M1-L15: Ax LL Ortho - Normal Variants Flashcards
What are the 2 considerations for the paediatric patient?
- Early musculoskeletal growth & development
- Guide to assessment components
What are the 3 practitioner guides to common paediatric orthpaedic conditions?
- Torsional variations
- Normal and minor variants in the feet
- Developmental Dysplasia of the Hip
What are 7 factors that affect musculo-skeletal development in children?
- Genetics
- major morphological abnormalities occur in the embryonic period (K2-8)
- Nutrition
- If they do not have enough nutrition during pregnancy
- Drugs
- Hormones
- Relaxin (in the mother –> as a result in baby) –> Contraindication for manipulations
- Mechanical forces
- Prenatal / postnatal
- Positioning & movement
- Injury / trauma
- Intervention
- Surgery / splinting / casting / restraints
- Activity
Need to stretch out –> from flexed position to extended position
What are the 2 mechanical forces in children?
- Create or correct an abnormal biologic situation in a growing organism
- Subject to the stretch creep principle
What are the 2 types mechanical forces in children?
- Prenatal Forces
- Postnatal Forces
What are 3 pre-natal forces?
- abnormal maternal structures / intra-uterine space occupying bodies e.g. multiple foetuses
- Can have a problem with twins, triples..etc where there is not enough space
- oligohydraminos - reduced amount amniotic fluid
- Unable to move around as much
- maternal abnormal tone
- Mum can not stretch out –> less room (eg. immobile- in a wheelchair)
What are 2 post-natal forces?
- Habitual positioning (sleeping and sitting)
- Sleeping
- Baby should sleep in supine (to avoid SIDS- sudden infant death syndrome)
- Baby’s will turn head –> baby will get a flat spot (at the back of the head) - parent might not see it sometimes
- Sitting
- W sitting (not natural)
- Can cause abnormal forces in the child’s join
- Sleeping
- Abnormal loading - muscle imbalance
- Abnormal bony development
- Eg. if not cruising well, pull up to stand
- Can cause abnormal femur development
- Abnormal bony development
What are the 4 types of differential diagnosis?
- Muscular
- Bony
- Neurological
- Other
What are 2 types of muscular conditions in children?
- Talipes
- Sprain, strain, tear
What are 5 types of bony conditions in children?
- Planar & torsional variations
- Slipped Capital Femoral Epiphysis
- Osteochondrodysplasias
- Abnormal development, growth of the bone and cartilage (eg. achondroplasia- short limbed dwarfism)
- Fractures
- (eg. jungle gym or trampolines) –> most common fracture activity. Arms and wrist are most common to fractures in children
- Limb deficiency
- Born without part of body (not just traumatic incident)
What is a type of neurological conditions in children?
Unbalanced tone, e.g. CP
What are 2 types other conditions in children?
- Perthe’s Disease - avascular necrosis of capital femoral epiphysis
- Inflammatory e.g. Osteomyelitis
What specific orthopaedic factors can impact development of movement?
- Activity levels
- BMD
- X-ray result s
- Birth history
- Weight
- Length discrepancy
- Gait
- Growth
- Postures
- Habits
- Beighton score
- Observation
- Height (or of relatives)
- Cultural background
- Squatting in Asian population
- Joint position sense
- Esp. for those with hypermobility
What is an example of observation in photograph?
What are 3 characteristics of growth rate?
- not linear
- spurts occur in different tissues at different times
- Girls end up stabilising/plateauing in growth early than boys do
What are the 6 age standardised measures of growth?
- height
- weight
- head circumference
- skeletal ossification
- growth plate fusion
- cellular age
Why is height not always a suitable age standardised measure of growth?
Not very useful for certain conditions (unless they have specific chart of the condition- do not use the normative chart)
Why is head circumference an important age standardised measure of growth? What sorts of children have a large head circumference?
Why? What shorts of children will have large circumference? –> CFS build up called hydrocephalus –> need to see a paediatrician –> which is common in spinal bifida (flaccid paralysis and hydrocephalus) or short limbed dwarfism (relative to body)
Why is growth plate fusion an important age standardised measure of growth? What is the complication?
