(From Foster HE, Kay LJ, Friswell M, et al: Musculoskeletal screening examination [pGALS] for school-age children based on the adult GALS screen, Arthritis Rheum 55:709–716, 2006.)

Inspection

Initial examination of the child begins with inspection. The clinician should use the guidelines listed in Table 665-2 during inspection.

Table 665-2 GUIDELINES DURING INSPECTION OF A CHILD WITH MUSCULOSKELETAL PROBLEM

• The patient should be comfortable with adequate exposure and well-lit surroundings (lest some important physical finding be missed). Infants or young children may be examined on their parent’s lap so that they feel more secure and are more likely to be cooperative.

• It is important to inspect how the patient moves about in the room before and during the examination as well as during various maneuvers. Balance, posture, and gait pattern should also be checked.

• General examination findings should include inspection for skin rashes, café-au-lait spots, hairy patches, dimples, cysts, tuft of hair, or evidence of spinal midline defects that can indicate serious underlying problems that need review.

• General body habitus, including signs of cachexia, pallor, and nutritional deficiencies, should be noted.

• Note any obvious spinal asymmetry, axial or appendicular deformities, trunk decompensation, and evidence of muscle spasm or contractures. The forward bending test is valuable in assessing asymmetry and movement of the spine.

• It is essential to perform and document a thorough neurologic examination. Motor, sensory, and reflex testing should be performed and recorded.

• Any discrepancies in limb lengths as well as muscle atrophy should be recorded.

• The range of motion of all joints, their stability, and any evidence of hyperlaxity, peripheral pulsations, and lymphadenopathy should also be noted in all cases.

Palpation

Palpation of the involved region should include assessment of local temperature and tenderness; assessment for a swelling or mass, spasticity or contracture, and bone or joint deformity; and evaluation of anatomic axis of limb and of limb lengths.

Contractures are a loss of mobility of a joint from congenital or acquired causes and are caused by periarticular soft-tissue fibrosis or involvement of muscles crossing the joint. Congenital contractures are common in arthrogryposis (Chapter 674). Spasticity is an abnormal increase in tone associated with hyperreflexia and is common in cerebral palsy.

Deformity of the bone or joint is an abnormal fixed shape or position from congenital or acquired causes. It is important to assess the type of deformity, its location, and degree of deformity upon clinical examination. It is also important to assess whether the deformity is fixed or can be passively or actively corrected and whether there is any associated muscle spasm, local tenderness, or pain on motion. Classification of the deformity depends on the plane of deformity: varus (away from midline) or valgus (apex toward midline) (coronal plane), or recurvatum or flexion deformity (sagittal plane). In the axial skeleton, especially the spine, deformity can be defined as scoliosis, kyphosis, hyperlordosis, and kyphoscoliosis.

Gait Assessment

Children typically begin walking between 8 and 16 mo of age. Early ambulation is characterized by short stride length, a fast cadence, and slow velocity with a wide-based stance. Gait cycle is a single sequence of functions that starts with heel strike, toe off, swing, and heel strike. The four events describe one gait cycle and include two phases: stance and swing. The stance phase is the period during which the foot is in contact with the ground. The swing phase is the portion of the gait cycle during which a limb is being advanced forward without ground contact (Chapter 664). Normal gait is a symmetric and smooth process. Deviation from the norm indicates potential abnormality and should trigger investigation.

Neurologic maturation is necessary for the development of gait and the normal progression of developmental milestones. A child’s gait changes with neurologic maturation. Infants normally walk with greater hip and knee flexion, flexed arms, and a wider base of gait than older children. As the neurologic system continues to develop in the cephalocaudal direction, the efficiency and smoothness of gait increase. The gait characteristics of a 7 yr old child are similar to those of an adult. When the neurologic system is abnormal (cerebral palsy), gait can be disturbed, exhibiting pathologic reflexes and abnormal movements.

Deviations from normal gait occur in a variety of orthopedic conditions. Disorders that result in muscle weakness (e.g., spina bifida, muscular dystrophy), spasticity (e.g., cerebral palsy), or contractures (e.g., arthrogryposis) lead to abnormalities in gait. Other causes of gait disturbances include limp, pain, torsional variations (in-toeing and out-toeing), toe walking, joint abnormalities, and leg-length discrepancy (Table 665-3).

