Pediatric MSK problems Flashcards
1
Q
In-toeing/out-toeing torsion what should you look for/ask
A
- w-sitting is typical but with abnormalities it can exacerbate them
- history: want to know prenatal history, delivery etc
- age questions: when did you notice this and how is it affecting them
- family history: was someone else having issues with toeing in or out
- sleeping and sitting positions: ex: stomach sleeping can cause ER at hips
2
Q
Examination of pediatric MSK problems
A
- observe child walking especially when they do not know they are being watched
- supported stance foot progression angle (FPA): walking on a floor with a line to look at if they are diverting in or out form the line
3
Q
Contributing factors to in-toeing
A
- femoral anteversion
- internal tibial torsion
- metatarsus adductus
- w-sitting
4
Q
In-toeing clinical features
A
- tripping and falling often is a presentation
- often noticed around 2 years old
- internal rotation:
1. 70-80 degrees: mild FA
2. 80-90 degrees: moderate FA
3. 90 degrees= severe FA
5
Q
Internal Tibial Torsion- how can it be corrected in children?
A
- children may have to wear bracing that looks like a snowboard
- this will help turn out the tibia
- some braces are made to allow for more mobility
6
Q
Metatarsus adductus or varus causes
A
- infant foot
- caused by intrauterine pressure, osseous abnormality and abnormal muscle attachments
- some genetic component
- contractures of soft tissue around tarsometatarsal joints
7
Q
Out Toeing
A
- rare in infants
- detected when held upright
- should not go beyond 2 years of life
8
Q
causes of out-toeing
A
- slipped capital femoral epiphysis
- legg-calve-perthes disease (LCP)
- idiopathic osteonecrosis of the hip
- neuromuscular disorders
9
Q
External tibial torsion
A
- worsens over time
- late childhood and adolescence is when they are diagnosed
- rotational deformity
- requires surgery
- derotational tibial osteotomy
- will complain of pain
10
Q
- genu varum
A
- concerning if present after age 4 years
- if anterolateral bow of tibia = X-rays needed
- at risk of fractures the first year of life
- most common cause blount disease
- can be hereditary
11
Q
genu valgus
A
- many are overweight
- gait patterns is circumduction
- angular deformity, anterior and medial knee pain are common
12
Q
Talipes varus vs talipes valgus
A
- walks on the outter portion of the foot
- walks on the medial portion of the foot
13
Q
talipes equinus vs talipes calcaneus
A
- in more plantar flexion
- ankle in more dorsiflexion
14
Q
what is clubfoot/metatarsus adductus
A
- congenital talipes equinovarus
- 1-2/1000 births
- different grades of severity
15
Q
Clubfoot/metatarsus adductus: treatment/goal of treatmetn
A
- serial casting birth up to 9 years to get into typical position using ponsetti method
- may need surgery if casting does not work
- goals:
1. full loading
2. plantigrade position
3. wear normal shoes
16
Q
Post ponsetti method improvments
A
- ambulation improves
- development of milestones improves
- motor learning (if left in this position they will develop bad movement patterns)
- balance
- strenght
- functional movement skills
17
Q
Surgical correction of alignment abnormalities- what indicates it/what do they do?
