import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Paediatric Upper Limb Examination Paediatric upper limb examination requires age-appropriate techniques and understanding of common conditions by age group. Examiners expect you to recognize brachial plexus palsy patterns, identify congenital differences, and adapt your examination technique for infants, toddlers, and older children. ## Quick Reference One-Pager ## Age-Appropriate Examination **Observation is Key:** - Watch spontaneous movement - Look for asymmetry - Position of limbs at rest - Movement with stimulation **Primitive Reflexes:** - Moro reflex (asymmetry = pathology) - Grasp reflex - Placing reflex **What You Can Assess:** - Active movement against gravity - Response to stimuli - Muscle tone (hypotonia/hypertonia) - Hand function (reaching, grasping) **Examination Tips:** - Warm room and hands - Parent holding/near - Quick, efficient assessment - Watch during feeding **Observation During Play:** - Hand preference (abnormal before 18 months) - Reaching for objects - Grip patterns - Bimanual activities **Distraction Techniques:** - Use toys, bubbles - Watch rather than examine - Make it a game - Let child come to you **Functional Assessment:** - Picking up small objects - Stacking blocks - Throwing ball - Feeding themselves **Standard Examination:** - Can follow instructions - Compare sides systematically - Full neurological assessment possible - Test individual muscles **Make it Interactive:** - "Push me away like a superhero" - "Hold on tight like a monkey" - Games for ROM testing - Rewards for cooperation **Full Assessment:** - Inspection - Palpation (ask about pain first) - Movement (active then passive) - Power (MRC grading) - Sensation - Special tests ## Brachial Plexus Palsy **Incidence:** 1-2 per 1000 live births **Risk Factors:** - High birth weight (macrosomia) - Shoulder dystocia - Prolonged labor - Instrumental delivery **Recovery:** - 70-90% recover spontaneously - Most improvement by 3-6 months - No biceps function at 3 months = poor prognosis **Brachial Plexus Injury Patterns:** | Type | Roots | Clinical Pattern | Recovery | |------|-------|-----------------|----------| | **Erb's** | C5-C6 | Waiter's tip (IR, adduction, pronation) | Good | | **Extended Erb's** | C5-C7 | Erb's + wrist/finger extension loss | Moderate | | **Klumpke's** | C8-T1 | Intrinsic weakness ± Horner's | Variable | | **Global** | C5-T1 | Flail arm | Poor | **Classic Posture (Waiter's Tip):** - Shoulder: Adducted and internally rotated - Elbow: Extended - Forearm: Pronated - Wrist: Flexed (if C7 involved) **Muscles Affected (C5-C6):** - Deltoid (shoulder abduction) - Supraspinatus (initiation of abduction) - Infraspinatus (external rotation) - Biceps (elbow flexion) - Brachioradialis (elbow flexion) **What is Preserved:** - Finger movements (C7-T1) - Wrist movements (C6-7) - Grasp (C8-T1) ## Congenital Differences **Syndactyly:** - Simple (skin only) vs Complex (bony fusion) - Complete (to fingertip) vs Incomplete - Assess: Function, associated anomalies **Polydactyly:** - Preaxial (thumb side) vs Postaxial (small finger side) - Assess: Size, function, stability of extra digit - Central polydactyly rarer, often with syndactyly **Radial Deficiency:** - Spectrum from hypoplastic thumb to absent radius - Assess: Thumb function, wrist stability - Associated: VACTERL, thrombocytopenia-absent radius **Ulnar Deficiency:** - Less common than radial - Often functional hand - Assess: Elbow stability, hand function **Syndromic Associations:** - **Radial deficiency**: VACTERL, TAR, Fanconi anemia, Holt-Oram - **Polydactyly**: Isolated common, but check for cardiac/renal anomalies - **Syndactyly**: Poland, Apert, Carpenter syndromes - **Multiple differences**: Chromosome analysis indicated ## Trauma Assessment **Common Fractures by Age:** - Clavicle: All ages - Supracondylar humerus: 5-8 years (peak) - Forearm fractures: Throughout childhood - Lateral condyle: 6-10 years - Radial neck: 8-12 years **Neurovascular Assessment is Critical:** - Always document BEFORE and AFTER any intervention - Compare with uninjured side - Serial examination if concerning **Neurovascular Examination:** **Anterior Interosseous Nerve (AIN):** - "Make OK sign" (FPL + FDP to index) - Inability to flex thumb IP and index DIP **Median Nerve:** - Thenar opposition - Sensation first/second web space **Radial Nerve:** - Wrist and finger extension - Sensation dorsal first web space **Ulnar Nerve:** - Finger abduction/adduction - Sensation small finger **Vascular:** - Radial pulse - Capillary refill - Hand warmth and color - Pain with passive finger extension (compartment syndrome) **Compartment Syndrome - The 6 Ps:** 1. **Pain** - Out of proportion, on passive stretch 2. **Pressure** - Tense compartments 3. **Paresthesia** - Nerve ischemia 4. **Paralysis** - Late sign 5. **Pulselessness** - Very late 6. **Pallor** - Unreliable **In Children:** - May not communicate pain well - "3 As": Anxiety, Agitation, Increasing Analgesia requirement - LOW threshold for fasciotomy ## Non-Accidental Injury **Concerning Features:** - Injury inconsistent with history - Delay in presentation - Changing history - Multiple injuries at different stages of healing - Patterned injuries (grip marks, belt marks) - Spiral fractures in non-ambulatory child **Upper Limb Specific:** - Humeral shaft fracture in infant - Multiple fractures - Metaphyseal corner fractures - Bruising in unusual locations **Action:** - Careful documentation - Skeletal survey if indicated - Follow local safeguarding pathway - Do not confront parents ## Systematic Examination **Inspection:** - Posture at rest - Muscle bulk symmetry - Skin changes (cafe-au-lait spots, bruising) - Scars - Deformity **Palpation:** - Bony landmarks - Soft tissue - Temperature - Pulses **Movement:** - Active movement (most important in children) - Passive movement (compare sides) - Power (use games/functional tasks) **Special Tests:** - Age-appropriate - Compare sides - Document clearly ## Summary Presentation ## Examination Sequence 1. **Observe at rest**: Posture, position, spontaneous movement 2. **Watch spontaneous activity**: Asymmetry, quality of movement 3. **Age-appropriate testing**: Reflexes (infant), play (toddler), formal (school age) 4. **Active movement**: Each joint, compare sides 5. **Passive movement**: ROM, contractures 6. **Power**: Functional or formal MRC grading 7. **Sensation**: Age-appropriate (observe withdrawal to pain in infants) 8. **Circulation**: Pulses, color, temperature 9. **Complete examination**: Look for associated anomalies 10. **Document**: Photograph/video if appropriate ## Examiner Tips