4/21/2020 The pediatric physical examination: Back, extremities, nervous system, skin, and lymph nodes - UpToDate

Author: Jan E Drutz, MD

Section Editor: Teresa K Duryea, MD
Deputy Editor: Mary M Torchia, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2020. | This topic last updated: Apr 08, 2019.

INTRODUCTION

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".)
● (See "The pediatric physical examination: HEENT".)
● (See "The pediatric physical examination: Chest and abdomen".)
● (See "The pediatric physical examination: The perineum".)

BACK

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 [1]. 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 and 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'.)

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Scoliosis in the neonate has great significance because it produces cosmetic problems and may
be associated with visceral and/or neurologic dysfunction. (See "Adolescent idiopathic scoliosis:
Clinical features, evaluation, and diagnosis", section on 'Congenital scoliosis'.)

Flattened buttocks and shortening of the cephalad extent of the gluteal cleft is the classic sign of
sacral agenesis. The clinician should ask the caregiver about maternal type 1 diabetes and must
order a lateral radiologic image of the lower spine to confirm the diagnosis (picture 1). (See
"Infants of women with diabetes", section on 'Congenital anomalies'.)

Darkly pigmented neonates and infants may have bluish macular skin lesions over the back
termed congenital dermal melanocytosis (also called Mongolian spots (picture 2)). These lesions
are benign accumulations of elliptical melanocytes that regress spontaneously after one to two
years. (See "Skin lesions in the newborn and infant", section on 'Dermal melanocytosis'.)

All patients, particularly children in the preadolescent years, should undergo examination of the
spine for scoliosis. Acquired scoliosis in preadolescents may herald important pathology (eg,
spinal cord or vertebral bone tumors). On the other hand, idiopathic scoliosis, which is most
common in adolescent girls, can usually be followed with observation. (See "Adolescent
idiopathic scoliosis: Clinical features, evaluation, and diagnosis", section on 'Clinical evaluation'.)

Proper examination requires unobstructed visualization of the back. The patient should be
standing straight, but not rigid, with feet together and arms at the sides. Asymmetry of the back
structures should be noted. For the second phase of the examination, the patient should be
asked to bend over at the waist with legs straight, feet together, arms in a dependent position
with the tips of the thumbs apposed, and head directed toward the floor in a relaxed position.
The presence of a rib hump or abnormal curvature should be noted.

In addition to inspection for scoliosis, the spine should be examined for kyphosis and lordosis. A
normal lumbar lordotic curvature, giving rise to a pot-bellied appearance, is found in most
toddlers. Spontaneous resolution of the curvature occurs in almost all as they advance into early
childhood. Mild lumbar lordosis and/or thoracic kyphosis require no intervention; more prominent
forms of either deformity warrant thorough evaluation.

EXTREMITIES

The approach to examination of the extremities in the older child and adolescent is similar to that
of the adult; examination of infants and younger children requires an understanding of
anatomical limitations and acceptable variations in normal rotation and alignment.

Inspection — Examination should begin with careful inspection of the upper and lower
extremities, looking for appropriate alignment, unusual masses or protuberances, joint
deformities, missing or fused digits, and/or integument abnormalities. Attention should be paid to

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muscle mass. Adverse effects from maternal drugs, congenital defects, and
chromosomal/genetic abnormalities may cause limb deformities and limb-length discrepancies.
Bilateral malformation of the great toes (short and laterally deviated with absent or fused
interphalangeal joint) is a characteristic finding of fibrodysplasia ossificans progressiva, a rare
condition associated with progressive heterotopic ossification [2]. (See "Fibrodysplasia
ossificans progressiva".)

Range of motion — Physical examination of the extremities includes determining the range of
motion of all joints. Normal, full-term, newborn infants have significant flexion contractures of the
upper and lower extremities, limiting the range of motion. Flexion, extension, abduction,
adduction, supination, pronation, eversion, and inversion should be demonstrated within the
normal anatomical limits of the particular joint. Variation from normal between paired joints and
extremities also should be noted. For older children, the clinician should evaluate gait as well as
the sitting and standing postures.

Palpation — Palpation of the extremities should be done to determine areas of tenderness,

swelling, and increased or decreased temperature. Any one or all of these findings may be noted
at sites of fracture, bone or joint disease, infection, and sprain.

