Pediatric Orthopedic Conditions

Question 1

What are the three stages of musculoskeletal development in children?

Answer 1

1. Embryonic: Limb buds form by the 4th week, and cartilaginous skeletal templates develop by 12 weeks.
2. Prenatal: Bone modeling occurs minimally; intrauterine positioning can lead to conditions like clubfoot or torticollis.
3. Postnatal: Rapid bone remodeling (50% annually in toddlers) with growth influenced by mechanical forces.

Question 2

Define endochondral ossification and appositional growth in bone development.

Answer 2

Endochondral ossification is the process of bone length growth via epiphyseal plates.

Appositional growth refers to the increase in bone diameter by layering new bone on existing structures.

Question 3

What are prenatal deformations, and what are common examples?

Answer 3

Prenatal deformations are musculoskeletal abnormalities caused by mechanical forces in utero.

Common examples include:

• torticollis (shortened neck muscle)
• clubfoot (inward foot positioning)
• metatarsus adductus (forefoot adduction)

Question 4

What is torticollis, and what causes it?

Answer 4

Torticollis is a condition characterized by the shortening or spasm of the sternocleidomastoid muscle, causing the head to tilt to one side and rotate to the opposite side.

It is often caused by intrauterine positioning or birth trauma.

Question 5

What is clubfoot (congenital talipes equinovarus), and what are its primary features?

Answer 5

Clubfoot is a congenital condition where the foot is twisted inward and downward.

Features include:

• forefoot adduction
• hindfoot varus
• ankle equinus (limited dorsiflexion)

Question 6

Differentiate between intrinsic and extrinsic causes of prenatal deformations.

Answer 6

Extrinsic causes are external mechanical forces such as limited uterine space or abnormal fetal positioning.

• Intrauterine constraints

Intrinsic causes involve fetal factors like genetic conditions or neuromuscular disorders.

• Fetal hypomobility, 2nd to diagnosis

Question 7

What is developmental dysplasia of the hip (DDH), and what factors contribute to its development?

Answer 7

DDH is a condition where the hip joint is improperly aligned, leading to instability.

Factors include breech delivery, first-born status, female gender, and a family history of hip dysplasia.

Question 8

What are the key differences between in-toeing and out-toeing in children?

Answer 8

In-toeing refers to inward rotation of the feet, often caused by femoral anteversion or tibial torsion.

Out-toeing refers to outward rotation, commonly due to femoral retroversion or external tibial torsion.

Question 9

What is femoral anteversion, and how does it present in children?

Answer 9

Femoral anteversion is an inward twisting of the femur, causing in-toeing and a W-sitting posture.

It is normal in young children but typically resolves by age 8-10.

Question 10

What is Blount disease (tibia vara), and what are its types?

Answer 10

Blount disease is a growth disorder of the proximal tibia causing bowing of the leg.

• Types include infantile (onset before age 4), adolescent (onset after age 10), and late-onset.

Question 11

What is the normal remodeling process of the tibial torsion in children?

Answer 11

Medial tibial torsion (in-toeing) in infants naturally derotates as they grow, leading to neutral or slightly outward tibial torsion by adolescence.

Question 12

How does intrauterine positioning affect musculoskeletal development?

Answer 12

Limited space or abnormal positioning in utero can cause deformities like clubfoot, torticollis, or hip dysplasia due to mechanical forces on the developing skeleton.

Question 13

What is Legg-Calvé-Perthes Disease, and what population is most affected?

Answer 13

Legg-Calvé-Perthes Disease is avascular necrosis of the femoral head, most commonly affecting boys aged 4-8 years.

Question 14

What is Slipped Capital Femoral Epiphysis (SCFE), and how does it differ from Legg-Calvé-Perthes Disease?

Answer 14

• Slipped Capital Femoral Epiphysis (SCFE) is the displacement of the femoral head at the growth plate, typically in adolescents.
• Unlike Legg-Calvé-Perthes, which is ischemic, SCFE is often associated with obesity or rapid growth.

Question 15

What is the difference between functional and structural scoliosis?

Answer 15

Functional scoliosis is caused by external factors like poor posture and is reversible.

Structural scoliosis involves fixed spinal deformities and requires more intensive management.

Question 16

What are the common signs and symptoms of developmental dysplasia of the hip (DDH) in infants?

Answer 16

Signs include:

• limited hip abduction
• asymmetrical thigh folds
• positive Ortolani and Barlow tests
• leg length discrepancy (Galeazzi sign)

Question 17

How is the Ortolani test performed, and what does a positive result indicate?

