Paediatric Musculoskeletal Development: Difference between revisions
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=== Hip === | === Hip === | ||
Infants at birth: | |||
* | * increased hip external rotation 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 | |||
* | * increased coxa valga - 140-160 degrees | ||
** decreases over time to 126 degrees in adults | ** decreases over time to 126 degrees in adults | ||
** as become more ambulatory, femoral neck angle decreases | ** as become more ambulatory, femoral neck angle decreases | ||
* | |||
* anteversion of the femur - 40 degrees; decreases to 16 degrees in adults | |||
==== Changes in Alignment to Consider ==== | ==== Changes in Alignment to Consider ==== | ||
| Line 78: | Line 79: | ||
===== Hip ===== | ===== Hip ===== | ||
* Femoral neck angle remains high | * Femoral neck angle remains high - high femoral anteversion: increased risk of posterior hip dislocation | ||
Please note that it is especially important to consider the hips of a child who is non-ambulatory at the age of 30 months.<ref name=":0" /> | |||
===== Increased Anterior Pelvic Tilt ===== | ===== Increased Anterior Pelvic Tilt ===== | ||
| Line 106: | Line 108: | ||
=== Knee === | === Knee === | ||
* | * Newborn: genu varum<ref>A El-Hak AH, Shehata EM, Zanfaly AI, Soudy ES. Genu Varum in Children; [https://ejhm.journals.ekb.eg/article_231636_f5bc851645db9d787fadaa87cf381506.pdf Various Treatment Modalities for Bowleg's Correction.] The Egyptian Journal of Hospital Medicine. 2022 Apr 1;87(1):1858-63.</ref> | ||
* | * Toddler: genu valgus | ||
** maximum valgus peaks around 2 1/2 years old | ** maximum valgus peaks around 2 1/2 years old | ||
** decreases over time<ref name=":0" /><ref>Ganeb SS, Egaila SE, Younis AA, El-Aziz AM, Hashaad NI. [https://erar.springeropen.com/articles/10.1186/s43166-021-00082-1 Prevalence of lower limb deformities among primary school students]. Egyptian Rheumatology and Rehabilitation. 2021 Dec;48:1-7.</ref> | ** decreases over time<ref name=":0" /><ref>Ganeb SS, Egaila SE, Younis AA, El-Aziz AM, Hashaad NI. [https://erar.springeropen.com/articles/10.1186/s43166-021-00082-1 Prevalence of lower limb deformities among primary school students]. Egyptian Rheumatology and Rehabilitation. 2021 Dec;48:1-7.</ref> | ||
* | * Adult: neutral | ||
* | * Newborn: 30 degree knee flexion contracture | ||
** resolves first few months of life | ** resolves first few months of life | ||
* | * Newborn: medial rotation of the tibia | ||
** 12 months: medial rotation resolve<ref name=":0" /> | ** 12 months: medial rotation resolve<ref name=":0" /> | ||
==== Increased Medial Tibial Torsion ==== | ==== Changes in Alignment to Consider ==== | ||
===== Increased Medial Tibial Torsion ===== | |||
* | * Not common | ||
* | * Toeing in | ||
* | * Most likely medial rotation occurring higher up in the chain<ref name=":0" /> | ||
==== Increased Lateral Tibial Torsion ==== | ===== Increased Lateral Tibial Torsion ===== | ||
* | * Individuals present with crouched posture<ref name=":0" /> | ||
==== Increased Genu Valgus ==== | ===== Increased Genu Valgus ===== | ||
Possible impairments: | Possible impairments: | ||
* pain in calf, thigh and/or knee | * pain in calf, thigh and/or knee | ||
| Line 134: | Line 138: | ||
** decreased balance | ** decreased balance | ||
* increase Q-angle | * increase Q-angle | ||
**[[Quadratus Femoris| | **[[Quadratus Femoris|quadriceps]] less efficient secondary to abnormal muscle pull<ref name=":0" /><ref>Çankaya T, Dursun Ö, Davazlı B, Toprak H, Çankaya H, Alkan B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344134/ Assessment of quadriceps angle in children aged between 2 and 8 years]. Turkish Archives of Pediatrics/Türk Pediatri Arşivi. 2020;55(2):124.</ref> | ||
* lateral subluxation of the [[patella]] | * lateral subluxation of the [[patella]] | ||
* collapse of medial foot arch | * collapse of the medial foot arch | ||
* protective in-toeing<ref name=":0" /> | * protective in-toeing<ref name=":0" /> | ||
=== Ankles/Feet === | === Ankles/Feet === | ||
* | * Newborn: hindfoot varus | ||
** weight-bearing changes to valgus | ** weight-bearing changes to valgus | ||
* | * Newborn: feet straight forward or slight toeing out | ||
* | * Adulthood: toeing out increases | ||
* | * Newborn: high arch<ref name=":0" /><ref>Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. [https://eor.bioscientifica.com/view/journals/eor/6/6/2058-5241.6.210021.xml How to manage pes cavus in children and adolescents?]. EFORT Open Reviews. 2021 Jun;6(6):510.</ref> | ||
* | * Adult: flat feet<ref name=":0" /> | ||
== Physiotherapy | == Role of Paediatric Physiotherapy == | ||
Physiotherapists can facilitate correct movement patterns to attain proper | Physiotherapists can facilitate correct movement patterns to help attain proper biomechanical 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: | ||
* weight shifts | * weight shifts | ||
Revision as of 02:05, 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 at birth:
- increased hip external rotation 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
- increased coxa valga - 140-160 degrees
- decreases over time to 126 degrees in adults
- as become more ambulatory, femoral neck angle decreases
- 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: increased risk of posterior hip dislocation
Please note that it is especially important to consider the hips of a child who is non-ambulatory at the age of 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]
Changes in Alignment to Consider[edit | edit source]
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]
- Individuals present 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
- quadriceps less efficient secondary to abnormal muscle pull[1][5]
- lateral subluxation of the patella
- collapse of the 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]
Role of Paediatric Physiotherapy[edit | edit source]
Physiotherapists can facilitate correct movement patterns to help attain proper biomechanical 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.
