Clinical Orthopedic Examination of a Child

Cover
Half Title
Title Page
Copyright Page
Dedication
Table of Contents
Foreword I
Foreword II
Preface
Acknowledgments
Editor
Contributors
Chapter 1 Approach to a Child in the Outpatient Clinic
	1.1 Introduction
	1.2 The Environment
	1.3 Communication with the Parents/Caretakers
	1.4 Communication with the Child
	1.5 The Art of Examining a Child
	Bibliography
Chapter 2 Biometric Measurements and Normal Growth Parameters in a Child
	2.1 Introduction
	2.2 General Growth Measurements
	2.3 Upper Limb
	2.4 Lower Limb
	2.5 Ligamentous Laxity
		2.5.1 Wynne–Davies’ Criteria
		2.5.2 Beighton’s Score
	References
Chapter 3 Examination of Gait in a Child
	3.1 Introduction
	3.2 Development of Gait
	3.3 Gait Cycle
		3.3.1 Phases of Gait
		3.3.2 Commonly Used Terminologies for Describing Gait
	3.4 How to Examine a Child’s Gait
	3.5 Common Problems in Gait Noticed by Parents
		3.5.1 Toe-Walking
		3.5.2 In-Toeing Gait
		3.5.3 Out-Toeing Gait
		3.5.4 Flat Feet
	3.6 Abnormal Gait Patterns Indicative of Pathology
		3.6.1 Antalgic Gait
		3.6.2 Trendelenburg Gait
		3.6.3 Short Limb Gait
		3.6.4 High Stepping Gait
		3.6.5 Gluteus Maximus Gait
		3.6.6 Quadriceps Avoidance Gait or Hand-to-Knee Gait
		3.6.7 Role of Using a Cane
	3.7 Gait in Cerebral Palsy
		3.7.1 Gait Patterns in Spastic Hemiplegia
		3.7.2 Gait Patterns in Spastic Diplegia/Quadriplegia
		3.7.3 Lever Arm Disease
		3.7.4 Plantarflexion–Knee Extension Couple
	References
Chapter 4 Evaluation of Congenital Limb Deficiencies
	4.1 Introduction
	4.2 Classification
	4.3 Diagnostic Evaluation
		4.3.1 History Taking
		4.3.2 General Physical Examination
		4.3.3 Systemic and Local Examination
		4.3.4 Specific Congenital Limb Deficiencies
	References
Chapter 5 Examination of Pediatric Shoulder
	5.1 Introduction
	5.2 Clinical Anatomy
	5.3 History
	5.4 Examination
		5.4.1 Inspection
		5.4.2 Attitude
		5.4.3 From the Front
		5.4.4 From the Side
		5.4.5 From the Back
		5.4.6 Palpation
		5.4.7 Movements
			5.4.7.1 Forward Elevation (Range 160–180°)
			5.4.7.2 External Rotation (Range 80–90°)
			5.4.7.3 Internal Rotation (Normal Range 60–100°)
			5.4.7.4 Abduction (Normal Range 170–180°)
			5.4.7.5 Adduction (Normal Range 50–75°)
			5.4.7.6 Scapular Elevation
			5.4.7.7 Scapular Retraction and Protraction
			5.4.7.8 Measurements
		5.4.8 Anterior Instability Tests
			5.4.8.1 Apprehension Test
			5.4.8.2 Fulcrum Test
			5.4.8.3 Load and Shift Test
		5.4.9 Posterior Instability Tests
			5.4.9.1 Posterior Apprehension Test
			5.4.9.2 Posterior Drawer Test
			5.4.9.3 Jerk Test
		5.4.10 Tests for Inferior and Multidirectional Instability
			5.4.10.1 Sulcus Sign
			5.4.10.2 Feagin Test
		5.4.11 Tests for the Anteriorly Dislocated Shoulder
			5.4.11.1 Hamilton Ruler Test
			5.4.11.2 Dugas Test
		5.4.12 Tests for Scapular Instability
			5.4.12.1 Lateral Scapular Slide Test/Scapular Load Test
