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Jan Bazner-Chandler RN, MSN, CNS, CPNP
Newborn Physical Assessment
Any family members with musculoskeletal problems; genetic component
shoulder presentation Asphyxia at birth: apgar score .Birth History Weight and height Gestational age Birth presentation Single or multiple birth Type of birth: NSVD. forceps. cesarean section. vaginal extraction.
.Brachial Plexus Injury Excessive traction of the spinal nerve roots C5-T3 Many brachial plexus injuries happen when the shoulders become impacted during delivery and the brachial plexus nerves stretch or tear.
hand or wrist Lack of feeling or sensation in arm or hand .Symptoms of Brachial Plexus injury Limp or paralyzed arm Lack of muscle control in arm.
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. or the hip may be completely dislocated at birth. Newborns and infants with DDH may have the ball of the hip loosely in the socket.
From that position the femoral head drops out of the acetabulum or can be gently pushed out of the socket. . The hip is flexed and the thigh is brought into an adducted position.Barlow Maneuver The maneuver dislocates a dislocatable hip posteriorly.
Barlow Maneuver Best done on a non-crying infant. .
Adducted hip position .
Ortolani Maneuver Reduces a posteriorly dislocated hip. . The femoral head is lifted anteriorly into the acetabulum. The thigh is flexed and then adducted while pushing up with the fingers located over the trochanter posteriorly.
Positive Ortolani A clunk and a palpable jerk are felt as the femoral head is re-located. . Most often positive in the first 1 to 2 months of age. A mild clicking sound is not a positive sign.
Ortolani Maneuver .
. Looking to see if the knees are aligned. placing both the soles of the feet on the table near the buttocks. Positive sign if knees are uneven.Galeazzi Maneuver Flex the hips and knees while the infant / child lies supine.
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 .
Interventions Maintain hips in flexed position Traction to stretch muscles Pavlik harness Hip surgery .
Pavlik Harness .
.Metatarsus Adductus Most common foot deformity 2 per 1000 Result of intrauterine positioning Forefoot is adducted and in varus. giving the foot a kidney bean shape. Most often resolves on own or with simple exercises.
creating a Cshaped lateral foot border with a prominent styloid process of the fifth metatarsal.Exam Toes angle toward the midline. .
Metatarsus Adductus .
Treatment Exercises Soft shoe Casting .
Clubfoot Talipes equinovarus is a congenital deformity. Has four main components: Inversion and adduction of the forefoot Inversion of the heel and hindfoot Equinus (limitation of extension) of ankle and subtalar joint Internal rotation of the leg .
Causes Result of intrauterine maldevelopment of the talus that leads to adduction and plantar flexion of the foot. .
Club Foot .
Often the toddler will get bored and climb off the parents lap and explore the room. . pick up the child. move the child a few feet away and have them walk back to the caretaker. Observe the child moving around the room.Tips to examining the toddler Start the exam by getting a good history. If the child does not get up and move around.
In the toddler the stance will be wider and arms are held out for balance.Gait Exam Observe child walking without shoes and with minimal clothing. Look for toe-walking . The 3-year-old should have a more mature walk.
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 legs Normal up to 3 years of age .
Genu Varum .
Associated internal tibial torsion Intercondylar (knee) distance greater than 4 to 5 inches. . Joint laxity in the older child.When is bowlegged considered a problem? Tibial-femoral angle greater than 15 degrees.
Figure II intercondylar distance .
Blount Disease .
Genu Valgum “Knock-Knees” Physiologic valgum tends to peak at around 24 to 36 months and self corrects at about 7 to 8 years. .
. Awkward gait Intermalleolar (ankle) distance with knees together greater than 4 to 5 inches.Examination Tibial-femoral angle less than 15 degrees of valgus in a child over 7 to 8 years of age. Often associated with short stature.
Intermalleolar Distance .
.Differential Diagnosis Rule out other causes of limb deformity.
What in the history would be important?
Vitamin D intake
Whole milk, butter, egg yolks, animal fat and liver, especially fish liver oil. 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.
Genetic disorder Caused by a genetic defect that affects the body’s production of collagen. Collagen is the major protein of the body’s connective tissue. Less than normal or poor collagen leads to weak bones that fracture easily.
Often called “brittle bone disease” Characteristics
Demineralization, cortical thinning Multiple fractures with pseudoarthrosis Exuberant callus formation at fracture site Blue sclera Wide sutures Pre-senile deafness
Brittle Bone Disease .
Clinical Pearl Child may present as child abuse. . The infant / child may have a minor reported accident that results in significant injury.
3-month-old with OI Old rib fractures Old fractures/demineralization .
School Age Child Osgood-Schlatter Disease Tibial Torsion Popliteal Cyst .
which results in inflammation. an apophysis site. and new bone formation at the tubercle apophysis.Osgood-Schlatter Disease Inflammation of tibial tubercle. Cause: repetitive micro-trauma to the tibial tubercle apophysis. microfractures. Most common: Boys ages 10 to 15 years Girls ages 8 to 14 years .
gymnastics. . soccer. football. surfboarding Pain increases during and immediately after activity.History Recent physical activity: track.
