Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the...

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Musculoskeletal Disorders in Pediatrics 칠곡경북대학교병원 재활의학과 민유선 2013.02.23

Transcript of Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the...

Page 1: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Musculoskeletal

Disorders in

Pediatrics

칠곡경북대학교병원

재활의학과 민유선

2013.02.23

Page 2: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Preview

Growth

Scoilosis Torticollis

BPI Elbow dislocation

Hip dysplasia

LCP

SCFE Transient hip synovitis

Foot

Pes planus

Cavus foot Epiphysis

Rotational deformity LLD

Rheumatis

Torticollis

Klippel-Feil

syndrome BPI,

clavicular

fracture

Developmental hip

dysplasia

LCP

SCFE

Club foot

Pes planus

Cavus foot

Scoliosis

Osteochondritis

dissecans

Femoral

anteversion Angular deformity

Bowlegs, knock knee

Page 3: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Contents

1.Growth and development

2. Musculoskeletal physical exam

3. Scoliosis / Kyphosis / Flippel-Feil syndrome

4. Torticollis

5. Brachial Plexus Injury

6. U/E Pathology

7. L/E Pathology

8. Rotational Deformity

9. Leg Length Discrepancy

10. Rheumatic disease

Page 4: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Growth and development of the bony skeleton

Skeletal system develops from

mesoderm and neural creast cells

Somites

form from paraxial mesoderm

differention into sclerotomes, dermatomes and myotomes.

Sclerotome - chondrocyte

Dermatome - dermis

Myotome – striated muscle

Page 5: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Growth and development of the bony skeleton

From the lateral plate mesoderm.

Limb bud appear in utero

day 26 - the upper extremities

day 28 - the lower extremity

5th wk – the hand plate form

6th wk – digitization of rays, chondrification start

7th wk – notch, U/E – lateral rotation, L/E –medial rotation,

early ossification

8th wk- muscle formation, human appearance

16th wk – subsequent joint cavity formation

Syndactylism

Page 6: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Physical Exam of Musculoskeletal System

Inspection, palpation, AROM, PROM, stance,

gait

Walking with or without shoes, heel and toe

walking

asymmetric stride length and stance phase in hemiplegia; toe walking scissoring with spasticity ; Crouch posture and gait in diplegic posture ; Trendelenburg’s gait in motor unit

disease, hip dislocation; gastrocnemius limp with lack of push of in L4-5 weakness due to spinal bifida; ataxia, tremor, dyskinesia in CNS disease

Static position (pelvic tilt, leg and feet axes,

Trendelenburg sign)

Spine (shoulder position, pelvic tilt, waist

triangles, sagittal profile, frontal profile, forward

banding, sitting up,lateral mobility)

Upper extremities (cursory examination of

mobility, apron grip, neck grip, turning up the

thumb)

Hips (mobility); Knees (mobility, stability,

meniscus sign); Feet (rearfoot, forefoot,

arches, mobility)

Torsions, clinically (anterversion, tibial

torsion, feet axes)

Alignment of femoral neck : coxa valga,

increased anteversion, Femoral inclination :

160, Anteversion : 60

adult: 120/10-20 accelerated weight

bearing

Capsular ligament laxity : preterm,

Scarf sign, Popliteal angle

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Diagnostic imaging

1. Simple X-ray

fracture, tumor, Legg-Perthes disease

2. Ultrasonography

Free from radiation hazard, easy, no need to sedation,

Dynamic test, vascular evaluation by color doppler

Developmental hip dysplasia

Hip effusion

Superficial soft tissue mass

3. CT

Fracture

Talocalcaneal coalition

Osteoid osteoma

4. MRI

Marrow conversion

Tumor

Epiphyseal injury

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Diagnostic imaging – ultrasonography

Congenital hip dysplasia

Page 9: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Diagnostic imaging - ultrasonography

Hip effusion

Popliteal cyst

Congenital muscular torticollis

Page 10: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Diagnostic imaging - CT

Tarsal coalition

Osteoid osteoma

Page 11: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Diagnostic imaging - MRI

Marrow conversion

Page 12: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Diagnostic imaging - MRI

Epiphyseal injury

Page 13: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scoliosis

frontal plane deformity of the spine of >10 degrees

frequent coexistence of rotational deformity

Respiratory compromise, seating compromise, pain, gait impairment, difficulty with acivities of daily living and psychological

distress

Page 14: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day
Page 15: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scoliosis – curve documentation

Named by direction, location and

magnitude

Curve’s convex apex (most laterally

deviated vertebrae from the sacral

line)

Cobb angle

Page 16: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scoliosis

History

Familial history

Back pain

Rapid curve progression, Bowel and bladder change, Recent trauma with Weight loss, Muscle weakness, Joint pain -> spinal cord syrinx or tethered cord, spinal fracture, rheumatologic disease,osteoblastoma, hip deformity

Reflex, strength, ROM, general posture, gait

café au lait spots, Webbed neck or lower hair line, hairy patch, skin dimple – klippel-Feil, spina bifida occulta or neurofibromatosis.

