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When are the growth plates most vulnerable because they are trying to set in place?
Around the age the child is beginning puberty
Name the SALTER-HARRIS classification
S - Separated growth plate
A - Above growth plate
L - below growth plate
T - Through growth plate
ER - Erasure (crush) of growth plate
Why are salter-harris fractures more common in males?
Performing more high risk activities than women
T/F: Salter-Harris fractures are more common in the LE
FALSE.. more common in UE
- Abnormally slowed growth of medial/proximal tibia
- Due to exercise load from obesity during bone development
- Infantile, juvenile or adolescent onset
- Bracing most effective in children < 3 years
- Surgical interventions required for teens
- Osteotomy
- External fixation for progressive realignment
- Hemiepiphysiodesis (pins creating an angle for bone to grow)
Blout's disease / tibia vara
- 15-30% of all bony injuries among children
- Females affected most at age 11-12 yo
- Males affected most at age 12-14 yo
Salter harris fractures
Which kind of pelvic avulsion fracture:
- Biceps femoris
- Semimembranosus
- Semitendinosus
- Sudden/forceful hip extension/knee flexion
Ischial tuberosity (29.7%)
Which kind of pelvic avulsion fracture:
- Rectus femoris
- During hip extension and knee flexion (kicking)
AIIS (33.2%)
Patient will have hip, thigh, knee pain and cannot pinpoint pain; treatment is glute strengthening, LE strengthening and have a fear of weightbearing, promote physical activity
SCFE tx
What structure is the issue in Legg-Calve-Perthes disease?
Issues with secondary artery supply (ossification center)
Name the number of salter-harris fractures in order from most common to least common
Type II, III, IV, I, V
1. Neuromuscular dysfunction (low muscle fitness, poor fundamental movement skills)
2. Physical illiteracy (reduced movement competence and confidence, disinterest in physical activity)
3. Kinesiophobia (fear or movement, perceptions of discomfort)
4. Unhealthy behaviors (increased screen time, poor sleep hygiene)
5. Injury and illness (activity related injuries, chronic disease)
Youth physical inactivity cycle
- AVN of the femoral head
- Occurs between the ages of 3-12 yo, average age 5-7 yo
- Male:Female ratio 4:1
- Healing time: 1-3 years
- Common presentations: ambulation with limp, pain referred to the groin, thigh or knee, limitations of hip IR and ABD
- Some evidence to suggest maternal smoking or second hand smoke increased risk
Legg-calve-perthes disease
- History: hearing/feeling a "pop"; during forceful eccentric contraction activity
- Exam: tenderness; swelling/ecchymosis may be present; pain with tension of involved tendon; pain/weakness with action of involved musculotendinous tissue
- Diagnosis: X-ray; MRI sometimes required
Avulsion fractures exam
- Self limiting disease
- Resolution typically with skeletal maturation
- Activity modification
- Maintain cardiovascular function via non-impact
- Swimming
- Cycling
- Progressive knee joint loading
OSD treatment
Which kind of pelvic avulsion fracture:
- Sartorius
- TFL
- Sudden/forceful contraction into hip extension/flexion (sprinting, bat swing)
ASIS (27.9%)
Typical treatment time
- Weeks 0-3: PWB initiated
- Weeks 3-5: FWB
- Week 8: return to running
- 3 months (2-6 months): return to sport
Avulsion fractures
- The metaphysis slips on the epiphysis at the femoral head
- Typical patient
- Obese
- Male
- 10-16 yo
- Bilaterally about 25%
- Reduction in hip flex, abd, IR
- Risk factors: obesity, femoral retroversion (toe out), radiation treatment, endocrine disorders
- Treatment: percutaneous pain, in children < 10 yo the contralateral hip may be performed to reduce risk
Slipped capital femoral epiphysis (SCFE)
- Tenderness
- Swelling
- Thickening of patellar tendon
- Tibial tuberosity enlargement
- Firm mass may be palpated
- Extensor lag may be present
- Soft tissue restrictions
- Quads
- Hamstrings
** You likely will NOT see flexion/extension mobility deficits, full joint effusion or instability of the knee
OSD exam
Overall goal:
- Optimize femoral head in acetabulum congruency
- Address impairments to improve/maintain function
AVN: NWB and joint protection, surgical osteotomy
Revascularization: Spica/Petrie case (if post surgical) or bracing with Scottish Rite brace achieves containment by abduction while allowing free knee motion
Bone healing: guide bone remodeling for spherical femoral head in acetabulum, restore ROM and muscle symmetry
Residual deformity: restore functional play skills, movement/recruitment patterns, and achievement of motor milestones
Legg-Calve-Perthes disease PT management
What is the test for Sever's disease that we can perform quickly to rule in this diagnosis?
Squeeze calcaneous and ask if painful... if yes, then patient has severs and there is no involvement of the Achilles tendon
- Osteochondrosis or traction apophysitis of the tibial tubercle
- Repetitive knee extension stress
- Presents as anterior knee pain at the tibial tubercle
- 20-30% bilateral knees
- More common in males
- Males: 12-15 yo
- Females: 8-12 yo
- Increased risk with repetitive running, sprinting and jumping
- Basketball
- Volleyball
Osgood Schlatter disease
- Abnormal development of acetabulum
- With or without hip dislocation
- Risk factors: breech in 3rd trimester; newborns; female; 1st birth; swaddling with hips adducted; post maturity; L hip (big babies adducted against mothers lumbosacral spine) (about 20% are bilateral issues)
Developmental dysplasia of the hip
- Inflammation of the calcaneal physis
- Child usually tall and overweight
- Patient will present with: posterior heel pain that worsens with physical activity/walking; positive heel squeeze test; reduction in DF ROM; Redness/swelling usually absent; radiographs negative
- Risk factors: running/jumping sports; high weight/BMI; increased plantar pressure (primarily at heel)
Calcaneal apophysitis AKA Sever's disease
- Initial reduction in load: activity modification, heel lift, crutches
- Increase DF ROM
- NSAIDs will likely be prescribed early on
- RTP average of 2 months (41-180 days)
See this when a child was not very active and then they become active all of the sudden
Calcaneal apophysitis treatment