How long does the leg spend in stance phase and how long in swing phase?

Stance: 60%

Swing: 40%

Name the gait

• less time spent in stance phase on painful side
• non-specific

Antalgic

When doing a w/u on a limping child...

1. Inquire about ___, ___, and ___
2. Examine joints for ___, bones for ___, and percuss spine to look for ___.

1. duration, night pain, fevers
2. range of motion, tenderness, pain

Name the gait

• associated with foot drop
• knee and hip brought into greater flexion in order to clear foot from the ground

When is it seen?

Steppage gait

Seen in neuromuscular conditions or after peroneal nerve injuries

Name the gait

• hip is swung out to the side to clear the ground when knee flexion is limited or ankle is in fixed equinus

Circumduction

Name the gait

• abnml gait caused by insufficiency of hip ABductor muscles either d/t muscle weakness or shortened muscle length (dislocated hip)
• lean toward side of problem to compensate

Trendelenburg

What are the three main categories of equinus gait?

1. Neuromuscular disorders - main group includes cerebral palsy
2. Otherwise normal kids w/tight heel cords
3. Idiopathic toe walkers (develop habit)

M/C

In-toeing or out-toeing

In-toeing

*may correct itself b/c leg naturally ext rotates over time*

• foot progression angle: foot line up w/direction of travel
• thigh-foot angle: assess tibia torsion
• hip rotation
• shape of foot

What are three causes of in-toeing?

• femoral anteversion
• internal tibial torsion
• metatarsus adductus

• external rotation of hips or femurs
• external tibial torsion

Name the growth plates

1. at the end of long bones, adds to length
2. adds to length/width of bone but not body length
3. at point of tendon insertion to bone
4. surrounds smaller bones such as tarsal bones

1. Epiphysis
2. Apophysis (ex: iliac crest)
3. Traction apophysis (ex: tibial tubercle)
4. Ring epiphysis

determines bone age by using a radiograph of the left hand

What type of bone growth

1. bone forms directly from mesenchymal cells
2. bone forms from chondrocytes that calcify. these form in wk 6 of gestation

1. Intramembranous - Ex:skull, clavicle
2. Enchondral - majority of bones

Where does the majority of growth happen in each of these bones?

1. Humerus
2. Radius
3. Femur
4. Tibia

1. proximal (80/20)
2. distal (25/75)
3. distal (30/70)
4. proximal (55/45)

Describe the direction of the fx when epiphysis is down.

S

A

L

T

R

S - same

A - above

L - lower

T - through

R - rammed

physeal bars and growth arrest

What Type of Salter Harris fx?

• thru growth plate
• often not seen on radiograph
• dx made clinically if point of greatest tenderness over growth plate

Type 1

closed reduction if displaced and fresh injury

What type of Salter Harris fx?

• thru growth plate into metaphysis
• most often treated with closed reduction

M/C type of SH fx!

Type II

What type of Salter Harris fx?

• extend into joint
• more likely to require surgery

Type III

What type of Salter Harris fx?

• goes into both metaphysis and epiphysis
• fairly rare

Type IV

What type of Salter Harris fx?

• Crush injury to physis
• very rare
• radiographically same as SH Type I

Type V

Type I: rare

Type II: low

Type III: higher

Type IV: very high

Type V: low

Name the fracture

• imcomplete fx that often leads to angulatory deformaties

How do you treat it?

Greenstick fx

Tx with closed reduction and casting/splinting

Name the fracture

• usually a few cm away from growth plate on the compression side
• stable, easy to reduce

Torus fx (buckle fx)

Name the fracture

• imcomplete fx
• microscopically made up of many small fx on concave side
• challenging to reduce since bone wants to spring back to its deformed shape

Plastic deformation

ischemia - muscle anoxia - increased capillary permeability, edema - increased pressure - pressure exceeds end-cap pressure - impedes outflow of venous system

*Pain out of proportion*

Pressure

Pulslessness

Paresthesias

Paralysis

Absolute pressure >30 mmHg or a difference b/t diastolic pressure and compartment of >30

How many compartments does each region have?

