Download The Essential Pediatric Musculoskeletal Exam

The Essential Pediatric
Musculoskeletal Exam
Cathleen S. McGonigle, DO
4/2011
Annual STFM Meeting 2011
Objectives
• Develop a plan of incorporating the
Essential Pediatric Exam into all Well
Child Checks
• Review essential exams in Primary
Care for newborn/infants, juvenile,
and adolescent patients.
• Common Conditions seen for each
patient age group (Handout)
Overview
• Newborn & Infant
– Extremities
• Hips
– Spine
• Juvenile
– Extremities
• Elbows
• Shoulders
• Hips
– Spine
• Adolescents
– Extremities
• Hip
• Knees
• Foot/Ankle
– Spine
Well Child Checks
• Opportunity to incorporate the
musculoskeletal exam
• Multiple visits in frequent intervals
– Lots of Normal for comparison
– Catch things early
• Systematic Approach to any
Musculoskeletal Exam
Physical Exam
• Inspection
– Symmetry, Birth Marks, Gait, hair, etc
• Palpation
– Bony Landmarks, Soft Tissues
•
•
•
•
ROM
Neurovascular
Special Testing
Related Areas
Newborns & Infants
Exam
• Inspection
–
–
–
–
•
•
•
•
Symmetry
Deformities
Skin Folds
Fingers & Toes
Palpation
ROM
NV
Special Tests
• Lower Limbs
– In-toeing
• Metatarsus Adductus
• Femoral Anteversion
• Tibial Torsion
• Hips
– DDH
• Spine
– Scoliosis
Skin Folds
• Asymmetry
– Developmental Dysplasia
of Hip (Congenital
Dysplasia of Hip)
• 72.7% - Asym. Folds -J
Child Orthop 2007
– Muscular Atrophy
– Leg Length Discrepancy
Evaluation for Lower Limb
• Foot Progression Angle FPA
• Thigh Foot Angle - TFA
• Hip Internal Rotation
• Hip External Rotation
• Heel Bissector Line
Foot Progression Angle
• Hereditary
• Infants
– Average Internal 5 degrees
– Range -30d to +20 d
• By Age 8
– Average External 10
degrees
– Range -5d to +30d
• Toes – In or Out
Thigh Foot Angle
• Exam
– Prone, Knee at 90 degrees,
Foot Dorsiflexed
• Infants
• Average Internal 5 degrees
• Range -30d to +20 d
• By Age 8
• Average External 10 degrees
• Range -5d to +30d
• Tibial Torsion
• Internal
• External
Heel Bisector Line
•
http://www0.sun.ac.za/ortho/webct-ortho/int-rot/internalrotational-deformities-of-the-lower-limb/internal-rotationaldeformities-of-the-lower-limb-6.png
Internal Rotation
Normal internal rotation:
35 degrees
Hoppenfeld, Stanley, Physical Exam of
Spine and Extremities, 1976.
External Rotation
Normal external rotation:
45 degrees
Hoppenfeld, Stanley, Physical Exam of
Spine and Extremities, 1976.
Femoral Version
• Femoral Angle
– At Birth 40 degrees
– Maturity 15 degrees
Angulation of the neck of
the femur
Physical Exam
Hoppenfeld, Stanley, Physical Exam of
Spine and Extremities, 1976.
Physical Exam
Hoppenfeld, Stanley, Physical Exam of
Spine and Extremities, 1976.
Hip Stability Tests
In a newborn, both hips can
be equally flexed, abducted,
and externally rotated
without producing a “click”
Ortolani is “OUT” to “IN”
DDH may be confirmed by
the Ortolani “click” test.
