Newborn Physical Assessment
Any family members with musculoskeletal
problems; genetic component
Weight and height
Single or multiple birth
Type of birth: NSVD, forceps, vaginal
extraction, cesarean section, shoulder
Asphyxia at birth: apgar score
Brachial Plexus Injury
Excessive traction of the spinal nerve roots C5-
Many brachial plexus injuries happen when the
shoulders become impacted during delivery and
the brachial plexus nerves stretch or tear.
Symptoms of Brachial Plexus
Limp or paralyzed arm
Lack of muscle control in arm, hand or wrist
Lack of feeling or sensation in arm or hand
Brachial Plexus Injury
Developmental Dysplasia of Hip
Developmental dysplasia of the hip is an
abnormal formation of the hip joint in which
the ball at the top of the femoral head is not
stable in the acetabulum. The severity of
instability varies in each patient. Newborns and
infants with DDH may have the ball of the hip
loosely in the socket, or the hip may be
completely dislocated at birth.
The maneuver dislocates a dislocatable hip
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.
Best done on a non-crying infant.
Adducted hip position
Reduces a posteriorly dislocated hip.
The thigh is flexed and then adducted while
pushing up with the fingers located over the
The femoral head is lifted anteriorly into the
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
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.
This would be a positive sign of developmental
dysplasia of hip in the older infant.
Limited hip abduction
Asymmetry of skin fold
Maintain hips in flexed position
Traction to stretch muscles
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
Toes angle toward the midline, creating a C-
shaped lateral foot border with a prominent
styloid process of the fifth metatarsal.
Talipes equinovarus is a congenital deformity.
Has four main components:
Inversion and adduction of the forefoot
Inversion of the heel and hindfoot
Equinus (limitation of extension) of ankle and
Internal rotation of the leg
Result of intrauterine maldevelopment of the
talus that leads to adduction and plantar flexion
of the foot.
Tips to examining the 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.
Observe child walking without shoes and with
In the toddler the stance will be wider and arms
are held out for balance.
The 3-year-old should have a more mature
Look for toe-walking
A toddler who is not walking by 15 to 18
Check to see if there is an older child in the
Ask parent is child is “cruising” or will pull
themselves up to a standing position.
Bowing of the legs
Normal up to 3 years of age
When is bowlegged considered a
Tibial-femoral angle greater than 15 degrees.
Associated internal tibial torsion
Intercondylar (knee) distance greater than 4 to 5
Joint laxity in the older child.
Figure II intercondylar distance
Physiologic valgum tends to peak at around 24
to 36 months and self corrects at about 7 to 8
Tibial-femoral angle less than 15 degrees of
valgus in a child over 7 to 8 years of age.
Intermalleolar (ankle) distance with knees
together greater than 4 to 5 inches.
Often associated with short stature.
Rule out other causes of limb deformity.
What in the history would be
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
Caused by a genetic defect that affects the
body’s production of collagen.
Collagen is the major protein of the body’s
Less than normal or poor collagen leads to weak
bones that fracture easily.
Often called “brittle bone disease”
Demineralization, cortical thinning
Multiple fractures with pseudoarthrosis
Exuberant callus formation at fracture site
Brittle Bone Disease
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
Old rib fractures
School Age Child
Inflammation of tibial tubercle, an apophysis
Cause: repetitive micro-trauma to the tibial
tubercle apophysis, which results in
inflammation, microfractures, and new bone
formation at the tubercle apophysis.
Boys ages 10 to 15 years
Girls ages 8 to 14 years
Recent physical activity: track, soccer, football,
Pain increases during and immediately after
Point tenderness pain, prominence over the
Pain with knee extension against passive
resistance or with full passive knee resistance.
R.I.C.E. - rest, ice, compression, and elevation
medications (for discomfort): Ibuprofen
elastic wrap or a neoprene knee sleeve around
physical therapy (to help stretch and strengthen
the thigh and leg muscles)
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.
Often parent states that the child seems to be
tripping over their own feet.
Observe the child’s gait.
Have the child kneel down and look at the feet
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.
90% will resolve by age 8 years
Avoid prone sleeping and sitting on feet.
Often called Baker’s Cyst are synovial lesion that
result from herniation of the synovium of the
knee joint into the popliteal space.
Swelling behind the knee with or without pain.
Occur in 13 to 18% of children
Called “leg aches”
Cause: thigh and calf muscle fatigue
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
Occurs in front of thighs, in the calves or
behind the knees.
No decreased ROM
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.
Duchenne’s Muscular Dystrophy
Difficulty rising to a standing position
Should be done with every well child physical
from about age 8 or 9.
May be referred to you after screening at school.
Lateral curvature of spine
• Pain is not a normal finding
for idiopathic scoliosis
• Often present with uneven hemline
• Unequal scapula
• Unequal hips
Unequal shoulder heights
Unequal waist angles – hip touches arm and
contralateral arm hangs free
Unequal rib heights when the child stands in a
Bowden & Greenberg
Ball & Bindler
Alert: If pain is a reported symptom of the
child’s 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.
Common Pediatric Orthopedic
Slipped Capital Femoral Epiphysis
Infection: septic arthritis
Inflammation of a joint: rheumatoid arthritis
Often called avascular necrosis of the femoral
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.
Acute or chronic onset with or without history
of trauma to the hip such as jumping from a
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
Antalgic gait with a positive Trendelenburg sign
Decreased abduction, internal rotation, and
extension of the hip
Pain on rolling the leg internally
AP Pelvis and frog-leg lateral
Slipped Capital Femoral
Upper femoral epiphysis slips from its position
in the hip joint
Most common hip disorder in the adolescent
Occurs more commonly in males
Males 10 to 15 years
Females 11 to 12 years
African American and Polynesian populations more
Acute or chronic thigh or knee pain
History of mild trauma to the hip area
Child is often large for age or overweight
Pain in groin or diffusely over knee or anterior
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
Infection within a joint or synovial membrane
Infection transmitted by:
Foreign body in joint
Erythrocyte Sedimentation Rate
Used as a gauge for determining the progress of an
Rises within 24 hours after onset of symptoms.
Men: 0 - 15 mm./hr
Women: 0 – 20 mm./hr
Children: 0 – 10 mm./hr
Administration of antibiotics for 4 to 6 weeks.
Oral antibiotics have been found to be effective
if serum bactericidal levels are adequate.
Ibuprofen for anti-inflammatory effect
Juvenile Rheumatoid Arthritis
Chronic inflammatory condition of the joints and
Often triggered by a viral illness
1 in 1000 children will develop JRA
Higher incidence in girls
Swelling or effusion of one or more joints
Pain with movement
Elevated ESR / erythrocyte sedimentation rate
+ genetic marker / HLA b27
+ RF 9 antinuclear antibodies