Chapter Outline
Recognizing Deformities 25
Joint Range of Motion 27
Muscle Strength 43
Neurologic Assessment 44
This chapter covers virtually all aspects of the general musculoskeletal and neuromuscular examination of the neonate, infant, child, and adolescent. Because proper function of the musculoskeletal system depends on proper functioning of the neurologic system, the boundary between orthopaedics and neurology is often blurred at the diagnostic level.
The orthopaedist is frequently the first to be consulted for clumsiness or delayed walking in a child, conditions that may be due to static encephalopathy or muscular dystrophy. Malfunction of the neurologic system can also have a significant impact on the child’s developing skeletal system. For example, muscle imbalance resulting from cerebral palsy, myelomeningocele, or spinal cord injury may lead to scoliosis or dislocation of the hip joint. Thus the pediatric orthopaedist must not only be familiar with examination of the musculoskeletal system but also knowledgeable about the neurologic examination of the child at different developmental stages. The form used at Texas Scottish Rite Hospital for Children to record the principal findings of the initial orthopaedic examination is provided in Appendix 3-1 .
Recognizing Deformities
The examiner should look for signs of musculoskeletal deformity, determine what type of deformity exists, and ascertain its exact location. If deformities exist, specific tests can help reveal them. Answers to the following questions will help accomplish this goal:
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Is the deformity in the bones, the joints, or the soft tissues?
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How severe is the deformity?
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Is the deformity fixed, or can it be passively or actively corrected?
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What factors are causing the deformity?
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Is there associated muscle spasm, local tenderness, or pain with motion?
Angular Deformity
The description of angular deformities should specify the site of the deformity and the position of the distal segment of the deformity relative to the proximal portion. The specific location of the deformity is denoted by its anatomic name, such as cubitus (elbow, forearm, ulna), coxa (hip), genu (knee), or pes (foot). The direction of the deformity is designated as either valgus or varus, terms that define alignment in the coronal plane.
Valgus denotes an angulation away from the midline of the body distal to the anatomic part named (i.e., the distal segment is deviated away from the midline). In cubitus valgus, the forearm is directed away from the midline, distal to the elbow. Approximately 10 to 15 degrees of cubitus valgus, or “carrying angle,” is normal. In coxa valga, the angle between the femoral neck and shaft is greater than normal and the distal segment is angled away from the midline.
Varus describes an angulation toward the midline of the body distal to the anatomic part named (i.e., the distal segment is deviated toward the midline). In cubitus varus, the forearm is bent inward toward the midline of the body, distal to the elbow, whereas in coxa vara, the angle between the femoral neck and shaft is smaller than normal and the distal segment is angled toward the midline.
Angular deformities are measured in degrees and are most accurately recorded using a hinged goniometer. With experience, the orthopaedist may be able to estimate angular measurements accurately, but more reliable measurements are usually obtained with a goniometer. However, when bony landmarks are not clear because of excess soft tissue coverage or other causes, the goniometer may give inaccurate results. If necessary, the examiner can gauge angles by visually dividing a 90-degree arc of motion into two 45-degree segments or three 30-degree segments and projecting the observed angle into these arcs. The affected limb should always be compared with the contralateral extremity.
The degree of cubitus valgus, or carrying angle, of the elbow is measured with the elbow at the zero starting position (i.e., with the elbow fully extended and at 0 degrees of flexion). The goniometer is positioned on the volar surface of the arm and aligned with the midaxis of the humerus and the midaxis of the forearm ( Fig. 3-1 ). Beals measured the mean carrying angle in a radiographic study conducted on 422 patients. Patients were divided into four age groups: newborn through 4 years of age, 5 through 11 years, 12 through 15 years, and adults, with approximately 50 male and 50 female subjects in each group. The mean carrying angle was 15 degrees in the newborn to 4-year-old group and increased slightly with age to 17.8 degrees in adults, both men and women.