Hip Stability Tests
• Barlow
Hip Stability Tests
Telescoping of the femur to aid in the
diagnosis of DDH
Galeazzi Test
Asymmetry in
Knee Height
Tibial length
discrepancy
Femoral length
discrepancy
Spine Exams
Juvenile
Exam
• Inspection
– Symmetry
– Deformities
– Growth Plates
•
•
•
•
Palpation
ROM
NV
Special Tests
• Upper Limbs
– Elbow
• Little League Elbow
– Shoulder
• Little League Shoulder
• Hips
– Legg Calve Perthes
• Spine
– Scoliosis
Elbow Ossification Centers
Shoulder Exam Overview
• Inspection
• Palpation
– Bones
– Soft Tissues
•
•
•
•
ROM
Neurological Exam
Special Tests
Exam of Related
Area
Back Exam
Adolescents
Exam
• Inspection
– Symmetry
– Deformities
• Palpation
• Growth Plates
• ROM
• NV
• Special Tests
• Lower Limbs
– Knees
• Osgood Schlatter
– Foot/Ankle
• Tarsal Coalition
• Hips
– Slipped Capital Femoral
Epiphysis (SCFE)
• Spine
– Scoliosis
– Scheuermann’s Kyphosis
Foot and Ankle
• Inspection
– Asymmetry
– Deformity
– Coloration
• Palpation
– Bony Landmarks
– Growth Plates
• ROM
• Neurovascular
• Special Tests
–
–
–
–
Anterior Drawer
Talar Tilt
Squeeze Test
External Rotation
Test
– Thompson Test
Knee
• Special Tests
• Inspection
• Palpation
– Bones
– Soft Tissues
– Ligaments
• ROM
• Neurovascular
–
–
–
–
–
–
Anterior Drawer
Posterior Drawer
Varus/Valgus
Lachman
McMurray
Appley’s Comp/Dist
• Exam of Related
Area
Hip
• Inspection
• Palpation
• ROM
– F, E, IR, ER, ABD,
ADD
• Neurovascular
• Special Tests
• Exam of Related
Area
Hip Exam
• Signs
– Hip held in
abduction and
external
rotation
– Markedly
limited internal
rotation
Test for internal and external
femoral rotation
Spine
• Inspection
– Curvature of the
Back Bone or
Spine
•
•
•
•
Palpation
ROM
NV
Special Tests
Questions?
Common Conditions
• Infant
– Intoeing
– DDH
• Juvenile
– Little League Elbow
– Little League
Shoulder
– Legg Calvé Perthes
• Adolescents
–
–
–
–
–
SCFE
OCD Lesion of Knee
Osgood-Schlatter
Tarsal Coalition
Spondylosis/
Spondylolisthesis
– Scoliois
– Scheuermann’s
Kyphosis
Newborns & Infants
Intoeing
• Foot is turned in
• Normal
– Resolves 18-24 mths
• Causes
– Hereditary
– Idiopathic
– Congenital
• Alignment from
• Foot
• Tibia
• Femur
http://orthoinfo.aaos.org/topic.cfm?topic=a00055
Metatarsus Adductus (Varus)
• Mechanism
– Forefoot alignment
• Metatarsals on
Cuneiforms
• Cause
– Position in uterus
• Incidence
– 1:1,000 - 2,000
– Male = Female
• Risk factors
– Oligohydramnios
http://www.wheelessonline.com/ortho/metatarsus_adductus
Metatarsus Adductus
• Diagnosis
– Physical Exam
• Flexible
• No equinus
• Bilateral 50%
• Associated Conditions:
– Hip dislocation (1015%)
http://www.orthoseek.com/articles/metatarsus.html
Metatarsus Adductus
• Recommendations
– None
• Improves over 6-12wks
– Stretching
• Severity
• Treatment (3-4mths)
– 15% needed
•
•
•
•
Bracing
Shoes
Casting
Surgery (rare)
http://www.orthoseek.com/articles/metatarsus.html
Internal Tibial Torsion
• Normal
– First 2 yrs of life
• Resolves
spontaneously by age
9 to 10 years
• Treatment
– recommended of TFA
> -45 degrees
– Bracing (little use)
– Orthotics
– Surgery (rarely)
Femoral Anteversion
• Resolves spontaneously
or improves 8-10yrs
• Treatment
– Not recommended
– Braces does not help
– Discourage “W”position
Run Forest Run
http://www.orthoseek.com/articl
es/femtorsion.html
Developmental Dysplasia Hip - DDH
• Epidemiology:
– Classic Congenital Hip Dislocation
–
• Incidence
–
–
–
–
Hip instability at birth: 1%
Hip dysplasia in infants: 0.1 to 0.3%
Girls - 9 times more often affected than boys
Unilateral, but bilateral is more common
