Peds Quiz #3 Flashcards
What is an Obstetric Brachial Plexus Injury (OBPI)?
- Obstetric Brachial Plexus Injury (OBPI) is a type of brachial plexus injury that occurs during delivery, often due to trauma to the shoulder or spine.
- Results from traction or compression of the brachial plexus nerves.
- This injury can range from mild (stretching of nerves) to severe (nerve rupture or avulsion).
- It is commonly associated with difficult vaginal births, including shoulder dystocia or breech presentations.
What are the four types of brachial plexus lesions?
(1) Avulsion: The nerve is torn away from its attachment to the spinal cord.
- Most severe form and typically irreversible.
(2) Rupture: The nerve is completely torn but remains detached from the spinal cord.
(3) Neuroma: Scar tissue grows around the injured nerve, applying pressure and preventing proper conduction.
(4) Neurapraxia: A stretch injury where the nerve remains intact but temporarily loses function.
- Neurapraxia has the best prognosis for recovery.
What is the clinical presentation of Erb’s Palsy?
Erb’s Palsy involves injury to the C5-C6 nerve roots, sometimes C7.
The affected limb assumes a “waiter’s tip” position:
- shoulder adduction, internal rotation, and extension; elbow extension;
- forearm pronation; and
- wrist/finger flexion.
Grip strength is typically intact since the lower nerve roots (C8-T1) are unaffected.
If C7 is involved, elbow, wrist, and finger extension may also be impaired.
What is the clinical presentation of Klumpke’s Palsy?
- Klumpke’s Palsy involves the C8-T1 nerve roots and results in “claw hand” deformity due to weakness in the intrinsic hand muscles and wrist/finger flexors.
- The forearm often rests in supination.
- Shoulder and elbow movements are typically unaffected.
In severe cases, it may be associated with Horner’s Syndrome, which presents as:
- ptosis (drooping eyelid)
- miosis (constricted pupil)
- anhidrosis (lack of sweating) on the affected side
What is the difference between Erb’s Palsy and Global Palsy?
Erb’s Palsy:
- Involves injury to the upper nerve roots (C5-C6, sometimes C7)
- Primarily affecting shoulder and elbow function.
Global Palsy:
- Affects the entire brachial plexus (C5-T1), resulting in complete paralysis and sensory loss of the arm.
- Global Palsy typically has a more severe prognosis and may include additional complications like Horner’s Syndrome.
What are the risk factors for Obstetric Brachial Plexus Injury?
Risk factors include:
- macrosomia (birth weight >4500 grams)
- shoulder dystocia
- prolonged labor
- maternal diabetes
- breech delivery
- use of mechanical assistance (forceps or vacuum)
- hypotonic infants (floppy babies)
These factors increase the likelihood of traction or compression on the brachial plexus during delivery.
- shoulder dystocia = obstetric emergency that occurs when a baby’s shoulder gets stuck during vaginal delivery
What is the purpose of the Active Movement Scale in brachial plexus examination?
The Active Movement Scale (AMS): Assesses voluntary muscle function in children with brachial plexus injury. It grades movement from
- 0 (no contraction), to
- 7 (full motion against gravity).
- 4 = Full joint motion
- AMS is critical in determining motor recovery, guiding therapy plans, and identifying candidates for surgical intervention.
How is sensory grading performed for brachial plexus injuries?
Sensory grading for brachial plexus injuries is based on response to stimuli:
- S0: No response to painful or touch stimuli.
- S1: Response to painful stimuli only.
- S2: Response to touch but not light touch.
- S3: Normal sensation.
This grading helps evaluate sensory recovery and guide intervention strategies, particularly in cases of neuroma or rupture where sensory function may be impaired.
What interventions are used to prevent contractures in brachial plexus injuries?
- Gentle range-of-motion (ROM) exercises are essential to prevent contractures in affected joints.
- These exercises should focus on maintaining flexibility in the shoulder, elbow, wrist, and fingers.
- Splinting or positioning devices may also be used to promote proper alignment and prevent fixed deformities, especially in cases of long-term nerve dysfunction.