1. Forearm
2. Upper arm
3. Thigh
4. Leg
5. Foot

1. 2
2. 2
3. 3
4. 4
5. 6

supracondylar fx and tibia fx

1. dislocation of hip joint
2. radiographic anatomy of acetabulum

stimulus of located femoral head

Neolimbus (felt as clunk on exam)

1. ligamentous laxity
2. prenatal/postnatal position

1. female
2. first born
3. breech
4. family history

also assoc - oligohydramnios, torticollis, metatarsus adductus

4-7 mos when ossific nucleus becomes visible

1. reduction and stabilization of hip joint
2. restoration of nml acetabular anatomy
3. maintenance of nml function

Younger: (less than 6-8yo) reshaping osteotomy given the potential for acetabular remodeling

Older: redirectional osteotomy

How do you classify SCFE?

By time, stability, severity.

• acute, acute-on-chronic, chronic
• stable, unstable (wt bearing?)
• mild, moderate, severe (depends on slippage)

What are the two main theories of the etiology of SCFE?

Endocrine: hypothyroidism m/c

Mechanical: obesity

anterior, superior

risk of AVN in acute and acute-on-chronic cases

*blood supply to femoral head through lateral epiphyseal artery*

What presents this way?

• anterior thigh pain
• limp, externally rotated limb
• obligate external rotation with hip flexion
• pain with internal rotation

SCFE

What view x-ray do you take for SCFE?

What do you see?

AP and frog leg lateral (frog leg better)

Pre-slip findings include widened and irregular physis

Subtle findings include Klein's line

What is this clinical work up for?

• History: pain v no pain, stiffness, trauma
• Exam: any other joints
• Labs: CBC, ESR, CRP, RF, ANA
• Imaging: often plain x-rays enough
• Joint aspiration: check cell count, culture

Monoarticular arthritis

axillary view. AP may look normal

• reduction (traction-countertraction)
• 1st time: rehab, PT w/strengthening
• Recurrent: surgical stabilization

Name the injury

• subluxation of radial head
• caused by forced extension and pronation
• rarely seen after age 5
• need to distinguish from congenital radial head dislocation and Monteggia fx

Nursemaid's elbow

How does nursemaid's elbow present?

How do you treat it?

• pronated and partially flexed elbow

• reduce by supination of forearm combined with flexion

Name the injury

• disruption of the growth center
• cartilage of the growth center is the weak link
• repetitive microtrauma causes slow motion fx

Little league shoulder (a.k.a. epiphysiolysis)

How does little league shoulder present?

How do you treat it?

• weakness on resisted rotation
• external rotation contractures can result

• 2-3 mos rest and activity modification followed by progressive throwing program

Name the injury

• presents with anterolateral shoulder pain
• treat with rest, NSAIDs, PT for 6-12 wks

*MRI is best test*

rotator cuff tendonitis

Name the injury

• chronic overload in overhead throwing
• present with decrsed throwing effectiveness, pain during late cocking and early acceleration
• exam shows anterior laxity and loss of internal rotation

anterior glenohumeral instability

Tx with rest, PT, proper throwing mechanics. Return to prior levels at 6mos. Persistent symptoms may need sx

Name the injury

• excessive valgus loads lead to avulsion fx
• feel a pop and feel elbow giving way, then pain
• if non-displaced, tx with casting followed by ROM
• occasionally require screw

medial epicondyle fx

Name the injury

• general term for injuries related to medial elbow and growth plate of medial epicondyle
• results from repetitive stress from valgus overload

little league elbow

2-4 wks rest followed by stretching and slow return to throwing by 6 wks

Name the injury

• usu in kids >13yo
• usu invovles capitellum
• vascular insult from microtrauma
• prsents with dull non-specific pain, worse with activity
• may see flexion contracture
• often needs surgical treatment

osteochondritis dissecans

Name the injury

• volar or dorsal (dorsal m/c)
• arise from joint or tendon sheath (joint m/c)
• minimal pain
• w/u should include x-rays
• Tx includes observation, *aspiration and injection*, excision

wrist ganglion cyst

more than 10 degrees of bilateral varus after 18 mos of age

• diff by x-ray
• phys bowing involves the entire leg while Blount's mostly involves the tibia

When do x-rays become useful for Blount's disease?

