FOPC Exam Two

Fryette’s Principles

Principle I: When the spine is in neutral, sidebending to one side will be accompanied by horizontal rotation to the opposite side. This law is observed in type I somatic dysfunction, where more than one vertebra is out of alignment and cannot be returned to neutral by flexion or extension of the vertebrae. The involved group of vertebrae demonstrates a coupled relationship between sidebending and rotation. When the spine is neutral, side bending forces are applied to a group of typical vertebrae and the entire group will rotate toward the opposite side: the side of produced convexity. Extreme type I dysfunction is similar to scoliosis.

Principle II: When the spine is in a flexed or extended position (non-neutral), sidebending to one side will be accompanied by rotation to the same side. This law is observed in type II somatic dysfunction, where only one vertebral segment is restricted in motion and becomes much worse on flexion or extension. There will be rotation and sidebending in the same direction when this dysfunction is present.

Principle III: When motion is introduced in one plane it will modify (reduce) motion in the other two planes. The third principle sums up the other two laws by stating dysfunction in one plane will negatively affect all other planes of motion.

What are some ways calcium is used in the body and how do we increase/decrease this level?

PTH - increase levels

Calcitonin - decrease levels

• Calcium is used for many different functions

  • Muscle contraction

  • Nerve transmission

  • Vascular Function

  • Coagulation

  • Intracellular signaling

  • Hormonal Secretion

  • Bone Structure

Vitamin D is required of the _______________________ of the dietary calcium.

the absorption of 75%

Vitamin D Metabolism Mechanism

What is a DEXA scan used for?

To determine Osteoporosis

If your T-score is: 1 or higher, your bone is healthy. –1 to –2.5, you have osteopenia, a less severe form of low bone mineral density than osteoporosis. –2.5 or lower, you might have osteoporosis.

Most common place to take a DEXA is in the spine, hip, or femur

What are some risk factors for osteoporosis?

• Post menopausal women that are older than 65

• Post menopausal women that are younger than 65 with high risk factors

• After a fracture

  • Most common fx in osteoporosis hip, femur, wrist

• Estrogen

  • ie; hormone replacement therapy

• Low body mass index = not enough stress, not putting as much bone down, we need lipids to help absorb vitamin d

• Alcohol = drinking calories

• Tobacco = appetite suppressant

• Clinical conditions/medications = long term steriod use, proton pump inhibitors (prilosec)

Rickett’s

Vitamin D Deficiency in children

Osteomalacia

Vitamin D Deficiency in adults

Trethowan's sign

Trethowan's sign is positive in slipped femoral epiphysis. If an anteroposterior view of the hip joint is taken then a line drawn along the superior surface of the neck should pass through the femoral head. If the line remains superior to the femoral head then this is termed Trethowan's sign.

Legg-Calve-Perthes Disease

Legg-Calve-Perthes disease (also known as Perthes disease) is a rare condition in which the ball-shaped head of the thighbone (femoral head) temporarily loses its blood supply. As a result, the head of the thighbone collapses, the femoral head becomes flat, and the area becomes inflamed and irritated.

Lateral Pillar (Herring) Classification

Used for diagnosing LCPD

Ottowa Knee Rules

• Age >55 years

• Isolated patellar tenderness

• Tenderness at the head of fibula

• Inability to flex knee 90 degrees

• Inability to bear weight (4 steps) immediately after injury

Ottawa Ankle Rules

• Point tenderness over the posterior edge or tip of the malleolus

• Inability to bear weight (4 steps) after the injury

• Age >55 years

• Point tenderness at the base of the fifth metatarsal

• Point tenderness at the navicular

• Inability to bear weight (4 steps) immediately after the injury

What is the most common complaint for the PCC and ER?

Back pain

What should you worry about with Bladder or Bowel Dysfunction, Saddle anesthesia?

Cauda Equina Syndrome

What are some red flags when a patient comes in for back pain?

