The Telemedicine-Based Pediatric Examination of the Neck and Upper Limbs: A Narrative Review

Figures & data

Table 1 Nested Searches Used in Second PubMed Iteration

Section	Nested Search	Citations Yielded	Citations Included
Neck and cervical spine	(“telemedicine”[MeSH] OR “telehealth” OR “tele-assessment” OR “teleconsultation” OR “eHealth” or “mHealth”) AND (“neck” OR “cervical spine”)	370	5
Shoulder	(“telemedicine”[MeSH] OR “telehealth” OR “tele-assessment” OR “teleconsultation” OR “eHealth” or “mHealth”) AND (“shoulder*” OR “rotator cuff”)	74	11
Elbow and Forearm	(“telemedicine”[MeSH] OR “telehealth” OR “tele-assessment” OR “teleconsultation” OR “eHealth” or “mHealth”) AND (“elbow*” OR “forearm”)	26	4
Wrist and Hand	(“telemedicine”[MeSH] OR “telehealth” OR “tele-assessment” OR “teleconsultation” OR “eHealth” or “mHealth”) AND (“wrist*” OR “hand*” OR “finger*”)	224	8

Table 2 Smartphone Apps and Their Studied Reliability and Validity in Measuring Joint ROM^a

Application	Technology	Platform	Demonstrated Validity and Reliability in Joint ROM
Clinometer + Bubble Level (Peter Breitling; Plaincode)	Inclinometer	AppStore Google Play	Cervical flexion/extension, lateral flexion, rotation^Citation32,Citation33
GetMyROM (Interactive Medical Productions, LLC)	Inclinometer	AppStore	Shoulder forward flexion, abduction, internal/external rotation^Citation46 Elbow extension^Citation66 Wrist extension^Citation66
Dr. Goniometer (CDM S.r.L)	Photo-capture	AppStore	Shoulder forward flexion, abduction, internal/external rotation^Citation46 Forearm supination^Citation70
Angle Meter* (Smart Tool Factory)	Inclinometer	Google Play	Elbow flexion/extension and forearm supination/pronation^Citation22
Goniometer Pro (5fuf5)	Inclinometer	AppStore	Cervical flexion/extension, lateral flexion, rotation^Citation31 Elbow flexion^Citation69,Citation71 Wrist flexion/extension, radial/ulnar deviation^Citation87
Measure (Apple)	Inclinometer	AppStore	Forearm supination/pronation^Citation72,Citation73 Wrist flexion/extension, radial/ulnar deviation^Citation72,Citation73
Compass (Apple)	Compass	AppStore	Cervical flexion/extension, lateral flexion, rotation^Citation33 MCP, PIP, DIP joint flexion (index)^Citation88
Goniometer (June Gaming)	Inclinometer	AppStore	MCP, PIP, DIP joint flexion (index)^Citation88

Notes: ^aAvailable as of June 2021. *Validated in children 6 to 15 years old.

Abbreviations: ROM, range of motion; MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal.

