Paediatric Musculoskeletal Development: Difference between revisions
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== Introduction == | == Introduction == | ||
The musculoskeletal system is influenced by many different factors as infants and children grow. This system adapts to the demands, or lack of demands, that are placed on it. When inappropriate forces are applied to muscles or bones, alignment may be impacted. Atypical alignment can directly affect functional activities and an individual's participation.<ref name=":0">Eskay K. Paediatric Musculoskeletal Development Course. Plus. 2023.</ref> | |||
The following sections will highlight | The following sections will highlight key stages and changes that occur during musculoskeletal development, and provide examples of atypical development. | ||
== Rib Cage == | == Rib Cage == | ||
{| class="wikitable" | {| class="wikitable" | ||
| Line 21: | Line 21: | ||
|- | |- | ||
|2 years old | |2 years old | ||
|Oblong- | |Oblong-shaped | ||
|Depressed due to [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]] pull and sitting/standing/walking | |Depressed due to [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]] pull and sitting/standing/walking | ||
|Lateral expansion | |Lateral expansion | ||
| Line 33: | Line 33: | ||
== Trunk == | == Trunk == | ||
* Initially, infants have a [[Kyphosis|kyphotic]] spine, which | * Initially, infants have a [[Kyphosis|kyphotic]] spine, which over time, becomes a more neutral spine (as seen in adults) | ||
* Prone push-ups and sitting | * Prone push-ups and sitting activate the posterior chain musculature (pushing into thoracic extension) | ||
* Crawling creates co-contraction of the anterior and posterior muscles<ref name=":0" /> | * Crawling creates co-contraction of the anterior and posterior muscles (for stability)<ref name=":0" /> | ||
=== Increased Curvature of the Spine === | === Increased Curvature of the Spine === | ||
Increased curvature of the spine | Increased curvature of the spine (e.g. scoliosis) can affect: | ||
* breathing | * breathing | ||
| Line 48: | Line 48: | ||
* Initially, infants have a rounded pelvis with a posterior tilt | * Initially, infants have a rounded pelvis with a posterior tilt | ||
* Sitting and standing | * Sitting and standing activate core muscles and lead to an anterior pelvic tilt | ||
* At 12 months old: 12 degrees of anterior pelvic tilt | * At 12 months old: an infant has 12 degrees of anterior pelvic tilt | ||
* At 30 months old: 15 degrees of anterior tilt | * At 30 months old: a child has 15 degrees of anterior tilt | ||
* With increased [[Gluteal Muscles|gluteal]] activity, the anterior tilt decreases slightly until age 8 | * With increased [[Gluteal Muscles|gluteal]] activity, the anterior tilt decreases slightly until age 8 | ||
* Adults have 10 degrees of anterior pelvic tilt<ref name=":0" /> | * Adults have 10 degrees of anterior pelvic tilt<ref name=":0" /> | ||
== Lower | == Lower Extremities == | ||
Typical joint patterns in infants are as follows: | Typical joint patterns in infants are as follows: | ||
| Line 63: | Line 63: | ||
=== Hip === | === Hip === | ||
* Infants: | * Infants: | ||
** | ** more external rotation at birth which decreases over time | ||
** hip adduction limitation | ** hip adduction limitation | ||
** 34 degrees of hip extension limitation | ** 34 degrees of hip extension limitation | ||
*** more time in prone | *** as infants spend more time in prone, their anterior capsule stretches | ||
*** 6 weeks old: 19 degrees of hip extension limitation | *** 6 weeks old: 19 degrees of hip extension limitation | ||
*** toddlerhood: 7 degrees of hip extension limitation | *** toddlerhood: 7 degrees of hip extension limitation | ||
* | * Newborn: increased coxa valga - 140-160 degrees | ||
** decreases over time to | ** decreases over time to 126 degrees in adults | ||
** more ambulatory, | ** as become more ambulatory, femoral neck angle decreases | ||
* | * Newborn: anteversion of the femur - 40 degrees; decreases to 16 degrees in adults | ||
==== Changes in Alignment to Consider ==== | |||
==== | ===== Hip ===== | ||
