Examination of a Paediatric Patient

Abstract

Paediatric orthopaedic clinical evaluation by means history taking and examination are far different from that of an adult. The child’s birth history, developmental history and family history have a significant bearing on the diagnosis of certain childhood orthopaedic problems. Most of the time, the history is elicited from the parents. Painless conditions like a deformity or a limp are brought to the clinician’s attention only when the parents start noticing them. Hence, the exact time of onset of symptoms is often unknown.

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Paediatric orthopaedic clinical evaluation by means history taking and examination are far different from that of an adult. The child’s birth history, developmental history and family history have a significant bearing on the diagnosis of certain childhood orthopaedic problems. Most of the time, the history is elicited from the parents. Painless conditions like a deformity or a limp are brought to the clinician’s attention only when the parents start noticing them. Hence, the exact time of onset of symptoms is often unknown.

History Taking

• 1. Patient demographics

  Knowledge about the child’s age, sex, place of origin, socio-economic status and educational status of the parents should be recorded in all cases before eliciting the chief complaints. These basic details might not only help in arriving at a diagnosis, but also, in deciding the apt treatment plan for the child.

• 2. Chief complaints:

  The presenting complaint should answer the question: “What made the parents bring their child to the hospital?” The commonly recorded chief complaints include pain, deformities, limp, swelling, weakness and stiffness.

• 3. History of present illness:

  The treating orthopaedician should elicit and record a chronological clear history regarding each of the presenting complaints. This should include:

  Location

  Onset

  Duration/Frequency

  Progression/Course

  Quality/Severity

  Aggravating/Relieving factors

  Associated manifestations

  The examiner should also determine the nature of response of each family member to the child’s symptoms and the reasons for their concern. It is also essential to rule out the possibility of any secondary gains from the child’s illness.

  Note: Malingering and Battered baby syndrome should be ruled out.

• 4. Treatment history:

  Previous treatment history has a significant bearing in deciding the management plan for the child. A thorough treatment history staring from the onset of presenting illness is necessary in all cases. This should include details of all possible modes of prior intervention—medical, surgical, plaster, traction, massage, physiotherapy, “desi”/native treatment modalities, etc. The examiner should be able to determine if the prior treatment has altered the original course of the disease or not.

• 5. Family history:

  History of similar complaints among the siblings or the parents must be elicited. This might help to rule out certain genetic/familial syndromes, metabolic conditions, bleeding disorders and infectious ailments. Note: The presence of skeletal dysplasias, scoliosis, clubfeet, developmental dysplasia of the hip [DDH], repeated fractures, rickets and neuromuscular disorders in family members should be specifically obtained. History of close contact with Tuberculosis [TB] patient is important in patients with suspected mycobacterial infection.

• 6. Birth history:

  A thorough birth history including the prenatal, natal and neonatal periods is important in the evaluation of certain congenital, developmental and neurologic impairments. The following checklist should be kept in mind while eliciting a birth history.

  • Prenatal: Abortion, maternal infections [rubella, syphilis, herpes, etc.], diabetes mellitus, illicit drug use/alcohol abuse, etc.

  • Natal: length of pregnancy, duration and nature of labor/delivery, presentation at delivery [breech/vertex], oligo-/poly-hydramnios, singleton/twins/multiple, condition of the newborn at birth, birth weight and height, etc.

  • Note: DDH and congenital muscular torticollis [CMT] are common with breech presentations.

  • Neonatal: respiratory difficulties, convulsions, blood transfusions, asymmetry of face/limbs, muscle tone, deformities, birth trauma, etc.

• 7. Developmental history:

  The examiner should evaluate the child for delayed developmental milestones. The child’s posture, functional development of the upper and lower limbs, activities of daily living, social development, speech and intellect should be assessed. The basic milestone history should include the following:

  • Head control, roll over, sit, crawl, pull up to a standing position, walk unsupported, run, climb stairs, hop on one foot

  • Hold/reach for/transfer objects, eat with a spoon, put on/off clothes

  • Social smile, wave “bye-bye”, say “da-da” or “ma-ma”, speak a few words/ sentences

  • Sleeping patterns, Age of toilet training

  • Problems with behavior, relationship, scholastic performance

Orthopaedic Examination [1,2,3,4,5]

By and large, majority of the paediatric patients presenting with musculoskeletal ailments are unco-operative. Effective communicative skills and tender loving care towards the paediatric patient are the important pre-requisites for a successful clinical examination. The examiner has to be patient in establishing a strong rapport with the parents and the child. It is essential to comfort them and gain their confidence before proceeding with the examination. The practice of wearing a white coat can be avoided in a paediatric clinic to enhance the child’s co-operation. The essential steps of examination should be adequately explained to the patient and the parents. The modesty of the paediatric and the adolescent patient must be maintained. Always examine the child in the presence of parents. Infants are better examined in the parent’s lap. As a rule, the normal asymptomatic limb is examined before proceeding to the involved limb.

Orthopaedic clinical evaluation in a child can be broadly divided into two groups: screening examination and focused examination.

