THE PEDIATRIC DIAGNOSTIC EXAMINATION - PART 5 potx

the hip, early Legg-Calve-Perthes disease, septic arthritis, osteomyelitis, fracture, diskitis, slipped capital femoral epiphysis, and inflammatory rheumatic joint disease. Causes of painless l imp include developmental dysplasia of the hip, spastic hemiplegic cerebral palsy with hip dislocation, Legg-Calve-Perthes disease, proximal femoral focal dysplasia, congenital coxa vara, and congenital bowing of the tibia. Toe Walking Toe walking (equinus gait) can be normal before 3 years of age. Common causes of unilateral toe walking are neuromuscular disease, hemiplegic cerebral palsy, relatively short le g, an d hip dislocation. Common cause s of bilateral toe walking are idiopathic or habitual and include cerebral palsy, neuromuscular conditions, Duchenne muscular dystrophy, myelom eningocele with tethered cord, and congenital contracture of the Achilles tendon. My Legs Hurt Acute and localized pain in the leg may be due to trauma, fracture, or infectious process. More diffuse aching pain should be differentiat ed from exertional-related undue fatigue indicative of metabolic or muscle disease. Juvenile myalgia (“growing pains”) is highly prevalent in children. Although the etiology and pathophysiol- ogy of this condition are not entirely clear, it is nonetheless a common cause of limb pain in children. Pain occurs typically at the end of the day, sometimes at night, and is deep and aching, affecting one or both lower limbs. It is most prevalent between the ages of 2 and 10 years, with a peak at about 5 years of age, and runs an intermittent course over a period of about 2 years. Massage, heat, and analgesics relieve the pain of juvenile myalgia. One Leg Is Short Leg-l ength inequality may be congenital or acquired and includes proximal femoral focal deficiency, coxa vara, hemi- atrophy-hemihypertrophy, Legg-Calve-Perthes disease, hemiplegic cerebral pa lsy, infectious osteomyelitis affecting the growth plate, trauma to the growth plate, and growth arrest or overgrowth owing to malunion. Appar- ent leg-length inequality may occur in neuromuscular disorders affe ct- ing lower back, spine, hip, and lower extremities. Does Not Move Her Arm Acute subluxation of the radial head can occur from a sudden pull of the arm, as in a child pulled by an adult or a child trying to reach for something high and catching himself or herself fr om falling. There is localized pain laterally over the elbow, mainly on attempt to move the elbow. The child typically will hold the arm close to the chest, with the elbow flexed at about 90 degrees and the arm partially pronated. There i s no swelling or local deformity. Closed reduction, gentle supination of the arm, and extension of the elbow followed by flexion are the treatment of choice. In many cases of trauma at this age, the history may not be clea r, and there always should be a high index of suspicion for a fracture. 314 Chapter 11: The Musculoskeletal System KEY PROBLEM KEY PROBLEM KEY PROBLEM KEY PROBLEM Joint Pain Causes of pain around the knee in children include injury to the distal femur and proximal tibia growth plate, lateral discoid meniscus, chronic juvenile arthritis, septic arthritis, juvenile osteochondritis dissec ans affecting the femoral condyles or the patella, acute lymphoblastic leu- kemia, and benign and malignant bone tumors. Many young children participate in gymnastics with great intensity, sp ending up to 30 to 40 hours per week in practice and competition in some cases. Wrist pain is a common symptom seen in young gymnasts and can be due to varied underlying pathology owing to overuse of the soft-tissue structures. Stress injury of the distal radial physis presents with activity-related chronic or recurrent pain (bilateral in about 30 per- cent) of the dorsal aspect of the wrist aggravated during floor exercises, vaulting, and loading the dorsiflexed wrist wi th localized distal radius and dorsal wrist tenderness. Early recognition of this condition is essen- tial to prevent the complication of premature fusion of the physis and growth arrest. In a child with a history of a fall on a n outstretched arm, one should have a high index of suspicion for fractures of the distal radius and scaphoid. Early recognition of elbow injuries in children involved in throwing sports is important to prev ent long-term complications. Throwing