The Pediatric Orthopaedic Physical Examination

Mininder S. Kocher, MD, MPH

Henry G. Chambers, MD¹

¹Guru:

General Approach

The musculoskeletal physical examination is why I went into orthopaedics. The ability to take a history and do a physical examination to diagnose an injured or dysfunctional structure, to correlate that to the patient’s symptoms, to try to correct this through treatment, and then to re-examine the patient is miraculous. Although advanced imaging techniques such as MRI or ultrasound are useful in confirming the diagnosis or gaining additional information to guide treatment, everything is based on the history and physical examination. Young clinicians who rely too much on an MRI may get led astray by incidental or misleading findings. Master your exam, practice it, refine it, and treasure it!

The physical examination of children presents the orthopaedic surgeon with unique challenges and demands. Children between the ages of 14 months and 3 years often have an appropriately learned fear of doctors and needles and may be uncooperative. Nevertheless, the physician is expected to perform a reliable examination upon which the diagnosis and future decisions are based. This chapter focuses on those aspects of the physical examination, which are of special concern to pediatrics.

While this chapter focuses on aspects of the physical examination, elements of the history are unique to pediatrics. Birth history, such as prematurity, birth weight, perinatal complications, and number of days spent in the hospital may provide clues to an underlying disorder. The most useful developmental milestone is the age independent walking began. This may be considered normal if the child began walking by roughly 18 months of age, and frequently no further milestones are needed if this is the case. Grandparents may elucidate the family history, such as the patient’s father walked on his toes till the age of 3 years. To stay out of trouble, proceed with the assumption that the parent or referring doctor is always right until proven otherwise by a thorough history and examination.

On entering the room, assess the child’s level of apprehension and consider sitting as far away as possible from the child while chatting in a friendly manner with the parents and occasionally engaging the child in part of the conversation. Try to get low by sitting instead of towering over the child. A little effort in relationship building rapport with the child up front usually leads to a better examination (which may explain why pediatric orthopaedists wear such silly ties.) Treating even young children with genuine respect and not ignoring them while talking to parents goes a long way.

Carefully observe the child’s movements and posture before touching them, because once the crying starts, the information that can be gained from observation will be quite limited. Some children, typically between 14 months and 3 years of age, will be completely uncooperative, and the only chance you will have to observe to their gait is when they walk into the room, so take advantage of that opportunity if possible. Distraction often works well with children. If they are tensing up or apprehensive, ask them questions about their pets, their favorite food, or the local sports team.

To help avoid missing serious underlying conditions, a good rule of thumb is to examine the hips and spine of every child younger than 5 years unless the patient has a fracture or other clearly localized complaint. This cursory examination may consist only of the Galeazzi test, abduction of the hips, and inspection and palpation of the spine under a child’s shirt. It is quite easy to forget to examine parts of the body other than the chief complaint. To avoid this blunder, plan on examining the area of chief complaint last. For example, when an infant is brought to you
for evaluation of a possible torticollis, examine the spine and upper and lower extremities first, before focusing in on the neck. The parents will not let you leave the room without examining the neck, but it is easy to forget to examine the hips.

Most areas of the body have more or less symmetrical sides; take advantage of this, by examining the “normal” side first for comparison. For example, you may think an injured knee is loose on examination; however, when you examine the contralateral knee, it is also loose indicating ligamentous laxity. Avoid loss of credibility in the parent’s eyes by checking for muscle tone. Many children have already been evaluated by a therapist or other doctor and diagnosed (often overdiagnosed) with hypo- or hypertonia. Muscle tone of the upper and lower extremities may be tested by rapidly flexing elbows, knees, and ankles to assess the overall tone as well as a side-to-side comparison.

Increased tone on one side compared to the other may be indicative of cerebral palsy with spastic hemiplegia, while increased tone of the lower extremities compared to the upper extremities may be indicative of cerebral palsy with spastic diplegia. In order to avoid trouble with parents and referring doctors, consider referral to an appropriate specialist for evaluation of the child’s increased muscle tone, rather than blurting out the emotionally laden diagnosis of cerebral palsy at the first visit.

Hypotonia is difficult to assess and may be more related to a child’s state of wakefulness rather than an underlying disorder. When lifting a child of any age with the examiner’s hands under the child’s axilla, muscle tone about the shoulder girdle should be strong enough to support the child’s weight. If a child slips through the examiner’s hands, consider Duchenne muscular dystrophy or some other neuromuscular disorder.

Also, assess for laxity and stiffness. The Beighton score (Table 2-1) is useful in assessing generalized ligamentous laxity or suspicion of Ehlers-Danlos syndrome. Conversely, assess for tightness with inability to fully extend. Laxity and tightness often play a role in the development or manifestation of pediatric orthopaedic pathology.