Excessive height, arm span, joint hyperextensibiity – connective tissue disease.

Leg length, straight-leg raise, ROM – length discrepancy, asymmetry, contracure, pain – hip dysplasia or hemiplegia, herniated disk

Page 17: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scoiliosis – P/E

Pelvic obliquity, elevation of

either iliac crest, asymmetry

of the scapula or shoulder

girdle

Forward banding (Adam’s

test) – asymmetry

prominence of the rib cage

(vertebra rotate into the

convexity of the curve)

Scoliometer

Side bending

Page 18: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scoliosis - imaging

Whole spine X-ray PA / Lat (rotational or kyphosis)

If possible, in and out of the brace

CT or MRI (congenital, infantile)

Page 19: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Idiopathic scoliosis

More than 80%

Type

infantile : birth -3yrs, Lt. thoracic curves common, boy > girl

associated with plagiocephay, DDH, congenital muscular

torticollis

Juvenile : 3-10yrs, male = female

bracing is effective, but >40 degrees is recommended surgical

intervention

Adolescent : >10yrs , Female > male, Rt. Thoricic curve common,

bracing is effective in more than 90%

Page 20: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Idiopathic scoliosis

Curve progression

Depend on age of onset, curve size, level of skeletal maturity

Risk factor

Young (<12 years), premenarchal, skeletal immature (Risser <2) females with large curve (>20 degrees)

Curve < 20 degree : observation, serial f/u over 6 mo.

Curve < 25-30, skeletal maturity, no progression -> observation

Curve > 20, skeletal immaturity, 5-10 progression/6mon -> Bracing for 16-24hours until skeletal maturity

Curve >40, rapid progression -> Surgery

Surgery

Right thoracic curve of 40-50, immature female -> posterior spine fusion

Thoracolumbar cureve, anterior fusion

Curve of 60-70, rigid curve -> anterior-posterior fusion

Page 21: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scoliosis - general treatment

Bracing

<40 degrees : bracing , consider LOCATION

Apex at or below T7 : soft or rigid TLSO

Above T7 : Milwaukee

Duration : 16~24 hours a day

Charleston or Providence style brace : thoracolumbar curve of less than 35 degrees

More tolerable

Page 22: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Congenital scoliosis

20% of all scoliosis, 5-10% FHx

Cause

prenatal disuption of vertebral formation (hemivertebra-m/c, wedge vertebra) or vertebra segmentation (block vertebra, unilateral bar)

Accompany defective organogenesis

Trachea, esophagus renal tract, gastrointestinal tract, lungs, hearts, radius, ear, lip, palate

renal disorder (up to 25%), cardiac (10%), spinal dysraphism (30%)

MRI of brain stem and entire spine is needed for tetherd cord, syringomyelia, etc

Tx :

orthosis is ineffective

Surgery : at an early age, before spinal rigidity or 2nd pulmonary deficiendies

Page 23: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Neuromuscular scoliosis

Very common

Quadraplegic CP (up to 70%), muscular dystrophy or

quadraplegic spinal cord injury (up to 90%)

Begin early, progress quickly

Unresponsive to bracing

Prefer extensive fusion to slow progression improving trunk

control and sitting posture

Page 24: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Scheuermann’s disease

Osteochondrosis of the vertebral end plate

0.5%-8% in general papulation

male: female = 2:1, peak 15-17yrs

Radioghraph :

irregular vertebral endplates, protrusion of disc meterial into the spongiosum of the vertebral body, Schmorl nodes, narrowed disc spaces, anterior wedging of the vertebral bodies

Pain in the one or more irregular vertebral body

Tx: TLSO or Milwaukee brace

conservative : RICE protocol, NSAIDs

severe (kyphosis >75 degree) : spinal fusion

Page 25: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Klippel-Feil syndrome