motion in a baseball pitcher imparts tremendous forces around the elbow that can lead to significant soft-tissue and bony injuries. If unrecognized and not treated early, these injuries can lead to long-term complications of elbow flexion contractures, intraarticular loose bodies, early arthritis, and functional limitations. Stress injury to the proximal physis of the humerus is an important consideration in a child presenting with shoulder pain who is involved in throwing sports. Acute pain also can occur in septic arthritis of the shoulder. Shoulder and upper back pain is also common in children car- rying heavy school ba gs and in children with bad posture. My Heel Hurts Sever disease refers to an overuse injury affecting the posterior calcaneal apophysis that presents with activity-related heel pain typically between 9 and 13 years of age. There is a hig h preva- lence in gymnasts, basketball players, and soccer players. Squeezing the heel medially and laterally elicits tenderness. It isa benign, self-limited condition, and its recognition will help to avoid unnecessary investiga- tions, overzealous treatment, or restriction of activities. Adolescents Limp Septic arthritis or osteomyelitis can affect joints or bones of the lower limbs, sacroiliac joint, symphysis pubis, or lumbosacral spine, causing a limp. Slipped capital femoral epiphysis can present as acute hip pa in or insidious, intermittent pain on weight bearing and movement. The hip is typically in external rotation and abduction. Patients with a slipped capital femoral epiphysis should have a referral to an orthope dic History 315 KEY PROBLEM KEY PROBLEM KEY PROBLEM surgeon on an emergent basis. Pain from the hip often refers to the knee. Pain in the groin and limp also can be due to a stress fracture of the femoral neck that requires an emergent referral for definitive treatment. Num erous conditions affecting the lower limb joints and bones can cause the adolescent to limp and appear in respective sections of this text. Bowlegs Juvenile Blount disease is an important consideration in adolescents who present with bowlegs. The juvenile form ini tially presents with progressively worsening genu varum, typically unilateral, and often seen in obese adolescents. Knee pain is not a consistent f eature. The diagnosis is apparent on examination, and radiographic features are characteristic. All patients with Blount disease should have a referral to a pediatric orthopedic surgeon for further evaluatio n and definitive management. Leg Pain Causes of pain in the leg include acute or stress fracture of the tibia or fibula, acute or chronic exertional compartment syndrome, medial ti bial stress syndrome (shin splints), neoplasia or infectious osteomyelitis of the tibia or fibula, acute musculotendinous strain, and deep vein thrombosis or superficial thrombophlebi tis. The most common site for stress fracture is the tibia and is directly a result of excessive, repetitive stress to the bone, typically from sport participation and running. The pain is consta nt, dull aching, typically localizes at the junction of the middle and lower thirds of the tibia, with localized tenderness, and worsens with weight bearing. In chronic exertional compartment syndrome, the symptoms relate to the speci fic leg compartment affected. The pain typically is concur- rent with the same activity, tends to recur at a specific time during the activity, and abates with a variable period of rest. Passive stretching of muscles in the compartment will reproduce the pain. Pain associated with fracture, neoplasia or infectious osteomyelitis is a constant and dull aching, occurs at rest, and often at nighttime. Other causes of lower limb pain include restless leg syndrom e and peripheral neuropathy. Pain from nerve is typically sharp, shooting or like pins and needles; vascular pain is throbbing; and articular or bone pain is dull aching pain. Neck Pain Pain and stiffness in the nec k also occurs in congenital, inflammatory, and infectious conditions affecting the head and neck region. It can be acute owing to soft-tissue strain or fracture of the vertebrae or insidious, as seen in diskitis, cervical spondylolysis, or lesions of the spinal cord such as syringomyelia. Disk herniation may present either acutely or insidiously. Syringomyelia may be associated with bilateral upper e xtremity