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

2. Newborn Physical Assessment

3. Family History
Any family members with musculoskeletal problems; genetic component

4. 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

5. 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.

6. 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

7. Brachial Plexus Injury

8. 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.

9. 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.

10. Barlow Maneuver
Best done on a non-crying infant.

11. Adducted hip position

12. 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.

13. 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.

14. Ortolani Maneuver

15. 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.

16. Galeazzi Maneuver

17. Limited Abduction
This would be a positive sign of developmental dysplasia of hip in the older infant.

18. Limited hip abduction

19. Asymmetry of skin fold

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

21. Pavlik Harness

22. 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.

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

24. Metatarsus Adductus

25. Treatment
Exercises
Soft shoe
Casting

26. 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

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

28. Club Foot

29. Toddler

30. 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.

31. 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

32. Toddler Walking

33. 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.

34. Infant Cruising

35. Gait Deformities

36. Genu varum
Bowing of the legs
Normal up to 3 years of age

37. Genu Varum

38. 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.

39. Figure II intercondylar distance

40. Blount Disease

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

42. 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.

43. Intermalleolar Distance

44. Differential Diagnosis
Rule out other causes of limb deformity.

45. Ricketts

46. 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.

47. 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.

48. 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

49. Brittle Bone Disease

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

51. 3-month-old with OI
Old rib fractures
Old fractures/demineralization

52. School Age Child Osgood-Schlatter Disease Tibial Torsion
Popliteal Cyst

53. 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

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

55. 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

56. Osgood-Schlatter Disease

57. 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)

58. 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.

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

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

61. Tibial Torsion

62. 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.

63. Management 90% will resolve by age 8 years
Avoid prone sleeping and sitting on feet.

64. 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.

65. Clinical Findings
Swelling behind the knee with or without pain.

66. Popliteal Cyst

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

68. 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.

69. Exam
No tenderness
No guarding
No decreased ROM
No limp

70. 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.

71. Duchenne’s Muscular Dystrophy
Difficulty rising to a standing position

72. 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.

73. Scoliosis
Lateral curvature of spine
Medline.com

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

75. 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.

76. Screening

77. Screening
Bowden & Greenberg

78. Mild Scoliosis
Mild forms
Strengthening and
stretching
Ball & Bindler

79. 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.

80. Bracing

81. Common Pediatric Orthopedic Disorders
Legg-Calves-Perthes Disease
Slipped Capital Femoral Epiphysis
Infection: septic arthritis
Inflammation of a joint: rheumatoid arthritis

82. 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.

83. 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

84. 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

85. Trendelenburg Sign

86. AP Pelvis and frog-leg lateral views

87. 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

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

89. 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

90. Clinical Manifestations

91. Septic Arthritis Infection within a joint or synovial membrane
Infection transmitted by:
Bloodstream
Penetrating wound
Foreign body in joint

92. Septic Hip

93. Diagnostic Tests
X-ray
Needle aspiration
under fluoroscopy

94. 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: mm./hr
Women: 0 – 20 mm./hr
Children: 0 – 10 mm./hr

95. 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

96. 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

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

98. Diagnostic Evaluation
Elevated ESR / erythrocyte sedimentation rate
+ genetic marker / HLA b27
+ RF 9 antinuclear antibodies
Bone scan
MRI
Arthroscopic exam