Pediatrics

Down's Syndrome Trisomy 21

Error in cell division through Type 1 Non disjunction (95%) /standard - faulty cell division results in 3 specific chromosomes, instead of two, and extra chromosomes are made for every cell. 47 chromosomes. Type 2 translocation (4%) - when part of chromosome breaks off in cell division, attached to another chromosome - the total no.of chromosomes exist - 46 but but DS exists. Type 3 Milder third type - mosaicism (17%) - milder form with abnormal cells - normal cognition and will have less impairment and disability. Occurs right after feritlisation when nondisjunction occurs in intial cell division. This results in cells with 46 and 47 chromosomes. Inference -?maternal age, and the age of the baby may cause predisposition to errors in meosis. Env - virus, paternal age, medical exposure, intirinsic predispositions, reproduction (meds) Clinical presentation - 80-1000 live births. Most common cause of mental retardation. Most commonly pair affected 21ST CHROMOSOME. Brain weight less than normal Cerebellum and brain stem lighter than normal Smaller convulutions in cortex Impairments: Hypotonia Flattened nasal bridge Almond shaped eyes Simian line - palmar crease Epicanthal folds Enlarged tongue Congenital heart defects - especially septal * Resp impairments * VIsual, hearing loss, *A/axial subluxation, dislocation due to laxity of the transverse odontoid ligements. * signs include dec strength, dec ROM, hyperreflexia, dec sensation, persitant head tult and inc tone Cognitive defect. Dev delay - varierty MSK Dec force generation of muscles *Celiac/epilesy constipation, dermatological. Umbilical hernia *Alzheimer FUNC LIMITATIONS - Gross motor development delat Difficulties eating and speech due to low tone Forceful neck flexion and rot activity should be lts due to A/A lig issues/ Cognitive and perceptual deficit, resuly in delay of fine motor, and psychosocial dev. Labs - alpha fetoprotein, human chorionic gonadotroping and unconjugated estrogen levels (triple screen) 3 diagnostic studies Chorionic villi sampling Amniocentesis Percutanoues umbillical sampling. - detec 60-70% Post delivery, chromosome analysis - KAROTYPE to confirm suspected diagnosis.

Symmetrical Tonic Reflex Prepares for crawling 6-8 mths

Extension of cervical joints produces ext of upper extremities and flexion of lower extremities. Flexion of cervical spine causes flexion of upper extremities. i.e. not differntiated F/E. If reflex persists it may interfere with development of stable quadroped position and creeping.

Craigs Test

Femoral anteversion - int fem torsion of femur. Compensate by ER of hip, Pelvis last to be ossified Palp/rotate for grtr troch most prominent and then measure angle.

Fetal sensiromotor development

GESTATIONAL AGE (GA) - Age of fetus or newborn in weeks, from first day of mum's last menstrual period. - Normal gestational period is 38-42 weeks, Infant is considered premature if born at <37 weeks GA - gestational period divided into 3 trimesters. CONCEPTUAL AGE - Age of fetus is or newborn in weeks since conception .

Cerebral Palsy 2-3 /1000 KIDS Multisystem - Sensation Perception Cognition Comm Behaviour Epilepsy Sec MSK

Group of disorders that are prenatal, perinatal or postnatal in origin. Perinatal - Non progressive encephalpopathy - major causes include hemorrage below lining of ventricles +/- Hypoxic encephalopathy, trauma of CNS Post natal - trauma or infection Premature birth. Prenatal - Malformations, genetic, Disorder of mvt and posture causing activity limitation that are caused by non progressive disturbances that occurred in the developing brain. CLASSIFICATIONS a) By areas of body with impairment - One limb MONOPLEGIA - 2 limbs - DIPLEGIA - Upper and lower limbs of one side of body - hemiplegia - All 4 limbs - quadriplegia. - trunk can be involved in all 4 types. b) MVT disorder type - SPASTIC - inc tone, lesion of motor cortex, or projections from motor cortex -ATHETOSIS - fluctuating tone, dyskinetic, lesion BG - DYSTONIA - invol mvts with sustained contractions - HYPOTONIA - dec tone - MIxed - ATAXIC - cerebellar impairment. c) Gross motor function classification for CP. Level 1 - walk without restrictions, ltd more advanced gross motor skills. CAN RUN Level 2 -Walk without assistive devices, limitations walking outdoors and in the community. CAN WALK Level 3 - Walk WITH assisted mobility device, limitations walk outdoors and community. CRUTCHES Level 4 - self-mobility with limitations, children are transported or use power mobility outdoor scooters, and in the community MOBILATOR Level 5 - self-mobility is sev ltd, even with use of adv tech. W/C Higher the score the more dependent are on devices. Other meas

Metatarsus Adductus

Pen along lat border, Ax MT hds - move in add postion.

Craniosynostosis

Rhomboid shape - area of flattening at back of skull - the right forehead is prominent in plagiocephaly, in cranio the prominent forehead is on opp side to flattening. Synostic One of sutures has fused and no grwoth in other sutures therefore wider on one side. At risk of ICP, inc risk of brain and growth problems - may need surgery.

Talipes equino varus NOT FLEXIBLE DF - structural

Birth - mainly cartilagenous, Talipes - down, INV, add, PF Positional or structural Equinus - foot point donw Calc - foot pointing up Varus - foot is turning in Valgus - foot is turning OUT Add/abd usually describes forefoot turning in or out. e.g MT adducus. Ax - look, feel, move -rest and activity, feel skin, bony prominence, calc, talus, Birth history NOT FLEXIBLE DF - structural Clubfoot - congenital talipes equinovarus Also calcaneovalgum Rx - Structural - ortho -op Ponsetti method Positional - gentle stretch, tactile stim of antagonists, edcuation, clothing

Greenstick #

Bow of bone instead of break Common mid diaphyseal forearm and lower extremity Breaks on convex side Concave side periosteum stays intact