Tone and strength — The tone and strength of the muscles should be examined. Patients with
Duchenne muscular dystrophy, who have pseudohypertrophy of muscle groups, will
(deceptively) appear to have adequate muscle mass, despite having decreased muscle tone and
strength. (See "Duchenne and Becker muscular dystrophy: Clinical features and diagnosis".)

Lower extremity rotation and alignment — In-toeing is common in young children and may be
caused by metatarsus adductus, internal tibial torsion, or increased femoral anteversion (figure
1). Out-toeing may be caused by physiologic external rotation contracture of the hip. These
anatomic variations usually result from in utero positioning and correct spontaneously. (See
"Approach to the child with in-toeing" and "Approach to the child with out-toeing".)

During the first seven years of life, lower extremity alignment goes through a predictable
progression from bow-legs to knock-knees (figure 2). In most young children, bow-legs and
knock-knees are physiologic, although pathologic causes must be considered (table 1A-B). (See
"Approach to the child with bow-legs" and "Approach to the child with knock-knees".)

Gait — In the early months of walking, infants have a normal, wide-based gait; the legs often are
rotated externally, and the feet are flat. The more normal gait of childhood develops with
anatomical and neurologic maturity.

Toe walking, found in patients with cerebral palsy, may be a transient finding in some normal
infants. Passive range of motion of the foot will help distinguish a tight heel cord that is limiting
normal dorsiflexion from the full range of motion seen in the otherwise normal toe walker.

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Possible causes of a limp in children include infection; neuromuscular or neurologic problems;

primary bone, cartilage, ligament, and/or joint abnormalities; allergic and/or inflammatory
processes; cancer; mass lesions; and foreign bodies (table 2). (See "Overview of the causes of
limp in children" and "Evaluation of the child with a limp" and "Approach to hip pain in childhood",
section on 'Common causes of hip pain in children'.)

Hip examination — Thorough examination of the hips for evidence of joint laxity or dislocation
should be performed on every infant from shortly after birth until several months after
independent walking. Findings compatible with developmental dysplasia of the hip (DDH) may
be detected in the newborn period (table 3); abnormal signs present at that time may disappear.
The clinical features of DDH are discussed separately. (See "Developmental dysplasia of the hip:
Clinical features and diagnosis", section on 'Examination'.)

NEUROLOGIC EXAMINATION

Complete neurologic examination is warranted in children who present with or are found to have
neurologic or neuromuscular abnormalities on examination. The neurologic examination for
infants and children is discussed separately. (See "Neurologic examination of the newborn" and
"Detailed neurologic assessment of infants and children".)

SKIN

Inspection and palpation — Examination of the skin requires careful inspection and palpation.
When describing individual skin abnormalities, the examiner should describe color and size and
whether the lesions, tumors, rashes, or defects are raised or flat, coalescent or isolated, well
localized or diffuse, pruritic or nonpruritic. Terms such as papule, macule, pustule, vesicle,
bullae, and nodule describe the appearance of rashes/lesions and have meaning for most health
professionals. However, because skin lesions from different causes can have the same
appearance, the clinician must be careful to make the correct diagnosis and recommend the
correct treatment. The history and physical examination are of significant benefit in helping to
differentiate among various disorders.

Essentially all lesions originating in the skin of children are benign. Lesions without an altered
appearance of the epidermis, however, may not be easy to categorize. A mass that during
palpation moves freely over the underlying fascia most likely is present in the subcutaneous
tissue and should be considered benign. Malignancy is a possibility when the lesion is fixed to
the underlying fascia or the examiner is unsure of what is being felt; an appropriate referral
should be made in this circumstance [3].

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Palpation of the skin may reveal rough, coarse, or dry areas in the region of the neck, knee, or
elbow, which often are found in patients with atopic dermatitis. Large patches of coarse papular
lesions palpable over the dorsal surfaces of the upper arms and thighs of an older child or
adolescent may be compatible with hyperkeratosis pilaris. An elongated or patchy area of moist,
erythematous, denuded, pruritic skin may be seen in patients with contact dermatitis caused by
poison ivy. Pink, raised, pruritic lesions of various sizes and shapes, diffusely scattered over the
body, are found in patients with urticaria.

Yellow discoloration — A yellow tint to the skin may be compatible with carotenemia or
jaundice (hyperbilirubinemia).

