INFANTS

KYPHOSIS, EXPECTED CONVEX CURVATURE OF THE NEWBORN'S THORACIC AND LUMBAR SPINE

All infants are flat-footed and many newborns have aslight varus curvature of the tibias or forefoot adduction from fetal positioning

easily missed on a newborn

Fractured clavicle-evident by a lump on the collarbone caused by the callus that forms on the healing clavicle noted in the first weeks after birth

Barlow-Ortalani maneuver

hip dislocation or subluxation should be assessed during the first year of life

Using little force-test one hip at a time, stabilizing the pelvis with the other hand.

Infant supine position yourself at infants foot, and flex the hip and knee at 90 degrees

Barlow Maneuver

For the Barlow maneuver, grasp the leg with your thumn on the knee and your fingers gripping the outer thigh with fingertips resting on the greater trochanter

Adduct the thigh and gently apply downward pressure on the femur in an attempt to disengage the femoral head from the acetabulum. A positive sign is when a clunk or sensation is felt as the femoral head exits the acetabulum posteriorly

Ortelani Maneuver

Slowly abduct the thigh while maintaining axial pressure. With the fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center. If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip subluxation or dislocation

Allis sign- infants

Used to detect hip dislocatin or shortened femur-

Infant supine on the table, flex both knees, keeping the feet flat on the table and the femurs aligned with each other. Position yourself at the child's feet and observe the height of the knees. When one knee appears lower than the other, the Allis sign is positive

Infant testing strength

Hold the infant in vertical position with hands under axillae. Adequate shoulder muscle strength is present if infant maintains the upright position. If the infant begins to slip through your fingers, proixmal muscle weakness is present

Children

Young children will have a lumbar curvature of the spine and a protuberant abdomen

After 3 yo the longitundinal arch of the foot should be apparent

Metatarsus adductus should be resolved

feet will pronate slightly inward until about 30 months of age

Tibial torsion

Flex one knee 90 degrees and align the midline of the foot parallel to the femur, using the thumb and index finger of one hand, grasp the medial and lateral malleoli of the ankle; grasp the knee, placing your thumb and index finger on the same side of the leg. If your thumbs are not parallel to each other, tibial torsion is present.

residual effect of fetal positioning should resolve within several years after weight bearing

Genu Varum (Bow leg)

When the child is facing you- measure the distance between the knees when the medial malleoli of the ankles are together- present if 2.5cm one inch exists

Common until about 18mo

Genu Valgum- knock knee

 When the child is facing you- with the knees togethermeasure the distance between the medial malleoli of the ankles, present if space of 2.5cm 1 inch

Tibiogemoral articulation angle will increase in the angle or increased space between the ankles

common in children 2-4 years of age

space should not exceed 5cm 2in

Gower sign

Child raises up from sitting position placing hands on the legs and pushing trunk up

Adolescents

Spine should be smooth, with balanced concave and convex curves, no lateral curvature or rib hump with foward flexion. The shoulders and scapulae should be level with each other within 1/2 inch and a distance of scapulae of 3 to 5 inches is usual.

May have slight kyphosis and rounded shoulders with interscapular space of 5 to 6 inches

Pregnancy

Postural changes are common- fetus shifts center of gravity forward leading to increased lordosis and cervical flexion

Increased mobility and instability of sacroiliac joints and symphysis pubis as the ligaments become less tense contribute to the waddling gait

Pregnancy

Carpal tunnel syndrome is experienced by some women due to fluid retention- should resolve in several weeks after delivery

Back pain should resolve within 6 months after delivery

Older Adults

Posture may display increased dorsal kyphosis, accompanied by flexion of the hips and knees, head may tilt backwaqrd to compensate for the increased thoracic curvature

Extremities may appear long from vertebral collapse

reduction in total muscle mass is often related to atrophy; loss of nerve innervation or disuse