Fracture through the growth plate
- Stops growing on one side of plate and keeps growing on other side
- Asymmetrical bony development
What are the 3 changes in shape and posture?
- Proportional changes
- Genetic characteristics
- Biomechanical implications
What are 3 characteristics of proportional changes in shape and posture?
- head v body size in and infant v adult
- limb length, trunk length
- growth of organs and soft tissues
Why does it take a a while for a baby to lift their head?
Takes a while for babies to lift up their own head
Why does head need to be quite large when born?
- Need a decent sized brain when you are born
- Once an adult (will be 1/9 of body)
- In dwarfism –> Will have a ratio that is more similar to a child
What is a genetic characteristic in changes in shape and posture?
physique and overall body structure
- Body weight –> related to activity levels and sugar levels
What are 2 biomechanical implications of changes in shape and posture?
- COG in infants = T12, adults = L5- As you grow taller, COG gets lower = more stable
- Normal skeletal growth patterns
- Medial longitudinal arch: infant fat pad
- LL: bow legs (genu varum) –> knock knees (genu valgum)
What does the development of of spinal curves look like?
What are 2 types of abnomal spinal curves?
- Scoliosis
- Kyphosis
What are 2 characteristics of goniometry and plurimetry in AROM and PROM?
- Joint specific protocols
- Very good reliability
What is the purpose of a muscle strength test (MMT)?
Muscle strength & isolation
What is the neurodevelopmental assessment and biomechanical assessment?
Plays a particular role in LL
Who can treat children with orthopaedic conditions impacting movement?
- Physio
- Walking aids (eg. wheelchairs)
- Orthopaedic surgeon (paeds)
- Paediatricians
- OT (esp. upper limb)
- Social worker
- Orthotists
- Dentists
- TMJ
- Teeth reconstruction
- Osteopathy
What are 2 other names for flexible pes planus?
- Hypermobile flat foot
- Flexible pes valgus
What is pes planus?
Physiotherapist must assess to distinguish flexible flat foot from pathological flatfoot deformities due to structural & neuromuscular deformities
What is okay for pes planus and what is not? Why?
Flexible flat foot= okay
Ridgit flat foot = possible blocks –> Gait abnormalities
How do you tension the plantar fascia?
extension of the great toe
What can be done to assess pes plantar? How can it be changed for young and older children?
Tip-toe test
- Can hold on to support (look at feet not balance)
- Young children - get children to reach up –> look at the feet
- Older children - get them to tip toe
What is the treatment for pes planus?
- There is no evidence that flexible flatfoot produces dysfunction
- The only indication for treatment of flexible flatfoot in a child is when there is pain or severe deformity
- Corrective shoes / splints do not affect the natural history of flexible pes planus
- Get better shoes –> heel should be vertical (for support)
- Heel piece and ball piece –> cut out middle –> not good
- Better to get oval shaped (eg. netball shoes) –> more support for flat feet
What is the only indication for treatment in flexible flatfoot in children?
The only indication for treatment of flexible flatfoot in a child is when there is pain or severe deformity.
What is the mistake with Congenital Vertical Talus?
DO NOT MISTAKE THIS FOR ‘FLAT FOOT’
- Very uncommon
When is Congenital Vertical Talus seen?
May be seen in association of other congenital abnormalities
- Eg.. Hip dislocations
What is the treatment for Congenital Vertical Talus?
Surgical correction is required to re-align this congenital anomaly.
What is Congenital Vertical Talus? What are the 5 features of it?
- Hindfoot is in equinus (plantarflexion)
- Talus is vertical
- Talo-navicular joint is subluxed
- Forefoot is abducted & dorsiflexed
- “Rocker bottom” foot
What are the 2 ROM in Congenital Vertical Talus?
- Talo-horizontal angle approaches 90°
- Tibio-talar angle approaches 180˚
What is seen in an AP radiograph for Congenital Vertical Talus?
