the essential pediatric musculoskeletal exam

The Essential Pediatric Musculoskeletal Exam

Cathleen S. McGonigle, DO

4/2011

Annual STFM Meeting 2011

Objectives

• Develop a plan of incorporating the Essential Pediatric Exam into all Well Child Checks

• Review essential exams in Primary Care for newborn/infants, juvenile, and adolescent patients.

• Common Conditions seen for each patient age group (Handout)

Overview

• Newborn & Infant – Extremities

• Hips

– Spine

• Juvenile – Extremities

• Elbows

• Shoulders

• Hips

– Spine

• Adolescents – Extremities

• Hip

• Knees

• Foot/Ankle

– Spine

Well Child Checks • Opportunity to incorporate the

musculoskeletal exam

• Multiple visits in frequent intervals – Lots of Normal for comparison

– Catch things early

• Systematic Approach to any Musculoskeletal Exam

Physical Exam • Inspection

– Symmetry, Birth Marks, Gait, hair, etc

• Palpation – Bony Landmarks, Soft Tissues

• ROM

• Neurovascular

• Special Testing

• Related Areas

Newborns & Infants

Exam • Inspection

– Symmetry

– Deformities

– Skin Folds

– Fingers & Toes

• Palpation

• ROM

• NV

• Special Tests

• Lower Limbs – In-toeing

• Metatarsus Adductus

• Femoral Anteversion

• Tibial Torsion

• Hips – DDH

• Spine – Scoliosis

Skin Folds • Asymmetry

– Developmental Dysplasia of Hip (Congenital Dysplasia of Hip) • 72.7% - Asym. Folds -J

Child Orthop 2007

– Muscular Atrophy

– Leg Length Discrepancy

Evaluation for Lower Limb

• Foot Progression Angle - FPA

• Thigh Foot Angle - TFA

• Hip Internal Rotation

• Hip External Rotation

• Heel Bissector Line

Foot Progression Angle

• Hereditary

• Infants – Average Internal 5 degrees

– Range -30d to +20 d

• By Age 8 – Average External 10

degrees

– Range -5d to +30d

• Toes – In or Out

Thigh Foot Angle • Exam

– Prone, Knee at 90 degrees, Foot Dorsiflexed

• Infants • Average Internal 5 degrees

• Range -30d to +20 d

• By Age 8 • Average External 10 degrees

• Range -5d to +30d

• Tibial Torsion • Internal

• External

Heel Bisector Line

• http://www0.sun.ac.za/ortho/webct-ortho/int-rot/internal-rotational-deformities-of-the-lower-limb/internal-rotational-deformities-of-the-lower-limb-6.png

Internal Rotation

Normal internal rotation:

35 degrees

Hoppenfeld, Stanley, Physical Exam of

Spine and Extremities, 1976.

External Rotation Normal external rotation:

45 degrees



Femoral Version • Femoral Angle

– At Birth 40 degrees

– Maturity 15 degrees

Angulation of the neck of

the femur

Physical Exam



Hip Stability Tests

In a newborn, both hips can

be equally flexed, abducted,

and externally rotated

without producing a “click”

DDH may be confirmed by

the Ortolani “click” test.

Ortolani is “OUT” to “IN”

Hip Stability Tests

• Barlow

Hip Stability Tests

Telescoping of the femur to aid in the

diagnosis of DDH

Galeazzi Test

Tibial length

discrepancy

Femoral length

discrepancy Asymmetry in Knee Height

Spine Exams

Juvenile

Exam

• Inspection – Symmetry

– Deformities

– Growth Plates

• Palpation

• ROM

• NV

• Special Tests

• Upper Limbs – Elbow

• Little League Elbow

– Shoulder • Little League Shoulder

• Hips – Legg Calve Perthes


Elbow Ossification Centers

Shoulder Exam Overview

• Inspection

• Palpation – Bones

– Soft Tissues

• ROM

• Neurological Exam

• Special Tests

• Exam of Related Area

Back Exam

Adolescents

Exam

• Inspection – Symmetry

– Deformities

• Palpation • Growth Plates

• ROM

• NV

• Special Tests

• Lower Limbs – Knees

• Osgood Schlatter

– Foot/Ankle • Tarsal Coalition

• Hips – Slipped Capital Femoral

Epiphysis (SCFE)


