Wednesday morning conference

Source:  Wednesday morning conference    Tag:  parental consanguinity

Part 1: "Late Walker":  Gross Motor Delay















Things to Consider
  • Gross motor development has wider variation than fine motor development
  • Premature babies can vary in timing and pattern of gross motor development
  • Environment usually does not play a big role
  • Family history matters
Milestones
  • Bearing weight: 4-6 months
  • No head lag: 4 months
  • Sit independently: 6-7 months
  • Walking: 9-18 months
  • Moro: Gone by 2 months
  • Asymmetric tonic neck reflex: Gone by 2-4 months
  • Clonus: normal at birth, should be gone by 6 months

Ellie's favorite way to assess tone in infants: vertical suspension
  • High tone: legs completely straight, scissor sign in vertical suspension (legs cross)
  • Low tone: slip through "feel like a noodle"

Case #1:  3 month old with isolated LE tone (increased LE tone, ankle clonus, weight bearing, rest of development normal).
  • OK to watch
  • PT in early infancy (first 6 months) does not make a difference in patients with cerebral palsy

Case #2:  10 month old with hypotonia, gross and fine motor delays (not sitting, raking grasp)

Could be neurological or neuromuscular disorder.
  • Central vs peripheral
    • No weakness vs + weakness (spinal cord, anterior horn cell, peripheral nerve, myoneural junction, muscle)- distinguish weakness from tone!
    • Static (CP) vs progressive (neurodegenerative, infection, metabolic)
      • Progressive: look for regression, parental consanguinity
  • Refer to neurology (may be helpful with diagnosis) vs. PMR vs. infants and toddlers (maybe all of the above)
  • Diagnostic testing: CK (r/o muscular dystrophy), check NMS, or if progressive (thyroid, lytes, Ca, P, urine for amino acids, mucopolysaccharides- consider waiting for specialist to order)

Case #3:  18 month old boy not walking yet, everything else normal
  • Probably normal variant (Oxford study: 257 non-walkers at 18 months: 3.5% CP; 2.3% minor neurological abnormality)
  • Also, consider muscular dystrophy (worth getting CK), DDH
  • Refer to PM+R
Toe-walking
  • Swedish study (7/2012) showed 2.1% of 5 1/2 year-olds (n=1406) still walked on toes and were otherwise normal
  • May refer if achilles is tight or obligate toe walker (all the time)

Part 2: In-toeing

Metatarsus Adductus

  • Can have parents do stretching
  • Refer (to ortho) if you can't correct or if still severe at 2 months
    • Mild to moderate: Reverse shoes
    • Severe: Casting

Femoral Anteversion

  • Positive if W to 45 degrees when prone
  • OK to watch and will improve- do not need to refer if not interfering with function
Tibial Torsion

  • Thigh foot angle (when prone, ankle of foot should = angle of thigh = slightly outward)
  • OK to watch and will improve- do not need to refer if not interfering with function
Knees: normal progression
  • 2 years: bow-leg (genu varum)
    • very bowed- consider Blount's and ricket's
  • 4 years: knock-kneed (genu valgum)
  • 6 years: normal