Brevicollis

short neck, low hair line, restricted neck motion

1/40,000~42,000

Scoliosis, rib and renal anomaly, hearing loss,

Sprengel deformity,cervical tib, cardiac anomaly

Pain, LOM

Renal U/S, cardiac evaluation, hearing evaluation

Contact sport is contraindication

Treatment : maintain ROM, orthosis, surgery if

unstable vertebra with symptom

Page 26: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Torticollis

Unilateral SCM shortening or tightening

The head tilt to affected side/ chin iturned away from the affected side

Cervical mass :60%, Facial hemihypoplasia, plagiacephaly, scoliosis

Clinical manifestation

Sternomastoid tumor: Palpable mass in SCM, 2~4 weeks,

disappear at 4~8 months, mid to lower 1/3

muscular torticollis: SCM stiffness, No palpable mass, normal

X-ray

positional torticollis: No SCM stiffness, No palpable mass,

normal X-ray

CHD, craniofacial asymmetry, metatarsus adductus, calcaneovalgus, flexible pes plnus, hallus valgus, internal tibial torsion

CHD : 2~29%, USG, X-ray, unilateral, same side

Page 27: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Torticollis

Treatment

As soon as possible

Goal

prevent development of contracture, Stretch tight muscles, Strength the antagonist

muscles including contralateral sternomastoid and neck muscles,Prevent delay of

normal neck activities, Encourage normal posture, Facilitate normal righting reactions

Stretching of the tight neck muscles

Directing the gaze toward the ipsilateral superior direction

Skull shaping orthotics

Botox injection

Op : after 1year, fail to conservative therapy, progressive facial

asymmetry, LOM>30

Page 28: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Brachial plexus palsy

Incidence : 1-2/1,000 live birth, m/c neuropraxic injury

Risk factor : increased birth weights, multiparous mothers, shoulder dystocia

Mechanism : lateral stretch related with shoulder dystocia, positioning of the mother and infant

At C5-C6 : Erb’s palsy, ¾, m/c

At C8-T1 : Klumpke’s palsy usually with another root injury

Diagnosis

Electrodiagnosis(SNAP, axonal loss), MRI

Plain X-ray for a fracture of the clavicle or humerus

Page 29: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Brachial plexus palsy - Treatment

Prognosis

Spontaneous recovery :50-90%

C5-7 early recovered than other level

Conservative treatment

Physical therapy

immediately gentle ROM (shoulder abduction with scapular stabilization

to stretch scapulohumeral adhesions, elbow supination, extension,

thumb abduction)

positioning instruction

Electrical stimulation

Surgery

At 6month, less-than-antigravity strength in elbow flexor

Page 30: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Clavicular fracture

Common injury

Imcomplete fracture vs Complete fracture at mid 1/3

Related with trauma, lump, crepitation

No neurovascular complication

Treatment

Figure eight clavicle strap

Recoverd with callus formation

Page 31: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Upper limb anomaly - Hand

syndactyly Brachydactyly Polydactyly

comptodactyly clininodactyly macrodactyly

Kirner’s deformity Ectrodactyly

Page 32: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Upper limb anomaly - Forearm

Amniotic band syndrome (Streeter dysplasia)

Radioulnar synostosis

Proximal forearm, M=F, 50% bilateral, emotional assurance

Madelung deformity

Radius malformation > ulnar malformation

Elbow dislocation, more common in radial head, relatea with radioulnar synostosis, Larsen syndrome, Arthrogryposis multiplex congenital

Conservative therapy

Page 33: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Upper extremity

dislocation and fracture

Elbow dislocation

Pulled elbow, nursemaid’s elbow

Transient subluxation

80~90%, posterior or posterolateral dislocation

Conservative therapy ; reduction - rapid supination and flexion

Fracture

In epiphyseal plate, bone shaft

Splint duration : 3~4 wks

5th metacarpal fracture

Scaphoid fracture

Fall down with arm extended during pressure on thena eminence

Distal radial fracture

Page 34: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Upper extremity

dislocation and

fracture

Shoulder dislocation

Rare in young children

More common in adolescence and young adult

Anterior or subcoracoid dislocation

Fixation during 3~6wks

Recurred 2~3 times -> consider operation

Page 35: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Upper extremity sports injury

