Musculoskeletal Paediatric Conditions

1. Musculoskeletal Paediatric Conditions Rachel Dyke Bsc (Hons) Physiotherapy

3. Aims • Review normal skeletal development in a child. • Recognise common conditions/ complaints. • Management options. • When to refer & is Physio an option?

4. Case studies • What do you commonly see in surgery? • 3 Case studies to consider – • What would you be looking at in this child? • Think about clinical diagnosis you would give • Think about differentiation of conditions • Think about management & advice you would give.

5. Growing Pains • We need to differentiate between ‘growing Pains’ & injury to specific growth tissues. • What are they? • Benign idiopathic nocturnal limb pains of childhood. • Cause distress, sleep disturbance & parental concern. • Boys & Girls

6. Usually below Knees in lower limb. • Symmetrical, may be worse in one limb. • Limping not a feature. • Pain in spine & upper limbs rare. • Daytime symptoms rare. • Pain on waking/night. • Remember Red Flags.

7. No visible signs of bruising, swelling or deformity. • ROM & muscle strength normal. • Often have features of hyper mobility. • Pain not reproducible with palpation or activity. • Reassure, advice Educate. • Prophylactic analgesia before bed.

8. Massage, core stability work and muscle imbalance work all help.

9. Injury to Growth Tissue • Most childhood injury is related to zones of growth: • Metaphysis • Physis • Epiphysis

10. Developmental issues • Injury related to developmental stage. • The Physis (growth plate) is 2-5 times weaker than fibrous tissue during growth spurt. • Peak injury rate is growth spurt at onset of adolescence. • Metabolic processes mean growth tissue at its weakest. • Mid Growth Spurt 6.5 – 8.5 years

11. Adolescent spurt Girls 10-12, Boys 13-14. • Full maturation Girls 16, Boys 18-19. • Remember that growth rate varies. • Heavy training can delay periods in girls. • Drugs/poor diet can delay development. • Age may not reflect skeletal maturation. • Be aware of diagnosis pitfalls!!!!

12. Assessment • Eliminate common pathologies. • Red Flags. • Gait. • Posture. • ROM. • Strength.

13. Osteochondroses • This term is synonymous with Epiphysitis. • Classification of Osteochondroses: • Articular epiphyseal lesions: • Perthes, Freiberg's, Kohlers, Osteochondritis Dissecans. • Physeal Lesions: • SUFE

14. Apophyseal Lesions: • Severs, Osgood Schlatters.

15. Perthes Disease • A self limiting Non-Inflammatory condition of the hip with degeneration & regeneration. • Avascular necrosis of the femoral head. • Boys:Girls 4:1. • Common age 4-8 years. • Presentation: • Limp, Pain in groin & knee area, Activity related, eases with rest.

16. Limited Abduction, internal rotation. • Flexion with abduction & external Rotation. • Normally runs a 2-3 year course. • By age of 7 vessels in ligamentum teres have developed so blood supply should be restored. • Prognosis depends on early diagnosis & maintaining containment of femoral head.

17. Management: • XRAY • Referral to Orthopaedics. • Physio management.

18. SUFE • Slipped Upper Femoral Epiphysis. • Epiphyseal plate at upper end of femur weakened & head of femur slips down & back. • Most common hip disorder in adolescence. • 30-60 per 100,000. • Age 10-16. • More common in boys. • Bilateral in 25% cases, normally within 18/12.

20. High proportion of heavy or tall children. • 50-75% patients obese over 95th centile. • 3 classifications: • Chronic • Acute • Acute on chronic • Pain often anterior thigh & knee

21. May be an associated limp and restricted ROM • May see rotated position of leg. • Shortening. • Muscle atrophy may be seen. • Surgery required to pin epiphysis. • Often dismissed as growing pains.

22. Apophyseal Injuries • The traction epiphysis is the cartilaginous plate at the tendon insertion, the apophysis. • 2 types of injury: • Avulsion fracture • Apophysitis(traction epiphysitis) • APOPHYSITIS is inflammation of the apophysis secondary to overuse. Causes small avulsions at the bone-cartilage junction representing

23. Micro fractures with healing. Fracture process rather than soft tissue inflammation.

24. Osgood Schlatters • Peak age is 12-14 years, more common in boys. • Commonly overload injury caused by repetitive traction on the anterior portion of developing ossification centre at tibial tuberosity. • Pain often localised to tibial tubercle/anterior knee.

25. Painful during sport, aches afterwards. • May ache on waking • Local swelling, prominence, warm & tender on palpation. • Kneeling/ squats often painful. • Often biomechanical predisposition. • Rest proportional to severity. • If avulsion occurs will require ortho intervention.

27. Sinding-Larson Johansson Syndrome • Similar history to Osgood Schlatters. • More common Boys 10-14. • Slow onset overuse traction injury. • History gradually deteriorating pain after sport initially, then during & after. • Localised to distal pole of patella, Q Tendon at insertion sore & swollen. • Fat pads may be effused.

28. Severs Disease • Classic overuse apophysitis linked with biomechanical abnormality. • Pain at TA insertion. • Occurs during sport & often at worst after sport. • Pain on walking, or limp. • Swelling absent or minimal. • Mild cases... Orthotics, heel pad, reduce training, rest, ice, NSAID.

29. Back Pain

32. NW England 24% 11-14 yr old girls had 1 month prevalence of LBP, higher in girls & increasing. • Watson et al 2002 • Swiss study 33% 8-10 yr olds • 47% of 14-16 yr olds experienced back pain • Wedderkop et al 2005 • Back pain is the largest single cause of long term sickness.

33. 75% of which is due to repetition & lifting. • Children's activity is very repetitive in a school day & often activity at home. • They have decreased postural stability, are exposed to uneven loads & awkward bags, poor furniture & sedentary hobbies. • Most adolescent back pain leads to postural malalignment & can cause scoliosis.

34. Postural: • Shoulder height, spinal curves/Scoliosis, • Hip & pelvic alignment, leg length discrepancy • Is it correctable????

35. Other factors to consider... • Scheurmanns Disease. • Usually asymptomatic until presents with back pain & /or kyphosis at age 11-15, normally in boys. • Normally Thorasic. • Its an osteochondrosis, defect in end plate with an anterior wedge.

36. 5 degree wedge in 3 or more vertebrae. • Pain progresses T7-T10 region. • Aggravated by exercise, prolonged sitting & flexion. • Active pain phase can last for up to 2 years. • Deformity if posture/core stability not addressed. • Physio, orthopaedics,??? Bracing

37. Feet • Toe walkers • If no underlying neurological cause, refer to physiotherapy!!!! • Flat feet • Over 20% adults have flat feet. • 97% children under 18/12 have flat feet • Medial arch starts to appear age 2-3& continues to age 10 • If no pain or problem in lower limb reassure & educate.

39. Limping... Age specific guide • 1-3 years • Child abuse, DDH, JIA, Neuromuscular disease, • Leg length discrepancy, Infection. • 4-10years • Transient synovitis, Perthes, LLD, JIA, Infection. • 10years plus • SUFE, overuse syndromes. • DONT FORGET SAFEGUARDING, TRAUMA OR TUMOUR IN ALL AGE GROUPS

40. PHYSIO • Best placed to give child full postural & biomechanical assessment. • Can advise & educate child, parents & coaches. • Experts in core strengthening, postural correction. • Work alongside GPS & Orthopaedic consultants • IF IN DOUBT... ASK US!!!!!!!!!!

41. THANKYOU