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

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

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

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

Disorders Scoliosis Hip Knee Fractures and Trauma

Scoliosis

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

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

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

Adolescent Idiopathic Scoliosis - forward bend test

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

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

Physiotherapy Treatment Historically Maintain mobility and strength in brace Post op

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

Disorders of the HIP Legg Calve Perthes Slipped Capital Femoral Epiphysis

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

Strength Training Ages Exercises per body part 112>2 Sets Repetitions Max Weight (resistance) V. LightLightModerateHeavy

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