2,500,000 /year in US, 5~14 years, male, Basketball, cycling, football, soccer

Sprain, contusion, fracture, Foot and ankle, hand and wrist

1) Overuse injury

apiphysitis, anterior knee pain, stress fracture, tendinitis

tendinitis

Less common than adult

SST in swimming, throwing

Iliopsoas in dancing

Ankle in dancing, athelete, figure skating

Apiphysitis

Bone cartilage junction – microtrauma, sx resolve with secondary ossification

Treatment

Activity regulation, cold, NSAID, exercise for flexibility and strengthening

Page 36: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Upper extremity sports injury

2) Little league elbow

throwing, pitcher

Medial elbow pain and tenderness

mechanism

Microtrauma on Medial epicondyle in children

Partial or complete avulsion fracture by excessive valgus in adolescence

Treatment

Avoid aggravating factor such as pitching

Activity modification

Page 37: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Developmental dysplasia of the hip

(발달성 고관절 이형성증)

1.7 birth / 1000 in Europe, M:F =1:4~6, FHx, Lt>Rt

Dysplasia : underdeveloped acetabulum, subluxation to hip, dislocation to femoral head not contained in the acetabulum

Risk factor : Breech presentation, primaparity, torticollis, plagiocephaly, oligohydramnios

Page 38: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Developmental dysplasia of the hip – P/E

Ortolani's sign : abduction and forward lifting of the thigh producing a palpable “clunk”

Barlow's sign : subluxation or dislocation by adduction, flexion, posterior pressure

Asymmetrical gluteal fold and an apparent limb-length inequality can further indicate unilateral hip dysplasia

Galeazzi's sign : decreased in height of the involved knee with the hip flexed supine to 90 degrees

Trendelenburg gait

Lateral waddling gait in bilateral case

Page 39: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Developmental dysplasia of the hip

Imaging

US : d/t capital femoral epiphysis ossification (4~6months)

normal : α angle ≥ 60, ᵦ angle ≤ 50

Simple X-ray : after 4~6months, f/u

Increased acetabular index, broken Sheton line, femoral head displacement

Page 40: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Developmental dysplasia of the hip

① Acetabular Roof Angle: Normal <30°.

② Hilgenreiner's line

③ Normal femoral head located medial to Perkin's line and inferior to Hilgenreiner's line

④ Perkin's Line

⑤ Shenton's Line: Normal

⑥ Shenton's Line: abnormal (broken)

⑦ Abnormal femoral head located lateral to Perkin's line and superior to Hilgenreiner's line.

⑧ Abnormal Acetabular Roof Angle: >30°.

⑨ Femoral head displacement(A) to neck distance(B)

Page 41: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Developmental dysplasia of the hip

Treatment

By Age, reduction, joint stability, severity

Parvlik hardness – up to 6 months

full time for at least six to eight weeks, then

part-time (12 hours per day) for six weeks

Closed reduction – up to 18mo, immobilization in the hip spica cast

for 3-4month cast changes about every 6wk

Open reduction – after 18mo, to remove obstacles to reduction, achieving increased stability

Page 42: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Legg-Calve-Perthes disease

Osteonecrosis of the capital femoral epiphysis

4-10yrs, M:F =4:1,10-12% bilateral

Limitations in internal rotation, extension, abduction of hip, knee pain (referral pattern), LLD, limping gait

Dx : bone scanning , MRI

Lab test (ESR, CRP, WBC etc) : normal

Catteral classification

I : up to 25% of capital femoral epiphysis

II : 25% -50%

III : 51% - 99%

IV : 100%

Page 43: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Legg-Calve-Perthes disease

Treatment: short term goal - relieve pain and stiffness

NSAIDs reduce synovitis

non-weight bearing with crutch

abduction orthosis, casting

femoral head in acetabulum

Prognosis : self-limited for 2-4yrs

Good Px : <8yrs, <50% of capital femoral epiphysis

Poor Px : involvement of lateral femoral head, more than 40%

Osteoarthritis : 50% of untreated patient showing severe changes by 50 years

Page 44: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Slipped capital femoral epiphysis(SCFE)

Post. Inf. displacement of the epiphysis on the prox. femoral metaphysis

Peak incidence : age of accelerated growth and start of adolescence (girl 10-14yrs, boy 12-16yrs) M:F =2:1

Bilateral : 25% , 5% simulataneously

Risk factor : overweight, hypothyroidism, hypopituriarism, excessive growth hormone)

Symptom

pain : acute or gradually over wk to mo

groin region radiate to knee and med. thigh

trendelenburg gait in limping with ER

Page 45: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Slipped capital femoral epiphysis

