Chapter Outline
Screening Examinations 61
The Focused Examination 63
The Art of Examining the Pediatric Patient 68
It is important for orthopaedic surgeons to be familiar with the numerous musculoskeletal and neuromuscular examinations detailed in Chapter 3 . Over time the orthopaedist will most likely perform many of these examinations on different patients presenting with a variety of complaints. If the nature of the patient’s medical condition is unclear, the physician may have to perform a comprehensive examination to arrive at a differential diagnosis.
In most cases, however, the orthopaedic surgeon does not have the time or the need to perform an all-encompassing examination on every patient seen in the clinical setting. In the real world, the pediatric orthopaedic examination must be tailored to the child’s age, level of cooperation, and chief complaint. The two most common types of examinations performed are the screening examination and focused examination.
Screening examinations are performed as part of a comprehensive or abbreviated examination to detect disorders that may be asymptomatic but could cause significant morbidity or mortality if undiagnosed and untreated. Focused examinations concentrate on specific abnormalities for which the patient has been referred, or on the chief presenting complaint. With these factors in mind, the examiner should make the clinical assessment as orderly and organized as possible to avoid neglecting any essential parts of the examination. However, the examination also needs to be performed as expeditiously as possible, before the examiner loses the child’s initial cooperation because of patient apprehension, fatigue, or boredom.
The final section of this chapter addresses the art of examining the pediatric patient. Although it is not difficult to outline the recommended principles for conducting the pediatric examination, rarely does the physician have the luxury of the ideal environment when seeing patients in the clinic. An uncooperative child, the presence of multiple family members, and limited time provide an impetus to perform the examination as expeditiously as possible while still maintaining good rapport with the patient and parents. To assist physicians inexperienced in examining children, we offer a number of suggestions based on years of personal experience that should help the physician conduct an examination that is efficient and enjoyable.
Screening Examinations
Screening examinations are conducted to determine whether the patient has any undiagnosed disorders that may be potentially harmful or deleterious if left unmanaged. In pediatric orthopaedics, two primary disorders of this sort are undetected developmental dysplasia of the hip (DDH) and scoliosis.
Hip Examination
All children are at risk for DDH, which, if not treated appropriately, can result in a limp and early degenerative arthritis. Because the condition is asymptomatic, all newborns and infants should be screened regularly for the condition until they have developed a mature normal gait. The most common clinical methods of detecting DDH are the tests for the Barlow sign and Ortolani sign.
First, the test for the Barlow sign is performed to determine whether the hip is dislocatable (i.e., whether the femoral head can be pushed out of the acetabulum on examination; Fig. 4-1 ). The examiner attempts to subluxate or dislocate the femoral head from within the acetabulum by gently pushing the relaxed infant’s hips laterally and posteriorly, with the leg in 90 degrees of flexion and neutral abduction. If there is instability, the femoral head will dislocate from the acetabulum and then spontaneously reduce, with a distinct “clunk” when pressure on the leg is relaxed. This may be the only physical finding on examination. Next, the examiner should determine whether the femoral head is dislocated out of the acetabulum by testing for the Ortolani sign ( Fig. 4-2 ). In neonates, it is usually possible to reduce the dislocated femoral head temporarily by gently abducting the hip and lifting the upper leg forward. A distinct clunk will be felt as the head is reduced. When pressure on the leg is released, the femoral head will dislocate again. If the hip is dislocated, physical findings may include limited abduction (normal abduction is approximately 90 degrees), asymmetric thigh folds (excess on the affected side), and shortening of the leg compared with the opposite side.
One point to emphasize regarding these two maneuvers is that the examiner cannot elicit both the Barlow and Ortolani signs from the same hip. Either the femoral head is sitting in the acetabulum and can be temporarily dislocated on examination (Barlow sign), or the head is dislocated and can be temporarily reduced on examination (Ortolani sign). If the physical examination findings are equivocal and the patient is considered to be at high risk for DDH, ultrasound studies should be ordered.
