Peds Physical Exam Flashcards
What are the 2 vasospastic disorders
Chilblains
Raynaud’s
What is Chilblains
Localized erythema with subcutaneous swelling from cold exposure usually involving the hands, feet, ears and face in children
What is Raynaud’s
Intermittent B/L attacks of ischemia to extremities brought in by cold due to underlying vasospastic condition in the vasculature
What is the pulse rate for a child less than 1
110-160 bpm
What is the pulse rate for a child 2-5 years old
95-140 bpm
What is the pulse rate for a child 5-12 years old
80-129 bpm
What happens to pulse rate when patient has a fever or is stressed
Pedal pulse increases
What is myelinization
Maturation of neurological system once the neural tube closes
How does myelinization progress
- head to toe with head lag progression
What is the time line for the head lag progression of myelinization
Newborn; 6 weeks; 6 months
When does myelinization start
At the second trimester and goes to the 2nd decade
What is the 1st step in neural development
Neural plate forms and closes dorsally forming the CNS
What is the 2nd step in neural development
Neural Crest cells proliferate and differentiate into dorsal root, sensory and motor nerves autonomic ganglia, Schwann cell making up the PNS
What is the 3rd step in neural development
The two areas fuse at the medulla nad progress superiorly until week 7
If this doesn’t happen, anencephaly and myelomeningocele can occur
What happens between weeks 8-16 during neural development
Neural proliferation occur (teratogens and infections blocks)
What happens between weeks 12-22 during neural development
Cells migrate to specific sites creating nerve tracts
What happens at week 20 during neural development
Neurons organize, align and develop
failure can result in metal retardation and Downs Syndrome
When does myelinization of the axons start
Second trimester
When does myelinization of the cerebrum and cerebellar hemispheres start
After delivery and continues for 1st 2 decades
(Fine motor and sensory control, balance, coordination, reasoning and intelligence)
What type of movements are initiated from the cerebral cortex
Voluntary movements
Control of posture and movement
What happens at 6 months during the pediatric neural development
- head control - raising head from bed
- rolling over
- sitting - trunk stability
What happens at 7-9 months during pediatric neural development
- crawling - reciprocal limb control
What happens during 12 months during pediatric neural development
Standing - center of gravity
What happens during 1yr -18 months during pediatric neural development
Independent walking
What happens during 2 years in pediatric neural development
Bowel and bladder control
What are some components of the neonatal neuro exam
- observation
- upright position
- prone position
- eye contact
- increase in muscle tone
- presence of earl reflexes
What do you expect at 18 months in a pediatric neurological exam
Hand dominance
Begin to run, climb
What are some upper limb evaluations on the pediatric neuro exam
Assess weakness - palmar drifting
Assess cerebellum - nose touch, eyes open
Assess sensory function - nose touch, eyes closed
Evaluate tone and ROM- equal b/l
Dexterity - 9 hole peg/ring test, gait exam if walking
How do you evaluate lower limb on peds neuro exam
- compare both sides for
- limb symmetry
-muscle bulk - tone
- strength and reflexes
Which nerve root for iliopsoas (hip flexors)
L1-L3
Which nerve root for gluteal muscles (hip extensors)
L4, L5, S1
Which nerve root for quads (knee extensors)
L2, L3, L4
Which nerve root for hamstrings (knee flexors)
L5, S1, S2
Which nerve root for tib anterior (ankle DFers)
L4, L5
Which nerve root for Gastroc (PF)
S1, S2
Which nerve root for subtalar inversion
L4
Which nerve root for subtalar eversion
L5, S1
Which nerve is tested in the ankle jerk reflex
S1, S2
Which nerve is tested in the patellar jerk reflex
L3, L4
Which nerve is tested in the supination Jerk
C6
Which nerve is tested in the Triceps jerk reflex
C7
What is he primitive reflexes
Spinal reflexes
What age should you get concern when a chilling is walking or not sitting up supported
- 18 months walking
- 10 months sitting up
At what age is the cortical thumb position developmental reflex
4 months
At what age is MORO developmental reflex
5 months
At what age is asymmetric tonic neck developmental reflex
6 months
At what age is palmer/plantar grasp developmental reflex
8-9 months
At what age is stepping response developmental reflex
8 months
Differentiate Chaddocks test from Babinski test
Chaddocks - lateral malleolus
Babinski - plantar foot
When should you have a positive Babinski response