A
- timing: so important generally earlier if casting is no working
- age dependent usually infants
- severity
- soft tissue release
- muscle transfer if muscles are not functioning
18
Q
Cavus foot
A
- abnormal elevation of the longitudinal arch of the foot
- forefoot equinus
- hindfoot calcaneus or varus deformity
19
Q
cavus foot and associated neurologic consitions
A
- 2/3rds have CP, spinal cord or charcot-marie-tooth disease (an immune disease that affects joints and causes them to maintain a contracted position - similar to arthritis)
20
Q
- surgical procedures of cavus foot
A
- soft tissue releases (plantar fascia)
- tendon transfer (especially with nerve damage)
- ostotomies: metatarsal, midfoot, or calcaneal osteotomies
- fusions: triple arthrodesis used as a last resort or children who are immobile to reduce risk of fractures
21
Q
when are feet normally flat until
A
- 2 years and sometimes 6 years
- there are flexibilty flatfoot and rigid flatfeet
22
Q
flexibile flatfeet
- signs
- treatment
- what occurs at subtalar and forefoot
A
- most common pediatric foot “deformity”
- uneven medial shoe wear down
- orthotics can improve uneven shoe wear
- tightness of the gastrocsoleus muscle
- higher incidence of flatfeet in blacks
- subtalar joint is DF, ER,
- midfoot: abducted
forefoot is supinated in relation to hindfoot
23
Q
Test for flexibility in flat feet
- windlass test or jack’s toes raising test
A
- looks at how flexible the plantar fascia is
- can be done in sitting or standing
- when the foot is flat on the ground you raise the big toe and watch if the arch height increases or decreases
24
Q
Calcaneovalgus:
- commonly seen
- treatments
A
- commonly seen with CP, spina bifida, idiopathic flatfoot
- treatments:
1. stretching
2. ankle foot orthosis or supramaleolar orthosis
3. sometimes surgery
4. serial casting
25
rocker bottom foot
- less commone
- surgery is needed
- similar to calcaneovalgus
- sometimes with mild cases splinting is needed
26
Knee injuries: adults in relation to kids
- lower incidence in children than in adults
- knee injuries are the most common cause of permanent disability in adults
27
Overuse injuries
- 50% of injuries in children are overuse
- stress fractures
- joint injuries
- muscle and tendon injuries
28
overuse injuries are related to
- increased participation in sports
- increase in specialization
- complex, longer training at younger ages
29
Injury prevention - pre participation examination
- vital sings, height, weight
- orthopedic exam
- flexibility and strength assessment
- body composition
- speed, agility, power, balance, endurance
30
Prevention of injuries
- improve muscle reaction time and proprioception
- muscle strengthening as a daily training routine
- physical examination
- diagnosis of muscular imbalances of functional restrictions
- proper use of protective equipment
- adequate field and surface playing conditions
- changes of rules in sports
31
training programs
- individualized based on age and development
- energy training aerobic and anaerobic
- resistance
- speed
- nutrition and hydration
32
Risk factors for injury
- training errors
- muscle tendon imbalance
- anatomical malalignment
- improper foot wear (suggested to replace every 3 months)
- playing surface
- disease
- growth-related factors
33
Scoliosis types
- idiopathic
- congenital
- neuromuscular
- degenerative
34
Scoliosis
- lateral deviation of spine from is central axis greater than 10º
35
Structural scoliosis
- person actually has a physical curve
36
functional scoliosis
- person appears to have a curve but caused by another condition such as a different in leg length or muscle spasm
- spine will compensate to maintain symmetry
37
What can happen with scoliosis
- can cause trunk imbalances that increase the likelihood for muscle spasms and others leading to pain
38
How does scoliosis progress
- many children is can progress quickly and become deadly
- accelerates during growth spurts
- estimated that it increases about 0.82º per year
adolescent scoliosis is the most common 11-18 years
39
Kyphosis types
- congenital
- postural
- scheuermann's kyphosis
40
Congenital kyphosis
- babies born with kyphosis often need surgery at a young age
41
postural kyphosis
- due to poor posture which is increased in girls
- shows up in teens
- if not self-corrected by standing up straight tan PT and bracing is needed for curves create than 65º
42
Scheuermann's kyphosis
- spinal bones grow in an abnormal wedged fashion
- usually in teens,
- physical therapy, medication, bracing and surgery are needed
43
Halo traction
- used for scoliosis and kyphosis
- upward pulling of the head and spine using a weighted pull system to elongate and straighten the spin
- stay in the hospital lasts nearly 3 months
- not as painful as it looks and you must watch for infections
44
backpack safety: what to look out for
- muscle strain can be caused by improper backpack use
- numbness/tingling
- tripping
- they don't cause scoliosis
- should not be carrying more than 15% of body weight in the backpack
- put the heaviest items low and near the center of the back
45
Growth related injury risk factors
- affects the growth plate
- osteochondritis
- apophysitis (inflammation of apophysis)
- severs
- osgood-schlatters diseases
- musculotendinous junction
46
apophysis