Increased talocalcaneal angle due to the equinovalgus angulation of the os calcis.
What is seen in a maximum DF test for Congenital Vertical Talus?
Maximum DF test reveals the rigidly fixed hindfoot equinus
- Unable to be corrected
What is seen in a maximum PF test for Congenital Vertical Talus?
Maximum PF test confirms the irreducibility of the midfoot on the hindfoot
What are the 2 features in Metatarsus Adductus?
- Sharp, inward angle of the forefoot
- Inner border of the forefoot is concave
When do children with Metatarsus Adductus usually come to clinic? Why?
Might not a functional problem so only come when they start walking
What is the aetiology of Metatarsus Adductus?
Thought to occur as a result of the infant’s position inside the uterus where the feet are bent inward at the instep
- Might be a packaging problem —> when in utero
What does ambulant mean when there is a child in-utero?
Ambulant –> mum can stretch up –>increase space
What are the 3 assessment of Metatarsus Adductus?
- “V finger test”
- Goniometry
- heel bisector
What is the V finger test in the assessment of Metatarsus Adductus?
What is the goniometry in the assessment of Metatarsus Adductus?
What are the 5 grades of the heel bisector in the assessment of Metatarsus Adductus?
- Normal: bisecting the 2nd and 3rd toes
- Valgus: bisecting the great and 2nd toes
- Mild: bisecting the 3rd toe
- Moderate: bisecting the 3rd and 4th toes
- Severe: bisecting the 4th and 5th toes
What are the 3 grades of flexibility in the foot with Metatarsus Adductus?
- Flexible
- ABD beyond the midline of the heel bisector possible
- Partly flexible
- ABD to the midline of the heel bisector only
- Inflexible
- rigid, no ABD possible
- To first resistance (don’t want to harm/break foot)
What is the 3 options for treatment of Metatarsus Adductus?
- Most (approximately 85%) cases resolve spontaneously
- If physiotherapists & parents decide to undertake gentle passive stretching & splinting, these techniques would be optimum if commenced during the first 8 months of life when there is profound growth & greater compliance of tissue.
-
Very few require surgery and this is usually in later childhood due to balance and gait difficulties
- Only go to surgery if they are unable to walk or run (eg. causes them to trip)
What is the 2 presentations of Postural Talipes Calcaneovalgus?
- Ankle is held in marked DF
- Heel in valgus
Upward and inward position
What is it important to distinguish between in the assessment of Postural Talipes Calcaneovalgus?
- postural talipes calcaneovalgus (TCV)
- fixed/neurological TCV
What are 4 management techniques of postural talipes calcaneovalgus (TCV)?
- gentle passive mobilization
- encouragement of active plantarflexion (Will encourage active kicking)
- encouragement of active inversion
- a dorsolateral splint is sometimes applied
Once correction of postural CTV is attained there ____ )(is still/ is no) potential of relapse
is no
Why should you not swaddle a baby tightly? What is better?
Do not swaddling baby (give them sleeping bag –> better for encouraging movement)
What do Torsional variations in childhood mean?
Rotation abnormalities of the lower limb (eg. out toed and in-toed –> accumulation of rotation of the lower limb)
What are 2 typical development variations?
- Out-ˇtoeing
- In-ˇ toeing
What is the prevalence of out-toeing? What is it due to?
extremely common in infants & young children up to 2 years because of the preponderance of lateral rotation of the hip.
What is the prevalence of in-toeing? What is it due to?
- more common 4-8 years
- Gradual spontaneous correction as muscular activity decreases the medial twist in femur & increased lateral torsion of tibia develops.
What are 2 postnatal mechanical forces on out and in-toeing?
- Habitual positioning (sleeping and sitting)
- Abnormal loading -°© muscle imbalance
What is the contributor to rotation?
Femoral Anteversion
What is the femoral anteversion as a contributor to rotation?
- Femoral head and neck are normally rotated anteriorly with respect to the femoral condyles.