Gait

If young children refuse to walk when asked, opening the door to the examination room and asking the parents if they would like to take their child for a walk in the hallway is often effective. If that doesn’t work, taking the child away from the parents to observe the child walk back to the parents usually works. Toddlers can be expected to walk with a wide-based-waddling-gait pattern with the hands held wide for balance. While it is normal for children learning to walk to fall down frequently, a history of increasing falling should alert the physician to the possibility
of a progressive neurologic condition, such as cerebral palsy, tumor, or other pathology. Where there is a history of progressive falling or weakness, a Gower test should be performed. To perform the Gower test, the child is asked to rise to a standing position from a sitting position on the floor. If the child uses their hands to climb up the legs and knees when arising, a muscular dystrophy should be suspected. A positive Gower test indicates proximal muscle weakness involving the gluteus maximus and the quadriceps muscles (Fig. 2-1). If a Gower test is positive, the calves should be inspected for pseudohypertrophy. If the patient has a positive Gower test with associated muscle weakness, a referral to a pediatric neurologist is recommended to evaluate for muscular dystrophy and a CPK blood test should be considered.

TABLE 2-1 Beighton Score

There are 9 points, and a score of 4 or more is considered a sign of generalized joint hypermobility likely being present.

One point if, while standing and bending forward, the patient can place their palms on the ground with the legs straight
One point for each elbow that extends more than 10°
One point for each knee that extends more than 5°
One point for each thumb that, with the wrist flexed, can be manipulated to the forearm
One point for each fifth finger that extends beyond 90°

Figure 2-1 Weakness of proximal muscles that causes child to use arms to climb up legs on arising from sitting position is present in Duchenne muscular dystrophy and other conditions. The hardest part about this test is remembering to do it.

If you are having difficulty evaluating the child’s gait pattern, it may be helpful to evaluate one aspect of gait at a time, moving from the feet, upward to ankles, knees, hips, torso, and arms. Walking up on one’s toes should alert the physician to the possibility of cerebral palsy or other neuromuscular conditions. Running often helps amplify otherwise subtle gait disturbances such as a unilateral flexed elbow indicative of cerebral palsy with spastic hemiplegia (Fig. 2-2).

THE GURU SAYS…

Taking a video (if your hospital allows it) and placing it in the electronic medical record is very helpful as one can take the time to watch the gait in slow motion and also compare to later examinations. As most of the pathology is in the sagittal plane, it is important to view the gait from the side of the patient (often difficult in small hallways). Of course, a three-dimensional computerized gait analysis should be considered if there is a complex gait abnormality.

HANK CHAMBERS

In the evaluation of intoeing, if the knees point straight ahead and the feet point inward during gait, this is consistent with internal tibial torsion. If both the feet and the knees point inward, this is consistent with internal femoral torsion. It is fairly easy to fall out of favor with the parents if they feel you have not spent sufficient time and attention analyzing their child’s gait pattern. Bringing a parent into the hallway and having them point out their concerns about the child’s gait pattern is usually time well spent. If you find some minor asymmetry in the gait and share this with parents it usually validates their concerns. If you are not certain whether a limp is present, closing your eyes and listening for an irregular cadence of foot strike often helps.

Hip

INFANTS

The examination of the infant’s hips is fraught with trouble and deserves in-depth attention in this text, and your practice. Examination of an infant’s hip should be performed first while the infant is calm and relaxed. Unlike many centers in Europe, with universal screening of infants’ hips for developmental
dysplasia of the hip (DDH), the physical examination is usually the only chance of picking up a dislocated, subluxated, or dislocatable hip in most children in North America.

Figure 2-2 Child with hemiplegia demonstrates characteristic elbow flexion. Note that this child has posturing of both elbows, suggesting asymmetric. (Courtesy of Robert Kay, MD, Children’s Orthopaedic Center, Los Angeles.)

The newborn with DDH will typically have ligamentous laxity with hip instability which is elicited by performing the Ortolani and Barlow tests. Once the infant is 3 months of age, the ligamentous laxity decreases and the Ortolani and Barlow tests typically are normal. At this age, the clinician looks for asymmetric abduction or a limb length discrepancy (with the Galeazzi test) as a sign of DDH.

For simplicity, historical accuracy will be sacrificed, and provocative tests of hip stability will be referred to as Barlow and Ortolani tests, which attempt to dislocate and relocate the hip respectively. These tests are technically difficult, especially in light of how rarely the test is positive in most practitioner’s hands. We recommend stabilizing the pelvis with one hand, with the thumb on the pubic symphysis and the fingers under the sacrum. While many physicians test both hips simultaneously, logic suggests that giving your full attention to one moving joint at a time is preferable in the setting of such an important examination.

