Palpation
In infants and young children, the fontanelles and cranial sutures should be palpated for patency, tension, and size with the child in sitting position and while the child is quiet and not crying.
A tense fontanel in a vigorously crying child does not necessarily mean increased intracranial pressure. In case of ventriculoperitoneal shunt, the reservoir should be located and checked for ease of emptying and speed of refill. The skin should be felt for texture, temperature, and absent or excessive perspiration. Pseudomotor paralysis in spinal cord injury eliminates sweating below the level of the lesion, and compensatory excessive perspiration occurs above the level of the lesion with high environmental temperature. Vasomotor dysfunction with coldness to touch and paleness or slight cyanosis of the skin may be present in severe upper motor neuron impairment. It is seen in the lower extremities of some children with cerebral palsy. Subcutaneous abnormalities may be palpable, such as hard calcific deposits in dermatomyositis or neurofibroma- tous nodules along the course of peripheral nerves. When arthritis is suspected, each joint should be felt for the cardinal signs of inflammation, warmth, discomfort, and swelling due to synovial thickening and effusion.Much can be learned from palpation of muscles. Tone and bulk are reduced in lower motor neuron paralysis; in longstanding denervation, the muscle tissue feels less resilient and fibrotic. The pseudo- hypertrophic calf muscles in Duchenne muscular dystrophy have a typical rubbery, doughy, hard consistency. A fibrotic nodule is usually palpable in the sternocleidomastoid muscle in congenital torticollis. In an infant who has an isolated knee extension contracture, a palpable nodule in the quadriceps indicates fibrotic muscle changes at the site of previous repeated intramuscular injections. Localized pain and swelling accompany injuries to soft tissue or bone. Osteoporotic fractures in lower motor neuron lesions with sensory deficit show swelling but are painless. Tenderness in many muscle groups with weakness, fatigue, or skin rash is suspicious for myositis due to collagen disease or parasitic or viral infections.