Knee joint alignment is measured with the patient standing with the knee fully extended. The goniometer is aligned with the midaxis of the distal femur and proximal tibia (the anatomic axis of the knee; Fig. 3-2 ). For most clinical evaluations, this measurement is sufficient; however, for hip surgery and lower extremity realignment, preoperative assessment of the axis of the hip, knee, and ankle (the mechanical axis) should be done using full-length, weight-bearing radiographs. Normal knee alignment, as measured by the femoral-tibial angle, changes as a child grows older. Neonates usually have 10 to 15 degrees of varus angulation. The angulation evolves to a neutral femoral-tibial alignment between 14 and 22 months of age, with a maximum valgus of 10 to 15 degrees by 3 to 3½ years of age. This is followed by a gradual decrease in valgus, with normal mature alignment of 5 to 7 degrees of femoral-tibial angle realized by 6 to 8 years of age.
Other objective methods of measurement can be used for specific situations. The degree of genu valgum (knock-knees) can be determined by measuring the distance between the medial malleoli when the knees are fully extended, the patellae are facing exactly forward, and the medial femoral condyles are brought together with moderately firm pressure to compress excessive subcutaneous fat. The degree of genu valgum can also be determined by measuring the angle between the lateral surface of the thigh and leg. The clinical appearance of knock-knees is exaggerated when there is excessive subcutaneous fat on the thigh or atrophy of the calf (especially of the medial head of the gastrocnemius). The degree of genu varum (bowlegs) can be similarly determined by bringing the medial malleoli together, firmly compressing them, and measuring the distance between the medial femoral condyles. The patellae must be facing exactly forward because medial rotation of the lower extremities at the hips will result in the appearance of bowlegs.
Contractures
Contractures result from fibrosis of the tissues supporting the muscles or joints or from muscle fiber disorders, either of which cause fixed resistance to passive stretch of a muscle. There is a shortening and loss of flexibility of muscles, joints, tendons, or fascia. Contractures can be either congenital or acquired. Examples of congenital contractures include congenital muscular torticollis, abduction contracture of the hip, and multiple pterygium syndrome. Children with spina bifida often have capsular contracture of the posterior knee capsule.
Acquired contractures of joints may be caused by muscle imbalance (as seen with cerebral palsy), inflammatory arthritis, muscle injury, periarticular trauma, or idiopathic conditions (e.g., morphea syndrome ). A tight iliopsoas muscle in a child with cerebral palsy or myelomeningocele may cause a hip flexion contracture. A displaced torn meniscus that impedes extension of the joint may cause flexion contracture of the knee. Synovial fluid collection secondary to juvenile arthritis may block normal joint motion. Forearm ischemia from a compartment syndrome results in Volkmann’s contracture, which is characterized by pronation and flexion of the hand, shrinkage and hardening of the forearm muscles, and loss of muscle power. Muscle or joint contractures can also occur after surgery if the patient does not perform appropriate strengthening and range-of-motion (ROM) exercises. Gastrocnemius contracture can occur if the ankle is immobilized with the foot in equinus.
Evaluating contractures is an important part of the pediatric orthopaedic examination. Neonates have physiologic contractures of upper and lower limbs. In infants and younger children, contracture assessment primarily focuses on the lower extremities, whereas in older children, particularly those who participate in throwing sports, it is important also to inspect the upper extremity (i.e., the elbow and shoulder). When assessing two-joint muscles (e.g., hamstrings, gastrocnemius) for contracture, the examiner needs to restrict the movement of one joint before testing the second joint. For example, when examining for a hamstring contracture, first the femur should be flexed and stabilized on the pelvis, and then the knee extended.
Joint Range of Motion
Measuring joint ROM provides important information regarding orthopaedic diseases and disorders, and the results of treatment. The effect of acute illness or injury on joint motion can help in diagnosing the disease or disorder. For example, both transient synovitis and septic arthritis of the hip reduce joint mobility, but the loss of motion is much greater in the infected joint. Improvement in joint motion during treatment for septic arthritis indicates that the hip is responding to therapy. The extent and type of injury to a joint during athletic competition can be determined to some degree by how much joint mobility is lost. A return to normal joint motion is an important factor in deciding when an athlete is ready to return to competition.
