Lower extremity problems in kids Flashcards by Cherylene Abalos

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

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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

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What must be integrated for gait to evolve?

Integration of the visual, vestibular, and somatosensory (proprioceptive) systems

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At what age to children develop an adult gait?

5-6 years

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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.

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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

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What do you look for in gait evaluation?

In-toeing
Out-toeing
Arm swing
Range of motion- global active and passive
Joint evaluation
Muscles

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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

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Signs and symptoms of Developmental dysplasia of the hip (DDH)

Asymptomatic

- Decreased ROM hip, difficulty with diaper change, delayed crawling, standing, walking

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When is the best time time to detect DDH

Early detection before 6 months gives best outcome

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Exam for DDH

Ortalani and Barlow

- Requires XR if positive or high suspicion

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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

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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

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XR of Legg-Calve-Perthes

Narrowed and irregular epiphysis

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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

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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

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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

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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

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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

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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)