Osgood-Schlatter Disease

A traction apophysitis (inflammation of a bony outgrowth) of the anterior aspect of the tibial tubercle - inflammation of anterior patellar tendon

boys between 9-15

walking with a limp* knee pain with activity*

swelling aggrevated by activity-pain with palpation over tibial tuberosity

Metatarsus Adductus (Varus)

Medial adduction of the toes and forefoot restults from angulation at the tarsometatarsal joint

Lateral border of the foot is convex

A crease is sometimes apparent on the medial border of the foot

Muscle strain

temporary muscle weakness, spasm, pain, and contusion

Dislocation

pressure or force pushing the bone out of the joint

deformity or inability to use joint as usual

Rheumatoid Arthritis

A chronic inflammatory disorder of the synovial tissue surrounding the joints

Joing pain and sitffness especially in the morning or after periods of inactivity

fatigue, myalgias, weight loss, and low grade fever

synovitis & nodules

Osteoarthritis

cartilage abrasion, pitting, and thinning, the bone surfaces are eventually exposed with bone rubbing against bone

pain in hands, feet, hips, knees, and cervical or lumbar spine,

onset after 40 yo- nearly 100% affected by 75yo

joints may be enlarged due to bone growths

may have crepitus and limited, painful, range of motion

Fracture

pain limited movement cannot bear weight, swelling, felt a pop or snap with injury

can occur more easily in patients with bone disorders

deformity, edema, pain, loss of function, color changes, and paresthesia

inflammation of the synovium-lined sheath around a tendon

seen with repetitive actions - can occur in rheumatoid arthritis

pain with movement of such common sites such as shoulder, knee, heel, and wrist

point tenderness over the involved tendon

pain with active movement, and some limitation of movement in the affected joint

most often supraspinatus

pain in the shoulder and deltoid area is common, awaken pt. at night

inability to maintain a lateral raised arm against resistance may develop

tenderness over the acromioclavicular joint

grating sound on movement, crepitus, and weakness in external shoulder rotation

Clubfoot (Talipes Equinovarus)

fixed congenital foot defect of ankle and foot

most common combination of position deformities includes inversion of the foot at the ankle and plantar flexion, with the toes lower than the heel

group of genetic disorders involving gradual degeneration of the muscle fibers

clumsiness, difficulty climbing stairs, and frequent falls

muscle atrophy and weakness and waddling gait

positive gower sign(using legs to sit up)

progressive loss of function, including ability to walk

Ankylosing Spondylitis

hereditary chronic inflammatory disease, inflamed intervertebral disks and longitudinal ligaments ossify

leads to eventual fusion and severe deformity of vertebral column

develops in men between 20-40 yo

begins with low back and buttock pain

restriction in the lumbar flexion of the pt

limited range of motion of the shoulders, chest wall, hips, and knees

uveitis may present

Lumbosacral Radiculopathy (Herniated Lumbar disk)

lumbosacral radiculopathy is herniation of a lumbar disk that irritates the corresponding spinal nerve root

most common L4, L5, and S1 nerve roots

31-50 yo

heavy lifting

low back pain with radiation to the buttocks and posterior thigh or down the leg in distribution of the dermatone of nerve root

lying down relieves pain

*Spasm & tenderness over the paraspinal musculature

Potential difficulty with heel walking or toe walking

numbness, tingling, or weakness in extremity

Lumbar Stenosis

narrowing of spinal canal

pain with walking or standing upright that originate in the buttocks and then radiate down the legs

relief occur with sitting or bending forward

pain may be worsened by prolonged standing, walking, or hyperextending the back

progression, neuro exam may show lower extremity weakness and sensory loss

Carpal Tunnel Syndrome

Compression of the median nerve

repetitive motion

associated with ra, gout, acromegaly, hypothyroidism, and hormones

numbness, burning, tingling at night

radiate to arms

weakness of the thumb and flattening of the thenar eminence of the palm

reporoduction of symptoms with provocation of the TINEL AND PHALEN maneuvers

Gout

form of arthritis of purine metabolism that results in elevated uric acid level

acute inflammatory attacks- uric acid build up

sudden onset of hot, swollen joint, exquisite pain, Limited rom

men older than 40 yo and women of postmenopausal age

poximal phalanx of the great toe, wrists, hands, ankles, knees

skin over the swollen joint may be shiny and red or purple

uric acid crystals may form as tophi under the skin

Temporomandibular Joint Syndrome (TMJ)