• Pathophysiology
– Femoral head dislocates from acetabulum
DDH
• Risk Factors
–
–
–
–
Female sex
First Born
Family History
Breech Presentation
J Child Orthop, 2007
Developmental Dysplasia Hip - DDH
• Types
– Classic congenital Hip Dislocation
– Teratologic Congenital Hip Dislocation
– Congenital Abduction Contracture of the Hip
(neurogenic)
• Associated Conditions
–
–
–
–
Congenital Torticollis
Breech Presentation in utero
First degree relative with hip dysplasia history
Clubfoot
Developmental Dysplasia Hip - DDH
• Clinical Signs
(J Child Orthop)
– Asymmetric skin folds
– Limitation of Abduction
• Signs: Classic Congenital Hip
Dislocation
– Ortolani Test (attempt to
dislocate hip)
• Hip Clunk felt on exam
• Distinguish from a hip click
– Galeazzi's Sign (compare the
2 femur lengths)
– Barlow's Test (attempt to
sublux unstable hip)
• Perform with caution
Developmental Dysplasia Hip - DDH
• Radiology
– Dynamic Hip Ultrasound (infant under age 3
months)
• Diagnostic for congenital Hip Dislocation
– Hip X-ray
• Not diagnostic for Congenital Hip Dislocation
– Femoral head not calcified under age 3 months
• Diagnostic for Acetabular Dysplasia
– Abnormal acetabular fossa will be seen
Normal X-rays
Developmental Dysplasia Hip - DDH
DDH
• Management: Classic
Congenital Hip Dislocation
– Refer to Peds Ortho
– Pavlik Harness
– Surgery – if needed
• Prognosis
– Delayed treatment risks worse
outcomes
Neurogenic Hip
Dislocation
Juvenile
ITE Question
• 122. Little League elbow refers to a
problem located over the
•
•
•
•
•
A) medial epicondyle
B) lateral epicondyle
C) olecranon
D) capitellum
E) ulnar groove
ITE Answer
• Right answer: A
• Little League elbow is an apophysitis of
the medial epicondyle of the elbow. It
occurs in throwing athletes between 9
and 12 years of age, and causes elbow pain
during throwing. It may also affect
velocity and control. It may cause pain
and swelling in the arm and/or elbow, but
the diagnosis should be considered in
throwing athletes with elbow pain even if
symptoms are minimal.
•
Ref: Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sportsrelated overuse injuries. Am Fam Physician 2006;73(6):1014-1022.
Little League Elbow
Little League Elbow
Little League Elbow
• Phases of Pitching
Little League Elbow
• Apophysitis
– Medical Epicondyle
• Causes
– Repetitive Throwing
– Specific throwing events
• Throwing too hard too often
• Increasing the number of pitches you throw
per week too quickly (pitch counts)
• Throwing too many curves or sliders at a
young age
• Changing to a league where the pitcher's
mound is farther away from home plate or
the mound is elevated
Little League Elbow
• Male greater than Female
• Pre-puberty - 10-15 years old
• Symptoms
–
–
–
–
Pain around the medial epicondyle
Swelling (possibly)
Pain when throwing overhand
Pain with gripping or carrying heavy
objects
Little League Elbow
• X-ray
Little League Elbow
• X-ray
Little League Shoulder
• Growth plate injury of
the proximal humerus
• Cause:
– Overuse and repetitive
microtrauma
• Presentation:
– Diffuse shoulder pain
worse with throwing or
extremes of shoulder
ROM
http://www.childrensmemorial.org/depts/sportsmedicine/im
ages/LittleLeagueShoulder.gif
Little League Shoulder
http://www.mritutor.org/mriteach/1401/int.jpg
Diagnosis
• Plain x-ray
• Physeal widening
• May reveal
metaphyseal
fragmentation and
periosteal reaction
Little League Elbow/Shoulder
• Prevention
– Always warm up before pitching
– light aerobic exercise, such as jogging or jumping jacks.
