Musculoskeletal
Disorders in
Pediatrics
칠곡경북대학교병원
재활의학과 민유선
2013.02.23
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
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
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
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
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
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
Diagnostic imaging – ultrasonography
Congenital hip dysplasia
Diagnostic imaging - ultrasonography
Hip effusion
Popliteal cyst
Congenital muscular torticollis
Diagnostic imaging - CT
Tarsal coalition
Osteoid osteoma
Diagnostic imaging - MRI
Marrow conversion
Diagnostic imaging - MRI
Epiphyseal injury
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
Scoliosis – curve documentation
Named by direction, location and
magnitude
Curve’s convex apex (most laterally
deviated vertebrae from the sacral
line)
Cobb angle
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
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
Scoliosis - imaging
Whole spine X-ray PA / Lat (rotational or kyphosis)
If possible, in and out of the brace
CT or MRI (congenital, infantile)
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%
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
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
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
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
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
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
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
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
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
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
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
Upper limb anomaly - Hand
syndactyly Brachydactyly Polydactyly
comptodactyly clininodactyly macrodactyly
Kirner’s deformity Ectrodactyly
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
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
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
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
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
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
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
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
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)
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
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%
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
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
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
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
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
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
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
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
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
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
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
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
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 °
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
Femoral retroversion
Down’s syndrome, Ehlers-Danlos syndrome
Low tone, ligament laxity
Excessive out-toeing
Genu valgum, flexible pes planus
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
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
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
Physcial exam
Femur-tibia angle, FTA
Metaphyseal-
diaphyseal angle,
MDA
Intermalleolar
distance, IMD
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
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
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
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
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
Rehabilitation of the child
with rheumatic disease
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
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%
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
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
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
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
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
Thank you for your attention