			5.4.12.2 Wall Pushup Test
		5.4.13 Impingement Tests
			5.4.13.1 Neers Impingement Sign and Test
			5.4.13.2 Hawkins–Kennedy Impingement Test
		5.4.14 Tests for Muscles Around the Shoulder
			5.4.14.1 Biceps Tendon
			5.4.14.2 Supraspinatus and Rotator Cuff Complex
			5.4.14.3 Subscapularis Muscle
			5.4.14.4 Infraspinatus and Teres Minor Muscles
			5.4.14.5 Trapezius
			5.4.14.6 Serratus Anterior
			5.4.14.7 Rhomboids
			5.4.14.8 Latissimus Dorsi
		5.4.15 Tests for the Labrum
			5.4.15.1 Clunk Test
			5.4.15.2 O’Brien’s Active Compression Test
		5.4.16 Tests for the Acromioclavicular Joint
			5.4.16.1 Acromioclavicular Shear Test
			5.4.16.2 Acromioclavicular Crossover/Cross Body or Horizontal Adduction Test
		5.4.17 Miscellaneous Tests
			5.4.17.1 Tests for Thoracic Outlet Syndrome
	References
Chapter 6 Examination of Pediatric Elbow
	6.1 Introduction
	6.2 Anatomy of the Elbow Joint
		6.2.1 Stability of the Elbow Joint
		6.2.2 Ligaments of the Elbow Joint
		6.2.3 Joint Capsule
		6.2.4 Muscles of the Elbow Joint
	6.3 History
	6.4 Inspection
		6.4.1 Look from the Front
		6.4.2 From Behind
		6.4.3 From the Side
	6.5 Palpation
		6.5.1 Lateral and Medial Epicondyle
		6.5.2 Palpation of Supracondylar Ridges
		6.5.3 Head of Radius
		6.5.4 The Proximal Ulna and Olecranon Process
		6.5.5 Three-Point Bony Relationship
	6.6 Movements
	6.7 Measurements
		6.7.1 Measurement of Carrying Angle
	6.8 Instability Tests
	6.9 Neurological Examination
		6.9.1 Motor Examination
		6.9.2 Sensory Examination
	References
Chapter 7 Examination of Pediatric Hand and Wrist
	7.1 Setting Up Hand Clinic and Establishing Rapport with the Child
	7.2 Surface Anatomy of the Hand
	7.3 Key Terminologies
	7.4 History
	7.5 General Examination
		7.5.1 Inspection
		7.5.2 Palpation
		7.5.3 Functional Tests
	7.6 Sensory Examination
	7.7 Motor Examination
		7.7.1 Power
			7.7.1.1 Examination of Tendons OF THE WRIST
			7.7.1.2 Examination of Extrinsic Muscles OF THE HAND
			7.7.1.3 Examination of Intrinsic Muscles OF THE HAND
		7.7.2 Examination of Nerves
			7.7.2.1 Median Nerve
			7.7.2.2 Ulnar Nerve
			7.7.2.3 Radial Nerve
		7.7.3 Test for Ligament Stability
		7.7.4 Movements and Measurements
		7.7.5 Vascular Examination
			7.7.5.1 Skeletal Examination
		7.7.6 Investigations
		7.7.7 Differential Diagnosis
	7.8 Wrist Examination
	References
Chapter 8 Examination of a Child with Birth Brachial Plexus Palsy
	8.1 Key Clinical Classification
	8.2 History and Initial Evaluation
	8.3 Clinical Examination
		8.3.1 General Examination of the Child
		8.3.2 Examination of the Affected Arm
			8.3.2.1 Special Tests
			8.3.2.2 Sensory Examination of the Affected Limb
	8.4 Assessment Scales for Motor and Sensory Functions in BBPP
	8.5 Scales to Assess Recovery
		8.5.1 Gilbert and Raimondi Score for Elbow Function
		8.5.2 Raimondi Score for Evaluation of Hand Function
