Peds Flashcards
Practice: How to Use the Pirani Score (Clubfoot Assessment)
The Pirani Score is a clinical tool used to assess the severity of clubfoot deformities. It evaluates specific criteria based on the position of the foot.
Steps to Perform the Test
1 Posterior Crease
Check for deep creases at the back of the heel.
Score 1 if deep, 0.5 if shallow, 0 if absent.
2 Empty Heel
Feel for the heel pad. If it’s atrophied or poorly developed, it gets a higher score.
3 Rigid Equinus
Assess the ability to dorsiflex the foot.
If rigidly plantarflexed, it’s a 1.
4 Medial Crease
Check for deep creasing along the medial side of the foot.
A deep crease = 1, shallow = 0.5, none = 0.
5 Curved Lateral Border
Look at the shape of the foot’s outer edge.
More curved = higher score.
6 Lateral Head of Talus
Feel the lateral head of the talus near the ankle.
If it’s prominent and easily felt, it gets a higher score.
Scoring:
The total score can range from 0 to 6, where:
0: No deformity.
1-3: Mild deformity.
4-6: Severe deformity.
The Pirani Score helps monitor progress and plan treatment.
Practice: Generic Whole Body Assessment of a Newborn
When assessing a newborn, including their spine, neck, hips, and feet, the goal is to detect any abnormalities or deformities.
Spine:
Inspect the alignment of the spine. Look for curvature (e.g., scoliosis or kyphosis). The spine should have a natural C-shaped curve in the lumbar region in infants.
Gently palpate the spine to check for any lumps or abnormalities.
Neck:
Turn the baby’s head gently to each side and observe the range of motion. There should be no resistance to turning, and the neck should not be stiff.
Check for muscle asymmetry (e.g., torticollis), where the neck muscles are tight on one side, causing the head to tilt.
Check for clavicular fractures, which can occur during delivery.
Hips:
Assess for hip dysplasia (dislocated or misaligned hips). Perform the Barlow and Ortolani tests:
Barlow test: Gentle pressure applied to the hips to check for dislocation.
Ortolani test: Push the hip joint back into place if it’s dislocated.
Check for asymmetry of the leg lengths or abnormal skin folds in the thighs.
Feet:
Assess for clubfoot (CTEV) or any other foot deformities such as metatarsus adductus or flat feet.
Check for movement of the foot and toe alignment.
Look for skin integrity and any signs of pressure sores from abnormal positioning.
Practice: How to Assess a Newborn Foot
Steps for Newborn Foot Assessment:
Visual Inspection:
Look for any deformities in the foot, including inversion (turning inward), equinus (downward pointing), and adduction (inward turning of the forefoot).
Compare both feet to ensure that the deformity is present in one or both feet.
Check for skin discoloration or redness, especially if there’s a tight cast in place.
Palpation:
Gently feel the bones and joints of the foot. Look for any rigidity or resistance to movement, which can indicate stiffness due to abnormal muscle tone.
Feel the Achilles tendon for tightness, as it is often contracted in CTEV.
Movement:
Range of motion: Gently test the range of motion in the foot, checking for flexibility. In a normal foot, the foot should be able to dorsiflex (move upward) and plantarflex (move downward) without resistance. In clubfoot, there will likely be limited dorsiflexion.
Manipulate the foot gently to see if the position can be corrected passively. If the foot cannot be easily moved into a neutral position, this may indicate more severe clubfoot.
Check for other deformities:
Assess for signs of other congenital conditions that may be associated with CTEV, especially if the baby has a syndromic form of the condition.
Congenital Talipes Equinovarus (CTEV)
What is Congenital Talipes Equinovarus (CTEV)?
Congenital Talipes Equinovarus (CTEV), commonly known as clubfoot, is a birth defect where a baby’s foot or feet are turned inward and downward. It is one of the most common musculoskeletal deformities seen in newborns.
The condition involves structural abnormalities of the bones, muscles, and tendons in the foot, and it can occur in one or both feet.