1. Age <20 or >50

2. History of cancer

3. Unexplained weight loss, fever, or decline in general health

4. Pain lasting more than 1 month or not responding to treatment

5. Pain at night or present at rest

6. History of IV drug use, addiction, or immunosuppression

7. Presence of active infection or HIV infection

8. Long-term steroid therapy

9. Saddle anesthesia or bowel or bladder incontinence

10. Neuro symptoms

Torticollis

It is contracture of the Sternocleidomastoid muscle, SCM, unilaterally that results in abnormal positioning of the head.

Congenital vs Acquired Torticollis

Congenital Torticollis

• Congenital muscular Torticollis is the most common kind of torticollis in children. The prevalence is 0.3%-2% of newborns in the US

• Believed to be due to intrauterine positioning or trauma to the soft tissue resulting in ischemia of the SCM and eventual fibrosis

• It occurs more often in breech presentation.

• Difficult w/ vertex delivery

• It is associated with hip dysplasia in 10-20% of affected children

• Although it is congenital, it may not appear until 2-4 weeks of age

• During the first 4-6 weeks, a firm, nontender mobile mass may appear at SCM body due to hematoma. It regresses gradually by 6 months of age

• Torticollis resolves spontaneously in most infants by 1-2 years of age.

  If it persists, surgical release of the contracted muscle may be required

Acquired Torticollis

• Much more common in older children

• Usually due to infection, like cervical lymphadenitis, retropharyngeal abscess, myositis, or even URI

• It can also happen due to trauma

• Benign paroxysmal torticollis can happen between 1-5 years of life. Familial tendency is noted

• Treatment depends on etiology

  

Scoliosis

• Any lateral curvature of the spine that measures more than 10˚ as determined on an upright posteroanterior, PA, radiograph of the spine

• Unlike Kyphosis or Lordosis which are curvatures seen on the lateral plane of the spine

• It can be congenital, neuromuscular or idiopathic

• Some scoliosis can cause secondary complications/associations such as heart disease and asthma

Types of Pars Defects

What is the most common scoliosis curve seen by physcians?

Right Thoracic Single Curve

Congenital vs Acquired Scoliosis Occurrence

• Congenital scoliosis affects boys more than girls, and is associated with other abnormalities

• Scoliosis that begins in childhood affects boys and girls equally

Scoliosis Prognosis

• Most mild idiopathic scoliosis in children resolve spontaneously

• Moderate scoliosis, 20-30 degrees needs exercise and close observation

• Severe scoliosis, > 30 degrees needs referral to Orthopedics

Brachial Plexus Palsy or “Erb’s Palsy”

• It usually occurs in cases of shoulder dystocia, Infant weight > 4 kg, diabetic mother and other causes of cephalopelvic disproportion

• C-Section and twin or triplet deliveries are protective from BPP

• The usual position of the arm is shoulder adduction, forearm pronation, wrist and fingers flexion ( Arthur)

• 80% of affected children recover completely, 20% will have some functional arm deficit

Nursemaid’s Elbow

• Subluxation of the proximal radial epiphysis due to a tear in the annular ligament at its attachment to the radius. A portion of the ligament gets trapped in the joint

• It usually happens when there is hyperextension of the forearm

• It presents with sudden extension and hyperpronation of the forearm

• It can be corrected by active hyperextension and supine positioning of the affected forearm

Polydactyly

Extra digits, Polydactyly, can be seen at the hands in one of two positions:

1. Attached to the fifth finger. It is benign and can be removed by tight suturing at the base of the digit. It falls off spontaneously in a few days.

2. Attached to the thumb. In this case, it usually is associated with other deformities, like renal abnormalities. Comprehensive evaluation should be carried out. The abnormal digit needs to be surgically removed.

Hip Dysplasia (Cause, Occurrence, Diagnosis, Treatment)

• Shallow acetabulum causes subluxation or complete dislocation of the femoral head

• Acetabulum is abnormally shallow

• Occurrence is markedly different among locations, genetics and sex.

• It occurs in females 7 times more than males due to intrauterine estrogen-induced ligamentous laxity

• Diagnosis can be done via:

  • Ortolani test: Performed to return a dislocated femoral head into the acetabulum

    Barlow test: To check to see if a normally placed femoral head is dislocatable

    Galeazzi test: to check the asymmetry of the height of the knees when the child is lying supine, and the hips are placed in 90 degrees of flexion

• Management

  • The goal of treatment is to keep the hip in abduction as early as possible so that the femoral head remains at the acetabulum.

