pediatrics

Question 1

obstetric brachial plexus injury

OBPI/BPI

Answer 1

• to upper and/or lower brachial plexus during difficult vaginal deliveries - can be at any level of brachial plexus
• 52% are C5-C6
• forceful traction or rotation of the head or shoulder: can also have fracture of clavicle or humerus
• usually made at birth - arm appears flaccid or only moves slightly, parents told right away
• EMG shows injury
• Erb’s palsy

Question 2

erb’s palsy

Answer 2

• injury to C5-C6, sometimes C5-C7
• sensory loss possible
• “waiter’s tip” position

Question 3

OBPI prognosis

Answer 3

• stretch heals faster than a full rupture
• 80-90% resolve in 3 months
• biceps recovery is predictive: cookie test

Question 4

OBPI intervention

Answer 4

• ROM
• sensory: protect, increase awareness, sensory input, never pull or traction affected arm
• active movement: meaningful, age appropriate, gross, and fine motor skills
• electrical stimulation
• possible splinting and kinesiotape
• constraint therapy
• the earlier the better
• focus on developmental and functional activities
• conservative treatment is effective intervention

Question 5

arthrogryposis multiplex congenita

Answer 5

• nonprogressive, congenital NM syndrome (multi system involvement)
• 2 or more body areas, may just have distal involvement
• incidence 1/3000-4000 births
• clinical picture is variable: joint contractures, muscle weakness/fibrosis, absence of muscles (amyoplasia)
• etiology unknown: correlates with lack of movement in utero
• possible causes: taratogens, virus, maternal fever, somee forms hereditary (chromosome 5)

Question 6

arthrogryposis multiplex congenita impairments and conditions

Answer 6

• primary impairments: joint contractures, muscle weakness
• associated conditions: clubfoot, hip dislocation, typically have normal cognition and speech
• diagnosis: no definitive tests, rule out other causes

Question 7

arthrogryposis presentations and associated factors

Answer 7

• scoliosis
• dimpling of skin over joints
• hemangiomas
• absent or decrease finger creases
• congenital heart disease
• faacial abnormalities
• respiratory problems
• abdominal hernias

Question 8

developmental dysplasia of the hip

Answer 8

• packaging
• test with Barlow maneuver
• treat with Ortolani maneuver

Question 9

torticollis

Answer 9

• sternocleidomastoid - named for side of tightness
• ipsilateral lateral rotation, contralateral rotation
• thir most common congenital abnormality
• active ROM - muscle function scale
• passive ROM - arthodial goniometer

Question 10

osteogenesis imperfecta

Answer 10

• brittle bone disease: mobility and developmental delays, pain, posture, ROM
• genetic, autosomal dominant, 1/20,000
• Type 1 - most common, mild, little or no deformity
• Type 2, 3, 7, 8 - severe symptoms, compromises respiratory or cardiac compromise
• Type 4, 5, 6 - moderate
• PT: family education, moving and positioning, adaptive/assistive equipment, aquatic therapy, robotics

not casts, too heavy to lift
transition well to adults

Question 11

clubfoot and ankle-foot conditions

Answer 11

• metatarsus adductus/varus
• calcaneovalgus
• talipes equinovarus (clubfoot)

Question 12

metatarsus adductus/varus

Answer 12

• mild: forefoot correctable, spontaneously corrects by 4-6 months
• moderate: straight last or reverse last shoes, possible serial casting
• severe: forefoot not correctable, serial casting, surgery

a packaging issue

can watch until 4 to see if it spontaneously resolves

Question 13

calcaneovalgus

Answer 13

• hindooft valgus, more than 30% of neonates have bilaterally
• excessive dorsiflexion
• corrects spontaneously

Question 14

clubfoot - talipes equinovarus

Answer 14

• 1-2/1,000, genetic, mostly male
• 50% bilateral
• forefoot curved medially, small calcaneus, hindfoot varus, ankle PF, calf atrophy

Question 15

ponsetti method

sequential serial casting

Answer 15

• standard for clubfoot outside of US
• can cause skin breakdown if not careful
• begin 7-10 days, most effective before 9 months
• PT’s can be trained in Ponsetti
• goals after casting: normal strength (PF and DF), mobility, positioning during gait, closed-chain and open-chain activities