Table 665-3 CAUSES OF ABNORMAL GAIT

Leg-length discrepancy

Limping

A thorough history and clinical examination are the first steps toward early identification of the underlying problem causing a limp. Limping can be considered as either painful (antalgic) or painless, with the differential diagnosis ranging from benign to serious causes (septic hip, tumor). In a painful gait, the stance phase is shortened as the child decreases the time spent on the painful extremity. In a painless gait, which indicates underlying proximal muscle weakness or hip instability, the stance phase is equal between the involved and uninvolved sides, but the child leans or shifts the center of gravity over the involved extremity for balance. A bilateral disorder produces a waddling gait. Trendelenberg gait is produced by weak abnormal hip abductors. In single leg stance, a Trendelenberg sign can often be elicited when abductors are weak.

Disorders most commonly responsible for an abnormal gait generally vary based on the age of the patient. The differential diagnosis of limping varies based on age group (Table 665-4) or mechanism (Table 665-5). Neurologic disorders, especially spinal cord or peripheral nerve disorders, can also produce limping and difficult walking. Antalgic gait is predominantly a result of trauma, infection, or pathologic fracture. Trendelenburg gait is generally due to congenital, developmental, or muscular disorders. Limping in some cases may also be due to nonskeletal causes such as testicular torsion, inguinal hernia, and appendicitis.

Table 665-4 COMMON CAUSES OF LIMPING ACCORDING TO AGE

ANTALGIC	TRENDELENBURG	LEG-LENGTH DISCREPANCY
TODDLER (1-3 YR)
Infection	Hip dislocation (DDH)	−
Septic arthritis	Neuromuscular disease
Hip	Cerebral palsy
Knee	Poliomyelitis
Osteomyelitis
Diskitis
Occult trauma
Toddler’s fracture
Neoplasia
CHILD (4-10 YR)
Infection	Hip dislocation (DDH)	+
Septic arthritis	Neuromuscular disease
Hip	Cerebral palsy
Knee	Poliomyelitis
Osteomyelitis
Diskitis
Transient synovitis, hip
LCPD
Tarsal coalition
Rheumatologic disorder
JRA
Trauma
Neoplasia
ADOLESCENT (11+ YR)
SCFE		+
Rheumatologic disorder
JRA
Trauma: fracture, overuse
Tarsal coalition
Neoplasia

From Thompson GH: Gait disturbances. In Kliegman RM, editor: Practical strategies of pediatric diagnosis and therapy, Philadelphia, 1996, WB Saunders, pp 757–778.

DDH, developmental dysplasia of the hip; JRA, juvenile rheumatoid arthritis; LCPD, Legg-Calvé-Perthes disease; SCFE, slipped capital femoral epiphysis; −, absent; +, present.

Table 665-5 DIFFERENTIAL DIAGNOSIS OF LIMPING

ANTALGIC GAIT

Congenital

Tarsal coalition

Acquired

Legg-Calvé-Perthes disease

Slipped capital femoral epiphysis

Trauma

Sprains, strains, contusions

Neoplasia

• Unicameral bone cyst

Infectious

Rheumatologic

Juvenile rheumatoid arthritis

Hip monoarticular synovitis (toxic transient synovitis)

TRENDELENBURG

Developmental

Developmental dysplasia of the hip

Leg-length discrepancy

Neuromuscular

Cerebral palsy

Poliomyelitis

From Thompson GH: Gait disturbances. In Kliegman RM, editor: Practical strategies of pediatric diagnosis and therapy, Philadelphia, 1996, WB Saunders, pp 757–778.

Back Pain

Children frequently have a specific skeletal pathology as the cause of back pain. The most common causes of back pain in children are trauma, spondylolysis, spondylolisthesis, and infection (see Table 671-2). Tumor and tumor-like lesions that cause back pain in children are likely to be missed unless a thorough clinical assessment and adequate work-up are performed when required. Nonorthopedic causes of back pain include urinary tract infections, nephrolithiasis, and pneumonia.

Neurologic Evaluation

A careful neurologic evaluation is a part of every pediatric musculoskeletal examination (Chapter 584). The assessment should include evaluation of developmental milestones, muscle strength, sensory assessment, muscle tone, and deep tendon reflexes. The neurologic evaluation should also assess the spine and identify any deformity, such as scoliosis and kyphosis, or abnormal spinal mobility. Specific peripheral nerve examinations may be necessary.

As the nervous system matures, the developing cerebral cortex normally inhibits rudimentary reflexes that are often present at birth (Chapter 584). Therefore, persistence of these reflexes can indicate neurologic abnormality. The most commonly performed deep tendon reflex tests include biceps, triceps, quadriceps, and gastrocnemius and soleus tendons. Localized or diffuse weakness must be determined and documented. A thorough assessment and grading of muscle strength is mandatory in all cases of neuromuscular disorders.