Paediatrics: Bones and joints Clinical assessment

Bones and joints

Clinical assessment

History

This should focus on the following:

·  Presenting complaint:

•   pain—site, severity, onset, nature, duration/chronicity, exacerbating/ relieving factors, rest pain, radiation;

•   if child presents with knee pain, always ask about and examine the hips;

•   swelling—site, size, onset, duration, exacerbating/relieving factors;

•   limp—refusing to weight bear 9 history of trauma or injury;

•   morning stiffness/start-up pain;

•   deformity—static/worsening or improving condition.

•   Associated systemic symptoms:

•   infection (rigors, night sweats, flu-like symptoms);

•   loss of appetite/weight.

•   Antenatal and birth history—important with congenital conditions.

•   Neurodevelopmental milestones.

•   Past medical history—previous trauma, surgery, medical illnesses.

•   Sports and activities.

•   Drug history—glucocorticoid usage, allergies.

•   Family history—hereditary conditions.

•   Neurological screening:—important in syndromic children.

Examination

Inspection

Observe the child walking and at play (don’t forget to watch as they walk into the consulting room).

•   General:

•   height, weight, proportion (long limbs, short trunk);

•   skin (scars, lesions, colour, discharge)—soft tissue (swelling, muscle wasting, contractures), skeletal (alignment, rotation, limb length);

•   limb—amelia (absence), hemimelia (absence of distal half), phocomelia (hand/foot attached directly to trunk), syndactyly (fused digits), polydactyly (additional digits);

•   gait—antalgic, Trendelenburg, high stepping, short leg, crouch, abnormalities of lower limb/spine

•   Skeletal alignment:

•   Spine—normally there is a flexible kyphosis of the thoracic spine, a lordosis at the cervical and lumbar spine (not noticeable in neonates). look also for plagiocephaly, torticollis, scoliosis;

•   lower limb—check rotational profile, symmetric range of movement, varus/valgus deformity; always examine the hips;

•   feet—babies have ‘flat’ feet. The medial longitudinal arch develops during childhood. Look at the shoes! elbows—there is a mild valgus deformity when in extension especially in females.

• Mobility and gait: toddlers have a wide stepping jerky gait. As the child matures (by the age of 7yrs), the gait becomes more ‘adult-like’ with the heel strike, stance phase (whole of foot to the ground), push off phase, and arm swing. The cadence decreases and the step length increases.

•   antalgic (painful) gait—short stance phase (child does not want to put weight on affected limb);

•   high stepping gait—usually due to foot drop (child lifts foot higher off the ground to avoid tripping over);

•   Trendelenberg gait—look at pelvis. When weight is loaded on the ipsilateral side, the contralateral hemipelvis tilts downwards (due to weak abductors or neurological, muscular, or hip joint causes in the weight-bearing ipsilateral limb). The upper body is then used to counter-balance;

•   toe walking—consider neurological causes. In boys consider DMD and check creatine kinase (CK).

• Trendelenburg test: stand facing the child with your hands out, palms facing upwards. Ask the child to rest their hands (palms down) on your hands. Then ask the child to lift one leg. If the pelvis tilts downwards on the non-weight-bearing side (you will feel the downward pressure on your hand of this side) the test is positive.

• Gower’s sign: child should be able to independently stand from a sitting position without using their upper limbs. With weak lower limb muscles, the child may ‘crawl’ hands up thighs in order to stand up, e.g. in muscular dystrophy.

• Neurodevelopmental assessment

• Can the child hop on either foot?

• Can the child climb on to the examination couch?

Feel

Tenderness, warmth, swelling (firmness, fluctuant), leg length discrepancy (true leg length: measure from the anterior superior iliac spine to the medial malleolus), pulses.

Move

• General: muscle tone, symmetric full joint range of movement, hyperlaxity/stiffness, contractures (are they fixed or can they be overcome?).

• Spine: fixed/correctable deformity?

• Hip: Ortolani and Barlow tests

Knee: patella instability, anterior drawer/Lachman test (ACL integrity)