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The Orthopaedic Examination: Clinical Application
The author wishes to acknowledge the contribution of John G. Birch for his work in the previous edition version of this chapter.
It is important for orthopaedic surgeons to be familiar with the numerous musculoskeletal and neuromuscular examinations detailed in Chapter 3 . Over time the orthopaedist will most likely perform many of these examinations on different patients presenting with a variety of complaints. If the nature of the patient’s medical condition is unclear, the physician may have to perform a comprehensive examination to arrive at a differential diagnosis.
However, in most cases the orthopaedic surgeon does not have the time or the need to perform an all-encompassing examination on every patient seen in the clinical setting. In the real world, the pediatric orthopaedic examination must be tailored to the child’s age, level of cooperation, and chief complaint. The two most common types of examinations performed are the screening examination and focused examination.
Screening examinations are performed as part of a comprehensive or abbreviated examination to detect disorders that may be asymptomatic but could cause significant morbidity or mortality if undiagnosed and untreated. Focused examinations concentrate on specific abnormalities for which the patient has been referred or on the chief presenting complaint. With these factors in mind, the examiner should make the clinical assessment as orderly and organized as possible to avoid neglecting any essential parts of the examination. The final section of this chapter addresses the art of examining the pediatric patient.
Although it is not difficult to outline the recommended principles for conducting the pediatric examination, rarely does the physician have the luxury of the ideal environment when seeing patients in the clinic. An uncooperative child, the presence of multiple family members, and limited time provide an impetus to perform the examination as expeditiously as possible while still maintaining good rapport with the patient and parents. To assist physicians inexperienced in examining children, we offer a number of suggestions based on years of personal experience that should help the physician conduct an examination that is efficient and enjoyable.
Screening Examinations
Screening examinations are conducted to determine whether the patient has any undiagnosed disorders that may be potentially harmful or deleterious if left unmanaged. In pediatric orthopaedics, two primary disorders of this sort are undetected developmental dysplasia of the hip (DDH) and scoliosis.
Hip Examination
All children are at risk for DDH, which, if not treated appropriately, can result in a limp and early degenerative arthritis. Because the condition is asymptomatic, all newborns and infants should be screened regularly for the condition until they have developed a mature normal gait. The most common clinical methods of detecting DDH are the tests for the Barlow sign and Ortolani sign.
First, the test for the Barlow sign is performed to determine whether the hip is dislocatable (i.e., whether the femoral head can be pushed out of the acetabulum on examination; Fig. 4.1 ). The examiner attempts to subluxate or dislocate the femoral head from within the acetabulum by gently pushing the relaxed infant’s hips laterally and posteriorly, with the leg in 90 degrees of flexion and neutral abduction. If there is instability, the femoral head will dislocate from the acetabulum and then spontaneously reduce, with a distinct “clunk” when pressure on the leg is relaxed. This may be the only physical finding on examination. Next, the examiner should determine whether the femoral head is dislocated out of the acetabulum by testing for the Ortolani sign ( Fig. 4.2 ). In neonates, it is usually possible to reduce the dislocated femoral head temporarily by gently abducting the hip and lifting the upper leg forward. A distinct clunk will be felt as the head is reduced. When pressure on the leg is released, the femoral head will dislocate again. If the hip is dislocated, physical findings may include limited abduction (normal abduction is approximately 90 degrees), asymmetric thigh folds (excess on the affected side), and shortening of the leg compared with the opposite side.
In some babies the examiner finds a hip which easily dislocates and relocates as the hip is adducted and then abducted. Depending on where the exam started, this exam could be considered positive for either an Ortolani sign or a Barlow sign. We prefer to describe the finding itself rather than rely on an interpretation of the eponyme.
Other Newborn Screening Examinations
Newborns should also be screened for spinal deformities and malformations (e.g., torticollis, spinal dysraphism), digital anomalies (e.g., syndactyly, absence), long bone deformities, and foot deformities (e.g., intoeing, rigid metatarsus adductus, clubfoot, calcaneovalgus foot). All children should also be evaluated for normal lower extremity alignment, limb length inequality, kyphosis, and gross motor skills. In addition, the child’s height, weight, and head circumference should be measured and charted to determine if the following are present:
- 1.
Weight or height is excessively high or low
- 2.
Weight or height is disproportionate
- 3.
Head circumference is disproportionate for height and weight
- 4.
Weight, height, or head circumference deviates from the percentile line identified for any particular child
Scoliosis Examination
Scoliosis can result in severe cosmetic deformity and pulmonary compromise. The forward-bending test is a reliable means of screening for scoliosis. The examiner views the patient from the back during the test. The patient stands evenly on both legs, with the knees straight, and then bends forward at the waist, with the arms hanging free. The examiner evaluates the back for elevation of one hemithorax or flank relative to the other to determine the presence of a rotational deformity caused by scoliosis.
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