Musculoskeletal Conditions Children Flashcards
Bony structure children
Physis - growth plate, causes longitudinal bone growth
Epiphysis - cartilagenous, then develops into secondary ossification centres
Apophysis - grows where large tendon attaches to the bone, contributes to overall shape of the bone
increased blood vessel concentration = reduced density
- means more elastic, highly vascular speeds up healing
Apophysitis - pathophysiology
traction of the msucle tendon unit on the apophysis distraction
causes very localised pain and swelling
can occur at any apophysis in the body
Apophysitis - assessment
onset related to increased activity or growth spurt
very localised pain
pain with contraction of relevant muscles
pain with palpation of local site
very localised swelling
Apophysitis - management
self limiting - will eventually resolve once the growth plate closes and ossifies need to manage their pain load reduction and modification stretching of involved muscle strengthening of involved muscles address biomechanics
Osteochrondroses - pathophysiology
disorder of the subchondral bone
may follow trauma/microtrauma
avauscular necrosis can cause it
family genetic defect
Osteochondritis Dissecans
can develop from osteochondroses - when bony damage causes loose bony fragment
has pain and may develop severe mechanical symptoms
Osteochondroses - management
Type 1 and 2 - activity modifcation, immobilisation
Type 3 and 4 - surgical intervention
Diaphysis/Metaphysis Fracture
Greenstick - partial fracture, doesn’t completely break the bone
Plastic Bowing - bone bent with pressure and doesn’t return to normal position
Buckle - crush fracture, tend to occur at metaphysis
Physis Fractures
Salter-Harris Classification of fractures Type 1 - straight across the physis Type 2 - above the physis Type 3 - lower than the physis Type 4 - two or through the physis Type 5 - erasure of teh physis
Avulsion Fracture
occur at the attachment of large tendons or ligaments to bone
Manage through load management, rest, gradually reloading
Red Flags Fractures
complete diaphysis fracture - not normal for childrne
Paediatric Limp - Red Flags
refusal to walk
pain
out toeing - when acute and with pain
Potential Diagnosis Limp 0-3yo
septic arthritis
DDH
fracture
soft tissue injury
Potential Diagnosis 3-10yo
irritable hip
septic arthritis
Perthes disease
Potential Diagnosis 10-15yo
SUFE septic arthritis Perthes disease fracture soft tissue injury
Acetabular Dysplasia
develops from DDH
Transient Synovitis/Irritable Hip
most common cause of hip pain in 2-10 yo diagnosis of exclusion - need to rule out other possibilities first Present with - limp - all movement is limited by discomfort - anterior thigh, groin or knee pain - normal x-ray Should begin to resolve within 3 days Be fully resolved by 2 weeks
Perthes Disease - pathophysiology
avascular necrosis of the femoral head
Perthes Disease - presentation
Presentation
- typically young male <13 yo
- usually small, thin and extremely active
- limp which is exacerbated by activity
- mild pain in groin, thigh or knee
- reduced ROM into Abduction, IR and maybe hip flexion
- gluteal atrophy
Perthes Disease - management
want to maintain the height of the femoral head
reduced weight bearing
use orthotic devices if needed
if >8 yo = require surgery
Leg Length Discrepancy - pathophysiology
Potential Causes
- congenital
- neurological conditions
- trauma
- infection
- tumours
- juvenile arthritis
- DDH
- perthes
- SUFE
Leg Length Discrepancy - assessment
Observation - gait, in standing, scoliosis, look at spine in sitting Galeazzi sign Measure anatomical landmarks x-ray CT scan
Leg Length Discrepancy - management
<1.5-2cm = monitor 1.5-2.5cm = shoe raise >2.5 cm - refer to ortho for surgical opinion - shorten longer limb - if >5cm lengthen shorter limb
Slipped Upper Femoral Epiphysis - Pathophysiology
femoral head slips from its normal allignment with the femoral neck at the physis
most common hip condition in adolescents
caused by weakness of and excessive stress through the growth plate
hormonal imbalances
Slipped Upper Femoral Epiphysis - patient demographic
adolescent 11-13 yo mainly
male
recent growth spurt
may be obese
Slipped Upper Femoral Epiphysis - Presentation
antalgic limp LL held in ER - out toeing Hip ROM restricted in IR and Abd passive ER when passively flex the hip leg shortened on the affected side ACUTE - sudden onset of severe pain - unable to WB on LL - pain with all movements CHRONIC - dull vague pain in the groin, thigh, and knee - able to WB on LL
Slipped Upper Femoral Epiphysis - Management
REFER TO ED
- need to be non weight bearing - wheelchair
Surgery - growth plate stabilisation and pinning of femoral head
Rehab
- NWB 2-6wks post op
- maintain ROM and strength
- hydro
- gait training
Osgood Schlatter Disease - pathophysiology and presentation
apophysitis of the tibial tuberosity mainly in 11-15yo pain with knee extension TOP of tibial tuberosity localised swelling