● Carotenemia — A yellow tint to the skin may be compatible with carotenemia or jaundice
(hyperbilirubinemia). Carotenemia can be found in infants and toddlers whose diets consist
of large amounts of strained yellow vegetables, particularly carrots and other carotenoid-
containing fruits and vegetables. Carotenoids include alpha- and beta-carotene, and
lycopene [4]. They are contained in carrots, sweet potatoes, mangoes, apricots, melons,
tomatoes, peppers, and green leafy vegetables. In addition, beta-carotene is frequently
used as a food-coloring agent.

Unlike jaundice, the skin color characteristically is more yellow-orange and more noticeable
in areas with increased sweat glands (eg, the palms, soles, and nasolabial folds), sparing
mucosal tissue and the sclerae [4]. Although diet is a major cause of carotenemia in
childhood, some diseases, such as nephrosis, diabetes mellitus, anorexia nervosa, liver
disease, and hypothyroidism, also can produce the condition [5].

● Jaundice — Jaundice (picture 3) can be differentiated from carotenemia by the yellow-

green skin color, yellow sclerae and mucous membranes, and the darkly colored urine and
lightly colored stools. Collection of bile pigment accounts for the change in tissue color.
Disorders giving rise to hyperbilirubinemia include neonatal (physiologic) jaundice, hemolytic
anemias, hepatitis, enzyme defects, and biliary tree obstruction [6]. (See "Unconjugated
hyperbilirubinemia in term and late preterm infants: Screening" and "Evaluation of jaundice
caused by unconjugated hyperbilirubinemia in children".)

Blue-gray discoloration — A bluish-gray discoloration of the skin may be a side effect of a drug
or caused by the ingestion of a toxic substance. The parts of the body most often involved are
the face, neck, and extremities [7].

Pigmentation — Hypopigmented or hyperpigmented skin lesions may have clinical significance.

Hypopigmented areas often are benign but can be compatible with various disease states [8].
(See "Acquired hypopigmentation disorders other than vitiligo" and "Acquired hyperpigmentation
disorders" and "Congenital and inherited hyperpigmentation disorders".)

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Hypopigmented lesions — Hypopigmented areas often are benign but can be associated with
various diseases [8]. (See "Acquired hypopigmentation disorders other than vitiligo" and "Vitiligo:
Pathogenesis, clinical features, and diagnosis".)

● Small hypopigmented or depigmented areas may be the result of postinflammatory lesions,

pityriasis alba (picture 4), or tinea versicolor (picture 5).

● Patients with neuroectodermal disorders, such as tuberous sclerosis complex, often have
hypopigmented ash leaf spots (picture 6).

● Streaked areas of hypopigmentation characteristically are seen in hypomelanosis of Ito, also

known as incontinentia pigmenti achromians (picture 7).

● Vitiligo, an autosomal trait of variable penetrance, is a patterned loss of pigmentation

secondary to the destruction of melanocytes (picture 8).

● Albinism is an entity with total or nearly complete absence of pigmentation. (See

"Oculocutaneous albinism".)

● Chediak-Higashi syndrome is a rare autosomal recessive immunologic disorder with diffuse

oculocutaneous hypopigmentation, leukocyte dysfunction, and recurrent infections. Patients
with this disorder have fair skin, light blond hair, translucent irises, and renal, hematologic,
and neurologic abnormalities [9]. (See "Chediak-Higashi syndrome".)

Hyperpigmented lesions — Hyperpigmented skin lesions may be clinically significant [8]. (See
"Congenital and inherited hyperpigmentation disorders" and "Acquired hyperpigmentation
disorders".)

Increased skin pigmentation owing to an excess of melanin may be localized or diffuse. Between
one and four light brown macular lesions (cafe-au-lait spots) no greater than 0.5 to 1.0 cm at
their largest diameter (depending on the patient's age) is a normal finding in many patients.
Larger and more numerous cafe-au-lait spots can be seen in neurofibromatosis (picture 9),
Bloom syndrome, ataxia telangiectasia, and several other syndromes [10]. (See
"Neurofibromatosis type 1 (NF1): Pathogenesis, clinical features, and diagnosis" and "Bloom
syndrome" and "Ataxia-telangiectasia".)

More darkly pigmented cutaneous tumors that appear anywhere on the body may be present at
birth or appear years later. Large congenital and atypical nevi (usually developing during the
second decade of life) may become melanoma. Melanomas are found rarely in infants and
children; they have an irregular border with deeply pigmented or varied colored areas, may have
ulcerations or satellite lesions, and have a tendency to grow [3,11]. (See "Congenital melanocytic
nevi" and "Acquired melanocytic nevi (moles)", section on 'Atypical nevi' and "Screening and
early detection of melanoma in adults and adolescents".)