  • The Pavlik harness is the most commonly used device worldwide

  • Closed reduction by well molded spica cast

  • Surgical correction

Hip Dysplasia Prognosis

• Depends on the time of diagnosis and severity of the deformity

• Generally, unilateral hip dysplasia has worse prognosis than if it is bilateral

Bowlegs and Knock-Knees Evaluation

• Evaluation for pathologic bowlegs is required if the intercondylar distance (i.e., distance between the knees) is more than 10 cm when the child is lying supine, and the malleoli are touching

• Evaluation for pathologic knock-knees is required if the intermalleolar distance (i.e., the distance between the ankles) is more than 10 cm with the child lying supine and the knees are touching

In-Toeing & Out-Toeing

• These deformities are the results of internal or lateral tibial torsions

• In-toeing after the second year of life is usually due to femoral internal torsion

• Out-toeing is almost always due to lateral tibial torsion

• The shape of the feet remains normal

Metatarsus Adductus & Abductus

• The forefront of the foot is curves inward along the tarso-metatarsal joint

• Occurs in 1/500 birth

• It causes in-toeing in neonates and young infants

• It is part of the clubfoot deformity

In abductus, the forefront of the foot is curved laterally along the tarso-metatarsal joint. It is rarely an isolated condition.

Clubfoot Diagnosis

• Congenital abnormality of the foot that is usually an isolated deformity or part of other neuromuscular abnormalities, amniotic band syndrome, arthrogryposis etc.

• The diagnosis is based on three conditions: forefoot varus, heel varus, and ankle equinus

• It can be a rigid or nonrigid deformity in which the forefront can be gently brought to the midline

Clubfoot Management

• Clubfoot is a pathologic condition that requires treatment since the first week after birth

• Serial manipulation and foot casting for several months is the first step

• Surgery is required in 50-75% of cases and is performed at 6-12 months of age

• Different surgical procedures “a la carte” are performed depending on the type and severity of the deformity

What conditions cause dystocia? (Dystocia = difficult birth)

Clavicle fracture, BPP, cephalhematoma = dystocia

Adam’s Forward Bend

• Purpose: Used to screen for scoliosis, a condition involving abnormal curvature of the spine.

• Procedure: The patient bends forward at the waist with arms hanging down, and the examiner observes the curvature of the spine.

Straight Leg Raise Test

• Purpose: To assess for nerve impingement or disc herniation in the lower back.

• Procedure: The patient lies on their back, and one leg is raised with the knee extended. Pain or radiation into the leg during this maneuver suggests nerve compression.

Braggard’s Test

• Purpose: A variation of the SLR test to further evaluate sciatic nerve compression.

• Procedure: Similar to the SLR test, but the examiner dorsiflexes the patient's foot (pulls the toes up) while keeping the knee extended. This may provoke pain or symptoms.

Valgus Stress Test (Knee & Ankle)

• Purpose: Assesses the stability of the knee and ankle joint by applying a valgus (inward) force.

• Procedure: The examiner applies a lateral force to the joint while stabilizing the opposite side.

Varus Stress Test (Knee & Ankle)

Purpose: Assesses the stability of the knee and ankle joint by applying a varus (outward) force.

Procedure: The examiner applies a medial force to the joint while stabilizing the opposite side.

Squeeze Test

• Purpose: Used to evaluate pain and instability in the ankle joint

• Procedure: The patient lies on their back, and the examiner compresses the thigh by squeezing. Pain or instability indicates potential issues.

Apley Distraction/Compression Test

• Purpose: Helps assess joint instability, especially in the knee.

• Procedure: Two versions - distraction (joint is pulled apart) and compression (joint is compressed). These tests are used to assess shoulder pain and instability.

Anterior Drawer Test

• Purpose: Assesses anterior cruciate ligament (ACL) injuries in the knee and ligament injuries in the ankle.

• Procedure: The examiner applies anterior force to the joint to assess for abnormal movement.

Posterior Drawer Test

• Purpose: Assesses posterior cruciate ligament (PCL) injuries in the knee.

