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Musculoskeletal. Development. Children are more likely to fracture than sprain Ligaments are stronger than bone until adolescence During adolescence, there is a greater potential for injury Rapid growth leads to: Decreased strength in the epiphyses Decreased strength and flexibility

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Development
Development

  • Children are more likely to fracture than sprain

    • Ligaments are stronger than bone until adolescence

  • During adolescence, there is a greater potential for injury

    • Rapid growth leads to:

      • Decreased strength in the epiphyses

      • Decreased strength and flexibility

  • Bone growth is completed ~age 20

  • Peak bone mass is achieved ~ age 35


Observe posture and movement
Observe Posture and Movement

Movements should be symmetric, no “twitching”

Prone:

  • Should be able to lift the head and trunk using forearms after 2 months

    Sitting:

  • Assess curvature of the spine and strength of paravertebral muscles

  • Kyphosis of the thoracic and lumbar spine is expected until the infant can sit without support

    VIDEO


Toddler…

  • Inspect the spine while standing

    • Increased lumbar lordosis and protruberant abdomen

  • Note ability to:

    • Sit

    • Creep

    • Grasp

    • Release objects


  • Place the newborn in the fetal position

    • Asymmetry of flexion, position, or shape?

  • The newborn will show some resistance to full extension (flexed) VIDEO

  • Hand fisted, thumb may be positioned inside the fingers

    • Hands should open periodically with fingers fully extended VIDEO


  • Observe palmar and phalangeal creases

    • Simian crease

      • Single crease extending across the entire palm

        • Down syndrome; other congenital syndromes

  • Count the fingers and toes

    • Polydactyly

    • Syndactyly


Fully undress the patient…

  • Arms and legs should be freely moveable (passive ROM)

    • Note symmetric flexion of extremities (newborn)

  • Note symmetric axillary, gluteal, femoral, and popliteal creases

  • Note asymmetry of limb length or circumference


Inspect the back…

  • Tufts of hair? Discoloration? Cysts? Masses?

  • Spine

    • Smooth with balanced concave and convex curves

    • No lateral curvature

    • No rib humping (forward flexion)

  • Shoulder and scapulae

    • Level (within ½ inch)

    • 3-5 inches apart


Spina bifida myelomeningocele
Spina Bifida Myelomeningocele

  • Congenital neural tube defects

  • Incomplete closure of the vertebral column

    • Meninges and sometimes spinal cord protrude into a saclike structure


Scoliosis
Scoliosis

  • Structural vs. Functional

    • Adams Test

  • “Idiopathic”

    • MC in girls

    • Progresses during early adolescence

    • No known cause…

  • Leg length discrepency

  • Uneven shoulder and hip levels

  • Scapular asymmetry

  • Rib humping & flank asymmetry on forward flexion

  • Physiologic alterations in the spine, chest, and pelvis result



Inspect alignment of legs and feet
Inspect Alignment of Legs and Feet tenderness

Infants may exhibit:

  • Pes planus

  • Metatarsus adductus

  • Tibial torsion

    Toddlers and older children…

  • Note the wear of the child’s shoes

  • Ask parent about favorite sitting posture

    Reverse tailor position

    • Places stress on joints

    • May lead to femoral anteversion


  • Inspect the longitudinal arch
    Inspect the tendernessLongitudinal Arch

    • Longitudinal arch is obscured by a fat pad until about 3 years of age

      • “Pes planus” is normal in the infant

    • After 3, the longitudinal arch should be apparent when not weight bearing

    • Compare weight bearing to non-weight bearing

      • Determine “rigid” vs. “flexible”


    Assess for metatarsus adductus
    Assess for Metatarsus Adductus tenderness

    • Medial adduction of the toes and forefoot

      • Heel and ankle are uninvolved

    • Lateral border of the foot is convex

    • Crease is sometimes apparent on the medial border of the foot

    • Midline of the foot may bisect the 3rd and 4th toes

      • 2nd and 3rd toes as they get older

    • Angulation at the tarsometatarsal joint

      • seen on x-ray

    www.orthoseek.com/ articles/img/metatar1.gif


    Metatarsus adductus
    Metatarsus Adductus tenderness

    www.orthoseek.com/ articles/img/metatar1.gif

    • Forefoot adduction

      • May be fixed or flexible

    • Related to intrauterine positioning

    • MC congenital foot deformity

      Management:

    • Mobilization, soft tissue?

    • Monitor apparent problems carefully

      • Rarely require intervention

        Feet will often pronate slightly until ~30 months of age but metatarsus adductus should be resolved in the toddler.


