associated findings: _skin_: neurocutaneous stigmata, scars neurological examination _pubertal staging:_ worsens in puberty respiratory compromise evidence of Marfan's if tall investigations: _bloods:_ inflammatory markers, antinuclear Ab and AI Ab imaging

palpate: localise tenderness movements: flexion 80 degrees extension 70 radial deviation 20 ulnar deviation 30

movements: flexion 135 degrees extension 0 supination 90 pronation 90 \ supination/pronation test with elbow flexed

Range of movement _"Put your hands above your head"_ flexion 90, abduction 180 _"Give yourself a hug"_ adduction 45 _"Scratch your back"_ internal rotation _"Hide your hands behind your back"_ internal roation 55, extension 45

jaw test movement TMJ opening and closing feel for crepitus look for micrognatihia and dental malocclusion C-spine flexion 45 extension 50 rotation 80 lateral flexion 40

examine child standing and bending forward look for kyphoscoliosis feel for tenderenss range or motion: flexion to toes, extension 30, lateral bending 50, lateral rotation 30 functional evaluation: shoes and socks

Look for wasting Note resting position Feel for tenderness Measure leg length between anterior superior iliac spine and medial malleolus Movement: flexion 120 degrees extension 30 internal rotation 35 external rotation 45 abduction 50 adduction 30 \ Internal and external rotation are measured with hips flexed

Ankle/feet ROM _sub-talar joints:_ plantar flexion 50 dorsiflexion 20 inversion 5 eversion 5 _mid-tarsal joints:_ abduction 10 adduction 20 _metatarsophalangeal:_ plantar flexion 45 extension 70

Musculoskeletal exam Flashcards by Elise Coker

Athrogryposis multiplex congenita

clinical: contraction of multiple joints and degeneration of motor neurons

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Inflammatory arthritis

associated findings:

eyes: blue sclera, uveitis
skin: striae, dermatomyositis rash, neurocutaneous stigmata, SLE rash, psoriatic lesions
nails: psoriatic changes
dactylitis
abdomen: HSM

investigations: check temperature, growth

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Scoliosis

associated findings:

skin: neurocutaneous stigmata, scars
neurological examination
pubertal staging: worsens in puberty
respiratory compromise
evidence of Marfan’s if tall

investigations:

bloods: inflammatory markers, antinuclear Ab and AI Ab imaging

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Wrist

palpate: localise tenderness

movements:

flexion 80 degrees
extension 70
radial deviation 20
ulnar deviation 30

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Elbow

movements:

flexion 135 degrees
extension 0
supination 90
pronation 90

*supination/pronation test with elbow flexed

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Shoulders

Range of movement

“Put your hands above your head”

flexion 90, abduction 180

“Give yourself a hug”

adduction 45

“Scratch your back”

internal rotation

“Hide your hands behind your back”

internal roation 55, extension 45

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Jaw and C-spine

jaw

test movement TMJ opening and closing
feel for crepitus
look for micrognatihia and dental malocclusion

C-spine

flexion 45
extension 50
rotation 80
lateral flexion 40

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Thoracolumbar spine

examine child standing and bending forward

look for kyphoscoliosis
feel for tenderenss
range or motion: flexion to toes, extension 30, lateral bending 50, lateral rotation 30
functional evaluation: shoes and socks

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Lower limbs

Gait

Leg length discrepancy

Make child squat: Proximal weakness

Make child stand on each leg: Trendelenburg

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Hips

Look for wasting

Note resting position

Feel for tenderness

Measure leg length between anterior superior iliac spine and medial malleolus

Movement:

flexion 120 degrees
extension 30
internal rotation 35
external rotation 45
abduction 50
adduction 30

*Internal and external rotation are measured with hips flexed

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Ankles/feet

Ankle/feet ROM

sub-talar joints:

plantar flexion 50
dorsiflexion 20
inversion 5
eversion 5

mid-tarsal joints:

abduction 10
adduction 20

metatarsophalangeal:

plantar flexion 45
extension 70

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Hand

Range of movement

MCP flexion 90, extension 30
PIP flexion 100
DIP flexion 90, extension 10

Assessment

“make a fist”: assesses median/ulnar

“make a star”: radial extends/adducts thumb, ulnar intrincic hand muscles

“make a circle”: medical opposes/flexes thumb

“touch fingers to your thumb”: dexterity, coordination

Function

grip
use utensils/cup/pencil
buttons

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Median nerve palsy

sensory loss: thumb and lateral fingers

wasting: thenar eminence

motor: weakness thenar eminence, opponens pollicis, lateral 2 lumbicals, adductor pollicis brevis