Full term Newborn, infant and child examination

APGAR screen - 5/10 MINS after birth and every 5 mins if child having difficulties. 5 items: a) HR, RESP, REFLEX IRRITABILITY, MUSCLE TONE, COLOR - each scored 0,1,2. Score of 7 considered good NEURO AX OF NEWBORN -assign state of consiousness -test newborn reflexes NEONATAL BEHAVIOUR AX SCALE - interactive tests, slef organisational abilities, and newborn reflex and tone ax SKELETAL SYSTEM AX - Fractured clavicle - dislocated hip - asymetrical gluteal folds -spine - curved, inflexible, kyphosis, scoliosis, spina bifida, dimple, patch of hair, pigementation visible - x-ray verification. -talipes equinovarus - clubfoot, ankle in PF, forefoot add and supination. ROM - newborn has decreased ROM into EXT due to physiological flexion, but inc DF of ankles and flexion of wrists. POSTURE -physiological F all 4 limbs due to position in utero. -head to one side MVT - spontaneous and reflexive - occasional tremor - normal NEONATAL REFLEXES -primary motor patterns and infant reflexes, reactions. - present at birth and become integrated or inhibited - in CNS lesions, may persist, and interfere with milestones, or cause deformity - BABINSKI - get ext of toes and fanning of toes (0-12 mths) - STARTLE - loud noise, light, jerking whole body or EXT and ABD of all extremities - followed add of shoulders. (0-6months) - FLEXOR WITHDRAWAL - sharp, quick pressure stimulus to sole of foot or palm of hand causes withdrawal (0-2mths - ?THRO LIFE) -CROSSED EXT - sharp, quick pressure stim to sole of foot, results in withdrawal of stimulated and LE extension of opposite leg (0-2MONTHS) - MORO REFLEX - sudden extension of the neck results in F/ABD of sh and E of elbows FOLLOWED by F of the elbows. Usually causes crying test last (0-4mths) - GALANT or TRUNK INCURVATION REACTION - sharp stroke along paravertebral line from scapula to top of illiac crest results in LAT TRUNK FLEXION to stimulated side (0-2months) - PRIMARY STANDING REACTION - infant ext lower legs in response - if persists will interfere with walking, causing EXT of all jts of LE and preventing disassociation of flexion and ext -PRIMARY WALKING - hold infant in st, tilt forward slightly, reciprocal stepping motion in LE (0-2mths unless practiced) -NEONATAL NECK RIGHTING - neck righting on body NOB) - turn head with infant supine, body log rolls to same side (0-6MONTHS)

Femoral anteversion - Internal tibial torsion Metatarsus adductus - intoeing

Corrects by 10 yrs Femoral anteversion/TORSION Internal femora torsion - thigh bone turns in between hip and knee. Corrects 8yrs - Int tibial torsion Corrects 2-3yrs - metatarsus adductus If symmetrical NO P, not ltd function. NORMAL Correction not needed, if not <60 deg will derotate *** Foot corrects distally (chart) then prox correction, shin and then thigh last. Hip IR usually <60-70, deg as grow hip derotates Fem anteversion - 30-40 deg at birth 15 deg at skeletal maturity. Retroversion - ER

Leg Calve Perthes - Dennis the menace. Age 2-18 yrs - most common 4-8 yrs old M 4x as frequent. Bilat in 10-15%

Idipathic ischemia of femoral capital epiphyses. Sudden inflammation, pain++ Normal -dying - dead (devascularisation) PROTECT -recovery (remodelling) (revascularisation) spontaenous Protect in dead phase, slings, springs, etc, Keep wt off, keep fem head round and reduce collapse. PT keep it in - physio +/- surgery keep it moving Wt relief, dying and recovery phases Preserve hd, liase school.

Genu valgum

Littles genu varum - run from each other, correct with growth by 2-3 years, can go to valgus 8yrs Then straight and sl valgus 11 yrs.

Plantar grasp 0-9months 28 weeks

Pressure to sole or lowering feet to ground, results in curling of toes. Must be integrated before walking. Indicates sacral cord integrity, integrates at time of independant gait.

Prognosis CP and other Rx

- Depends on sev of brain lesion, Most children with spastic hemiplegia, mild -mod spastic CP, and mild ataxia will be able to walk. Good prognosis for walking if child can sit independently by 2 years. If child going to walk - most will achieve by 8 yrs of age. SPASTICITY CARE a) Oral meds - presynaptic inhibition of acetylcholine a) Intrathecal baclofen pump GABA b agonist ; GABA is a inhibitory CNS neurotransmitter, Subarachnoid space, intrathecal, in SC. gives more muscle relaxation with less meds. Implanted in abd, spasticity below level inserted in spine. +ve - longer lasting, inc motor control, reversible, non invasive dose, fewer SE, reservoir holds 1-4 mths supply -ve - SE of hypotonia, nausea, headache, surgical complications, catheter kink, malfunction, overdose, withdrawal, Overdose signs - drowsy, dizzy, resp depression, aeizures, hypotonia, loss of consiousness can lead to coma. Withdrawal - inc spasticity, itch no rash, tingle, headache, hyperthermia, hypotension, seizures, hallucinations, altered mental state, autonomic dysreflexia - call EMS b) Neurosurgery NEURECTOMY etc, deep brain stim Selective dorsal rhizotomy - common procedure, dorsal cell rootlets are stim those repsonding abn are severed. Usually done between 4-10 yrs Pros -dec spasticity, inc motor control, not reversible COns - poss sens loss, not revesible, not effective for dystonia, anesthesia risks.. Intensive strengthening after surgery when ambulation is goal. c) Peripheral nerve block - Injection of phenol/alchohol into periph NS. from NR to motor end plate. Last 3-6 mths i) Procain, lidocaine - anesthetic n block Dec spasticity, dystonia, not permanent, dec contractures, improves motor control, not systemic. ii) Neurolytic nerve blocks - phenol, ethanol Dec local spasticity, dystonia, not permanent, red contractures, improves muscle control, not systemic. Great skill needed to apply. d) Botox injections - minute amt paralysing it for 4-6 mths. Expensive Not permanent Dec spasticity, dystonia, not permanent, dec contractures, improves motor control, not systemic. Can be given no anaesthesia, lasts 3-6 mths. Interferes with relase of acetylcholine at NMJ, ORTHOPEDIC MANAGEMENT - Soft tissue length, tendon transfers, bone relater - osteotomies, fusions. Pros - dec contracture, dec abn bony alignement, improve motor control, effects last a few yrs Cons - anesthesia, NWB after bony for sev weeks, risk of weakness and dec function. Lenghten - Often TA, hamstrings, illeopsoas, add. Prevents hip sublux, dislocation, weak muscle, correct deformity. Tendon transfers - change direction force to inc function and dec spasticity, HIP ADD, transfer to hip ABD Osteotomies - prevent subluxation, inc normal alignement COmmon - LE, femoral, tibial or pelvic. MEDS BACLOFEN (lioseral) CNS action Dec spasticity -ve - dec stregnth, may lose postureal control DIAZEPAM (Valium) CNS action Improves motor control -ve - difficult to maint steady state TIZANDINE (zanaflex) CNS action Non invasive, not permanent -VE -dose schedule may be diffiuclt DANTROLEN SODIUM (dantrium) MUSCLE action Can be effective in some patients Side effects, drowsy, hypotonia, weakness. Oral meds are systemic and used for widespread spasticity.

