Acquired disorders

Acquired pediatric conditions are those that are developed after birth and do not have a link to genetic abnormalities.

Legg-calve perthes disease

Legg-calves perthes disease is a cause when there is a temporary interruption in blood flow to the femoral head causing femoral head death and eventual collapse of the femoral joint. The interruption of blood flow can be due to trauma or blood clots. Medical confirmation is performed through physical examination, MRI, x-ray. Most common in children under 10 years old.

Phases of Legg-calve perthes:

• 1.) Necrosis-part of the femoral head has died,
• 2.) Fragmentation- the body attempts to clean-up the broken pieces of bone from area
• 3.) Re-ossification- blood flow restored to femoral head and bone begins to re-grow,
• 4.) Remodeling- new bone is new in place.

Each phase can last from months to years but indicates the body has the potential to heal itself once temporary blood flow is restored.

Symptoms include:

• Antalgic gait
• Pain/stiffness in thigh/groin
• Leg length discrepancy
• Limitations in range of motion- abduction, flexion, and internal rotation

Physical therapy interventions and legg-calve perthes disease

• Activity modifications
• Bracing/splinting to keep femoral head in contact acetabulum
• Strengthening and range of motions activities of hip

Medical management of legg-calves perthes disease

• Use of anti-inflammatory medications
• Surgical interventions to correct blood flow- not indicated for children under 6

Slipped-capital epiphysis

Slipped-capital epiphysis is a condition in which the femoral head slips from the femoral plate at the growth place. Etiology can be due to hormonal changes during puberty, growth spurt, obesity, weakening of the growth place, family history. The most common age of injury is between 10-16 years of age.

Symptoms

• Inability to bear weight on extremity
• Pain in groin/thigh
• Leg length discrepancy
• Limitations in range of motion- flexion, internal rotation, and abduction

Medical management and slipped-capital epiphysis

Surgery is indicated once confirmed through physical examination and x-ray imaging. Delay in intervention can cause serious damage such as avascular necrosis, arthritis, or deformity of hip joint. Surgery entails the implementation of a metal screw to maintain the position of the femoral neck through the growth plate.

Physical therapy intervention and slipped-capital epiphysis

Physical therapy interventions are dependent upon the surgeon’s protocol post-op and will gauge the progression of activities until return to full weight bearing.

Osgood-schlatter

Osgood-schlatter is a condition in which an individual experiences knee pain and swelling at the tibial tuberosity due to increased pulling by quadriceps of patellar tendon. Common causes are repetitive movements, excessive growth during puberty, and participation in sports that require increased running and jumping. Age of onset is typically after age 12 during the time of puberty. Confirmation of diagnosis is through physical examination and x-ray.

Symptoms

• Palpable swelling at tibial tuberosity
• Pain at anterior knee
• Increased pain during running, jumping activity with relief of pain during rest

Physical therapy interventions and Osgood-Schlatter

• Strengthening of lower extremity muscles to create even pull of muscles
• Dynamic balance activities to mimic times of exacerbation
• Postural re-education when performing running, jumping activities

Scoliosis

Scoliosis is an increased curvature of the spine. Scoliosis may develop due to cerebral palsy, muscular dystrophy, birth defects, trauma, infections to the spine, or can be idiopathic. Most idiopathic cases are diagnosed during the time of adolescence. Diagnosis is confirmed through physical examination and x-ray imaging. Severity of scoliosis is defined by degree of curve- this also guides interventions that may be performed

Cobb angle (severity of scoliosis):

• Mild scoliosis: Cobb angle less than 10 degrees
  • No intervention or conservative management
• Moderate scoliosis: Cobb angle between 10 and 25 degrees
  • Bracing and physical therapy may be indicated
• Severe scoliosis: Cobb angle greater than 25 degrees
  • Surgical intervention to correct curve as curve >25 degrees could compromise respiratory system

Symptoms

• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• Uneven waist
• One hip higher than the other
• One side of the rib cage jutting forward

Physical therapy interventions and scoliosis

• Address muscle imbalances that may be present due to curvature
• Provide shoe inserts to correct leg length discrepancy
• Prescribe durable medical equipment as necessary

Autism spectrum disorder

Autism is a developmental disorder that causes difficulties in verbal and nonverbal communication, social interaction, gross motor development, and atypical play skills. Etiology is unknown but some link to genetic predisposition and/or diet. Diagnosis is made through observation, use of outcome measures, interview with parents and child, and diagnostic criteria. Reliable diagnosis can be done at age 2.

Symptoms

• Sensory integration dysfunction
  • Hyposensitive (sensory seeking) or hypersensitivity (sensory avoidant)
• Difficulty with verbal and non-verbal communication
• Impaired coordination
• Balance deficits
• Occasional strength and range of motion deficits
• Developmental delay

Physical therapy and autism spectrum disorder

• Address developmental delay
• Improve strength
• Improve balance and coordination
• Sensory integration activities
• Be aware that new people and situations can cause either withdrawal behavior or increased aggression

Brachial plexus injuries

Brachial plexus injuries are compression or traction injuries that occur during birth that lead to dysfunction of one or both upper extremities. Common causes of brachial plexus injuries can be breech birth causing use of assisted birth techniques (forceps or vacuum), increased birth weight, twins or more, or gestational diabetes. Diagnosis of brachial plexus injuries is performed via physical examination (movement of upper extremity and/or testing of primitive reflexes), x-ray, and MRI if needed.

Severity of brachial plexus injuries are as follows:

• Traction
  • Stretching of nerve with spontaneous recovery
• Rupture
  • Nerve is torn but remains attached to spinal cord; may require surgical intervention
• Avulsion
  • Nerve is completely torn from spinal cord; permanent disability may result after surgical intervention

Common brachial plexus injuries

• Erb’s palsy
  • Involves C5-C6 nerve roots- upper arm paralysis involving rhomboids, serratus anterior, levator scapula, deltoid, infraspinatus, supraspinatus, biceps
    • Immobility of shoulder girdle leading to subluxation of shoulder
  • Only use of hand muscles
• Klumpke’s palsy
  • Involve s C8-T1 nerve roots- lower arm paralysis involving intrinsic muscles of hand, finger flexors, and finger extensors
    • Contractures of hand may result
  • Functional use of shoulder and elbow; deficits in use of wrist and hand
• Global palsy
  • Involves C5-T1- total arm paralysis

Physical therapy interventions and brachial plexus injuries

• Partial immobilization for 1-2 weeks of injured extremity
• Constraint induced therapy of non-injured arm
• Range of motion to avoid contractures
• Age appropriate movements to decreased likelihood of of developmental delay
• Parent education on positioning and handling of infant

Tortocolis

Tortocolis is a condition in which an infant’s neck bends and rotates due to tightness in neck muscles. The muscle that is tight or contracted is the sternocleidomastoid which is responsible for cervical lateral flexion to the same side and cervical rotation to the opposite side. Tortocolis can be caused by difficulties at birth, large infant weight, breach birth, or improper positioning after birth. Diagnosis is confirmed via physical examination.

Symptoms:

• Persistent head tilt to one side
• Difficulty turning the head to the opposite side
• A lump or knot may be felt in the tight neck muscle
• Facial asymmetry may develop over time
• Flat head on side of muscle tightness may present (plagiocephaly)

Physical therapy interventions and torticollis

• Stretching of contracted sternocleiodomastoid muscle
• Positioning to allow for prolonged stretched
• Addressing any developmental delay issues