Up to 6 months
When should you see the StePPAGE reflex
Present at birth and remains
When should you see tendon jerks (eg patella, ankle)
Present at birth and continues
when should you see withdrawal reflex
Present at birth; pinprick, normal up to age 2
When should you see Landau’s reflex
From 6 mths to 2.5 years
When should you see accoustic blink reaction
Replaced by startle reflex at 4 months
When should you see tilting reflexes
Appears at 6-7 mths
Which nerve roots does the cremaster reflex test
L1. L2
What is the nerve root for the anterior thigh
L1, L2, L3
What is the nerve root for anteromedial leg
L4
What is the nerve root for the anterolateral leg
L5
What is the nerve root for the outer foot and sole
S1
What is the nerve root for the back of the leg
S2
What is the nerve root for the buttock
S3, S4, S5
How do you perform cerebella function tests
- speech - slurring
- eyes - nystagmus
- finger nose - coordination
- rapid movement - hand wrist movement
- tandem gait - walk the plank
- heel to shin - fine motor coordination
What are movement disorders for UMN lesions
- spasticity, hyper-reflexia, extensor plantar response
- Weakness of UL extensors
- Weakness LL flexors
Movement disorder of unilateral UMN lesion
One arm flexes while one leg extends
Movement disorder for B/L UMN lesion
cerebral palsy, scissor gait, knees rub, feet PF
Movement disorder for basal ganglia lesion
- tremors,
- rigidity
- flexed posture
- slow movement
- dyskenesias
Movement disorder for cerebella lesion
- speech
- ataxic gait
Movement disorders for muscle disorder
- Duchenne, polymyositis
- Presence of normal reflexes
Movement disorder of cerebrum lesion
- hypertonicity and hyperreflexia
- loss of reflex arc, purposeful movement is affected, abnormal posture leads to contracture, motor landmarks not acquired
Movement disorder in the LMN lesion
- muscle wasting
- hypotonia
- muscles denerve (loss of anterior horn cells)
- unstable, no center of gravity
Movement disorder for neuromuscular junction lesion
- fatigue: myotonia (inability to relax)
- myasthenia
Movement disorder of the peripheral nervous system and central nervous system lesion
- degeneration
- motor and sensory dysfunction/neuropathy
- tuning fork
- motor weakness and imbalance limit locomotion
What is patterned response - cord mediated response
Present at birth and involute by 2 months
- flexor withdrawal
- extensor thrust
- crossed extension
What is crossed extension in patterned response
- flex the tested limb, then flex the opposite limb; spontaneous extension of the first limb
- in extension rubbing the medial side of one foot produces abduction in the contralateral limb
What is patterned response - brain stem mediated
Involuted at 6 months
- static postural reflexes
- asymmetrical tonic reflex - supine
- symmetrical tonic reflex - prone
Flex head ventrally: UL flex LL extend
Extend head dorsally: UL extends LL felx
What are patterned responses - midbrain
Neck righting reflex
- head rotation and body follow
Disappears at 6 mths
If there is a problem with volitional control, what does that mean
CND disease, have to retrain and readapt - complete loss of voluntary muscle control
What are the detrimental factors of Bleck’s Prediction of Walking Factors
- asymmetrical tonic
- neck righting
- Symmetrical tonic
- MORO
- Extensor thrust
What are the favorable factors on the Bleck’s Prediction of Walking Factors
- foot placement
- parachute
What is the scale for Belcks prediction of walking factors
0 = good
1 = guarded
2 = poor prognosis
What are 3 specific foot and ankle problems with neurological roots
- equinus - common in CP, Duchennes, doesn’t allow swing phase, stance phase delayed, stance no heel contact, premature heel off
- hallux varus - contracture of abductor hallucis
- hallux abducto valgus - muscle and soft tissue imbalance
What are some other neurological rooted problems
- osteopenia- disuse atrophy
- fracture - equinus and calcaneal fracture
- myelomingenocele - high fracture rate
- ante torsion and internal and external torsion
What is the most common hereditary ataxia
Frederich’s ataxia
What is the presentation for Frederich’s ataxia
- worsening ataxic gait
- degenerative changes in cerebellum, worsens
- absent DTR, loss of vibratory cardiac problems
- peds cavus, TEV
- need to support the trunk and lower leg
What is Gillian Barre
- post infection demyelinating neuropathy
- respiratory infection
- pain with significant motor weakness
- drop foot - weakness occur distally (PNS)
Take care of infectious cause support the drop foot
What is myasthenia Travis
- atuoimmune
- stars with fatiguable muscle weakness
-steroid therapy or removal of thymus