– Always stretch before pitching.
– Always follow the pitching rules of their
baseball league
– Do not play in multiple leagues at the same time.
– Limit their pitching to:
– a maximum of 4-10 innings a week
– aim for no more than 80-100 pitches per game, or 30-40
pitches per practice
– Learn and practice the mechanics of good
pitching techniques.
– Do not throw curve balls and sliders until high
school
Little League Elbow/Shoulder
• Treatment
• Severity of the injury.
– Recovery time ranges from 6 weeks to 3 months.
• Rest—Do not pitch or do any activities that cause
elbow pain.
• Cold—Ice
• Medications—NSAIDs
• Physical Therapy—After the pain is gone
– Strengthening exercises
– Range of motion exercises
• Gradual Return to Pitching—Begin throwing
motions and gradually progress to pitching
• Surgery
– Elbow: may be needed to reattach the ligament and bony
fragment if it is widely separated from the growth plate.
This is rarely needed.
– Shoulder: depends on displacement, alignment and growth
remaining at physis
Little League Pitching
Limits
•
•
•
•
•
17-18 y/o: 105 pitches/day
13-16 y/o: 95 pitches/day
11-12 y/o: 85 pitches/day
9-10 y/o: 75 pitches/day
7-8 y/o: 50 pitches/day
ITE Question
• A 6-year-old white male is brought to the office
because of left hip and knee pain of 6 months'
duration. There is no history of trauma or illness.
• On physical examination he is afebrile and pleasant.
His height and weight are at the 5th percentile.
Examination of the knee is normal. The hip has
decreased internal rotation and abduction. There is
slight atrophy, with the left thigh measuring onehalf inch less in circumference than the right, and
there is tenderness over the left hip anteriorly.
• Roentgenograms of the hip show a subchondral
fracture of the femoral head. A complete blood
count and sedimentation rate are normal. Which one
of the following is the most likely diagnosis?
ITE Question
• Which one of the following is the
most likely diagnosis?
•
•
•
•
•
A.
B.
C.
D.
E.
Lyme disease
Gaucher's disease
Tuberculosis
Juvenile rheumatoid arthritis
Legg-Calvé-Perthes disease
ITE Answer
• Right answer: Legg-Calvé-Perthes disease
• The case described is a typical
presentation of Legg-Calvé-Perthes
disease. The subchondral fracture and
normal CBC and sedimentation rate would
not be seen in the other choices listed.
• Ref: Behrman RE, Kliegman RM, Jenson HB (eds): Nelson
Textbook of Pediatrics, ed 16. WB Saunders Co, 2000, pp
2080-2081.
Legg Calvé Perthes Disease
• Healthy children
• Increased Risk
– Boys (4-12yrs) more than girls
– Family History
• Avascular Necrosis of Femoral Head
Legg Calvé Perthes
• Where does it come from?
•
•
•
•
Lack of blood supply
Increased pressure of joint
Immature bones
Infection
• What are the symptoms?
• Limp
• No pain
• Pain in knee or thigh or groin
How is it diagnosed?
• X-rays of the
hips
Legg Calvé Perthes
What happens?
• Forces applied to hip
joint further smash
the head of the
thigh bone or femur
• Deformity of the
thigh bone at the hip
• Remodeling and
Healing over time
Phases of Recovery
• Initial
• Reabsorption
• Reossification
• Healing
• Help keep pressure off the hip
Treatment - Bracing
Casting
Casting
What can happen?