Why is caregiver education critical in managing brachial plexus injuries?
- Caregiver education ensures consistency in performing home exercises, maintaining positioning, and monitoring the child’s progress.
- Caregivers play a vital role in encouraging active use of the affected limb during daily activities and preventing neglect of the limb.
- Without caregiver involvement, therapeutic benefits may be limited.
What are key surgical interventions for brachial plexus injuries?
Surgical options include
- nerve grafting (replacing damaged nerve segments with donor tissue)
- nerve transfers (redirecting functional nerves to replace damaged ones).
- Surgery is typically recommended if no significant recovery is observed by 3-8 months, especially in cases of avulsion or rupture.
- Early surgery is more effective in restoring function and preventing long-term deficits.
What are the indications for nerve transfer surgery in brachial plexus injuries?
Nerve transfer surgery is indicated in severe cases like avulsion or rupture when spontaneous recovery is unlikely.
Key signs include
- the absence of biceps function by 3 months old, or
- minimal improvement in other muscle groups
- The procedure aims to reinnervate paralyzed muscles and improve limb function.
How does kinesiotaping support therapy in brachial plexus injuries?
- Kinesiotaping provides support and promotes proper alignment by facilitating or inhibiting specific muscles.
- For example, it may enhance activation of weak shoulder stabilizers while reducing spasticity in overactive muscles.
- This adjunct therapy complements active and passive exercises to improve function and prevent compensatory patterns.
How does electrical stimulation assist in the treatment of brachial plexus injuries?
- Electrical stimulation helps activate weak or paralyzed muscles, promoting neuromuscular reeducation and preventing muscle atrophy.
- It is particularly useful in outpatient settings for muscles that have partial innervation or are beginning to recover from neurapraxia.
- This modality is often used in conjunction with active movement exercises.
What are the long-term outcomes of untreated brachial plexus injuries?
Untreated brachial plexus injuries may lead to
- permanent weakness
- sensory deficits
- joint contractures
- In severe cases, limb function may be severely impaired, impacting the child’s ability to perform age-appropriate activities and potentially leading to lifelong disability.
- Early intervention significantly improves outcomes.
What is Congenital Muscular Torticollis (CMT)?
Congenital Muscular Torticollis (CMT) or “wry neck,” is a condition characterized by unilateral shortening of the sternocleidomastoid (SCM) muscle, leading to:
- Lateral head tilt toward the affected side
- Rotation to the opposite side.
- It may involve other muscles like the scalenes, levator scapulae, and upper trapezius.
- It often develops due to intrauterine positioning, birth trauma, or postnatal factors like prolonged positioning.
What are the associated conditions with CMT?
- Conditions commonly associated with CMT include:
- deformational plagiocephaly (skull asymmetry due to positioning)
- congenital hip dysplasia
- brachial plexus injury
- facial asymmetry
- scoliosis
- foot deformities (metatarsus adductus)
- These associations highlight the importance of a thorough examination beyond just the neck.
What prenatal, perinatal, and postnatal factors contribute to CMT?
Prenatal:
- intrauterine positioning
- ischemic injury to SCM leading to compartment syndrome.
Perinatal:
- breech presentation
- use of forceps/vacuum
- birth trauma
Postnatal:
- positional preference
- plagiocephaly
- reflux
- These factors influence the degree and severity of SCM shortening.
How is CMT severity classified?
According to the APTA’s Clinical Practice Guidelines, CMT severity is graded from
- 1 (mild, early identification), to
- 8 (severe, late identification and significant ROM limitations).
Severity is based on
- the age of identification
- degree of cervical ROM restriction
- presence of an SCM mass
- age at physical therapy evaluation.
- Higher grades indicate a poorer prognosis if untreated.
What are the three types of cranial deformation associated with plagiocephaly?
Plagiocephaly:
- Flattening on one side of the back of the head, with asymmetrical ear and facial alignment.
Brachycephaly:
- Generalized flattening of the back of the head, leading to a wide and short skull shape.