– Scheuermann’s Kyphosis

Foot and Ankle

• Inspection – Asymmetry

– Deformity

– Coloration

• Palpation – Bony Landmarks

– Growth Plates

• ROM

• Neurovascular

• Special Tests – Anterior Drawer

– Talar Tilt

– Squeeze Test

– External Rotation Test

– Thompson Test

Knee

• Inspection • Palpation

– Bones – Soft Tissues – Ligaments

• ROM • Neurovascular

• Special Tests – Anterior Drawer

– Posterior Drawer

– Varus/Valgus

– Lachman

– McMurray

– Appley’s Comp/Dist


Hip

• Inspection • Palpation • ROM

– F, E, IR, ER, ABD, ADD

• Neurovascular

• Special Tests


Hip Exam

• Signs – Hip held in

abduction and external rotation

– Markedly limited internal rotation

Test for internal and external

femoral rotation

Spine • Inspection

– Curvature of the Back Bone or Spine

• Palpation

• ROM

• NV

• Special Tests

Questions?

Common Conditions • Infant

– Intoeing

– DDH

• Juvenile – Little League Elbow

– Little League Shoulder

– Legg Calvé Perthes

• Adolescents – SCFE

– OCD Lesion of Knee

– Osgood-Schlatter

– Tarsal Coalition

– Spondylosis/ Spondylolisthesis

– Scoliois

– Scheuermann’s Kyphosis

Newborns & Infants

Intoeing • Foot is turned in

• Normal – Resolves 18-24 mths

• Causes – Hereditary

– Idiopathic

– Congenital

• Alignment from • Foot

• Tibia

• Femur

http://orthoinfo.aaos.org/topic.cfm?topic=a00055

Metatarsus Adductus (Varus) • Mechanism

– Forefoot alignment • Metatarsals on

Cuneiforms

• Cause – Position in uterus

• Incidence – 1:1,000 - 2,000

– Male = Female

• Risk factors – Oligohydramnios

http://www.wheelessonline.com/ortho/metatarsus_adductus

http://www.wheelessonline.com/ortho/metatarsus_adductus

Metatarsus Adductus

• Diagnosis – Physical Exam

• Flexible

• No equinus

• Bilateral 50%

• Associated Conditions: – Hip dislocation (10-

15%)

http://www.orthoseek.com/articles/metatarsus.html


Metatarsus Adductus • Recommendations

– None • Improves over 6-12wks

– Stretching • Severity

• Treatment (3-4mths) – 15% needed

• Bracing

• Shoes

• Casting

• Surgery (rare)



Internal Tibial Torsion

• Normal – First 2 yrs of life

• Resolves spontaneously by age 9 to 10 years

• Treatment – recommended of TFA

> -45 degrees – Bracing (little use) – Orthotics – Surgery (rarely)

Femoral Anteversion • Resolves spontaneously

or improves 8-10yrs

• Treatment – Not recommended

– Braces does not help

– Discourage “W”position

http://www.orthoseek.com/articles/femtorsion.html

Run Forest Run



Developmental Dysplasia Hip - DDH

• Epidemiology: – Classic Congenital Hip Dislocation –

• Incidence – Hip instability at birth: 1% – Hip dysplasia in infants: 0.1 to 0.3% – Girls - 9 times more often affected than boys – Unilateral, but bilateral is more common

• Pathophysiology

– Femoral head dislocates from acetabulum

DDH

• Risk Factors – Female sex

– First Born

– Family History

– Breech Presentation

J Child Orthop, 2007


• Types – Classic congenital Hip Dislocation – Teratologic Congenital Hip Dislocation – Congenital Abduction Contracture of the Hip

(neurogenic)

• Associated Conditions – Congenital Torticollis – Breech Presentation in utero – First degree relative with hip dysplasia history – Clubfoot

Developmental Dysplasia Hip - DDH • Clinical Signs (J Child Orthop)

