Paediatric

Cerebral Palsy

Examination

 

Aids 

 

AFO / KAFO

- ankle foot orthosis

- knee ankle foot orthosis

 

GRAFO

- ground reaction AFO

 

Kaye walker 

- seat on it

- co-ordinates walking

 

Reciprocal Gait Orthoses

 

Sitting

 

Short adducted leg - dislocated hip

Scoliosis

Kyphosis - query secondary tight hamstrings

 

Walking

 

Decreased velocity 

 

Coronal Plane

- scissoring / tight adductors)

- asymmetrical arm swing / hemiplegia

- LLD / hip dislocation

 

Sagittal

- equinus / jump / crouch 

 

A.  Equinus

- ankle in equinus

- knee straight or in recurvatum

- hip extends full

 

B.  Jump

- equinus of ankle

- flexion of knees and hips, never extend fully

 

C.  Crouch

- ankle in dorsiflexion

- over lengthening of T Achilles

- have to flex knees and hips to regain centre of balance 

 

Lower Limb

 

R1 - do slowly

R2 - do quickly

 

Looking for a difference between the R1 and R2

- if reduced ROM on R2, have spasticity / dynamic element

- amenable to botox

 

Supine

 

1. Psoas

- FFD / Thomas test

- must test knee first

- do over edge of bed if FFD knee

 

2. Adductors

- scissored gait if bilateral

- apparent leg length inequality if unilateral

- Trendelenburg gait 

- decreased hip abduction

 

3. Hamstrings

- FFD at knee

- knee flexed at start of stance phase

 

Popliteal angle (hip flexed at 90°)

- straight is 0˚

 

Unable to sit up with legs straight

- decreased  SLR

- can't touch toes

 

4. Triceps Surae

- ankle equinus

- tiptoe gait

 

Silverskiold test 

- distinguish between the gastrocnemius and soleus

- test ankle DF range with knee flexed and extended

- if gastrocnemius tight, reduced DF with knee extended

 

On side

 

5. Iliotibial Tract

 

Obers' test 

- patient on side and flex knee with hip in neutral abduction then as flex knee further hip abducts 

 

Prone

 

6. Quadriceps

- stiff leg gait

- inability to flex knee with hip extended suggests tight rectus

 

Ely test (RF)

- child prone 

- when the knee is flexed the hip flexes suggesting tight RF

 

7.  Rotational profile

 

Tone

 

Increased / clonus / clasp knife

 

Reflexes

 

Increased

 

Primitive Reflexes

 

Moro  

- child supine in arms, allow head to drop back 

- arms & legs stick out in extension

- disappears by 4 months

 

Parachute

- arms and legs extend when child held prone

- appears at 5 months

 

Labyrinthine

- tone reduced & arms/legs flex when prone but increased tone & extended arms & legs with supine position

 

Upper Limbs 

 

General

- resting position

- contractures

- joint stability

 

Hand placement

- ability to place hand in space

- < 10 seconds

 

Stereognosis

- ability to identify ojects in hand without looking

 

LLD Exam

Four Physical Outcomes

 

1.  Symmetrical Stance & Level Pelvis 

 

A.  LL Equality

- Components equal with no deformity

 

B.  Components equal with bilateral symmetrical deformity

- eg Bilateral varus knees

 

2.  Symmetrical Stance with Oblique Pelvis 

 

Uncompensated LLD

 

3.  Asymmetrical Stance & Level Pelvis 

 

A. Fully Compensated LLD

- Flexed contralateral knee 

- Equinus ipsilateral ankle

 

B. Sagittal deformity with ipsilateral sagittal compensation

- FFD knee with Equinus & hip flex OR

- Fixed Equinus with flex knee & hip OR

- FFD hip with equinus & flex knee

 

C.  Coronal deformity with contralateral coronal deformity

- Valgus of knee & contralat varus of knee

 

4. Asymmetrical Stance with Oblique Pelvis 

 

A.  Partly compensated LLD

- Partly flexed contralateral knee

- Partly equinus of ipsilateral ankle

 

B. Coronal hip deformity with sagittal compensation

- Fixed hip adduction with contralateral knee flexion / ipsilateral equinus

- Fixed hip abduction with ipsilateral knee flexion / contralat equinus

 

C.  Sagittal def c coronal compensation

- FFD knee c ipsilateral hip abduction

- Fixed equinus c ipsilateral hip ADD

 

Leg length Examination

 

1.  Look

 

Posture

- flexed knee

 

Signs hemihypertrophy

- NF
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)

 

Scars

- trauma, infection

 

Aids / Shoes

- heel inserts / raises

 

2.  Gait

 

Children

 