• 1. Screening examination:

  The aim of screening examinations is to identify the asymptomatic disorders that can cause significant morbidity if undiagnosed and untreated. The common disorders which are screened for are listed below:

  • Hip: DDH

  • Spine: Scoliosis, kyphosis, spinal dysraphisms, torticollis

  • Long bone: deformities, limb length discrepancies

  • Foot: clubfoot, calcaneovalgus foot, metatarsus adductus, intoeing

  • Digits: syn-/poly-dactyly, absence

  Note: DDH and scoliosis are the most commonly screened conditions.

  Screening for DDH:

  The two most commonly used tests for DDH screening include: Barlow sign and Ortolani sign.

  Barlow sign is done to identify whether the hip is dislocatable. 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° 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. 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°), 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).

  Screening for Scoliosis:

  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.

  A quick screening for detecting other potential deformities or disorders can be done simply by observing the child during certain maneuvers. The child is asked to do the following:

  • Hop off the examination table.

  • Walk back and forth.

  • Hop on one foot.

  • Hop on the other foot.

  • Heel-walk.

  • 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.

• 2. Focused examination:

  Focused examination targets a particular joint or anatomical region based on the patient’s chief complaints. The reader is advised to refer to relevant sections of this textbook for further details.

Certain ground rules of deformity assessment are outlined below. Whenever there is a deformity, the following things have to be evaluated:

• Location of the deformity: bone/joint/soft tissue

• Severity

• Status: Fixed/correctable

• Etiology

• Associated factors: muscle spasm, tenderness, pain with motion

Nomenclature: The terminology of an angular deformity ideally consists of two parts. The first part describes the site of the deformity. For example: cubitus [elbow], coxa [hip], genu [knee], and pes [foot]. The second part describes the direction of the deformity. For example: 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. On the contrary, 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 coxa vara, the angle between the femoral neck and shaft is smaller than normal and the distal segment is angled toward the midline.

Measurement tool: Angular deformities are measured in degrees and are most accurately recorded using a hinged goniometer. However, when bony landmarks are not clear because of excess soft tissue coverage or other causes, the goniometer may give inaccurate results.

Methodology

• 1. 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° 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.

• 2. 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.

Other Methods

• 1. The degree of genu valgum (knockknees) 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.

• 2. 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).

• 3. 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.

The salient clinical features of some of the common paediatric conditions are discussed below.

Developmental Dysplasia of Hip

• History:

  • 1. First born

  • 2. Female > male

  • 3. Left hip > right hip

  • 4. Bilateral in 20%

  • 5. Breech delivery [frank breech with knee extended (20%) > single footling breech (2%) > double breech]

  • 6. Oligohydramnios

  • 7. Ligamentous laxity

  • 8. First term hyperthyroidism

  • 9. Postnatal positioning [hips swaddled in extension]

  • 10. Family history

  • 11. Associations: torticollis, metatarsus adductus

• Examination:

   Neonate:

  • 1. Barlow sign to identify dislocatable hips

  • 2. Ortolani sign to identify reducible hips

  • 3. Klisic’s sign—line from GT to ASIS should continue medially and pass towards the umbilicus; in the dislocated hip, the GT is high and the line passes under the umbilicus

  • 4. Asymmetric groin creases, thigh folds, popliteal and gluteal creases

   Infant:

  • 1. Klisic’s sign

  • 2. Decreased abduction: most reliable sign

  • 3. Galeazzi sign: Apparent limb length discrepancy due to a unilateral dislocated hip with hip and knee flexed at 90°; femur appears shortened on dislocated side

   Walking child:

  • 1. Klisic sign

  • 2. Decreased abduction

  • 3. Excessive internal and external rotation of the dislocated hips

  • 4. Pelvic obliquity

  • 5. Galeazzi sign

  • 6. Trendelenburg sign and gait

  • 7. Shortening : This is also evident by toe walking

  • 8. Increased lordosis (bilateral)

Perthes Disease

• History

  • 1. Age: 4–8 years [most common]

  • 2. Male > female

  • 3. Bilateral in 10–13%

  • 4. Family history

  • 5. Low birth weight

  • 6. Painless Limp : exacerbated by activity and relieved with rest

  • 7. Occasional Pain: Located in the groin, thigh, knee, greater trochanter; Aggravated by physical activity; Usually worse late in the day; Occasional night pain

  • 8. Associations: trauma, hereditary factors, coagulaopathy, type 2 collagenopathy, hyperactivity, passive smoking

    Note: The classic portrait of the child with LCPD—small, often thin, extremely active, constantly running and jumping, and limping after strenuous physical activities.

• Examination

  • 1. Abductor limp

  • 2. Decreased abduction and internal rotation

  • 3. Resistance to logroll

  • 4. When the hip is flexed, it may go into obligatory external rotation.

