week 3 assessment and management of MSK cond. in infancy Flashcards
1. Outline the musculoskeletal development seen in infants and children 2. Describe the changes seen in lower limb alignment in infants 3. Outline musculoskeletal conditions seen in infancy 4. Outline some current physiotherapy intervention strategies for infants with musculoskeletal conditions
1
Q
Features at birth
A
- kyphosis from Cx to sacrum
- Hip flexion/ Lateral rotation
- IR of tibia
- Equinus position of feet (upward)
- varied limitations of hip, knee, elbow extension
2
Q
Outline the musculoskeletal
development seen in infants and
children (muscle and bone)
A
*response to physical demands.
Muscle:
- tension leads to longitudinal growth
- rapid fetal growth stretches muscles and stimulates it to grow longer and at the same rate as bone
Bone:
- after birth, long bones grow in length at epiphyseal plate
- cartilaginous plate stages: Proliferates> chondrocytes> convert to bone> ossification
3
Q
Describe the changes seen in
lower limb alignment in infants
A
normal changes:
- newborn: genu varum
- 1-2 years starts to straighten out
2-4 years can develop genu valgum, some males genu varum
these are normal
4
Q
Neonatal fractures : when are they common and what is the Rx, how long ?
A
- common during delivery (shoulder dystonia - shoulder gets caught during birth)
- Rx = immobilisation (eg. in a tubigrip)
- healed within 2 weeks
5
Q
The normal foot :
describe features +
how infant differs from adults (structure and ROM)
A
-26 bones
Most cartilagenous at birth:
- hindfoot = calcaneus and talus
- midfoot - navicular, cuboid, cuneiform bones
- forefoot = metatarsals and phalanges
Infant ROM> adult
6
Q
Foot deformities in infancy
A
talipes or pes = foot
- equinus = plantar flexion
- varus = turns in
- valgus = turns out
- pes planus = flat feet
- pes cavus - high arch
7
Q
Clubfoot
definition, features and Outcome measure scoring
A
a complex congentical contractual malalignment of the foot and ankle
features: C: cavus A: adductus V: carus E: equinus
(+ wasted calf muscles , empty heal)
Pirani Score
8
Q
Management of Clubfoot (what is the gold standard, what are the results)
A
A conservative method of casting and splinting, with minimal surgery is now seen as the gold standard Rx of clubfoot
Results :
- good long term outcomes
- low rates of relapse
- min requirements for extensive corrective surgery
9
Q
Describe the Pirani Score
A
A. Curvature of lateral border B. Medial crease C. Lateral head of talus D. Posterior crease E. Emptiness of heel
10
Q
Postural foot deformities
A
- talipes equinovarus
- overriding toes
- talipes calcaneovalgus
11
Q
Management of postural foot deformities
A
- careful Ax to rule out serious causes (eg. congenital vertical talus, neurological conditions)
- “unpack the baby”
- gentle stretches if needed
- reassure parents
- monitor resolution
- Check for DDH and head preference
- encourage tummy playtime
12
Q
Congenital Vertical talus
A
- talar head prominant medially
- sole is convex
- forefoot abducted and DF’d
- hindfoot is in equinovalgus
- rocker bottom foot
- often associated with other abnormalities (meningomyelocoele)
13
Q
Myelomeningocoele associated foot deformity
and management
A
a birth defect that occurs in the early weeks of fetal development. It is the most common and most serious type of spina bifida
The paralysis can lead to deformities of the legs, feet, and back.
(management can include serial casting)
14
Q
Developmental Dysplasia of the Hip (DDH) (what is it?/ aetiology? presentation?)
A
- abnormal development of the hip joint
Aetiology:
- intrauterine positioning resulting in a stretched posterior capsule
- neurological condition
The hip presents as dislocated, dislocatable or subluxed
15
Q
Management of DDH
A
- all babies screened at birth
(Ortolani or Barlow) - Diagnosis confirmed with US
- Irremovable splint fitted on day 1 if possible
-other splints available (Von Rosen Splint- only 1.2% failure rate)
16
Q
Physiotherapy management of DDH
A
- understanding of DDH May suspect the condition if: - limb length discrepancy - assymetry of movement - limited ROM of hip ABd - asymmetrical thigh folds - limping of waddling gait (toddler) *may be associated with torticollis*
Immediate referral or orthopaedic review
17
Q
Torticollis ( what is it secondary to?)