•
•
•
•
Over time – bone starts to heal then remodel
Worsening deformity of hip joint
Pain
Early arthritis
Surgery
Adolescents
12 year old obese girl with knee pain
Slipped Capital Femoral Epiphysis - SCFE
• Epidemiology
– Occurs during maximal pubertal growth spurt
• Males: age 13 to 15 years
• Females: age 11 to 13 years
• Most common adolescent hip disorder
– Incidence: 1 to 4 per 100,000
• Black race > white race
• Unilateral involvement in 90% of cases
• Child is often overweight
SCFE Physical Exam
• Signs
– Hip held in
abduction and
external
rotation
– Markedly
limited internal
rotation
Test for internal and external
femoral rotation
SCFE
• Radiology: Hip Xray (Compare
sides)
– Widened epiphyseal plate
– Displacement of femoral head
SCFE
• Management
– Orthopedic Emergency!
– Immediate hospitalization and operative fixation
– Spica hip casting for 6 to 8 weeks
• Decreases risk of Femoral Neck Fracture
• Protects epiphyses
• Severe chronic Slipped Capital Femoral
Epiphyses
– Requires osteotomies to realign and stabilize
Osteochondritis Dissecans
• Most Common Location:
• Medial Femoral Condyle
• Lateral Border
• Cause
• Trauma to bone
• AVN, ischemia to bone
• Treatment
• Activity Modification,
NSAIDs, NWB
• Refer to Ortho
• Classification
OCD
OCD Lesion
Osteochondritis
Dissecans OCD
ITE Question
• 49. A 15-year-old male who is active in sports most
of the year presents with bilateral anterior knee
pain that is worse in the right knee. An
examination reveals tenderness and some swelling
at the tibial tubercles.
Which one of the following is true regarding this
patient’s condition?
A) It is almost never seen in adults
B) Treatment with a straight leg cylinder cast for 6 weeks
is often needed
C) Corticosteroid injection of the tibial tubercle is a safe
and effective treatment
D) Radiographs should always be ordered to rule out other
conditions
E) Bilateral symptoms are unusual
ITE Answer
• Right answer: A
• Osgood-Schlatter disease is encountered in patients
between 10 and 15 years of age. These patients are
often active in sports that involve a lot of jumping.
It is thought to be secondary to repetitive
microtrauma and traction apophysitis of the tibial
tuberosity.
• Bilateral symptoms are present in 20%–30% of
patients.
• Radiographs may reveal abnormalities, but are rarely
indicated in straightforward cases. This condition is
usually self-limited, and most patients are able to
return to full activity within 2–3 weeks.
• Treatment includes rest, ice, anti-inflammatory
medications, a rehabilitation program, and an
infrapatellar strap during activities. Casting and
corticosteroid injections are not indicated.
•
Ref: Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sportsrelated overuse injuries. Am Fam Physician 2006;73(6):1014-1022..
Osgood Schlatter’s Disease
•
•
•
•
Apophysitis
Tibial Tubercle
During rapid growth
Treatment
– Ice, NSAIDs,
– PT, stretching
ITE Question
• 5. A 15-year-old white male complains of
bilateral foot pain. He does not recall any
injury, and the pain improves with rest.
Examination reveals tenderness over the
lateral and anterior ankle, along with a
rigid flatfoot, peroneal tightness, and pain
on foot inversion.
• The most likely diagnosis is
• A) tarsal coalition
• B) stress fracture
• C) plantar fasciitis
• D) turf toe
• E) foot sprain
•
•
•
•
•
•
ITE Answer
Right answer: ANSWER: A
Tarsal coalition is the fusion of two or more of the tarsal bones. It is
congenital, and 50% of the time is bilateral. It is asymptomatic until
early adolescence. On clinical examination there is tenderness over
the subtalar joint (lateral and anterior ankle), rigid flatfoot, limited
subtalar motion, peroneal tightness, and pain on foot inversion.
Treatment is conservative.
A stress fracture would present with pain in the forefoot, warmth,
mild swelling, and point tenderness over the affected metatarsals,
most commonly the second or third. Radiographs are often negative
initially, but a callus is usually evident by the third week of symptoms.
Plantar fasciitis presents with pain in the heel or sole of the foot and
is most painful with the first step after arising from bed or prolonged
sitting. It may be associated with pes planus (flat foot), but in plantar
fasciitis the flat foot is flexible, not rigid.