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Acquired nevi (not present at birth) are less than 1 cm in diameter, may be flat or slightly raised,
are light brown to black in color, and have discrete regular borders. They develop during the first
several decades of life and often eventually disappear. Though the vast majority of acquired nevi
are harmless, certain changes, including rapid darkening, changes in size or borders, ulceration,
itching, pain, or bleeding, indicate a need for biopsy and histologic evaluation [3]. (See "Acquired
melanocytic nevi (moles)".)

Vascular lesions — Vascular lesions commonly seen in children may have clinical significance.
The most common vascular lesion seen in infants is a pink nevus simplex (often called salmon
patch, stork bite, or angel kiss (picture 10)) most often found on the nape of the neck, glabella,
upper eyelids, forehead, and nasolabial folds. They require no treatment, and the vast majority
fades within the first year of life [12]. (See "Vascular lesions in the newborn", section on 'Nevus
simplex (macular stain)'.)

Infantile hemangiomas are benign vascular tumors composed of proliferating vascular

endothelium (picture 11). Approximately 90 percent of these lesions undergo spontaneous
involution by the time the child is nine years old. Hemangiomas of the face and/or lumbosacral
region may be associated with extracutaneous manifestations and require additional evaluation.
The clinical features, evaluation, and management of hemangiomas are discussed separately.
(See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications"
and "Infantile hemangiomas: Evaluation and diagnosis" and "Infantile hemangiomas:
Management".)

Vascular lesions that neither proliferate nor involute and are caused by inborn errors of vascular
morphogenesis are termed venous malformations [13]. They grow in proportion to the growth of
the child and may require treatment. The facial port-wine stain (picture 12A-B), the most
frequently occurring example of this condition, often is associated with a neurocutaneous
disorder (Sturge-Weber syndrome) (picture 13A-B). Port-wine staining of one of the extremities
may be associated with soft tissue hypertrophy and overgrowth of the underlying bone (Klippel-
Trenaunay syndrome) [13,14]. (See "Sturge-Weber syndrome" and "Vascular lesions in the
newborn", section on 'Klippel-Trenaunay syndrome'.)

The spider nevus, the best-known type of telangiectasia (also known as spider angioma,
vascular spider, or nevus aranei), is a central vascular papule surrounded by symmetrically
radiating branches [14]. Spider nevi appear most commonly on exposed areas of the face, upper
trunk, arms, hands, and fingers. They are associated with liver disease, pregnancy, and estrogen
therapy but also may occur in individuals without these conditions. In an observational study, 38
percent of 426 children (aged 1 to 15 years) without liver disease had ≥1 spider nevus; most had
between one and four; only 7 children (1.6 percent) had ≥5 [15]. Among children with chronic
liver disease, 16 of 34 (47 percent) had no spider nevi and four (12 percent) had ≥5 [15]. Most
spider nevi persist indefinitely, although some may regress spontaneously [14]. When treatment
is desired, treatment options include electrocoagulation and pulsed dye laser therapy [14,16].
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Striae — Striae, or "stretch marks," also known as striae distensae, are linear depressions of the
skin with epidermal atrophy. They are typically several centimeters long and 1 to 10 mm wide
[17]. Initially pink or purple, striae later become white, translucent, and atrophic [11]. Striae
occasionally may mimic physical abuse or nonaccidental injury [18]. (See "Striae distensae
(stretch marks)".)

Striae tend to occur in areas of excessive stretching of the skin, eg, the abdomen, lower back,
breasts, buttocks, and thighs. Individuals with rapid weight gain, females who are pregnant, and
pubescent adolescents with rapid overall growth frequently develop striae. Striae also may occur
in patients with anorexia nervosa [19]. Adolescents engaged in weight-lifting programs may
develop striae of the shoulder and chest areas. Excessive adrenocortical activity (Cushing's
disease), as well as prolonged use of oral and potent topical corticosteroids, can lead to striae
formation (picture 14) [11].

Striae appearing during adolescence tend to regress spontaneously over time. Treatment may
be warranted for striae that are persistent or cosmetically unacceptable. Treatment of striae is
discussed separately. (See "Striae distensae (stretch marks)", section on 'Treatment'.)

