1. Physiotherapy in Pediatric Orthopedics III: School Age and Adolescence Kristy Brundage, B.Sc. P.T., M.Sc.

2. Skeletal Changes and Growth Disorders –Scoliosis –Disorders of the Hip –Disorders of the Knee –Other: Fractures, Trauma Sports and Recreation

3. Skeletal Changes and Growth Continued longitudinal and appositional bone growth dependent on: –Hormones –Nutrition –Mechanical factors growth spurts proportions change at puberty

4. Development Mature patterns of running, jumping, throwing Increased coordination, eye-hand coordination, balance, endurance, attention span Develop sense of competitiveness

5. Disorders Scoliosis Hip Knee Fractures and Trauma

6. Scoliosis

8. Etiology: idiopathic, congenital, neuromuscular Plane of deformity: coronal, sagittal Levels of spine involved: cervical, thoracic, lumbar

9. Scoliosis - etiological subtypes Congenital: secondary to bony abnormality Neuromuscular: secondary to muscular weakness, imbalance Idiopathic: most common type; precise etiology unknown

10. Adolescent idiopathic scoliosis Asymptomatic Most common age presentation (10+ years) Not associated with back pain May have positive (extended) family hx Forward bend test – screening important Careful neurological exam mandatory

11. Adolescent Idiopathic Scoliosis - forward bend test

12. Adolescent idiopathic scoliosis Goal of treatment is to prevent progression of curve Risk of progression related to growth remaining and curve magnitude

13. Adolescent idiopathic scoliosis treatment options < 20 o : observation, serial x-rays 20-29 o : brace if progression noted on follow-up x-rays 30-45 o :brace immediately larger curves: surgical correction and fusion

14. Physiotherapy Treatment Historically Maintain mobility and strength in brace Post op

15. Disorders of the Hip Common Conditions unique to childhood Most have potential for early osteoarthritis Important to know what conditions are likely at various ages

16. Disorders of the HIP Legg Calve Perthes Slipped Capital Femoral Epiphysis

17. Legg-Perthes disease Initial presentation: pain, limp, normal x- rays (synovitis phase) More common (later) presentation: painless limp, abnormal x-rays Age 2-8 years M>F

18. Legg-Perthes disease Etiology unknown Femoral head dies, resorbs, reforms over 18-24 months Treatment principle: maintain range, containment Observation, physio, bracing, surgery (osteotomy of femur or pelvis)

21. PT Management of LCP Crutch walking ROM: –With or without traction –all movements, BID –Passive, by parents –Within pain limits –Close monitoring

22. Slipped Capital Femoral Epiphysis Fracture through upper femoral growth plate Usually no identified trauma Pre-adolescent age group

23. Slipped Capital Femoral Epiphysis Usually obese Presentation: hip (groin) or knee pain (referred); acute or chronic Up to 40% are bilateral—monitor other hip

24. Slipped Capital Femoral Epiphysis: Treatment Surgical: Stabilize with insertion of screw across growth plate (encourage fusion of plate) Physio: –Post op care –Abductor strengthening

25. Disorders of the Knee Osgood Schlatter Patella femoral Discoid meniscus Osteochondritis dessicans

26. Osgood-Schlatter’s Disease Inflammation of the patellar tendon insertion (apophysitis) on the tibial tubercle ?from rapid growth of long bone, microavulsion, repetitive stress Presents as pain, swelling, prominence of tibial tubercle, occasionally limp

27. Osgood-Schlatter Disease: Treatment Analgesics/anti-inflammatories Ice (massage) Rest, activity modification (no jumping, squatting) ?stretching and strengthening ?ultrasound **self limiting ALSO: Sinding Larsen Johansson, Sever’s

28. Patella Femoral Syndrome Most common complaint of young athlete SPECTRUM Malalignment and maltracking Causes: –anatomical factors –acquired factors

29. PFS: Treatment PHYSIO: –Rest/activity modification –strengthening –Stretching –Other: orthotics, bracing, taping SURGICAL: –Lateral release –Patellar realignment

30. Discoid Lateral Meniscus Uncommon, but important diagnostically Lateral meniscus undeveloped, remains thick, disc shaped Presents as joint line tenderness, decreased ROM, swelling and snap on flexion- extension Rx is surgical removal with post op rehab (ROM, quads)

31. Osteochondritis Dessicans Usually medial femoral condyle Necrosis of segment of articular bone and its overlying cartilage, often resulting in separation of fragment—intrarticular loose body. Presents as pain, swelling, giving way

32. Osteochondritis Dessicans: Treatment Rest +/- cast Surgical: –removal of loose fragment –resorbing pin Physio: –Post op –ROM, strengthening, retraining

33. Trauma and Fractures Upper Extremity: –Acromioclavicular –Clavicle fracture –# upper humerus –Subluxation of G-H joint –Elbow fractures: supracondylar –Pulled elbow –Wrists fractures: torus, both bones –Hand: scaphoid, gamekeepers

34. Trauma and Fractures Lower Extremity: –Stress fractures –Snapping hip –#’s of femur, tibia –Ligamentous injury –Jumper’s knee –Growth plate #’s of distal tibia and fibula

35. Sports and Recreation 1. Team/competitive: school or community, coach +/-trainer, demanding, may involve contact, 2.Individual: recreational or training, with or without coach, protective equipment inconsistent 3.Family/community recreational: no trained supervision *relate to types of injuries

36. Risk Factors for Injury Training Muscle tendon imbalance Anatomic malalignment Equipment, footwear and playing surface Associated disease states growth

37. Competition Young: learn to compete against other teams and individually Older: also learn to compete against themselves to better performance Injuries from: –Children –Parents –safety

38. Training Fitness stats Training program: 1.Energy: aerobic,anaerobic 2.Muscle: A.Strength B.Endurance C.Flexibility D.Power 3.Speed

39. Strength Training Ages9-1112-1415-1617+ Exercises per body part 112>2 Sets 233-44-6 Repetitions 12-1510-127-116-10 Max Weight (resistance) V. LightLightModerateHeavy

40. Return to Sport No swelling ROM: full, normal, pain free Strength: objective and functional testing Use of braces GRADUAL!