Table 3 Special Testing of the Shoulder via Telemedicine

Test (Clinical Correlate)	Assistance Required?	How to Examine via Telemedicine
Jobe/Empty can test (supraspinatus injury)	No*	Patient is asked to hold a weighted object, such as a large soda bottle, with their arms in 90º abduction and 40º of forward flexion with the thumbs pointing down (pronation). Alternatively, a caregiver can provide resistance. Pain or weakness with resistance is a positive test.
Gerber/Lift-off test (subscapularis injury)	No*	With their back facing the camera, patients are asked to place the dorsum of their hand on their lower back in internal rotation and lift their hand away. If the patient is able to do the latter, a caregiver can provide resistance against extension of the arm as it lifts off the back. Pain and weakness are a positive test.
Hornblower test (teres minor injury)	Yes	Patient places their arm in 90º in the scapular plane and flexes the elbow to 90º. Caregiver provides resistance against the patient’s external rotation. Pain or weakness is a positive test.
Resisted external rotation (infraspinatus and teres minor injury)	No*	Patient lies on unaffected side facing the camera so that the injured shoulder faces up. With that elbow flexed at 90º and tucked to the side, patient lifts a weighted object in external rotation. Alternatively, patient sits with arms close to their side and elbow flexed at 90º and caregiver resists patient’s external rotation. Pain or weakness is a positive test.
Drop arm sign (complete RC tear)	No*	Patient is asked to abduct their arm to 90º with the palm down, then lower that arm slowly. The arm dropping to the side is a positive test. Alternatively, a caregiver can be asked to passively abduct the patient’s arm and let it go.
Neer’s sign (subacromial impingement)	No*	Patient is asked to hold a weighted object and perform maximal forward flexion and internal rotation of their shoulder. Alternatively, a caregiver can passively put the patient’s arm in forward flexion and internal rotation. Pain reproduction is a positive test.
Hawkins-Kennedy test (subacromial impingement)	No*	Ask patient to abduct the shoulder and flex the elbow, both to 90º and use the other hand to grasp the wrist. While keeping the elbow in the same bent position, ask patient to push their wrist down, while internally rotating the shoulder.^Citation18,Citation47,Citation48 Repeat several times. Pain is a positive test. Patient can also touch the top of their nonaffected shoulder with the hand of affected side while lifting that elbow.^Citation76 Alternatively, a caregiver can perform the original test with guidance.
Painful arc (subacromial impingement)	No	Patient is instructed to abduct the arm in the scapular plane and communicate when they feel pain. A positive test is pain between 60–120º which reduces past 120º.
O’Brien test (AC joint pathology, glenoid labrum injury)	No*	Patient forward flexes shoulder to 90º with full elbow extension, combined with 10–15º of horizontal adduction and internal rotation. Self-resistance or caregiver resistance can be applied with a downward force to the tested arm. The maneuver is repeated will full forearm supination. A weighted object can also be used.^Citation20,Citation47,Citation48
Apley scarf (crossover) test (AC joint pathology)	No*	Patient places their arm in 90º forward flexion and can use their other arm to adduct the injured arm across their chest. Pain at AC joint with or without limitation of movement is a positive test. Alternatively, a caregiver can passively perform the adduction.
Speed test (bicipital tendonitis)	No*	While holding a weighted object, patient forward flexes their shoulder to 60º with the elbow in extension and forearm in supination. Pain in the bicipital groove is a positive test. Alternatively, the patient can use resistance provided by pushing upwards on a table/desk or apply self-resistance with the opposite arm.^Citation18 A caregiver can also resist the patient’s flexion while palpating the bicipital groove.
Yergason test (bicipital tendonitis)	No*	With the arm to the side and elbow flexed at 90º, patients are to provide self-resistance against supination and external rotation. Alternatively, a caregiver can resist supination and external rotation. Pain or weakness in the bicipital groove is a positive test.
Load-shift test (glenohumeral joint instability)	Yes	Patient sits with arms relaxed at sides while caregiver moves humeral head anteriorly and posteriorly. Substantial movement is a positive test.
Anterior apprehension (anterior shoulder instability)	No*	Patient performs 90º of shoulder abduction combined with 90º of external rotation. Apprehension with the sensation of subluxation of the humeral head is a positive test, not pain. Patient can also place their elbow against a vertical surface and slightly lean forward.^Citation76 Alternatively, the patient can lie supine in the same position with the arm hanging off the bed while the caregiver slowly provides an external rotation force.
Sulcus sign (inferior shoulder instability)	Yes	Patient sits with the arm to the side and caregiver pulls elbow downward. A gap > 1 finger-width between lateral acromion and humeral head suggests inferior instability.
Roos test (thoracic outlet syndrome)	No	Instruct patient to place shoulders in 90º abduction- external rotation and then open and close fists slowly for 3 minutes. Pain in the neck, shoulder, arm with paresthesia in forearm and fingers is a positive test.

Note: *Test can be facilitated by a caregiver.

Abbreviations: RC, rotator cuff; AC, acromioclavicular.

Figure 1 Special testing of the upper limbs | (A) Jobe/Empty can test: patient holds weighted object, such as bag with canned goods, with their arms in 90º abduction and 40º of forward flexion with the thumbs pointing down. (B) Resisted external rotation: in the lateral decubitus position with the elbow flexed at 90º and tucked to the side, patient lifts weighted object in external rotation. Hawkins-Kennedy test: (C) with the shoulder and elbow abducted to 90º, patient pushes their wrist down while internally rotating that shoulder. (D) Alternatively, patient can touch the top of their unaffected shoulder with the hand of affected side while lifting that elbow. (E) Mill test: patient extends the affected arm in pronation with the wrist in flexion. Their opposite hand grips the other and pulls downward, providing resistance.