Avulsion #

Adolescents Illiiac crest - abdominals ASIS - sartorius AIIF - RF GRTR TROCH - gluts, med, min Lesser troch - illeopsoas Ischeal tub - hamstrings - soccer. Symph pubis - add

Long bone

Baby bones are primarily cartilagenous, older cartilage becomes ossified, centres primary diapheses and epipheses.

Common pediatric Assessment tools

* Peabody Developmental Motor Scale gross and fine motor devlopment 0-42 months, lenghty. Spontaneous and elicited reflexes and automatic reactions. Test of Infant Motor performance TIMP 32 wks -5 mths postural and selected control of head and trunk in GM positions. Can predict CP Alberta Infant Motor Scale 0-18 mths - MOST accurate 4-10 mths 10 mins, Bayley Scale dev Ax - motor and mental scales, birth to 42 mths. Community tests Pediatric Eval of Disablilty Inventory ( PEDI), caregiver completes func limitaitons and participation restricitons. * Gross motor function Measue (GMFM -88) - CP and Downs - 5-16 yrs. Also used typical 5 year old with norm development. Vol mvt and fine motor development, prone, supine, crawl, kneel ,st and jump. Func Measures Wee FIM - self care, locomotion, and comununication, social Adult outcome measures validated in peds - 6MWT, Berg balance, stand and reach, P CTSIB,

Palmar grasp reflex 0-4mths 32 weeks

- PALMAR GRASP - pressure stim in palm results in grasp, with slow release (0-4 mths) If persists - abnormal neuro.

Rooting reflex 0-3mths 28 weeks

- ROOTING - STROKING of perioral area results in hd turn to that side; with mouth opening (0-3mths) - IMP FOR FEEDING

Osteochondritis Dissecan

/?Trauma, necrosis, and recalcification involving both bone and cartilage. Common ant/lat aspect med fem condyle.

FIne motor development

2/12 - holds object intentionally 3-4 mths - rotates object * 3 months - REACH OBJECT AND BRING TO MOUTH 4 mths - shakes objec 4-5 mths - Bilateral hold 2 objects 4.5-6 mths - transfer between hands 5.0-6.5 mths - holds and manip objects * 6-8 MONTHS - strikes blocks together, or clap 7-8.5 ths - object deformation 7.5-9.5 mths - opens and unpacks boxes * 8-9 MONTHS - INF PINCER GRASP e.g question re PRECISION pincer grasp is different to inf pincer grasp 12 months - precision pincer grasp.

Torticollis

? Traumatic, delivery, miscrotrauma SCM Congenital muscular torticollis - unilat tightness of 1 or more of the neck muscles (espec. SCM) causing ipsilateral head tilt, and CLAT rotation. 3rd most common congenital MSK disorder after hip dysplasia and club foot. Rx - stretch, right side, gentle, comfy, massage, educ Ax Hd to toe - all peds, Plagiocephaly, scoliosis, hip displasia, talipes, gross and fine motor dev.

Asymmetrical Tonic Reflex 0-6mths 28 weeks appear

ASYMMETRICAL TONIC REFLEX (ATNR) - rotation of the head, EXT of face side extremities and flexion of skull side extremities. Leg on same side extended. Stonger in LE of neonates (0-5mths) If persists might dev scoliosis, or hip dislocation and interfere with grasp and hand mouth activity. Persistance is the most freq obsv abnormality of infantile reflexes, in infants with neuro disorder

Hip dysplasia

Abnormal relationship btw femoral hd and acetabulum Congenital - Infant, babies first few weeks Developmental - 6-12 wks 1:100 DDH - 2.5:1000 Risk factors - breech, FH of DDH, female 1st born. - minor multiple preg, large birth wt Ax - 6/52, hip abd rom, LLD, gluteal creases, Barlow/Ortalani reliable 6/52 not as reliable Rx- refer ortho Brace -rhino brace, surgery -spica, LT better with early diagnosis Late - pain, dysfunction, as early as adolescence, early onset OA - not normal relationship of femur, acetabulum

Interventions CP

Age, ability, individual, type CP *Prevention disability, min effects of impairments, prevent or limit secondary impairment, e.g contratures. - static positioning and dynamic patterns of mvt opposite to normal spastic patterns - facilitate symmetry in postures - elongate spastic hamstrings and heel cords - serial cast, inc length muscle and tone. * Max gross motor func level - Prinicples of motor learning, control and facilitate func motor skills, incl vol mvt, anticipatory and reactive postural adjustments. - fun, balls, bolsters, dev activities * Wt b and postural challenge to inc muscle tone and strength. * Inc orthosis as nec - AFO - common, rigid or articulated. -submalleollar orthosis for forefoot, and midfoot malalignment, e.g pronated foot. * Use adaptive equip as nec - SEATING - maint head neutral, trunk upright, hips and knees flexed, 90 deg. hips in ABD is spastic. W/C can be tilted posterioly to reduce ext tone and maint hip F PRONE OR SUPINE - standers, and parapodium help develop wt b thro LE and encourage bone mineralisation (requires min 5hrs per week), Gi func, tone, strength LE, socail. TLR tonic labrinthe reflex will elicit more ext tone in supine, more flexor tone in prone. Side lying - will help reduce the effect of TLR ROLLATOR WALKERS - often used, posterior walker help maint upright position, and arm position helps dec extensor tone. Func mobility scale Ashworth - spasticity MSK role in hip surveillance Devices, equip Scoliosis, contractures MDTA GMFM - 2x/year e.g school

Infant gait

Babies intially walk with a high guard gait. - hips wide, arms out Frankenstein. Toe strike first, wide base, faster cadence, short step length, variable less efficient. With confidence arms mid guard, low guard. Birth - 9 mths - antigravity strength is obtained by hip f, kicking, hip E crawl, and knees kneeling. hip abd by cruising. Extremities lengthen and myelin nerves completed. 9-15mths - fat decreases, initial gait F/AB/ER hips, genu VARUM, ev of calc, absent longitudinal arches, fem anteversion, int tibial torison 18-24 mths - reduced BOS, heel remains EV, less coocontraction of muscles, genu varum resolved. 3-3.5 years - genu valgum, heel ev decreasing consistent heel strike, fem anteversion. 6-7 yrs - Fully mature gait, heels, knee in neutral position, fem anteversion resolved. almost. Angle at 0-7 yrs ER, outtoeing 0-9 months NO ARCH in prep for walking 3 yrs some arms swing 7 yrs full arm swing Normal postural variations: Intoeing - femoral anteversion , int tibial torison Varum Valgum Pes planus ** When to worry - Asymmetry - Pain - Affecting function Your not sure - refer

Functional limitations

Depends on classification of CP SPASTICITY may limit ROM, limit mobility. Special attention to ROM in growth spurts. AMBULATION - rollator, crutches by some with diplegia, athetosis and a few with mild quadriplegia.

