee, the ankle or the foot. Each of these presentations have both mechanical orthopedic or somatic dysfunction etiologies, or both.

27
Q

What is metatarsus adductus? Does it resolve?

A

Metatarsus adductus is an orthopedic problem inherent to the structure of the foot. Metatarsus adductus is medial deviation of the forefoot on the hindfoot.

Metatarsus adductus is characterized by a “kidney bean” or “C” shape; heel bisector line that is lateral to the second toe; normal range of motion of the ankle and subtalar joint; internal foot progression angle; and a neutral or external patella progression angle.

It usually resolves spontaneously by two years of age.

28
Q

What is the most most common cause of in-toeing in infants younger than one year of age?

A

metatarsus adductus

29
Q

What is the difference between rigid and functional flat foot?

A

Pes Planus/flat foot

functionally - when great toe is passively extended the median arch will lift up

rigid flat foot - it will remain flattened, arch does not elevate with passive extension of the big toe

30
Q

What type of pes planus is pathological?

A

Functional pes planus is normal in the child until around the age of 2-3 years old.

Rigid pes planus warrants further evaluation

31
Q

What does absence of foot arches in a child indicate?

A

Over the age of 2-3 years, the foots arches should be developing.

Absence of these arches can be a result of orthopedic problems or somatic dysfunction. From an osteopathic perspective, it could indicate weakness in the associated muscles, talar or sub-talar joints.

32
Q

What is the osteopathic approach to a child with LE orthopedic problem(s)?

A
  • You *will* be a fully licensed physician.
  • Find and treat all medical, orthopedic problems FIRST.
  • Do not delay appropriate diagnosis and treatment.
  • OMT can be appropriate after, and sometimes during, medical evaluation and treatment
  • Always address somatic dysfunction in the joints above and below the ‘problem’ area
33
Q

What is the goal of treating SD in children with orthopedic problems?

A
  • Goal is to balance musculoskeletal tensions across all joints to
  • optimize function and decrease biomechanical pressures across the joint and minimize damage
34
Q

What do the anterior hip mm affect in terms of SD?

A
  • Anterior hip muscles affect LSJ, SIJ and acetabular function
  • Indirectly affects knee and ankle function
35
Q

How are tensile forces produced around the knee?

A

Tensile forces are created by opposition between the knee extensors and the tibia

Common dysfunctions may produce different symptoms in children than adults

36
Q

What is the position of the innominate in OSD?

A

Posterior rotations and lateral flares may increase tensile forces across the patella

Anterior rotations alter tone in knee flexors and may influence knee rotation

37
Q

What happens to the tibia in knee extension?

A

Tibia rotates laterally with knee extension

The medial femoral condyle is larger than the lateral.

38
Q

What happens if the tibia cannot rotate?

A

•If the tibia can not externally/internally rotate with knee flexion and extension tensile forces are increased.

39
Q

What should be considered with the tibia?

A

Need to consider knee flexors which can limit tibial accommodation of femur

40
Q

What can cause external tibial rotation?

A

Hypertonicity of the Sartorius

41
Q

What are the effects of a shortened biceps femoris medially & laterally?

A

Medially: Can limit external rotation of tibia during knee extension

Laterally: Can limit internal rotation of tibia during knee flexion

42
Q

What does pes planus in OSD result in?

A

Pes planus results in compensatory internal rotation of tibia during loading

43
Q

Explain how arches act as a diaphragm.

A

Fibrous connective tissue arches

With normal gait mechanics:

  • “Pup Tent”
  • Base of a pyramid

Alternating flattening/stretching and peaking/relaxing:

  • Creates pumping action
  • Energy transducer

Navicular “keystone” of median arch:

•Highly adaptable –> shock absorber & stabilizer

44
Q

What makes up the transverse arch of the foot?

A

3 Cuneiforms and Cuboid

  • Relatively rigid
  • Peak of the “Tent”
  • Maintains osseus architecture of the foot

Support –> Plantar Fascia, Tibialis Posterior, Tibialis Anterior and Peroneus Longus.

45
Q

What are some causes of a limping child age 4-10 years?

A

Trauma: Physeal fracture, Puncture wound, Sprain, Contusion

Infectious: Transient/toxic synovitis, Septic arthritis, Osteomyelitis

Osteochondroses: Legg-Calve-Perthes disease

Neoplasm: Leukemia

Inflammatory: Juvenile idiopathic arthritis

46
Q

What are some common causes of a limping child ages 10-18 yo?

A

Trauma: Slipped capital femoral epiphysis, Fracture, Sprain, Contusion

Neoplasm: Various

Infectious: Osteomyelitis, Septic arthritis, Lyme arthritis, Gonococcal arthritis

Osteochondroses: Various

Microtrauma: Stress fracture

Tarsal coalition: Various

47
Q

So, here’s Logan:

™10 y/o overweight male presents to the clinic with a cc of 4 months of dull, achy 4/10 left hip pain that began “all of the sudden” and has not gone away. Nothing alleviates or worsens. Associated sx include a left leg limp. Pt has never had these sx before.