Turf toe is inflammation of the first metatarsophalangeal joint due to
acute and/or repetitive hyperextension injury resulting from sudden
toe-off against an unyielding surface, such as artificial turf. The
patient may present acutely with a tender, red, swollen first
metatarsophalangeal joint, with pain on passive extension. Others may
develop a chronic condition and present with hallux rigidus. Foot sprain
is a nonspecific term for an acute ligamentous injury.
Ref: Andrews JR, Harrelson GL, Wilk KE: Physical Rehabilitation of the Injured Athlete,
ed 3. Saunders, 2004, p 370. 2) Pommering TL, Kluchurosky L, Hall SL: Ankle and foot
injuries in pediatric and adult athletes. Prim Care 2005;32(1):133-161.
•
•
•
•
•
•
ITE Answer
Right answer: ANSWER: A
Tarsal coalition is the fusion of two or more of the tarsal bones. It is
congenital, and 50% of the time is bilateral. It is asymptomatic until early
adolescence. On clinical examination there is tenderness over the subtalar
joint (lateral and anterior ankle), rigid flatfoot, limited subtalar motion,
peroneal tightness, and pain on foot inversion. Treatment is conservative.
A stress fracture would present with pain in the forefoot, warmth, mild swelling, and
point tenderness over the affected metatarsals, most commonly the second or third.
Radiographs are often negative initially, but a callus is usually evident by the third
week of symptoms.
Plantar fasciitis presents with pain in the heel or sole of the foot and is most painful
with the first step after arising from bed or prolonged sitting. It may be associated
with pes planus (flat foot), but in plantar fasciitis the flat foot is flexible, not rigid.
Turf toe is inflammation of the first metatarsophalangeal joint due to acute and/or
repetitive hyperextension injury resulting from sudden toe-off against an unyielding
surface, such as artificial turf. The patient may present acutely with a tender, red,
swollen first metatarsophalangeal joint, with pain on passive extension. Others may
develop a chronic condition and present with hallux rigidus. Foot sprain is a
nonspecific term for an acute ligamentous injury.
Ref: Andrews JR, Harrelson GL, Wilk KE: Physical Rehabilitation of the Injured
Athlete, ed 3. Saunders, 2004, p 370. 2) Pommering TL, Kluchurosky L, Hall SL: Ankle
and foot injuries in pediatric and adult athletes. Prim Care 2005;32(1):133-161.
Tarsal Coalition
• Abnormal union between tarsal bones:
– Osseous
– Fibrous
– Cartilaginous.
• Abnormal articulation within the mid &
hind foot
– Accelerated degenerative osteoarthritis
of the hindfoot and midfoot.
• Frequency approximately 1%
• Males greater than females.
Tarsal Coalition
• Congenital
– 2nd or 3rd decade of life
– a painful flatfoot deformity also known
as "peroneal spastic flatfoot."
• Acquired can follow
–
–
–
–
Infection
Trauma
Surgery
Inflammatory arthritis
Tarsal Coalition
• Which bones?
– Calcaneus, talus, navicular and cuboid
• Most frequent first:
– 1. Calcaneo-navicular
– 2. Talo-calcaneal,
• middle facet
– 3. Talo-navicular
– 4. Calcaneo-cuboid
Tarsal Coalition
Tarsal Coalition
• X-rays - Anteater
Sign
Tarsal Coalition
• X-rays
Tarsal Coalition
• X-rays
Tarsal Coalition
• X-rays
Tarsal Coalition
• X-rays
Harris View
Tarsal Coalition
• X-rays - CT
Tarsal Coalition
• X-rays
Normal
Reshaping Mortise
Tarsal Coalition - Treatments
• Calcaneo-navicular coalition:
– Interval casting: 4 - 6 week periods of casting
to relieve symptoms
– Resection of the calcaneo-navicular
bar: Resection is followed by fat or muscle
inerposition to prevent re-unification.
• 70% report complete or near complete resolution of
symptoms and do not need further intervention
(Campbell's Operative Orthopedics).
