Lower extremity problems in kids Flashcards
What are the growth centers and when do they appear? (6)
- Iliac crest- 11-14 years
- Ischial tuberosity- 13-15 years
- Femoral head- 4 months
- Greater trochanter- 4-6 years
- Femoral condyle- 39 weeks
- Tibial plateau- birth
When do the growth centers close? (6)
All between 16-20 years
- Iliac crest- 20 years
- Ischial tuberosity- 16 years
- Femoral head- 16-18 years
- Greater trochanter- 16-17 years
- Femoral condyle- 16-19 years
- Tibial plateau- 16-19 years
What must be integrated for gait to evolve?
Integration of the visual, vestibular, and somatosensory (proprioceptive) systems
At what age to children develop an adult gait?
5-6 years
Evolution of childhood gait
high-guard gait –> low-guard gait –> adult gait
- Persistence of high or low guard gait is a sign of pathology that needs to be followed up.
Static visual inspection of the lower extremity
- Line and shape of legs: genu valgum/varus, muscular tone and power
- Symmetry and shape of joints and folds: gluteal and popliteal
- The weight bearing foot: flat feel normal in kids until 3
What do you look for in gait evaluation?
- In-toeing
- Out-toeing
- Arm swing
- Range of motion- global active and passive
- Joint evaluation
- Muscles
What are you looking for in X-ray evaluation of lower extremity?
- Presence and shape of 3 innominate bones
- Growth centers: b/l presence according to age
- Special tests according to site
Signs and symptoms of Developmental dysplasia of the hip (DDH)
- Asymptomatic
- Decreased ROM hip, difficulty with diaper change, delayed crawling, standing, walking
When is the best time time to detect DDH
Early detection before 6 months gives best outcome
Exam for DDH
Ortalani and Barlow
- Requires XR if positive or high suspicion
What happens if you don’t diagnose DDH as a child?
The adult will have a misshapen acetabulum.
This sets the joint up for mechanical and orthopedic problems- arthritis
Legg-Calve-Perthes Disease characteristics and demographic
A form of aseptic necrosis of the femoral head in 2-12 year olds
- Boys > girls
- Aching groin or proximal thigh
- Pain worse at the end of the day
- Antalgic gait
XR of Legg-Calve-Perthes
Narrowed and irregular epiphysis
Slipped Capital Femoral Epiphysis characteristics and demographic
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
- B/L in 40-50% of pts
Osgood-Schlatter disease
Effects the knee
- Caused by repetitive, tensile forces on developing tibial tubercle
- Most common pediatric overuse syndrome
- May be benign, self-limit
- May occur after getting kicked in soccer
- 20% of all young athletes
- 20% b/l
Presentation of osgood-schlatter and types
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
Intoeing- medial deviation of the forefoot on the hindfoot.
Important to determine the location of the internally rotated lower extremity- can occur at hip, knee, ankle, or foot
Rigid vs functional flat foot
- Functional: when great toe is passively extended, the median arch will lift up. Normal in the child until age 2-3 years.
- Rigid: flat foot will remain when great toe is extended. Never normal
What could flat foot indicate?
Weakness in the associated muscles, talar, or sub-talar joints
Goal of OMT
Balance musculoskeletal tensions across all joints to:
- optimize function
- decrease biomechanical pressures across the joint and minimize damage
What do anterior hip muscles effect?
Lumbar sacral joint
sacral iliac joint
acetabular function
indirectly- knee and ankle function
What dysfunctions can osgood-schlatter cause in the innominate?
- Posterior rotations
- Lateral flares
may increase tensile forces across the patella - Anterior rotations alter tone in knee flexors and may influence knee rotation
How does the tibia move with knee extension and what happens if it can’t move?
Rotates laterally
- The medial femoral condyle is larger than the lateral
If it can’t move, tensile forces are increased
How can knee flexors cause somatic dysfunction?
Can limit tibial accommodation of femur
What can hypertonicity of sartorius cause?
External tibial rotation
How can shortened biceps femoris cause somatic dysfunction?
Medially- can limit external rotation of tibia during knee extension
Laterally- can limit internal rotation of tibia during knee flexion
Foot mechanics of pes planus
Pes planus results in compensatory internal rotation of tibia during loading
How does the foot arch act as a diaphragm?
- Fibrous connective tissue arches
- With normal gait mechanics is a the base of a pyramid
- Alternating flattening/stretching and peaking/relaxing, creates pumping action
- Navicular “keystone” of median arch- shock absorber and stabilizer
What makes up the transverse arch and what is it’s purpose?
- 3 cuneiforms and cuboid
Relatively rigid, peak of the ‘tent’ - Maintains osseus architectue of the foot and provides support for the plantar fascia, tibialis posterior, tibialis anterior, and peroneus longus
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.
Slipped capital femoral epiphysis
- Noninflammatory condition typically in overweight boys
What endocrine disorders can be seen in slipped capital femoral epiphysis
Hypothyroidism or pituitary deficiencies
What does the Frog leg pelvis x-ray lets you diagnose?
Slipped capital femoral epiphysis
Slip angles of slipped capital femoral epiphysis
0-30: mild
30-60: moderate
60-90: severe
Goal of treatment of slipped capital femoral epiphysis
Stabilization of the femoral to prevent vascular damage and further deformity
Tx- surgical fixations with central screw or bone graft epiphysiodesis
What are the 2 risks of the post op slipped capital femoral epiphysis patient
Avascular necrosis and destruction of articular cartilage
OMT in slipped capital femoral epiphysis
OMT is directed toward improving vascular and lymphatic circulation –> 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
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.
Osgood-Schlatter Disease
OMT treatment of Osgood-Schlatter disease
OMT to address any contributing mechanical strains/stresses
- Tibial rotation
- Hip restriction
Maintain balance between quadriceps and hamstrings
Treat
- pelvis –> innominates
- hip rotators –> piriformis
- Long restrictors –> quadriceps/hamstring
- Tibial mechanics
- Fibula
- Foot mechanics
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.
Metatarsus Adductus
Common somatic dysfunctions metatarsus adductus
- Tightness in the medial fascia and adductors of the foot
- Torsion of the first and second metatarsals and innversion rotation of the first cuneiforms
- Everted calcaneus
- Lateral longitudinal arch flattened
- Posterior fibular head
what part of the foot does metatarsus adductus involve?
Forefoot
Hindfoot is relatively flexible
Toddler’s fracture
Subtle undisplaced sprial fracture of the tibia usually seen in preschool children. Caused by a sudden twist, often after an unwitnessed fall
(from reading)
Septic arthritis
An infection of the synovium and joint space.
Staph aureus is the most common organism.
(from reading)
Perthes disease
Idiopathic avascular necrosis of a developing femoral head.
Typically in boys aged 4-8.
Affected children are usually shorter than their peers.
Xray shows sclerosis, fragmentation, and flattening of the proximal femoral epiphysis.
(from reading)
What are children under 3 most vulnerable to?
Septic arthritis and non-accidental injury
from reading
What are children 3-9 years most vulnerable to?
Transient synovitis
from reading
What are children over 9 vulnerable to?
Slipped capital femoral epiphysis
from reading
How can transient synovitis and septic arthritis be differentiated?
Gold standard: Aspirate the joint and identify the presence, or absence, of organisms.
(from reading)
