4.3 Acquired disorders

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4. Pediatrics

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Acquired disorders

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

Legg-Calve Perthes disease

Legg-Calve-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, and 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 the area
3.) Re-ossification- blood flow is restored to the femoral head, and the bone begins to re-grow,
4.) Remodeling- new bone is new in place.

Each phase can last from months to years, but it 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 the femoral head in contact acetabulum
Strengthening and range of motion activities of the hip

Medical management of Legg-Calve-Perthes disease

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

Radiograph of Legg-calve perthes disease

Slipped-capital epiphysis

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

Symptoms

Inability to bear weight on the extremity
Pain in the 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 the 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 the quadriceps of the 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 the tibial tuberosity
Pain at anterior knee
Increased pain during running, jumping activities , with relief of pain during rest

Physical therapy interventions and Osgood-Schlatter

Strengthening of lower extremity muscles to create an 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 of 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 the 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 the curve , as a curve >25 degrees could compromise the respiratory system

Symptoms

Uneven shoulders
One shoulder blade that appears more prominent than the other
Uneven waist
One hip is 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, an interview with parents and child, and diagnostic criteria. A reliable diagnosis can be made 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 leading to dysfunction of one or both upper extremities. Common causes of brachial plexus injuries can be breech birth, causing the 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 the upper extremity and/or testing of primitive reflexes), x-ray, and MRI if needed.

Severity of brachial plexus injuries is as follows:

Traction
- Stretching of the nerve with spontaneous recovery
Rupture
- Nerve is torn but remains attached to the spinal cord; may require surgical intervention
Avulsion
- Nerve is completely torn from the 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 the shoulder girdle leading to subluxation of the shoulder
- Only use of hand muscles
Klumpke’s palsy
- Involve s C8-T1 nerve roots- lower arm paralysis involving intrinsic muscles of the hand, finger flexors, and finger extensors
  - Contractures of the hand may result
- Functional use of the shoulder and elbow; deficits in the use of the 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 the injured extremity
Constraint-induced therapy of the non-injured arm
Range of motion to avoid contractures
Age-appropriate movements to decrease the likelihood of developmental delay
Parent education on positioning and handling of the infant

Tortocolis

Torticollis is a condition in which an infant’s neck bends and rotates due to tightness in neck muscles. The tight muscle or contracted muscle 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, breech 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 the side of muscle tightness may present (plagiocephaly)

Physical therapy interventions and torticollis

Stretching of the contracted sternocleidomastoid muscle
Positioning to allow for prolonged stretched
Addressing any developmental delay issues

Legg-Calve Perthes disease

Temporary interruption of blood flow to femoral head; leads to bone death and collapse
Four phases: necrosis, fragmentation, re-ossification, remodeling
Symptoms: antalgic gait, thigh/groin pain, leg length discrepancy, limited hip ROM
Interventions: activity modification, bracing, hip strengthening/ROM, anti-inflammatories, surgery (not for <6 yrs)

Slipped-capital epiphysis

Femoral head slips at growth plate; often during puberty (ages 10-16)
Symptoms: inability to bear weight, groin/thigh pain, leg length discrepancy, limited hip ROM
Management: surgical fixation with metal screw, urgent intervention to prevent complications
PT: post-op rehab per surgeon protocol, gradual return to weight bearing

Osgood-Schlatter

Knee pain/swelling at tibial tuberosity from patellar tendon traction
Common in adolescents with growth spurts, sports participation
Symptoms: anterior knee pain, swelling, worse with activity, relieved by rest
Interventions: LE strengthening, dynamic balance, postural re-education

Scoliosis

Increased spinal curvature; idiopathic or secondary to other conditions
Diagnosis: physical exam, X-ray, Cobb angle measurement
- Mild: <10°, usually no intervention
- Moderate: 10–25°, bracing/PT may be indicated
- Severe: >25°, possible surgery (risk to respiratory system)
Symptoms: uneven shoulders/waist/hips, rib cage asymmetry
PT: address muscle imbalances, correct leg length discrepancy, DME as needed

Autism spectrum disorder

Developmental disorder affecting communication, social skills, motor development
Symptoms: sensory integration dysfunction, communication difficulties, impaired coordination/balance, developmental delay
PT: address developmental delay, improve strength/balance/coordination, sensory integration, awareness of behavioral responses

Brachial plexus injuries

Birth-related nerve injuries causing upper extremity dysfunction
- Traction: nerve stretch, likely recovery
- Rupture: torn nerve, may need surgery
- Avulsion: nerve torn from spinal cord, possible permanent disability
Types:
- Erb’s palsy (C5-C6): upper arm paralysis, shoulder immobility
- Klumpke’s palsy (C8-T1): hand/wrist paralysis, contractures
- Global palsy (C5-T1): total arm paralysis
PT: partial immobilization, constraint-induced therapy, ROM to prevent contractures, developmental activities, parent education

Torticollis

Neck tilting/rotation due to sternocleidomastoid tightness; often from birth trauma or positioning
Symptoms: persistent head tilt, limited neck rotation, palpable muscle knot, facial asymmetry, possible plagiocephaly
PT: stretching of SCM, positioning for prolonged stretch, address developmental delays

Acquired disorders

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