Dx : radiography, Bone scan and MRI

Trethowan sign

Grade :

mild slip : displacement of the epiphysis up to 1/3 of width of the metaphysis

moderate slip : up to 2/3

severe slip : more than 2/3

Page 46: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Slipped capital femoral epiphysis

Treatment

Goal : preventing further epiphyseal displacement , avoiding

complication such as acute cartilage necrosis

surgery than conservative therapy

If manupulation, 10-25% risk of avascular necrosis

weight bearing is avoided for 6wks, active assistive exercise and

strengthening to restore lengthening, adduction and internal rotation

Page 47: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Acute transient synovitis

M/C cause of hip pain in children, Self-limited

Any time from toddler age, Peak 3-6yrs, M>F

50% with ATS, recently have an upper respiratory illness

Sx : unilateral hip or groin pain, refering to knee, limping ,

refusal to bearing weight, Hip LOM : esp. IR,

turned outwards and away from the middle line:

flexion, abduction, external rotation

Imaging

X-ray: normal, some slight intracapsular effusion

Ultrasonography : most helpful, effusion detect

MR imaging, positive radionuclear bone scan

Treatment: rest, NSAIDs

Page 48: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Osteochondritis dissecans

partial or complete seperation of a

segment of normal highland cartilage

from its supporting bone

cause : inflammation, ischemia, genetic predisposition, abnormal ossification, trauma, and cyclical strain

Location : knee

lateral aspect of the medial femoral condyle – 70%

Lateral femoral condyle – 20%

Patella – 10%

Symptom : activity related anterior knee pain

Imaging : X-ray, MRI

Treatment : controversial

Intact lesion – symptomatic treatment

free fragments - surgical removal

Page 49: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Club foot (talipes equinovaus)

Forefoot – equinous,

Hindfoot – varus and severe adduction

1:250~1,000

Cause : multifactorial genetic inheritance, environmental factor

intrauterine crowding, myelodysplasia, arthrogryposis, hip dislocation

Treatment

casting by Ponseti technique

From forefoot to hindfoot

Caution to rocker-bottom deformity, vertical talus, calcaneal equines

Passive ROM exercise into dorsiflexion and eversion

surgical procedure, supramalleolar orthosis

Page 50: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Flat foot (Pes planus)- flexible

m/c in children, usuallay asymptomatic

P/E

Ankle and subtalar joint, transverse tarsal joint ROM

Too many toe sign, single heel rise, double heel rise

Treatment

Orthosis

Custom molded shoe, UCBL

Surgery: after 5yrs

Untreated progression

hallus valgus, planovalgus, 2nd bunion, toe deformity

Page 51: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Flat foot (Pes planus) – rigid

In 50% associated with other anomalies

Cause: failure of the tarsal bone separate leaving a

bony cartilage or fibrous bridge or coalition between two or more tarsal bones

Talocalcaneal coalition – 8-12yrs, 48%

calcanonavicular coalition – 12-16yrs, 43%

Sx : insidious but acute arch, ankle, metatarsal pain

Frequent sprain

Diagnosis : CT scans

Treatment :

conservative with short-leg casting or modeled orthosis and rest, if fails, surgical intervention

Page 52: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Cavus foot

Metatarsalgia, clawing, intrincsic muscle

atrophy

Underlying neurologic condition

Charcot-Marie-Tooth disease, spinal dysraphism, Freidrich’s ataxia, spinal tumor

Treatment

Custom molded insert, orthosis for arch support, decreased pain

Cleman block test

Hindfoot flexibility

Page 53: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Apophysitis

common in knee, foot, ankle

Cause : Traction, overuse, microtrauma

Apophysitis location

① At inferior pole of patella : Sinding-Larsen-Johansson syndrome

② At tibial tuberosity : Osgood-Schlatter disease

③ At posterior calcaneous : Sever's disease

10~15 years, few years earlier in girls

Treatment

conservative with RICE protocol

① Sever's disease : heel cup

② Osgood-Schlatter disease : quadriceps, hamstring steretching, knee strap, short period of casting or splinting

