Neuroskeletal Assessment Flashcards
What is the function of the neuroskeletal system?
- provides stability and mobility
- protects vital organs
- skeleton is flexible and joints are elastic
What elements are included in the neuroskeletal system?
includes joints, bones and supporting tissues
What are bones comprised of?
mostly comprised of cartilage; store Ca, Phos & produce RBCs
What is important to review in the infant’s prenatal history?
- oligohydramnios (amniotic fluid permits mvmt)
- breech
- abnormal growth patterns
- teratogenic agent exposure
- birth trauma
- multiple gestation
What is flexion?
bending a limb at a joint
What is extension?
straightening a limb at a joint
What is abduction?
moving a limb away from the midline of the body
What is adduction?
moving a limb toward the midline of the body
What is pronation?
facing downward
What is supination?
facing upward
What is dorsiflexion?
flexion toward the back, as in flexion of foot so that the forefoot is higher than the ankle
What is plantar flexion?
extension of the foot so that the forefoot is lower than the ankle
What is rotation?
turning as in face to the side
What is valgus?
bent outward or twisted away from the midline of the body
What is varus?
turned inward
What is everted?
turning out and away from the midline of the body
What is inverted?
turning inward toward the midline of the body
What is normal position of the term infant?
limbs flexed
legs partially abducted at hip
head turned to one side
What can extremity positioning reflect?
intrauterine positioning
How should tremors in the arms and legs with crying be interpreted?
normal in first 4 days of life
What does an infant in breech positioning typically look like?
flexed, abducted hips and extended knees; corrects with time and passive joint manipulation
What are the bones most likely to break in labor?
1) clavicle
2) humerus
How far should the neck rotate at birth?
80 degrees
What is the degree of lateral flexion of the neck?
40˙ right and left
What is the degree of anterior flexion of the neck?
chin should touch or almost touch the chest
What is the degree of extension of the neck?
occipital part of the head should touch or almost touch back of the neck
What is torticollis?
- spasmodic, unilateral contraction of neck muscles
- firm, fibrous mass or tightness appreciated mid sternocleidomastoid muscle
- 1-2cm mass (hard, immobile)
- R affected more than L
When does torticollis present?
not seen in immediate newborn peril; by 2weeks of age
What is the cause of torticollis?
birth trauma or ischemia in utero
How does torticollis present?
head tilted toward shoulder on affected side, chin rotated away from affected shoulder
How is torticollis treated?
can lead to plagiocephaly; stretching exercises can correct it
What is Klippel- Feil syndrome?
- defect of the cervical vertebrae (reduction in the # of vertebrae and fusion of 2 or more)
- neck shorter than usual
- motion is limited
- confirmation by Xray
- mistaken for torticollis
When should a fractured clavicle be suspected?
1) difficult delivery
2) irregularity in contour
3) crepitus on palpation
4) tenderness on palpation- may become edematous
What should be suspected if an infant fails to move an extremity?
1) spinal cord injury
2) brachial plexus injury
3) fracture
What is VACTERL?q
V- vertebral anomalies A- anal atresia C- cardiac anomalies T- TE fistula E- esophageal atresia R- renal anomalies L- limb anomalies
What can cause a brachial palsy?
1) traumatic delivery
2) stretching injury to brachial plexus (C5-C8, T1); traction injury on the neck from delivery
What is Klumpke’s palsy?
LOWER ARM paralysis; wrist and hand are paralyzed
- C8- T1
- no Moro, negative grasp
What is Erb’s palsy?
UPPER ARM paralysis; holds arm adducted and internally rotated with extension of elbow, pronation of forearm and flexed wrist
- C5-C6-C7
- No Moro, positive grasp
What is Horner’s syndrome?
reflects injury to sympathetic nerve at C8-T1
The symptoms occur on the same side as the lesion of the sympathetic trunk. It is characterized by myosis (a constricted pupil), ptosis (a weak, droopy eyelid), and anhidrosis (decreased sweating over the forehead)
How does phrenic nerve palsy present?
symptoms usually apparent at birth
cyanosis
increased WOB
asymmetrical chest mvmt
What percentage of brachial plexus injuries will achieve complete recovery?