Slipped Capital Femoral Epiphysis

• History:

  • 1. Age: adolescence [12–15 years in boys and 11–13 years in girls]

  • 2. Male > female

  • 3. Left hip > right hip

  • 4. Bilateral in 20–40%

  • 5. Obesity

  • 6. Endocrinopathy :hypothyroidism [most common], hypogonadism, growth hormone deficiency, secondary hyperparathyroidism [ in chronic renal failure], Primary hyperparathyroidism, panhypopituitarism [ in intracranial tumors]

  • 7. Pain: Located in the groin, referred to anteromedial thigh and knee; Exaggerated with activity

  • 8. Unable to bear weight [in unstable SCFE]

  • 9. Prior pelvic radiation

  • 10. Syndromes: Klinefelter, Rubinstein-Taybi

  • 11. Associations: Blount disease, peroneal spastic flat foot, Perthes disease

• Examination:

  • 1. Antalgic limp

  • 2. External rotation attitude

  • 3. Shortening

  • 4. Thigh atrophy: But difficult to make out in obese children

  • 5. Anterior hip joint tenderness

  • 6. Restriction of FABIR [flexion, abduction and internal rotation]

  • 7. Increased hip extension, adduction and external rotation

  • 8. When the hip is flexed, it may go into obligatory external rotation

  • 9. Hip flexion contracture and painful global restriction of movements is seen in Chondrolysis complicating SCFE.

Congenital Talipes Equinovarus

• History:

  • 1. Male > female

  • 2. Bilateral in 50%

  • 3. Associations: DDH

  • 4. Neuromumuscular diseases and syndromes [Arthrogryphosis, spina bifida, Down syndrome, Larsen syndrome, constriction band syndrome, etc.]

  • 5. Maternal smoking

  • 6. Treatment history

• Examination:

  • 1. small foot and calf

  • 2. shortened tibia

  • 3. medial and posterior foot skin creases

  • 4. hindfoot in equinus and varus : differentiated from more common positional foot deformities by rigid equinus and resistance to passive correction

    Note: postural clubfoot is fully (or nearly fully) correctable passively and does not exhibit atrophy or significant contractures and deep skin creases of a true clubfoot.

  • 5. midfoot in cavus

  • 6. forefoot in adduction and pronation

Pirani score [modified]:

Findings	Score = 0	Score = 0.5	Score = 1
Curvature of lateral border of foot	Straight	Mild distal curve	Curve at calcaneocuboid joint
Severity of medial crease (foot held in maximal correction)	Multiple fine creases	One or two deep creases	Deep creases change contour of arch
Palpation of lateral part of head of talus (forefoot fully abducted)	Navicular completely “reduces”; lateral talar head cannot be felt	Navicular partially “reduces”; lateral head less palpable	Navicular does not “reduce”; lateral talar head easily felt
Severity of posterior crease (foot held in maximal correction)	Multiple fine creases	One or two deep creases	Deep creases change contour of arch
Emptiness of heel (foot and ankle in maximal correction)	Tuberosity of calcaneus easily palpable	Tuberosity of calcaneus more difficult to palpate	Tuberosity of calcaneus not palpable
Rigidity of equinus (knee extended, ankle maximally corrected)	Normal ankle dorsiflexion	Ankle dorsiflexes beyond neutral, but not fully	Cannot dorsiflex ankle to neutral

Congenital Vertical Talus

• History:

  • 1. Family history

  • 2. Associations: myelomeningocoele, arthrogryposis, spinal muscular atrophy, DDH, neurofibromatosis, trisomy 13–15 and 18

• Examination:

  • 1. Rigid rocker bottom deformity: The components include

    • (a) fixed hindfoot equinovalgus

    • (b) rigid midfoot dorsiflexion

    • (c) forefoot abducted and dorsiflexed

  • 2. prominent talar head can be palpated in medial plantar arch; produces a convex plantar surface

  • 3. “peg-leg” or a calcaneal gait due to decreased push-off

Congenital Muscular Torticollis

• History:

  • 1. Breech delivery

  • 2. Associations: DDH, metatarsus adductus

• Examination:

  • 1. Cock robin appearance: Head tilt towards same side and chin rotated toward the contralateral shoulder

  • 2. Palpable mass or knot on the involved side in the body of the SCM muscle in the first three months of life

  • 3. Contracture of SCM

  • 4. Restriction of neck movements

  • 5. Ear anomalies: bat ear

  • 6. Flattening of occipital area

  • 7. Flattening of the ipsilateral face

  • 8. Plagiocephaly [in severe cases]

  • 9. Scoliosis

Sprengel Shoulder

• History:

  • 1. Bilateral in 10–30%

  • 2. Associations: rib cage and cervicothoracic chest wall asymmetry, Klippel-Feil syndrome, congenital scoliosis, torticollis, and pulmonary and renal disorders

• Examination:

  • 1. Absent or hypoplastic high riding medially rotated scapula

  • 2. Loss of long medial border of scapula

  • 3. Equilateral triangle like shape

  • 4. Asymmetric, painless, bony mass in the web of the neck

    Note: These patients have normal glenohumeral motion but severely restricted scapulothoracic motion

  • 5. Restricted abduction and flexion