Other Newborn Screening Examinations
Newborns should also be screened for spinal deformities and malformations (e.g., torticollis, spinal dysraphism), digital anomalies (e.g., syndactyly, absence), long bone deformities, and foot deformities (e.g., intoeing, rigid metatarsus adductus, clubfoot, calcaneovalgus foot). All children should also be evaluated for normal lower extremity alignment, limb length inequality, kyphosis, and gross motor skills. In addition, the child’s height, weight, and head circumference should be measured and charted to determine if the following are present:
- 1.
Weight or height is excessively high or low
- 2.
Weight or height is disproportionate
- 3.
Head circumference is disproportionate for height and weight
- 4.
Weight, height, or head circumference deviates from the percentile line identified for any particular child
Scoliosis Examination
Scoliosis can result in severe cosmetic deformity and pulmonary compromise. The forward-bending test is a reliable means of screening for scoliosis. The examiner views the patient from the back during the test. The patient stands evenly on both legs, with the knees straight, and then bends forward at the waist, with the arms hanging free. The examiner evaluates the back for elevation of one hemithorax or flank relative to the other to determine the presence of a rotational deformity caused by scoliosis.
General Childhood Screening Examination
An initial screening examination to help detect other potential deformities or disorders can be done simply by observing the child during certain maneuvers. Observing the patient standing upright with feet together identifies any bowlegs or knock-knees, foot deformities, or limb length inequality. The child’s gross motor skills can be assessed in a number of ways. Having the patient heel-walk, toe-walk, and hop on each foot in turn allows the examiner to evaluate gross strength in the legs and balance. When the child walks and runs, the examiner should look for limping or other gait abnormalities that may be caused by muscle weakness or spasticity. Many neuromuscular disorders disrupt this normal motion and function. How easily the patient rises from a supine position on the floor is a general indication of neurologic integrity or may indicate the presence of proximal leg muscle weakness, as seen in muscular dystrophy. Having the child bend over to pick up an object tests eye-hand coordination and muscle balance and also helps determine the severity of back pain, if that is the chief complaint.
Screening examinations should be cost-effective, reliable, and specific in identifying the disorder in question. Ideally, there should also be a cost-effective treatment available that can significantly alter the natural history of the disorder if applied early. Such is the case with DDH, in which early use of the Pavlik harness usually corrects the condition and prevents the need for more costly treatment later. Scoliosis screening is more controversial, however. Although the forward-bending test is a reliable means of screening for scoliosis, it may be too sensitive because many false-positive results occur with this maneuver. Radiography is highly specific for identifying scoliosis but is not a cost-effective means of screening the population at risk. In addition, whether treatment can effectively change the natural history of the deformity has been under debate. The benefits of early detection of other commonly encountered orthopaedic conditions are detailed in the chapters dealing with the specific entities.
The Focused Examination
The focused clinical examination provides an expedient, organized approach to the assessment of commonly encountered pediatric orthopaedic complaints ( Box 4-1 ). The topics discussed here are intoeing, flatfoot, leg length discrepancy, and spinal deformity. These entities collectively account for a large proportion of presenting complaints of pediatric patients and referrals by their pediatricians when children are seen by orthopaedic surgeons in a nonemergent or office setting. Detailed differential diagnoses and the management of the disorders are discussed in the respective chapters on the various conditions.
Have the patient do the following in continuous succession:
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Hop off the examination table.
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Walk back and forth.
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Hop on one foot.
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Hop on the other foot.
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Heel-walk.
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Toe-walk.
- •
Walk on the lateral border of the feet.
- •
Squat down and stand up.
If the patient does all these without noticeable abnormality, the examiner can rule out muscular dystrophies, cerebral palsy, ataxias, Charcot-Marie-Tooth disease, septic arthritis in the lower extremity, tarsal coalition, patellar dislocation, and drop foot. The patient with DDH may have such a subtle gait deviation that it is not noted on this brief examination.
Intoeing
One of the most common parental concerns prompting an orthopaedic evaluation is intoeing, or walking with an excessively inward foot progression angle. Typically the parent is concerned that the child will have a permanent disability or that the condition will interfere with the child’s physical performance. In most cases, however, the problem is minor and self-limiting, and no treatment is necessary.