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Ulnar nerve palsy

sensory loss: medial 1.5 fingers

motor: claw hand, weakness and wasting of small muscles

sparing of thenar eminence

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Radial nerve palsy

sensory loss: snuffbox

motor loss: wrist, finger and thumb extension

weakness of extensors of wrist, thumb, MCP joints
wrist drop

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Erb’s palsy

causes: obstetric complications (shoulder dystocia)

deficit: C5/6 right>left but can be bilateral

features:

asymmetrical moro
adduction/internal rotation at shoulder
extension elbow
pronation of forearm
flexion of the wrist
hypotonic lumb
reduced bicep jerk

association: Horner’s

Klumpke’s palsy

(less common)

deficit: C8, T1

clinical:

claw hand

Osteogenesis imperfecta

genetics: AR/AD type 1 collagen

clinical:

blue sclera
short stature
bony deformities
decreased tone

investigations: skull XR (wormian bones)

Beighton score

Score more than 4 is generalised hypermobility:

Touch palms on the floor: spine hypermobility (1)
Extend 5th MCP joint >90 degrees (1 each side)
Oppose thumb to forearm (1 each side)
Extend elbow >10 degrees (1 each side)
Extend knee >10 degrees (1 each side)

Joint hypermobility

arthralgia:

anterior knee pain
worse stopping/starting exercise

difficulty gripping:

grasping pens/pencils

delayed walking:

clumsiness

Ehler danlos syndrome

clinical:

paper-like scars: forehead, LL
skin hyperelasticity
extreme joint hypermobility

types:

type 1. severe form: PROM, normal life expectancy, MV prolapse

type 3. hypermobility

type 4. vascular form: spontaneous rupture of arteries

Juvenille Idiopathic Arthritis

clinical:

onset <16 years
arthritis in one or more joints with swelling/effusion, limited ROM, tenderness, pain on movement
duration > 6 weeks
polyarticular: 5 or more joints
oligoarticular: 4 or less joints
systemic: intermittent fevers

Systemic JIA

clinical:

onset <5years
systemic: fevers precede by months, macular rash
polyarticular arthritis
other: anorexia, weight loss LN, HSM< pericarditis, pleural effusion, anaemia, uveitis, myalgia
ANA/RF negative
progresses to severe and long-term arthritis 1/3

Oligoarticular JIA (40%)

clinical:

onset 2-5years
large joints: knees, ankle, wrists
joints warm, swollen, tender
chronic uveitis 30%
leg length discrepancy

prognosis:

most resolve in 6 months
polyarthritis in 20%

Enthesitis related arthritis (15%)

**clinical:** * 90% males late childhood * few large joints: hip girdle, sacroilitis, spine * enthesitis: inflammation of tendon insertion * enthesitis in achilles, plantar fascia * sausage fingers (dactylitis) * acute eveitis 20% * HLA B27 positive 75% \*May develop ankylosing spondylitis

Polyarticular JIA

**clinical:** * 90% females * more than 4 joints in first 6 months * symmetrical both large and small joints * NO sacroiliitis * uveitis if ANA positive * RF 100%, ANA 75% * prognosis worse if ANA positive: poor functional outcome in 50% cases

Management arthritis

**Non-drug:** * physiotherapy: exercise, hydrotherapy * OT * spinting **Drug:** * NSAIDs * corticosteroid injection (oligoarticular) * systemic steroids * DMARDs (MTX) * Anti-TNF monoclonal Ab (infliximab)

Psoriatic arthritis

**definition:** chronic inflammatory arthritis \< 16 years **Vancouver criteria:** * arthritis with psoriatic rash * arthritis with 3 of 4: dactylitis, nail pitting/anycholysis, psoriasis-like rash, family hx psoriasis

Juvenille dermatomyositis

**onset:** 20% childhood **clinical:** * painful tender muscles with lethargy, rashes, proximal muscle weakness of shoulders or LL * asymmetrical * rash: upper eyelids/cheek, elbows, hyperaemic nail beds * dysphagia * skin calcification **investigations:** * elevated ESR/CPK * muscle biopsy

Hemihypertrophy

**causes:** * usually idiopathic * embryonal tumours: Wilm's, hepatoblastoma * syndromic: BWS, NG, Klippel-Trenauney sx (failure of BV, lymph vessel formation, Proteus

Short neck

**causes:** * Turner's * skeletal dysplasia * Klippel-Feil syndrome (congenital fusion c-spine)

Rickets

**signs of rickets:** * delayed dentition * delayed closure anterior fontanelle * bow legs * swelling epiphyses wrists/ankles * curving long bones * cranitabes * kyphoscoliosis * pathogical fractures * rickety rosary * myopathy **investigations:** * calcium, phosphate, Ca:Cr, ALP, PTH, vitamin D, XR

Intoeing

**causes:** * femoral anteversion * tibial torsion * metatarsus adductus

Foot drop

**clinical:** * stepping gait * unable to walk on heels **causes:** * lateral popliteal nerve palsy * peroneal muscle atrophy: hereditary motor/sensory neuropathy, CMT * poliomyelitis

Perthe's disease

**definition:** ischaemic necrosis of upper femoral epiphysis **clinical:** * onset 4 to 9 years * bilateral 15% * limp * pain **investigations:** XR **treatment:** bracing, surgery