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Family History
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
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.
Limp or paralyzed arm Lack of muscle control in arm, hand or wrist Lack of feeling or sensation in arm or hand
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
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.
Ortolani Maneuver
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.
Galeazzi Maneuver
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
Pavlik Harness
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 Cshaped lateral foot border with a prominent styloid process of the fifth metatarsal.
Metatarsus Adductus
Treatment
Clubfoot
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.
Club Foot
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
Toddler Walking
Red flags!
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.
Infant Cruising
Gait Deformities
Genu varum
Genu Varum
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.
Blount Disease
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.
Intermalleolar Distance
Differential Diagnosis
Ricketts
Vitamin D intake
Whole milk, butter, egg yolks, animal fat and liver, especially fish liver oil. 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.
Environment:
Osteogenesis Imperfecta
Genetic disorder Caused by a genetic defect that affects the bodys production of collagen. Collagen is the major protein of the bodys connective tissue. Less than normal or poor collagen leads to weak bones that fracture easily.
Osteogenesis Imperfecta
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.
3-month-old with OI
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:
History
Recent physical activity: track, soccer, football, gymnastics, surfboarding Pain increases during and immediately after activity.
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
Osgood-Schlatter Disease
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)
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.
History
Often parent states that the child seems to be tripping over their own feet.
Exam
Observe the childs gait. Have the child kneel down and look at the feet from behind.
Tibial Torsion
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.
Management
90% will resolve by age 8 years Avoid prone sleeping and sitting on feet.
Popliteal Cyst
Often called Bakers Cyst are synovial lesion that result from herniation of the synovium of the knee joint into the popliteal space.
Clinical Findings
Popliteal Cyst
Growing Pains
Occur in 13 to 18% of children Called leg aches Cause: thigh and calf muscle fatigue
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.
Exam
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.
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.
Scoliosis
Medline.com
Clinical Manifestations
Pain is not a normal finding for idiopathic scoliosis Often present with uneven hemline Unequal scapula Unequal hips
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.
Screening
Screening
Mild Scoliosis
Mild forms
Strengthening and
stretching
Assessment
Alert: If pain is a reported symptom of the childs 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.
Bracing
Legg-Calves-Perthes Disease Slipped Capital Femoral Epiphysis Infection: septic arthritis Inflammation of a joint: rheumatoid arthritis
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.
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
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
Trendelenburg Sign
Upper femoral epiphysis slips from its position in the hip joint Most common hip disorder in the adolescent
History
Acute or chronic thigh or knee pain History of mild trauma to the hip area Child is often large for age or overweight
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
Clinical Manifestations
Septic Arthritis
Septic Hip
Diagnostic Tests
ESR Used as a gauge for determining the progress of an inflammatory disease. Rises within 24 hours after onset of symptoms. Men: 0 - 15 mm./hr Women: 0 20 mm./hr Children: 0 10 mm./hr
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
Chronic inflammatory condition of the joints and surrounding tissues. Often triggered by a viral illness 1 in 1000 children will develop JRA
Clinical Manifestations
Swelling or effusion of one or more joints Limited ROM Warmth Tenderness Pain with movement
Diagnostic Evaluation
Elevated ESR / erythrocyte sedimentation rate + genetic marker / HLA b27 + RF 9 antinuclear antibodies Bone scan MRI Arthroscopic exam