Impairments of spina bifida

Depends on lesion and amt of malformation of the cord. Muscle paralysis and imbalance from spinal and lower limb deformities and contractures. - KYPHOSCOLIOSOS - SHORTENED HIP F AND ADD - FLEXED KNEES - PRONATED FEET L4/5 results in B/B dysfunction Sensory loss Dev delays Abn tone - may have low tone, leading to poor strength, and or spasticity, in UE. OP Cognitive - mental retardation, learning and perceptual disabilities, language. FUNCTIONAL IMPAIREMENTS - Highly variable, depending on level of scoliosis Weak.paralysis hip F (upper lx lesion) - walk only possible with reciprocating gait orthosis Learning and communication. Levels and function sim to SCI not as specific Lowest intact func and neuromuscular segment Complete, incomplete and skip lesions - func in specific muscles below level - impaired function in specific muscles above last func level. SCI -T12 Myelomingocele and meningocele - Motor and sens func at that level GD 3 Direct level above needs to be a GD 5 Skips - some nerves below still functioning get a mixed picture.

Plagiocephaly

Descriptive term - not a diagnosis Oblique slanty head, Also deformational, positional plagiocephaly DD CRANIOCYNASTOSIS Infant 5 main bones of skull sep by sutures (also temporal and sphenoid) Sutures are fibrous allow skull to distort during birth, (allows rapid growth of brain immed after birth), Fontanelles - Soft - spot anterior (9-24 mths close) small one posteriorly closes within first few months. Sutures stay open, no growth problem, See plagioparralelogram Picture - right plagiocephaly, side flattened lower skull, soft, inc rep turn head to right causes the flattening, brain has to move somewhere - skull is moldable. Zyogomatic arch forward, right ear forward. = eyes wonky from front. Encourage lye on opp side - wedge or towel under mattress, cot position Education Back to sleep, tummy to play Sleeping turn hd to opp side of flattening, wedge Helmet 23 hrs per day, orthotist to adjust, 2-6 months, outcome usually good. Play prone at least 1 hr per day, alt positions for toys, baby looks to non preferred side. S/lye towards non preferred side Stretches if torticollis present. Ax - palp fontanelle Palp suture lines for symmetry Sev Ax fomr Developmental Ax prone, sup, sitting and st MSK

AUTISM SPECTRUM DISORDER

Dev disorder that appears in the first 3 years of life and affects normal development of social and communication skills Linked to abnormal biology and chemistry, in the brain Exact causes are unknown, it is probably a combo of factors that lead to autism. But there seems to be a link of 'runnning in the family' Difficulties with verbal and nonverbal communication, social, atypical play Sensory integration - hyposensitive (sensory seekers) to hypersensitive (sensory avoiders). Complex condition, varies greatly in sev. 40% have above ave intelligence, >common in boys, (1:54 boys vs 1:252 girls). Diagnosis can now be made in some cases as early as 6 months. Impairments: Dec coordination High level bal impairments Occ strength and ROM deficits Sens impairments. Func limitations: Delayed gross motor skills PT EXAMINATION Func age testing - age appropriate gross motor func skills Muscle strength - MMT, dynamometer Co-ordination High level balance activities Active and passive ROM Sensory exam Rx - Gross motor skill training to promote age appropriate abilities. Strengthening Coordination training Balance training Sensory integration. Children appear high functioning and age app becuase they are independant ambulators, Many have delay in high level skills such as coordinated run, skip, ride a bike, st on on leg. Some will toe walk. (bike 2 yr milestone, skip 5-8 yrs, hop 2 yr)runs on toes 2 yrs. Difficulty with new routine, new people Aggressive and passive behav are seen Speech and OT common Meds for attention deficits and anxiety Some are on special diets.

Peds Rx

Developmental activity - to facilitate dev of func motor skills Use postures from the developmental sequence to inc strength, ROM, coordination. NDT - sets outcomes, and impairment goals in partnership team and family Encourages active goal directed func mvts approp for development level of the child. Uses tehrapeutic handling as primary intervention strategy Specific sensory input, using careful grading of of int, rythm, and duration of somatosensory inputs. Focus on important moror learning * Practise of task components as well as practise of whole task * Reps * Structure env appropriate to individual child. Principles of motor control and learning approaches - + early motor learning at appropriate level. Sensory integration - Goal is to facilitate child's organisation and processing of prop, tactile, and vestib input. Facilit will influence postural responses, env awareness, motor planning.

Duchenne's Muscular Dystrophy

Incidence 1/3500 Live births Diagnosis age 3-5 yrs, symptoms as early as 2.5 yrs. Can develop reasonably normally intially. Cause: x-recessive gene, inherited by boys carried by recessive gene of mother. Diagnosis -EMG, muscle biposy, DNA anlysis and blood enzyme levels Distrophin gene missing and results in increased permeability of sacrolemma, and destruction of muscle cells, Collagen, adipose laid down, in muscle leading to pseudohypertrophic calf muscles. Characterised by Muscular weakness - progressive prox to distal 3 yrs on. Positive GOWERS sign - due to weak quads, child use UE to walk up legs. and rise from prone to stand Muscle atrophy Contracture - and def develop, due to muscle imbalance esp heel cords, TFL, as well as lumbar lordosis and kyphoscoliosis. Deformity Progressive disability (walking loss 12 yrs, cardioresp late teens - cardiac tissue also involved. Shortened life span (variable, late teens to 3rd decade.Use of NIPPV Bilateral trendelenburg Pull upstairs Massive calves Functional limitation - Dev milestones may be delayed - Ambulation will be lost -eventual WC - Progressive CP impairments.

Conditions by age

Infancy Plagiocephaly Brachial plexus Palsy Torticollis Dev hip dysplasia DDH Bow legs - genu varum Intoeing Talipes Diapheseal# Childhood Perthes - 2-18 Common 4-8yrs Knock knee /VALGUM Metaphyseal # Intoeing Adolescence Scoliosis - usually girls, r) TH, IDIOPATHIC Slipped capital femoral epiphyses - Peak 13 yrs boys, 11 girls Epipheseal # Chondromallacia Osgood shlatters Apophysitis Osteochondritis Dissecans

Landau or ventral suspension 4-18 mths

Infant held in ventral suspension - will extend neck, trunk, hips, Absensce can indicate hypotonia or other neuro disorder.