30% as edema resolves
If function r/t brachial plexus injury does not return by 3 months, what long term sequela can be expected?
muscle atrophy > impaired bone growth > osteoarthritis > scapular winging > scoliosis
How do palmar creases develop?
result from intrauterine movement
How do the hands of infants with Down’s syndrome appear?
simian crease, short fingers, incurved little finger, low set thumb
What is the distance front the tip of the middle finger to base of the palm?
6.75 cm (+/- 1.25 cm)
What is macrodactyly?
enlargement of finger/ toe
- may be normal or a sign of neurofibromatosis
What should be suspected with the presentation of overlapping 2nd and 3rd fingers?
TRISOMY 18
What is clinodactyly?
crooked digits; can be a normal finding
What is syndactyly?
congenital webbing of fingers or toes; the more severe, the greater the likelihood of bone abnormalities
- fx deteriorates when multiple digits are involved
- tx depends on severity- ortho consult
What is polydactyly?
extra digits; more common in AA; familial tendency
What is the most common presentation of polydactyly?
floppy digit or skin rage on ulnar side of hand (post axial)
- tx depends on extent of anomaly
What is sprengel’s deformity?
winged or elevated scapula; one sits higher than the other
What is lordosis?
abnormal inward curvature of the lumbar and cervical regions of the spine
What is kyphosis?
an exaggerated rounding of the back
What is an occult dysraphism?
a tethered spinal cord; may be symptomatic at birth of at 2-4 years (dx more likely if 2+ symptoms present)
- lesions, dimples, hair tuft
- foot and spinal deformities
- weakness in the legs
- low back pain
- change in gait
- scoliosis
What is a plinodial dimple?
“simple dimple”; located < 2.5cm from gluteal cleft
- assess for sinus tract or observable base
What is a hamartoma?
benign abnormal growth that’s made up of the same tissues from which is grows
What is a meningocele?
usually involve more than one vertebra
- the meninges, covered by thin, atrophic skin, protrude through the bony defect
- spinal roots and nerves are all normal, neurologic deficits are unusual
What is a myelomeningocele?
congenital NTD; functional defect of the lower extremities
What is the etiology of a myelomeningocele?
occurs very early in embryologic development; caudal end of neural tube fails to close permitting meninges and sometimes spinal cord to protrude into a sac like structure
In what population does developmental dysplasia of the hip most commonly occur?
1) first born children (r/t tight uterus)
2) females (estrogen causes pelvis to be looser)
3) infants in breech position regardless of how they are delivered
How should children with developmental dysplasia of the hip be managed?
- u/s at 6 weeks and X-ray at 4 months
- does not always present in the newborn period
- all infants should be checked at every health visit for the first year
How should hips be sassed in the newborn?
1) check for stability
2) asymmetry of gluteal folds
3) Allis’ sign
4) Barlow and Ortolani maneuvers
What percentage of infants with normal hips will have asymmetric gluteal folds?
25%
How do you assess for Alli’s sign?
- feet flat on bed
- align femurs
- bend both knees
- tip of big toes in same horizontal plane
- note height of knees
- sign= one knee is higher than the other (head of femur is out of the acetabulum)
- suspect hip dislocation > shorter on one side of dislocation
What does Ortolani test for?
hip reduction- produces a reduction of a dislocated femoral head into acetabulum by abduction
(you’re assuming the hips are dislocated and you’re trying to reduce the joint)
What does a + Ortolani indicate?
feeling a distinct clunk as the femoral head repositions into the acetabulum (clicks and snaps may be heard, but not a/w pathology)
What does Barlow test for?
tests for hip dislocation by evaluating if the femoral head can be dislocated from the acetabulum with pressure
What does a + Barlow indicate?
feel a clunk over lateral edge indicating femoral head has slipped out of acetabulum
What is arthrogryposis?
describes congenital joint contractures in two or more areas of the body; “curving of joints”
What can cause ankle and foot rotational deformities?
oligohydramnios, macrosomia, multiple gestations
When does the plantar fat pad disappear?
by 1 yr of age
What is metatarsus adductus?
most common foot anomaly, will spontaneously correct; caused by intrauterine positioning; foot is turned in; can be structural- if foot cannot be brought past midline, it will not self correct
What are risk factors from club foot?