During the physical examination, joint motion can be measured actively, whereby the patient moves the limb, or it can be measured passively, whereby the examiner moves the patient’s limb. Active and passive ROM often differs when disease or injury to a joint renders the patient incapable of completing full ROM against gravity. When this occurs, both arcs of motion should be recorded. The examiner should also compare the motion of the affected extremity with that of the normal, contralateral one because joint mobility is normally the same on the right and the left sides. *
* References .
Joint motion is most accurately measured with a goniometer, particularly at the elbow, wrist, finger, knee, and ankle joints. Because overlying soft tissue at the shoulder and hip obscures bony landmarks, it is more difficult to obtain consistent alignment of the goniometer at these joints. To measure an extended extremity, one arm of the goniometer is aligned with the axis of the proximal segment and the other arm is aligned with the axis of the distal extremity. The 0-degree mark is positioned on the distal segment. The proximal end of the goniometer is held in place while the joint is moved and the distal arm of the goniometer rotated. At completion of the movement, the degree of joint ROM is recorded from the goniometer.Motion is measured in degrees of a circle, with the joint as its center. The degrees of motion of a joint are added in the direction in which the joint moves from the anatomic zero starting position. To ensure conformity when measuring joint ROM, the extended anatomic position of a limb is designated as being 0 degrees (rather than 180 degrees). Thus when a fully extended extremity joint is bent from the anatomic zero position to a right angle, the range of motion is 90 degrees of flexion. The different joint motions are described in Box 3-1 .
Flexion: Act of bending a joint; a motion away from the zero starting position.
Extension: Act of straightening a joint; a return motion to the zero starting position.
Hyperextension: When the motion opposite to flexion is an extreme or abnormal extension (as may be seen with the knee or elbow joint), and the joint extends beyond the zero starting position.
Abduction: Lateral movement of the limbs away from the median plane of the body, or lateral bending of the head or trunk.
Adduction: Movement of a limb toward the median plane of the body.
Supination: Act of turning the forearm or hand so that the palm of the hand faces upward or toward the anterior surface of the body.
Pronation: Turning of the palm of the hand so that it faces downward or toward the posterior surface of the body.
Inversion: An inward turning motion (seen primarily in the subtalar joint of the foot).
Eversion: An outward turning motion.
Internal (inward) rotation: Process of turning on an axis toward the body.
External (outward) rotation: Process of turning on an axis away from the body (opposite motion of internal rotation).
Normal joint ROM varies among persons based on age and sex. Neonates typically have (1) decreased abduction of the shoulder, (2) greater external rotation and limited internal rotation of the hip, (3) greater dorsiflexion and limited plantar flexion of the ankle, and (4) flexion contractures at the elbow, hip, and knee. By 3 months of age a child usually exhibits an adult arc of motion at all joints except the hip. The hip joint continues to show an increase in external rotation and a decrease in internal rotation until the child is 8 to 24 months of age. Joint ROM is greater in children than in adults because children have greater joint laxity. Children also have a greater inversion and dorsiflexion of the foot and ankle than adults. As a person ages, connective tissue becomes progressively more rigid, particularly in and around muscles and tendons, resulting in decreased joint ROM. Because of greater ligamentous laxity, girls and women have greater ROM than boys and men in some joints, but not in all joints or in all planes of motion.
Spasticity
Spasticity refers to an abnormal increase in muscle tone (excessive muscle tension) that interferes with muscle relaxation, impedes normal joint ROM, and causes stiff and awkward movements. Spasticity can result from upper motoneuron injury, with cerebral palsy the most common cause of both. During the physical examination, the degree of actual spasticity in a particular muscle can change significantly depending on numerous factors, including patient anxiety, room temperature, and time of day.
It is more difficult to put certain joints through passive ROM when a patient has spastic muscles (e.g., extension of the knee joint when the hamstrings are spastic). However, with gentle persuasion by the examiner, the spastic muscle usually will relax and greater joint motion can be attained. Changes in patient body position can also affect ROM. Because of this, measurements of the same parameter may vary during the examination. A review by Perry showed that ankle dorsiflexion decreased as patients went from the supine position to sitting to standing. In 95% of patients with cerebral palsy, flexion of the knee permitted greater ankle dorsiflexion. To accommodate this variability, the examiner should note at what degree initial resistance is encountered and the total ROM attained with persuasion. The reliability of goniometric measurements in determining joint motion in patients with spasticity is debatable.