Other skin lesions — Among the more common skin lesions seen in childhood are warts,
pyogenic granulomata, and sebaceous (epidermal) cysts. The examiner should be suspicious of
a potential underlying neurologic defect whenever a pigmented lesion (with or without a tuft of
hair), a vascular lesion, a soft tissue mass, or a skin defect is found over the midline of the head,
neck, or back.

Though cosmetically unattractive, warts on the hands and feet (picture 15A-C) do not always
require treatment, and most regress spontaneously. Warts in the genital or perianal areas should
alert the examiner to the possibility of sexual abuse. (See "Cutaneous warts (common, plantar,
and flat warts)" and "Evaluation of sexual abuse in children and adolescents".)

Pyogenic granulomata are benign, generally small, raised papules appearing anywhere on the
skin (picture 16) [3]. They bleed easily and are best treated with silver nitrate or electrocautery.

Sebaceous cysts occur at anatomical sites where hair is present. They should be surgically
removed if unsightly or bothersome.

LYMPH NODES

The lymph node examination requires careful inspection and palpation. The approach should be
symmetric and sequential (eg, beginning with simultaneous palpation of the occipital and
posterior cervical nodes, followed by palpation of the anterior cervical nodes, preauricular and
postauricular nodes, submental nodes, supraclavicular nodes, axillary nodes, and inguinal nodes
(figure 3)).

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Routine examination of the lymph nodes includes attention to size, consistency mobility,
tenderness, adhesion to adjacent tissues, and the temperature and condition of the overlying
skin [20]. Nodes that grow slowly generally are benign; those that grow rapidly and are rubbery,
hard, nontender, and matted tend to be malignant. Enlarged, tender nodes with increased
warmth to the overlying skin usually are infected. The causes of enlarged lymph nodes, the
lymph node examination, and the approach to the child with enlarged lymph nodes are
discussed in detail separately. (See "Peripheral lymphadenopathy in children: Evaluation and
diagnostic approach" and "Peripheral lymphadenopathy in children: Etiology", section on
'General classification'.)

SUMMARY

● The back examination should include assessment of spinal alignment, structural asymmetry,
soft tissue masses, skin lesions, and points of tenderness. Important findings may include
(see 'Back' above):

• Soft tissue lesions overlying the spine (possible neurologic defect)

• Flattened buttocks, shortened gluteal cleft (possible sacral agenesis)
• Scoliosis in preadolescents (possible pathology of the spine or spinal cord)

● Examination of the extremities should include assessment of alignment, symmetry, masses,

joint deformities, missing or fused digits, skin abnormalities, muscle mass, tone, strength,
range of motion, tenderness, and temperature. For older children, gait and sitting and
standing postures also should be evaluated. (See 'Extremities' above.)

● Children who present with or who are found to have neurologic or neuromuscular
abnormalities on examination should undergo a complete neurologic assessment, including
mental status, cranial nerves, muscle tone and strength, deep tendon reflexes, cerebellar
function, and sensory responses. (See "Detailed neurologic assessment of infants and
children".)

● Examination of the skin requires careful inspection and palpation. Skin abnormalities should
be described in terms of color, size, morphology (eg, papule, macule, pustule, vesicle, bulla,
nodule), distribution, pattern (coalescent, isolated), and pruritus. (See 'Inspection and
palpation' above.)

● Hypopigmented skin lesions may be a sign of a number of disorders, including tuberous

sclerosis complex (picture 6), vitiligo (picture 8), Chediak-Higashi syndrome. (See
'Hypopigmented lesions' above.)

● Hyperpigmented skin lesions may be a sign of neurofibromatosis (picture 9), Bloom

syndrome, ataxia telangiectasia, and several other syndromes. (See 'Hyperpigmented

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lesions' above.)

● Vascular lesions may include macular stains (picture 10), infantile hemangiomas (picture
11), venous malformations, port-wine stain (picture 12A-B), and spider nevi. (See 'Vascular
lesions' above.)

● Striae ("stretch marks") are linear depressions of the skin with epidermal atrophy. They tend
to occur in areas of excessive stretching (eg, the abdomen, lower back, breasts, buttocks,
and thighs). Striae appearing during adolescence tend to regress spontaneously over time.
(See 'Striae' above.)

● Examination of the lymph nodes requires symmetric and sequential inspection and
palpation, with assessment of size, mobility, tenderness, adhesion to adjacent tissues, and
condition of the overlying skin. (See 'Lymph nodes' above.)

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