– Asymmetric skin folds – Limitation of Abduction

• Signs: Classic Congenital Hip Dislocation – Ortolani Test (attempt to

dislocate hip) • Hip Clunk felt on exam • Distinguish from a hip click

– Galeazzi's Sign (compare the 2 femur lengths)

– Barlow's Test (attempt to sublux unstable hip)

• Perform with caution


• Radiology – Dynamic Hip Ultrasound (infant under age 3

months) • Diagnostic for congenital Hip Dislocation

– Hip X-ray • Not diagnostic for Congenital Hip Dislocation

– Femoral head not calcified under age 3 months

• Diagnostic for Acetabular Dysplasia – Abnormal acetabular fossa will be seen

Normal X-rays

DDH

• Management: Classic Congenital Hip Dislocation – Refer to Peds Ortho – Pavlik Harness – Surgery – if needed

• Prognosis

– Delayed treatment risks worse outcomes

Neurogenic Hip Dislocation

Juvenile

ITE Question

• 122. Little League elbow refers to a problem located over the

• A) medial epicondyle

• B) lateral epicondyle

• C) olecranon

• D) capitellum

• E) ulnar groove

ITE Answer

• Right answer: A • Little League elbow is an apophysitis of

the medial epicondyle of the elbow. It occurs in throwing athletes between 9 and 12 years of age, and causes elbow pain during throwing. It may also affect velocity and control. It may cause pain and swelling in the arm and/or elbow, but the diagnosis should be considered in throwing athletes with elbow pain even if symptoms are minimal.

• Ref: Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sports-related overuse injuries. Am Fam Physician 2006;73(6):1014-1022.

Little League Elbow

Little League Elbow

• Phases of Pitching

Little League Elbow • Apophysitis

– Medical Epicondyle

• Causes – Repetitive Throwing – Specific throwing events

• Throwing too hard too often • Increasing the number of pitches you throw

per week too quickly (pitch counts) • Throwing too many curves or sliders at a

young age • Changing to a league where the pitcher's

mound is farther away from home plate or the mound is elevated

Little League Elbow

• Male greater than Female

• Pre-puberty - 10-15 years old

• Symptoms – Pain around the medial epicondyle

– Swelling (possibly)

– Pain when throwing overhand

– Pain with gripping or carrying heavy objects

Little League Elbow • X-ray

Little League Shoulder

http://www.childrensmemorial.org/depts/sportsmedicine/images/LittleLeagueShoulder.gif

• Growth plate injury of the proximal humerus

• Cause: – Overuse and repetitive

microtrauma

• Presentation: – Diffuse shoulder pain

worse with throwing or extremes of shoulder ROM

Diagnosis

• Plain x-ray

• Physeal widening

• May reveal metaphyseal fragmentation and periosteal reaction http://www.mritutor.org/mriteach/1401/int.jpg

Little League Shoulder

Little League Elbow/Shoulder

• Prevention – Always warm up before pitching

– light aerobic exercise, such as jogging or jumping jacks.

– Always stretch before pitching. – Always follow the pitching rules of their

baseball league – Do not play in multiple leagues at the same time. – Limit their pitching to:

– a maximum of 4-10 innings a week – aim for no more than 80-100 pitches per game, or 30-40

pitches per practice

– Learn and practice the mechanics of good pitching techniques.

– Do not throw curve balls and sliders until high school

Little League Elbow/Shoulder • Treatment • Severity of the injury.

– Recovery time ranges from 6 weeks to 3 months.

• Rest—Do not pitch or do any activities that cause elbow pain.

• Cold—Ice • Medications—NSAIDs • Physical Therapy—After the pain is gone

– Strengthening exercises – Range of motion exercises

• Gradual Return to Pitching—Begin throwing motions and gradually progress to pitching

• Surgery – Elbow: may be needed to reattach the ligament and bony

fragment if it is widely separated from the growth plate. This is rarely needed.

– Shoulder: depends on displacement, alignment and growth remaining at physis

Little League Pitching Limits

• 17-18 y/o: 105 pitches/day





• A 6-year-old white male is brought to the office because of left hip and knee pain of 6 months' duration. There is no history of trauma or illness.