	8.6 Clinical Examination and Correlation with Timing of Surgery
	8.7 Common Secondary Deformities in BBPP
	8.8 Differential Diagnosis for BBPP
	References
Chapter 9 Examination of Hip Joint in a Child
	9.1 History
		9.1.1 Why May Hip Pain Be Referred to the Knee?
	9.2 Head-To-Toe Examination
	9.3 Local Physical Examination
		9.3.1 Inspection of the Hip in Standing Position
			9.3.1.1 Inspection from the Front
			9.3.1.2 Inspection from the Side
			9.3.1.3 Inspection from the Back
		9.3.2 Inspection in Supine Position
			9.3.2.1 Inspection from the Front
			9.3.2.2 Inspection from the Side
			9.3.2.3 Inspection from the Back
		9.3.3 Palpation
			9.3.3.1 Anatomical Landmarks
		9.3.4 Movements
			9.3.4.1 Assessment of Hip Range of Motion
			9.3.4.2 Movements
		9.3.5 Thigh Girth Measurement
		9.3.6 Deformity
			9.3.6.1 Fixed Deformity
			9.3.6.2 Fixed Flexion Deformity
			9.3.6.3 Thomas Test
			9.3.6.4 Prone Hip Extension Test
			9.3.6.5 Fixed Abduction Deformity
			9.3.6.6 Alternative Method
			9.3.6.7 Fixed Adduction Deformity
			9.3.6.8 Fixed Rotational Deformities
		9.3.7 Measurements
			9.3.7.1 Apparent Measurement
			9.3.7.2 True Measurement
			9.3.7.3 True Measurement in Supine Position
			9.3.7.4 Segmental Measurements
			9.3.7.5 Lines
	9.4 Special Tests
		9.4.1 Standard Trendelenburg Test
			9.4.1.1 Interpretation
		9.4.2 Telescopy Test
		9.4.3 Sectoral Sign
		9.4.4 Impingement Test
			9.4.4.1 Anterior Impingement Sign
			9.4.4.2 Posteroinferior Impingement Sign
			9.4.4.3 Gear-Stick Sign
		9.4.5 Modified Schober’s Test
		9.4.6 SI Joint Tests
			9.4.6.1 Patrick’s Test
			9.4.6.2 Gaenslen’s Test
		9.4.7 Examination of Lymph Nodes
			9.4.7.1 Deep Inguinal Lymph Nodes
			9.4.7.2 External Iliac Nodes
		9.4.8 Tests Specific for DDH
			9.4.8.1 Ortolani Test
			9.4.8.2 Barlow’s Test
			9.4.8.3 Klisic Test
	9.5 Torsional Assessment of the Lower Limb
		9.5.1 Femoral Version
			9.5.1.1 Craig’s Test/Ryder Method
			9.5.1.2 Tibial Torsion
	References
Chapter 10 Examination of Knee Joint in a Child
	10.1 Introduction
	10.2 History
	10.3 Examination
		10.3.1 Gait Examination
		10.3.2 Position of Examination
		10.3.3 Inspection
			10.3.3.1 Attitude
		10.3.4 Palpation
		10.3.5 Evaluation for Warmth
		10.3.6 Evaluation of Point Tenderness
		10.3.7 Evaluation of Quadriceps Mechanism and Patellofemoral Articulation
		10.3.8 Evaluation for Bursal Inflammations and Effusions
		10.3.9 Range of Movement
		10.3.10 Muscle Power and Neurological Assessment
	10.4 Evaluation of Instability
		10.4.1 Anterior Instability
			10.4.1.1 Lachman’s Test (Sensitivity 75–90%, Specificity 80–95%)
			10.4.1.2 The Anterior Drawer Test (Sensitivity 40–80%, Specificity 80–90%)
			10.4.1.3 Pivot Shift Test (Sensitivity 85–100%, Specificity 95–100%)
		10.4.2 Posterior Instability
			10.3.2.1 Posterior Drawer Test (Sensitivity 90%, Specificity 99%)