• Procedure: The examiner pushes the tibia backward to assess posterior movement.

Lachman’s Test

• Purpose: A specific test for ACL injury.

• Procedure: The examiner stabilizes the femur while pulling on the tibia to assess anterior movement.

Ballotment Test

• Purpose: Detects knee effusion (excess fluid in the knee joint).

• Procedure: The examiner pushes the patella downward to assess for fluid movement.

McMurray’s Test

• Purpose: Detects meniscal tears in the knee.

• Procedure: The examiner rotates the tibia while extending and flexing the knee to elicit pain or clicking.

ATFL Ultrasound

Patellar Tendon Ultrasound

Medial Meniscus Ultrasound

Lateral Meniscus, Lateral Collateral Ligament, Popliteus Tendon Ultrasound

Sciatic Nerve Ultrasound

Log Roll Test

The log roll test is a physical exam technique for hip disorders. It's used to assess the integrity of the hip joint and help identify potential hip pathology such as: Labral tears, Ligament laxity.

To perform the log roll test, the examiner:

1. Grasps the mid thigh and calf

2. Gently rolls the thigh internally and externally

3. Attempts to move the limb into maximal range of motion

A positive test is pain, clicking, or popping suggesting intra-articular disease. Other positive results include:

Hip or groin pain

Clicking or crepitus

Increased or decreased joint mobility

Thomas Test

• Purpose: Assesses hip flexion contractures and identifies potential issues with the iliopsoas muscle.

• Procedure: The patient lies on their back, and one leg is flexed toward the chest while the other leg is extended. The examiner observes the angle of hip flexion and to see if the extended leg lifts.

Piriformis Test

• Purpose: Assesses the piriformis muscle for tightness or irritation.

• Procedure: The patient lies on their back with the hips and knees flexed. The examiner externally rotates the patient's hip, which can provoke pain or discomfort if the piriformis is involved.

Trendelenburg Test

• Purpose: Assesses hip abductor strength, especially the gluteus medius muscle.

• Procedure: The patient stands on one leg, and the examiner observes for a drop or tilt of the pelvis on the unsupported side.

Femoroacetabular Impingement (FAI) Test

• Purpose: Used to assess for hip impingement, which can lead to pain and limited range of motion.

• Procedure: Brings the patient's knee up to their chest, Rotates the knee inward towards the opposite shoulder, Flexes the hip and knee to 90°, Progressively rotates the hip from external rotation to internal rotation while moving from abduction to adduction, Raises the affected leg so that the knee and hip are bent at 90 degrees

Labral Loading & Distraction Test

Purpose: Assesses labral tears or hip joint instability.

Procedure: The examiner applies force to load or distract the hip joint to elicit pain or discomfort.

Scour Test

• Purpose: Helps evaluate labral tears, cartilage damage, and impingement in the hip joint.

• Procedure: The patient's hip is flexed, and the examiner applies a compressive and rotational force to the joint.

Apprehension Test

Purpose: Detects hip instability or potential dislocation in individuals with a history of hip instability.

Procedure: The examiner flexes and abducts the hip while assessing the patient's reaction to the potential sensation of instability.

FABER Test

• Purpose: Assesses hip joint mobility, pain, and potential issues involving the sacroiliac joint.

• Procedure: The patient's hip is flexed, abducted, and externally rotated, and the examiner observes for pain or discomfort.

Ober’s Test

• Purpose: Assesses the iliotibial band (ITB) tightness and tensor fasciae latae (TFL) syndrome.

• Procedure: The patient lies on their side, and the examiner assesses the ability to adduct the hip past neutral.

When asking about duration and timing during an abdominal exam you should relate it to:

Eating/drinking

Melena

Dark, tarry stools

Hematochezia

Bright, red stools

Patterns of Pain

Visceral-Precipitated by stretch of or pressure within viscera. Usually referred to midline due to innervation.

Colicky-Due to contraction of a muscular tube against an obstruction. Perceived as waxing and waning or coming in waves.

Referred-Inflammation or pathology results in pain in another location.

Parietal-Localized pain caused by inflammatory process affecting somatic nerve fibers. (Dermatomal)

Important factors when noting N/V during an Abd exam.