paresthesia. Low Back Pain Low back pain is a common complaint in adolescents. Soft-tissue injuries (musculotendinous sprains and ligamentous 316 Chapter 11: The Musculoskeletal System KEY PROBLEM KEY PROBLEM KEY PROBLEM KEY PROBLEM sprains) are the most common cause, followed by postural or mechanical back pain and psychosomatic back pain. The most common identifiable cause of low back pain in adolescents is lumbar spondylolysis. Spondylolysis is a stress fractu re of the pars interarticularis most com- monly affecting L 5 and resulting from repetitive hyperextension, such as gymnastics. The pain is insidious in onset, intermittent, and activity- associated. With bilateral spondylolytic lesions at th e same level, there may be anterior slippage of the vertebra over the one below, resulting in spondylolisthesis. The most common identifiable cause of thoracic back pain in adolescents is Scheuermann disea se. Tumors such as osteoblastoma, osteosar- coma, and lymphoma and infection (osteomyelitis) are relatively more likely causes of significant back pain in adolescents that occurs at rest or during nighttime or is persistent. Disk rupture and herniation can cause acute or chronic intermittent low back pain. In adolescents, neurologic findings are uncommon. Slipped vertebral ring apophysis and apophyseal ring fracture can cause acute low back pain. Back pain due to infectious diskitis, vertebral osteomyelitis, or sacroiliitis may be either acute or insidious and may or may not be associated with systemic symptoms. Developmental con ditions of the spine—adolescent idiopathic scoliosis, spina bifida occulta, and lumbarization or sacralization—are uncommon causes of back pain. Neuromuscular scoliosis, syringomyelia, spinal cor d tumors, and tethered cord cause chronic back pain and may be associated with abnormal neurologic findings. Insidious onset, chronic, gradually worsening back pain is often the initial and only symptom of anky losing spondylitis, spondyloarthropathy, or juvenile chronic arthritis. Lower back pain may be referred pain from inflammatory bowel disease, renal disease, urinary tract infection, gynecologic condit ions, or intraabdominal neoplasms. Foot and Ankle Pain Stress fracture of the me tatarsal or tarsal bones can present with localized pain that is worse with weight bearing during running or jumping. In tarsal coalition, there is a fusion or failure of segmentation of two or more tarsal bones. Talocalcaneal and calcaneonavicular coalitions are the most common types and present with foot pain initially during adolescence that in- creases with activ ity and prolonged walking, especially on uneven ground. Pain in plantar fasciitis, occurring typically in runners, localizes to the ball of the foot, more prominent in the morning and on weight bearing. Other causes of foot pain in adolescen ts are metatarsalgia, osteomyelitis, puncture wound, sesamoiditis, Morton’s neuroma, Freiberg disease, Kohler disease, and tarsal tunnel syndrome. Ingrown toenails are a common cause of toe pain in adolescents. A bunion, or hallux valgus, is a common cause of pain in the great toe, especially in adolescent females who wear shoes with a narrow toe box and high heels. Bunion also may accompany metatarsus primum varus, shor t first metatarsal, and flatfeet. History 317 KEY PROBLEM Pain predominantly in the heel area is characteristic of Achilles tendonitis, tibialis posterior tendonitis, peroneal tendonitis and subluxation, calcaneal stress fracture, posterior calcaneal burs itis, and plantar fasciitis. Sprain is a common cause of ankle pain in adolescents. Most ankle sprains are inversion ty pe and present with lateral pain. Pain in the medial side associated wi th eversi on injury i s indicative of a more significant injury; associated injuries including fractures are possible. Chronic ankle pain can result from inadequately rehabilitated ankle sprain or other associated inj uries. The differential di agnosis of delayed recovery or per- si stent disability following ankle injury includes inadequate rehabilitation, anterior talar impingement, impingem ent spurs, peroneal tendon subluxation or dislocation, osteochondral fracture of the talus, tibiofibular syn- desmosis sprain, instability, nerve traction injury (superficial peroneal, sural, or t ibial), sinus tarsi syndrome, occult fracture, and reflex sympathetic dystrophy. Joint