③ Pain-free strengthening of weight-bearing soft tissue

Using more closed kinetic chain technique

Page 54: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Osteochondrosis

Disturbance in endochondral ossification, both

chondrogenesis and osteogenesis

Freiberg's disease

second metatarsal, collapse of articular surface in subchondral bone

More common in girls ,12-15 yrs

Kohler's disease

irregular ossification of tarsonavicular joint with localized pain and increased density

younger individual (than Freiberg's disease), 2-9 yrs

Conservative treatment in orthosis and casting

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Femoral anteversion

femoral neck and shaft

At birth 160° -> 5 yrs 140° -> adulthood 120°

Femoral anteversion (femoral neck angle to transcondylar line)

At birth 40° -> 5 yrs 25 °->

adulthood 15 °

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Femoral anteversion

Femoral anteversion (the normal anterior femoral neck angle relative to transcondylar line of distal femur )

At birth 40° -> 5 yrs 25 °-> adulthood 15 °

Increase of anteversion: in-toeing and

increased internal rotation

Spontaneous resolved in 8 years

Evaluation on supine

Treatment

ER strengthening, out-toeing

Surgery in anteversion>50°, IR>80°, over 8yrs

Proximal or distal femoral osteotomy

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Femoral retroversion

Down’s syndrome, Ehlers-Danlos syndrome

Low tone, ligament laxity

Excessive out-toeing

Genu valgum, flexible pes planus

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Tibial torsion

Tibial torsion (both internal and external)

compensation for femoral version

in-toeing and out-toeing

Thigh foot angle(TFA)

At birth 4° internal tibial torsion

adult 23 ° external tibial torsion

Transmalleolar axis (TMA)

In toddler. lateral malleolus 5-10 ° posterior to medial malleolus

In adolescence, 15 °

Naturally recovered by growth

Surgery

Over 8yrs, severe deformity, functional limitation, TFA<-10, or >40

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Angular deformities of femoral-tibial alignment (bowlegs, knock knee)

New born 10~15° genu varum

12~18 months Straight leg

3~4 yrs 12~15 ° genu valgum

12 yrs 5-7 ° genu valgum

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Angular deformities of femoral-tibial

alignment (bowlegs, knock knee)

Genu varum

M/C cause : physiologic bowlegs !!

may persists at 18 months, usually resolving before age 3yrs

DDx

Infantile tibia vara or Blount, hypophosphatemic rickets, metaphyseal chondrodysplasia, focal fibrocartilaginous dysplasia, trauma to ephiphyses

Genu valgum

Observation

femoral-tibial angle greater than 20 degrees require follow-up

If abnormal genu valgum persists into teens, hemiepiphysiodesis, or stapling of medial physis

Advantage of staping - can be removed before excessive overcorrection occurs

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Physcial exam

Femur-tibia angle, FTA

Metaphyseal-

diaphyseal angle,

MDA

Intermalleolar

distance, IMD

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Metatarsus adductus

Medial deviation of the forefoot in relation to

the rearfoot

1/5000 birth, male, twin, preterm

cause - intrauterine crowding or positioning

internal tibial torsion may be associated

86~89% Spontaneous recovery, till 3~4 years

If not, Passive stretching, orthotic shoe, serial

casting

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Leg Length Discrepancy (LLD)

Common, 1/3 having a 2 cm or less discrepancy

Two basic types

True leg length discrepancy

greater trochanter (ASIS) ~ medial malleolus

Apparent leg length discrepancy

ASIS ~ umbilicus, Present when bony lengths are same

But joint alignment or pelvic femoral asymmetry is present (eg.

Adductor spasticity, pelvic obliquity)

Imaging

Teleradiography, orthoradiography, scenography

CT scanogram- standard

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Leg Length Discrepancy (LLD)

Treatment

< 1.5 cm : observation !!

< 3cm : Shoe modification, othosis

horizontal alignment of iliac crest or sacral base in

standing position

3-6 cm: Stapling or epiphysiodesis of longer

side

>6cm: limb lengthening of shorter side,

Wagner or Ilizarov procedures

Limb shortening : Prosthetic consideration

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Arthrogryposis multiplex

congenital (AMC)

a symptom complex characterized by

multiple joint contractures that

present at birth

1/3000 live births

Classification

1) Larson syndrome- total body

2) Freeman-Sheldon syndrome –distal hand and feet, facial, “whistling face”

3) pterygia syndrome - webbing

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Arthrogryposis multiplex

congenital (AMC)

Deformity

U/E – adduction, internal rotation of shoulder, fixed flexion or extension contracture of elbow, fixed flexion and ulnar deviation or fixed extension and radial deviation, thumb in palm

L/E – flexion, abduction, external hip rotation contracture, fixed extension or flexion contracture of the knee, bilateral club feet