The examiner should also describe the general muscle tone of the patient, characteristics of the resistance (e.g., persistent initial resistance with ensuing relaxation, constant fixed resistance), and the position of adjacent joints (e.g., whether the hip or knee was flexed or extended, or the foot was neutral or supinated, when testing ankle dorsiflexion). For example, one might record that the ankle has 10 degrees of dorsiflexion with the knee extended.
Shoulder
The shoulder has the greatest ROM of any joint in the body, allowing a myriad of positions and planes of motion. Shoulder motion is divided into true glenohumeral motion, pure scapulothoracic motion, and combined glenohumeral and scapulothoracic motion ( Fig. 3-3 ). Maximum shoulder motion normally is a combined movement rather than motion in a single plane. For example, to achieve maximum elevation (flexion), there must be a combination of slight external rotation and abduction. Extension (backward motion) and flexion (forward motion) of the shoulder occur in the sagittal plane ( Fig. 3-4 ). Abduction and adduction of the shoulder occur only in the horizontal plane from the midsagittal zero position of the body ( Fig. 3-5 ). Abduction is motion of the arm away from the midsagittal axis of the body; adduction is movement of the arm toward the axis.
During the physical examination, shoulder motion is assessed with the patient standing. However, if the examiner cannot control spine and pelvic motion, the patient should be supine when external rotation and elevation are measured.
The term elevation (i.e., flexion) is used to define all upward motions of the humerus in any plane; that is, motions entailing the vertical raising of the arms in any position of the horizontal plane of abduction or adduction (see Fig. 3-4, B ). The zero starting position is with the arm at the side of the body. When assessing range of elevation of the glenohumeral joint, the examiner stands behind the patient and immobilizes the scapula by holding its inferior angle (see Fig. 3-3, A ). Scapulothoracic joint motion can be further restricted by firmly placing a hand over the acromion of the upper limb being tested. In combined glenohumeral and scapulothoracic motion, the scapula rotates upward and forward over the chest wall, allowing the shoulder to elevate to 180 degrees (see Fig. 3-3, B and C ).
When the shoulder is elevated, the first 20 degrees of motion represents pure glenohumeral joint motion, and the scapula does not move ( Fig. 3-6, A ). After this point, continued elevation of the arm results in combined movement of the glenohumeral and scapulothoracic articulations in a 2:1 ratio (i.e., for every 3 degrees of total shoulder elevation, 2 degrees of elevation represents motion of the glenohumeral joint and 1 degree of elevation comes from the scapulothoracic joint ; see Fig. 3-6, B ). When the scapula is immobilized, pure glenohumeral elevation is approximately 90 degrees (see Fig. 3-6, C ). At approximately 120 degrees of combined shoulder elevation, the surgical neck of the humerus abuts the acromion process (see Fig. 3-6, D ). Complete elevation of the shoulder (i.e., 180 degrees) is a combined glenohumeral and scapulothoracic movement. The elevation is made possible by external rotation of the shoulder, which turns the surgical neck of the humerus away from the tip of the acromion and increases the articular surface of the humeral head (see Fig. 3-6, E ).
Shoulder extension (posterior elevation) is motion of the extended arm in the opposite direction from that of forward elevation (see Fig. 3-4, A ). For maximum extension, the shoulder must rotate internally. Normally, the shoulder is able to extend 45 to 55 degrees.
Internal and external shoulder rotation are assessed with the patient’s arm in the neutral position and the examiner standing in front of the patient. The patient’s elbow must be at the side of the body and flexed 90 degrees to prevent substitution of adduction for external shoulder rotation and abduction for internal shoulder rotation. The forearm, which is parallel to the sagittal plane of the body, is rotated internally toward the sagittal axis of the body and externally away from the body. The shoulder is the axis and the forearm is the indicator of motion ( Fig. 3-7, A ). The normal range of internal shoulder rotation is 50 to 60 degrees (the chest wall blocks its motion), and the normal range of external shoulder rotation is 40 to 45 degrees.