Dolichocephaly (Scaphocephaly):
- Long, narrow head shape often seen in premature infants due to extended time in the NICU.
- These deformations can occur secondary to CMT.
What are the 7 key components of a PT examination for CMT?
- Infant posture in supine, prone, sitting, and standing.
- Bilateral active cervical rotation, lateral flexion, and diagonal movements.
- Passive and active ROM of the cervical spine and extremities.
- Hip screening for dysplasia.
- Pain assessment (e.g., FLACC scale).
- Integumentary evaluation (skin folds and integrity).
- Craniofacial assessment for asymmetry and deformities like plagiocephaly.
- These components guide diagnosis and treatment planning.
What is the Muscle Function Scale, and how is it used for CMT?
The Muscle Function Scale measures active lateral head righting ability in infants with CMT.
- It assesses the strength of the SCM & other neck muscles during lateral flexion against gravity.
- Scoring ranges from
- 0 (no response), to
- 4 (full ability to hold the head laterally aligned for >5 seconds)
- This scale helps monitor progress and guide strengthening interventions.
What are the primary interventions for CMT?
Interventions include:
- Stretching exercises for cervical rotation and lateral flexion.
- Strengthening of cervical and trunk muscles through active head righting and midline control.
- Positioning techniques to avoid prolonged postures and encourage symmetrical development.
- Tummy time to promote prone play and neck strengthening.
- Parent education for home exercises and positioning.
- These approaches aim to restore cervical ROM, prevent deformities, and support symmetrical developmental milestones.
How can kinesiotaping assist in CMT treatment?
Kinesiotaping
- Provides sensory input to facilitate active movement or inhibit overactive muscles.
- For CMT, it may help activate weakened neck muscles on the non-affected side or provide gentle resistance to improve alignment and reduce reliance on passive structures.
- It complements manual therapy and positioning.
What is the purpose of cranial orthoses in plagiocephaly management?
Cranial orthoses, like the DOC Band or STAR Band, are used to remodel the shape of the skull in infants with plagiocephaly or severe asymmetry.
- These devices are typically prescribed around 4-5 months of age (after head control develops) and are worn 23-24 hours per day.
- They apply gentle pressure to redirect growth toward flattened areas, improving cranial symmetry.
When are Botox injections indicated?
Botox injections may be used in severe CMT cases to reduce overactivity in the SCM or upper trapezius muscles, allowing for more effective stretching and active movement.
- These injections are typically paired with intensive physical therapy to optimize outcomes.
What surgical interventions are available for severe CMT?
Surgical options include
- Distal SCM release
- Z-plasty for severe cases unresponsive to conservative treatment.
- Surgery is typically considered after 12 months of age and involves cutting the shortened SCM to allow for greater ROM.
- Post-operative splinting and intensive therapy are essential to prevent recurrence.
What factors influence the prognosis of CMT?
Early identification and intervention significantly improve outcomes.
- Infants diagnosed before 3 months of age typically achieve full ROM and symmetrical development.
- Late identification, severe ROM limitations, and the presence of an SCM mass are associated with poorer prognoses.
- Persistent deformities may lead to secondary issues like plagiocephaly, facial asymmetry, and scoliosis.
What are the benefits of prone positioning in CMT treatment?
Prone positioning, or tummy time =
- strengthens neck and trunk muscles
- promotes symmetrical development
- counters the effects of supine positioning that may worsen deformational plagiocephaly.
- Encouraging at least 30-60 min/day helps infants develop head control and improves cervical ROM.
What is the referral process for cranial orthosis treatment?
- Referral for cranial orthoses typically occurs at 4-5 months of age when head control develops.
- Evaluation by a specialist determines the need for treatment.
- Delayed referral may reduce the effectiveness of orthoses as cranial sutures begin to close.
What is pediatric cancer?
Pediatric cancer refers to the uncontrolled growth of abnormal cells in children, which do not function properly and may crowd out normal cells.
- These cancers often start at a primary site and may metastasize to other areas.
Unlike adult cancers, they are less likely linked to environmental factors
- More often associated with genetic or developmental processes.