Onset relative to pain

Frequency

Relation to eating/drinking

Ability to tolerate intake

Presence/Absence of Blood

Hematemesis, Coffee ground

Presence/Absence of Bile

Important factors when noting diarrhea during an Abd exam.

Frequency

Consistency

Relationship to pain

Presence/Absence of Blood

Hematochezia

Melena

Acholic – grey colored stool

Amber colored stools – bile duct obstruction

Three important associated symptoms to ask when a patient presents with abdominal pain.

Fever, Chills, Weight loss

What other history is important with an abd exam?

Surgical, medical, health maintenance, medications, social, family

Auscultation for abdominal exam

• Perform before percussion or palpation

• Bowel sounds due to movement of air and fluid

• Heard as gurgling and clicks under normal circumstances

• Listen with stethoscope lightly on skin

• Listen for bowel sounds in all four quadrants

• Also listen for abdominal bruits

Describing bowel sounds

• Absent-none heard for 3 minutes

• Hypoactive-fewer than 5 sounds in a minute

• Normoactive-5 to 30 sounds in a minute

• Hyperactive-greater than 30 sounds/minute (sounds almost continuous)

• Rushes-sound of fluid being forced

• Tinkles-higher pitched sounds that occur infrequently

Tympany vs. Dullness

Tympany-underlying air

Dullness-underlying fluid, organs, or solid mass

What are signs of possible peritonitis.

• Guarding -Voluntary contraction of abdomen to protect an area you are trying to examine

• Rigidity - Involuntary contraction of abdominal wall from peritoneal inflammation, usually sustained

• Rebound Tenderness

Shifting Dullness

"Shifting dullness" is a medical term used in physical examination to assess for the presence of ascites, which is an abnormal accumulation of fluid in the abdominal cavity. Ascites is often associated with various underlying medical conditions, such as liver disease, heart failure, kidney disease, or certain cancers.

The presence of shifting dullness during this examination is suggestive of ascites. It's an important clinical sign that may prompt further evaluation, including diagnostic imaging (such as ultrasound or CT scans) and blood tests, to determine the underlying cause of ascites.

Fluid Wave Testing

• Have assistant apply pressure in midline with edge of hand

• Tap one side of abdomen firmly and feel on opposite side for transmitted pulsation

• Feeling pulsation signifies presence of ascites

• A rarely used test

• Do not perform if patient has signs of peritonitis!

• Document as “Positive Fluid Wave”

Rovsing Sign

• Used specifically to evaluate for peritoneal inflammation in right lower quadrant

• Palpate in left lower quadrant toward right side

• Ask patient where they feel it most

• If they feel it more in right lower quadrant than at site of palpation, then test is

• positive (suggests appendicitis)

• Describe as “Positive or Negative Rovsing”

Psoas Sign

Used to evaluate for inflammation adjacent to psoas muscle on right side

Two techniques-active flexion and passive stretch

Have patient flex hip with leg straight

Alternatively, have patient on left side.

Place hand on hip and extend hip.

Increased pain with either maneuver suggests appendicitis.

If positive, document as “Positive Psoas Sign”

Obturator Sign

• Used to evaluate for peritoneal inflammation in right lower quadrant and pelvis

• With hip and knee flexed, internally rotate the hip

• Increased pain in right lower quadrant suggests irritation of the internal obturator muscle by appendix

• Very low sensitivity

• Document as “Positive Obturator Sign”

Murphy Sign

• Used to evaluate for gallbladder inflammation (cholecystitis)

• With patient supine, have patient exhale completely

• Palpate under costal margin as deeply as possible, then have patient inhale

• Arrest of inspiration due to pain is a positive

• Murphy sign (tenderness alone inadequate)

Costovertebral Angle significance

1. Location: The CVAs are situated on both sides of the spine, where the 12th rib descends to meet the vertebrae of the lower thoracic and upper lumbar regions of the back. They are located on the posterior (back) aspect of the body.

2. Palpation: Healthcare professionals often perform a physical examination of the CVAs by palpating (pressing or tapping) this area. This examination is typically done to assess for tenderness or pain, particularly in the context of evaluating the kidneys.