Childhood Milestones Normal motor dev (gross) Roll, sit, crawl, stand, walk. Cephalic to caudal, dev of head and UE prior to trunk and LE Gross then fine motor, simple to complex Proximal to distal - uses midline as ref point, trunk then distal extremities. Develop towards goal of upright posture, mobility and manipulation.

Key milestones: see sheet ROLLING prone -supine 3-4 mths sup -side - 4-5 mths supine -prone - 6-7 mths SITTING Full support - 3-4 mths Little support - 4-5 mths Independant - 6 mths - 8mths (i.e 8 months can leave the room,) CRAWL(9) Backwards - 6-7 months Crawl , 4 PT POSITION -8-9 mths STANDING Wt bear - 4-5 mths St at furniture - pulls up - 8-9mths (9) ST no support 10-11 MTHS WALKING - 12-18 mths Walk both arms held - 10-11 mths Independant 12 mths. STAIRS Creep - 12-15 mths Assistance 16-24 mths Independant - 2yrs. GRASP REFLEXIVE - 2-3mths 4-5 mths - ulnar palmar grasp 6-7 mths radial palmar grasp +VOL RELEASE 8-9 mths - PINCER grasp, out of container 10-11 mths - FINE PINCER, IN container 12-15 MTHS -2 brick tower, marks paper 16-24 mths - 6 brick tower, folds paper, string beads. 2 YEAR - turns knob, opens and closes jar. 3-4 yrs cuts scissoirs, hand pref, match colors, copies circle or cross

Myelomengocele prognosis ADULTS

Level Thoracic - later life supervised living, and more likely vol than competitive employment High LX -L1-2 By 20's W/C dependant all mobility 50% live independantly, vol employment L3 - FT employment 20% 60% LIVE INepednantly W/C primary mob L4 - 20% continue ambulation as adults, work as L3 Barriers to ambulation = adol grwth spurts, ankle, knee valgus, elb and wrist pain. L5 80% indep, 30% FT work 20%PT W/C long distance rough terrain.

Management of spina bifida

MEDICAL SURGICAL - open defect closure within 24-48 hours - ventriculoperitoneal VP shunt, performed for hydrocephalus. or ventroatrial shunt. - ortho sim to CP PT Ax - physiological homeostasis, breahting, o2 - gross and fine motor dev, including reflex and behav exam of infant. - communicate with parents, MDTA, ETC - func ability using PEDI or Wee FM Active passive ROM Muscle strength, may observe dev skills if child under 3 Skin - incl shunt line Sens - stroke skin and note response do by dermatome. PT GOALS - Teach positioning, handling, and exc, keeping physiological F of the newborn. include prone positioning, to avoid short hip F, as well as hip ROM, low tone, OP - Use of adaptive equip, orthosis - spinal for alignement, adaptive chairs for sitting if needed, parapodium for standing, LE orthosis, and ambulation assistive. device, W/C - Facilitate func motor dev, incl app developmental activity, primary or voluntary mvt as well as reactive and anticipatory postural adjustments. - educate re shung malfunction. Signs inc irritability, dec muscle tone, seizures, vomit, bulge fontanelles, headache, and redness along shunt tract. - home, school, day care educ Myelodysplasia Orthotics and functional prognosis THORACIC- L2 - WC Prep WC, siting balacne, UE strength and propulsion, trasnfers, env exlor 1 yr orthosisi - THKAFO, Parapodium Func prognosis - W/C all func mobility, st and walking for physiologic benefits. All below, contracture prevention, maint function, jt alsignement, gross motor, adaptations, splint and casting. L1-3 Orthosis - Rec gait orthosis HKAFO Prognosis - w/c for most func mobility, short house tasks possible. St/walk for phsyiolgical benefits. L3-4 Orthosis - KAFO Prognosis -WC for community mob, House ambulation possible L4-S1 Orthosis - AFO, ground reaction AFO Prognosis - W/C community, ambulation though may be ltd S1 orthosis - foot orthosis, supramalleollar orthosis Prognosis - community ambulation.

Early motor learning

MOTOR SKILL -any motor activity that becomes better organised, more effective and more efficient as a result of practise. Enhancement of early motor skills development -GOAL ORIENTED TASKA - INT FEEDBACK via corollary discharge and effective organ feedback (visual, S/S, vestibular) - EXT FEEDBACK - KOR, KOP, FB every other time, and after delay - PRACTICE of high intensity and duration as tolerated. PRINCIPLES OF MOTOR LEARNING - Occurs in cephcaud direction and prox to distal -Unrefined to refined mvt - Stability to controlled mobility - Occurs in spiraling manner, with periods of equalibrium and disequilibrium - Sensitive periods - when infant/child is especially affected by env input.

Assessment SB

MSK Scoliosis Hip dislocation Torsional def Genu varum, valgum Talipe esp L4.5 Calc valgus OP Skin -susepctible no pain sensation - teach older kids Obesity, Cognitive Mutlisystem - MMC myelomenigocele Evaluation MMC - Neuro, sensation -Spasticity - low,, normal, inc - hydrocephalus - 28% cong, 60% after closure of spinal lesion, 80-90% require a shunt. - CN palsies (visual, pharyngeal, laryngeal, and swallow). -neurogenic bladder, (<5% dev bladder control). - UE coordin deficits - cererrbal ataxia, (arnolf chiari malfomraiton), damaged motor pathway ( hydroceph) restricted UE motor dev (use UE to get around, not using hands - less fine hand skills).

PT MUSCULAR DYSTROPHY

Maintain mobility for as long as possible by encourage rec and func activity, to maint strength and CP function. Maint Jt ROM, with AROM and PROM, and postioning devices, e.g prone exc, and postioning devices such as prone standers or standing frame. Gastroc and TFL shorten first . Gastroc inc toe walk, off feet earlier. HEP++ STRETCH Stretch, AFO, KAFO Night splints can be used. Gait posture, esp spine, and balacne 50% scoliosis 12-15 yrs 90% scoliosis by 17 yrs W/C posture+++ Resp function - linked to scoliosis. ES - yger children may inc contractility Educate and support parents *** Do not exc at max level, may injure muscle tissue, overwork injury, Supervise use of adaptive equipment as needed, Plan ahead, w/c home, shcool, predict cesssation of walking. e.g time climb 4 steps/ Disease is progressive leading to resp insufficiency and death Medical, surgical - Palliative and supportive -rx symptoms as they occur, *** Steroids (prednisone_ inc life by dec pulm; improve decline in muscle strength, reduce risk scoliosis - and when used with KAFO inc ambulation up to 3 years. SE - wt gain, bone density, cataracts, Antibios for pulm infections Ortho - scoliosis, muscle lenghtening of gastroc. Beckers; MD SLOWER VARIANT - emreges in late childhood, or adolesence, cease walking aroun 27 yrs, and death approx 42 yrs.