What are the general risk factors for pediatric cancer?
Risk factors for pediatric cancers include
- genetic predispositions (e.g., Down syndrome, Li-Fraumeni syndrome)
- environmental exposures (e.g., ionizing radiation toxic chemicals)
- developmental abnormalities.
- Unlike adult cancers, lifestyle factors (e.g., smoking, diet) are typically not significant contributors in pediatric cases.
What are common signs and symptoms of pediatric leukemia?
- Common symptoms include:
- anemia (fatigue, pallor)
- thrombocytopenia (easy bruising, bleeding)
- neutropenia (frequent infections)
- bone pain
- fever
- lymphadenopathy (enlarged lymph nodes)
- splenomegaly
- hepatomegaly
- These symptoms result from overproduction of immature white blood cells, crowding out normal bone marrow function.
What are the common symptoms of CNS tumors in children?
Symptoms vary based on tumor location but may include:
- headaches
- seizures
- drowsiness
- nausea/vomiting
- poor coordination
- ataxic gait,
- changes in speech, vision, or hearing
- Tumors in the posterior fossa (e.g., medulloblastoma) often present with balance and coordination deficits.
- Tumors in the cerebral hemispheres may cause focal neurological signs.
How are CNS tumors typically treated in pediatric patients?
Depending on tumor type, size, and location, CNS tumors are treated with a combination of:
- surgery
- radiation therapy
- chemotherapy
- For example, medulloblastoma often requires surgical resection followed by radiation and chemotherapy.
- Radiation is generally avoided in children under 3 years old due to its severe cognitive effects.
What differentiates Hodgkin lymphoma from Non-Hodgkin lymphoma in children?
Hodgkin lymphoma:
- Primarily affects older children/adolescents
- Presents with painless cervical or supraclavicular adenopathy, night sweats, fatigue, and weight loss.
- Survival rate of 98%
Non-Hodgkin lymphoma (NHL):
- More common in younger children
- Presents with abdominal swelling, changes in bowel habits, or respiratory symptoms.
- NHL varies based on subtype, with a survival rate of ~91%.
What is neuroblastoma, and where does it commonly occur?
Neuroblastoma is the most common extracranial solid tumor in infants.
- Typically arising from the adrenal glands or sympathetic nervous system.
- Commonly metastasizes to lymph nodes, bones, and bone marrow.
- Often presents as a palpable, hard mass in the neck or abdomen.
- Other symptoms depend on tumor location and may include
- pain
- paralysis (if nerves are involved)
- systemic (fever & weight loss)
What are the main treatment modalities for sarcomas in children?
Sarcomas (Osteosarcoma, Ewing sarcoma, rhabdomyosarcoma) are treated with a combination of
- surgery (e.g., limb-sparing or amputation),
- chemotherapy,
- sometimes radiation therapy
- Pre-operative (neoadjuvant) chemo may reduce tumor size.
- Post-operative (adjuvant) chemo/radiation ensures local and systemic control.
- Osteosarcoma = Bone tumor
- Ewing Sarcoma = Bone or soft tissue
- Rhabdomyosarcoma = Soft tissue
What are the key features of retinoblastoma?
Retinoblastoma is a malignancy of the retina.
- Most common in children under 6 years.
- It can be unilateral (75% of cases) or bilateral.
- It may present with
- leukocoria (white reflection in the pupil)
- strabismus (misaligned eyes - cross eyed)
- visual deficits
- Treatment options include
- radiotherapy
- laser therapy
- chemotherapy
- enucleation (removal of the eye) for advanced cases
What are the clinical features of Wilms tumor, and how is it staged?
Wilms tumor is a nephroblastoma commonly diagnosed in children aged 3-4 years.
- Presents with
- abdominal swelling/mass
- fever
- anemia
- hypertension
- COG Staging System:
- Stage I: continued in kidney, removed by surgery
- Stage II: grown beyond kidney (nearby fatty tissue or blood vessels, removed by surgery
- Stage III: Not fully removed by surgery, cancer remains in abdomen
- Stage IV: Spread by blood or organ away from kidney
- Stage V: tumor in both kidneys
- Treatment
- surgery
- chemotherapy
- possibly radiation (depending on the stage)
What are the primary side effects of chemotherapy in children?
