Orthopedic Physical AssessmentJan Bazner-ChandlerRN, MSN, CNS, CPNP

Newborn Physical Assessment

Family HistoryAny family members with musculoskeletal problems; genetic component

Birth HistoryWeight and heightGestational ageBirth presentationSingle or multiple birthType of birth: NSVD, forceps, vaginal extraction, cesarean section, shoulder presentationAsphyxia at birth: apgar score

Brachial Plexus InjuryExcessive traction of the spinal nerve roots C5-T3Many brachial plexus injuries happen when the shoulders become impacted during delivery and the brachial plexus nerves stretch or tear.

Symptoms of Brachial Plexus injuryLimp or paralyzed armLack of muscle control in arm, hand or wrist Lack of feeling or sensation in arm or hand

Brachial Plexus Injury

Developmental Dysplasia of Hip (DDH) Developmental dysplasia of the hip is an abnormal formation of the hip joint in which the ball at the top of the femoral head is not stable in the acetabulum. The severity of instability varies in each patient. Newborns and infants with DDH may have the ball of the hip loosely in the socket, or the hip may be completely dislocated at birth.

Barlow ManeuverThe maneuver dislocates a dislocatable hip posteriorly.The hip is flexed and the thigh is brought into an adducted position.From that position the femoral head drops out of the acetabulum or can be gently pushed out of the socket.

Barlow ManeuverBest done on a non-crying infant.

Adducted hip position

Ortolani ManeuverReduces a posteriorly dislocated hip.The thigh is flexed and then adducted while pushing up with the fingers located over the trochanter posteriorly.The femoral head is lifted anteriorly into the acetabulum.

Positive OrtolaniA clunk and a palpable jerk are felt as the femoral head is re-located. A mild clicking sound is not a positive sign.Most often positive in the first 1 to 2 months of age.

Ortolani Maneuver

Galeazzi Maneuver Flex the hips and knees while the infant / child lies supine, placing both the soles of the feet on the table near the buttocks.Looking to see if the knees are aligned.Positive sign if knees are uneven.

Galeazzi Maneuver

Limited Abduction This would be a positive sign of developmental dysplasia of hip in the older infant.

Limited hip abduction

Asymmetry of skin fold

InterventionsMaintain hips in flexed positionTraction to stretch musclesPavlik harnessHip surgery

Pavlik Harness

Metatarsus AdductusMost common foot deformity2 per 1000Result of intrauterine positioningForefoot is adducted and in varus, giving the foot a kidney bean shape.Most often resolves on own or with simple exercises.

ExamToes angle toward the midline, creating a C-shaped lateral foot border with a prominent styloid process of the fifth metatarsal.

Metatarsus Adductus

TreatmentExercisesSoft shoeCasting

ClubfootTalipes equinovarus is a congenital deformity.Has four main components: Inversion and adduction of the forefootInversion of the heel and hindfootEquinus (limitation of extension) of ankle and subtalar jointInternal rotation of the leg

CausesResult of intrauterine maldevelopment of the talus that leads to adduction and plantar flexion of the foot.

Club Foot

Toddler

Tips to examining the toddler

Start the exam by getting a good history.Often the toddler will get bored and climb off the parents lap and explore the room.Observe the child moving around the room.If the child does not get up and move around, pick up the child, move the child a few feet away and have them walk back to the caretaker.

Gait ExamObserve child walking without shoes and with minimal clothing.In the toddler the stance will be wider and arms are held out for balance.The 3-year-old should have a more mature walk.Look for toe-walking

Toddler Walking

Red flags!A toddler who is not walking by 15 to 18 months.Check to see if there is an older child in the household.Ask parent is child is cruising or will pull themselves up to a standing position.

Infant Cruising

Gait Deformities

Genu varum Bowing of the legsNormal up to 3 years of age

Genu Varum

When is bowlegged considered a problem?Tibial-femoral angle greater than 15 degrees.Associated internal tibial torsionIntercondylar (knee) distance greater than 4 to 5 inches.Joint laxity in the older child.