    Assess for tibial torsion
    Assess for Tibial Torsion tenderness

    • Child prone

    • Flex knees 90 degrees

    • Align the midline of the foot parallel to the femur

    • Using thumb and index finger, grasp the medial and lateral maleoli

    • Place other thumb and index finger on either side of the knee

    • If your thumbs are not parallel to eachother…

      TIBIAL TORSION


    Tibial torsion
    Tibial Torsion tenderness

    • Slight varus curvature of the tibia

    • Related to fetal positioning

    • Expected to resolve after 6 months of weight bearing


    Assess for genu varum
    Assess for Genu Varum tenderness

    • Child standing, ankles together

    • Knees at your eye level

    • Measure distance between the knees

      • Genu varum: 1 inch between the knees


    Genu varum
    Genu Varum tenderness

    • Common finding in toddlers

      • Up to 18 months of age

    • Note any increase on future examination

    • Tibiofemoral angle should stay symmetrical

      *Evaluate further if…

      • Asymmetry of the tibiofemoral angle

      • Space between the knees > 1.5 inches

    Image from: http://www.zadeh.co.uk/paediatricorthopaedics/tibiofemoral_angle_2.jpg


    Assess for genu valgum
    Assess for Genu Valgum tenderness

    • Child standing, knees together

    • Measure the distance between the medial maleoli

      • Genu Valgum: 1 inch space between the ankles


    Genu valgum
    Genu Valgum tenderness

    • Common: children 2-4 years

    • On future examination note:

      • Variation in tibiofemoral ange

      • Increased space between ankles

        *Evaluate further if…

      • Asymmetry of the tibiofemoral angle

      • Space between the ankles >2 inches0

    Image from: http://www.zadeh.co.uk/paediatricorthopaedics/tibiofemoral_angle_2.jpg


    Assess for femoral anteversion
    Assess for tendernessFemoral Anteversion

    Clinical findings:

    • Increased internal rotation of the hip (>70 degrees) & decreased external hip rotation

    • Femurs twist medially, patella facing inward

    • In-toeing of the feet increases up to 5-6 years of age

      • Tibias may twist laterally to compensate

    • More common in females

    • Associated with “reverse tailor” sitting


    Assess for congenital hip dysplasia
    Assess for Congenital Hip Dysplasia tenderness

    • Asymmetrical thigh and buttock skin folds or creases

    • Decreased hip abduction

    • Allis’ Test

      • legs may appear to be different lengths

    • Barlow’s

    • Ortolani’s

    *Should be performed each time the infant is examined during the first year of life…


    Allis sign
    Allis Sign tenderness

    • Used to detect a shortened femur

      • dDx: hip dislocation

    • Infant supine

    • Flex both knees

      • Keep feet flat on the table

      • Femurs aligned with eachother

    • Observe the height of the knees

      + Allis sign: one knee appears lower than the other


    Barlow
    Barlow tenderness

    • Infant supine

    • Flex the hips & knees to 90 degrees

    • Grasp a leg with each hand

    • Adduct the thighs to the maximum

      • Doctor’s thumbs should touch

    • Apply downward pressure on the femur

      • Not too vigorous

      • Attempt to disengage the femoral head from the acetabulum


    Ortolani
    Ortolani tenderness

    • Slowly abduct the thighs

      • Maintain axial pressure

    • Fingertips on the greater trochanter, exert a lever movement in the opposite direction

      • Fingertips press the femoral head back toward the acetabulum center

    • If there’s a “palpable clunk”…

      femur head slipped back into the acetabulum

      *Suspect hip subluxation/dislocation


    Testing muscle strength infant
    Testing Muscle Strength - Infant tenderness

    • Hold infant upright with your hands under the axillae

      If infant maintains the upright position:

      • Adequate shoulder muscle strength

        VIDEO

        If infant slips through your fingers:

      • Muscle weakness

        VIDEO

    © 1998 Anrig & Plaugher. Used with permission.


    Motor development
    Motor Development tenderness

    • Know the expected sequence of motor development


    VIDEO tenderness

    Watch the child play…

    • Suggest activities that will enhance your observations

      • Limited movement Getting up

      • Function of joints Jumping

      • Range of motion Hopping

      • Bone stability Climbing

      • Muscle strength

        Playing with toys


    Ask the child to stand up from sitting… tenderness

    Gower sign:

    • Child rises from a sitting position by placing hands on the legs and pushing the trunk up

      • “crawl up their legs”

    • Indicates muscle weakness

      dDx: muscular dystrophy


    Muscular dystrophy
    Muscular Dystrophy tenderness

    • Group of genetic disorders

    • Gradual degeneration of the muscle fibers

      • Range from mild disability (normal life-span) to severe disability, deformity and death.