Congenital Talipes Equinovarus (CTEV)
How Does it Occur?
CTEV typically occurs due to abnormal development of the foot and ankle during pregnancy. It can be caused by a variety of factors, including:
Genetic factors: Family history of clubfoot increases the likelihood of the condition.
Environmental factors: In some cases, the condition may develop due to factors such as abnormal fetal positioning, lack of amniotic fluid (oligohydramnios), or intrauterine constraint.
Neuromuscular factors: Abnormal development of the nerves and muscles controlling the feet can contribute to CTEV.
Congenital Talipes Equinovarus (CTEV)
When Can It Occur?
CTEV is a congenital condition, meaning it is present at birth. The deformity occurs in utero, during the fetal development stage.
Congenital Talipes Equinovarus (CTEV)
Who Does It Affect?
Incidence: CTEV affects about 1 in 1,000 live births. It is more common in males than females (approximately 2:1 ratio).
It may affect one or both feet. If both feet are involved, the condition is usually more severe.
Genetic predisposition: A family history of the condition increases the likelihood of it occurring in other siblings or future generations.
Congenital Talipes Equinovarus (CTEV)
How Does It Present?
Appearance of the foot: The foot is pointed downward (equinus), the heel is turned inward (varus), and the forefoot is turned inward (adduction). The arch of the foot is also collapsed or absent.
The Achilles tendon is tight, and the muscles on the inside of the foot and lower leg may be shortened.
In severe cases, the foot may appear rigid, and the skin over the foot and ankle can be stretched.
Congenital Talipes Equinovarus (CTEV)
What Are the Different Types of CTEV?
There are three main types of congenital talipes equinovarus:
Idiopathic (Primary) CTEV:
This is the most common form and is not associated with any other condition.
It occurs without an identifiable cause and is usually seen in otherwise healthy babies.
Neurogenic CTEV:
This form of CTEV is associated with neurological disorders, such as spina bifida or cerebral palsy.
There may be nerve damage that leads to abnormal foot positioning.
Syndromic CTEV:
This occurs as part of a genetic syndrome, such as arthrogryposis or Edwards syndrome.
It is often associated with other congenital anomalies.
Congenital Talipes Equinovarus (CTEV)
How is CTEV Treated?
The goal of treatment is to correct the deformity and allow the foot to develop normally. There are various treatment approaches:
Non-surgical methods:
Ponseti method: This is the most common and effective method for treating CTEV. It involves:
Serial casting: The foot is gently manipulated and placed in a cast to stretch the tissues and gradually correct the position.
Achilles tendon lengthening: If needed, the Achilles tendon is lengthened through a small surgical procedure to allow for proper dorsiflexion.
Bracing: After the casting phase, the child wears braces to maintain the corrected position and prevent relapse.
Surgical intervention:
If the Ponseti method does not work or if the condition is severe, surgery may be needed.
Surgery typically involves:
Tendon lengthening.
Soft tissue releases.
Bone surgery in extreme cases.
Physical therapy: Once the foot is corrected, physical therapy can help with strength and range of motion.
Plagiocephaly
What is it?
Plagiocephaly is the condition where a baby’s head develops an asymmetrical shape, typically a flat spot on one side of the head.
It is often referred to as flat head syndrome.
Plagiocephaly
How does it occur?
Positional Plagiocephaly usually occurs when an infant spends a lot of time lying on their back, putting pressure on one side of their head. This can cause flattening of the skull.
It can also occur in the womb due to limited space or positioning (e.g., breech position or multiple births).
Torticollis (tightening of the neck muscles) can also contribute to plagiocephaly by causing a baby to favor one side of the head.
Plagiocephaly
When can it occur?
Plagiocephaly typically develops within the first few months of life, while the skull is still soft and malleable. It can begin in the first 6 to 8 weeks of life.
Plagiocephaly
Who does it affect?
Plagiocephaly is most common in healthy infants under 6 months of age. It affects approximately 1 in 5 babies.