What additional ROS do you want to know?

A

™Gen: ø fever, chills, weight changes or night sweats

™HEENT: ø runny nose, eye discharge/redness or ear pain

™CV: ø CP, palpitations, edema

™Resp: ø SOB, wheezing, cough

™GI: ø nausea, vomiting or diarrhea

™MSK: see HPI

48
Q

™10 y/o overweight male presents to the clinic with a cc of 4 months of dull, achy 4/10 left hip pain that began “all of the sudden” and has not gone away. Nothing alleviates or worsens. Associated sx include a left leg limp. Pt has never had these sx before.

What PE is needed?

A

™Vitals: T98.6 P80 R16 97% on RA weight 120 lbs. height 54 in

™Gen: AAOx3 NAD, obese

™HEENT: NCAT, PERRLA, EOMI, TMI B/L & pearly gray, nares patent without erythema/discharge, ø erythema in post pharynx

™Neck: supple without masses

™CV: Reg +S1/S2 ø S3/S4/m/r/t/g

™Pulm: CTA B/L ø r/r/w

™Abd: S/NT/ND +BS ør/g/o

™Neuro: CN II-XII GI, reflexes +2/4 all stations, sensation +5/5 all stations

™MSK: +left Trendelenberg gait, left hip is held slightly ext rotated and flexed; strength 5/5 all stations; FROM all stations except left hip which is decreased in internal rotation secondary to pain

™Osteo: T8-10 left paraspinal muscle hypertonicity/bogginess, T10 FRSL, left posterior innominate

49
Q

What tests do you want to order for Logan?

A

™3 view X-ray (including frog leg view) of B/L hips

50
Q

Name A-N in the image below:

A

A. Iliac crest

B. Sacroiliac joint

C. Femur head

D. Acetabulum

E. Femoral capital physis

F. Obturator foramen

G. Pubic symphysis

H. Lumbosacral junction

I. Iliac fossa

J. Pubic ramus

K. Ischial tuberosity

L. Femur neck

M. Greater trochanter

N. Anterior superior iliac spine

51
Q

What’s this?

(Frog leg pelvis X-ray)

A

SCFE

52
Q

Describe the SCFE severity scale.

A
53
Q

What’s the difference between mild and severe SCFE? How often is it b/l?

A

Bilateral in up to 30% of cases

Mild—<1/3 of diameter of femoral head

Severe—2/3 to complete

54
Q

How is SCFE treated?

A

™Primary goal of treatment is the stabilization of femoral to prevent vascular damage,– prevent futher deformity

–Tx: surgical fixation with central screw or bone graft epiphysiodesis, Non-weight bearing until assessed by ortho

–Most patient have good prognosis

–Risk for acute chondrolysis or avascular necrosis

55
Q

How is OMT for SCFE used?

A

In addition to surgery and everything orthopedics says, OMT is directed toward improving vascular and lymphatic circulation

56
Q

How are OMT goals for SCFE reached?

A

™Goal:

Directed toward improving vascular and lymphatic circulation

™How we get there:

–Improve and balance muscular tone across the joint and in the areas above and below

–From above: psoas, erector spinae, abdominals, innominates, sacrum, junctions

–From below: quads, hams, adductors, abductors, knee, ankle, foot

57
Q

What does Tucker have?

™Tucker is a 12 year old Caucasian male presenting with his mother complaining of bilateral knee pain that began 3 months ago and has gotten progressively worse. Physical exam reveals tender and warm nodules over anterior superior aspect of the tibias bilaterally.

A

OSD

58
Q

What is the Tx for OSD?

A

™OMT to address any contributing mechanical strains/stresses

–Tibial rotation

–Hip restriction

™Rehab exercises to maintain balance between quadriceps and hamstrings

™Activities do not need to be curtailed

™Ice, NSAIDS only when severe

™Conservative treatment works with improvement of symptoms

59
Q

What areas should be addressed for OMT treatment of OSD?

A

™Pelvis

–Innominates

™Hip rotators

–Piriformis

™Long restrictors

–Quadriceps/hamstring

™Tibial mechanics

™Fibula

™Foot mechanics

60
Q

What’s wrong with Allison?

™An 18 month old female is brought in by parents for in-toeing. Parents report the right is worse than the left, but she is tripping more than their other children.

A

Metatarsus Adductus

61
Q

How can metatarsus adductus be treated with OMT? What are some common SDs associated with it?

A

™Unlike clubfoot, or rigid adductus, the adduction deformity only involves the forefoot and the hindfoot is relatively flexible.

™Common somatic dysfunctions:

–tightness in the medial fascia and adductors of the foot

–Torsion of the first and second metatarsals and inversion rotation of the first cuneiform

–Everted calcaneus

–Lateral longitudinal arch flattened

–Posterior fibular head

OPP IV Exam 2 (3 decks)

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