Answer 17

The Ortolani test involves abducting the infant’s hip while applying gentle anterior pressure.

• A positive result (a click or clunk) indicates reduction of a dislocated hip, suggestive of DDH.

Question 18

What does a positive Barlow test indicate?

Answer 18

The Barlow test involves adducting the infant’s hip with posterior pressure.

• A positive result (hip dislocation) indicates hip instability associated with DDH.

Question 19

What are the clinical features of torticollis in infants?

Answer 19

Features include head tilt toward the affected side, rotation to the opposite side, limited cervical ROM, and a palpable SCM mass.

Question 20

What diagnostic tools are used to confirm developmental dysplasia of the hip (DDH)?

Answer 20

Ultrasound is used for infants under 6 months, and X-rays are used for older infants and children to confirm DDH.

Question 21

What are the common postural presentations of in-toeing in children?

Answer 21

In-toeing often presents as W-sitting, tripping during gait, and medial-facing feet. It may be caused by femoral anteversion or tibial torsion.

Question 22

What are the typical clinical presentations of scoliosis in children?

Answer 22

Signs include uneven shoulder or hip levels, a visible curve in the spine, rib hump on forward bending, and potential back pain in severe cases.

Question 23

What is the Galeazzi sign, and what does it indicate?

Answer 23

The Galeazzi sign involves comparing knee heights while the infant is supine with hips and knees flexed. Unequal heights indicate leg length discrepancy, often due to DDH.

Question 24

What physical examination findings are consistent with clubfoot?

Answer 24

Findings include forefoot adduction, hindfoot varus, and limited ankle dorsiflexion (equinus). The foot appears twisted inward and downward.

Question 25

What are the clinical signs of Blount disease (tibia vara)?

Answer 25

Signs include progressive bowing of the lower legs, inward knee angulation, and, in severe cases, knee instability or pain.

Question 26

How does a scoliometer assist in scoliosis assessment?

Answer 26

A scoliometer measures the angle of trunk rotation (ATR) during a forward bend test to identify and quantify spinal curvature.

Question 27

What are common symptoms of Legg-Calvé-Perthes Disease?

Answer 27

Symptoms include hip or groin pain, limited hip ROM (especially abduction and internal rotation), limping, and leg length discrepancy.

Question 28

How does the thigh-foot angle test differentiate between tibial torsion types?

Answer 28

The thigh-foot angle test measures the angle between the axis of the thigh and the foot. A negative angle indicates internal tibial torsion, while a positive angle indicates external tibial torsion.

Question 29

What is the role of ROM testing in diagnosing rotational deformities?

Answer 29

ROM testing evaluates hip rotation and thigh-foot angles to identify in-toeing or out-toeing caused by femoral anteversion or tibial torsion.

Question 30

What are the diagnostic imaging options for Slipped Capital Femoral Epiphysis (SCFE)?

Answer 30

X-rays (AP and frog-leg lateral views) are used to confirm SCFE, showing displacement of the femoral head relative to the neck.

Question 31

What is the primary treatment for developmental dysplasia of the hip (DDH) in infants under 6 months?

Answer 31

The Pavlik harness is the primary treatment, which holds the hips in flexion and abduction to promote proper alignment and joint development.

Question 32

What surgical intervention is used for severe or unresponsive cases of DDH?

Answer 32

Open or closed reduction of the hip joint, often combined with spica casting, is used to realign the femoral head and acetabulum.

Question 33

What are the key physical therapy interventions for torticollis?

Answer 33

PT focuses on stretching the affected SCM, strengthening the contralateral neck muscles, promoting symmetrical developmental milestones, and educating caregivers on positioning strategies.

Question 34

What is the Ponseti method, and what condition does it treat?

Answer 34

The Ponseti method is a non-surgical treatment for clubfoot, involving weekly manipulation and casting, followed by bracing to maintain correction.

Question 35

What orthotic devices are commonly used to manage scoliosis in children with curves less than 40 degrees?

Answer 35

Common orthoses include the Boston brace and Milwaukee brace, designed to prevent further curve progression during growth.

Question 36

What surgical options are available for severe scoliosis?

Answer 36

Surgical options include spinal fusion with instrumentation, such as rods and screws, to correct and stabilize the curvature.

Question 37

What conservative treatments are recommended for in-toeing caused by femoral anteversion?

Answer 37

Conservative treatments include postural education, encouraging activities like sitting cross-legged, and avoiding W-sitting, which can exacerbate in-toeing.

Question 38

What is the recommended treatment for Legg-Calvé-Perthes Disease during its early stages?