Theories of pediatric development

Maturationist - Hierachial model - individual genetically and biologically determined - aspects of human behaviour are performed - are innate Empiricist - - source of human behaviour is the env Behaviourist - - env reinforcement motivates and shapes cognitive and motor behaviour - used in behav modification Rx where, desired beahviours are positively reinforced. and unwanted behav ignored. Interactionist theory - child is active social being, who contributes to his, her development. Plagetian theory - interaction of env and neural maturation, results in spiraling of development and equilibrium, disequilibrium.

PT rx Downs Max potenital and level of function Meds as req - e.g seizure, PT Dec delay Hypotonia Laxity of ligs Poor strength Specific learnig strategies based on mental retardation Usually significant verbal and motor impairments.

Minimise gross motor delay - facilitate gross and fine motor devlopment thro positioning, posture and mvt actvitities - inc strength and stability, by manipulating gravity, and res in a graded manner Encourage oral motor function - facilitate lip closure, tongue retrusion - short freq feeding sessions for energy conservation Avoid hyperextension of elbows and knees during weight bearing activity Avoid all traction on extremities of the spine, due to lig laxity and low tone Prognosis - may be correlated with tone, the lower the tone the more significant the motor delay. Most children will walk by age 2 and all will walk by age 5. Medical surgical - Yearly x-ray to rule out A/A subluxation starts age 3. Prior to this unable to aAx if pt has A/A sublux -rx as if has. Medical correction of cardiac problems

Osgood Shlatters Disease P extreme, growth spurt, sudden Apophysis - secondary ossification centre. Other traction injury - Sever's disease - TA Sindig Larsen - pat tip f traction apophysitis.

Most common cause of knee pain in adolscent Extra articular swelling tib tubercle Benign, self limiting Traction apophysitis exac by exc 50% relate history and precip trauma, ? chronic microtrauma to tib tub secondary to quads overuse. Imaging - ossification irregular, fragemented apophysis, superficial ossicle, calcification in pat tendon. Tendon thickening, soft tissue edema. After recovery remains thickened. Rx -conservative 90% Initally, ice, nsaid, analgesics, brace (rx as acute) Enc dec agg activity Inc stretch as p/inflamm settles, Surgery usually only after phsyal closure(to excise ossicle) - if still pa and func difficulty.

Subjective history

Mothers pregnancy and birth history Prematurity, fetal distress, difficult labor, cord issues Medical history, special care unit, diagnosis, intubated or ventilator, surgeries, meds FH - caretalers, current home, support, soccioecconomin REVIEW OF SYSTEMS Determine corrected age if premature e.g. if child is 6 months old the chronological age is 24 weeks. If the same child was born 8 weeks early, the corrected age is 16 weeks. Correct for prematurity up to 2yr or 1 yr. CHILD, roll etc Consider ICF.

Assessment of muscular dystrophy

Muscle strength, MMT, dynamometer Active, PROM Func testing Skeletal alignement - check lordosis, scoliosis, kyphosis. Resp function, chest excursions, in breahting or spirometer. Ax need for adaptive equip 6MWT Timed function test, timed transfer, 10MWT Multitaks func motor skills NORTH STAR AMBULATION ax Gower's

Spina Bifida Myelodysplasia

NEURAL tube defect resulting in vertebral and or SC malformation. Elevated serum alfaprotein, amniotic acteylcholinerterase in prenatal and sonogram used to detec. SB OCCULTA - NO SC involvement, may have tuft of hair, dimple or sinus. SB CYSTICA - visible or open lesion (Aperta) 1) Meningocele - cyst includes CSF, cord intact Myelomenigocele - cyst includes CSF and herniated cord tissue. Failure of neural tube to close. Now closed with earlysurgery. Picked up in utero, c/section and less chance of damage to open area. Neural tube defects linked to maternal dec folic acid, infection, hot tub and exposure to terogens e.g alchohol and acid. MMC - Hydrocephalus is closely related to closure of neural tube defect. Shunting relieves pressure of hydrocephalus. May develop Arnold Chiari malformation Type2 (cerebellum andbrain stem are pushed thro forament magnum). Menigintis is common if defect not closed soon after birth. Foot def e.g talipes common esp with L4/5 level. Tethered cord - may lead to inc severity of problems as child grows.

Preterm infant examination

NEUROLOGICAL ASSESSMENT -preterm and full term - newborn reflexes, infant state of alertness - neurobehavioural items from Neonatal Behavioural Assessment Scale (NBAS) - assessment of gestational age, by evaluation of tone, physical characterisitcs. AX OF PREMATURE INFANT BEHAV (APIB) - refinement and extension of NBAS - Ax the orgnaisation and balance of the infant's physiological, motor and behavioural states. - test is lengthy, used mainly for research. NEWBORN INDIVIDUAL DEV CARE AND AX OF PROGRESS (NIDCAP) - systematic behavioural observation of preterm or full term infant in nursery or home during env input, caretaking, and treatments. - note what stresses, consoles infant. TEST OF INANT MOTOR PERFORMANCE (TIMP) -dev for infants from 32 weeks postconception to 31/2 mths postterm. -Ax of spontaneous and elicited mvts to analyse postural alignment and selective control for functional mvts

Slipped Capital Epiphyses Fat Albert - adolescent teenager 1:50000 Peak age 13 yrsM, 11G 5-10% ARE UNSTABLE and at risk of AVN

Neck slips/moves and hd stays Frogleg view best - can be missed on AP. Note risk of AVN if unstable Posterior then inferior displaced of fem epiphyses

Ortalani

Ortalani - +ve hd dislocate and relocateable Follow finger grtr troch, abd femur and puts head back in BARLOW - +ve if head can be manually dislocated ADD of femur, longitudinal force of femur, sublux posterior.

