Orthopedic Physical Assessment Jan Bazner-Chandler RN, MSN, CNS, CPNP
Family History • Any family members with musculoskeletal problems; genetic component
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
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.
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
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 • 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 • Best done on a non-crying infant.
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.
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.
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.
Limited Abduction • This would be a positive sign of developmental dysplasia of hip in the older infant.
Interventions • Maintain hips in flexed position • Traction to stretch muscles • Pavlik harness • Hip surgery
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.
Exam • Toes angle toward the midline, creating a C-shaped lateral foot border with a prominent styloid process of the fifth metatarsal.
Treatment • Exercises • Soft shoe • Casting
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
Causes • Result of intrauterine maldevelopment of the talus that leads to adduction and plantar flexion of the foot.
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.
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
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. Red flags!
Genu varum • Bowing of the legs • Normal up to 3 years of age
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.
Genu Valgum • “Knock-Knees” • Physiologic valgum tends to peak at around 24 to 36 months and self corrects at about 7 to 8 years.
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.
Differential Diagnosis • Rule out other causes of limb deformity.
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.
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.
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
Clinical Pearl • Child may present as child abuse. • The infant / child may have a minor reported accident that results in significant injury.