Pearls and Pitfalls of the Pediatric Musculoskeletal Examination

Andrew Howard

Martin Herman

Michael Wolf

• Introduction

The clinical history and physical examination are the basis for diagnosis. The clinic visit is also used to establish rapport and trust, to convey information, to assess understanding, to advise about treatment options, and to assist in making a treatment decision.

Pediatric musculoskeletal conditions range from trivial to significant, can involve any part of the body, and can present before birth or in fully grown young adults. In addition, a full spectrum of pathophysiology includes congenital abnormalities, developmental conditions, infections, benign and malignant tumors, neurodevelopmental conditions, syndromes, genetic and metabolic diseases, inflammatory problems, and of course traumatic conditions. The children with these conditions may have developmental differences or medical comorbidities. Children are seen with parents or caregivers representing the entire spectrum of adults and the entire spectrum of family and social circumstances.

Pearl: In pediatrics, the family and caregivers are an inseparable part of evaluation of a patient.

Pitfall: Do not address the parents and ignore the patient. This is important at all ages, not just teens!

• What You Know Before Entering the Room

Most orthopedic consultations start with information in hand—sometimes considerable information. This comes from the referring physician, the medical charts, and existing imaging studies. In many cases, the definitive diagnosis may be made by reviewing radiographs or other studies before seeing the patient. This is no way reduces the importance of taking a history and performing a clinical examination, although it may guide the process considerably. Even if you think you know what is wrong with the patient, you need to confirm that the diagnosis you are considering matches the patient’s concerns and that it is correct. Some diagnoses need to be made on the first encounter and acted on immediately to prevent the patient from further harm. These include child abuse, septic arthritis, slipped epiphysis, and malignant tumors. A table outlining key features on history and physical examination is provided (Table 3.1).

Pearl: Every diagnosis is a “working” diagnosis—question, confirm, and verify!

Pitfall: What is the easiest diagnosis to miss? The second one…

Do not miss an asymptomatic contralateral slipped epiphysis.

Do not miss a second spinal/cervical spine fracture in a trauma patient.

Table 3.1 Do Not Miss Diagnoses in Children’s Orthopedics, With Key Findings on History and Physical Examination

	HISTORY	PHYSICAL EXAMINATION	OTHER
Slipped capital femoral epiphysis	Insidious onset of painful limp in adolescent	Shorter stance phase Trendelenburg lurch toward the affected side Externally rotated foot progression Obligatory external rotation of thigh with passive hip flexion Pain with hip IR	Usually more evident on lateral than anteroposterior view Contralateral hip involved in 20% at presentation MRI may be required for “preslip”
Child abuse	May be inconsistent with injury seen, vague, or changing May have multiple health care or injury visits Developmentally disabled child Psychosocial stressors Unrelated adult caregiver, stepparent	Skin injuries Patterned injuries Burns Bruising Oral injury Genital injury Apprehensive or hypervigilant child	Multiple fractures “Corner” metaphyseal fractures Rib fractures Skull fractures Any pattern of long bone injury that does not fit the reported mechanism
Malignancy	Limb pain not associated with activity Night pain Enlarging mass Weight loss Fever, unwellness, constitutional symptoms	Deep, firm, fixed mass Warm Hypervascular May be tender	Bony destruction Reactive bone formation
Septic arthritis (hip)	Limb pain or disuse in an unwell child or infant	Limb held flexed and externally rotated Febrile Will not weight bear Toxic appearing Pain with ranging hip, especially extension, IR	High white cell count, ESR, CRP Not all findings present in early cases

• Who Is Who?

Children rarely come alone and sometimes come with a considerable entourage. Introduce yourself to the child first, and tell them briefly what will happen in the visit. Then ask who is accompanying the child to introduce themselves, and establish their relationship to the child. This can be done in a confirmatory manner if the chart is open, for example say “and are you Wendy, Peter’s mother?,” or you may simply ask. If there are a lot of people in the room and/or relationships are unclear, just ask.

Pearl: Doctors may also come with an entourage! Introduce yourself, state your role in the team, and introduce the rest of the team who are or will be there.

Pitfall: Family structures are varied, complex, fluid, and may be unstable or dysfunctional. Know who is who!

• Language

Having an interpreter present, or using a phone link to an interpreter service, is very helpful for understanding medical concepts for many people who have English as a second language. Ideally, this is arranged beforehand but now is a good time to ask if an interpreter is desired.

Pearl: In the interest of clinic efficiency, consider having a another team member articulate the assessment and plan with the aid of a translator. Let the family know you will be back at the end to confirm all questions are answered.

Pitfall: Even if a relative has come as an interpreter, it is often better to use a neutral, professional interpreter instead. Some hospitals require a certified medical translator for all of these clinics.

• Developmental Delay

Developmentally delayed children always communicate, even if it is limited to parents interpreting gestures or expressions. Some have considerable scope for detailed expression and/or have tremendous receptive language. Address the child first, as you would a child with evidently normal development. If appropriate, then ask the caregiver how does the child communicate best. Everybody has heard of people with disabilities creating sophisticated art and literature—remember that you may be meeting such a child.

Pearl: Developmentally delayed children may have substantial ability to communicate, even if not readily apparent.

Pitfall: In families with high medical need children, the siblings can often be ignored and may spend their childhood living in the shadow of their sister or brother. Say hi to them, and engage them if only for just a short bit.

• The Uncooperative/Crying/Anxious Toddler

Toddlers and behaviorally challenged children can be difficult to evaluate and anxiety (stranger danger) will demand that the clinician have a stealthy approach to examining the uncooperative or crying child. Observational examination begins as the child walks through the hall to the clinic room and may be most useful, especially with props and toys (

Video 3.1). In children with obvious fear, it may be beneficial to keep the clinic door open in order to reduce anxiety. It may be best to stand in the doorway, avoid eye contact, and completely ignore the child and talk with the parents. Many components of the examination can be passively observed and elicited by playing with child, which may also settle him or her down. When it becomes time to examine the child, engage a parent or sibling and perform a basic examination (eg, internally and externally rotating a hip) on one of these family members. Once the examination begins, always start at unaffected areas away from the site of the chief complaint. A forceful examination or examination with patient restrained by parents is not effective and potentially leads to missed diagnosis. However, be careful not to obtain insufficient information by evaluating a patient on a parent’s lap (

Video 3.2).

Pearl: Remember you can have the family return at a later date in those instances where the child is completely uncooperative and the examination is critical in the decision-making process.

Pitfall: Hip internal and external rotation is best documented in the prone position, which makes toddlers nervous. You can get the same information by having the child lay supine (where they can watch you) with their knees flexed over the edge of the bed.

• Chief Complaint

In older less anxious children, first ask why they have come to clinic, even if it is obvious that the parent will have to answer for them to get the real information. An engaged, interested child who feels involved often warms up and interacts more readily and without fear or apprehension. Asking a few questions like
how old are you or who are your brothers and sisters will engage a younger child in a nonthreatening and familiar manner. With a teenager, we explore the chief complaint more fully before turning to the parent for their own perspective. After speaking with the child, ask their permission, or tell them, that you are going to ask the parent(s) some questions as well. Include both parents. Different people have different concerns. Try to find out what concern, expectation, or meaning is attached to the condition.

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