Table 4 Special Testing of the Elbow and Forearm via Telemedicine

Test (Clinical Correlate)	Assistance Required?	How to Examine via Telemedicine
Chair push-up test (posterolateral rotatory instability)	No	Patient is seated and instructed to push off from a chair with the forearms in supination. Pain or apprehension suggests instability.
Mill test (lateral epicondylitis)	No*	Patient extends the affected arm in pronation with the wrist in flexion. Their opposite hand grips the other and pulls downward, providing resistance. Pain in the lateral epicondyle or on palpation is a positive test. If present, caregiver can provide resistance.
Cozen test (lateral epicondylitis)	No*	With the patient’s forearm and palm flat on a table, they are instructed to make a fist, radially deviate and extend the wrist while providing resistance against extension with the contralateral hand.^Citation77 Pain in the lateral epicondyle or on palpation is a positive test. If present, caregiver can provide resistance.
Maudsley test (lateral epicondylitis)	No*	With the patient’s forearm flat on a table and in pronation, they are asked to provide self-resistance against ipsilateral 3rd digit extension. Pain in the lateral epicondyle or on palpation is a positive test. If present, caregiver can provide resistance.
Reverse Mill test (medial epicondylitis)	No*	Patient extends the affected arm in supination with the wrist in extension. Their opposite hand grips the other and pulls back, providing resistance. Pain in the medial epicondyle or on palpation is a positive test. If present, caregiver can provide resistance.
Hook test (distal biceps tendon rupture)	No	With the unaffected elbow in flexion, patient is asked to “hook” its biceps tendon with their index finger and compare this to the contralateral side. Inability to hook the tendon is a positive test.
Tinel sign over the ulnar groove (cubital tunnel syndrome)	No*	Physician can direct patients (or caregivers) to locate then tap on the ulnar nerve at the elbow. A tingling sensation in the ulnar distribution of the forearm and hand is a positive sign.
Elbow flexion test (cubital tunnel syndrome)	No	Patient is asked to touch their shoulder with the fingertips of the ipsilateral hand and hold this position for 1 minute. A tingling sensation in the ulnar distribution of the forearm and hand is a positive sign.
Resisted supination (PIN syndrome)	No*	Patient is asked to rest the forearm on the armrest of a chair with the wrist hanging off the edge. While holding a weighted object or weighted bags, they are asked to supinate the forearm.^Citation60 Reproduction of symptoms is a positive test. Alternatively, a caregiver can provide resisted supination.
Resisted pronation (pronator teres syndrome)	Yes	Caregiver is asked to provide resistance against patient’s pronation while extending the patient’s elbow. Reproduction of pain or discomfort is a positive test.

Note: *Test can be facilitated by a caregiver.

Abbreviation: PIN, posterior interosseous nerve.

Table 5 Special Testing of the Wrist and Hand via Telemedicine

Test (Clinical Correlate)	How to Examine via Telemedicine
Phalen test (carpal tunnel syndrome)	Patient is instructed to place the dorsum of both hands against each other in forced flexion and hold this position for 30–60 seconds. Presence of paresthesia in the median nerve distribution is a positive test.
Reverse Phalen test (carpal tunnel syndrome)	Patient is instructed to place both palms against each other as in a prayer and hold this position for 30–60 seconds. Presence of paresthesia in the median nerve distribution is a positive test.
Tinel sign at the wrist (carpal tunnel syndrome)	Patient (or caregiver) is instructed to gently tap along the base of the palm over the distal palmar crease where a positive test is reproduction of paresthesia in the median nerve distribution.
Finkelstein test (de Quervain’s tenosynovitis)	Patient places wrist at edge of table with ulnar aspect of hand hanging off the edge. They are asked to actively ulnar deviate their wrist. If there is no pain aggravation at tip of radial styloid process, patient can use the contralateral hand to provide an ulnar deviation force. If there still is no pain provocation, patients can use the contralateral hand to flex the thumb into the palm, assessing for pain along the tip of the styloid process.
Wartenberg sign (ulnar nerve palsy, cervical myelopathy)	Patient is asked to hold all fingers in adduction while fully extending them. The small finger drifting into abduction indicates a positive test.
Froment sign (ulnar nerve palsy)	Patient grasps piece of paper between thumb and index finger on affected side and attempts to pull it out with the opposite hand. Difficulty holding the paper or compensation by flexing interphalangeal joint of thumb is a positive test.
TFCC load test (TFCC tear)	With the affected wrist in ulnar deviation, patient is instructed to apply a force across the ulna with the contralateral hand, furthering the ulnar deviation. Pain is a positive test.
Press test (TFCC tear)	Seated patient pushes their body weight up off of a chair using the wrists. Focal ulnar wrist pain is a positive test.^Citation102
Thumb MCP joint stress test (ulnar collateral ligament rupture/“skier’s thumb”)	Patients should be asked to use their opposite hand to radially deviate the affected thumb from the MCP joint. Physician observes for either increase in angulation in the case of a complete tear, or laxity in the joint in the case of a partial tear.
Triggering of finger	Patients can be asked to grab and release the large handle of a mug or other similar object with digits 2–5.^Citation76 Subsequent extension with pain and triggering of a digit after removing the fingers form the handle may be suggestive of trigger finger.
1st CMC grind test (carpometacarpal OA)	Patient grips the metacarpal bone of their affected thumb and moves it in a circle, loading it with gentle axial forces. Pain with possible crepitus is a positive test.

Abbreviations: TFCC, triangular fibrocartilage complex; MCP, metacarpophalangeal; CMC, carpometacarpal; OA, osteoarthritis.

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