The valgus is worse on the left than the right. Note the medial femoral condyles bumping into each other during the gait cycle.
This toddler with achondroplasia has genu varum with internal tibial torsion.
His unsteadiness results in a significant increase in double-limb stance (usually 20% of the gait cycle) and a decrease in single-limb stance (usually 80%), compared to typical gait. (Video with permission of the Children's Orthopaedic Center, Los Angeles.)
Plain radiograph shows soft tissue swelling over the distal fibula and lytic changes at the metaphysis. MRI shows significant involvement of distal tibia and fibula and a large abscess infiltrating the surrounding soft tissues. Video of incision of drainage of the lesion.
The tibia subluxes laterally on the femur during stance phase with each step. This is revealed as a momentary wobble (or thrust) at the knee during walking.
This child with a syrinx has asymmetric abdominal reflexes.
This young boy has a spinal cord tumor documented in Figure 5.49. During play, he has difficulty walking and does not move his neck in order to see things. Torticollis can be one of the earliest physical examination features for spinal cord tumors of the cervical spine.
Child presented as nonweight bearing with history of left hip pain for 3 days. Radiographic analysis is negative. Ultrasound indicated the presence of a left hip effusion. Even under sedation, hip is flexed externally rotated and abducted.
(Courtesy of Joshua M. Abzug, MD.)
Note that this test is best performed while the patient is under anesthesia. (Courtesy of Joshua M. Abzug, MD.)
This young woman with hemiplegia has dynamic forefoot supination, secondary to spasticity of the anterior tibialis tendon. She is unable to dorsiflex her foot without flexing her hip and knee, demonstrating a positive confusion test.
Our patient underwent bilateral talectomies and 6 weeks later had distal femoral extension osteotomies.
This seven-year-old girl with DD has crouched gait with severe knee and foot contractures.
It is important to note that Achilles tightness should be assessed with the foot inverted to lock the midfoot which otherwise may mask the true tightness, then first with the knee extended to keep the gastrocnemius tight, and then with the knee flexed to relax the gastrocnemius. In this child the tight Achilles prevents full ankle dorsiflexion, requiring motion through the midfoot to allow the foot to fully dorsiflex. The axis of movement of the midfoot is different from the ankle, and out-toeing is created.
Blocks can be used to level the pelvis. If blocks are not available, books or magazines can be stacked under the short limb to determine the leg length discrepancy.
Sitting allows the spine to be examined without the influence of leg lengths on the spinal alignment.
With the feet placed flat on the examination table and the knees flexed, the length of the tibia to the plantar aspect of the foot can also be compared between the two sides.
Notice the substantial anterior translation of the tibia on the femur in this patient with an incompetent ACL.
Inverting the foot prevents inadvertent motion in the midfoot. Flexing the knee relaxes the gastrocnemius muscle because it crosses both the knee and ankle joints.
This is consistent with the diagnosis of slipped capital femoral epiphysis.
This child with hemiplegia has a dropped foot on the left side. Accommodation to clear the foot during swing phase is noted with increasing hip and knee flexion in swing phase.
This girl with spastic diplegia has a positive Duncan-Ely test. By flexing the knee rapidly, the hip will secondarily rise due to increasing contracture/spasticity in the rectus femoris tendon.
This hemiplegic boy has an equinovarus foot deformity marked by equinus positioning and fixed varus positioning in stance phase; likely due to spasticity/contracture of the posterior tibialis tendon.
This boy with cerebral palsy has an equinovarus deformity of his right foot. During gait, he has a foot drop and must have his leg abducted in order to clear it in swing phase. The tight Achilles leads to equinus positioning and back knee gait in stance phase.
This boy with facioscapulohumeral dystrophy has difficulty with shoulder abduction. Winging of the scapula is noted.
This boy with hemiplegia has an equinus gait and upper extremity posturing often seen when walking and running.
In the thumb, the MCP joint is stabilized by the volar plate when fully extended, so the MCP joint should be flexed 30° to assess the collateral ligaments. In the fingers, the collateral ligaments are slack in MCP extension and taut in MCP flexion, so the MCP joint should be flexed 90° before applying radial or ulnar deviation stress to assess the collateral ligaments.
A 10-year-old male basketball player with a right ankle injury and subsequent RSD. This video demonstrates mirror therapy utilizing his unaffected left lower extremity.
More mild tightness can lead to hip and knee pain in normal athletes.
The right side is short causing the pelvis to tilt downwards on that side. Notice how the pelvis tilts back and forth with each stride.
(Courtesy of Dan A. Zlotolow, MD.)
Her foot is in equinus to accommodate the difference in length as a result of her dislocation. This is an example of a functional limb length discrepancy. Her femur is not anatomically short, but she has a joint problem (hip dislocation) that makes her functional limb short.
Clinical palpation and an MRI confirmed a primary neuroma of her peroneal nerve.
When asked to selectively dorsiflex the ankle, the child is unable. When he flexes the hip, a mass action pattern is activated, and the tibialis anterior fires, dorsflexing the ankle. (Video with permission of the Children's Orthopaedic Center, Los Angeles.)
Ultrasound can be used as a diagnostic study and/or as an adjunct to physical examination.
This boy with spastic hemiplegia has classic findings in the upper extremity including flexion, ulnar deviation, and decreased supination. He has difficulty with grip and is only able to actively extend his fingers with the wrist flexed.
This adolescent girl with MFS has genu valgum which is not symmetric and affects her ambulatory ability.
Please note skin dimpling and medial-sided ray duplication commonly seen with tibial deficiency.
A positive test is one that provokes dorsal wrist pain (even though no direct pressure is applied dorsally) or a palpable and painful clunk in the wrist when pressure is released.