			10.3.2.2 The Quadriceps Active Test (Sensitivity 50–98%, Specificity 97–100%)
		10.4.3 Medial and Posteromedial Instability
		10.4.4 Posterolateral Instability
			10.4.4.1 DIAL Test (Tibial External Rotation Test)
			10.4.4.2 Other Tests for PLC Injury
		10.4.5 Patellofemoral Instability Assessment
	10.5 Evaluation of Meniscal Injuries
		10.5.1 Joint Line Tenderness (Sensitivity 55–85%, Specificity 29–67%)
		10.5.2 McMurray Test (Sensitivity 16–58%, Specificity 77–98%)
		10.5.3 Apley’s Grind Test/Apley’s Compression Test (Sensitivity 13–16%, Specificity 80–90%)
	10.6 Test for Osteochondritis Dissecans
		10.6.1 Wilson Test
	10.7 Regional Examination
	Bibliography
Chapter 11 Examination of Foot and Ankle in a Child
	11.1 Introduction
	11.2 Brief Anatomy
	11.3 Local Physical Examination
		11.3.1 Inspection
			11.3.1.1 Attitude Description
		11.3.2 Palpation
			11.3.2.1 Thompson’s Test
			11.3.2.2 Tibialis Posterior Tendon Tenosynovitis
	11.4 Tests for Ankle Instability
		11.4.1 Anterior Drawer Test
		11.4.2 Talar Tilt Test
	11.5 Movements of Foot and Ankle
		11.5.1 Movements of the Foot
		11.5.2 Assessment of Subtalar Motion
	11.6 Deformities Pertaining to Foot and Ankle in a Child
		11.6.1 Cavus
			11.6.1.1 Coleman Block Test
		11.6.2 Pes Planovalgus
			11.6.2.1 Jack Toe Raise Test
			11.6.2.2 Lever Arm Dysfunction
		11.6.3 Adductus
			11.7.4.1 Flexibility Method of Assessing Metatarsus Adductus
		11.6.4 Equinus
			11.6.4.1 Silfverskiold Test
	11.7 Neurological Examination
		11.7.1 Motor and Sensory Examination
	References
Chapter 12 Evaluation of the Spine in a Child
	12.1 Basic Anatomy of the Spine
	12.2 Basics of Pediatric Spine Examination
		12.2.1 History
		12.2.2 Age
		12.2.3 Pain
			12.2.3.1 Axial Versus Radicular Pain
			12.2.3.2 Constitutional Symptoms
		12.2.4 Birth History
		12.2.5 Past Medical History
		12.2.6 Family History
		12.2.7 Psychosocial History
		12.2.8 Development History
		12.2.9 Tanner’s Stages of Development
	12.3 Examination of Spine
		12.3.1 Inspection
		12.3.2 Palpation
	12.4 Movements
		12.4.1 Cervical Spine
		12.4.2 Thoracolumbar Spine
			12.4.2.1 Flexion
		12.4.3 Ott Test
		12.4.4 Schober’s Test
		12.4.5 Modified Schober’s Test
			12.4.5.1 Extension
			12.4.5.2 Lateral Bending
			12.4.5.3 Rotation
	12.5 Thoracic Expansion Test
	12.6 Special Tests
		12.6.1 Foramina Compression Test (Modified Spurling’s Maneuver)
		12.6.2 Lhermitte’s Test
		12.6.3 Adson’s Test
		12.6.4 Passive Straight Leg Raise (PSLR)/Lasègue’s Test
		12.6.5 Braggard’s Test
		12.6.6 Bowstring Test
		12.6.7 Crossed SLR
		12.6.8 Slump Test
		12.6.9 Femoral Nerve Stretch Test/Reverse Straight Leg Raise Test
	12.7 Deformity Evaluation
		12.7.1 Kyphosis
		12.7.2 Scoliosis
			12.7.2.1 The Adam’s Forward Bending Test
		12.7.3 Flexibility of Curve
	12.8 Examination of Sacroiliac Joints
	12.9 Additional Orthopedic Examination
	12.10 Neurological Examination
	12.11 Motor Examination