Side effects vary but often include:
- fatigue
- nausea/vomiting
- chemotherapy-induced peripheral neuropathy (CIPN)
- hair loss
- bone marrow suppression (causing anemia, thrombocytopenia, and neutropenia)
- cognitive deficits
- Long-term effects may include
- infertility
- osteoporosis
- secondary cancers
What is Staheli’s rotational profile, and how is it assessed?
Staheli’s rotational profile measures lower extremity alignment through:
- the foot progression angle,
- hip rotation (IR/ER),
- thigh-foot angle,
- transmalleolar axis
- For example, medial rotation of the hip >70° may indicate femoral anteversion.
- This assessment identifies abnormal torsional patterns contributing to in-toeing or out-toeing.
What is metatarsus adductus, and how is it classified?
Metatarsus adductus is a congenital forefoot deformity where the forefoot is adducted relative to the midfoot.
- It is classified into three grades:
- Grade I (mild): Fully correctable beyond the lateral border of the foot.
- Grade II (moderate): Corrects to neutral.
- Grade III (severe): Does not correct to neutral.
- Treatment includes stretching, serial casting, or Bebax shoes for severe cases.
What is clubfoot (talipes equinovarus), and how is it managed?
Clubfoot (talipes equinovarus) is a congenital deformity characterized by:
- forefoot adduction
- hindfoot varus
- ankle plantarflexion.
- Causes include
- intrauterine positioning
- neuromuscular (myelomeningocele)
- Management includes
- Ponseti method (manual correction followed by serial casting)
- Achilles tenotomy for residual equinus deformity
- PT interventions focus on developmental skills, weight-bearing, and ambulation.
What are the classifications of DDH?
Subluxable: Femoral head in the acetabulum but partially displaceable.
Dislocatable: Head can be fully dislocated using maneuvers (e.g., Barlow).
Subluxed: Head is partially displaced but reducible.
Dislocated: Head is completely out of the acetabulum and unreducible without intervention.
What are the Ortolani and Barlow maneuvers, and how do they detect DDH?
The Ortolani maneuver reduces a dislocated hip by abducting and externally rotating the hip while applying gentle pressure.
- A palpable “clunk” indicates reduction.
The Barlow maneuver tests for dislocatable hips by adducting and applying posterior pressure to a flexed hip.
- Both are most effective before 2 months of age for detecting hip instability.
What is the management strategy for DDH in infants under 6 months of age?
Pavlik harness is the first-line treatment for infants under 6 months.
- It holds the hips in flexion (90-100°) and abduction, promoting proper alignment of the femoral head in the acetabulum.
- The harness is worn 23-24 hours/day.
- Complications include avascular necrosis and femoral nerve palsy if improperly fitted.
What is arthrogryposis multiplex congenita (AMC), and what are its clinical features?
Arthrogryposis multiplex congenita (AMC) is a non-progressive condition characterized by multiple congenital joint contractures due to reduced fetal movement.
- Clinical features include cylindrical limbs without skin creases, symmetrical joint contractures, hip dislocations, muscle atrophy, and intact sensation.
- Common deformities include shoulder internal rotation, elbow extension or flexion, wrist flexion, and clubfoot.
How is AMC managed during infancy?
- Management includes positioning and stretching, serial casting, and splinting to prevent contractures.
- Physical therapy focuses on developmental progression (e.g., sitting, standing) and bracing to support mobility.
- Parent education is essential for home stretching and positioning routines.
- Surgical corrections may address severe deformities.
What is osteogenesis imperfecta (OI), and what are its key clinical features?
Osteogenesis Imperfecta (OI) is a genetic connective tissue disorder affecting collagen production, leading to fragile bones.
- Key features include frequent fractures, bowed long bones, spinal deformities, muscle weakness, and ligament laxity.
- Other findings include hearing loss, growth deficiency, and cardiopulmonary issues.