Pain Ascertain evolution of joint pain in terms of the nature of onset, duration, temporal sequence, and progressio n. Charac- terize pain based on location, acuity, severity, aggravating and relieving factors, diurnal variation, and progression. Note the circumstances of how the pain started. In case of an acute injury, inquire about the me chanism of injury. In chronic overuse injuries, a detailed history of the volume and intensity of physical activity, as well as the time frame of progression of the activity prior to the onset of pain, is impo rtant. Typically, joint pain owing to septic arthritis is of acute onset, whereas that owing to rheumatic disease or overuse syndrome is insidious. Localized pain may be due to conditions affecting the joint itself or those affecting the periarticular connective tissue, bursae, or tendons. Joint pain may be migratory, affecting multiple joints sequentially, as seen, for example, in disseminated g onococcal arthritis or acute rheumatic fever. It may be additive, affecting new joints while the joints affected previously are still symptomatic, as seen in juvenile chronic arthritis and spond yloarthropathies. It may be episodic, affecting one or more joints at a given time, as in inflammatory bowel disease or Lyme disease. Shoulder Pain Acute septic arthritis, shoulder dislocation, and fractures presen t with acute shoulder pain, swelling, and loss of motion. Acute traumatic biceps tendon strain or subluxation or supraspinatus musculotendinous tear also can present with acute pain. The causes of chronic or recurrent shoulder pain in the adolescent include glenohumeral instability, tears of the glenoid labrum, tendonitis of the long head of the biceps, subacromial bursitis, and rotator cuff impingement and ten donitis.Acromioclavicular joint sprain and atraumatic osteolysis of the distal clavicle pre sent with pain in the acromioclavicular joint area. Scapular dyskinesis, stress fracture of the scapula, and su prascapular neuropathy present with pain that is more wide- spread and discomfort in the shoulder region and the scapulothoracic area. Shoulder pain occurs in rheumatic diseases and myopathy. Shoulder pain may be ref erred pain from the neck in spine conditions, including 318 Chapter 11: The Musculoskeletal System KEY PROBLEM KEY PROBLEM cervical spinal cord impingement or tumor, syringomyelia, cervical disk herniation, cervical nerve root impingement, brachial plexus neuropathy, and thoracic outlet syndrome. In Paget-Schrotter syndrome, the patien t develops thrombosis of the axillary veins resulting from repetitive physical stress of the shoulder and arm and presents with effort-related shoulder and arm pain that may progress to further signs of vascular compromise. Elbow Pain Pre dominant location is important in evaluating intrinsic causes of elbow pain in adolescents. Lateral elbow pain is characteristic in lateral epicondylitis (tennis elbow), osteochondritis dissecans of the capitell um, and posterior interosseous nerve entrapment. Medial elbow pain occurs in flexor-pronator syndrome, medial collateral ligament sprain, ulnar neuritis or compressive neuropathy, a nd medial epicondylitis (golfer’s elbow). Posterior elbow pain is characteristic of olecranon bursitis, stress fracture of the olecranon, triceps insertional tendonitis, and intraarticular loose bodies. Ant erior elbow pain results from biceps strain or tendonitis, flexor-pronator exertional compartment syndrome, and anterior capsulitis. Juvenile chronic arthritis, infectious arthrit is, and fracture/dislocations are also significant causes of elbow pain in this age group. Wrist Pain Relatively more common intrinsic causes of chronic or recurrent wrist pain in adolescents include de Quervain tenosynovit is, distal radial physis stress injury, dorsal soft-tissue impingement syndrome, and triangular fibrocartilage complex injury. Le ss common intrinsic causes of chronic or recurrent wrist pain are many and include carpal instability, carpal bone chondromalacia, distal radiou lnar joint instability, ganglion cyst, intersection syndrome, Kienbock disea se, median nerve e ntrapment neuropathy, ulnar nerve entrapment neuropathy, stress fracture of the scaphoid, wrist flexor or extensor tendonitis, wrist joint capsulitis, and wrist splints. Hip, Groin Pain Causes of th e hip and groin area pain include slipped