    • Progressive weakness

    • Muscle atrophy

    • Pseudohypertrophy from fatty infiltrates

    • Gower sign


    Common conditions

    Common Conditions tenderness


    Cleidocranial dysplasia
    Cleidocranial Dysplasia tenderness

    • Excessive forward movement of the shoulders

      • Complete or partial absence of the clavicles

    • Large fontanels & delayed closure of the sutures

      • Defective ossification of the cranium

    • Waddling gait

      • Defective symphysis pubis

    academic.sun.ac.za/.../ dept/ccdbskou.jpg


    Erb s palsy
    Erb’s Palsy tenderness

    MC brachial plexus injury (C5/C6)

    • Paralyzed arm, “waiter’s tip”

      • Internal rotation and adduction of the shoulder, extension of the elbow, pronation of the forearm, and wrist flexion

    • Absent moro, biceps, & radial reflexes

    • Grasp reflex is present

    • 5% ipsilateral phrenic nerve paresis


    Risk factors: tenderness

    Large infant

    Shoulder dystocia

    Associated with:

    Fractured clavicle

    Fractured humerus

    Subluxation (medical) of the cervical spine

    Cervical cord injury

    Facial palsy

    www.keenanlawfirm.com/.../ shoulder_dystocia.jpg


    Klumpke s palsy
    Klumpke’s Palsy tenderness

    • Brachial plexus injury of C7-8, T1

    • Less common

    • Weakness of the intrinsic muscles of the hand

    • Grasp reflex is absent (infant)

    • Horner’s synrome

      • If cervical sympathetic fibers of the first thoracic spinal nerve are involved


    Radial head subluxation aka nursemaid s elbow
    Radial Head Subluxation tendernessaka Nursemaid’s Elbow

    • Common in children 1-4 years old

    • Relatively easy to cause…

      • Tugging on a child’s arm (removing clothing)

      • Lifting a child by grabbing the hand

      • Jerking the arm upward while the elbow is flexed

    • Child complains of pain in the elbow and wrist

    • Refuses to move the arm

    • Holds arm slightly flexed and pronated

    • Resists supination


    Developmental hip dysplasia
    Developmental Hip Dysplasia tenderness

    • Common congenital defect

    • Females > males (6:1)

    • Associated with intrauterine constraint

      • Commonly seen along with torticollis

    • Varying degrees of involvement

      • Displasia? Subluxation? Dislocation?

    • Management

      • Bracing? Surgery?


    Acetabular displasia tenderness

    • Delay in ossification of the acetabulum

      • Oblique and shallow

    • Femoral head remains in the acetabulum

      Subluxation

    • Incomplete dislocation

    • Femoral head remains in contact with the acetabulum

    • Joint ligaments and capsule are stretched

      • Allows displacement of the femoral head

        Dislocation

    • Femoral head loses contact completely with the acetabular capsule

    • Displaced over the fibrocartilaginous rim


    Talipes equinovarus
    Talipes Equinovarus tenderness

    • Congenital defect of the ankle and foot

      • Inversion of the foot (at the ankle)

      • Plantar flexion

        • Contracted triceps surae

      • 1/1000 live births (USA)

      • Male-to-female ratio is 2:1

      • Bilateral involvement 30-50% of cases

      • 10% chance of a subsequent child being affected

    Image from: clubfoot.homestead.com/ files/Jakob_1_week.jpg


    Treatment tenderness

    • Ponseti method

      (Ignacio Ponseti, MD, University of Iowa)

      • Series of manipulation and casting

        • Usually 4-6, full leg cast (bent at the knee)

      • Tenotomy (achiles tendon)

      • Foot Abduction Brace aka Denis Browne Bar

        www.emedicine.com

    Image from: http://www.mgh.harvard.edu/ortho/BabyCast.gif


    Talipes calcaneovalgus
    Talipes tendernessCalcaneovalgus

    • Exaggerated dorsiflexion

      • calcaneus in valgus position and forefoot abducted

    • 1% of live births

      • mild form may be in up to 30-50% of normal births

    • Probably due to abnormal intrauterine position

    • Most resolve spontaneously (weightbearing)

    • Occasionally serial casting needed


    Legg calve perthes
    Legg-Calve-Perthes tenderness

    • Epiphyseal osteochondritis of the hip

    • 2-10 years old

    • Limp


    Osgood schlatter
    Osgood-Schlatter tenderness

    • Epiphyseal osteochondritis of the knee

    • 9-15 years old

    • Pain & swelling of the tibial tuberosity

    Image from: http://www.menshealth.com/media/MH_Static/osgood_schlatters_200x200.jpg


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