Mark Webb. Shoulder examination, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31287
Johnny is five. He fell onto his outstretched arm and now is sat in your ED, crying and holding his shoulder adducted. Triage has been ace and given him analgesia so he is adequately comfortable before you examine him.
Joint examinations can be easily remembered by “look, feel, move” and special tests. It’s important that in addition to the joint you’re interested in that you also examine the joint above and below.
Look
- Deformity
- Swelling
- Atrophy: Asymmetry
- Wounds
- Bruising
- Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and thought to cause skin necrosis, although this is controversial)
A chaperone may be needed to expose the joint adequately in older children.
Feel
Feel for warmth, which could indicate septic arthritis.
From the front:
Start medially at sternoclavicular joint
- Clavicle
- AC joint
- Coracoid process
- Humeral head
From the back:
- Scapula: spine, supraspinatus, infraspinatus muscle
Neurovascular assessment:
- Check for distal pulses: brachial/ radial.
- Always check the regimental patch for axillary nerve injury and document it.
Move
Assess for range of motion, both active and passive.
Flexion: 180 degrees. Raise arm forward up until they point to the ceiling.
Extension: 45-60 degrees. Stretch the arm out behind them.
ABduction: 150-160 degrees. Put arms out to the side like an aeroplane’s wings and then bring them above their head to point to the ceiling.
ADduction: 30-40 degrees. Put arms out to the side like an aeroplane’s wings and move them in front of their body so they cross over.
External rotation: 90 degrees. Tuck their elbows to their side and swing the hands out.
Internal rotation: 70-90 degrees. Tuck elbows to the side and bring their hands across their tummy.
Scapula winging: Ask the child to push against the wall or your hand. If the scapula wings out this suggests long thoracic nerve pathology.
Some special tests
It is easy to get lost in the number of special tests when examining the shoulder and the trick is to perform those most relevant to the patient in front of you. Many are to test the integrity of the rotator cuff tendons, i.e. Supraspinatus, Infraspinatus, Teres minor and Subscapularis. (SITS)
“Appley Scratch” test: (1) Ask the child to reach behind their back to touch the inferior border of the opposite scapula (internal rotation and aDDuction) and then (2) reach behind their head to touch the superior angle of the opposite scapula (external rotation an Abduction). A positive test of pain indicates tendinitis of the rotator cuff, usually supraspinatus.
Empty can test: Ask the child to hold their arm raised parallel to the ground and then point their thumbs towards the ground as if they were holding an empty can (this rotates the shoulder in full internal rotation while in abduction). Then push down on the child’s wrist while asking them to resist. A positive test is pain or weakness, suggestive of supraspinatus tear or suprascapular nerve neuropathy.
Lift off test: The child stands and places the back of their hand against their back. Put your hand against theirs, palm to palm, and ask them to push against you. A positive test is pain or weakness, indicating subscapularis muscle pathology.
Scarf test: Ask the child to wrap their arm over the front of their neck reach down over their opposite shoulder towards the scapula (like a scarf). Pain over ACJ when doing this indicates ACJ pathology.
Although the standard approach to limb examination involves a LOOK, FEEL and MOVE (and special tests) structured assessment, in reality, if a young patient has a significant injury, a more pragmatic approach is needed. An X-ray may be warranted before a more thorough exam. This doesn’t mean that you can get away without a documented range of motion exam (even if you explain it is limited by pain) and neurovascular assessment.
Back to Johnny. You noticed a deformity over the middle third of the clavicle, but no skin tenting. He was neurovascularly intact and range of movement only marginally reduced by pain, so you discharged him with a broad arm sling and follow-up (or not) according to your local guidelines.
Selected references
Carson, S., Woolridge, D.P., Colletti, J. and Kilgore, K. (2006) Pediatric upper extremity injuries. Pediatric Clinical North American: 53(1) pp. 41-67
Chambers, P.N., Van Thiel, G.S. and Ferry, S.T. (2015) Clavicle Fracture more than a theoretical risk? A report of 2 Adolescent cases. The American Journal of Orthopedics. 44(10)
https://fpnotebook.com/Ortho/Exam/ShldrExm.htm [Accessed April 2019]
McFarland, E.G., Garzon-Muvdi, J., Jia, X., Desai, P. and Petersen, S.A. (2010) Clinical and diagnostic tests for shoulder disorders: a critical review. British Journal of Sports Medicine. 44(5) pp. 328-32.
NationwideChildrens.org/Sports-Medicine
https://shouldercomplexgocatsnmu.weebly.com/range-of-motion.html [Accessed April 2019]
Foot and toe injuries
Taskin Kadri. Foot and toe injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32663
A child’s foot is significantly more cartilaginous than an adult foot, making foot fractures an uncommon injury in children. Foot fractures constitute about 5-8% of paediatric fractures. Evaluation and management of a paediatric foot injury requires an understanding of paediatric anatomy, a careful history, clinical examination, and potentially radiography.