capital femoral epiphysis, late-onset Legg-Calve-Perthes disease, stress fracture of the femoral neck, stress fracture of the pubic rami, hip flexor adductor tendonit is, iliopectineal bursitis, trochanteric bursitis, iliac crest apophysi- tis, apophyseal avulsions (greater trochanter, lesser trochanter, ischial tuberosity), osteitis pubis, meralgia p aresthetica, snapping hip syndrome, iliopsoas abscess, acetabulum injury, malignancy, osteoid osteoma, rheumatic disease, and septic arthritis. Pain in the hip and groin may be referred pain from intr aabdominal, pelvic, and renal pathology. Knee Pain The most common cause of knee pain in older children and adolescents is idiopathic adolescent knee pain (patellofemoral syndrome) that can affect one or both knees. The patient presents with in- si dious onset poorly localized anterior knee pain that is mild to moderate History 319 KEY PROBLEM KEY PROBLEM KEY PROBLEM KEY PROBLEM in severity and aggravated with going up or down stairs and after prolonged sitting. It also can worsen with excessive activity that involves repetitive bending of the knees. Examination of the knee is no rmal in most cases. This is a benign, self-limited condition, and overzealous treatment or restriction of activities is unnecessary. The differential diagnosis of anterior knee pain includes patellar o r quadriceps tendonitis, prepatellar or infrapatellar bursitis, patellar stress fracture, multipartite patella, juvenile osteochondritis dissecans of the patella, patellar subluxation, Sinding- Larsen-Johan sson syndrome, patellar tendonitis, Hoffa’s fat pad syndrome, and Osgood-Schlatter disease. Causes of posterior knee pain are Baker’s cyst associated with a meniscal tear, fabella syndrome, gastrocne mius tendonitis, and hamstring tendonitis. Causes of medial knee pain include medial meniscal tear, pathologic medial synovial plica, pes anserine bursitis, semimembranosus bursitis/tendonitis, and juvenile osteochondritis dissecans of the medial femoral condyle. Predomi- nantly lateral pain is prominent in iliotibial band friction syndrome, popliteus tendonitis, discoid lateral meniscal injury, and d isruption of the proximal tibiofibular articulation. Pain in the knee occurs in systemic inflammatory diseases such as rheumatic diseases, hemophilia, and sickle cell arthropathy; infecti ous or reactive arthritis; benign and malignant bone tumors; and acute lymphoblastic leu- kemia. Pathologic conditions of the hip, such as slipped capital femoral epiphysis, Legg-Calve-Perthes diseas e, and stress fracture of the femoral neck, all may present with pain referred to the knee. Stiffness Stiffness is a feeling of discomfort or tightness associated with movement of a joint following a period of rest typically felt after an hour or so of inacti vity. Stiffness usually resolves with activity. Morning stiffness is characteristic of inflammatory or rheumatic diseases. Patients with fibromyalgia complain of generalized stiffness. Stiffness is not true locking of the j oint, which is due to a mechanical block. Joint Swelling Characterize joint swelling based on the acuity of onset and progression; precipitating or relieving factors; its location, size, and consistency; and whether it is w ell defined or diffuse. In- ternal trauma to a joint such as the ligament, cartilage, or intraarticular fracture, septic arthritis, and bleeding in a joint from a bleeding diathesis such as hemophilia all cause acute swelling , whereas chronic juvenile arthritis causes insidious onset and progressive swelling. Intermittent swelling is more characteristic of osteochondritis dissecans or intraarticular cartilage injuries. Weakness Weakness is a true loss of muscle power. It may result from neurologic disease, primary muscle disease, or systemic disease. Acute cerebrovascular insults can present with sudden onset of focal weakness or paral ysis, whereas insidious onset of weakness is more characteristic of primary muscle disease. Myopathy tends to affect 320 Chapter 11: The Musculoskeletal System KEY PROBLEM KEY PROBLEM KEY PROBLEM the proximal muscle more, whereas neuropathy tends to affect the distal muscles. Myopathy can be associated with muscle pseudohypertrophy, whereas neuropathy may be associated with paresthesia. Deterioration of Function The adolescent may first presen t with deterioration or inability to perform certain