Figure II intercondylar distance

Blount Disease

Genu ValgumKnock-KneesPhysiologic valgum tends to peak at around 24 to 36 months and self corrects at about 7 to 8 years.

ExaminationTibial-femoral angle less than 15 degrees of valgus in a child over 7 to 8 years of age.Awkward gaitIntermalleolar (ankle) distance with knees together greater than 4 to 5 inches.Often associated with short stature.

Intermalleolar Distance

Differential DiagnosisRule out other causes of limb deformity.

Ricketts

What in the history would be important?Vitamin D intakeWhole milk, butter, egg yolks, animal fat and liver, especially fish liver oil.Environment: Cool mountain areas of Asia and Latin America where babies are kept wrapped up and inside.Crowded cities where children are not exposed to sunshine.

Osteogenesis ImperfectaGenetic disorderCaused by a genetic defect that affects the bodys production of collagen.Collagen is the major protein of the bodys connective tissue.Less than normal or poor collagen leads to weak bones that fracture easily.

Osteogenesis ImperfectaOften called brittle bone diseaseCharacteristicsDemineralization, cortical thinningMultiple fractures with pseudoarthrosisExuberant callus formation at fracture siteBlue scleraWide suturesPre-senile deafness

Brittle Bone Disease

Clinical PearlChild may present as child abuse.The infant / child may have a minor reported accident that results in significant injury.

3-month-old with OIOld fractures/demineralizationOld rib fractures

School Age ChildOsgood-Schlatter DiseaseTibial TorsionPopliteal Cyst

Osgood-Schlatter DiseaseInflammation of tibial tubercle, an apophysis site.Cause: repetitive micro-trauma to the tibial tubercle apophysis, which results in inflammation, microfractures, and new bone formation at the tubercle apophysis.Most common:Boys ages 10 to 15 yearsGirls ages 8 to 14 years

HistoryRecent physical activity: track, soccer, football, gymnastics, surfboardingPain increases during and immediately after activity.

Physical ExamPoint tenderness pain, prominence over the tibial tuberclePain with knee extension against passive resistance or with full passive knee resistance. Decreased ROM

Osgood-Schlatter Disease

Treatment R.I.C.E. - rest, ice, compression, and elevation medications (for discomfort): Ibuprofenelastic wrap or a neoprene knee sleeve around the knee activity restrictions physical therapy (to help stretch and strengthen the thigh and leg muscles)

Tibial TorsionTibial torsion is a term used to describe the normal variation in tibial rotation.Medial tibial torsion describes abnormal medial rotation or twisting, resulting in in-toeing of the feet.Lateral tibial torsion results in out-toeing.

HistoryOften parent states that the child seems to be tripping over their own feet.

ExamObserve the childs gait.Have the child kneel down and look at the feet from behind.

Tibial Torsion

Thigh-foot AngleA line drawn thru the heel should intersect with the second toe of the foot. The image shows a foot with MTA where the line intersects with the fourth toe.

Management90% will resolve by age 8 yearsAvoid prone sleeping and sitting on feet.

Popliteal CystOften called Bakers Cyst are synovial lesion that result from herniation of the synovium of the knee joint into the popliteal space.

Clinical FindingsSwelling behind the knee with or without pain.

Popliteal Cyst

Growing PainsOccur in 13 to 18% of childrenCalled leg achesCause: thigh and calf muscle fatigue

Clinical FindingsDiscomfort appears in evening or late in the day; may even wake the child up from sleep.Pain gone by the morning with no limitation of activity.Occurs in front of thighs, in the calves or behind the knees.

ExamNo tendernessNo guardingNo decreased ROMNo limp

ClumsinessAbout 6% of school-aged children have coordination problems serious enough to interfere with simple motor tasks such as running, buttoning or using scissors. First identified in 1975Now called: developmental coordination disorder or DCD.

