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Top 10 Pediatric Musculoskeletal Conditions in Primary Care

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Top 10 Pediatric Musculoskeletal Conditions in Primary Care 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 • Adolescents – Extremities – Extremities • Hips • Hip – Spine • Knees • Foot/Ankle • Juvenile – Spine – Extremities • Elbows • Shoulders • Hips – 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 • Lower Limbs – Symmetry – In-toeing – Deformities • Metatarsus Adductus – Skin Folds • Femoral Anteversion • Tibial Torsion – Fingers & Toes • Hips • Palpation – DDH • ROM • Spine • NV – Scoliosis • Special Tests 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 Hoppenfeld, Stanley, Physical Exam of Spine and Extremities, 1976. Femoral Version • Femoral Angle – At Birth 40 degrees – Maturity 15 degrees Angulation of the neck of the femur Physical Exam Hoppenfeld, Stanley, Physical Exam of Spine and Extremities, 1976. Physical Exam Hoppenfeld, Stanley, Physical Exam of Spine and Extremities, 1976. Hip Stability Tests In a newborn, both hips can Ortolani is “OUT” to “IN” be equally flexed, abducted, and externally rotated DDH may be confirmed by without producing a “click” the Ortolani “click” test. Hip Stability Tests • Barlow Hip Stability Tests Telescoping of the femur to aid in the diagnosis of DDH Galeazzi Test Asymmetry in Tibial length Femoral length Knee Height discrepancy discrepancy Spine Exams Juvenile Exam • Inspection • Upper Limbs – Symmetry – Elbow – Deformities • Little League Elbow – Growth Plates – Shoulder • Palpation • Little League Shoulder • Hips • ROM – Legg Calve Perthes • NV • Spine • Special Tests – Scoliosis 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 • Lower Limbs – Symmetry – Knees – Deformities • Osgood Schlatter • Palpation – Foot/Ankle • Tarsal Coalition • Growth Plates • Hips • ROM – Slipped Capital Femoral • NV Epiphysis (SCFE) • Special Tests • Spine – Scoliosis – Scheuermann’s Kyphosis Foot and Ankle • Inspection • Neurovascular – Asymmetry • Special Tests – Deformity – Anterior Drawer – Coloration – Talar Tilt • Palpation – Squeeze Test – Bony Landmarks – External Rotation – Growth Plates Test • ROM – Thompson Test Knee • Special Tests – Anterior Drawer • Inspection – Posterior Drawer • Palpation – Varus/Valgus – Bones – Lachman – Soft Tissues – McMurray – Ligaments – Appley’s Comp/Dist • ROM • Exam of Related • Neurovascular Area Hip • Inspection • Special Tests • Palpation • Exam of Related • ROM Area – F, E, IR, ER, ABD, ADD • Neurovascular 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 • Adolescents – Intoeing – SCFE – DDH – OCD Lesion of Knee • Juvenile – Osgood-Schlatter – Little League Elbow – Tarsal Coalition – Little League – Spondylosis/ Shoulder Spondylolisthesis – Legg Calvé Perthes – 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 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) http://www.orthoseek.com/articles/metatarsus.html 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 Run Forest Run http://www.orthoseek.com/articl es/femtorsion.html 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 Developmental Dysplasia Hip - DDH • 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 Developmental Dysplasia Hip - DDH • 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 Developmental Dysplasia Hip - DDH 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 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 Elbow • X-ray Little League Shoulder • Growth plate injury of the proximal humerus • Cause: – Overuse and repetitive microtrauma • Presentation: – Diffuse shoulder pain worse with throwing or extremes of shoulder ROM http://www.childrensmemorial.org/depts/sportsmedicine/im ages/LittleLeagueShoulder.gif Little League Shoulder Diagnosis • Plain
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