Pediatric adaptive equipment

POSITIONING: Used to maintain skeletal alignment, prevent or reduce development of contractures, and deformities, and facilitate functional abilities. STANDERS Give child wt bearing experience, maint hip, knee, ankle and trunk in optimal position, facilitates formation of acetabulam and aids bowel and bladder function. SIDE LYERS dec effect of TLR, put hands in visual fielsd ADAPTIVE SEATING - customised to meet specific support and posture to meet needs to individual. ABDUCTOR PAD at hips, often used in positioning equipment, to dec scissor ext patterns of hip ex,t, add, knee ext and PF of ankles. THERAPEUTIC EXC EQUIPMENT BALLS different sizes to promote strengthening, balance, and coordination, make motor learning fun WEDGES - facilitate or inc muscle contraction needed depending on position of wedge BOLSTERS - characteristics of ball and wedge SWINGS - promote sens integration SCOOTER BOARDS - prone stability, mobility work Others incl toys, modified tricycles, music, pets, and family members. LOWER EXTREMITY ORTHOTICS AFO for support foot, knee and ankle, provide a stable base, and to reduce effect of spasticity and hypoextensibility of muscles Ankle set at 5-10 deg DF to deg genu recurvatum. Articulating ankle AFO controls amt of DF and PF Tone reducing AFO may be polyproplene or plaster cast bivalved. - dec effects of spasticity, incl scissor by maint stretch - stretches and maintains length of heel cord, to prevent or lessen contracture. - provides goof mechanical base of support for walking. KNEE AFO - for standing or ambulation - reciprocal or swing thro gait knee may be solid at 0-5 deg F or hinges. - used spina bifida, MD HIP -KNEE-ANKLE foot orthosis - For standing and ambulation - Swing thro gait - Used by children with spina bifida or SC injuries. RECIPROCATING GAIT ORTHOSIS - HKAFO with molded body jacket -Cable system allows forward step with lat wt shift - thoracic level SCI and spina bifida PAVLIK HARNESS - Infants with Cong hip displasia -hip held in F, ABD, to maint fem hd in acetabulum MOBILITY AIDS - Wheelchairs Must be correct size for child Posture, mvt, strength, end, abnormal tone, contractures, imp to consider, incl method of mobility and seating stability. Stroller type chairs limit independance of child Scooter 3 wheelers require fair (3/5 ) sititng balance, and UE control. Power WC can be used to as early as 18 months, dep on specific child WALKERS Rollator wlakers with wheels usually used Forward walker - anterior rollator encorages forward trunk lean, provides max anterior stability Posterior walker - posture control walker Encourages trunk ext Encourages shoulder depression , elbow extension, neutral wrist, which may decrease scissoring in LE. GAIT TRAINERS Offer max support to UE AND TRUNK CRUTCHES - need more postural control than walkers. - axillary and loftsrand - available.

Pediatric pes planus

Planus on wt b - when on toes arch develops e.g reach for toy. i.e. flexible flat foot normally in kids Should correct by school age - develop arch by age 6 , 1:5 never develop an arch Familial Ok if symmterical

TBI

Primary brain injury due to mechanical forces of inital impact. 1) Accleration dependant injuries- force is applied to movable head such a coup-contrecoup and rotational head injury. 2) Non accleration dependant - skull depression into brain tissue and vibration. 3) May be accidental, or child abues- e.g shaken baby Secondary brain injury processes initiated by initial trauma 1) Cerebral edema inc ICP and may lead to brain herniation, cerebral infarction, brain stem injury and coma 2) Epidural hematoma - bleeds of middle meningeal artery, vein or vnous sinus bleeds into epidural space. 3) Subdural hematoma - due to lacerated cortical blood vessels. Evaluation TBI Imaging CT, MRI extent of primary and sec brain injury Monitor ICP Glasgow coma scale, ranchos los amigos ax child orientation and repsonse to stimuli. Infant coma scale for non verbal kids. Impairments; Sev and location of injury dependant. Loss of consiousness or cognitive level may be temp or permanently impaires Spasticity, loss of func ROM, contracture, def Weakness, bal, coord Heterotopic ossification - path bone jt due to inc tone, immobility and coma. Functional limitations; Dec mobility skills Cognitive and perceptual difficulty Dev process delay PT History, MRI, EEG, meds etc Level of alertness, coma scale, ranchos Active and PROM Muscle strength - obs spont mvt if no MMT capable Sens Bal and coordin, dev testin Muscle tone -Ashworth CN Func level testing Skin RX Maint and improve jt flexibilty, position, splint, casting Stim, arouse, thro sens stimuli. Min gross and fine motor delay - facilitate gross and fine motor dev thro appropriate positioing, postures, and mvt activities. - inc strenght, stability by manip gravity and res in a graded manner. Parent, family, Medical May need ventilation Meds ICP pressure, paralytics, diuretics, sedatives, barbiturates, ICP monitored by icp BOLT Surgical evacuation hematoma.

Traction pull to sit reflex 4-5 months

Pull infant to sitting from supine, upper extremities will flex and head will lag until 4-5 months

Pulled elbows/nursemaids elbow

Rad hd subliuxed out under annular ligament. - relocated, rot 180 deg.

Impairments by classification of CP

SPASTIC CP - Inc tone antigravity muscles - Abn postures and mvt with mass patterns of F/E - Imbalance of tone contractures and deformities - across jts, especially hip flexors, adductors, IR and knee F, PF, UE- scapular retractor, GH extensors, add and elb flexors, fa pronation. - visual, auditory, cognitive, and oral motor deficit, may be present. - 'crouched gait walk' with hip F, IR, possible toe walk ATHETOID CP - Generalised dec tone, floppy baby syndrome - Poor func stability, espec. proximal joints. - Ataxia, incoordination, when child assumes upright, wiht dec base of support and muscle tone fluctuations. - Poor visual tracking, speech delay, oral motor problems. - tonic reflxes such as ATNR - and symmetrical tonic neck reflexes - and tonic labrinthe reflex may be present blocking func postures and mvt. ATAXIC CP - Low postural tone and poor bal - Stance and gait are WIDE BASED - Intention tremor of hands - Uncoordinated mvt - Ataxia follows initial hypotonia - Poor visual tracking, nystagmus - Speech articulation problems - May occur with spastic ro athetoid types.