Osgood Schlatter Disease - assessment and management
don't require imaging load management stretching strengthening address biomechanics
Sinding Larsen Johanssen Disease
apophysitis of the inferior pole of the patella
TOP inferior pole of patella
less common
Sever’s Disease - pathophysiology and presentation
calcaneal apophysitis
heel pain
10-12 yo
affects boys more than girls
Sever’s Disease - assessment and management
+ve squeeze test - pain with mediolateral compression of teh calcaneal growth plate
reduced DF ROM
recommend use of heel raise - temporarily de-load the area load management stretching strengthening address biomechanics
Pes Cavus - pathophysiology and presentation
may be a sign of Charcot Marie Tooth Disease - need to assess for neuropathy
may have pain
high arch with clawed toes
Pes Cavus - assessment and management
Neurological assessment
foot structure
Scoliosis - non structural vs structural
Non-Structural - non progressive, fixed
Structural - progressive, fixed
Scoliosis - Structural types
Neuromuscular
- result of spasticity, weakness, abnormal strength
- pulled into position
- develop contracture and lengthening, results in scoliosis
Congenital
- failure of formation
- may have partial or complete hemivertebrae
- failure of natural segmentation
Idiopathic
Scoliosis - Management
monitor as they grow
manage pain
Surgery - if arc is greater than 40 degrees
- aims to reduce magnitude of deformity and prevent cardiopulmonary function regression
Shouder Pain Syndromes
mainly affect children who participate in lots of shoulder activity
- overhead sports
manual wheelchair
may have other pre existing conditions - fracture
Shoulder Stress Fracture
occur at the growth plate
involved in sports with lots of throwing
have pain with throwing
Shoulder Stress Fracture - assessment and management
pain on palpation
x-ray shows widening of teh epiphyseal line
rest
load management
progressive throwing program
Rheumatology - red flags
atypical injury for age and situation prolonged loss of function night pain fever visual deficits weight loss
Rheumatology - red flags
atypical injury for age and situation prolonged loss of function night pain fever visual deficits weight loss
Rheumatology Non-Inflammatory conditions
haemophilia
osteogenesis imperfects
arthrogyposis
hypermobility
Rheumatology Inflammatory
JIA
Osteomyelitis
Septic arthritis
Haemophilia
x-linked blood clotting disorder
severe spontaneous bleeding in muscles and joints
persistent joint effusion and chronic synovitis
effects multiple joints
Pulled Elbow
subluxed radial head mainly in very young children history of tension on pronated forearm pain pseudopalsy - refuse to use the arm refer to GP
Elbow Apophysitis
chronic apophysitis of the medial elbow
may also have avulsion fracture and lateral structure compression - can cause osteochondritis dissecans
history of overuse
pain with valgus force movements
Osteogenesis Imperfecta
Brittle bone disease
abnormal type 1 collagen
bones more susceptible to fracture and may not form properly
Arthrogryposis
disorders characterised by multiple joint contractures affecting two or more body areas prior to birth
physical symptoms, not diagnosis
Acute Osteomyelitis/Septic Arthritis
Osteomyelitis - bacterial infection of bone, affects the metaphysis of long bones
local inflammation can lead to necrosis and bone absorption
Septic Arthritis - bacterial infection of the joint
rapid onset of pain
all movement of the joint are painful
Manage - antibiotics, surgery
physio to address any complications
Goal of Physio Rheumatology
minimise pain protect joints maintain FROM prevent contractures preserve joint allignment maintain muscle strength address motor control, balance and proprioception Exercise - to maintain build strength and endurance, advice on sport participation
Resistance Training Children
6-12yo - body weight only
13-17yo - load lifted for at least 6 reps, no maximal lifts
18yo - weight lifting allowed
To calculate weight
- assess 8-15reps, see when they fatigue/lose form
Juvenile Idiopathic Arthritis - pathophysiology
cause is unknown, autoimmune disease
age onset <16yo
most children will grow out of their condition
Juvenile Idiopathic Arthritis - presentation
active inflammation >6 weeks swelling hot pain stiffness, worse in morning rash/fever fatigue muscle weakness
Juvenile Idiopathic Arthritis - impact on muscle system
swelling
swelling reduces = ligament laxity
inflammation of adjacent muscles and tendons
pain and fatigue
results in reduced activity = reduced AROM and eventually PROM
reduced strength
poor nutrition to cartilage
results in cartilage damage and erosion, narrows the joint space
causes joint remodelling and deformity
Juvenile Idiopathic Arthritis - Management
medication - to control the disease process
Physio
- activity modification
- hyro
- splinting
- avoid vicious cycle of damage and inactivity
