3Family HistoryAny family members with musculoskeletal problems; genetic component
4Birth History Weight and height Gestational age Birth presentation Single or multiple birthType of birth: NSVD, forceps, vaginal extraction, cesarean section, shoulder presentationAsphyxia at birth: apgar score
5Brachial Plexus Injury Excessive traction of the spinal nerve roots C5-T3Many brachial plexus injuries happen when the shoulders become impacted during delivery and the brachial plexus nerves stretch or tear.
6Symptoms of Brachial Plexus injury Limp or paralyzed armLack of muscle control in arm, hand or wristLack of feeling or sensation in arm or hand
8Developmental 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.
9Barlow ManeuverThe 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.
10Barlow ManeuverBest done on a non-crying infant.
12Ortolani 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.
13Positive OrtolaniA 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.
15Galeazzi ManeuverFlex 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.
22Metatarsus Adductus Most common foot deformity 2 per 1000 Result of intrauterine positioningForefoot is adducted and in varus, giving the foot a kidney bean shape.Most often resolves on own or with simple exercises.
23ExamToes angle toward the midline, creating a C-shaped lateral foot border with a prominent styloid process of the fifth metatarsal.
26Clubfoot Talipes equinovarus is a congenital deformity. Has four main components:Inversion and adduction of the forefootInversion of the heel and hindfootEquinus (limitation of extension) of ankle and subtalar jointInternal rotation of the leg
27CausesResult of intrauterine maldevelopment of the talus that leads to adduction and plantar flexion of the foot.
30Tips 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.
31Gait ExamObserve 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
33Red 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.
38When is bowlegged considered a problem? Tibial-femoral angle greater than 15 degrees.Associated internal tibial torsionIntercondylar (knee) distance greater than 4 to 5 inches.Joint laxity in the older child.
41Genu Valgum “Knock-Knees” Physiologic valgum tends to peak at around 24 to 36 months and self corrects at about 7 to 8 years.
42ExaminationTibial-femoral angle less than 15 degrees of valgus in a child over 7 to 8 years of age.Awkward gaitIntermalleolar (ankle) distance with knees together greater than 4 to 5 inches.Often associated with short stature.
46What in the history would be important? Vitamin D intakeWhole 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.
47Osteogenesis Imperfecta Genetic disorderCaused 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.
48Osteogenesis Imperfecta Often called “brittle bone disease”CharacteristicsDemineralization, cortical thinningMultiple fractures with pseudoarthrosisExuberant callus formation at fracture siteBlue scleraWide suturesPre-senile deafness
50Clinical Pearl Child may present as child abuse. The infant / child may have a minor reported accident that results in significant injury.
513-month-old with OIOld rib fracturesOld fractures/demineralization
52School Age Child Osgood-Schlatter Disease Tibial Torsion Popliteal Cyst
53Osgood-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 yearsGirls ages 8 to 14 years
54HistoryRecent physical activity: track, soccer, football, gymnastics, surfboardingPain increases during and immediately after activity.
55Physical ExamPoint tenderness pain, prominence over the tibial tuberclePain with knee extension against passive resistance or with full passive knee resistance.Decreased ROM
57Treatment R.I.C.E. - rest, ice, compression, and elevation medications (for discomfort): Ibuprofenelastic wrap or a neoprene knee sleeve around the kneeactivity restrictionsphysical therapy (to help stretch and strengthen the thigh and leg muscles)
58Tibial TorsionTibial 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.
59HistoryOften parent states that the child seems to be tripping over their own feet.
60Exam Observe the child’s gait. Have the child kneel down and look at the feet from behind.
67Growing Pains Occur in 13 to 18% of children Called “leg aches” Cause: thigh and calf muscle fatigue
68Clinical FindingsDiscomfort 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.
69ExamNo tendernessNo guardingNo decreased ROMNo limp
70ClumsinessAbout 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 1975Now called: developmental coordination disorder or DCD.
71Duchenne’s Muscular Dystrophy Difficulty rising to a standing position
72Scoliosis ScreeningShould be done with every well child physical from about age 8 or 9.May be referred to you after screening at school.
79AssessmentAlert: 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.
81Common Pediatric Orthopedic Disorders Legg-Calves-Perthes DiseaseSlipped Capital Femoral EpiphysisInfection: septic arthritisInflammation of a joint: rheumatoid arthritis
82Legg-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 monthsMore common in boys age between 4 and 8 years of age.
83HistoryAcute 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 stiffnessChronic: Mild aching in hip (groin area) or referred to the knee or anterior thigh. Limping after activity or in the morning
84Exam Antalgic gait with a positive Trendelenburg sign Muscle spasm Decreased abduction, internal rotation, and extension of the hipPain on rolling the leg internally
87Slipped Capital Femoral Epiphysis Upper femoral epiphysis slips from its position in the hip jointMost common hip disorder in the adolescentOccurs more commonly in malesSkeletal immaturity:Males 10 to 15 yearsFemales 11 to 12 yearsAfrican American and Polynesian populations more susceptible
88History Acute or chronic thigh or knee pain History of mild trauma to the hip areaChild is often large for age or overweight
89Exam Pain in groin or diffusely over knee or anterior thigh Pain and decreased internal rotationAntalgic limp (due to shorter leg)External rotation of leg when walkingExternal rotation of the thigh when hip is flexedThigh atrophy (measure and compare)Limited abduction and extension
94Erythrocyte Sedimentation Rate ESRUsed as a gauge for determining the progress of an inflammatory disease.Rises within 24 hours after onset of symptoms.Men: mm./hrWomen: 0 – 20 mm./hrChildren: 0 – 10 mm./hr
95Management Administration of antibiotics for 4 to 6 weeks. Oral antibiotics have been found to be effective if serum bactericidal levels are adequate.Fever controlIbuprofen for anti-inflammatory effect
96Juvenile Rheumatoid Arthritis Chronic inflammatory condition of the joints and surrounding tissues.Often triggered by a viral illness1 in 1000 children will develop JRAHigher incidence in girls
97Clinical Manifestations Swelling or effusion of one or more jointsLimited ROMWarmthTendernessPain with movement