A
- skeletal
- neurological
- muscular (SCM, muscular tightness, postural)
- visual disorder
18
Q
What is congenital muscular torticollis (CMT) ?
Sand S’s?
A
-shortening of the SCM + tumour
SandS’s:
- tilt head toward affected muscle
- rotated toward contralateral side
-upper traps can also be involved and contribute to neck deformity
19
Q
What is CMT prevalence and cause?
A
- prevalence varies (0.3%-2.0%)
causes = unknown
20
Q
What happens if toricollis persists ?
A
craniofacial deformities or plagiocephaly can occur
21
Q
Torticollis - things to rule out in subjective/objective
A
- History - VIP: rule out ==
- Reflux
- Pharyngeal abscess
- Cervical rib
- CTEV, DDH
- Older child (visual and/or hearing)
22
Q
deformational plagiocephaly (what it is, what are signs?)
A
- postural condition
- oblique, mishapen, parallelogram head
- repeated external pressure to the head as a result of being in the one position for extended lengths of time (eg. sleeping)
- flattening of occipital bone
- more prominent head and cheek on that side
- ear pushed forward compared with the other
23
Q
Craniosynostosis (what is it? what imaging can be used to DDx between plagiocephaly?)
A
- skull asymmetry
- premature fusion of one or more skull sutures
- x-rays +/- CT scans
24
Q
Prevention and management of plagiocephaly ?
A
-professional Ax and advice (infant positioning is associated with early head orientation and plagiocephaly) parent often reports assymetry during wakening and sleep
- from birth: alternate the head position when sleeping
- encourage active head control strategies (prone, sideways lift, etc. )
- if no improvement after 2 sessions = medical review to rule out pathology (craniosynostosis, Cx rib)
-do NOT refer for helmet unless specialist review has occured
25
Brachial plexus palsy (what is it?)
trauma to spinal roots of C5- T1 (brachial plexus)
26
Causes of brachial plexus palsy
1. prenatal:
- in utero positioning
2. Trauma related to labour:
- shoulders get stuck
3. delivery:
- shoulder dystocia due to extra force required to deliver shoulders
27
Common Types of brachial plexus palsy (Erb- the nerve roots and presentation)
Erb : (whole arm)
- C5-C6 nerve roots - upper brachial plexus palsy
presentation :
- shoulder ADD/IR
- elbow ext.
- forearm pronated with wrist flexed
=-absent Moro; intact grasp
- 'waiters' tip position
28
Test for brachial plexus palsy where baby is held and slightly dropped to see for reaction of arms spread out.
Moro reflex
29
Common Types of brachial plexus palsy (Klumpe- the nerve roots and presentation)
Klumpe: (wrist)
- C7-8, T1 nerve roots- lower brachial plexus palsy
presentation :
- small muscles of hand with localised wrist drop
- flaccid paralysis of hand
- absent grasp
30
Other Types of brachial plexus palsy: Entire arm involvement
(cause/presentation)
- all the trunks in brachial plexus are damaged
Presentation:
- total paralysis of the arm with flaccidity and sensory, trophy and circulatory changes
- absent reflex
31
Other Types of brachial plexus palsy: Phrenic nerve paralysis
(cause/presentation)
- injury to C3-5 nerve roots
| - generally associated with brachial plexus palsy
32
Other Types of brachial plexus palsy: Horner's syndrome
| cause/presentation
- clinical syndrome caused by damage to the sympathetic nervous system
- may be caused by birth trauma
- associated with brachial plexus palsy
- other features: Ptosis = dropping upper eyelid from loss of sympathetic innervation
33
Brachial plexus assessment (background medical info)
- background info
- medical review
- CNS + PNS exam (gentle) and documentation
- X-ray - fractures, hemidiaphragm (phrenic nerve injury)
- serology (eg. exclude septic joint)
34
Brachial plexus assessment (objective)
- observe (supine and prone - including alertness, shoulder muscle wasting, marked deformities)
- spontaneous movement whole baby
- sucking (facial nerve)
- active movement - shoulder abduction (Moro), elbow flexion (recoil or stroking of biceps), wrist extension (placing reaction - eg.dorsal surface of hands/feet on table)
- Passive movement (including shoulder ER in neutral
- sensation (eg. tickling, stroking)
- Other problems : # clavicle or humerus, postural foot deformities, torticollis, DDH
35
Brachial plexus palsy- Early management (24-48 hrs)
- pain relief
- parental reassurace (90% recover in 3/12)
- minimal handling - do not passively move/range arm
- swaddling with hands to mouth
- swaddling bathing
- positioning affected side up for feeding and sleeping
- education parents/staff re: supporting arm with handling
- peanut pillow
36
Brachial plexus palsy : ongoing management
- gentle passive movements : esp. shoulder ER (in neutral)
- stimulation of affected muscle groups (eg. C5-6 : deltoid and infraspinatus muscles (mainly C5) and biceps (mainly C6)
- monitoring progress: (joint ranges, muscle power and neurology)
- movements are carried out with great care to avoid possible damage to shoulder, elbow and MCP jt of thumb.
