Here is described how doctors perform orthopedic examinations in children and adults and what they concider during these examinations.
An orthopedic examination is an integral part of a well-child periodic assessment, and it is also performed both on children and on adults upon special concerns. The extent of the examination varies however much from setting to setting.
CHECK OF GAIT AND MOVEMENT
Checking gait and other movements is often done first in the examination, but can also be an intergral part of the examinations of the separate body areas. One lets the patiant go from and to the examinator while watching him/her walking in both directions. While the pantient is walking, one plays special attention to the function of the hip area, the knees and simultaneous movement in the spinal column.
One also performs other movement tests of the lower or upper body. One lets the patient kneel down, lift the legs up in foreward and sideways direction, lift the arms up over the head foreward or sidewise, bend and twist the neck.
BACK AND SPINE CHECK
The part which is nearly always present is the back and spine check, with a main purpose of caching a developing scoliosis as early as possible, but also to check flexibility of the spine in all natural directions, or flexibilities in abnormal directions. The scoliosis exam which is typically done after the gait inspection, is usually done like this:
One first checks if one shoulder is higher than the other. Then one checks if one hip crest is higher than the other. One looks and feels along the spine while the patient is standig upright to see and feel the curvature. Often abnormal twistings and bendings can be seen right away. To be more sure one also lets the patient bend foreward. Where the spine is curved towards one side, one will see a bump on that side of the back, because the bent part of the spine will be pressed outward on that side. By letting the patient do other bends and twistes with the torso, arms and legs, a more complete picture can be made.
By a more thorrough scoliosis test, geometric instruments to check the angles of the misalignments, so-called scoliometers, are used.
During this test the patient must be naked on the back and also on the upper parts of the buttocks. The very best for the diagnosis is a totally naked patient, so that on can also see misalignment of the buttocks that are assosiated with scoliosis, but one usually lets the patient wear underpants and pulls these down more or less at some point in the test. It is generally recommended that children and teens are examined by such a simple test each year.
If scoliosis is detected with such simple tests, and it looks severe enough, one will often do more thorrough examinations, especially with x-ray imaging.
CHECK OF THE UPPER LIMBS
In addition to the back and scoliosis check, the checking of limbs, joints and their function is a main topic by the orthopedic examination, and especially at the legs and the pelvic zone. Usually the patient will wear short briefs only during this examination. In certain settings one prefere to examine children totally naked.
The shoulder and elbow joints will typically be tested in the next stage. Typically the examination of the upper extremities are performed like this, but all the following movements do not necessarily occur or may occur in another sequence:
- One feels along the arms of the patient from shoulders to fingers to check muscle tone, consistency and temperature.
- On lets the patient swing the arms from a position pointing downwards to a position 90 degrees to the body and pointing foreward.
- One instructs the patient to bend the hands up and down, to each side, and to rotate the hands in both directions.
- On lets the patient swing the arms further so they are pointing stright upwards.
- The patient is then instructed to swing the arms down to a 90 degree to the body and pointing out to each side.Often
- Often the examinator also will take hold of the straight arms and swing them in all directions and press somewhat at the extreme points to thet the flexibility of the shoulder joint.
- The examinator may also take hold of the underarms of the patient, and bend the arms in all ways to test the elbow joint.
- Then the patient is asked to flex the elows as far inwards as possible, and then to a 90 degree angle, and then swing the lower arms and hands in a circle in both directions.
CHECKING THE LEGS AND PELVIC AREA
Later on one usually checks the hip joints and the legs. The patient will usually be laying on the back on an examination table. One will then do several handlings and bendings of the legs to check range of movement:
- One feels along each legs to test consitency, tone of the muscles and the temperature in the leg.
- With both leg straight out, the examinator swings and stretches the foot outwards and inwards, up and down. One also look under the feet to check for abnormalities.
- The patient lays with straight legs and the examinator spreads the legs as far as possible out to each side.
- One flexes the knees of the patient up in a frog fashion and let hisher soles touch each other. Then the legs are spread down to each side.
- One lets the legs lay straight out on the examination table. With one leg still laying straight, one swings the other straight leg up as far as possible and then down again, and the foot is held so that the calves are maximally stretched.
- While one legs lays straight, one flexes the other leg up and tries to press the knee of that leg as far down towards the chest area as possible, while also trying to press the foot as far as possible down towards the thigh, and the foot is held so that the toes point upwards.
- Whith one leg laying straight, one flexes the other leg up so that the thigh and calve make a 90 degree angle, and then one swings the calve as far as possible inwards and outwards.
- With one leg laying straight, one holds under the foot and over the knee, lets the knee joint be flexed and rotate the leg around.
The same tests are then done with the other leg while the first leg is held straight. Many of these tests are often done in one continuous movement. Often the examinator will repeat each test several times to see if the repetition changes the muscle tone and flexibility.
One also lets the patient lift the straight legs with some downward pressure to test strength.
USE OF INSTRUMENTS
The standard orthopedic exam is traditionally a manual and visual examination, but in some areas technical instruments are used by now. Ultrasound exam of the knees, hip joints and shoulder joints is standard in many places, especially in Eastern Europe.
The feet are often checked by letting the patient stand on a hightened transparent platform with a oblique mirror at the underside, so that the examinator can look under the feet of the patient.
OTHER CONCIDERATIONS DONE REGARDING THE PATIENT
As said one will sometimes prefere to have a child completely naked during these tests. This has the advantage that one can see if the cleft between the buttocks, the natal cleft, and the vulvar cleft in girls, are alligned normally. But the child might, depending much upon its cultural heritage, feel it to be embarressing being totally naked during these hip and leg tests.
Even though these tests are necessary for a thorrough assessment of the joints of the lower extremities, the very nature of the movements will also give a mechanical stimulation upon the genital organs and upon the area around the anus. The examinator possibly also looks for the nature of the reactions caused by this stimulation, but will never mention that he she so does.
Even though it is never said openly, one possibly also prefere the child to be naked to test his her psychological reactions upon being inspected rather intimately this way, or to see if the movements cause leakage from the urinary tract, the vagina or anus.
The pediatric services in most countries have a standing order form the authorities of being on constant allert for signs of sexual abuse of children or for signs that the children themselves have unwanted sexual habits, and suspect every parent of being abusers. Even though it is never said openly, it seems that the reactions of the child during these tests often are registered and used to assess the possibility of the child being a victim of abuse or of "self-abuse", an obsolete concept that has gained a new popularity among some pediatricians and child psychologists.
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