Duchennes Muscular DystrophyDifficulty rising to a standing position

Scoliosis ScreeningShould be done with every well child physical from about age 8 or 9.May be referred to you after screening at school.

ScoliosisLateral curvature of spineMedline.com

Clinical ManifestationsPain is not a normal findingfor idiopathic scoliosisOften present with uneven hemlineUnequal scapulaUnequal hips

ExamUnequal shoulder heightsUnequal scapulaUnequal waist angles hip touches arm and contralateral arm hangs freeUnequal rib heights when the child stands in a forward bend.

Screening

ScreeningBowden & Greenberg

Mild ScoliosisMild forms

Strengthening and

stretchingBall & Bindler

AssessmentAlert: If pain is a reported symptom of the childs scoliosis, it should be investigated immediately. Pain is not a normal finding for idiopathic scoliosis, and the presence of this symptom could be signaling an underlying condition such as tumor of the spinal cord.

Bracing

Common Pediatric Orthopedic DisordersLegg-Calves-Perthes DiseaseSlipped Capital Femoral EpiphysisInfection: septic arthritisInflammation of a joint: rheumatoid arthritis

Legg-Calve-Perthes DiseaseOften called avascular necrosis of the femoral head.Cause: some ischemia episode of unknown etiology that interrupts vascular circulation to the capital femoral epiphysis. Takes place over about 18 to 24 monthsMore common in boys age between 4 and 8 years of age.

HistoryAcute or chronic onset with or without history of trauma to the hip such as jumping from a high place.Acute: sudden onset of pain in the groin or knee often occurring at night and stiffness

Chronic: Mild aching in hip (groin area) or referred to the knee or anterior thigh. Limping after activity or in the morning

ExamAntalgic gait with a positive Trendelenburg signMuscle spasmDecreased abduction, internal rotation, and extension of the hipPain on rolling the leg internally

Trendelenburg Sign

AP Pelvis and frog-leg lateral views

Slipped Capital Femoral EpiphysisUpper femoral epiphysis slips from its position in the hip joint Most common hip disorder in the adolescentOccurs more commonly in malesSkeletal immaturity: Males 10 to 15 yearsFemales 11 to 12 yearsAfrican American and Polynesian populations more susceptible

HistoryAcute or chronic thigh or knee painHistory of mild trauma to the hip areaChild is often large for age or overweight

ExamPain in groin or diffusely over knee or anterior thighPain and decreased internal rotationAntalgic limp (due to shorter leg)External rotation of leg when walkingExternal rotation of the thigh when hip is flexedThigh atrophy (measure and compare)Limited abduction and extension

Clinical Manifestations

Septic ArthritisInfection within a joint or synovial membraneInfection transmitted by:BloodstreamPenetrating woundForeign body in joint

Septic Hip

Diagnostic Tests

X-ray

Needle aspirationunder fluoroscopy

Erythrocyte Sedimentation RateESRUsed as a gauge for determining the progress of an inflammatory disease.Rises within 24 hours after onset of symptoms.

Men:0 - 15 mm./hrWomen:0 20 mm./hrChildren:0 10 mm./hr

ManagementAdministration of antibiotics for 4 to 6 weeks.Oral antibiotics have been found to be effective if serum bactericidal levels are adequate.Fever controlIbuprofen for anti-inflammatory effect

Juvenile Rheumatoid ArthritisChronic inflammatory condition of the joints and surrounding tissues.

Often triggered by a viral illness

1 in 1000 children will develop JRA

Higher incidence in girls

Clinical ManifestationsSwelling or effusion of one or more jointsLimited ROMWarmthTendernessPain with movement

Diagnostic EvaluationElevated ESR / erythrocyte sedimentation rate+ genetic marker / HLA b27+ RF 9 antinuclear antibodiesBone scanMRIArthroscopic exam