LGA, smoking in 1st trimester, early amnio (amy of fluid never fully recovers)
When is sandal toe present?
45% of trisomy 21; can be a normal variant
In infants with brachial plexus injury, what other injury should be assessed for?
5% of infants will also have phrenic nerve damage
When is “frog legged” posture considered abnormal?
> 32 weeks GA
Describe tremors/ jitteriness.
Rapid alternating movement of equal amplitude in all directions
Describe clonic movements.
as seen with sz; fast & slow components, cannot be stopped with holding; rhythmic; horizontal eye deviation
Why does sz presentation in infants differ from adults?
neurons are not as integrated with sporadic neuronal firing
When do sleep/wake cycles regulate in an infant?
< 28 weeks- hard to identify a state
longer sleep periods in preterm
cycles are more appropriate by 32 weeks
alertness readily seen by 37 wk
How is active tone assessed in the pull to sit maneuver?
have to be able to resist pull of gravity; term infant: contracts shoulder and arm muscles, flexes neck (absent < 33 wk), head comes up then falls forward
When is opisthotonus observed?
bacterial meningitis, severe HIE, tetanus, kernicterus and IVH
What is the purpose of testing deep tendon reflexes?
to assist in determining the integrity of the spinal cord and peripheral nervous system
When are deep tendon reflexes weak or absent?
1) <28 weeks
2) birth asphyxia
3) sepsis
4) encephalopathy
* * exaggerated with NAS
What does the patellar reflex test?
L2-L4; normal response- extension of knee and visible ctx of quadriceps
What does the biceps reflex test?
test C5-C6; normal response- flexion of biceps muscle
What is clonus?
rapid mvmt of a particular joint due to sudden/abrupt stretching of tendon
How much clonus is expected in a preterm and term infant?
PT < 10 beat; FT< 5 beats
*** more than 10 at any age is abnormal; sustained = cerebral irritation
When does the rooting reflex appear and disappear?
onset at < 28wks; disappears by 3-4 mos
When does the sucking reflex appear and disappear?
onset at 28 weeks- readily elicit at 32-34 weeks; disappear by 12 mos
When should the asymmetric tonic neck reflex appear?
onset at 35 weeks; absent or sustained= CNS abnormalities
When does the hand grasp appear and disappear?
onset at 28-34 weeks, disappear by 2 mod; if weak = CNS or local nerve/muscle damage
When does the plantar grasp appear and disappear?
disappears by 8-9 months; prelude to walking; if weak- lower spinal cord injury/defect
When does the babinski reflex appear and disappear?
onset 34-36 weeks, abnormal after 2yrs; evaluates spinal cord innervation- does not require a functional brain
When does the truncal incurvation reflex/ Galant reflex appear and disappear?
onset at 28 weeks, disappears by 3-4 months; if negative could be a spinal cord lesion or injury
When does the steeping reflex appear and disappear?
onset at 37 weeks, more active after 72 hours post birth
When does the Moro reflex appear and disappear?
onset at 28 weeks, disappears by 6 months
What is the Moro reflex a reaction to?
produced by suddenness of stimulus, not distance of fall
How should an asymmetric or absent Moro be interpreted?
- brachial plexus injury or upper extremity injury
- underlying CNS pathology
What is habituation?
defense mechanism enabling infant to alter response to repeated stimuli; term infant is able to control effect of surrounding environment by regulating his/her physiological and emotional response to stimuli
What is an organized infant?
infant maintains stable VS, smooth state transitions and smooth movements
What is an unorganized infant?
infant will exhibit changes in HR, color, will have sudden state changes, may become jittery and/or hypotonic
