Ferrill: LE MSK DSA Flashcards
Growth Centers appear:
Femoral Condyle: 39 wks
fetal age
Tibial Plateau: Birth
Femoral head: 4 months
Gr. Troch: 4-6 yrs
Iliac Crest: 11-14 years
Ischial Tub: 13-15 yrs
Centers close/Growth
Complete:
Iliac Crest: 20 years
Ischial Tub: 16-18 yrs
Femoral head: 16-18 years
Gr. Troch: 16-17 years
Femoral Condyle: 16-19 years
Tibial Plateau: 16-19 years
Common Orthopedic Problems of the Lower Extremities
Hip Dysplasia Legg- Calvé Perthes Disease Slipped Capital Femoral Epiphysis Osgood-Schlatter Disease Intoeing Metatarsus Adductus Pes Planus (rigid vs. functional)
Evaluation of lower extremity
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
Gait evaluation
- In-toeing
- Out-toeing
- Arm swing
- – High guard-> middle guard->low guard
- normal adult gait mechanics not achieved until 5-6 y/o
Symmetry and ability
- 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
Normal pediatric Pelvis XR
Presence and shape of 3 innominate bones:
Cortical lines
Density
Growth centers:
Bilateral presence according to age
Growth plates
- Presence and symmetry
The hip problems
Congenital dysplasia of the hip (DDH)
Legg-Calve Perthes Disease
Slipped Capital Femoral Epiphysis (SCFE)
Developmental Dysplasia of the Hip (DDH)
Signs and symptoms:
- asymptomatic,
- decreased ROM hip; difficulty w/ diaper change; delayed crawling, standing, walking; gait asymmetry
Early detection before 6mo old-best outcome
Exam:
Ortalani and Barlow
Requires XR if positive or high suspicion
Treatment of DDH
Diagnosed at birth, DDH will reduce and stabilize with a brace (or double diapers!)
Open reduction is needed in some later diagnoses.
Diff:
- CP; other neurologic disorder
- Congenital coxa vara (decreased abduction with decreased femoral neck-shaft angle)
- Fracture
Etiology: utero rigid dislocation, perinatal hip dislocation, or ligament laxity or neuromuscular issues from CP or meningomyelocyle
The result of missed DDH diagnosis as a child is
a misshapen acetabulum in the adult, e.g.flattened superior border of the right acetabulum
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.
Legg-Calvé-Perthes Disease
A form of aseptic necrosis of femoral head 2-12 years old Usually 4-8 years Boys: Girls 4:1 Aching groin or proximal thigh Worse at the end of the day Antalgic gait X-ray: narrowed and irregular epiphysis
avascular necrosis on xray looks like…
Note the mottled appearance of the left femoral head as a result of avascular necrosis.
Slipped Capital Femoral Epiphysis
Orientation of physis changes in adolescence (horizontal to more oblique)
Increased body size is a risk factor
Ages 10-16
Pain and antalgic gait
- sudden onset or insidious
Decreased physical activity
Bilateral in 40-50% of patients
What SCFE looks like on x-ray
“fallen ice cream scoop” look of the femoral head (epiphysis). This is the epiphysis literally slipping off the femoral neck.
Osgood-Schlatter Disease
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
Repetitive, tensile forces on developing tibial tubercle resulting in microtrauma and avulsion
Osgood Schlatter Presentation
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
Metatarsus adductus
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.
Metatarsus adductus is an orthopedic problem inherent to the structure of the foot. Metatarsus adductus is medial deviation of the forefoot on the hindfoot. It is the most common cause of in-toeing in infants younger than one year of age. 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.
Rigid vs Functional
Flat Foot
”functionally” - when great
toe is passively extended
the median arch will lift up
-while in a rigid flat foot
it will remain flattened
Functional pes planus is normal in the child until around the age of 2-3 years old. Rigid pes planus is never normal. the arch does not elevate with passive extension of the big toe, indicating rigid pes planus. This warrants further evaluation.
Functional pes planus
the medial arch elevates with passive extension of the big toe indicating functional pes planus. As an isolated finding in the younger child, this is likely a normal finding. 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 os osteopathic perspective, it could indicate weakness in the associated muscles, talar or sub-talar joints.
First and foremost….
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 most often during, medical evaluation and treatment
OMT
Always address somatic dysfunction in the joints above and below the ‘problem’ area
Goal is to balance musculoskeletal tensions across all joints to
optimize function and
decrease biomechanical pressures across the joint and minimize damage
Anterior hip muscles affect
lumbosacral junction, sacroiliac joint, and acetabular function
Indirectly affects knee and ankle function
tensile forces- knee
Tensile forces are created by opposition between the knee extensors and the tibia
Common dysfunctions may produce different symptoms in children than adults
the innominates in osgood schlatter
Posterior rotations and lateral flares may increase tensile forces across the patella
Anterior rotations
alter tone in
knee flexors and may
influence knee rotation
tibia movement with knee extension
Tibia rotates externally with knee extension
comparative sizes of femoral condyles
The medial femoral condyle
is larger than the lateral
the larger medial condyle causes an external (lateral) rotation of the tibia on the femur causing a lateral rotation as the knee extends.
rotations of the tibia
Internal/external rotations of the tibia need to be addressed
If the tibia can not externally/internally rotate with knee flexion and extension tensile forces are increased increasing the propensity for injury
knee flexors and tibial accommodation of the femur
Need to consider knee flexors which can limit tibial accommodation of femur
Hypertonicity of the
Sartorius may cause
External tibial rotation
Shortened biceps femoris
- Medially:
Can limit external rotation of tibia during knee extension - Laterally:
Can limit internal rotation
Of tibia during knee flexion
osgood schlatter and pes planus
Pes planus results in compensatory internal rotation of tibia during loading
Arches as a Diaphragm
With normal gait mechanics
- “Pup Tent”: flattens with load, springs with unloading
- 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
Transverse Arch
3 Cuneiforms and Cuboid
Relatively rigid
Peak of the “Tent”
Maintains osseus architecture of the foot
- Key area to treat for flat feet and transverse arch
Cuboid and Navicular– when to treat
Cuboid: key area to treat for lateral arch
Navicular: key area to treat for medial arch