Premature babies or babies with limited movement due to physical challenges or conditions (e.g., torticollis) are at higher risk.
Plagiocephaly
How does it present?
A baby with plagiocephaly may have a flat spot on one side of the head, typically near the back of the skull.
The ear on the affected side may appear to be pushed forward.
The forehead on the flattened side may protrude slightly.
If torticollis is also present, the baby’s head may be tilted to one side, and the baby may prefer to turn their head to one side more than the other.
Plagiocephaly
How is it treated?
Positioning: Change the baby’s head position while sleeping and when awake (tummy time is especially important).
Physical therapy: If the baby has torticollis, stretching exercises and positioning techniques may be prescribed.
Helmet therapy: In severe cases, helmets may be used to help reshape the skull as the baby’s head grows.
Surgery: This is rarely needed but may be considered in cases that do not respond to other treatments.
Torticollis
What is it?
Torticollis is a condition where a baby’s neck muscles become tight, causing the head to tilt to one side, often with the chin turning to the opposite side.
It is also called wry neck or cervical dystonia in adults, but in infants, it often presents as congenital muscular torticollis.
Torticollis
How does it occur?
Torticollis in babies can occur due to a tightened sternocleidomastoid muscle (SCM) in the neck, which causes the head to tilt to one side.
The cause of this muscle tightening is not always clear but can be associated with:
Birth trauma (such as forceps delivery).
Positioning in utero (such as breech position or crowded womb).
Muscle strain during birth or early development.
Torticollis
When can it occur?
Torticollis is present at birth or develops within the first few weeks of life, often before 2 months of age.
Torticollis
Who does it affect?
Torticollis affects about 1 in 250 to 300 infants.
It is more common in babies who had a difficult birth or were breech.
Torticollis
How does it present?
The baby’s head may be tilted to one side, with the chin pointing to the opposite side.
The sternocleidomastoid muscle on the affected side may feel tight or enlarged.
The baby may have difficulty turning their head to one side or may prefer to turn only one way, leading to asymmetrical head positioning and possibly contributing to plagiocephaly.
The baby may show signs of neck stiffness or limited range of motion in the neck.
Torticollis
How is it treated?
Physical therapy: The primary treatment is stretching exercises to help lengthen the tight SCM muscle. This is often done by a pediatric physical therapist.
Positioning: Encourage tummy time and adjust the baby’s positioning to avoid prolonged pressure on one side of the head.
Surgical intervention: In rare cases, if physical therapy is ineffective, surgery may be needed to release the tightened muscle.
Practice: How to Assess a Baby for Plagiocephaly and Torticollis
Visual Inspection:
Look at the baby’s head from different angles to assess for asymmetry or flattening. Note if the forehead or ears are misaligned on one side.
Check for tilting of the head or neck stiffness, especially when the baby is in an upright or seated position.
Look for any flattening of the skull (posterior or lateral), as well as asymmetry in the face or head.
Palpation:
Feel the baby’s neck muscles. The sternocleidomastoid muscle (SCM) on one side may feel tight or enlarged in cases of torticollis.
Gently palpate the skull to check for any flattened areas or raised areas.
Range of Motion:
Gently turn the baby’s head from side to side. A normal baby will turn their head freely to both sides. If the baby has torticollis, the head may only turn to one side, with stiffness or resistance on the affected side.
Test lateral flexion by trying to tilt the head from shoulder to shoulder. Note if there is any limitation in movement.
Observing Posture:
Observe the baby’s usual head and body posture. If the baby consistently holds their head to one side or tilts it, this may indicate torticollis.
Look for a flat spot on the baby’s head or any signs of favoring one side of the head during sleeping or resting positions.
Practice: How to Advise a Parent to Encourage Head Turn to the Non-Preferred Side
Tummy Time:
Encourage daily tummy time when the baby is awake. This helps strengthen the neck and shoulder muscles and promotes better head control.
