NEUROLOGICAL EXAMINATION
Cranial
nerves examination. Examination of old child. Examination of baby & toddlers. Cerebellar system
lower limbs
Gait
Power
Observe
Observe
Observe
Only when you have obtained as much information as possible from observation proceed to the remainder of examination
Start with observing the baby fully dressed on parents lap or while playing with toys in an enjoyable nonthreatening environment.
Observing what the baby choose to do is more instructive than their compliance with actions which you have requested them to carry out.
General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head. Upper limbs. Trunk & back. Lower limbs. Reflexes.
GENERAL INSPECTION
State of consciousness :
Conscious. Irritable. Lethargic (sleepy , arousable by fine stimuli). Obtundation ( arousable by sever stimuli ). Stupor (unarousable but respond to pain). Coma (unarousable & unresponsive).
Mentality
the patient's level of awareness and interaction with the environment. Can be assisted b observing the baby while interacting with parents or toys. Clues for retarded infant : Long periods without crying or interest in surroundings. Prolonged crying with no cause. Delayed speech. Delayed gross motor. Delayed fine motor.
Handedness
It became obvious between age of 1.5-5 years. Hand preference in infants < 1.5 years (hemiplegic).
Coordination :
Offer the child an interesting play & observe : Does he reach out for it ? Is there is an intention tremor ? What sort of grasp ? Does he transfer objects between hands ?
If
Poor
General inspection : Cerebral functions. Coordination Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head. Upper limbs. Trunk & back. Lower limbs.
Reflexes.
Overall
Dysmorphic
features:
Posture
:
Frog like position :
Hip abducted & knee flexed in hypotonia
Erbs palsy
Shoulder adducted & internally rotated , elbow extended & wrist flexed
Torticollis
Abnormal posture of head towards one side
Opisthotonus:
Involuntary extension of neck with arching of back occurs in meningitis , tetanus or CP.
Scissoring of legs
Legs cross over each others in spastic diplegia
Movement
Tics : repeated identical movement. Tremors : involuntary rhythmical alternating movements (resting or intentional). Titubation : tremor of head & neck. Athetoid : Slow involuntary writhing movements usually of proximal limbs. Chorea : rapid involuntary irregular movements usually of face & extremities. Convulsions
General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait Eyes & Cranial nerves. Head.
Upper limbs.
Trunk & back.
Lower limbs.
Reflexes.
HEAD Shape . Size (HC) . Fontanelles. Sutures. VP shunt. Look for tongue fasciculation.
HEAD
Shape
Scaphocephaly
Head is long & narrow due to premature closure of sagittal suture
Trigonocephaly
Pointed forehead due to premature closure of metopic sutures
Plagiocephaly
Either frontal (unilateral closure of coronal suture) or occipital (Postural or unilateral closure of lambdoid suture)
Brachycephaly
Back of head is flat as in down syndrome or bilateral closure of coronal sutures.
Head
Fontanelles
o o
Sutures. VP shunt.
General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head.
Upper limbs.
Trunk & back.
Lower limbs.
Reflexes.
UPPER LIMBS
Motor system Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power.
Sensation.
Reflexes.
CP
Claw hand
In radial nerve or lower plexus injury
Erbs palsy
Syndactyly
Polydactyly
Clinodactyly
Muscle bulk : Lost in LMNL , generalized wasting or disuse atrophy. Muscle fasciculation's : LMNL. Muscle tone :
Passively flex & extend the elbow & the wrist. Hold both wrists in your hands & shakes them quickly to & fro. Scarf Sign. Handling the child (Shoulder girdle). Head support. Always remember to distract the baby by speaking with him
Scarf Sign
The tone of the shoulder girdle is assessed by taking the baby's hand and pulling the hand to the opposite shoulder like a scarf. The hand should not go past the shoulder and the elbow should not cross the midline of the chest
joints
Hand shaking
joints
Scarf sign
Handling (normal)
06Hipoton-a.MPG.flv
Handling (Hypotonia)
HYPOTONIA
Central.
Cerebellar disease. Anterior horn cells. Peripheral nerves. Neuromuscular junction. Muscle.
HYPERTONIA
Spasticity
Initial resistance to passive movements followed by sudden release (Clasp Knife). Due to UMNL (CP).
Rigidity
Constant resistance to passive movements such as (lead pipe) or (Cogwheel). Due to lesions in basal ganglia.
Clonus :
Rhythmic series of involuntary contractions evoked by stretching the muscle. May be normal :
Muscle Power :
Impossible to test formally in this age group. Power of hand muscles can be tested by :
Pulling the infant up by the arms from supine position , the infant with normal power will flex at the elbow to resist your pull..
Sensation :
It is difficult to test in infants .
UPPER LIMBS
Motor system Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination.
Sensation. Reflexes.
General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves.
Head.
Upper limbs. Trunk & back Lower limbs Reflexes.
General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head.
Upper limbs.
Trunk & Back. Lower limbs. Reflexes.
TRUNK
All children > 1.5 y should be able to get up from supine position. , if not (Proximal weakness). All children > 10 m should be able to sit unsupported , if not ( Truncal weakness or ataxia). With the child sitting give a gentle sideways push against the shoulder , if the child falls sideways it indicates weakness of trunk. Hold the baby in the prone position by your hand & observe the axial tone.
Here the head drops much lower than one would expect, and the examiner has the sense that the infant could easily slip out of her hand without extra support
Hypotonia 5.flv
BACK
Palpate : Run your finger quickly over the spinous processes to detect spina bifida occulta.
General inspection : Cerebral functions. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Eyes & Cranial nerves. Head. Upper limbs. Trunk & Back. Lower limbs. Reflexes.
LOWER LIMBS
Motor system Gait Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination. Sensation. Reflexes.
Gait :
Wide based gait
Normal in toddlers.
Hemiplegic gait
Hip & knee are extended (straight leg). Leg move stiffly by circumduction. Arm swinging is limited on the affected side.
Waddling gait
subject sways from side to side. due to a lack of hip stabilization. In DDH & duchenne muscle dystrophy.
Hemiplegia gait
Waddling gait
Bowed Legs
Normal in toddlers. If extreme : Rickets. Osteogenesis imperfecta. Achondroplasia.
Knock Knee
Rickets in preschool age.
Toe walking
May be normal. Spastic diplegia. Contractures.
Limp Gait where less time is spent bearing weight on one leg than on the other.
Examine legs for : Deformities. Scars. Joint swelling. Rashes. range of movements.
LOWER LIMBS
Motor system Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination. Gait. Sensation. Reflexes.
Deformity
Muscle
bulk .
Hemi hypertrophy Measure thigh & calf girth at fixed distances from knees
Fasciculation
Fasciculations
Muscle
tone :
Lightly left each leg & flex it at knee & hip for few times & feel the amount of tone you have to overcome. Abduct each hip while the knee flexed & pelvis fixed by one hand.
Clonus
Can be tested by sudden dorsiflexion of foot with the knee partially flexed.
Power
Passively flex the legs & observe how hard the infant pushes against you. The ability to stand up from lying position reflects good tone of pelvic girdle muscles. Can be partly gauged from the gait. Application of powerful stimuli to different sites (rarely used)
GOWERS SIGN
Gower's Sign.flv
Coordination:
LOWER LIMBS
Motor system Gait Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination. Sensation. Reflexes.
Sensation :
It is difficult to test in infants .
Thank you