Physical Exam Point tenderness pain. prominence over the tibial tubercle Pain with knee extension against passive resistance or with full passive knee resistance. Decreased ROM .
Osgood-Schlatter Disease .
Treatment R. ice. and elevation medications (for discomfort): Ibuprofen elastic wrap or a neoprene knee sleeve around the knee activity restrictions physical therapy (to help stretch and strengthen the thigh and leg muscles) .C.I. compression.E.rest. .
.Tibial Torsion Tibial torsion is a term used to describe the normal variation in tibial rotation. Lateral tibial torsion results in out-toeing. Medial tibial torsion describes abnormal medial rotation or twisting. resulting in in-toeing of the feet.
History Often parent states that the child seems to be tripping over their own feet. .
Exam Observe the child’s gait. Have the child kneel down and look at the feet from behind. .
Tibial Torsion .
.Thigh-foot Angle A 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.
Management 90% will resolve by age 8 years Avoid prone sleeping and sitting on feet. .
Popliteal Cyst Often called Baker’s Cyst are synovial lesion that result from herniation of the synovium of the knee joint into the popliteal space. .
Clinical Findings Swelling behind the knee with or without pain. .
Popliteal Cyst .
Growing Pains Occur in 13 to 18% of children Called “leg aches” Cause: thigh and calf muscle fatigue .
Pain gone by the morning with no limitation of activity. may even wake the child up from sleep. Occurs in front of thighs. .Clinical Findings Discomfort appears in evening or late in the day. in the calves or behind the knees.
Exam No tenderness No guarding No decreased ROM No limp .
buttoning or using scissors. .Clumsiness About 6% of school-aged children have coordination problems serious enough to interfere with simple motor tasks such as running. First identified in 1975 Now called: developmental coordination disorder or DCD.
Duchenne’s Muscular Dystrophy Difficulty rising to a standing position .
. May be referred to you after screening at school.Scoliosis Screening Should be done with every well child physical from about age 8 or 9.
com .Scoliosis Lateral curvature of spine Medline.
Clinical Manifestations • • • • Pain is not a normal finding for idiopathic scoliosis Often present with uneven hemline Unequal scapula Unequal hips .
.Exam Unequal shoulder heights Unequal scapula Unequal waist angles – hip touches arm and contralateral arm hangs free Unequal rib heights when the child stands in a forward bend.
Screening Bowden & Greenberg .
Mild Scoliosis Mild forms Strengthening and stretching Ball & Bindler .
it should be investigated immediately. Pain is not a normal finding for idiopathic scoliosis.Assessment Alert: If pain is a reported symptom of the child’s scoliosis. and the presence of this symptom could be signaling an underlying condition such as tumor of the spinal cord. .
Common Pediatric Orthopedic Disorders Legg-Calves-Perthes Disease Slipped Capital Femoral Epiphysis Infection: septic arthritis Inflammation of a joint: rheumatoid arthritis .
. Cause: some ischemia episode of unknown etiology that interrupts vascular circulation to the capital femoral epiphysis.Legg-Calve-Perthes Disease Often called avascular necrosis of the femoral head. Takes place over about 18 to 24 months More common in boys age between 4 and 8 years of age.
Limping after activity or in the morning .History Acute 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.
and extension of the hip Pain on rolling the leg internally .Exam Antalgic gait with a positive Trendelenburg sign Muscle spasm Decreased abduction. internal rotation.
Trendelenburg Sign .
AP Pelvis and frog-leg lateral views .
Slipped Capital Femoral Epiphysis Upper femoral epiphysis slips from its position in the hip joint Most common hip disorder in the adolescent Occurs more commonly in males Skeletal immaturity: Males 10 to 15 years Females 11 to 12 years African American and Polynesian populations more susceptible .
History Acute or chronic thigh or knee pain History of mild trauma to the hip area Child is often large for age or overweight .
Exam Pain in groin or diffusely over knee or anterior thigh Pain and decreased internal rotation Antalgic limp (due to shorter leg) External rotation of leg when walking External rotation of the thigh when hip is flexed Thigh atrophy (measure and compare) Limited abduction and extension .
Clinical Manifestations .
Septic Arthritis Infection within a joint or synovial membrane Infection transmitted by: Bloodstream Penetrating wound Foreign body in joint .
Septic Hip .
Diagnostic Tests X-ray Needle aspiration under fluoroscopy .
Erythrocyte Sedimentation Rate
ESR Used as a gauge for determining the progress of an inflammatory disease. Rises within 24 hours after onset of symptoms. Men: 0 - 15 mm./hr Women: 0 – 20 mm./hr Children: 0 – 10 mm./hr
Administration of antibiotics for 4 to 6 weeks. Oral antibiotics have been found to be effective if serum bactericidal levels are adequate. Fever control Ibuprofen for anti-inflammatory effect
Juvenile Rheumatoid Arthritis
Chronic 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 Manifestations Swelling or effusion of one or more joints Limited ROM Warmth Tenderness Pain with movement .
Diagnostic Evaluation Elevated ESR / erythrocyte sedimentation rate + genetic marker / HLA b27 + RF 9 antinuclear antibodies Bone scan MRI Arthroscopic exam .
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