- Femoral anteversion decreases from an average of 40° at birth to 15° at skeletal maturity (25° change).
- The Dermal tibia is externally rotated 5° at birth and 15° at skeletal maturity.
- Total for femur and tibia = 35° of external rotation.
What are 2 contributoris to in-toeing?
- Internal tibial torsion
- Metatarsus Adductus
What are 3 features of internal tibial torsion as a contributor to in-toeing?
- Rotational malalignment > 2SD from normal
- Average adult 10° external rotation @ foot
- Intoeing >10° abnormal
What is a feature of Metatarsus Adductus as a contributor to in-toeing?
Forefoot adduction
What are 3 features of External tibial torsion as a contributor to out-toeing?
- Rotational malalignment > 2SD from normal
- Average adult 10° external rotation @ foot
- Out-toeing >30° abnormal
What are 2 prognositic features of internal tibial torsion as a contributor to in-toeing?
- 90-95% resolve by adulthood
- Can be a functional problem, rarely progresses to surgery
What are 2 functional impacts of external tibial torsion as a contributor to out-toeing?
- 90-95% resolve by adulthood
- Rarely a functional problem
Does ballet dancers have out-toeing?
Increase ROM at hips –> ballet dancers (this is flexibility rather than caused by bones)
What are 4 features of foot progression angle when observting gait (walk and run)?
- Angle from the foot to the line of progression in gait
- Medial rotation is signified by a negative number
- Normal = -5° to + 20°
- Can be normal if combined torsional deformity (e.g. medial femoral torsion + lateral tibial torsion)
When is surgery used as a treatment for these LL conditions/?
Surgery is not used unless if it is a functional issue
When observing, and the patella is internally rotated, what does that mean?
femoral anteversion
When observing, and the patella forward, but medial malleoli directed medially, what do you suspect?
tibial torsion
When observing, and the patella is forward, ankle malleoli in coronal plane, but forefoot directed medially, what do you suspect?
metatarsus adductus
What are the 2 levels for medial rotation for the hip for femoral anteversion?
Prone hip ROM
- Normal = 20-°©60°
- > 70° = femoral anteversion
What are the 2 levels for lateral rotation for the hip for femoral anteversion?
Prone hip ROM
- Normal = 30-60°
- < 20° = femoral anteversion
What is important anterversion for the legs?
Nearly always bilateral & symmetrical
What are the 5 characteristics of thigh-foot angle for tibial rotation?
- Knee bent, foot up
- Compare the line of the central axis of the thigh posteriorly and the central axis of the foot plantarly
- Medial rotation is signified by a negative number
- Normal = O° to 30°
- If < -10° = tibial torsion
What are the 3 normal changes (physiological) in LL alignement from 18 months to 6 years?
What does the normal changes in LL alignment in real children look like?
What are 2 assessments in the LL alignment in children?
- Intercondylar distance
- The width between the knees when the feet are placed as close together as possible
- Intermalleolar distance
- The width between the ankles when thechild’s knees are placed together
What is the intercondylar distance for the assessment of LL alignment?
The width between the knees when the feet are placed as close together as possible
What is the ntermalleolar distance for the assessment of LL alignment?
The width between the ankles when the child’s knees are placed together
What are 3 features of genu varum?
- Seen in typically developing children (0-2 years)
- intercondylar distance (width between knees) when feet are as close together as possible (approximate the medial malleoli) in supine
- If severe, can be corrected by stapling of the lateral femoral growth plate in teenage years
What are the 5 differntial diagnosis of genu varum?
- Physiologic bowlegs
- Infantile tibia vara
- Hypophosphatemic rickets
- Metaphyseal chondrodysplasia
- Focal fibrocartilaginous dysplasia
What are 3 features of genu valgus?
- Seen in typically developing children (4-8 years)
- Increased intermalleolar distance (width between the ankles) when the child’s knees are placed together in supine or standing
- If severe, can be corrected by stapling of the medial femoral growth plate in the teenage years
What are the 5 differential diagnosis of genu valgus?