		12.11.1 Bulk
		12.11.2 Tone
		12.11.3 Muscle Strength
		12.11.4 Bevor’s Sign
	12.12 Reflexes
		12.12.1 Deep Tendon Reflexes
		12.12.2 Biceps Reflex (C5, C6)
		12.12.3 Triceps Reflex (C7)
		12.12.4 Supinator Reflex/Brachioradialis Reflex (C6)
		12.12.5 Crossed Radial Reflexes
			12.15.5.1 Inverted Radial Reflex
		12.12.6 Knee Reflex (L3–L4)
		12.12.7 Ankle Reflex (S1)
		12.12.8 Clonus
		12.12.9 Peripheral Reflexes/Superficial Reflexes
			12.12.9.1 Babinski’s Reflex/Plantar Reflex
			12.12.9.2 Hoffmann’s Reflex
			12.12.9.3 Cremasteric Reflex
			12.12.9.4 Abdominal Reflex
			12.12.9.5 Bulbocavernosus Reflex (S2, S3, S4)
			12.12.9.6 Anocutaneous Reflex (S3, S4, S5)
		12.12.10 Coordination of Movements
			12.12.10.1 Static Romberg’s Test
			12.12.10.2 Dynamic Romberg’s Test
	12.13 Sensory Examination
	12.14 Autonomic Nervous System
	References
Chapter 13 Examination of a Child with Cerebral Palsy
	13.1 Definition of CP
	13.2 History-Taking
	13.3 Infantile Reflexes
	13.4 Assessment of Ambulatory Potential
	13.5 Physical Examination
		13.5.1 Classification
		13.5.2 Gait
		13.5.3 Power/Strength
		13.5.4 Selective Motor Control
		13.5.5 Tone Assessment
			13.5.5.1 Spasticity
			13.5.5.2 Tardieu Scale
			13.5.5.3 Dystonia
		13.5.6 Muscle Tendon Reflexes
		13.5.7 Joint Contractures
		13.5.8 Evaluation of Skeletal Deformation: Torsional Anomalies of Femur and Tibia
			13.5.8.1 Lever Arm Disease
			13.5.8.2 Femoral Anteversion
			13.5.8.3 Tibial Torsion
	13.6 Individual Joint Assessment in a Child with Cerebral Palsy
		13.6.1 Examination of Foot
			13.6.1.1 Equinus Deformity
			13.6.1.2 Equinovarus
			13.6.1.3 Pes Equinovalgus
			13.6.1.4 Hallux Valgus
		13.6.2 Examination of Knee Joint
			13.6.2.1 Popliteal Angle Test
			13.6.2.2 Rectus
		13.6.3 Examination of Hip Joint
			13.6.3.1 Hip Flexion Contracture
			13.6.3.2 Adduction Contracture
			13.6.3.3 Iliotibial Tract
	13.7 Evaluation of Upper Limb Involvement in Cerebral Palsy
	References
Chapter 14 Peripheral Nerve Examination in a Child
	14.1 Introduction
	14.2 History
	14.3 General Examination
	14.4 Local Examination
		14.4.1 Inspection
		14.4.2 Palpation
		14.4.3 Muscle Power
		14.4.4 Radial Nerve
			14.4.4.1 Brachioradialis
			14.4.4.2 Extensor Muscles of Wrist Joint
		14.4.5 Median Nerve
			14.4.5.1 Flexor pollicis longus
			14.4.5.2 Flexor Digitorum Superficialis and Lateral Half of Profundus
			14.4.5.3 Abductor pollicis brevis
			14.4.5.4 Opponens pollicis
		14.4.6 Ulnar Nerve
			14.4.6.1 Flexor Carpi Ulnaris
			14.4.6.2 Interossei
			14.4.6.3 First Dorsal Interossei and Adductor Pollicis
		14.4.7 Common Peroneal Nerve
			14.4.7.1 Presentation
		14.4.8 Combined and Mixed Nerve Lesions
		14.4.9 Sensations and Reflexes
		14.4.10 Nerve Course and Tinel’s Sign/Formication Sign
		14.4.11 Movements of Joints and Deformities
	Bibliography
Chapter 15 Evaluation of Swelling/Tumor in a Child
