The pediatric physical examination: Back, extremities, nervous system, skin, and lymph nodes
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
Examination of the back, extremities, nervous system, skin, and lymph nodes in children will be reviewed here. Other aspects of the pediatric physical examination are discussed separately. (See "The pediatric physical examination: General principles and standard measurements" and "The pediatric physical examination: HEENT" and "The pediatric physical examination: The perineum" and "The pediatric physical examination: Chest and abdomen".)
The back examination is relatively standard for all ages. Spinal alignment, structural asymmetry, soft tissue masses, skin lesions, and points of tenderness should be noted. The vertebral column should be straight, with alignment along an imaginary vertical line from the midpoint of the occiput to the gluteal cleft. The level of the shoulders, scapulae, and pelvic rims should be symmetrical.
Any midline soft tissue lesion overlying the spine (eg, dimple, vascular anomaly, pigmented nevus, hairy patch) should raise suspicion of an underlying neurologic defect . Defects of the bony spine or of the overlying skin or soft tissue in an infant may indicate the presence of a meningocele, myelomeningocele, lipomeningocele, diastematomyelia, abscess, or tumor. With many of these lesions, the neurologic deficits may be sufficiently severe to lead to genitourinary tract, gastrointestinal tract, and/or lower-extremity impairment. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Cutaneous'.)
Midline dimples in the skin overlying the coccyx generally are of no significance. Dimples above the gluteal cleft, on or above the flat part of the sacrum (ie, lumbosacral dermal sinus tracts) usually require neuroimaging and/or neurosurgical evaluation. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Evaluation and diagnosis'.)
Scoliosis in the neonate has great significance because it produces cosmetic problems and potential visceral and/or neurologic dysfunction. Almost 33 percent of children with congenital scoliosis have associated urinary tract anomalies .
- Dias M, Partington M, SECTION ON NEUROLOGIC SURGERY. Congenital Brain and Spinal Cord Malformations and Their Associated Cutaneous Markers. Pediatrics 2015; 136:e1105.
- Keim HA, Hensinger RN. Spinal deformities. Scoliosis and kyphosis. Clin Symp 1989; 41:3.
- Barness LA. Manual of pediatric physical diagnosis, 6th ed, Mosby Year Book, St. Louis 1991.
- Fishman MA. Pediatric Neurology, Grune and Stratton, Orlando, FL 1986.
- Putnam TC. Lumps and bumps in children. Pediatr Rev 1992; 13:371.
- Karthik SV, Campbell-Davidson D, Isherwood D. Carotenemia in infancy and its association with prevalent feeding practices. Pediatr Dermatol 2006; 23:571.
- Leung AK. Carotenemia. Adv Pediatr 1987; 34:223.
- Gollan JL, Knapp AB. Bilirubin metabolism and congenital jaundice. Hosp Pract (Off Ed) 1985; 20:83.
- Disorders of pigmentation. In: urwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence, 3rd, Paller AS, Mancini AJ (Eds), WB Saunders, Philadelphia 2006. p.265.
- Vanderhooft SL, Francis JS, Pagon RA, et al. Prevalence of hypopigmented macules in a healthy population. J Pediatr 1996; 129:355.
- Amichai B, Zeharia A, Mimouni M, et al. Picture of the month. Chédiak-Higashi syndrome. Arch Pediatr Adolesc Med 1997; 151:425.
- Korf BR. Diagnostic outcome in children with multiple café au lait spots. Pediatrics 1992; 90:924.
- Endocrine disorders and the skin. In: Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence, 3rd, Paller AS, Mancini AJ (Eds), WB Saunders, Philadelphia 2006. p.615.
- Burns AJ, Kaplan LC, Mulliken JB. Is there an association between hemangioma and syndromes with dysmorphic features? Pediatrics 1991; 88:1257.
- Muliken JB, Young AK. Vascular birthmarks: Hemangiomas and malformations, WB Saunders, Philadelphia 1988.
- Vascular disorders of infancy and childhood. In: Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence, 3rd, Paller AS, Mancini AJ (Eds), WB Saunders, Philadelphia 2006. p.307.
- Finn SM, Rowland M, Lawlor F, et al. The significance of cutaneous spider naevi in children. Arch Dis Child 2006; 91:604.
- Scheepers JH, Quaba AA. Treatment of nevi aranei with the pulsed tunable dye laser at 585 nm. J Pediatr Surg 1995; 30:101.
- Burk CJ, Pandrangi B, Connelly EA. Picture of the month. Striae. Arch Pediatr Adolesc Med 2008; 162:277, 278.
- Cohen HA, Matalon A, Mezger A, et al. Striae in adolescents mistaken for physical abuse. J Fam Pract 1997; 45:84.
- Strumìa R, Varotti E, Manzato E, Gualandi M. Skin signs in anorexia nervosa. Dermatology 2001; 203:314.
- Shuster S. The cause of striae distensae. Acta Derm Venereol Suppl (Stockh) 1979; 59:161.
- Fox JL. Pulsed dye laser eliminates stretch marks. Cosmetic Dermatol 1997; 10:51.
- Kang S, Kim KJ, Griffiths CE, et al. Topical tretinoin (retinoic acid) improves early stretch marks. Arch Dermatol 1996; 132:519.
- McDaniel DH. Laser therapy of stretch marks. Dermatol Clin 2002; 20:67.
- Obagi ZE, Obagi S, Alaiti S, Stevens MB. TCA-based blue peel: a standardized procedure with depth control. Dermatol Surg 1999; 25:773.
- Carpentieri U, Smith LR Jr, Daeschner CW 3rd. Approach to a child with enlarged lymph nodes. Tex Med 1983; 79:58.
- Margileth AM. Cervical adenitis. Pediatr Rev 1985; 7:13.
- Chesney PJ. Cervical adenopathy. Pediatr Rev 1994; 15:276.