In the Barlow maneuver (Fig. 2-3), while bringing the hip from abduction to adduction, the primary maneuver is pushing downward in line with the femoral shaft with your palm on the knee, while the secondary maneuver is pushing laterally on the medial proximal femur with your thumb. A positive finding is a palpable, and usually visible, posterior dislocation of the hip. It is not a high-pitch tissue click, but rather a deeper clunk, with significant motion such as going over a speed bump.

In the Ortolani maneuver (Fig. 2-4), while bringing the hip from an adducted to abducted position, the primary maneuver is gently lifting the hip into the socket with your long finger. As in the Barlow test, a positive finding is the palpable deep resonance of going over a speed bump. Usually a positive finding can be seen by others in the room. A high-pitched “click” is common and does not represent DDH, but probably a product of soft-tissue structures moving over bony prominences.

If a baby is crying, high quality provocative tests of the hip are impossible. This point cannot be overstated. Even a newborn’s tight muscles may mask instability. Do whatever is necessary to obtain a hip examination in a calm baby, including pacifiers, reexamination after feeding, during feeding, or even rescheduling the examination for a different day. Unlike the Galeazzi test, the Barlow provocative test and the Ortolani tests may be performed on a parent’s lap if this helps keep the infant calm. To stay out of trouble do not be afraid to consider an ultrasound
as an extension of the physical examination of a hip. There is no shame in sending the baby with an equivocal examination for an ultrasound with a repeat examination in 1 to 2 weeks. Decreased abduction is indicative of a dislocated or subluxated hip (Fig. 2-5). However, there are three pitfalls to avoid with this test. One, in the first few weeks of life an infant’s hip joints may be hyperlax and abduct fully, even with a dislocated hip. Thus, testing hip abduction is of limited value in the evaluation of newborns. Once the infant is 3 months old, if the femoral head is still subluxated or dislocated, the adductor muscles become tight causing an adduction contracture of the hip. Two, in the case of bilaterally dislocated hips, abduction is symmetrical, though decreased. In most infants, one should be suspicious of DDH if the hips do not abduct more than 60° to 70°. And three, a child on a parents lap may be positioned with the pelvis slightly tilted, which may mask hip asymmetry. Thus, hip abduction should be better evaluated with the child supine on an examining table.

Figure 2-3 Barlow maneuver. A: Resting position. B: Provacative Position—palm pushes down on the knee in adduction to dislocate the hip posteriorly.

Figure 2-4 Ortolani maneuver. A: Resting Position. B: Provacative Position—fingers lift up on the greater trochanter in abduction to reduce the dislocated hip.

The appearance of asymmetrical skins folds is of questionable value. They are easily seen, but often are not always indicative of underlying DDH. The simplest test to perform is the Galeazzi test, in which the child lies supine, with the hips fully flexed, and the feet flat on the table and the ankles touching the buttocks (Fig. 2-6). If the knees are at different heights, this is indicative of a dislocated hip
or other less common conditions such as proximal femoral focal deficiency, hemi-hypertrophy, etc. To stay out of trouble, this test is best performed on an examining table, not the mother’s lap, with all diapers, blankets, and clothing out from under the baby, as even a 1 cm fold of clothing under the hemipelvis may mask a limb length discrepancy. Being peed on at times is just part of the job.

Figure 2-5 Asymmetry of hip abduction is associated with a unilateral hip dislocation in the hip that abducts less. A potential pitfall is not leveling the pelvis on the examination table; subtle asymmetry may be missed in that event.

Figure 2-6 Galeazzi test is positive when knees are at different heights. When positive, there may be a unilateral dislocated hip or a leg length discrepancy.

Be aware that the Galeazzi test may be negative in bilateral dislocated hips. In a newborn with bilateral dislocated hips, the only abnormality on physical examination may be a lack of the normal hip flexion contractures of infancy.

OLDER CHILDREN

The single most useful exam in the evaluation of an older child’s hip is prone internal rotation. The child lies prone on the examining table, with the knees flexed 90° and the tibias pointing toward the ceiling. The ankles are then brought outwards as far as the child comfortably tolerates. Hip internal rotation is 0° if the tibia points toward the ceiling or 90° if they fall completely outward and become horizontal. Asymmetry of hip internal rotation usually defines intra-articular hip pathology in the hip with less rotation (Fig. 2-7). Common conditions causing limited internal rotation include transient synovitis, infection, and Legg-Calvé-Perthes disease. Uncommon causes of asymmetric internal rotation include a healed femur fracture with axial malalignment and asymmetric unilateral femoral torsion. This test should be performed in any child who is limping or complaining of leg pain without clear localization. Another pitfall with this test is not stabilizing the pelvis in neutral rotation, allowing pelvic tilt to mask the asymmetric internal rotation. The most common problem with this test is simply forgetting to do it. Remember that in children, hip pathology may cause referred pain to the thigh, or even the knee.

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