* Femoral neck angle remains high: high femoral anteversion: increase risk of posterior hip dislocation (especially cautious of this with non-walkers aged 30 months)<ref name=":0" /> | |||
* | |||
==== Pelvic Obliquity ==== | ===== Increased Anterior Pelvic Tilt ===== | ||
* | * Abdominals and hip extensors long | ||
* | * Hip flexors and lumbar extensors short | ||
*'''Results''': unable to have appropriate muscle pull of both abdominals and [[Gluteal Muscles|gluteus]] muscles when performing functional activities<ref name=":0" /> | |||
===== Decreased Anterior Pelvic Tilt ===== | |||
*[[Iliopsoas]] and anterior hip capsule is stretched out | |||
*[[Gluteus Maximus|Gluteus maximus]] is shortened | |||
*'''Results''': anterior hip laxity and hip instability<ref name=":0" /> | |||
===== Pelvic Obliquity ===== | |||
* Common in individuals with [[hemiplegia]] and diplegia | |||
* Depressed hip side (shorter side): | |||
** increased pronation of the foot on that extremity | ** increased pronation of the foot on that extremity | ||
** reduced stance time | ** reduced stance time | ||
** reduced loading | ** reduced loading | ||
** functional ankle plantarflexion | ** functional ankle plantarflexion | ||
* | * Longer side: | ||
** compensatory foot pronation | ** compensatory foot pronation | ||
** medial rotation of the lower extremity | ** medial rotation of the lower extremity | ||
** compensatory knee flexion | ** compensatory knee flexion | ||
* ''' | *'''Results''': gait asymmetry, pelvis rotation on the shorter side<ref name=":0" /> | ||
* '''Significant increase in pelvic obliquity''' | *'''Significant increase in pelvic obliquity''' leads to a seating imbalance, pain from pelvic impingement on the ribs and ischial decubitus ulcers<ref>Karkenny AJ, Magee LC, Landrum MR, Anari JB, Spiegel D, Baldwin K. [https://journals.lww.com/jbjsoa/Fulltext/2021/03000/The_Variability_of_Pelvic_Obliquity_Measurements.13.aspx The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis]. JBJS Open Access. 2021 Jan;6(1).</ref> | ||
=== Knee === | === Knee === | ||
Revision as of 01:37, 17 March 2023
Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti, Jess Bell and Naomi O'Reilly
Top Contributors - Robin Tacchetti, Jess Bell and Naomi O'Reilly
Introduction[edit | edit source]
The musculoskeletal system is influenced by many different factors as infants and children grow. This system adapts to the demands, or lack of demands, that are placed on it. When inappropriate forces are applied to muscles or bones, alignment may be impacted. Atypical alignment can directly affect functional activities and an individual's participation.[1]
The following sections will highlight key stages and changes that occur during musculoskeletal development, and provide examples of atypical development.
Rib Cage[edit | edit source]
| Rib Cage | Shape | Location of Ribs | Other |
|---|---|---|---|
| Infant | Barrel-shaped | Elevated; perpendicular to Spine | Rigid |
| 2 years old | Oblong-shaped | Depressed due to diaphragm pull and sitting/standing/walking | Lateral expansion |
| **Atypical | **Persistence of barrel-shape |
Trunk[edit | edit source]
- Initially, infants have a kyphotic spine, which over time, becomes a more neutral spine (as seen in adults)
- Prone push-ups and sitting activate the posterior chain musculature (pushing into thoracic extension)
- Crawling creates co-contraction of the anterior and posterior muscles (for stability)[1]
Increased Curvature of the Spine[edit | edit source]
Increased curvature of the spine (e.g. scoliosis) can affect:
- breathing
- lung positioning
- heart location
- visceral function[1]
Pelvis[edit | edit source]
- Initially, infants have a rounded pelvis with a posterior tilt
- Sitting and standing activate core muscles and lead to an anterior pelvic tilt
- At 12 months old: an infant has 12 degrees of anterior pelvic tilt
- At 30 months old: a child has 15 degrees of anterior tilt
- With increased gluteal activity, the anterior tilt decreases slightly until age 8
- Adults have 10 degrees of anterior pelvic tilt[1]
Lower Extremities[edit | edit source]
Typical joint patterns in infants are as follows:
- Hip: flexion, abduction and lateral rotation
- Knee: flexion, genu varum, medial rotation of tibia
- Ankle: dorsiflexion, slight pronation[1]
