(From Jacobson RD: Approach to the child with weakness and clumsiness, Pediatr Clin North Am 45[1]:145-168. 1998.)
Musculoskeletal System
Examination
Technique
Findings
Posture and General Guidelines
Inspect skeleton and extremities, comparing sides
Inspect anterior, posterior, lateral aspects of posture; ability to stand erect; body parts; extremities.
EXPECTED: Bilateral symmetry of length, circumference, alignment, position and number of skinfolds; symmetric body parts; and aligned extremities.
UNEXPECTED: Gross deformity, lordosis, kyphosis, scoliosis, bony enlargement.
Inspect skin and subcutaneous tissues over muscles, cartilage, bones, joints
UNEXPECTED: Discoloration, swelling, or masses.
Inspect muscles and compare sides
EXPECTED: Approximately symmetric bilateral muscle size.
UNEXPECTED: Gross hypertrophy or atrophy, fasciculations, or spasms.
Palpate all bones, joints, surrounding muscles (palpate inflamed joints last)
EXPECTED: Firm.
UNEXPECTED: Hard or doughy, spasticity.
UNEXPECTED: Heat, tenderness, swelling, fluctuation of a joint, synovial thickening, crepitus, resistance to pressure, or discomfort to pressure on bones and joints.
Test each major joint and related muscle groups for active and passive range of motion, and compare sides
Ask patient to move each joint through range of motion (see instructions for specific joints and muscles in individual sections that follow), then ask patient to relax as you passively move same joints until end of range is felt.
EXPECTED: Passive range of motion often exceeds active range of motion by 5 degrees. Range of motion with passive and active maneuvers should be equal between contralateral joints.
UNEXPECTED: Pain, limitation of motion, spastic movement, joint instability, deformity, contracture, discrepancies greater than 5 degrees between active and passive range of motion. When increase or limitation in range of motion is found, measure angles of greatest flexion and extension with goniometer, as shown in figure below, and compare with values as described for specific joints in individual extremities.
Test major muscle groups for strength, and compare contralateral sides
For each muscle group, ask patient to contract a muscle by flexing or extending a joint and to resist as you apply opposing force. Compare bilaterally.
EXPECTED: Bilaterally symmetric strength with full resistance to opposition.
UNEXPECTED: Inability to produce full resistance. Grade muscular strength according to the following table.
Muscle Function Level
Grade
No evidence of contractility
0
Slight contractility, no movement
1
Full range of motion, gravity eliminated∗
2
Full range of motion against gravity
3
Full range of motion against gravity, some resistance
4
Full range of motion against gravity, full resistance
5
Technique
Findings
Hands and Wrists
Inspect dorsum and palm of each hand
EXPECTED: Palmar and phalangeal creases, palmar surfaces with central depression with prominent, rounded mound on thumb side (thenar eminence) and less prominent hypothenar eminence on little-finger side.
EXPECTED: Fingers able to fully extend and align with forearm when in close approximation to each other.
UNEXPECTED: Deviation of fingers to ulnar side or inability to fully extend fingers; swan neck or boutonnière deformities.
EXPECTED: Lateral finger surfaces gradually tapered from proximal to distal aspects.
UNEXPECTED: Spindle-shaped fingers, bony overgrowths at phalangeal joints.
Palpate each joint in hand and wrist
Palpate interphalangeal joints with thumb and index finger, as shown in figure on p. 198, panel A; metacarpophalangeal joints with both thumbs, as shown in figure on p. 198, panel B; and wrist and radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist, as shown in figure on p. 198, panel C.
EXPECTED: Joint surfaces smooth.
UNEXPECTED: Nodules, swelling, bogginess, tenderness, or ganglion.
Assess integrity of median nerve
UNEXPECTED: Tingling sensation radiating from wrist to hand along pathway of median nerve.
EXPECTED: Full resistance to pressure.
UNEXPECTED: Inability to produce full resistance.
UNEXPECTED: Numbness, paresthesia in distribution of median nerve.
UNEXPECTED: Pain, numbness, tingling in pattern shown in figure below.
Test range of motion
Ask patient to perform the following movements:
EXPECTED: 90-degree metacarpophalangeal flexion and as much as 30-degree hyperextension.
EXPECTED: Able to perform all movements.
EXPECTED: Both movements possible.
EXPECTED: 90-degree flexion and 70-degree hyperextension.
EXPECTED: 20-degree radial motion and 55-degree ulnar motion.
Test muscle strength
Ask patient to perform the following movements:
EXPECTED: Bilaterally symmetric with full resistance to opposition.
UNEXPECTED: Inability to produce full resistance.
EXPECTED: Firm, sustained grip.
UNEXPECTED: Weakness or pain.
Elbows
Inspect elbows in flexed and extended positions
UNEXPECTED: Subcutaneous nodules along pressure points of extensor surface of ulna.
EXPECTED: Usually 5 to 15 degrees laterally.
UNEXPECTED: Lateral angle exceeding 15 degrees (cubitus valgus) or a medial carrying angle (cubitus varus).
Palpate extensor surface of ulna, olecranon process, medial and lateral epicondyles of humerus, groove on each side of olecranon process
Palpate with patient’s elbow flexed at 70 degrees.
UNEXPECTED: Boggy, soft, tenderness at lateral epicondyle or along grooves of olecranon process and epicondyles.
Test range of motion
Ask patient to perform the following movements:
EXPECTED: 160-degree flexion from full extension at 0 degrees.
EXPECTED: 90-degree pronation and 90-degree supination.
UNEXPECTED: Increased pain with pronation and supination of elbow.
Test muscle strength
Ask patient to maintain flexion and extension, as well as pronation and supination, while you apply opposing force.
EXPECTED: Bilaterally symmetric with full resistance to opposition.
UNEXPECTED: Inability to produce full resistance.
Shoulders
Inspect shoulders, shoulder girdle, clavicles and scapulae, area muscles
EXPECTED: All shoulder structures symmetric in size and contour.
UNEXPECTED: Asymmetry, hollows in rounding contour, or winged scapula.
Palpate sternoclavicular and acromioclavicular joints, clavicle, scapulae, coracoid process, greater trochanter of humerus, biceps groove, area muscles
Palpate the biceps groove by rotating the arm and forearm externally. Follow the biceps muscle and tendon along the anterior aspect of the humerus into the biceps groove.
EXPECTED: No tenderness or masses, bilateral symmetry.
Palpate the muscle insertion for the supraspinatus, infraspinatus, and teres minor near the greater tuberosity of the humerus by lifting the elbow posteriorly to extend the shoulder.
UNEXPECTED: Pain, tenderness, mass.
Test range of motion
Ask patient to perform the following movements:
EXPECTED: Symmetric rising.
EXPECTED: 180-degree forward flexion.
EXPECTED: 50-degree hyperextension.
EXPECTED: 180-degree abduction.
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