The most common benign causes of intoeing are metatarsus adductus, increased or persistent internal tibial torsion, and increased or persistent femoral anteversion. Other benign causes include structural anomalies of the legs or feet. Most of these conditions do not need to be treated. Instead the parents simply need to be reassured that the condition usually resolves on its own and the patient should be observed on a regular basis to ensure that the foot progression angle gradually returns to normal.
Occasionally, however, intoeing can be a manifestation of a more significant problem that necessitates further evaluation and may require treatment. Examples include static encephalopathy, other neurologic disorders, some mild tibial deficiencies, infantile Blount disease, metabolic bone diseases, and skeletal dysplasias. Patients with these conditions are sometimes referred or present with an initial complaint of intoeing.
Thus, the focused examination of the child with intoeing is concerned with ruling out one of the aforementioned serious causes, making sure that the child has normal neurologic function, and confirming that the cause of the problem is benign. The physician should ascertain whether there is a family history of DDH, neuromuscular disease (especially muscular dystrophies), or other, relatively rare, hereditary neurologic conditions, such as Charcot-Marie-Tooth disease or familial spastic paraparesis. The examiner should be familiar with the child’s neonatal history and developmental history when assessing the patient’s neurologic status.
In addition the age of the child can be of help in determining the cause of the intoeing. Typically metatarsus adductus becomes evident after birth and before walking, increased internal tibial torsion is seen in toddlers to preschoolers, and increased femoral anteversion is most commonly found in school-age children to adolescents.
During the history taking, the younger child should be allowed to play or move about the room freely. From this free movement, the physician can gain some idea of the nature and severity of the problem, which can be especially helpful if the patient becomes resistive or uncooperative during the formal physical examination. If it is not possible to observe the child walking or running while taking the history, the examiner should do so afterward, but from a safe distance. The child should be undressed from at least the knees down during the physical examination.
While the patient is ambulating, the examiner should first look for evidence of impaired mobility, significant balance problems, lethargy, or weakness in movement. Barring any of these problems, the physician should then try to discern the source of the intoed gait and its approximate severity ( Fig. 4-3 ). Important observations to make while the patient is walking or running include the following:
- 1.
Noting whether the lateral border of the foot is turned in, as occurs with metatarsus adductus
- 2.
Observing whether the feet are oriented medially relative to the knee, as occurs with increased tibial torsion
- 3.
Noting whether the entire leg rotates inward, with “squinting” patellae, as seen with increased femoral anteversion ( Fig. 4-4 )
FIGURE 4-4
Evaluation of the cause of intoed gait in healthy children. A, When the cause of the intoed gait is increased internal tibial torsion, the foot progression angle will be negative and the patellae will point forward. B, Alternatively, the child may rotate the entire lower limb externally through the hip, resulting in a neutral foot progression angle, externally rotated patellae, and apparent tibia vara. C, When the cause is increased femoral anteversion, the foot progression angle is negative and the patellae are rotated medially.
Older children may try to mask an intoed gait during the physical examination. To counter this attempt, the examiner should have the patient heel-walk, toe-walk, and hop across the room on each leg. This will make the intoeing gait more evident to the examiner, as it is to the parent who sees it on a daily basis.
Having the child perform these maneuvers will also provide the physician with valuable initial information regarding the neurologic status of the patient. Although neurologic conditions are not the most common cause of intoeing, it is important for the examiner to rule them out as the cause of the problem.
The torsional profile can be expediently assessed with the patient prone on the examining table, as described by Staheli. With the patient in this position, the examiner can determine the amount of internal and external rotation of the hip as an indication of the amount of femoral anteversion, assess the thigh-foot axis to estimate tibial torsion, and examine the shape of the lateral border of the foot ( Fig. 4-5 ). If, however, a younger child is uncomfortable or feels threatened in this position, the examination can be conducted with the child in the comfort and safety of the parent’s lap, making for a calmer patient. With the patient in this position, the lateral aspect of the foot can be assessed, bimalleolar axis of the ankle relative to the knee can be estimated, and amount of internal and external rotation of the hip in the flexed position can be assessed. The examiner should also feel the patient’s muscle tone to determine whether there is hypertonia (suggesting spasticity) or hypotonia (suggesting muscle weakness).