Start with a few minutes each session and gradually increase the duration as the baby gets stronger.
Positioning during Sleep:
While the baby is awake, alternate the direction they face in their crib or bassinet. Ensure the baby is encouraged to turn their head to both sides by placing toys or a mobile at different positions to the left and right.
If the baby has a flat spot on one side of the head, avoid lying them on that side too often and gently encourage them to turn their head the other way.
Encourage Movement:
Place toys to the opposite side of the baby’s preferred head position to encourage the baby to turn their head.
Try lying the baby on their side for short periods (when awake) to encourage them to hold their head up.
Feeding Position:
During breastfeeding or bottle-feeding, vary the position of the baby to encourage head turning. For example, switch sides to encourage the baby to turn their head to both sides during feeding.
Monitoring Progress:
Advise the parents to keep track of the baby’s head position and consult with a healthcare provider if there is no improvement or if the baby continues to have significant difficulty turning the head.
Developmental Hip Dysplasia (DHD)
What is it?
Developmental Hip Dysplasia (DHD), also called hip dysplasia or congenital hip dislocation, refers to a condition where the hip joint does not develop properly in infants and young children.
In this condition, the ball (femoral head) and socket (acetabulum) of the hip joint do not fit together properly. This can lead to the femoral head being partially or fully dislocated from the acetabulum.
Developmental Hip Dysplasia (DHD)
How does it occur?
DHD occurs when the hip joint is loose or not properly aligned during fetal development or shortly after birth.
This can happen due to:
Genetic factors: A family history of hip dysplasia increases the risk.
Positioning in the womb: Breech position (where the baby is positioned with feet first) is one of the most common causes.
Hormonal influences: Relaxin, a hormone produced during pregnancy, can cause the ligaments to be more relaxed, contributing to the looseness of the hip joint.
First-born children: The risk is higher for first-born babies, possibly due to a more confined space in the womb.
Swaddling: Tight swaddling of the baby’s legs can restrict hip movement, increasing the risk of hip dysplasia.
Developmental Hip Dysplasia (DHD)
When can it occur?
Developmental Hip Dysplasia typically occurs during pregnancy or early infancy, when the hip joint is still developing.
The condition can either be present at birth or develop within the first few months of life.
Developmental Hip Dysplasia (DHD)
Who does it affect?
DHD affects about 1 in 1,000 to 1 in 2,000 newborns, but the incidence is higher in firstborn babies, female babies (due to their wider pelvis), and breech births.
It is more common in female infants, with a ratio of about 6:1 compared to males.
Developmental Hip Dysplasia (DHD)
How does it present?
In mild cases, there may be no immediate signs, and the condition may be noticed during a routine check-up.
In severe cases, the femoral head may be fully dislocated, and the baby may have:
Asymmetry in the legs (one leg may appear shorter than the other).
Uneven skin folds in the thigh or buttock.
Limited range of motion in the hip joint, especially abduction (moving the leg away from the body).
A clicking or clunking sound when the hip is moved (in cases of partial dislocation).
Limping or walking on tiptoes may appear in older children who have undiagnosed or untreated DHD.
Developmental Hip Dysplasia (DHD)
How is it treated?
Early diagnosis and treatment are crucial for the proper development of the hip joint.
Pavlik Harness:
For infants under 6 months, the Pavlik harness is often used to keep the hips in a flexed and abducted position, allowing the joint to develop correctly.
The harness is worn full-time for 6-12 weeks.
Closed Reduction:
If the Pavlik harness does not work, or if the baby is older than 6 months, a procedure called closed reduction may be performed. This involves manipulating the hip back into its socket without surgery.
Open Reduction:
In severe or older cases, where the joint cannot be repositioned manually, surgical intervention (open reduction) may be required to realign the hip joint.
Spica Cast:
After surgery, a spica cast is used to immobilize the hips and legs and maintain the correct position while healing.
Physical Therapy:
After successful treatment, the child may need physical therapy to strengthen the muscles around the hip and improve mobility.
