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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

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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

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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

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- 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

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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

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- 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

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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

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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

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- 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

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- 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

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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

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- 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°

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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)

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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

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- 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

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- 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

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- 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

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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

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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

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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

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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

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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

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- 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"

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

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

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