Download Orthopedic Physical Assessment

Orthopedic Physical
Assessment
Jan Bazner-Chandler
RN, MSN, CNS, CPNP
Newborn Physical Assessment
Family History
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Any family members with musculoskeletal
problems; genetic component
Birth History
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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
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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
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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
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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
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Best done on a non-crying infant.
Adducted hip position
Ortolani Maneuver
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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
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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
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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
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This would be a positive sign of
developmental dysplasia of hip in the older
infant.
Limited hip abduction
Asymmetry of skin fold
Interventions
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Maintain hips in flexed position
Traction to stretch muscles
Pavlik harness
Hip surgery
Pavlik Harness
Metatarsus Adductus
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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
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Toes angle toward the midline, creating a Cshaped lateral foot border with a prominent
styloid process of the fifth metatarsal.
Metatarsus Adductus
Treatment
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Exercises
Soft shoe
Casting
Clubfoot
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Talipes equinovarus is a congenital
deformity.
Has four main components:
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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
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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
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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
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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!
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A toddler who is not walking by 15 to 18
months.
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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
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Bowing of the legs
Normal up to 3 years of age
Genu Varum
When is bowlegged considered a problem?
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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
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“Knock-Knees”
Physiologic valgum tends to peak at around
24 to 36 months and self corrects at about 7
to 8 years.
Examination
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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
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Rule out other causes of limb deformity.
Ricketts
What in the history would be important?
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Vitamin D intake
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Whole milk, butter, egg yolks, animal fat and liver,
especially fish liver oil.
Environment:
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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
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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
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Often called “brittle bone disease”
Characteristics
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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
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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
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Osgood-Schlatter Disease
Tibial Torsion
Popliteal Cyst
Osgood-Schlatter Disease
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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:
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Boys ages 10 to 15 years
Girls ages 8 to 14 years
History
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Recent physical activity: track, soccer,
football, gymnastics, surfboarding
Pain increases during and immediately after
activity.
Physical Exam
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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
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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
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Tibial torsion is a term used to describe the
normal variation in tibial rotation.
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Medial tibial torsion describes abnormal medial
rotation or twisting, resulting in in-toeing of the
feet.
Lateral tibial torsion results in out-toeing.
History
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Often parent states that the child seems to be
tripping over their own feet.
Exam
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Observe the child’s gait.
Have the child kneel down and look at the
feet from behind.
Tibial Torsion
Thigh-foot Angle
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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
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90% will resolve by age 8 years
Avoid prone sleeping and sitting on feet.
Popliteal Cyst
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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
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Swelling behind the knee with or without pain.
Popliteal Cyst
Growing Pains
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Occur in 13 to 18% of children
Called “leg aches”
Cause: thigh and calf muscle fatigue
Clinical Findings
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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
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No tenderness
No guarding
No decreased ROM
No limp
Clumsiness
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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
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Difficulty rising to a standing position
Scoliosis Screening
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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
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Pain is not a normal finding
for idiopathic scoliosis
Often present with uneven hemline
Unequal scapula
Unequal hips
Exam
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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
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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
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Legg-Calves-Perthes Disease
Slipped Capital Femoral Epiphysis
Infection: septic arthritis
Inflammation of a joint: rheumatoid arthritis
Legg-Calve-Perthes Disease
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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
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Acute or chronic onset with or without history
of trauma to the hip such as jumping from a
high place.
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Acute: sudden onset of pain in the groin or knee
often occurring at night and stiffness
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Chronic: Mild aching in hip (groin area) or referred
to the knee or anterior thigh. Limping after activity
or in the morning
Exam
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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
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Upper femoral epiphysis slips from its
position in the hip joint
Most common hip disorder in the adolescent
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Occurs more commonly in males
Skeletal immaturity:
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Males 10 to 15 years
Females 11 to 12 years
African American and Polynesian populations
more susceptible
History
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Acute or chronic thigh or knee pain
History of mild trauma to the hip area
Child is often large for age or overweight
Exam
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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
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Infection within a joint or synovial membrane
Infection transmitted by:
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Bloodstream
Penetrating wound
Foreign body in joint
Septic Hip
Diagnostic Tests
X-ray
Needle aspiration
under fluoroscopy
Erythrocyte Sedimentation Rate
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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
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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
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Chronic inflammatory condition of the joints and
surrounding tissues.
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Often triggered by a viral illness
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1 in 1000 children will develop JRA
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Higher incidence in girls
Clinical Manifestations
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Swelling or effusion of one or more joints
Limited ROM
Warmth
Tenderness
Pain with movement
Diagnostic Evaluation
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Elevated ESR / erythrocyte sedimentation
rate
+ genetic marker / HLA b27
+ RF 9 antinuclear antibodies
Bone scan
MRI
Arthroscopic exam