Practice: How to Assess a Baby for Developmental Hip Dysplasia
When assessing a baby for developmental hip dysplasia, it’s important to conduct a thorough clinical examination, focusing on the baby’s hips, legs, and range of motion.
Visual Inspection:
Observe for asymmetry in the thighs, buttocks, and legs. This may include:
Uneven skin folds: Check for asymmetry in the skin folds around the thighs or buttocks, which may indicate hip dislocation.
Leg length discrepancy: The affected leg may appear shorter than the other, particularly in cases of dislocation.
Look for signs of limp or altered walking patterns in older infants or children, which may suggest undiagnosed DHD.
Palpation:
Gently palpate the baby’s hips and legs, feeling for any unusual bumps, clicks, or lack of mobility in the joint.
Feel for increased tightness or resistance during hip movements, particularly in abduction (moving the legs outward).
Movement:
Check the range of motion:
With the baby relaxed and, on their back, gently flex and abduct each hip to check for any restriction in movement.
Passive abduction should bring the thighs apart easily, with no resistance. A lack of abduction or restricted motion may indicate hip dysplasia.
Perform the Ortolani and Barlow tests (explained below) to assess for dislocation or instability in the hip joint.
Practice: How to Assess a Baby for Developmental Hip Dysplasia
When assessing a baby for developmental hip dysplasia, it’s important to conduct a thorough clinical examination, focusing on the baby’s hips, legs, and range of motion.
Visual Inspection:
Observe for asymmetry in the thighs, buttocks, and legs. This may include:
Uneven skin folds: Check for asymmetry in the skin folds around the thighs or buttocks, which may indicate hip dislocation.
Leg length discrepancy: The affected leg may appear shorter than the other, particularly in cases of dislocation.
Look for signs of limp or altered walking patterns in older infants or children, which may suggest undiagnosed DHD.
Palpation:
Gently palpate the baby’s hips and legs, feeling for any unusual bumps, clicks, or lack of mobility in the joint.
Feel for increased tightness or resistance during hip movements, particularly in abduction (moving the legs outward).
Movement:
Check the range of motion:
With the baby relaxed and, on their back, gently flex and abduct each hip to check for any restriction in movement.
Passive abduction should bring the thighs apart easily, with no resistance. A lack of abduction or restricted motion may indicate hip dysplasia.
Perform the Ortolani and Barlow tests (explained below) to assess for dislocation or instability in the hip joint.
Practice: How to Explain the Ortolani Test
Ortolani Test
Purpose: The Ortolani test is used to detect hip dislocation (specifically, a hip that is already dislocated but can be reduced into place).
How to perform:
Place the baby on their back, with the legs bent at a 90-degree angle at the hips and knees.
Place your fingers on the baby’s greater trochanter (the outer part of the thigh bone) and thumbs on the inner thigh near the groin.
Gently abduct (move the legs outward) while pushing the femoral head gently into the socket.
Listen for a “clunk”: If you feel or hear a clunk or click, the hip has been relocated into its proper position. This indicates hip instability or a dislocated hip.
If there is no clunk, the hip is likely not dislocated.
Practice: How to Explain the Barlow Tests
Barlow Test
Purpose: The Barlow test is used to detect hip instability (whether the hip can be dislocated from the socket).
How to perform:
Place the baby on their back and flex the legs at the hips and knees at about a 90-degree angle.
Hold the baby’s thigh and gently adduct (bring the legs together).
Apply gentle pressure with your thumbs on the inner thigh towards the hip joint.
If the hip dislocates, you may feel a laxity or movement as the femoral head slips out of the socket.
If the hip does not dislocate, the Barlow test is negative, meaning the hip is stable.
Interpreting the Results:
A positive Ortolani test (clunking sound as the hip relocates) combined with a positive Barlow test (hip can be dislocated) indicates hip dysplasia.
If either test is positive, further imaging (such as an ultrasound or X-ray) is recommended to confirm the diagnosis.