tasks, especially in sports, as a result of joint pain, limitation of motion, stiffness, or weakness. Constitutional Symptoms In addition to musculoskeletal features, TABLE 11–1 l ists systemic or constitutional signs and symptoms that are common in rheumatic diseases. History 321 KEY PROBLEM KEY PROBLEM TABLE 11–1 Systemic or Constitutional Symptoms and Signs Signs or Symptoms Condition Abdominal pain Inflammatory bowel disease, dermatomyositis, systemic lupus erythematosus, irritable bowel syndrome, Henoch-Schonlein purpura AlopeciaDermatomyositis, systemic lupus erythematosus (SLE) Chest pain SLE, acute rheumatic f ever Conjunctivitis Kawasaki disease, systemic vasculitis, Reiter syndrome DysphagiaDermatomyositis, systemic scleroderma DyspneaSLE, systemic vasculitis Fatigue Juvenile chronic arthriti s, dermatomyositis, fibromyalgia, SLE Fever Acute rheumatic fever, infectious arthritis, SLE, systemic vasculitis HeadachesSLE, fibromyalgia, systemic vasculitis HemoptysisSLE, systemic vasculi tis IritisBehçet disease, juvenile chronic arthritis, inflammatory bowel disease Mucosal ulcersBehçet disease, Reiter syndrome, disseminated gonococcal disease, inflammatory bowel disease Raynaud ph enomenon SLE, systemic scleroderma, reflex and vasomotor sympathetic dystrophy instability Skin rashesSLE, dermatomyositis, psoriatic arthritis, systemic vasculitis, Henoch-Schönlein purpura, acute rheumati c fever, Lyme disease Weight loss Inflammatory bowel disease, malignancy Physical Examination Neurologic examination for muscle tone, bulk, strength, and sensation is an integral part of musculoskeletal diagnosis. Chapters 5 and 12 contain components of the neurologic examination. Meticulous examination of the infant must identify and describe any congenital musculoskeletal anomalies. We discuss additional key aspects of the examination below. Infants Head Note the shape of the head. Measure the head circumfer- ence. Note any midfacial deficiencies, retrognathia, mandibular or max- illary hypoplasia, and/or frontal bossing. Head and face anomalies are frequent in a number of genetic syndromes. Feel the anterior fontanel, and palpate skull for swelling or defects. Neck Note swelling, deformity, range of motion, position, or attitude of the head and neck in relation to the chest (torticollis). Palpate for any soft-tissue mass in the neck and the cervical spine for deformity. In case of muscular torticollis, a firm, nontender swelling may be pal- pable in the belly of the sternocleidomastoi d muscle. There is restriction of range of motion and the typical position of the head and neck. Avoid hyperextension or flexion movements in Down syndrome when cervical spine anomalies or instab ility is present. Hypotonia and ligamentous laxity can predispose to cervical subluxation. Any degree of loss of the normal cervical lordosis or the presence of cervical kyphosis is pathologic and should prompt further investigation and pediatric orthopedic consultation. Congenital or developmental cervical kyphosis may be associated with Larsen syndrome, Conradi syndrome, cervical dysplasia, or neurofibro matosis. Shoulders, Clavicles Note range of motion and symme- try at shoulders and spontaneous movements of the shoulders and arms. In osteomyelitis of the humerus, septic arthritis of shoulder, or fracture of the humerus, the infant does not move the ar m. In fracture of the clavicle, there may be localized swelling, crepitus, and tenderness. The Moro reflex is absent on the side of a brachial plexus traumatic injury, fracture or osteomyelitis of humerus, septic arthriti s of the shoulder joint, or fracture of the clavicle. Also palpate the sternoclavicular joint for swelling or crepitus. Chest Wall Observe for pectus carinatum or excavatum (see Chapter 8). Palpate the ribs, and note any chest wall deficien cy. Pectus excavatum (or funnel chest) is usually present from birth, manifested as 322 Chapter 11: The Musculoskeletal System KEY FINDING KEY FINDING KEY FINDING KEY FINDING [...]... 