Compensate well 

- Walk on toes short leg usually / equinus

- Flexion long knee uncommon as energy++

 

Adults

 

Compensate less well

- Walk with bilateral heel-toe gait

- Vaults over long leg

- Excess Sagittal head motion

 

3.  Measure LLD
 

A.  Functional LLD

- on blocks

- heels flat, nil knee FFD (if able)

- correct pelvic tilt

- should correct scoliosis

 

Conclusion

- if can make pelvis stable

- ASIS equal

- blocks are a quantitative measure of functional LLD

 

B.  Apparent LLD

 

Lying on bed

- measure from xiphisternum to medial malleolus

- no correction for contractures

 

C. Real / True LLD

 

Must correct for deformity in coronal and sagittal plane

 

Exclude

- hip adduction / abduction contracture

- hip FFD

- knee FFD

 

Scenarios

1.  Hip FFD

- pillow under both thighs

2.  Knee FFD

- pillow under both knees

3.  Hip adduction contracture won't correct to neutral

- measure each leg crossed over the other

4.  Hip abduction contracture won't correct to neutral

- place both legs in similar position

 

If there is a contracture, perform the above measures

- then meaure the intercalated segments

- from ASIS to medial joint line

- medial joint line to medial malleolus

 

4.  Identify site of shortening

 

Galeazzi

- must not forget can have small foot / old calcaneal fracture / wasted buttock

- hips and knees flexed

- side by side

- look for tibial / femoral shortening

 

If shortening above knee, find out if shortened above greater trochanter

- i.e. hip deformity

 

Bryant's triangle

- line perpendicular to GT and ASIS

- distance between

- quantify in fingerbreadths

 

Nelaton's line

- line from ischial tuberosity to ASIS

- GT should be on or below line

 

Klisics line

- GT to ASIS

- should aim to umbilicus

- will be more parallel

 

5.  Other

 

Examine Knee stability

- can have problems lengthening femur if ACL deficient

- i.e. fibula hemimelia

Ligamentous Laxity

Wynne Davies Ligamentous Laxity JBJS 1970

 

Original Paper

 

2486 individuals examined

- aged 1 week to 18 years

- at birth - no child lax jointed by criteria

- 2 years - 45% of normal children lax jointed

- 6 years - only 5% of normal children had lax joints

- 12 years - <1% of normal children had lax joints

 

Criteria

 

If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive

 

1. Thumb touching forearm on flexing wrist

2. Fingers parallel to forearm with wrist extension

3. Elbows extend past 180°

4. Knees extend past 180°

5. Foot dorsiflex past 45°

 

Ligamentous Laxity Thumb to ForearmLigamentous Laxity Elbow HyperextensionLigamentous Laxity Knee HyperextensionLigamentous Laxity Hands to Floor.

 

 

 

 

 

 

Pes Cavus

Goal Of Examination

 

1.  Identify possible aetiology

- NM axis

- RA

- trauma

- clubfoot / arthrogryposis

 

2.  Define the deformity & its flexibility

- fixed / flexible forefoot

- fixed / flexible hind foot

- fixed / flexible lesser toes

 

Look

 

Aids / shoes

 

Front

 

Stork Legs

Lesser toes clawing

Scars

Hands (dorsal wasting intrinsics (CMT 1), rheumatoid hands)

 

Medial Side

 

High Medial arch

Plantar flexed first ray

Claw first toe

 

Behind

 

Hindfoot varus

Calf muscle bulk

 

Back 

- scoliosis

- cutaneous manifestations spinal dysraphism

 

Double heel raise 

- Heel swings into varus or remains in valgus

- does the medial arch restore

- bilateral suggests neurological

 

Single heel raise

- Must put patient close to wall

- otherwise will cheat by pushing up or leaning forward against wall 

 

Coleman Block Test

- block under lateral foot

- allow first ray to touch ground

- Assess hindfoot

- If hindfoot varus flexible, heel corrects

- Elimination of forefoot deformity will correct hindfoot deformity if hindfoot flexible

 

Lateral side

 

Exclude calcaneo-cavus

 

Gait

 

Stiff ankle 

 

Marionette Gait / High stepping

- Fixed equinus (weak Tib ant)(back knee gait)

 

Tip toe & heel walk

 

Sit

 

Examine Sole

- callosities over metatarsal head

 

Feel

- tenderness

- thickening CPN

 

Move

- range AKJ

- range STJ

- Silverskiold

- active v passive

 

Motor examination

- T. Ach strong / plantarflexion

- T. Ant weak / dorsiflexion and inversion

- T. Post strong / plantarflexion and inversion

- PB weak / eversion

 

First MT

- is plantar flexion correctable

 

