Joint examination of a child

Lower limbs - Patient lying down

1. Inspection.

a. Symmetry.

b. Size (limb length, muscle wasting, joint enlargement).

c. Skin (scars, color, warmth, vascular pattern and vascular malformations).

d. Postural deformity (flexion, valgus).

2. Palpation.

a. Soles of feet, insertions of tendon into bone (enthesitis).

b. Joint margins (metatarsal squeeze, anterior ankle, medial knee).

c. Palpate joint enlargement. (Is it bony, soft tissue, or fluid?)

3. Active movement - Curl toes, dorsiflex ankles, bend knees and hips, watch for subtle compensatory movements.

4. Passive movement - Joint range of movement (note both increased range [hypermobility] and reduced range [restriction]). Forefoot and hindfoot inversion/eversion, relaxed passive extension of knees, internal rotation of hips (knees and hips flexed to 90%). Watch for subtle guarding and compensatory movements.

Upper limbs - Patient sitting up

1. Inspection similar to evaluation for lower limbs - Symmetry, size, scars, wasting, enlargement, nails.

2. Palpation - Joint margins (metacarpal squeeze, dorsal wrist, anterior glenohumeral), palpate bony enlargements, warmth.

3. Active movement - Finger extension, fist, tuck, wrist extension (prayer position), arms straight up then behind head then behind lower back, neck extension and rotation (chin to shoulder), beware compensatory movements (especially elbow lift on wrist flexion, lateral flexion of spine on shoulder abduction).

4. Passive movement - Joint range of movement, wrist flexion and extension (watch for subtle guarding and compensatory movements).

Axial skeleton - Patient standing up

1. Inspect symmetry from behind - Especially posterior ankles, pelvic position, spine.

2. Spinal movements - Scoliosis, lumbar mobility (lumbar curve on forward flexion, lumbar pain on hyperextension), cervical spine extension and lateral rotation.

3. Gait - Normal, tip toes, heels.

4. Muscle power - Gowers test, Trendelenberg gait.

5. Temporomandibular joint.

6. Sacroiliac joints - Direct palpation.

Courtesy of Yukiko Kimura, MD and Taunton R Southwood, MD, FRACP, FRCPA, FRCP, FRCPCH.

Graphic 55468 Version 5.0

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Joint examination of a child