Shoulder rotation may also be assessed with the neutral zero position of the shoulder at 90 degrees of elevation and 90 degrees of abduction, and with the forearm parallel to the floor (see Fig. 3-7, B ). In internal rotation, the arm is moved inferiorly toward the floor, with the average internal rotation approximately 70 degrees. Restricted internal rotation in this position may be due to shoulder instability. In external rotation, the shoulder is moved superiorly toward the ceiling, with the average external rotation approximately 100 degrees.
There are a number of quick and easy methods of clinically estimating active shoulder ROM. To measure shoulder elevation, the patient should stand with elbows straight and forearms fully supinated, and then raise both arms vertically and touch the fingers over the head ( Fig. 3-8, A ). To measure horizontal abduction and external rotation, the patient should place both hands behind the neck and push the elbows posteriorly (see Fig. 3-8 , B ). Adduction and internal rotation are measured by having the patient reach across the chest and touch the opposite shoulder (see Fig. 3-8 , C ). Extension, internal rotation, and adduction are tested by having the patient reach behind the back and touch the lower angle of the opposite scapula (see Fig. 3-8 , D ). Elevation, internal rotation, and adduction are tested by having patient reach behind the head and neck and touch the upper angle of the opposite scapula (see Fig. 3-8, E ). Finally, having the patient reach behind the back and touch the opposite buttock allows the examiner to measure extension, adduction, and internal rotation (see Fig. 3-8, F ). (These measurements are best used comparing both sides.)
Elbow
The elbow is a typical hinge joint in which there is only one freedom-of-motion plane. Although there are three sites of movement—the ulnohumeral, radiohumeral, and radioulnar articulations—elbow motion is centered at the ulnohumeral joint, and the description of motion is typically limited to the flexion-extension plane.
The zero starting position is with the elbow fully extended and straight (0 degrees) and the arm in supination. The normal elbow ROM is from 0 to 150 degrees of flexion and from 150 degrees (the angle of maximum flexion) to 0 degrees of extension (the zero starting position; Fig. 3-9 , A ). Hyperextension, measured as degrees by which the joint extends beyond the zero starting position, varies from 5 to 15 degrees. Hyperextension is not seen in all individuals. Restricted elbow ROM may be described, for example, as flexion from 30 to 90 degrees, or a joint that has a flexion deformity of 30 degrees with further flexion to 90 degrees (see Fig. 3-9 , B ).
Forearm
Rotation of the forearm is a combined motion of the proximal and distal radioulnar joints and the radiohumeral joint. The planes of motion are pronation (turning of the palm backward or posteriorly: the palm faces down) and supination (turning of the palm forward or anteriorly: the palm faces up; Fig. 3-10 ). To assess forearm rotation, the humerus is stabilized against the torso (to prevent any compensating adduction and abduction motion by the humerus to augment pronation and supination), and the elbow is flexed to 90 degrees. The zero starting position is with the extended thumb aligned with the humerus. To better evaluate the degree of pronation and supination, the examiner should palpate the radial and ulnar styloid as the forearm is being rotated. Having the patient hold a pencil or similar object in the palm with flexed fingers can make it easier to discern forearm rotation. Normal range of pronation is 70 to 80 degrees, and normal range of supination is 80 to 90 degrees.
Cervical Spine
The cervical spine is the most flexible part of the vertebral column. There are goniometers specific for measuring cervical spine motion; however, standard goniometers are just as accurate. Visual evaluation of cervical spine motion is not as reliable as goniometric measurement. The ROMs evaluated include flexion, extension, right and left lateral bending, and right and left rotation.
Normally, opposite movements (e.g., flexion/extension, right/left bending, right/left rotation) are nearly equal. However, the ROM in particular planes varies at different vertebral levels ( Box 3-2 ). Parameters for cervical spine mobility based on the age of the patient are provided in Table 3-1 . Box 3-3 shows the movement of the vertebrae at the various levels of the cervical spine. A more extensive discussion of the various ROMs of the cervical spine can be found in The Cervical Spine, by the Cervical Spine Research Society.
