Evaluation of the Child

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Chapter 665 Evaluation of the Child

Lawrence Wells, Kriti Sehgal, John P. Dormans

A detailed history and thorough physical examination are invaluable in the evaluation of a child with an orthopedic problem. Often the child’s family and acquaintances are important sources of information, especially in younger children and infants. Appropriate radiographic imaging and, occasionally, laboratory testing may be necessary to support the clinical diagnosis.

History

A comprehensive history should include details about the prenatal, perinatal, and postnatal periods. Prenatal history should include maternal health issues: smoking, prenatal vitamins, illicit use of drugs or narcotics, alcohol consumption, diabetes, rubella, and sexually transmitted infections. The child’s prenatal and perinatal history should include information about the length of pregnancy, length of labor, type of labor (induced or spontaneous), presentation of fetus, evidence of any fetal distress at delivery, requirements of oxygen following the delivery, birth length and weight, Apgar score, muscle tone at birth, feeding history, and period of hospitalization. In older infants and young children, evaluation of developmental milestones for posture, locomotion, dexterity, social activities, and speech are important. Specific orthopedic questions should focus on joint, muscular, appendicular, or axial skeleton complaints. Information regarding pain or other symptoms in any of these areas should be appropriately elicited (Table 665-1). The family history can give clues to heritable disorders. It also can forecast expectations of the child’s future development and allow appropriate interventions as necessary.

Table 665-1 CHARACTERIZATION OF PAIN AND PRESENTING SYMPTOM

Location: Whether pain is localized to a particular segment or involves a larger area.

Intensity: Usually on a pain scale of 1 to 10.

Quality: Tumor pain is often unrelenting, progressive, and often present during the night. Pain at night particularly suggests osteoid osteoma. Pain in inflammation and infection is usually continuous.

Onset: Was it acute and related to specific trauma or was it insidious? Acute pain and history of trauma are more commonly associated with fractures.

Duration: Whether transient, only lasting for minutes, or lasting for hours or days. Pain lasting for longer than 3-4 wk suggests a serious underlying problem.

Progress: Whether static, increasing, or decreasing.

Radiation: Pain radiating to upper or lower extremities or complaints of numbness, tingling, or weakness require appropriate work-up.

Aggravating factors: Relationship to any activities such as swimming or diving or any particular position.

Alleviating factors: Is the pain relieved by rest, heat, and/or medication? Conditions such as spondylolysis, Scheuermann disease, inflammatory spondyloarthropathy, muscle pulls, or overuse are improved by bed rest.

Gait and posture: Disturbances associated with pain.

Physical Examination

The orthopedic physical examination includes a thorough examination of the musculoskeletal system along with a comprehensive neurologic examination. The musculoskeletal examination includes inspection, palpation, and evaluation of motion, stability, and gait. A basic neurologic examination includes sensory examination, motor function, and reflexes. The orthopedic physical examination requires basic knowledge of anatomy of joint range of motion, alignment, and stability. Many common musculoskeletal disorders can be diagnosed by the history and physical examination alone. One screening tool that has been useful in adults has now been adapted and evaluated for use in children, the pediatric gait, arms, legs, spine (pGALS) test, the components of which are listed in Figure 665-1.

Figure 665-1 The components of pediatric gait, arms, legs, spine screen (pGALS), with illustration of movement. Screening questions: (1) Do you have any pain or stiffness in your joints, muscles, or back? (2) Do you have any difficulty getting yourself dressed without any help? (3) Do you have any difficulty going up and down stairs? *Additions and amendments to the original adult gait, arms, legs, spine screen.

(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.

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