Claw toes 

- correctible

 

Neurological Exam

 

Abdominal Reflexes

 

Decreased or absent DTR

- CMT 1

 

Sensory decrease in 25%

Rotational Deformity Exam

NHx

 

In-toeing is normal up til 8 - 10 years

- combination ITT / PFA

- anteversion decreases, ETT increases

 

Causes Intoeing

 

PFA

- usually symmetrical

- unilateral consider CP

 

ITT

- usually asymmetrical

 

Foot

- metatarsus adductus

- CTEV

- metatarsus primus varus

- skewfoot

 

Causes out-toeing

 

ETT

- usually unilateral

- consider NM cause i.e. CP, SB

 

SUFE

 

Examination

 

Staheli's Torsional Profile

 

Look

 

Squinting patella

- rotation above patella, in femur

 

Foot Progression angle

- Us 10° out (0°-30°) 

 

Prone

 

Foot

- curved lateral border

- heel bisector should pass through second MT

 

Thigh- Foot Angle TFA

- knees flexed

- Reconstruct foot

- Usually 15° (0°-30°) ER

 

Transmalleolar Axis (TMA)

- knees flexed

- Usually 0 - 30° ER

 

Hip Internal Rotation

- Usually < 65° 

- > 70° = FAV

 

Gage's trochanteric angle

- GT most prominent laterally

- angle of tibia from verticle

 

Hip External Rotation

- Usually 40° (20-60°)

- Greater in young child

- Note IR + ER should  = 90°

 

 

Scoliosis Exam

Aims of Examination

 

1.  Identify cause

 

- Marfan's / Neurofibromatosis / Skeletal Dysplasia

 

2.  Balance & body asymmetry

 

3.  Exclude LLD as cause

- correct with blocks or sit patient

 

4.  Forward flexion / Adams forward bending

- look for rotation / rib hump

 

5.  Assess flexibility if considering surgery

 

Typical curve

 

The right shoulder is raised

The right scapula is prominent

The loin creases are asymmetrical

The pelvis is level

There is flattening of the normal thoracic kyphosis

There is a normal lumbar lordosis

On forward bending, there is a (mild/moderate/severe) (well rounded/angular) rib hump and a mild left lumbar fullness

 

Front

 

Maturity

- height / breasts / pubic hair

 

Skin

- cafe-au-lait spots

- axillary freckling (look in axilla)

- neurofibromas

 

Eyes

- Lisch nodule (NF)

- blue sclera (OI)

- cloudy cornea (mucopoly)

- dislocated lens (Marfan's)

- optic glioma

 

Mouth

- Abnormal teeth (OI)

- high-arched palate (Marfan's)

- large tongue (Achondroplastic)

 

Trunk

- pectus carinatum or excavatum

- protruberant sternum with sharp manubriosternal angle

 

Limbs

- hemihypertrophy

- dolichostenomelia (long limbs)

- arachnodactyly (thumb in palm)

- clubfoot - often first sign of dysraphism

- cavovarus foot

 

LLD

 

Side

 

Thoracic kyphosis

- exaggerated, normal or reduced / hypokyphotic

 

Lumbar lordosis

- exaggerated, normal or reduced

 

Protruberant abdomen

 

Back

 

Curve 

- right or left

 

Balanced or Unbalanced 

- alignment of C7 over gluteal cleft (ask for plumb bob)

 

Shoulder height

 

Scapular symmetry

 

Loin creases / lumbar fullness

 

Flattened heart-shaped buttocks

 

Pelvis 

- level or not (pant line or PSIS)

 

Spinal dysraphism

- hyperpigmentation / hairy patch / dimple / lipoma / tail

 

Leg length 

- if abnormal use blocks & reassess curve

 

Adam's test 

- hands together & bend forwards to touch floor

- mild/mod/severe rib hump

- well rounded or angular

- satisfactory unroll

 

Supine

 

SLR

- hamstring tightness

 

Neurological

- Reflexes UL / LL / Abdominal / Babinski

- Sensation

- Power UL/LL

 

Scoliosis + No Abdominal reflexes & No Axillary sensation 

 Syrinx till proven otherwise

 

Abdominal reflexes disappear during teens

 

Xray

 

"This is a PA spine radiograph of a __ old skeletally mat/immature Risser __ male/ female with Scoliosis"

 

"There is a R/L typical/atypical curve thoracic/lumbar curve ±  a R/L T/TL/L lower curve"

 

"The spine is/isn't balanced, the pelvis is/isn't level & the curve has a rotational component"

 

"The curve appears to be Idiopathic / Congenital / NF ? NM

 

Don't mention which is 1°/ 2° or postural or structural