Question 16

developmental dysplasia of the hip (DDH)

Answer 16

• packaging and associated conditions: CMT and plagiocephaly, metatarsus adductus, calcaneovalgus
• Barlow and ortolani tests until 3 months old
• use Pavlik harness, hip spicea, osteotomies, ROM and developmentally appropriate activity and strengthening

Question 17

tests for infant hip DDH

Answer 17

• B before O
• barlow test: flex and abducted, then gradually adduct with pressure in posterior direction
• ortolani maneuver: if B test is positive, gentle flexion then abduction, slight anterior traction

can also look at asymmetrical skin folds, atypical gait

Question 18

legg-calve-perthes disease

Answer 18

• osteochondrosis: ossification which begins as degeneration followed by regeneration
• avascular necrosis of femoral head (obturator if < 10, med circumflex femoral if > 10)
• 1/1200 under 12, mostly active boys 4-8
• pain in knee, hip, groin - unilaterally (10% bilateral)
• limp/trendelenburg gait
• PT: pain management, ROM, rest or activity modification, crustches or WC, promote symmetry

50% have degenerative hip disease by 50

Question 19

slipped capital femoral epiphysis (SCFE)

Answer 19

• displacement of femoral head on femoral neck, head inferior and posterior in relationship to femoral neck
• 10/100,000, more boys than girls, more children who are Black or PI
• tend to be obese, skeletally immature males, around time of puberty/growth spurt
• ROM limited hip flexion and lateral rotation, rest in lateral rotation, limp, pain
• surgical intervention
• PT: strength, ROM, nWB most often pre-op, promote symmetry, have THA 11 years earlier than OA patients

Question 20

limping and leg length discrepancy

Answer 20

• history of trauma
• normal neurologic examination
• fever

Question 21

differential diagnosis of antalgic gait

Answer 21

• congenital conditions: hemihypertrophy, hemiatrophy, focal deficiencies

Question 22

treatments for leg length discrepancy

Answer 22

• conservative: observation (0-2 cm), lift (2-4 cm)
• surgical: shortening (4-6 cm), lengthening (4-20 cm), prosthesis (>20 cm)
• epiphysiodesis: surgical shortening of long leg
• Wagner or Ilizarov: lengthening for short leg
• PT post-op: ROM, strengthening, stretching, pain management, gait training, functional activities, developmental

Question 23

pediatric amputation

Answer 23

• congenital, traumatic, cancer, focal deficiencies, other
• rotationplasty

Question 24

pediatric pelvis begins in [ ] tilt

Answer 24

posterior tilt
* increases through 2-4 years
* age 3-5 between 10-20 degrees anterior tilt

Question 25

test to measure femoral anteversion

Answer 25

* Craig's or Ryder method * 40 degrees at birth, 35 at 1 year, 21 at 9 years, 15-20 for adult * if anteverted, improves possible around age of 6

Question 26

4 possible reasons for pediatrics toe-in

Answer 26

* increased femoral anteversion at hip * increased tibial torsion at knee (less common) * increased axial tibio-femoral rotation at knee -- W-sitting * metatarsus adducts at foot (in babies) | babies at the foot, toddlers at the knee, school at the hip

Question 26

4 possible reasons for pediatrics toe-in

Answer 26

* increased femoral anteversion at hip * increased tibial torsion at knee (less common) * increased axial tibio-femoral rotation at knee -- W-sitting * metatarsus adducts at foot (in babies) | babies at the foot, toddlers at the knee, school at the hip

Question 27

general changes from birth to adulthood in MSK * sacral angle * acetabulum * coxa vera and valga * anteversion * hip ER * hip flexion * genu varum and valgum * foot progression angle * axial tibio/femoral rotations * arch development

Answer 27

* sacral angle: posterior to anterior * acetabulum: retroverted to anteverted * coxa vera and valga: valga to vera * anteversion: 40 degrees to 8-15 degrees * hip ER: large to less * hip flexion: large to less (contracture to extension) * genu varum and valgum: varum to valgum * foot progression angle: 10 degrees to 0 degrees * axial tibio/femoral rotations: 65 degrees to less than 40 * arch development: increases from birth to 3 years