painful jaw movement

unilateral facial pain that usually worsens with joint movement

muscle spasm and clicking, popping, or crepitus to affected joint

infection in the bone

decreased blood flow to the affected bone may lead to necrosis

dull pain develops insiduously at the involved site and progresses over days to weeks- limp or decreased movement

signs of infection include edema, erythema, warmth, tenderness on palpation, pain with movememnt, and signs of inflammation such as fever

inflammation of the bursa

repetitive movement- infection- gout

pain is usually worse during activity

limitation of the motion caused by swelling; pain on movement; point tenderness; and erythematous, warm site

soreness may radiate to tendons at the site

Paget disease of the bone

(Ostetis Deformans)

focal metabolic disorder of the bone

over 45 yo

excessive bone resorption and bone formation produce a mosaic pattern of lamellar bone

skull- vertigo and headache

bowed tibias, misshapen pelvis, prominent skull forehead, frequent fractures

avascular necrosis of the femoral head

decreased blood supply to femoral head

boys between 3-11

pain is often reffered to the medial thigh, knee, or groin

child may have a limp that is painless or antalgic

loss of internal rotation; abduction and decreased range of motion on the affected site

muscle weakness of the upper leg may be present if symptoms have been present for a prolonged period

Slipped Capital Femoral Epiphysis

femoral epipysis slips over the neck of the femur

between 8-16yo

L side is more involved than R

presents with knee pain and a limp

leg weakness and reduced internal hip rotation

Radial head Subluxation

(Nursemaid's Elbow)

dislocation injury

jerking the arm upward while the elbow is extended

jerking pulls apart the elbow joing and tears the margin of the annular ligament around the radial head into the joint

children 1-4 yo

child complains of pain in the elbow and wrist and refuses to move arm

child holds arm slightly flexed and pronated supination motion is resisted

Dupuytren Contracture

flexor hands tendons

flexion contractures develop

over age of 40 in men

flexor tendons generally contract causing fingers to curl with impaired extension

easily palpable tendons

embryologic connective tissues to form cartilage that calcifies and eventually becomes bone

long bones increase in diameter by the growth of new bone tissue around the bone shaft

increased length of long beones results from the proliferation of cartilage at growth plates

LIGAMENTS ARE STRONGER THAN BONE UNTIL ADOLESCENCE THEREFORE FRACTURES MORE COMMON THAN SPRAINS

adolescents

rapid growth during tanner stage 3

results in decreased strength in the epiphyses as well as overall decreased strength and flexibility

Bone growth completes at 20- last ephiphysis closes and becomes firmly fused to the shaft

bone density and strength continue to increase when bone growth stops

Peak bone mass is not achieved until 35yo

Pregnancy

Increased hormone contribute to elasticity of ligaments and softening of the cartilage in pelvis at 12-20 wks

Increased mobility of the sacroiliac, sacrococcygeal, and symphysis pubis joints results

Lordosis occurs in an effort to shift center of gravity back to lower extremities

ligaments and muscles of the lower spine may become stressed leading to lower back pain in many women

equilibrium between bone deposition and resorption changes- resorption dominates

menopausal women, decreased estrogen increases bone resorption and decreases calcium deposition, resulting in bone loss and decreased density

Weight-bearing bones may become predisposed to fractures

Bony prominences become more apparent with the loss of subcutaneous fat- cartilage around joints deteriorates

Older Adults

Muscle mass has increased amounts of collagen collecting in the tissues initially followed by fibrosis of connective tissue

tendons become less elastic- resulting in reduction of total muscle mass, tone, and strength

progressive decrease in reaction time, speed of movement, agility, and endurance occurs