- secondary ossification center which acts as an insertion site for tendons
47
Types of injuries in bone
- stress fracture
- epiphyseal plate fracture
- shaft fracture (more common in adults
48
Salter-harris classification of growth plate fractures
- type 1: Straight across
- type 2: Above
- type 3: Lowe or beLow
- type 4: Two or Through
- type 5: ERsture of growth plate or cRush
49
Head injuries from sports
1. concussion = mild traumatic brain injury
- more common in skeletally mature kids
- rest and return to play guidelines are important
2. skull fracture: environmental trauma, shaken baby syndrome, birth trauma
50
cervical injuries from sports
1. damage to CNS leading to paralysis
- football causes most injuries
- tends are high % risk of kids who have this
2. hyperflexion or hyperextension injury:
- caused by tackling
3. traction injury to brachial plexus (burner)
51
Thoracic spine injuries from sports
- rara
- costovertebral injury
- occurs with high impact
52
lumbar spine injuries from sports
1. spondylolysis
- result of overuse and hyperextension of the lower back often with gymnastics, racket sports, wrestling and football
- stress fracture to pars interarticularis
2. spondylolisthesis: may require surgery
- slippage
- usually L5 overS1 or L4 over L5
53
Shoulders injuries from sports
more mature MSK tends to have these
1. acromioclavicular sprains:
- fall on an outstretched arm
- common in skeletally mature
2. clavicular fracture
- direct blow
- middle third
3. dislocation: anterior or posterior
4. rotator cuff:
- impingement
- tears
- 50% of swimmer 12-18 years
54
little league shoulder
- affects proximal humeral physis of the throwing arm
- skeletally immature youth baseball pitchers 13-16 years
- overuse injury
- widening of the growth plate at the humeral scapular junction
- also know as epiphysiolysis, epiphysis, osteochondrosis, apophysitis or stress fracture of the proximal humerus
- can also occur in swimmers, and football quarterbacks
55
elbow injuries from sports
1. supracondylar fracture
- 2nd most common fracture
- 5-10 years old
- landing on an outstretched arm
56
other elbow fractures
- epiphyseal fracture of radial head from pitching (occurs at growth plate)
- subluxation of radial head = nursemaid's elbow (don't pull on the arms of young kids)
- elbow dislocation = throwing injury
- little league elbow: extreme valgus and stress on epicondyles (overuse)
- tennis elbow (lateral epicondylitis = overuse)
57
wrist and hand injuries from sports
- age rrelated
- distal radial epiphysis fracture in the younger population
- distal radius and ulna fracture in children 10+
- navicular and scaphoid fractures 12-15 years old that fall on a dorsiflexed hand with elbow extended
58
mallet finger-
- caused be over stretching
- extensor tendon ruptures
- or an avulsion injury
- long, ring, and small fingers of the dominate hand
59
bony Gamekeepr's (skiers thumb)
- MCP joint
- chronic or acute
- partial or complete rupture of the UCL
- hyperabduction trauma of the thumb
60
Pelvis and hip injuries: avulsion fractures
- common sites
- caused by
- common in what sports and situations
- avulsion fractures
- occurs most commonly at ASIS, ischium, lesser trochanter, AIIS, iliac crest
- related to a sudden stretch or strong muscle contraction
- common in sprinting, soccer, jumping, football, weight lifting
- can happen with child abuse
61
pelvis and hip injuries: stress fracture or osteitis pubis
- related to micro trauma
- occurs more in runners
- bone scan to identify stress fracture
- snapping hip =IT band irritation
- vascular necrosis
- hip pointer bruise to iliac crest (mostly in football na hockey)
62
knee injuries
- distala femoral epiphyseal fracture
- proximal tibial epiphyseal fracture
- ACL injuries
- avulsion frractures
- meniscal injuries
- patellar femoral malalignment: most frequent in young children
- intrapatellar tenditinitis (jumpers knee)
- patellar subluxation or dislocation (high impact and change in positions) – most common in soccer dancing, cheerleading, gymnastics, track
63
Blount's disease
- 3 years and up
- lateral epiphysis is not growing but medial is
- abnormality of the growth plate in the upper part of the tibia
- awkward walking
- persistent bowing leads to discomfort in hips, knees, nakles
- adolescents experience pain
- bracing for tubers and up to adolescence
- surgery over 4 years old
64
Q-angle
- pull from quad can cause valgus and a wider stance
- normal angle should fall between 8-20º
- women <22 degrees with knee extension and less then 9 with knee in 90º of flexion
- men <18 in knee extension and 8º in 90º of knee flexion
65
injuries of the ankle and foot
- distal tibia and fibula growth plate fractures related to ankles sprains
- metatarsal stress fractures
- avascular necrosis of metatarsal epiphysis - Freiburg infarction (often seen in toe walkers)
- ankle sprains
66
Sever's disease
- most common cause of heel pain in growing children
- growth plate in the back of the heel becomes inflammed and painful
- caused by repetitive stress on growth plate
- usually between 8-13 years old
- most common with basketball and socer
67
symptoms of sever's disease
- heel pain with limping especially after running
- swelling and redness
- foot discomfort and stiffness after sleeping
- pain when the heel is squeezed on both sides