What is cerbral palsy
CNS lesion
Non progressive
Global: cognitive dysfunction developmental disorder, attention deficit,
- diagnosed b 2 years
- intraventricular hemorrhage, infection, toxin, trauma
How common is spastic CP
75% of cases
Type of spastic CP
- monoplegia (single limb, rare)
- hemiplegia (both limbs on one side) b/c cerebral dominance occurs early
- diplegia - most common all four extremities, B/L, equniovalgus
- quadriplegia (total body CP, primitive reflexes remain)
/what can you do for dynamic contractures in CP
Botulinum toxin A
What can you do for equinovalgus in CP
Bracing may be difficult
Calc osteotomyq
What can you do for equinovarus in CP
Lengthen or advance Achilles tendon
Lengthen TP and TA, transfer to lateral foot
What is Type 1 and II HSMN (hereditary motor sensory neurotpathy)
Charcot Marie tooth
- feet always affected first
- clumsy presentation
- champagne legs
What is Type III HSMN (hereditary motor sensory neurotpathy)
Dejerine-Sottas
- uncommon involves the decrease in NCV (nerve conduction velocity), weakness
What is Type IV HSMN (hereditary motor sensory neurotpathy)
Refsum’s
- hypertrophic neuropathy
- first and second decades of life
What is spina bifida
- failure to close neural tube
- asymptomatic spina bifida occulta
- myelomeningocele
Which nerve roots affected in pt with spina bifida and no major problems
S2
Which nerve roots affected in pt with spina bifida and peas planus
L5-S1
Which nerve roots affected in pt with spina bifida and calcaneal deformity
L5
Which nerve roots affected in pt with spina bifida and varus, insensate foot
L4
What causes HIV
T-cell disturbance
What percentage of intrauterine transfer of HIV
80%
What are symptoms of Duchenne and Becker’s Muscular Dystrophy
- waddle gait, weak pelvic girdle, equinus and hypertrophic calves
- presents before 5 years
- delay in walking
- progressive
- WC at 12
Which is milder between Duchenne and Becker’s
Becker
Describe idiopathic toe walking
- normal finding in children up to 5
- prolonged toe walking noted in children with cognitive delays
- cerebral palsy, muscular dystrophy etc
Describe Hypotonia
Floppy CNS and connective tissue
Spinal muscular atrophy
Down’s syndrome
Describe unilateral foot deformity
Size differences
Spinal cord neuro anatomy
Describe tethered cord
Small and deformed single foot and leg
Gait disturbances
Bladder dysfunction
What are the components of a orthopedic peds exam
ARM
Attitude at rest
Relationship of component parts
Motion of joints
What are the components of he “relationship to component parts”
- thigh and body
- ankle to knee
- rearfoot to leg
- forefoot to rearfoot
What is the relationship between thigh and body
Femur assume a lateral rotation
What is the relationship of ankle to knee
Knee face anteriorly, if not, worry about torsion
What is the relationship between the rearfoot to leg
Grasp the heel and look for abnormality in sagittal and frontal planes
What is the relationship between forefoot to rearfoot
Look plantarly, met adductus or adductus
Then look at forefoot varus and valgus
What are some tests for motion of joints
Ortolani’s test - spreading the thigh to elicit “click”
Telescoping the femur - symmetry of the pelvis and thighs
What is hip ROM external:internal in kids up to 3 years old
2:1
Ex:in
External ROM decreases till 5-6 years then equalizes
What is the total ROM of the hip
More Han 100 degrees, decreases with age
What is the Ryder’s test
Test for femoral torsion
In a tibia torsional exam, when looking at the thigh-foot angle, if met adductus is present where must we use as a reference
Hindfoot
How do you check thigh-foot angle
Compare trans malleolar axis to coronal plant of the proximal tibia
For knee ROM describe frontal plane motion
Minimal frontal plane ROM
For knee ROM describe transverse plane motion
IR = ER
Describe hip ROM for up to 3 years
ER: IR
2:1
How much ankle DF is there at birth
60
How much ankle DF is there at 3 yrs
25 degrees
‘How much STJ ROM is there at birth
50 deg
How much STJ ROM is there at 3 yrs
30 deg
What are the most common foot abnormalities in peds
Calcaneovalgus
Met adductus
Equinus
TEV
What is the black grading system for met adductus
Normal (midline runs between 2nd and 3rd)
mild midline runs through 3rd
moderate midline between 3rd and 4th
severe midline between 4th and 5th
What do expect to see in a shoe of a person with calcaneal gait
Excessive heel wear
What do expect to see in a shoe of a person with pronation
Medial heel wear
What do expect to see in a shoe of a person with neurological gait
Tip of sole
What do expect to see in a shoe of a person with supinating, varus
Excessive lateral heel wear