Normal anatomy
The foot is anatomically divided into 3 sections: hindfoot, midfoot and forefoot.
The hindfoot includes the talus and calcaneus. The inferior surface of the talus is more prone to avascular necrosis due to its retrograde blood supply. The part of the calcaneus most prone to fracture is its large posterior facet.
The midfoot includes the navicular, cuboid and the three cuneiform bones.
The forefoot includes the metatarsals and phalanges.
Evaluation of foot injuries
History
The following specific enquiries should be made about the injury:
Examination
Clinical examination should be tailored to the history.
Look
For external skin abrasions or obvious open fractures.
Feel
Palpation of the bones: tarsals, metatarsals, toes and the base of the 5th metatarsal.
Palpation for tenderness along the ligaments: deltoid ligament on medial side and anterior talofibular, calcaneofibular and posterior talofibular ligaments on the lateral side.
Move
The active movement should be followed by passive movement as much as pain allows.
The usual range of movements are: subtalar eversion (15-20°), subtalar inversion (35-40°), forefoot adduction (20°), forefoot abduction (10°), 1st metatarsal phalangeal (MTP) flexion (45°), 1st MTP extension (70-90°) and free motion of lesser toes.
Neurovascular examination
Two pulses: dorsalis pedis and posterior tibial.
Five sensory nerves: saphenous (medial calf and hindfoot), superficial peroneal (dorsum of the foot), deep peroneal (1st dorsal webspace), sural (lateral foot) and posterior tibial nerve (plantar foot and heel).
Imaging
The Ottawa foot rules can be applied to children. The rules have 97-100% sensitivity in paediatric injury investigation. According to the rules, x-rays of the foot are required if the child is unable to weight bear both immediately after the injury and in the ED, plus bony tenderness over the base of 5th metatarsal or the navicular.
Accessory ossicles
Accessory foot ossicles can cause pain as a result of stress injuries. The navicular ossicles, arise either on the medial side of (os tibiale externum) or on the lateral tubercle of the navicular bone (os trigonum).
Os tibiale externum
This is an ossification centre that arises at the site of the tibialis posterior tendon on the medial side of the navicular bone. It becomes an accessory bone when it fails to fully ossify. It is present in 4-14% of patients.
The usual presentation is in adolescence when the patient has pain from overuse, especially in athletes.
Examination may reveal pes planus (flat foot). This happens as the tibialis posterior tendon, maintaining the medial longitudinal arch, attaches to the accessory bone rather than the navicular bone.
Investigations include plain films and, occasionally, MRI scan.
Treatment is initially conservative with orthotics and casting. The ossicle is excised if these measures fail to resolve the pain.
Os trigonum
This is present in 10-25% of the population. It is often associated with heel pain in ballet dancers due to repetitive microtrauma.
Hindfoot fractures
These are rare, constituting only 0.008% of all paediatric fractures. Children usually present after falling from height or after a motor vehicle injury. The talus can be fractured in multiple places including avulsion fracture.
‘Snowboarder’s fracture’ is a fracture of the lateral process of the talus. The mechanism of injury involves dorsiflexion and inversion.
Do not miss: Snowboarder’s fractures are often misdiagnosed as an ankle sprain. If not evident on x-ray, a CT or MRI should be performed if there is clinical suspicion. Think carefully about the mechanism.
Calcaneus fractures typically occur due to axial loading and are frequently associated with vertebral compression fractures. Radiography should include AP, lateral and axial views. The axial view offers a better view of the fracture.
Treatment of talus and calcaneus fractures is dependent on the degree of displacement.
Midfoot fractures
These are also rare fractures and usually result from severe blunt injury. Most fractures are avulsion or stress fractures and are associated with other injuries.
Treatment depends on the severity of displacement of the fracture and associated injuries.
Midfoot fractures have minimal long term sequelae.
Forefoot fractures
Forefoot fractures represent about 60% of paediatric foot fractures and can result from either direct or indirect trauma. They are easily missed: about 41% are missed due to high energy trauma causing other significant injuries.
Lisfranc fracture
Lisfranc fractures occur due to axial loading with forced plantar flexion (commonly seen in bicycle or horseback riders where a foot gets caught in a pedal or stirrup) or with a crush injury.
Clinical examination
Diagnosis is made with a weight bearing x-rays (as the fracture may not be evident on non-weight bearing views) – AP, lateral and oblique radiographs of the foot. The normal alignment of the foot should have the 2nd metatarsal aligning with the intermediate cuneiform on the dorsoplantar view and the 3rd metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms to the 2nd metatarsal. Disruption of this ligament leaves the foot unstable and hence it is an important not to miss this injury. Due to the ligament attachment, there is often associated fracture of the bases of the 1st or 2nd metatarsal in a Lisfranc injury.
Treatment depends on the degree of severity of the injury.
There is a high rate of residual pain in children with a Lisfranc injury.
