Musculoskeletal Paediatric Conditions

Rachel DykeBsc (Hons) Physiotherapy

Aims

• Review normal skeletal development in a child.

• Recognise common conditions/ complaints.• Management options.• When to refer & is Physio an option?

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.

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

• 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.

• 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.

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

Injury to Growth Tissue

• Most childhood injury is related to zones of growth:

• Metaphysis• Physis• Epiphysis

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

• 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!!!!

Assessment

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

Osteochondroses

• This term is synonymous with Epiphysitis.• Classification of Osteochondroses:

• Articular epiphyseal lesions:• Perthes, Freiberg's, Kohlers, Osteochondritis

Dissecans.

• Physeal Lesions:• SUFE

• Apophyseal Lesions:• Severs, Osgood Schlatters.

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.

• 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.

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

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.

• 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

• 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.

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

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

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.

• 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.

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.

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.

Back Pain

• 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.

• 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.

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

• 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.

• 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

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.

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

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!!!!!!!!!!

THANKYOU