Clinical Exam from Bone School website

Question 1

Angular deformity LL in Paeds Examination

Answer 1

Unilateral / bilateral

• angular profile
• femorotibial angle
• inter-malleolar / intercondylar distance (quantify)

LLD / rotational profile / joint laxity

Height vs Age

Question 2

Dynamic contractures in Cerebral Palsy Examination

Answer 2

R1 v R2

• R1 is passive range of motion performed slowly
• R2 is passive range of motion performed quickly
• a difference between the two indicates dynamic component

Question 3

Walking aids in Cerebral Palsy Examination

Answer 3

AFO / KAFO

• ankle foot orthosis
• knee ankle foot orthosis

GRAFO
- ground reaction AFO

Kaye walker

• seat on it
• co-ordinates walking

Reciprocal Gait Orthoses

Question 4

Gait in Cerebral Palsy Examination

Answer 4

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

Question 5

Supine Examination in Cerebral Palsy

Answer 5

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

Question 6

On the Side and Prone Examination in Cerebral Palsy

Answer 6

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

Question 7

Tone and Reflexes Examination in Cerebral Palsy

Answer 7

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

Question 8

Upper Limb Examination in Cerebral Palsy

Answer 8

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

Question 9

Full Examination in Talipes Equinovarus

Answer 9

Look, Walk, ROM, Feel, Exclude, Rotation

Look

Deformity / CAVES
Cavus - relative pronation of forefoot c.f. hindfoot
Adduction - forefoot
Varus - heel
Equinus - heel
Supination - midfoot

Posterior / medial crease
Curved lateral border of foot
Calf atrophy

Walk older child

Dynamic supination - require T anterior transfer
Metatarsus adductus
Foot progression angle - tibial torsion

ROM

DF
Eversion

Feel

Empty heel
Palpable talus - devils thumbprint anterior to lateral malleolus
Navicular fixed to medial malleolus
Os calcis fixed to the lateral malleolus

Exclude

• spinal dysraphism - look at spine
• arthrogryposis
• neuromuscular disorders

Rotational Profile

Question 10

Pes Planus Examination

Answer 10

On weight bearing have combination of

• flat longitudinal arch
• pronated forefoot
• valgus heel

Flexible flatfoot

1. Foot appears normal when suspended / NWB
2. Recreation of longitudinal arch & heel varus on toe raise / windlass
3. Recreation of longitudinal arch by passive DF of Hallux (Jack’s test) with weight bearing
4. Mobile or hypermobile STJ
5. Weight bearing callus on lateral longitudinal arch

Must look at back
- exclude spinal dysraphism

DDx

Congenital

Flexible

• compensatory - tight T achilles / out-toeing / genu valgum
• physiological

Rigid - CVT / tarsal coalition / skewfoot

Acquired

Trauma - midfoot fracture / Lisfranc / rupture spring ligament / rupture plantar fascia
Neuromuscular - CP, spina bifida, polio

Question 11

Toe Walking Paeds Examination

Answer 11

Rule Out

1. CP
2. Duchenne’s MD
3. CMT
4. Short Leg / DDH
5. Dysraphism

Hip

• Trendelenberg
• LLD

Spine

• signs spinal dysraphism
• scoliosis

Gait

• Heel / Toe walk
• running coordination - hemiplegic / brings out very minor posturing / look at UL

Gower’s sign

• Duchenne’s muscular dystrophy
• ask to squat then stand up
• have to hand walk up their legs as severe proximal muscle weakness

Upper limbs
- for hemiplegia, increased tone

Foot

• active +/- passive ROM
• sole of foot - if always on toes then heel will be soft
• Silverskiold

Neurological exam
- especially abdominal reflexes