Occiput to C1: Substantially greater extension than flexion
C1-6: Flexion and extension approximately equal
Lower cervical segments: Flexion/extension greater, with maximum movement at C5-6
C6-T1: Flexion greater than extension, particularly at C7-T1
| Age (yr) | Total (1-16 yr) | Total (1-7 yr) | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Displacement/Mobility | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | No. | (%) | No. | (%) |
| Anterior displacement C2-3 (marked) | 4 * | 1 | 3 | 1 | 2 | 2 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 15 | (9) | 13 | (19) |
| Anterior displacement C2-3 (moderate) | 1 | 2 | 1 | 3 | 2 | 2 | 4 | 1 | 1 | 2 | 3 | 1 | 1 | 0 | 0 | 0 | 24 | (15) | 15 | (21) |
| Anterior displacement C2-3 (total) | 5 | 3 | 4 | 4 | 4 | 4 | 4 | 1 | 2 | 3 | 3 | 1 | 1 | 0 | 0 | 0 | 39 | (24) | 28 | (40) |
| Measured AP movement ≥ 3 mm | 5 | 4 | 5 | 2 | 5 | 6 | 5 | 2 | 4 | 5 | 4 | 6 | 7 | 4 | 4 | 3 | 71 | (44) | 32 | (46) |
| Number of children with measured AP movement > 3 mm and observed anterior displacement at C2-3 | 4 | 3 | 3 | 1 | 3 | 4 | 3 | 0 | 1 | 3 | 1 | 1 | 1 | 0 | 0 | 0 | 28 | (18) | 21 | (30) |
| Anterior displacement C3-4 † | 3 | 2 | 1 | 1 | 2 | 4 | 1 | 0 | 2 | 2 | 2 | 1 | 1 | 0 | 0 | 0 | 22 | (14) | 14 | (20) |
| Overriding of anterior arch of atlas relative to odontoid (extension views) ‡ | 2+ | 4++ | 3++ | 1 | 1+ | 3 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 14 | (9) | 14 | (20) |
| Wide space between anterior arch of atlas and odontoid (flexion views) | 2 | 2 | 3 | 2 | 2 | 2 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 14 | (9) | 14 | (20) |
| Total (5-11 yr) | ||||||||||||||||||||
| No. | (%) | |||||||||||||||||||
| Presence of apical odontoid epiphysis | 0 | 0 | 0 | 0 | 3 | 2 | 3 | 1 | 4 | 1 | 4 | 0 | 0 | 0 | 0 | 0 | 15 | (9) | 18 | (26) |
| Total (1-5 yr) | ||||||||||||||||||||
| No. | No. | |||||||||||||||||||
| Presence of basilar odontoid cartilage plate | 10 | 9 | 9 | 6 | 4 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 48 | (30) | 38 | (76) |
| Angulation at single level | 1 | 4 | 1 | 1 | 3 | 3 | 2 | 0 | 1 | 2 | 1 | 2 | 2 | 1 | 2 | 0 | 25 | (16) | ||
| Absent lordosis in neutral position | 3 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 2 | 1 | 3 | 2 | 2 | 5 | 1 | 2 | 22 | (14) | ||
| Absent flexion curvature C2-7 in flexion view | 1 | 2 | 1 | 6 | 4 | 1 | 0 | 0 | 2 | 3 | 1 | 1 | 1 | 1 | 2 | 0 | 26 | (16) | ||
* Boldface numbers represent predominant age range for particular variable.
† Twenty of 22 children with anterior displacement at C3-4 also had displacement at C2-3.
‡ Presence of wide atlanto-odontoid space in same child (each + represents one child).
C1-2: 55%-60% of rotation occurs at this level.
Occiput to C5: Flexion is coupled with rotation.
C5-7: Extension is combined with rotation.
Upper cervical spine: Lateral bending goes in opposite direction of rotation.
Lower cervical spine: Bending goes in same direction as rotation.
Although goniometric measurement is more accurate, clinical evaluation is usually performed by visual assessment, with the patient’s nose and chin used as midline landmarks. Inclinometers may also be used during an examination. The tool is accurate in measuring flexion/extension and lateral bending but is not as reliable for rotation.
