Orthopedic Physical Assessment

Jan Bazner-Chandler

RN, MSN, CNS, CPNP

Newborn Physical Assessment

Family History

Any family members with musculoskeletal problems; genetic component

Birth History

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

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.

Symptoms of Brachial Plexus injury 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

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

Best done on a non-crying infant.

Adducted hip position

Ortolani Maneuver

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

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

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

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.

Exam

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

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

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 Exam

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!

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

When is bowlegged considered a problem? 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

“Knock-Knees” Physiologic valgum tends to peak at around

24 to 36 months and self corrects at about 7 to 8 years.

Examination

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

Rule out other causes of limb deformity.

Ricketts

What in the history would be important? Vitamin D intake

Whole 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 Imperfecta

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

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 fractures/demineralization

Old rib fractures

School Age Child

Osgood-Schlatter Disease Tibial Torsion Popliteal Cyst

Osgood-Schlatter Disease

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: Boys ages 10 to 15 years Girls ages 8 to 14 years

History

Recent physical activity: track, soccer, football, gymnastics, surfboarding

Pain increases during and immediately after activity.

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.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

Tibial 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.

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

Clinical Findings

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

No tenderness No guarding No decreased ROM No limp

Clumsiness

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 Difficulty rising to a standing position

Scoliosis Screening

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

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

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 Legg-Calves-Perthes Disease Slipped Capital Femoral Epiphysis Infection: septic arthritis Inflammation of a joint: rheumatoid arthritis

Legg-Calve-Perthes Disease

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

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. Limping after activity or in the morning

Exam

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 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 aspirationunder 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

Management

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