Orthopedic Physical Assessment

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Orthopedic Physical Assessment

• Jan Bazner-Chandler
• RN, MSN, CNS, CPNP

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Newborn Physical Assessment
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Family History

• Any family members with musculoskeletal problems
  genetic component

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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

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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.

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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

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Brachial Plexus Injury
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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.

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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.

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Barlow Maneuver

• Best done on a non-crying infant.

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Adducted hip position
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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.

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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.

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Ortolani Maneuver
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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.

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Galeazzi Maneuver
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Limited Abduction

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

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Limited hip abduction
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Asymmetry of skin fold
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Interventions

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

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Pavlik Harness
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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.

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Exam

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

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Metatarsus Adductus
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Treatment

• Exercises
• Soft shoe
• Casting

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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

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Causes

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

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Club Foot
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Toddler
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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.

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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

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Toddler Walking
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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.

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Infant Cruising
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Gait Deformities
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Genu varum

• Bowing of the legs
• Normal up to 3 years of age

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Genu Varum
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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.

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Figure II intercondylar distance
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Blount Disease
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Genu Valgum

• Knock-Knees
• Physiologic valgum tends to peak at around 24 to
  36 months and self corrects at about 7 to 8 years.

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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.

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Intermalleolar Distance
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Differential Diagnosis

• Rule out other causes of limb deformity.

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Ricketts
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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.

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Osteogenesis Imperfecta

• Genetic disorder
• Caused 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.

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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

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Brittle Bone Disease
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Clinical Pearl

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

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3-month-old with OI
Old rib fractures
Old fractures/demineralization
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School Age Child

• Osgood-Schlatter Disease
• Tibial Torsion
• Popliteal Cyst

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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

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History

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

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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

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Osgood-Schlatter Disease
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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)

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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.

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History

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

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Exam

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

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Tibial Torsion
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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.

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Management

• 90 will resolve by age 8 years
• Avoid prone sleeping and sitting on feet.

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Popliteal Cyst

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

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Clinical Findings

• Swelling behind the knee with or without pain.

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Popliteal Cyst
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Growing Pains

• Occur in 13 to 18 of children
• Called leg aches
• Cause thigh and calf muscle fatigue

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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.

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Exam

• No tenderness
• No guarding
• No decreased ROM
• No limp

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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.

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Duchennes Muscular Dystrophy

• Difficulty rising to a standing position

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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.

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Scoliosis
Lateral curvature of spine
Medline.com
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Clinical Manifestations

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

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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.

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Screening
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Screening
Bowden Greenberg
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Mild Scoliosis
Mild forms Strengthening and stretching
Ball Bindler
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Assessment

• Alert 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.

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Bracing
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Common Pediatric Orthopedic Disorders

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

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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.

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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

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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

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Trendelenburg Sign
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AP Pelvis and frog-leg lateral views
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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

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History

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

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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

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Clinical Manifestations
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Septic Arthritis

• Infection within a joint or synovial membrane
• Infection transmitted by
• Bloodstream
• Penetrating wound
• Foreign body in joint

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Septic Hip
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Diagnostic Tests
X-ray Needle aspiration under fluoroscopy
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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

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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

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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

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Clinical Manifestations

• Swelling or effusion of one or more joints
• Limited ROM
• Warmth
• Tenderness
• Pain with movement

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Diagnostic Evaluation

• Elevated ESR / erythrocyte sedimentation rate
• genetic marker / HLA b27
• RF 9 antinuclear antibodies
• Bone scan
• MRI
• Arthroscopic exam