- There are eight types
- Type II = lethal
- Type III and VIII = severe
What are common interventions for osteogenesis imperfecta?
Osteogenesis Imperfecta (OI) interventions include:
- pharmacologic treatments (e.g., bisphosphonates to improve bone density)
- orthopedic management (e.g., IM rods, soft splints), and
- rehabilitation
- PT focuses on safe mobility, strengthening, and aquatic therapy to reduce fracture risk.
- Handling and positioning in infancy are critical to prevent injury.
What is Legg-Calve-Perthes disease, and what are its signs and symptoms?
Legg-Calve-Perthes is an avascular necrosis of the femoral head.
- Most common in boys aged 3-13 years.
- Symptoms include groin, thigh, or knee pain, a limp or Trendelenburg gait, and decreased hip ROM (especially abduction and internal rotation).
- The condition progresses through four stages:
- condensation
- fragmentation
- reossification
- remodeling
How is Legg-Calve-Perthes disease managed?
Early management includes
- pain relief (anti-inflammatories),
- traction,
- partial or non-weight bearing with crutches
- Orthotic bracing (e.g., abduction braces) supports proper alignment.
- Surgical options, such as femoral osteotomy, may be used for severe cases.
- PT focuses on restoring ROM, strengthening, and gait training post-surgery.
What is Slipped Capital Femoral Epiphysis (SCFE), and what are its causes?
Slipped Capital Femoral Epiphysis (SCFE) is the displacement of the femoral head at the growth plate, typically anteriorly and superiorly.
- It most commonly occurs in adolescents and is associated with factors like obesity, hormonal imbalances, femoral retroversion, and certain conditions (e.g., Down syndrome).
- SCFE is more common in boys and presents with pain in the groin, medial thigh, or knee and limited hip flexion, abduction, and internal rotation.
How is SCFE managed, and what role does PT play?
- Management involves surgical stabilization, such as pin fixation, to prevent further slippage.
- PT is crucial post-surgery, focusing on gait training with assistive devices, maintaining knee and ankle ROM, core strengthening, and gradual return to weight-bearing activities.
- Open-chain exercises and aquatic therapy may be introduced early to improve strength without stressing the hip.
What are the treatment options for Blount disease?
- Early stages may be treated with orthotics to realign the tibia, but surgical intervention (e.g., tibial osteotomy) is required for severe deformities or older children.
- PT focuses on lower extremity strengthening, ROM exercises, and gait training to improve functional mobility and reduce compensatory patterns.
What is a limb length discrepancy (LLD), and what are its common causes?
Limb Length Discrepancy (LLD) refers to a difference in the length of the lower extremities
- Caused by congenital limb deficiencies, fractures, growth plate injuries, neuromuscular disorders, or tumors.
- It may lead to compensatory gait patterns, scoliosis, and functional limitations.
- Differences greater than 2 cm typically require intervention.
How is LLD managed?
Management depends on the severity:
- < 2 cm: Shoe lifts.
- 2-5 cm: Guided growth (epiphysiodesis) or femoral osteotomy.
- >5 cm: Limb-lengthening procedures, such as external fixation or internal lengthening devices.
- PT plays a key role in post-surgical rehabilitation, focusing on ROM, strength, and gait mechanics to ensure proper function.
What is scoliosis, and what are its types?
Scoliosis is a lateral curvature of the spine >10°, classified as:
- Functional (due to posture or leg length discrepancy)
- Neuromuscular (from CP or other pathologies)
- Idiopathic (unknown cause, often in adolescents)
- Idiopathic scoliosis is the most common
- particularly in girls aged 10-13
- becomes significant when the curve exceeds 30°
How is scoliosis treated, and what role does PT play?
Treatment depends on curve severity:
- 25-40°: Bracing to slow progression
- >40°: Surgical correction with spinal rods
- PT focuses on postural education, muscle strengthening, flexibility, and post-operative care, including spinal precautions, bed mobility, and transfer training.
- For functional scoliosis, addressing the underlying cause (e.g., LLD) can resolve the issue.