- encourage hands to mouth
- daily deep warm bath (providing stimulation and movement opportunites to all effects mm groups; ensure care with handling)
- gentle massage/stroke
- side lying with affected side up.
- prone positioning if shoulder stable (supervised)
37
Brachial plexus palsy- monitoring progress
- MMT
- joint range and muscle length measurement (+ active and passive head and neck)
- hand and arm function (older baby)
- shoulder and elbow joint integrity
- neurodevelopment
*quick referral if any concerns
38
Brachial Plexus Palsy – Other Rx Options
```
early microsurgical nerve repair
• neurolysis - release of a nerve
sheath by cutting it longitudinally,
• nerve grafting,
• later reconstructive surgery
• de-rotating osteotomy of the
humerus
• tendon transfers
• occupational therapy
Generally . . . good functional outcome
```
39
Brachial Plexus Palsy – Measurements of
| Residual Deformity and Disability
• Modified Mallet scale – 5 functions are assessed: hand to
mouth, hand to neck, hand to spine, global abduction,
global external rotation
• Assisting Hand Assessment – measures effectiveness with
which a child with unilateral impairment makes use of
his/her affected hand in bimanual activity performance
• Survey of adults with obstetric brachial plexus palsy identified
many problems including - pain, impaired sensation, arthritis and
limitation of function affecting ADL (Partridge, 2004)
40
Sciatic nerve Palsy (cause, presentation, management)
```
• Common cause
• misplacement of the needle tip during intramuscular
injection into the buttock region
• Presenting problem
• foot drop
• Management
• splinting
• passive movements
• stimulation of affected muscle groups.
```
41
Facial Palsy (cause, presentation, management)
```
• Common cause
• oblique application of the forceps blade
• prolonged pressure on the maternal
sacral promontory
• Presenting problem
• Feeding
• Asymmetrical facial movements
• Management
• Oral stimulation, including jaw and
cheek support for feeding
• Watch for other asymmetries
• torticollis
```
42
radial nerve palsy (cause, presentation, management)
```
• Common cause
• fracture of the humerus
• use of the ‘deltoid region’ as a site
for intramuscular injection repeated
brachial artery sampling of arterial
blood
• Presenting problem
• Wrist drop
• Management
• splinting
• stimulation of affected groups
```
43
Osteogenesis imperfecta
```
• Brittle Bone Disease
• Failure of bone matrix
formation
• Congenital osteoporosis
• X bone fractures
• Blue sclera
• Early hearing loss
```
44
Physiotherapy management: osteogenesis imperfecta
* Developmental approach
* Equipment – bean bags, seating etc.
* # identification and immobilisation
* Parental support
45
Arthrogryposis multiplex congenita
```
• Non progressive neuromuscular
syndrome
• Joint contractures
• Muscles
• poorly developed
• replaced by fibrous tissue
```
46
Physiotherapy Management of Arthogryposis multiplex congenita
```
• Early treatment of
deformities (clubfoot hip
and knee contractures)
• Casting
• Splinting
• Handling and positioning
• Developmental care.
```