PT ASSESSMENT DOWNS

SUBJ - Cardiac history FH HO seazures Current history Physical attributes Dev delay Social support Dev test gross and fine motor skills, sensory integration Reflex motor patterns Test of tone - PROM Arom and PROM - jt integirty, hypermobile, hypomobile,lig laxity. Muscle testing, obsv dev postures in kids <3yrs Motor equilibrium, righting reactions, motor ass scale, coord, posture and balance, sensorimotor integration. (Peabody Dev Motor Scales) Skin, sensory integrity. Posture analysis -sit and standing Gait locomotion and bal (static and dynamic) in sitting, and standing, safety gait, device, Func level. Pulses, PFT, asucultation of hrt and lungs Ventilation - resp, circulation Cough and expectoration, resp strenght, acc muscles, VC, Pulse oximeter. Arousal, attention, cognition Learning ability, memory, intelligence Env home and work barriers Ergonomics and body mechanics Func capacity - WeeFIM

Sucking reflex 0-6mths 28 weeks

SUCKING - touch lips, tongue, palate results in suck (0-6mths). Imp for feeding

Motor control

Study of postures and mvt and parts of the mind and body that control them. NEUROMATURATIONIST THEORY -Cortex is command center with desc control and inhibition of lower centers by higher centers in CNS a) DYNAMIC SYSTEMS THEORY -command center can change ot different areas of the cortes, depending on tasks -stresses interaction brain, body, inc including biomechanics and body geometry - sens systems mature, become integrated, and connected to muscle coordination patterns - starting with VISUAL system - Immature postures involve co contraction of the agonists, and antagonists. - this co contraction reduces with maturation. b) NEURONAL GROUP SELECTION THEORY -genetic code of species outlines limits of neural network formation - actual network formation results from indiv. experience -cell death of unexperienced synaptic strengthening of synaptic connections selectively activated.

Tonic Labrinthe Reflex Important for rolling Inner ear 0-6mths

TONIC LABRINTHE REFLEX - classic - prone position, results in MAX F TONE, head F - supine results in MAX E TONE, back arches If reflex persists - block ROLLING from supine., due to inc ext tone (0-6mths)

Compression #

Torus #, BUCKLE #

Brachial Plexus Injury Avulsion no recovery, can't reattach Rupture - Neuroma Neurpraxia - shocks nerve, stretch injury - 3/12 better Neurotmesis - complete rupture, e.g surgery Note partial, complete, rupture turn into mass of neurons, neuroma Axonotmesis - axonal disruption but neural sheath intact, recovery by regrowth 1 mm per day. 4-6 mths, upper arm; 7-9 in lower arm

Traction or compression to unilateral brachial plexus in birth or due to cervical rib anomaly. ERB'S PALSY - or ERB DUCHENNE paralyisis, involves C5.6 Upper arm parlaysis, rhomboids, lev scap, SA, SSP, IFSP, biceps, b/radialis, brachialis, sup and long extensors of the wrist and fingers. KLUMPKE's PARALYSIS- C8-T1, sens and motor Lower arm paralysis, intrinsics of hand, flexors and extensors or wrist and fingers. TOTAL OR WHOLE ARM (Erb -Klumpke paralysis)C5-T1 Nerve sheath is torn and nerve fibres compressed by hemorrage and edema, although total avulsion of nerve is possible. Impairements: Sensory of UE Paralysis of UE Erbs - add, IR, and E of elbow, pronation F/A and flex of wrist. Waiters tip palsy. FUNC LIMITATIONS - Dependant on sev of injury ERBS - dec shoulder function 1;1 humeroscap mvt KLUMPKE'S - dec wrist and hand function Traction injuries resolve spontaneously. Avulsion injuries may require surgical nerve repair, if not resolved in 3 months. Shoulder subluxation adn contractures may result. PT Ax infant posture, arm position and mvt both arms Gross and fine motor assessment Sens (take up to 2 years to recover) Test reflexes MORO, biceps, radial reflexes are not present; grasp is intact rx Partial immobilisation of limb, across upper abdomen 1-2 weeks to avoid further injury Gentle ROM after initial immobilisation to avoid contractures. Splints - resting night. Elicit muscle activity with age appropriate func mvts of UE, PROM, skin checks Dev therapy - positioning, play and active mvt. May use gentle constraint of unaffected arm to facilitate use of aff UE - positioning Prognosis depend on severity, favorable in most instances. If no recovery - surgery needed.

Scoliosis Congenital Neuromuscular Bone dysplasia IDIOPATHIC - infantile -0-3; Juvenile 3-10; Adolescent >10 y Traumatic, neoplastic, iatrogenic.

Uneven sh, uneven hips Fetal spin - C shaped Newborn - C shaped slight lower lx, less 1-2 years TH AND SACRAL - primary curves Lx - secondary curves Always abnormal Must be >10 deg Described according whihc way CONVEX towards. Watch LLD - sitting, no discepancy - not true scoliosis, Ax pediatric spine Keep in mind - Growth - age of child, potential for progression e.g maturity, prepubescent hige grwth years Pain - severe bp uncommon in peds RF Cause - identify clues in history, and Ax History Onset, yg, child, Progression Pain Func Maturity Dev Hx FH idiopathic scoliosis Ax - Age, maturity, skin - cafe au lait, Marfan -Curve balanced ? , e.g Cx, LX Location Rigidity - lat F l/r Rotation - forward bend test - rib hump -seen in 80% of idiopathic curves - shows a rotation component in scoliosis Fem, thoracic right common Rx Active, stregnth, exc right curve and lenthen short side, postural, gym ball, pool Pthway directed by orthopedist Bracing - curves >20 deg 70% success rate help control the curve slow progressions avoids surgery in some cosmesis Surgery Curves 40-45 deg and immature, severe angle curves >50 at skeletal maturity -will progress 1 deg per yesr curves >80 deg risk C/P and mortality. Early identiy, early ref ortho Pt at risk of progression - still growing, e.g Risser 1, curve, sev pain, abn neuro and evaluation. CP abnormal pulls on spine, spstic quadriplegia - severe scoliosis, respiratory.

Pediatric fractures

Why are they different ? Infants - diaphaseal (shaft) Children - metaphaseal (e.g supracondylar) Adults - epiphyseal (growth plate) SALTER S slipped - 5% A - ABOVE - 75% - L - lower, 3-10% T - Through (4-10%) R - rammed - uncommon AVULSION # Type 1 Non displaced Type 2 Displacement up to 2 cm Type 3 Diplacement >2cm Type 4 - Symptomatic non union or pful exosotosis Type 1=2 non op Type 3=3 surgical Post op NWB 7-10 days Progressive WT B 3-6 weeks Retn to sport - surgeon Varies 4-6w and 3-4 months. Stage 1 ice, meds, 7 days Stage 2 gentle AROM, PROM Stage 3 once 75% ROM guided strenght training.