Johnny is five. He fell onto his outstretched arm and now is sitting in your ED, crying and holding his shoulder adducted. Triage has been ace, and he was given 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 you examine the joints above and below in addition to the joint you’re interested in.
Look
- Deformity
- Swelling
- Atrophy: Asymmetry
- Wounds
- Bruising
- Skin tenting (typically clavicular fractures, whereby the bony fragment is causing pressure on the skin and is 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 the 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 their 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 and 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 his range of movement was 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]