1 3 5 10 1 3 5 10 65 degrees 55 50 40 40 degrees 40 45 45 15 60 degrees 15 60 20– 65 20– 65 40–90 degrees 35 75 30–70 25 55 Range = ±2 standard deviations Source: From Rudolph CD, et al (eds): Rudolph’s Pediatrics, 21st ed New York: McGraw-Hill, 2003, p 2424, with permission 328 Chapter 11: The Musculoskeletal System Long axis of thigh Thigh-foot angle Thigh-foot angle FIGURE 11– 15 Measurement of the. .. Nelson Textbook of Pediatrics, 17th ed Philadelphia: Elsevier-Saunders, 20 05, Fig 66 5- 0 4, p 2264, with permission.) FIGURE 11–14 Thigh-Foot Angle Measure thigh-foot angle with the child lying prone on the examination table with the hips extended and knees flexed at 90 degrees (FIGURE 11– 15) It is the angle between the long axis of the foot and the long axis of the thigh (a line bisecting the posterior thigh)... assess the degree of genu varum, have the patient stand with the legs (knees) together, and then measure the distance between the medial malleoli Similarly, to assess the degree of genu valgum, measure the distance between the medial epicondyles of the femur Assess true leg length with the child supine on the examination table, and measure the distance from the anterosuperior iliac spine to the medial... (FIGURE 11– 25) Loss of a definite endpoint to the motion indicates tear of the anterior cruciate ligament FIGURE 11– 25 Lachman Test Physical Examination 339 McMurray test With the patient supine on the table with the hip and knee flexed, with one hand over the knee with thumb on the lateral joint line, and the fingers on the medial joint line, passively extend and rotate the knee with the other hand... leg length is the distance between the umbilicus and the medial malleolus Other Key Areas of Examination The general approach to examination of other regions and joints is similar in children and adolescents, with some differential age-appropriate emphasis depending on the likelihood of predominant pathology at a particular age Details of the examination are similar to those described in the section... With the patient supine on the examination table with knees extended, apply laterally directed force to the patella Pain or apprehension indicates patellar subluxation Lachman test With the patient supine on the table with the knee at about 30 degrees of flexion, stabilize the femur with one hand just above the knee, and with the other hand just below the knee over the proximal tibia attempt to move the. .. Torticollis demonstrates the typical attitude of the neck and restricted motion TABLE 11–3 Normal Value of Thigh-Foot Angle Age Average Range 1 3 5 10 5 degrees +5 +10 + 15 –30 to +20 degrees –20 to + 25 –10 to + 25 +5 to + 25 Range = ±2 standard deviations Source: From: From Rudolph CD, et al (eds): Rudolph’s Pediatrics 21st ed New York: McGraw-Hill, 2003, p 2423, with permission Physical Examination 329 KEY... bisects the heel and extends to second toe, bisecting it When the long axis of the foot directs inward, the angle is negative, indicating in-toeing, and when it directs outward, the angle is positive and indicates the degree of out-toeing The normal range of foot progression angle is from –3 to 20 degrees Hip Rotation Assess hip rotation with the child lying prone on the examination table with the hips... instability with the arm pulled straight down (called the sulcus sign) There is flattening of the shoulder contour in anterior dislocation of the shoulder Note any swelling over the clavicles In most individuals, the dominant shoulder is relatively low compared with that of the nondominant arm From the back with the patient’s arms by the side, note any asymmetry of the scapulae Look for winging of the scapula... of the scapula—called the scapulohumeral rhythm—achieves abduction During abduction, typically there is a 2:1 ratio of movement at the glenohumeral-to-scapular movement—initial 30 degrees at the glenohumeral joint followed by rest of the 100 to 120 degrees accompanied by 50 to 60 degrees of scapular rotation Lesions of the glenohumeral joint cause a painful arc during abduction in the range of 45 to . 15 60 degrees 1 65 degrees 40–90 degrees 3 40 15 60 3 55 35 75 5 45 20– 65 5 50 30–70 10 45 20– 65 10 40 25 55 Range = ±2 standard deviations. Source: From Rudolph CD, et al (eds): Rudolph’s Pediatrics,. McGraw-Hill, 2003, Fig. 2 7-3 , p. 2423.) TABLE 11–3 Normal Value of Thigh-Foot Angle Age Average Range 1 5 degrees –30 to +20 degrees 3 +5 –20 to + 25 5 +10 –10 to + 25 10 + 15 +5 to + 25 Range = ±2 standard. Shape With the child prone on the examination table with the knees flexed at 90 degrees, note the shape of the foot. Physical Examination 327 (a) (b) FIGURE 11–14 Measurement of the hip rotation with the

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