Orthopedic Physical Assessment Jan BaznerChandler RN MSN CNS

Orthopedic Physical Assessment Jan Bazner-Chandler RN, MSN, CNS, CPNP

Newborn Physical Assessment

Family History n Any family members with musculoskeletal problems; genetic component

Birth History n n n Weight and height Gestational age Birth presentation Single or multiple birth Type of birth: NSVD, forceps, vaginal extraction, cesarean section, shoulder presentation Asphyxia at birth: apgar score

Brachial Plexus Injury n n Excessive traction of the spinal nerve roots C 5 -T 3 Many brachial plexus injuries happen when the shoulders become impacted during delivery and the brachial plexus nerves stretch or tear.

Symptoms of Brachial Plexus injury n n n Limp or paralyzed arm Lack 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 Maneuver n n n The 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 Maneuver n Best done on a non-crying infant.

Adducted hip position

Ortolani Maneuver n n n Reduces 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 Ortolani n n n A 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 n n n 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 n This would be a positive sign of developmental dysplasia of hip in the older infant.

Limited hip abduction

Asymmetry of skin fold

Interventions n n Maintain hips in flexed position Traction to stretch muscles Pavlik harness Hip surgery

Pavlik Harness

Metatarsus Adductus n n n 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.

Exam n Toes angle toward the midline, creating a Cshaped lateral foot border with a prominent styloid process of the fifth metatarsal.

Metatarsus Adductus

Treatment n n n Exercises Soft shoe Casting

Clubfoot n n Talipes equinovarus is a congenital deformity. Has four main components: q q 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 n Result of intrauterine maldevelopment of the talus that leads to adduction and plantar flexion of the foot.

Club Foot

Toddler

Tips to examining the toddler n n 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 Exam n n Observe 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! n A toddler who is not walking by 15 to 18 months. q q 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 n n Bowing of the legs Normal up to 3 years of age

Genu Varum

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

Figure II intercondylar distance

Blount Disease

Genu Valgum n n “Knock-Knees” Physiologic valgum tends to peak at around 24 to 36 months and self corrects at about 7 to 8 years.

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

Intermalleolar Distance

Differential Diagnosis n Rule out other causes of limb deformity.

Ricketts

What in the history would be important? n Vitamin D intake q n Whole milk, butter, egg yolks, animal fat and liver, especially fish liver oil. Environment: q q 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 Imperfecta n n 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.

Osteogenesis Imperfecta n n Often called “brittle bone disease” Characteristics q q q 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 n n 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 n n n Osgood-Schlatter Disease Tibial Torsion Popliteal Cyst

Osgood-Schlatter Disease n n n Inflammation 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: q q Boys ages 10 to 15 years Girls ages 8 to 14 years

History n n Recent physical activity: track, soccer, football, gymnastics, surfboarding Pain increases during and immediately after activity.

Physical Exam n n n 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 n n n R. I. C. E. - rest, ice, compression, 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)

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

History n Often parent states that the child seems to be tripping over their own feet.

Exam n n Observe the child’s gait. Have the child kneel down and look at the feet from behind.

Tibial Torsion

Thigh-foot Angle n 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 n n 90% will resolve by age 8 years Avoid prone sleeping and sitting on feet.

Popliteal Cyst n 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 n Swelling behind the knee with or without pain.

Popliteal Cyst

Growing Pains n n n Occur in 13 to 18% of children Called “leg aches” Cause: thigh and calf muscle fatigue

Clinical Findings n n n Discomfort 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.

Exam n n No tenderness No guarding No decreased ROM No limp

Clumsiness n n n About 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 1975 Now called: developmental coordination disorder or DCD.

Duchenne’s Muscular Dystrophy n Difficulty rising to a standing position

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

Scoliosis Lateral curvature of spine Medline. com

Clinical Manifestations • • Pain is not a normal finding for idiopathic scoliosis Often present with uneven hemline Unequal scapula Unequal hips

Exam n n 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

Screening Bowden & Greenberg

Mild Scoliosis Mild forms Strengthening and stretching Ball & Bindler

Assessment n Alert: If pain is a reported symptom of the child’s 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 Disorders n n Legg-Calves-Perthes Disease Slipped Capital Femoral Epiphysis Infection: septic arthritis Inflammation of a joint: rheumatoid arthritis

Legg-Calve-Perthes Disease n n Often 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 months More common in boys age between 4 and 8 years of age.

History n Acute or chronic onset with or without history of trauma to the hip such as jumping from a high place. q q 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

Exam n n Antalgic gait with a positive Trendelenburg sign Muscle spasm Decreased abduction, internal rotation, and extension of the hip Pain on rolling the leg internally

Trendelenburg Sign

AP Pelvis and frog-leg lateral views

Slipped Capital Femoral Epiphysis n n Upper femoral epiphysis slips from its position in the hip joint Most common hip disorder in the adolescent q q Occurs more commonly in males Skeletal immaturity: n n q Males 10 to 15 years Females 11 to 12 years African American and Polynesian populations more susceptible

History n n n Acute or chronic thigh or knee pain History of mild trauma to the hip area Child is often large for age or overweight

Exam n n n n 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 n n Infection within a joint or synovial membrane Infection transmitted by: q q q Bloodstream Penetrating wound Foreign body in joint

Septic Hip

Diagnostic Tests X-ray Needle aspiration under fluoroscopy

Erythrocyte Sedimentation Rate n n n 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

Management n n 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 n Chronic inflammatory condition of the joints and surrounding tissues. n Often triggered by a viral illness n 1 in 1000 children will develop JRA n Higher incidence in girls

Clinical Manifestations n n n Swelling or effusion of one or more joints Limited ROM Warmth Tenderness Pain with movement

Diagnostic Evaluation n n n Elevated ESR / erythrocyte sedimentation rate + genetic marker / HLA b 27 + RF 9 antinuclear antibodies Bone scan MRI Arthroscopic exam