• On physical examination he is afebrile and pleasant. His height and weight are at the 5th percentile. Examination of the knee is normal. The hip has decreased internal rotation and abduction. There is slight atrophy, with the left thigh measuring one-half inch less in circumference than the right, and there is tenderness over the left hip anteriorly.

• Roentgenograms of the hip show a subchondral fracture of the femoral head. A complete blood count and sedimentation rate are normal. Which one of the following is the most likely diagnosis?

ITE Question

• Which one of the following is the most likely diagnosis?

• A. Lyme disease • B. Gaucher's disease • C. Tuberculosis • D. Juvenile rheumatoid arthritis • E. Legg-Calvé-Perthes disease

ITE Question

ITE Answer • Right answer: Legg-Calvé-Perthes disease

• The case described is a typical presentation of Legg-Calvé-Perthes disease. The subchondral fracture and normal CBC and sedimentation rate would not be seen in the other choices listed.

• Ref: Behrman RE, Kliegman RM, Jenson HB (eds): Nelson Textbook of Pediatrics, ed 16. WB Saunders Co, 2000, pp 2080-2081.

Legg Calvé Perthes Disease • Healthy children

• Increased Risk – Boys (4-12yrs) more than girls

– Family History

• Avascular Necrosis of Femoral Head

Legg Calvé Perthes

• Where does it come from? • Lack of blood supply

• Increased pressure of joint

• Immature bones

• Infection

• What are the symptoms? • Limp

• No pain

• Pain in knee or thigh or groin

How is it diagnosed? • X-rays of the

hips

Legg Calvé Perthes

What happens?

• Forces applied to hip joint further smash the head of the thigh bone or femur

• Deformity of the thigh bone at the hip

• Remodeling and Healing over time

Phases of Recovery • Initial

• Reossification

• Reabsorption

• Healing

Treatment - Bracing

• Help keep pressure off the hip

Casting

What can happen? • Over time – bone starts to heal then remodel • Worsening deformity of hip joint • Pain • Early arthritis

Surgery

Adolescents

12 year old obese girl with knee pain

Slipped Capital Femoral Epiphysis - SCFE

• Epidemiology – Occurs during maximal pubertal growth spurt

• Males: age 13 to 15 years • Females: age 11 to 13 years

• Most common adolescent hip disorder – Incidence: 1 to 4 per 100,000

• Black race > white race • Unilateral involvement in 90% of cases • Child is often overweight

SCFE Physical Exam

• Signs – Hip held in

abduction and external rotation

– Markedly limited internal rotation

Test for internal and external

femoral rotation

SCFE • Radiology: Hip Xray (Compare sides) – Widened epiphyseal plate

– Displacement of femoral head

http://imaging.birjournals.org/content/vol16/issue2/images/large/IMJ52497-3.jpeg

http://imaging.birjournals.org/content/vol16/issue2/images/large/IMJ52497-3.jpeg

SCFE

• Management – Orthopedic Emergency!

– Immediate hospitalization and operative fixation

– Spica hip casting for 6 to 8 weeks • Decreases risk of Femoral Neck Fracture

• Protects epiphyses

• Severe chronic Slipped Capital Femoral Epiphyses – Requires osteotomies to realign and stabilize

Osteochondritis Dissecans • Most Common Location:

• Medial Femoral Condyle • Lateral Border

• Cause • Trauma to bone • AVN, ischemia to bone

• Treatment • Activity Modification,

NSAIDs, NWB • Refer to Ortho • Classification

OCD Lesion

Osteochondritis Dissecans OCD

ITE Question

• 49. A 15-year-old male who is active in sports most of the year presents with bilateral anterior knee pain that is worse in the right knee. An examination reveals tenderness and some swelling at the tibial tubercles.

Which one of the following is true regarding this patient’s condition? A) It is almost never seen in adults B) Treatment with a straight leg cylinder cast for 6 weeks

is often needed C) Corticosteroid injection of the tibial tubercle is a safe

and effective treatment D) Radiographs should always be ordered to rule out other

conditions E) Bilateral symptoms are unusual

ITE Answer • Right answer: A • Osgood-Schlatter disease is encountered in patients

between 10 and 15 years of age. These patients are often active in sports that involve a lot of jumping. It is thought to be secondary to repetitive microtrauma and traction apophysitis of the tibial tuberosity.