The zero starting position for measuring flexion/extension motion is with the neck aligned with the trunk ( Fig. 3-11 ). The examiner should stabilize the trunk during the movements so that thoracic spine motion does not come into play. Flexion can be measured in degrees or, if motion is limited, by the distance remaining between the chin and sternum on maximum forward bending. With normal range of flexion, the patient should be able to touch the chin to the chest, and with normal range of extension, the patient should be able to look at the ceiling.
The zero starting position for measuring lateral bending and rotation is with the nose vertical and perpendicular to the axis of the shoulders ( Fig. 3-12 ). Again, the trunk should be stabilized when testing lateral bending. The degree of bending is measured as the angle between the midaxis of the face and the beginning vertical line. Rotation is measured from the zero starting position ( Fig. 3-13 ). If the neck is placed in maximum flexion, rotation is restricted to the upper cervical spine. Normally, a child’s cervical spine is mobile enough to permit touching of the ear to the adjacent shoulder when bending the neck, and touching of the chin to the shoulder when rotating the head.
Cervical spine disorders result in a decreased ROM in the affected vertebral segments. However, because clinical demonstration of limited cervical motion indicates only that a disorder is present, radiographs are needed to determine the extent of the problem and its cause.
Thoracolumbar Spine
Like motion of the cervical spine, thoracolumbar spine motion represents a combination of movements of several joints to produce flexion/extension, right and left lateral bending, and right and left rotation. In the thoracic spine, flexion/extension is greatest in the lower thoracic spine, lateral bending is slightly increased in the lower thoracic region, and rotation is greatest in the upper thoracic segment. In the lumbar spine, flexion/extension is greatest in the lower lumbar vertebrae, lateral bending is most restricted at the lumbosacral junction, and rotational movements are relatively limited.
Accurately measuring thoracolumbar joint motion can be difficult. Assessment can be made by visual estimation, goniometric measurements, skin distraction, or inclinometer techniques. The combination of extensive soft tissue coverage and obscured midline landmarks makes visual assessment extremely subjective and goniometric measurements difficult. The examiner usually is able to obtain more objective and accurate measurements of thoracolumbar motion using skin distraction or inclinometer techniques.
Flexion
The zero starting position for measuring flexion is with the patient standing with the hips and knees straight, the trunk aligned with the lower limbs, the feet slightly apart, and the arms hanging to the sides in a relaxed, extended position ( Fig. 3-14 ). Measuring the distance between fingertips and floor when the patient is at maximum flexion ( Fig. 3-15 ) is a simple technique, but this method of assessment has poor repeatability and is not considered reliable for patients with low back problems. The double inclinometer test can be used to measure lumbar flexion more accurately, but the test requires two inclinometers and a cooperative patient ( Fig. 3-16 ). One inclinometer is placed over the sacrum and the other inclinometer is positioned over the spinous process of T12. With the patient in maximum flexion, the degree of flexion is obtained by subtracting the sacral inclinometer reading from the reading of the T12 inclinometer.
When examining the lower back, it is important to remember that limited flexion of the lumbar spine may be caused by disorders that do not involve the spine, such as any restriction of hip flexion or contractures of the hamstrings.
Extension
Back extension is evaluated by having the patient stand in the zero starting position with the palms on the buttocks and then bend backward as far as possible. Extension can be estimated visually or with a goniometer, or it can be more accurately measured with the double inclinometer test ( Fig. 3-17 ). One inclinometer is placed over the sacrum and the other inclinometer is positioned over T12. With the patient in maximum extension, the degree of extension is obtained by subtracting the sacral inclinometer reading from the reading of the T12 inclinometer.
Lateral Bending
Lateral bending is measured by marking the spinous processes of T1, T2, and S1. The patient then starts in the zero starting position and inclines the trunk to the right and left while keeping the knees straight. The degree of bend can be estimated visually or with a goniometer ( Fig. 3-18 ). Lateral bending also can be determined with a tape measure. The double inclinometer also can be used to measure lateral bending, with the inclinometers set the same as for measuring flexion and extension, and calculated by subtracting the sacral inclinometer reading from the T12 reading at maximum bending.
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