Particular clinical manifestations are associated with the three most common causes of intoeing. Typically metatarsus adductus is characterized by an inward deviation of the lateral border of the foot from the base of the fifth metatarsal. This deviation may or may not be flexible. With increased internal tibial torsion, there is an excessive inward (or negative) thigh-foot angle or bimalleolar axis. Excessive femoral anteversion is typified by increased internal rotation and decreased external rotation of the hip in flexion or extension.
Flatfoot
When assessing children with flatfoot deformity, the examiner should first consider the patient’s age because certain underlying conditions tend to be age-specific. An infant may have a simple positional deformity, medial arch fat pad obscuring visual evidence of the underlying arch, calcaneovalgus foot, or—least likely but most significant—congenital rocker bottom foot (vertical talus). The young child most likely has a flexible flatfoot deformity. An adolescent may have a tight heel cord with secondary midfoot breakdown or a peroneal spastic flatfoot caused by tarsal coalition or another problem.
While taking the history, the examiner should determine whether there is associated pain, where it is located, and when it occurs. Pain that is not related to exercise may be caused by inflammatory arthritis (the tarsal joints are a common location for juvenile arthritis), infection or, rarely, a bone lesion. Nonspecific foot, ankle, or lower leg pain in the adolescent or preadolescent patient may be caused by tarsal coalition.
Examination of the feet starts by having the patient walk and observing whether the gait pattern is normal, antalgic, or indicative of neuromuscular dysfunction (e.g., hemiparesis). The child should then be asked to heel-walk, toe-walk, and hop on each foot in turn, if possible. This allows further assessment of neurologic and musculoskeletal function, as well as a stress examination if pain is present. If the longitudinal arch is absent when the patient is standing still, the examiner should look for reconstitution of the arch when the patient is walking on the toes.
With the patient standing facing forward, the examiner should look for evidence of muscle atrophy, swelling, erythema, or deformity of the lower leg. The lower extremity alignment should be checked to determine if there is femorotibial valgus. Next the patient’s foot should be examined from behind because it is easier to assess hindfoot valgus from this position. Reconstitution of the longitudinal arch can also be assessed at this point by having the patient stand on the toes. The examiner should also note whether the hindfoot swings from valgus to varus. If the hindfoot stays in valgus, tarsal coalition may be present.
Next the examiner should have the patient sit with the feet hanging freely over the edge of the examination table (younger children can sit in the parent’s lap). Passive range of motion should be checked, specifically to rule out the presence of a tight heel cord. A tight heel cord, regardless of cause, can lead to flatfoot because of compensatory midfoot breakdown. The examiner should then rock the subtalar joint into inversion and eversion. Any stiffness (with or without discomfort) or peroneal muscle spasm during this maneuver suggests the presence of tarsal coalition, or possibly inflammatory arthritis. If the physician has not yet checked for reconstitution of the longitudinal arch, it should be done at this point.
The examination concludes with a neurologic assessment of the lower extremities. The extent of this evaluation is based on the findings from the history and preceding physical examination and the examiner’s degree of suspicion at this point regarding the cause of the deformity.
The most common type of flatfoot that the pediatric orthopaedist will see is the so-called flexible flatfoot deformity of childhood. There is no pain associated with this condition. Typically the child is between 18 months and 6 years of age, when physiologic genu valgum is the norm and may not be noticed by the parents. The foot will have supple range of motion on examination and the longitudinal arch will readily reconstitute during toe-walking or when the foot is in a non–weight-bearing position ( Fig. 4-6 ). Most flexible flatfeet resolve spontaneously, with no residual adverse effects as the child ages; surgery is rarely indicated to treat this condition.