• Bilateral symptoms are present in 20%–30% of patients.

• Radiographs may reveal abnormalities, but are rarely indicated in straightforward cases. This condition is usually self-limited, and most patients are able to return to full activity within 2–3 weeks.

• Treatment includes rest, ice, anti-inflammatory medications, a rehabilitation program, and an infrapatellar strap during activities. Casting and corticosteroid injections are not indicated.

• Ref: Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sports-related overuse injuries. Am Fam Physician 2006;73(6):1014-1022..

Osgood Schlatter’s Disease • Apophysitis

• Tibial Tubercle

• During rapid growth

• Treatment – Ice, NSAIDs,

– PT, stretching

ITE Question • 5. A 15-year-old white male complains of

bilateral foot pain. He does not recall any injury, and the pain improves with rest. Examination reveals tenderness over the lateral and anterior ankle, along with a rigid flatfoot, peroneal tightness, and pain on foot inversion.

• The most likely diagnosis is • A) tarsal coalition • B) stress fracture • C) plantar fasciitis • D) turf toe • E) foot sprain

ITE Answer • Right answer: ANSWER: A • Tarsal coalition is the fusion of two or more of the tarsal bones. It is

congenital, and 50% of the time is bilateral. It is asymptomatic until early adolescence. On clinical examination there is tenderness over the subtalar joint (lateral and anterior ankle), rigid flatfoot, limited subtalar motion, peroneal tightness, and pain on foot inversion. Treatment is conservative.

• A stress fracture would present with pain in the forefoot, warmth, mild swelling, and point tenderness over the affected metatarsals, most commonly the second or third. Radiographs are often negative initially, but a callus is usually evident by the third week of symptoms.

• Plantar fasciitis presents with pain in the heel or sole of the foot and is most painful with the first step after arising from bed or prolonged sitting. It may be associated with pes planus (flat foot), but in plantar fasciitis the flat foot is flexible, not rigid.

• Turf toe is inflammation of the first metatarsophalangeal joint due to acute and/or repetitive hyperextension injury resulting from sudden toe-off against an unyielding surface, such as artificial turf. The patient may present acutely with a tender, red, swollen first metatarsophalangeal joint, with pain on passive extension. Others may develop a chronic condition and present with hallux rigidus. Foot sprain is a nonspecific term for an acute ligamentous injury.

• Ref: Andrews JR, Harrelson GL, Wilk KE: Physical Rehabilitation of the Injured Athlete, ed 3. Saunders, 2004, p 370. 2) Pommering TL, Kluchurosky L, Hall SL: Ankle and foot injuries in pediatric and adult athletes. Prim Care 2005;32(1):133-161.

Tarsal Coalition

• Abnormal union between tarsal bones: – Osseous – Fibrous – Cartilaginous.

• Abnormal articulation within the mid & hind foot – Accelerated degenerative osteoarthritis

of the hindfoot and midfoot.

• Frequency approximately 1% • Males greater than females.

Tarsal Coalition • Congenital

– 2nd or 3rd decade of life

– a painful flatfoot deformity also known as "peroneal spastic flatfoot."

• Acquired can follow – Infection

– Trauma

– Surgery

– Inflammatory arthritis

Tarsal Coalition • Which bones?

– Calcaneus, talus, navicular and cuboid

• Most frequent first: – 1. Calcaneo-navicular

– 2. Talo-calcaneal, • middle facet

– 3. Talo-navicular

– 4. Calcaneo-cuboid

Tarsal Coalition

Tarsal Coalition

• X-rays - Anteater Sign

Tarsal Coalition • X-rays

Tarsal Coalition

• X-rays


Harris View

Tarsal Coalition • X-rays - CT


Reshaping Mortise Normal

Tarsal Coalition - Treatments • Calcaneo-navicular coalition:

– Interval casting: 4 - 6 week periods of casting to relieve symptoms

– Resection of the calcaneo-navicular bar: Resection is followed by fat or muscle inerposition to prevent re-unification.

