Pediatric Orthopaedic Exams: The Back

Jennifer Winell, MD, Orthopedic Surgeon at Children's Hospital of Philadelphia (CHOP), demonstrates how to properly perform a back exam on a pediatric patient. Dr. Winell conducts a full assessment of the patient's range of motion, muscle strength, and sensory/reflex. She also demonstrates effective use of a scoliometer; and provides advice regarding when findings for scoliosis warrant consultation with a specialist.


Pediatric Orthopaedic Exams: The Back

Jennifer Winell, MD: Hello, I'm Doctor Jennifer Winell. I'm one of the orthopedic surgeons at The Children's Hospital of Philadelphia. Today I'm going to be performing a back exam on my patient, Stewart. Hello, Stewart. Nice to see you. 

Stewart, patient: Hello.

Dr. Winell: It's important when examining a patient for their back that they get undressed completely. For boys, that means down to shorts; and girls, usually a gown and shorts. 

Stewart, we’re going to have you come on down, and the first thing I'd like you to do is just walk to the door. So this part is examining their gait and making sure that they have a normal-appearing gait.

Can you walk on your tiptoes towards me? Great. Can you walk on your heels towards the door? 

And this is doing a very gross lower extremity neurologic exam for strength and range of motion. 

Can you jump up and down on both feet together for me a couple times? Good. Can you hop on one foot a couple of times? Great. And then the other foot a couple of times? Great. And can you squat down like a catcher in a baseball game and touch the ground? Perfect, come on up. 

Then, through all this, you want to look for any asymmetry, any inability to do that. 

The next thing we're going to do is examine the neck. Stewart, can you bring your chin down to your chest? Good. Chin up towards the ceiling, look straight at me. Turn your head to one side. And the other side. And your ear down to your shoulder. And the other shoulder. 

And again, you're wanting to note any differences in the range of motion. Note if they appear uncomfortable in any way in any motion. Obviously, ask them if they have any pain with range of motion. 

Stewart, we're going to have you come towards me. I just like to look at their skin and make sure that they have no birthmarks that can under ... signify any kind of any underlying medical or neurologic issues. 

Next, you want to examine their shoulder height and make sure that their shoulders are level. I then move down to the top of their pelvis and make sure that their pelvis is level, and also examine their shoulder blades for any asymmetry or differences in height of them. 

Stewart can you put your feet together for me? And can you bend forward and try and touch your toes?

And now you're looking for any rib prominences or asymmetries. A lot of people like to use a scoliometer. They come digitally now on iPhone applications, and you basically want to run this down the mid-line of their spine and see what degree you get. Any degree over five degrees would indicate a possible scoliosis, warranting an X-ray. 

OK. Stewart, come on back up. I want you to lean back for me. Great. And here again, forward and backwards, you want to note the range of motion. We're going to bend you to one side, and the other side. And then I want you to twist to one side and twist to the other side. And again, noting any problems or asymmetry in their motion, and making sure they don't have any pain with motion. 

Next, you want to palpate along their spine and make sure they don't have any pain anywhere. So you start along the midline, working your way all the way down to the sacrum, working on the paraspinal muscles and making sure they don't have any tenderness.

Next, moving to their S-I joints — which are laterally out here — making sure they don't have any tenderness. And finally, moving to their S-I joints underneath here, and making sure they don't have any pain or tenderness. 

OK. Stewart, can you come on up on the table? So the next part of the exam is looking for range of motion of their upper extremities as well as muscle strengths and doing a sensory and reflex exam. 

Stewart, can you bring your arms up over your head for me? Great. Arms out to the side. Can you touch your shoulders? Arms out like this. Can you bring your elbows like this and the elbows like that? Can you reach up your back? Good. Can you bring your arms up like this? Bring your hands up like this, down like that. Can you give me the thumbs-up sign and make the OK sign and open and close your fingers? Fantastic. 

Can you hold your arms out real strong? Good. And elbows like this at your side. Push my hands out. Push my hand in. Hands like this. Push my hands up. Push my hands down. Good. Hands like that, and hold your hands up real high. Push down hard here. Push, push, push. Yep. Push hard here. Good. Thumb up, hold it real high. Make the OK sign, hold it real strong, and spread your fingers wide apart. Good. All right. Relax. Down. 

Stewart, do you feel me touching you here? 

Stewart: Yeah.

Dr. Winell: Good. We're just testing his sensation. Next, we'll test his reflexes and make sure that he has reflexes bilaterally and that they are symmetric. Testing the biceps, the triceps, and the brachioradialis reflex. Next we're going to have you lie down on your back. 

Stewart: All the way up there? 

Dr. Winell: Yep. All right. And then with them flat, we like to examine their leg lengths to make sure that their legs are symmetric and there's no difference in the leg length which could be causing an apparent scoliosis. We also like to do just a gross range of motion of the hips, knees and ankles to make sure that the motion is normal as well. Put that one down.

And we also like to note their popliteal angles here, which Stewart's quite tight in his hamstring muscles which can sometimes signify an underlying spondylosis if the child has back pain. Same thing on this side, and make sure they are symmetric, which they are. He's equally tight. Great. 

And next, you want to do an abdominal reflex. Many kids are very ticklish for this, so sometimes you kind of have to distract them while you're doing it. Stewart, are you involved in any activities? 

Stewart: Um, yeah, I do drama club. 

Dr. Winell: And what do you do? 

Stewart: I sing and dance and stuff like that. 

Dr. Winell: Oh, great. So, actually he has a nice abdominal reflex. When we bring our reflex hammer toward his belly button, the belly button pulls in the direction of the reflex hammer symmetrically. And Stewart, while he was distracted, actually did that quite nicely. 

All right. Come sit up for me, let's bring your legs back around. And since we already did basically a strength exam with the walking and the toes and the heels, I don't do any major strength exam here, just test their sensation. You feel me touching you here? Great. 

And then you want to test them for clonus or any signs of hyperreflexia. You want to do their patellar tendon reflex, which he has a good one, as well as the Achilles reflex. Good reflexes. And then finally, the Babinski test where you test for, again, any hyperreflexia. And that's essentially a back exam for the pediatric patient.

Related Centers and Programs: Division of Orthopaedics, Spine Program