Musculoskeletal

1. Musculoskeletal

2. 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

3. 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

4. Toddler… • Inspect the spine while standing • Increased lumbar lordosis and protruberant abdomen • Note ability to: • Sit • Creep • Grasp • Release objects

5. 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

6. 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

7. 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

8. 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

9. Spina Bifida Myelomeningocele • Congenital neural tube defects • Incomplete closure of the vertebral column • Meninges and sometimes spinal cord protrude into a saclike structure

10. 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

11. Palpate for fractures, dislocations, crepitus, masses & tenderness • Long bones • Clavicle One of the most easily missed finding in a newborn is a fractured clavicle • Eventually notice a “lump” as the callus forms

12. Inspect Alignment of Legs and Feet 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

13. Inspect the Longitudinal 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”

14. Assess for Metatarsus Adductus • 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

15. Metatarsus Adductus 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.

16. Assess for Tibial Torsion • 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

17. Tibial Torsion • Slight varus curvature of the tibia • Related to fetal positioning • Expected to resolve after 6 months of weight bearing

18. Assess for Genu Varum • Child standing, ankles together • Knees at your eye level • Measure distance between the knees • Genu varum: 1 inch between the knees

19. Genu Varum • 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

20. Assess for Genu Valgum • Child standing, knees together • Measure the distance between the medial maleoli • Genu Valgum: 1 inch space between the ankles

21. Genu Valgum • 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

22. Assess for Femoral 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

23. Assess for Congenital Hip Dysplasia • 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…

24. Allis Sign • 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

25. Barlow • 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

26. Ortolani • 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

27. Testing Muscle Strength - Infant • 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.

28. Motor Development • Know the expected sequence of motor development

29. VIDEO 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

30. Ask the child to stand up from sitting… 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

31. Muscular Dystrophy • 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

32. Common Conditions

33. Cleidocranial Dysplasia • 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

34. Erb’s Palsy 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

35. Risk factors: 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

36. Klumpke’s Palsy • 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

37. Radial Head Subluxationaka 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

38. Developmental Hip Dysplasia • 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?

39. Acetabular displasia • 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

40. Talipes Equinovarus • 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

41. Treatment • 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

42. Talipes Calcaneovalgus • 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

43. Legg-Calve-Perthes • Epiphyseal osteochondritis of the hip • 2-10 years old • Limp

44. Osgood-Schlatter • 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