• 70% report complete or near complete resolution of symptoms and do not need further intervention (Campbell's Operative Orthopedics).

– Arthrodesis: Standard triple arthrodesis, including subtalar, talo-navicular and calcaneo-cuboid joints, is performed as the definitive therapy.

• Talo-calcaneal coalition: – Interval casting – Triple arthrodesis.

ITE Question • 138. A high-school gymnast presents to your

office with a history of back pain for the past 3–4 weeks. She reports that symptoms are worse with any hyperextension activity. Examination demonstrates a hyperlordotic posture with mild tenderness in the lower lumbar spine. Radiographs demonstrate the classic “Scotty dog with a collar” appearance of spondylolysis. Which one of the following statements about this diagnosis is true?

A) Most athletes can resume full activity in 4–6 weeks B) Spondylolisthesis >25% requires referral to a spine

surgeon C) Inadequate treatment can lead to complete fracture

and spondylolisthesis with prolonged disability D) Adolescents should be followed with serial CT every

6 months until they reach skeletal maturity

ITE Answer • Right answer: C • Complete fracture and spondylolisthesis with

prolonged disability may occur if spondylolysis is not diagnosed early and treated appropriately. Most athletes respond to conservative management and return to full activity approximately 6 months after diagnosis.

• Treatment for low-grade spondylolisthesis (up to 50% slippage) is similar to treatment for spondylolysis. Patients should be followed with serial radiographs at 6-month intervals until they reach skeletal maturity.

• Patients with a high-grade slippage (>50%) may need to be co-managed by an orthopedic or spine surgeon to guide treatment and assist in return-to-play decisions.

• Ref: Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sports-related overuse injuries. Am Fam Physician2006;73(6):1014-1022.

Spondylosis/Spondylolithesis

Normal

Normal Anatomy

Traumatic

•Spondylolysis

•Spondylolithesis

Spondylolysis •Extension

•Young Athletes

•Symptoms –Pain with motion

Spondylolithesis

Spondylolisthesis

Spondylolysis

Spondylolithesis

Surgery

Treatment

•Bracing

•Physical Therapy –Strengthening

–Flexibility

–Comfort

Surgery

Restrict Activity

•No pounding activity –Jumping

–Running

–Extension

•Prevents further damage

•Keep Range of Motion

Different Types of Scoliosis

• Congenital Scoliosis

• Infantile Scoliosis

• Juvenile Scoliosis

• Idiopathic Adolescent Scoliosis – 70-80% of all cases

Congenital Causes

Pediatric Exams

KEYS • Infants and juvenile patients should

be screened during ALL well visits and newborn exams in hospital

• Must expose the back to evaluate

• Any abnormalities REFER to Pediatric Orthopedics Specialist

Where does Adolescent Idiopathic Scoliosis come

from? • We don’t know

Some things are associated with increased risk: o Female

o Family History

o Rapid Growth o like puberty

What is a Scoliometer? • A device that

measures the OUTSIDE ANGLE of their back

• And X-rays measure the INSIDE ANGLE of their back

What is a Scoliometer?

• And X-rays measure the INSIDE ANGLE of their back

• Cobb Angle

X-rays of the Spine

No two curves are alike

Bracing

• Purpose: Prevent progression of the spine curve.

• It does NOT reverse or cure the curve

Milwaukee Brace

Surgical Intervention • Here are some

pictures of a surgical correction.

Scheuermann’s Kyphosis

• Described in 1920 by Dr. Holger Werfel Scheuermann

• Excessive Kyphosis of thoracic spine

• Can run in families

• Anterior Vertebral wedging

• Not Postural Kyphosis

Scheuermann’s Kyphosis • Treatment

– Bracing

– Physical Therapy • CORE strengthening

• Hamstrings

• Spine muscles

• Strength, Flexibility, ROM

– Maintain Weight

– Surgery

Questions? • Thank You.

Thank You

the essential pediatric musculoskeletal exam

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