Metatarsal fractures
Metatarsal fractures are associated with athletic activity and are becoming more common. The 5th metatarsal is the most commonly fractured metatarsal in paediatric patients. It can result from twisting, repetitive stress or direct trauma. 1st and 5th metatarsal fractures can be isolated whereas 2nd-4th metatarsal fractures often occur along with other metatarsal fractures. It is a frequently missed fracture on a radiograph.
Children younger than 5 years of age are more likely to be injured by a fall from height and fracture the 1st metatarsal. Older children are more likely to fracture it from falling from a standing position, during sports and tend to fracture the 5th metatarsal.
Pseudo-Jones fracture
A Pseudo-Jones fracture is an avulsion fracture of the base of the 5th metatarsal resulting from a twisting injury of the foot. The examination will reveal focal point tenderness. The patient should be immobilised for 3-4 weeks in a weight-bearing cast.
Treat with a short walking boot or hard sole shoe for 6 weeks. Follow-up with orthopaedic surgeons.
Jones fracture
The Jones fracture is a fracture of the metaphyseal-diaphyseal junction at the base of the 5th metatarsal bone. It is the most common of metatarsal fractures (40%), representing about 25% of all paediatric foot fractures.
Fractures at or distal to the metaphyseal-diaphyseal junction require 6 weeks in a non–weight bearing cast, with crutches. All patients should be referred to orthopaedic surgeons as there is a high incidence of delayed union of the fracture. Many of these patients will require ORIF subsequently.
The apophysis of the base of the 5th metatarsal appears at age 10 for girls and at age 12 for boys. An unfused apophysis runs longitudinally whereas pseudo-Jones fracture runs transversely.
Toe fractures
Toes fractures are one of the most common fractures in the paediatric population. Phalangeal fractures constitute about 3-7% of all physeal fractures and are usually Salter-Harris I or II injuries. They are more common in boys than girls and are mostly closed in nature.
The patient may present with localised tenderness to the toe, a limp or inability to bear weight. Nail bed bleeding and bleeding from or around the nail fold should prompt the possibility of an open fracture through the nail bed. Alignment, rotation and neurovascular status should be checked.
Fractures of the 2nd-5th toes are usually treated by buddy strapping and weight bearing as much as possible. Healing can take up to 3-4 weeks. A hard-soled shoe or walking boot may be used for patient comfort. Follow-ups with orthopaedic surgeons can cease 3 weeks after the injury. If there is possible injury to physis then follow-up should continue for 1-2 years to detect abnormal growth.
The big toe
The big toe plays an important part in bearing weight. Fractures of the big toe are therefore managed slightly differently. Salter-Harris III or IV fractures of the proximal phalanx of the hallux are often intra-articular.
Urgent orthopaedic consultation for closed or open reduction for K wiring if:
In other cases, toe platform cast or a walking boot is used.
The epiphysis of the proximal phalanx of the 1st toe is sometimes bipartite, simulating a Salter-Harris III fracture. If there is no tenderness on the 1st toe, no treatment is indicated.
Phalangeal open fractures require thorough irrigation and debridement in addition to antibiotics to avoid osteomyelitis. A nail-bed injury to the germinal matrix will require surgical repair.
Long term complications include growth arrest and angular deformities from physeal injury, degenerative joint disease from intra-articular fractures and osteomyelitis from open fractures.
References
Boutis K: Paediatric metatarsal and toe fractures. Up to Date 2019
Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].
Boutis, K., 2021. UpToDate. [online] Uptodate.com. Available at: <https://www.uptodate.com/contents/foot-fractures-other-than-metatarsal-or-phalangeal-in-children> [Accessed 4 April 2021].
Eiff, M. and Hatch, R. Fracture management for primary care and emergency medicine. Elsevier.
Halai, M., Jamal, B., Rea, P., Qureshi, M. and Pillai, A., 2015. Acute fractures of the pediatric foot and ankle. World Journal of Pediatrics, 11(1), pp.14-20.
Horner K and Tavarez M, 2016. Paediatric Ankle and Foot Injuries. Clin Pediatr Emerg Med, 17 pp. 38-52
Juliano, P., 2018. Lateral Talar Process Fractures – FootEducation. [online] FootEducation. Available at: <https://footeducation.com/lateral-talar-process-fractures/> [Accessed 4 April 2021].
Malanga, G. and Ramirez – Del Toro, J., 2008. Common Injuries of the Foot and Ankle in the Child and Adolescent Athlete. Physical Medicine and Rehabilitation Clinics of North America, 19(2), pp.347-371.
Metaizeau, J. and Denis, D., 2019. Update on leg fractures in paediatric patients. Orthopaedics & Traumatology: Surgery & Research, 105(1), pp.S143-S151.
Smit, K. Foot Fractures – Phalanx | Pediatric Orthopaedic Society of North America (POSNA). [online] Posna.org. Available at: <https://posna.org/Physician-Education/Study-Guide/Foot-Fractures-Phalanx> [Accessed 4 April 2021].