- Physiological knock knees
- • Hypophosphatemic rickets
- • Previous metaphyseal fracture of the
- proximal tibia
- • Multiple epiphyseal dysplasia
- • Pseudoachondroplasia
What is Developmental Dysplasia of the Hip (DDH)?
Abnormal development or growth of the acetabulum or/and proximal femur –> thereby the femoral head will have an abnormal relationship to the acetabulum
- Subluxation or dislocation is very common
What can be done for the Developmental Dysplasia of the Hip?
Splints keep femur in acetabular until acetabular deepens and HOF is able to maintain in the fossa
- Keep it on for 6-8 weeks
- Can have developmental delay (difficult in prone)
What are the 4 classifications of Developmental Dysplasia of the Hip?
- Subluxable
- femoral head can be partially displaced to the rim of the acetabulum
- Not coming outside of the joint
- Dislocatable
- femoral head is in the socket but it can be displaced completely outside the acetabulum with manual pressure.
- Able to be dislocated and relocated
- Dislocated
- femoral head lies completely outside the hip socket but can be reduced with manual pressure.
- Already in the position (can be reduced in this position with manual pressure)
- Teratologic
- femoral head lies completely outside the hip socket & cannot be reduced with manual pressure
- Unable to relocated
What are potential causes of Developmental Dysplasia of the Hip (DDH)?
- positioning in-utero- Extreme flexion (feet very close in head) or breeched delivery (feet first)
- hormonal influences- Relaxin
- genetic predisposition
- swaddling practices may have an impact on the incidence of DDH- Full bilateral extension –> does not develop femur head/acetabular relationship
What are 2 DDH assessments from birth?
- Observation / function (all staff / parents)
- unequal creases in the buttocks or thighs
- difficulty in spreading the legs
- inequality in leg length
- Manual assessment (paed / surgeon only)
- Ortolani
- Barlow
What are 3 DDH assessment from 2-4 weeks of age?
- Observation / function (all staff / parents)
- unequal creases in the buttocks or thighs
- difficulty in spreading the legs
- inequality in leg length
- Manual assessment (paed / surgeon only)
- Ortolani
- Barlow
- USS to image hip joint development
What are 3 DDH assessment from after 6 weeks of age?
- Observation / function (all staff / parents)
- unequal creases in the buttocks or thighs
- difficulty in spreading the legs
- inequality in leg length
- Manual assessment (paed / surgeon only)
- Ortolani
- Barlow
- hip x-ray
What are 3 DDH assessment for an older age?
- Observation / function (all staff / parents)
- unequal creases in the buttocks or thighs
- difficulty in spreading the legs
- inequality in leg length
- Manual assessment (paed / surgeon only)
- Ortolani
- Barlow
- Observe gait
What are 4 orthopaedic assessment for DDH?
- Early diagnosis
- Routine neonatal screening
- by a paediatrician
- Referral to orthopaedic surgeon
- Concomitant findings
- Approximately 8% of children with torticollis will also have hip disease
What are the 2 features in the Ortolani manouvre in the surgeon’s assessment for DDH?
- Initial downward pressure further dislocates the hip, which then
- relocates as the thigh is adducted. A palpable “clunk” will be noted.
What are the 2 features in the Barlow manouvre in the surgeon’s assessment for DDH?
- The leg is pulled forward and then
- adducted in an attempt to dislocate the femur.
What are 4 orthopaedic management of a DDH?
- Reduction
- Maintenance of reduction
- until stability is obtained & normal growth & development is observed
- Splinting
- Restrict hip EXT & ADD
- Hips maintained FLEX & ABD
- Surgery
- required for teratologic hips as deformity of hip surfaces is significant
What are the 4 splinting devices for DDH?
- Pavlik harness
- Von Rosen splint
- Sydney Children’s splint
- Plaster orthosis
What does a Pavlik harness look like?
What does a Von Rosen splint look like?
What does a Sydney Children’s splint look like?
What does a Plaster orthosis look like?