Hip[edit | edit source]
- Infants:
- more external rotation at birth which decreases over time
- hip adduction limitation
- 34 degrees of hip extension limitation
- as infants spend more time in prone, their anterior capsule stretches
- 6 weeks old: 19 degrees of hip extension limitation
- toddlerhood: 7 degrees of hip extension limitation
- Newborn: increased coxa valga - 140-160 degrees
- decreases over time to 126 degrees in adults
- as become more ambulatory, femoral neck angle decreases
- Newborn: anteversion of the femur - 40 degrees; decreases to 16 degrees in adults
Changes in Alignment to Consider[edit | edit source]
Hip[edit | edit source]
- Femoral neck angle remains high: high femoral anteversion: increase risk of posterior hip dislocation (especially cautious of this with non-walkers aged 30 months)[1]
Increased Anterior Pelvic Tilt[edit | edit source]
- Abdominals and hip extensors long
- Hip flexors and lumbar extensors short
- Results: unable to have appropriate muscle pull of both abdominals and gluteus muscles when performing functional activities[1]
Decreased Anterior Pelvic Tilt[edit | edit source]
- Iliopsoas and anterior hip capsule is stretched out
- Gluteus maximus is shortened
- Results: anterior hip laxity and hip instability[1]
Pelvic Obliquity[edit | edit source]
- Common in individuals with hemiplegia and diplegia
- Depressed hip side (shorter side):
- increased pronation of the foot on that extremity
- reduced stance time
- reduced loading
- functional ankle plantarflexion
- Longer side:
- compensatory foot pronation
- medial rotation of the lower extremity
- compensatory knee flexion
- Results: gait asymmetry, pelvis rotation on the shorter side[1]
- Significant increase in pelvic obliquity leads to a seating imbalance, pain from pelvic impingement on the ribs and ischial decubitus ulcers[2]
Knee[edit | edit source]
- newborn: genu varum[3]
- toddler: genu valgus
- adult: neutral
- newborn: 30 degree knee flexion contracture
- resolves first few months of life
- newborn: medial rotation of the tibia
- 12 months: medial rotation resolve[1]
Increased Medial Tibial Torsion[edit | edit source]
- not common
- toeing in
- most likely medial rotation occurring higher up in the chain[1]
Increased Lateral Tibial Torsion[edit | edit source]
- presents with crouched posture[1]
Increased Genu Valgus[edit | edit source]
Possible impairments:
- pain in calf, thigh and/or knee
- increased fatigue with activities
- less efficient gait
- decreased gait velocity
- decreased balance
- increase Q-angle
- lateral subluxation of the patella
- collapse of medial foot arch
- protective in-toeing[1]
Ankles/Feet[edit | edit source]
- newborn: hindfoot varus
- weight-bearing changes to valgus
- newborn: feet straight forward or slight toeing out
- adulthood: toeing out increases
- newborn: high arch[1][6]
- adult: flat feet[1]
Physiotherapy Role[edit | edit source]
Physiotherapists can facilitate correct movement patterns to attain proper bio-mechanical alignment. The earlier in life the interventions are applied, the better the functional outcome will be. Some of the interventions that physiotherapist can use are listed below:
Resources[edit | edit source]
References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Eskay K. Paediatric Musculoskeletal Development Course. Plus. 2023.
- ↑ Karkenny AJ, Magee LC, Landrum MR, Anari JB, Spiegel D, Baldwin K. The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis. JBJS Open Access. 2021 Jan;6(1).
- ↑ A El-Hak AH, Shehata EM, Zanfaly AI, Soudy ES. Genu Varum in Children; Various Treatment Modalities for Bowleg's Correction. The Egyptian Journal of Hospital Medicine. 2022 Apr 1;87(1):1858-63.
- ↑ Ganeb SS, Egaila SE, Younis AA, El-Aziz AM, Hashaad NI. Prevalence of lower limb deformities among primary school students. Egyptian Rheumatology and Rehabilitation. 2021 Dec;48:1-7.
- ↑ Çankaya T, Dursun Ö, Davazlı B, Toprak H, Çankaya H, Alkan B. Assessment of quadriceps angle in children aged between 2 and 8 years. Turkish Archives of Pediatrics/Türk Pediatri Arşivi. 2020;55(2):124.
- ↑ Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. How to manage pes cavus in children and adolescents?. EFORT Open Reviews. 2021 Jun;6(6):510.