	15.1 Introduction
	15.2 History
		15.2.1 History of Swelling
			15.2.1.1 Onset
			15.2.1.2 Duration
			15.2.1.3 Progression
			15.2.1.4 Number
		15.2.2 History of Associated Symptoms
			15.2.2.1 Pain
			15.2.2.2 Constitutional Symptoms
			15.2.2.3 Loss of Function
	15.3 Examination
		15.3.1 GPE
		15.3.2 Local Examination of Swelling
			15.3.2.1 Inspection
			15.3.2.2 Palpation
			15.3.2.3 Movements
			15.3.2.4 Measurements
	15.4 Draining Lymph Nodes
Chapter 16 Evaluation of a Child with Short Stature
	16.1 Is the Child Really Short?
		16.1.1 One-Time Measurement
		16.1.2 Serial Monitoring
	16.2 Measurements
		16.2.1 Measuring Length/Height
		16.2.2 Measurement of Body Proportions
		16.2.3 Arm Span – Height Difference
	16.3 Growth Potential
	16.4 History and Physical Examination
	16.5 Correlation of Clinical Findings
		16.5.1 Skeletal Age
		16.5.2 Height Age
	16.6 Further Workup and Investigations
	References
Chapter 17 Evaluation of Pediatric Limb Deformities
	17.1 Introduction
		17.1.1 Differentiate Physiological Variants from True Deformity
		17.1.2 Identify the Deformity Plane (Frontal/Sagittal/Oblique/Axial)
		17.1.3 Identify the Deformity Site (Epiphysis and Metaphysis versus Diaphysis)
		17.1.4 Quantify the Deformity
		17.1.5 Identify the Etiopathogenesis of the Deformity
		17.1.6 Determine the Effects of the Deformity on Adjacent Joints and Gait
	17.2 Relevant History
	17.3 Relevant General Examination
	17.4 Assessment of Gait
		17.4.1 Varus Thrust Gait
		17.4.2 Valgus Thrust Gait
		17.4.3 Dynamic Knee Recurvatum
		17.4.4 In-Toeing and Out-Toeing
	17.5 Examination of Lower Limbs
		17.5.1 Assessment of Frontal Plane Limb Alignment and Deformity
		17.5.2 Assessment and Quantification of Sagittal Plane Deformity
		17.5.3 Assessment and Quantification of Axial Plane (Rotational) Deformity
		17.5.4 Assessment of Limb-Length Discrepancy
		17.5.5 Assessment of Joint Range of Motion
	17.6 Other Relevant Examination
	17.7 Summary
	Bibliography
Chapter 18 Miscellaneous Topics
	18.1 Rickets
		18.1.1 Presenting Complaints
		18.1.2 History
		18.1.3 Examination
	18.2 Muscular Dystrophies and Myopathies
		18.2.1 History and Findings
	18.3 Arthrogryposis
	18.4 Infective Conditions (Osteomyelitis/Septic Arthritis)
		18.4.1 Findings
	18.5 Child Abuse
		18.5.1 History and Findings
	18.6 Surface-Marking of Peripheral Nerves
		18.6.1 Median Nerve
			18.6.1.1 In the Arm
			18.6.1.2 In the Forearm
			18.6.1.3 In the Hand
		18.6.2 Radial Nerve
			18.6.2.1 In the Arm
			18.6.2.2 In the Forearm
		18.6.3 Posterior Interosseous Nerve or Deep Branch of Radial Nerve
		18.6.4 Ulnar Nerve
			18.6.4.1 In the Arm
			18.6.4.2 In the Forearm
			18.6.4.3 In the Hand
		18.6.5 Sciatic Nerve
		18.6.6 Common Peroneal Nerve
		18.6.7 Deep Peroneal Nerve
		18.6.8 Superficial Peroneal Nerve
		18.6.9 Medial Plantar Nerve
		18.6.10 Lateral Plantar Nerve
	References
Index