Treatment

Goal : increased self-help skill such as feeding, toileting, mobility

Stretching, serial casting

Surgery

Talectomy, talus enucleation, extension wedge osteotomy

Bilateral hip dislocation-conservative, unilateral-surgery d/t scoiliosis

U/E op delayed till definite functional assessment

Op < 6 yrs, better prognosis

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Rehabilitation of the child

with rheumatic disease

Page 68: Musculoskeletal Disorders in Pediatrics · Growth and development of the bony skeleton From the lateral plate mesoderm. Limb bud appear in utero day 26 - the upper extremities day

Juvenile Idiopathic Arthritis (JIA)

16-150/100,000

7 Subtype : 1) systemic JIA 2) oligoarthritis 3) RF negative

arthritis polyarthritis 4) RF positive arthritis 5) psoriatic arthritis, 6) enthesitis-related arthritis 7) undifferentiated arthritis

Symptoms

Duration >6 wks, exclusive diagnosis

swelling, warmth, joint stiffness, worse at beginning of day,

improving with activity

usually fluctuation

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Juvenile Idiopathic Arthritis -subtype

Systemic JIA :10~20 %

many extra-articular feature

5-8% develops life threatening Cx. (ex. Macrophage activation syndrome, lymphadenopathy, splenomegaly, depression in blood cell line)

½ follows a relapsing-remitting course

Poor Px : systemic features, platelet >600,000/mm3 at 6mo after onset

Oligoarthritis

Less than 4 joints in first 6 months

Asymmetric, before 6 years, L/E involve, ANA – 70-80%

More favorable prognosis but risk of fatal uveitis

Polyarthritis

affecting more 5 joint in first 6months

Symmteric, adolescent, ANA -20~40%, chronic uveitis : 5-20%

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Rehabilitation of the Child with JIA

Goal : Sx control, prevent joint damage, achievement of

normal growth and development, maintain function and

normal activity levels

Acute flare-up

resting a joint(using splinting- to prevent flexion contracture, splinted in a functional position) and cold therapy

Heat in maintenance phase- hydrotherapy, fluidotherpy,

paraffin or moist heat, but Ultrasound is C/Ix

Adaptive strengthening exercise

Activity and ambulation

- posterior walker for upright posture, standing program

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Medical and surgical treatments of

JIA

NSAID in initial phase

Intra-articular steroid injection or systemic steroid at disease

onset or during the disease course

Methotrexate in the disease course as second line agent –

with NSAIDs

Biologics (entanercept, infliximab, adalimumab, ankinra,

abacept, and rituximab) – increased risk for infections

Tumor necrosis factor (TNF) inhibitor (etanercept and

adlimumab)

Surgery is rarely used in early but in later phase, release joint

contracture, and replace a damaged joint

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Take Home Messages

Growth and development

Deferring radiography until 6 months allowing bones to ossify

Malformation of the radius are more common and associated with more syndrome than ulna

To be a club foot, there must be hindfoot varus and adduction

Cavus feet always need an explanation and can be a superficial sign of an underlying neurological diagnosis

Brachial plexus palsy

m/c risk factor : shoulder dystocia, large birth weights, and multiparous mothers

Neuropraxia – no permenant anatomical changes and will recover

Axonotmesis (partial) and neurotmesis (complete) – long lasting sequelae

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Take Home Messages

Developmental conditions

Observation is the rule in Legg-Calve-Perthes disease, with minimal pain, good ROM, and a strong lateral bony column

Overweight, adolescent, altered gait, hip – think SCFE

DDH, if not detected and treated before 18 months – life long disability and degenerative arthritis

In toeing in abled-bodied child get better overtime with or without correction

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Take Home Messages

Scoliosis

If pain with scoliosis, check for other etiology (neoplasm, infection)

Scoliosis in children is typically not painful

Steroid reduce the incidence of scoliosis in Duchenne’s muscular dystrophy, delay loss of muscle strength and ambulation

Atypical left thoracic curve –need MRI imaging for spinal pathology

50° or greater – progress, averaging a degree per year over a lifetime

Leg Length Descrepancy

3cm or less is common – shoe lift or observed

Rheumatic Disease

JIA – before age 16, persist at least 6 weeks

Enthesis, uveitis, rash, fever, lymphadenopathy – early sign

Treatment – eliminating inflammation, promoting appropriate function and activity, minimizing complication

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Thank you for your attention