Answer 38

Treatment includes activity modification, physical therapy to maintain hip ROM, and bracing or casting to offload the joint and prevent deformity.

Question 39

What is the primary management approach for Slipped Capital Femoral Epiphysis (SCFE)?

Answer 39

Immediate surgical stabilization using in situ pinning to prevent further slippage and complications like avascular necrosis.

Question 40

How is Blount disease typically managed in young children?

Answer 40

Bracing is often the first-line treatment for infantile Blount disease, but severe cases may require surgical correction like tibial osteotomy.

Question 41

What role does PT play in managing limb length discrepancies (LLD)?

Answer 41

PT focuses on gait training, strengthening, and balance exercises. Shoe lifts or orthotics are used for smaller discrepancies, while surgical intervention may be required for larger ones.

Question 42

What surgical techniques are used to address limb length discrepancies greater than 2 cm?

Answer 42

Techniques include epiphysiodesis (slowing growth on the longer limb) or limb lengthening procedures using external fixators like the Ilizarov device.

Question 43

What is the typical treatment progression for clubfoot after Ponseti casting is complete?

Answer 43

A Dennis-Browne bar is used for bracing to maintain correction, worn 23 hours per day initially, and then reduced to nighttime use.

Question 44

What PT interventions are used to manage scoliosis in patients not undergoing surgery?

Answer 44

PT focuses on core strengthening, postural exercises, flexibility training, and breathing exercises to improve spinal alignment and respiratory function.

Question 45

What treatments are recommended for adolescents with external tibial torsion causing out-toeing?

Answer 45

Surgical correction, such as tibial derotation osteotomy, may be considered if the torsion causes significant functional impairments or pain.

Question 46

An infant presents with asymmetrical thigh folds and a positive Ortolani test. What condition is likely, and what is the first-line treatment?

Answer 46

The likely condition is developmental dysplasia of the hip (DDH). The first-line treatment is the Pavlik harness to maintain hip flexion and abduction.

Question 47

A 5-year-old boy presents with a limp and hip pain, and imaging shows avascular necrosis of the femoral head. What condition is likely, and what is the initial treatment?

Answer 47

The likely condition is Legg-Calvé-Perthes Disease. Initial treatment includes activity modification, PT to maintain ROM, and bracing or casting as needed.

Question 48

A 12-year-old girl has a visible spinal curvature and rib hump on forward bending. What condition is suspected, and what diagnostic tools are used?

Answer 48

The suspected condition is scoliosis. Diagnostic tools include a scoliometer for trunk rotation measurement and X-rays to assess spinal curvature.

Question 49

A newborn’s foot appears twisted inward and downward, with limited dorsiflexion. What condition is likely, and what treatment method should be initiated?

Answer 49

The likely condition is clubfoot (congenital talipes equinovarus). The Ponseti method involving manipulation and serial casting should be initiated.

Question 50

A 13-year-old boy presents with groin pain and difficulty bearing weight. X-rays reveal slippage of the femoral head. What condition is diagnosed, and what is the recommended treatment?

Answer 50

The diagnosis is Slipped Capital Femoral Epiphysis (SCFE). The recommended treatment is immediate surgical stabilization with in situ pinning.

Question 51

A 10-year-old child has progressive bowing of the legs and inward knee angulation. What condition is suspected, and what treatment may be required?

Answer 51

The suspected condition is Blount disease (tibia vara). Treatment may include bracing or surgical correction such as tibial osteotomy.

Question 52

A parent reports their child prefers W-sitting and has inward-facing feet. What condition is likely, and what PT recommendations should be made?

Answer 52

The likely condition is in-toeing caused by femoral anteversion. PT recommendations include discouraging W-sitting and encouraging activities that promote external rotation, like sitting cross-legged.

Question 53

A 3-month-old infant presents with a palpable SCM mass and limited cervical ROM. What condition is likely, and what are the primary PT interventions?

Answer 53

The likely condition is torticollis. Primary PT interventions include stretching the affected SCM, promoting symmetrical movements, and educating caregivers on positioning.

Question 54

A 14-year-old with scoliosis has a Cobb angle of 45 degrees. What treatment options should be considered?

Answer 54

Treatment options include surgical intervention such as spinal fusion to correct and stabilize the curve, as bracing is generally not effective at this severity.

Question 55

A 6-year-old child has a leg length discrepancy of 3 cm. What are the potential treatment options?

Answer 55

Treatment options include shoe lifts for smaller discrepancies and surgical interventions like epiphysiodesis or limb lengthening for larger discrepancies.