Clinical orthopedic examination

All patients with vascular malformations should undergo regular (pediatric) orthopedic examinations, especially during growth. The first examination should be performed as soon as the vascular malformation becomes visible. This applies to all patients with venous, arteriovenous, lymphatic, capillary or combined malformations, but not to those with infantile hemangiomas. The latter are not likely to present with orthopedic problems.

After the initial examination, further examinations are performed annually until growth completion. In case of acute need for action or in times of rapid growth in length (e.g., during puberty), shorter intervals between examinations may be advisable.

After the standard medical history has been obtained, the examination must be carried out with the patient undressed except for underwear.

First, the patient is inspected from the front and back while standing. In addition to the visible skin and vascular changes caused by the malformation, particular attention is paid to the leg axis, the pelvic position, and the symmetry of the waist and shoulders.

In patients who are unable to stand (infants or due to physical limitations), the examination is performed in a sitting position to examine the spine and in a lying position to examine the legs.

Particularly where the extremities are affected by the malformation, an examination of the passive and active range of motion of the joints must be performed using the neutral-zero method to document findings.

In addition to the standing, sitting, and supine examination, the gait pattern should be assessed in all patients capable of walking freely. This can show the functional consequences of a leg length discrepancy or contractures, e.g., resulting in limping. As well as the so-called short leg limp caused by different leg lengths, another form of limp may occasionally be observed: the antalgic limp.

An antalgic limp results from the attempt to relieve a painful limb. Many patients with vascular malformations suffer from sometimes chronic pain, e.g., caused by repeated inflammation of the vessels.

In this case, it is not uncommon for the muscles to shorten and contract as a result of many years of adopting a protective posture (e.g., bending the knee). Patients affected by such disease processes may show a combination of short leg limp (due to leg length discrepancies and/or contractures) and an antalgic limp during walking. Analyzing and evaluating the different causes of the conspicuous gait pattern requires a thorough examination and precise assessment, although it may not always be possible to do so definitively in individual cases.

The exact procedures for examining possible leg length discrepancy, scoliosis, or contracture are discussed in the following subsections.