What are you looking for?

• become useful at ages 2-3
• specifically looking for Langenskiold changes and metaphyseal-diaphyseal angles

• most resolve spontaneously w/o tx
• regular f/u every 6mos in more involved cases, with repeat x-rays for kids with borderline m-p angles

• non-op tx in young kids with mild stages - locked KAFO
• very successful if started early, correct by age 4
• failed bracing or advanced dz requires sx
• options include proximal tibia osteotomies to correct alignment and try to restore joint anatomy

Name the condition

• becomes concern around age 3-5 when angle at its max
• often notice flat appearance of foot first
• can be up to 20 degrees by age 4, back to 12 degrees at age 7
• x-rays for kids outside nml range or asymmetric

• bracing for child <4yo w/rickets
• no bracing for physiologic
• if abnml mechanical alignment, defer tx until after age 10
• sx options - hemiepiphyseodesis by staples or plates
• correction takes 6-12 mos with epiphyseodesis

How do you treat limb length discrepancy...

1. For shorter discrepancies?
2. Greater discrepancies?
3. Even greater?

1. (1-2.5cm) insert and shoe lifts
2. halt growth of long leg thru closing the growth plate (remove or tether it)
3. lengthening of short side

kids' almost never communicate with the joint

Name the injury

• lesion involving subchondral bone
• caused by trauma, vascular insufficiency, genetic factors
• more common locations: knee (med femoral condyle), talus, capitellum
• avg age at presentation 11yo

osteochondritis dissecans

• small and stable lesions include activity modification, crutches, immobilization
• larger lesions that are unstable may need drilling or fixation

Name the condition

• traction apophysitis of tibial tubercle
• occurs b/t 10-15 yrs
• presents with isolated activity related pain and swelling over tibial tubercle
• tx with NSAIDs, ice, stretch, rest

Osgood-Schlatter disease

Name the condition

• quite common during rapid growth
• presents with anterior knee pain 
• usu aggrevated by stairs or prolonged sitting

patellofemoral syndrome

• method of treatment for club foot (talipes equinovarus)
• series of six casts changed every week
• after weekly casts, release heelcord
• three more weeks of cast
• then Denis-Brown bar and shoes

Scoliosis

• Frontal plane deformity of spine greater than __ degrees
• Categories include ___, ___, ___
• Most common type is ___

• >10 degrees
• idiopathic, congenital, neuromuscular
• idiopathic

Classify the idiopathic scoliosis

1. many resolve at less than 20 degrees
2. occasionally resolve, respond well to bracing
3. all curves with onset after age 10

1. infantile
2. juvenile
3. adolescent

How do you treat scoliosis?

• Curve <25
• Curve 25-40 or 50
• Curve >50

• <25 = observation
• 25-50 = brace
• >50 = surgery

20-50 degrees

at least 3 consecutive vertebrae with at least 5 degrees of wedge

>60 = bracing

>80 = fusion

L5/S1

percent slip of L5 on S1

1. 1-25%
2. 25-50%
3. 50-75%
4. 75-100%

• pain m/c initial symptom
• hamstring tightness
• short stride, Phalen-Dickson sign (knees/hips flexed during gait)
• hyperlordosis
• foreshortened torso
• protuberant abd, sacral prominence, vertical sacrum

How do you treat spondylolysis/lysthesis...

1. Asymptomatic Grade 1
2. Asymptomatic Grade 2
3. Symptomatic Grade 1 or 2
4. If symptoms persis
5. Any grade 3 or 4

1. observe w/radiographs every 4-6 mos until age 10, every 6 mos until age 15
2. same as above, warn against contact sports
3. institute resting, then exercise, PT, activity modification, brace if no repsonse in 2-4 wks
4. fusion
5. in growing child - operate

Rotatory subluxation