Pediatric Hip/LE Orthosis

Question 1

Positioned in flexion & abduction in utero leads to tight hip ______ & anteriolateral orientation of acetabulum.

What may cause hip dislocation and what happens to the labrum?

Answer 1

flexors

kicking may cause posterior dislocation and labrum can be everted and flattened

Question 2

Barlow maneuver

- What is a positive test?

Answer 2

• bad - dislocating hip
• from horizontal abducted position, bring leg to horizontal adduct and try to dislocate hip posterior (bad – dislocating hip)
• Positive test: ”clunk” palpated as femoral head slides posteriorly over posterior acetabular rim (“sign of exit”)

Question 3

Ortolani maneuver

- What is a positive test?

Answer 3

• good - relocating hip
  Hips placed in 90 deg flexion (neutral rotation), f/b gentle abduction of the hip while lifting leg anteriorly
• Positive test: ”clunk” palpated as femoral head slides anteriorly over posterior acetabular rim (“sign of entry”)

Question 4

What is the best way to determine a hip dislocation in a 3-13 month baby? What is a positive finding?

Answer 4

hip abduction ROM

• in supine w/ 90 deg hip flexion - hip abducted and abducted
• • finding - <75 deg abduction and 30 deg adduction past midline

Question 5

What is the best way to determine hip dislocation in older children?

Answer 5

observation of limping, Trendelenburg gait, in-toeing, out-toeing

Question 6

What is a Slipped Capital Femoral Epiphysis (SCFE) and what are complications?

Answer 6

• Sudden or gradual anterior displacement of femoral neck from capital femoral epiphysis

Complications

• AVN
• chondrolysis

Question 7

What is the most common disorder of the hip among adolescents? What is the average age for male and female?

Answer 7

Slipped Capital Femoral Epiphysis (SCFE)

Average age

• male - 14.4 years
• female - 12.1 years

Question 8

Symptoms and Physical Exam of SCFE

Answer 8

Symptoms

• knee/lower thigh pain as inital symptom
• medial thigh pain
• pain is dull/aching

Physical Exam

• limping, often ER of involved LE seen at foot
• mild weakness of leg
• Diminished ROM (most limited IR, ABD, flexion)
• unstable - inability to bear weight or consistent with fracture presentations

Question 9

What do patients who have a SCFE have medial thigh pain?

Answer 9

obturator nerve involvement

Question 10

What is Legg-Calve-Perthes Disease and its history?

Answer 10

• Blood supply to femoral head is interrupted and femoral head necrosis begins (unknown cause)

History

• insidious onset
• gradual progression over several years

Question 11

Symptoms and Physical exam of Legg-Calve-Perthes Disease

Answer 11

Symptoms
- vague ache in groin, medial thigh, and medial knee (obturator nerve distribution)

Physical Exam

• gait abnormality
• small child
• thigh muscle atrophy
• ROM limitations (most limited w/ IR and ABD)
• hip flexion/hip ADD contracture

Question 12

What are lifts and wedges used for? What biomechanical changes occur with a wedge?

Answer 12

lifts - leg length discrepancy > 3/8 in

wedge - small leg length discrepancy
- places pt in PF which causes knee extension

Question 13

What are rocker bottom shoes used for?

Answer 13

decrease met head pressure

Question 14

What type of orthotic insert is better for more subluxed, rigid, and deformed feet?

Answer 14

accommodative - provide protection or relief

- better for impaired sensation

Question 15

What type of orthotic insert is better for more normal foot but has extra motion?

Answer 15

functional - control and support the subtalar joint, rearfoot, and/or forefoot
- influences the biomechanics of the foot

Question 16

What is the most common structural foot deformity? What is common with this deformity?

Answer 16

rearfoot varus - inversion of calcaneus

- high arches are common

Question 17

In rearfoot varus, what motion is limited and why?

Answer 17

limited pronation due to lack of calcaneal eversion

Question 18

What does gait of rearfoot varus look like?

Answer 18

increased lateral heel contact, rapid and excessive pronation

Question 19

What is rearfoot valgus? What motions are limited?

Answer 19

rearfoot valgus - eversion of calcaneus in neutral

- limited supination and excessive pronation

Question 20

What are orthotic options for rearfoot varus? Why?

Answer 20

medial wedge - to help control amount of pronation

Question 21

forefoot valgus gait

Answer 21

excessive supination during loading response and stance

Question 22

forefoot valgus orthotic options? Why?

Answer 22

lateral forefoot wedge

- limit supination and promote pronation

Question 23

Which forefoot structural abnormality is more likey to have MSK injuries such as chronic ankle sprains? Why?

Answer 23

forefoot valgus

- more rigid foot that stays in supination so they have trouble distributing forces in foot

Question 24

forefoot varus gait

Answer 24

excessive pronation during stance, lack of re-supination at terminal stance and pre-swing

Question 25

What is the difference between forefoot varus and rearfoot varus?

Answer 25

forefoot varus patients never re-supinate

Question 26

What muscle is typically weak with forefoot varus patients?

Answer 26

posterior tib due to hypermobile subtalar and lack of supination (PF, ADD, INV)
- post tib - plantarflexor

Question 27

forefoot varus orthotic option

Answer 27

Post medial to control pronation bc foot never resupinates prior to push off and patients tend to have flexible foot type

Question 28

What is the goal of prophylactic (PKO) knee brace?

Answer 28

mitigate or prevent soft tissue or ligamentous injury to the healthy knee

Question 29

What is the goal of functional (FKO) knee brace?

Answer 29

• provide mechanical stabilization that is usually provided by anatomical structures
• protect the joint following surgical repair and return to sport