3. Clinical Significance: Tenderness or pain upon palpation of the CVA can be indicative of various medical conditions, including kidney problems, such as kidney infection (pyelonephritis), kidney stones, or other kidney-related disorders. Pain in the CVA can also be caused by musculoskeletal issues, spinal problems, or referred pain from other organs.

4. Diagnosis: Tenderness or pain in the CVA is often evaluated alongside other clinical signs and symptoms, medical history, and diagnostic tests like urinalysis, blood tests, and imaging (such as ultrasound or CT scans) to determine the underlying cause of discomfort or tenderness.

What are some common GI symptoms in children?

• Difficulty swallowing (dysphagia) and/or painful swallowing (odynophagia)

• Abdominal pain, acute or chronic. Associated with/without indigestion, substernal discomfort, nausea, vomiting, hematemesis, anorexia, early satiety

• Changes in bowel habits

• Diarrhea, constipation

• Jaundice

Dyspepsia

is a chronic or recurrent discomfort or pain centered in the upper abdomen

It can be associated by epigastric pain, burning, postprandial fullness, satiety, bloating, nausea or belching

Delayed gastric emptying, peptic ulcer disease (PUD) or H. Pylori can cause dyspepsia

In toddlers, a crampy abdominal pain associated with elongated mass in the right abdomen suggests

intussusception

Cramping pain radiating to the flank or groin accompanied by urinary symptoms is suggestive of

nephrolithiasis

RLQ pain that migrates from the periumbilical region, combined with nausea, vomiting and loss of appetite is suspicious for

appendicitis

What can be a diagnosis of exclusion for chronic abdominal pain?

• Inflammatory Bowel Disease (IBS) is a diagnosis of exclusion

• It requires intermittent pain and changes of form and frequency of stools for 12 weeks of the preceding 12 months

• If it presents with changing bowel habits and alternating diarrhea and constipation, consider Cystic Fibrosis

• If accompanied by an elongated mass at the LLQ, it usually is due to constipation

What is due to elevated plasma bilirubin >3 mg/dl?

Icterus

Unconjugated Bilirubin occurs in:

a. Increased production of bilirubin, like in hemolytic anemia

b. Decreased uptake of bilirubin by hepatocytes

c. Decreased ability of the liver to conjugate bilirubin

Conjugated Bilirubin occurs in:

a. Extrahepatic jaundice from obstruction of the extrahepatic bile ducts, most commonly in the common bile ducts

b. Impaired excretion of conjugated bilirubin as in viral hepatitis, cirrhosis, drug induced cholestasis such as oral contraceptive, methyl testosterone, and chlorpromazine

What is the order of the pediatric abdominal physical exam?

1. Inspection

2. Auscultation

3. Percussion

4. Palpation, Light/Deep

Hirschsprung's Disease

Hirschsprung disease is a birth defect in which some nerve cells are missing in the large intestine, so a child's intestine can't move stool and becomes blocked.

How do you assess CVA tenderness?

It can be elicited by placing the palm of one hand on the CVA area and strike with the other hand on it.

What are heart murmurs?

Audible variations

What are three types of heart murmurs?

Stenotic value: obstructs blood flow & causes a characteristic murmur

Regurgitant valve: value that DOES NOT fully close

Septal defects: abnormal opening btw heart chambers (ASD, VSD, PFO patent foreman ovale)

What makes the following sounds: S1, S2?

S1: mitral and tricuspid valve closure, systole

S2: Aortic & Pulmonary valves close, diastolic

Where is the best place to access the jugular venous pressure?

R internal carotid vein

Where is the point of maximal impulse?

5th intercostal space

7-9cm lateral to midsternal line

Classification of murmurs

1. Innocent - No detectable anomaly

2. Physiologic - related to demand supply ie: anemia, pregnancy, fever

3. Pathologic - tangible cardiac disorder ie: valvular lesions

Who is the father of the ECHO?

Inge Elder

Where do you hear the heart valves?

1. Aortic, right 2nd intercostal space

2. Tricuspid, right 5th intercostal space

3. Pulmonary, left 2nd intercostal space

4. Mitral, left 5th intercostal space