– Arthrodesis: Standard triple arthrodesis,
including subtalar, talo-navicular and calcaneocuboid joints, is performed as the definitive
therapy.
• Talo-calcaneal coalition:
– Interval casting
– Triple arthrodesis.
ITE Question
• 138. A high-school gymnast presents to your
office with a history of back pain for the past 3–
4 weeks. She reports that symptoms are worse
with any hyperextension activity. Examination
demonstrates a hyperlordotic posture with mild
tenderness in the lower lumbar spine. Radiographs
demonstrate the classic “Scotty dog with a collar”
appearance of spondylolysis. Which one of the
following statements about this diagnosis is true?
A) Most athletes can resume full activity in 4–6 weeks
B) Spondylolisthesis >25% requires referral to a spine
surgeon
C) Inadequate treatment can lead to complete fracture
and spondylolisthesis with prolonged disability
D) Adolescents should be followed with serial CT every
6 months until they reach skeletal maturity
ITE Answer
• Right answer: C
• Complete fracture and spondylolisthesis with
prolonged disability may occur if spondylolysis is
not diagnosed early and treated appropriately.
Most athletes respond to conservative
management and return to full activity
approximately 6 months after diagnosis.
• Treatment for low-grade spondylolisthesis (up to
50% slippage) is similar to treatment for
spondylolysis. Patients should be followed with
serial radiographs at 6-month intervals until they
reach skeletal maturity.
• Patients with a high-grade slippage (>50%) may
need to be co-managed by an orthopedic or spine
surgeon to guide treatment and assist in returnto-play decisions.
•
Ref: Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sportsrelated overuse injuries. Am Fam Physician2006;73(6):1014-1022.
Spondylosis/Spondylolithesis
Normal
Normal Anatomy
Traumatic
•Spondylolysis
•Spondylolithesis
Spondylolysis
•Extension
•Young Athletes
•Symptoms
–Pain with motion
Spondylolithesis
Spondylolisthesis
Spondylolysis
Spondylolithesis
Surgery
Treatment
•Bracing
•Physical Therapy
–Strengthening
–Flexibility
–Comfort
Surgery
Restrict Activity
•No pounding activity
–Jumping
–Running
–Extension
•Prevents further
damage
•Keep Range of
Motion
Different Types of
Scoliosis
•
•
•
•
Congenital Scoliosis
Infantile Scoliosis
Juvenile Scoliosis
Idiopathic Adolescent
Scoliosis
– 70-80% of all cases
Congenital Causes
Pediatric Exams
KEYS
• Infants and juvenile patients should
be screened during ALL well visits
and newborn exams in hospital
• Must expose the back to evaluate
• Any abnormalities REFER to Pediatric
Orthopedics Specialist
Where does Adolescent
Idiopathic Scoliosis come
from?
• We don’t know
Some things are associated with
increased risk:
o Female
o Family History
o Rapid Growth
o like puberty
What is a Scoliometer?
• A device that
measures the
OUTSIDE ANGLE
of their back
• And X-rays measure
the INSIDE ANGLE
of their back
What is a Scoliometer?
• And X-rays measure
the INSIDE ANGLE
of their back
• Cobb Angle
X-rays of the Spine
No two curves are alike
Bracing
• Purpose: Prevent
progression of the spine
curve.
• It does NOT reverse or
cure the curve
Milwaukee Brace
Surgical Intervention
• Here are some
pictures of a
surgical correction.
Scheuermann’s Kyphosis
• Described in 1920 by Dr.
Holger Werfel Scheuermann
• Excessive Kyphosis of
thoracic spine
• Can run in families
• Anterior Vertebral wedging
• Not Postural Kyphosis
Scheuermann’s Kyphosis
Scheuermann’s Kyphosis
Scheuermann’s Kyphosis
• Treatment
– Bracing
– Physical Therapy
• CORE strengthening
• Hamstrings
• Spine muscles
• Strength, Flexibility, ROM
– Maintain Weight
– Surgery
Scheuermann’s Kyphosis
Questions?
• Thank You.
Thank You