Pediatric musculoskeletal examination including P-GALS

P-GALS

1. PAEDIATRIC MUSCULOSKELETAL EXAMINATION including P-GALS SPEAKER: DR. ARNAB NANDY MBBS(H), MD YUVA CME W.B.A.P.

2. prelude Paediatric musculoskeletal (MSK) examination stands out to be unique by its’ essence. The key is to differentiate NORMAL from ABNORMAL . Universal challenges: - Three way communication - Age appropriate interpretation of results Manifestation of musculoskeletal problems: - Primary diseases - Secondary afflictions YUVA CME, W.B.A.P. 2

3. Importance of history taking before MSK examination: - Ante-natal history - Birth history - Developmental history - Family history YUVA CME, W.B.A.P. 3 Figure 1. Figure 2.

4. SALIENT FEATURES It is of utmost importance to know the developmental status of the child. The status quo for MSK examination primarily relies upon: – Inspection (Observation) – Palpation (Functional assessment) Fundamental operational principle for MSK examination is based on: “Look, Feel & Move” YUVA CME, W.B.A.P. 4 Foster H, Kay L, May C, Rapley T. Pediatric regional examination of the musculoskeletal system: A practice‐and consensus‐based approach. Arthritis Care Res. 2011;63:1503-10.

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6. Age dependent normal appearance of joints shall be kept in view while documenting locomotor history and examination findings. Pediatric MSK evaluation includes observation, palpation, range of motion, strength testing, and functional assessment. Observation (look) focuses on swelling, rashes, nail changes, wasting, posture, body symmetry, disproportions, deformities, dysmorphism and different movements. Palpation (feel. move and functional assessment) includes the skin, muscles, spine and joints. YUVA CME, W.B.A.P. 6 Foster HE, Cabral DA. Is musculoskeletal history and examination so different in paediatrics ?. Best Pract Res Clin Rheumatol . 2006;20:241-62.

7. Spine and joints Tenderness, Swelling, Temperature, Synovial thickening, Range of motion: active & passive. YUVA CME, W.B.A.P. 7 Palpation Muscles Size, Bulk, Tenderness, Tone. Skin Elasticity, Rashes, Nodules, papules etc.

8. Clinical vignette Figure 3. YUVA CME, W.B.A.P. 8

9. Clinical vignette Figure 4. YUVA CME, W.B.A.P. 9

10. Clinical vignette Figure 5. YUVA CME, W.B.A.P. 10

11. The spine and back examination: - It includes an assessment of the bones and muscular components, along with the postural assessment. - Evaluation includes, having the child stand and/or sit while the back is examined. - The height of the shoulders, position of scapula, and height of the pelvis should be assessed. - The child is asked to bend forward in order to look for rib and back asymmetries. YUVA CME, W.B.A.P. 11

12. APPROACH YUVA CME, W.B.A.P. 12 Preliminary Screening examination (triage) Focussed formal assessment of the involved joint or limb

13. Screening pMSK screening in Neonates and Infants: The Infants are usually examined on the Mother's lap. Observation of the general body contour, symmetry and proportion, and record anthropometry. Evaluation of tone and reflexes. Observation of spontaneous movements. ‘Toe to tip’ examination including the back to look for congenital anomaly. YUVA CME, W.B.A.P. 13

14. pMSK screening in Children and adolescents: The child shall be adequately exposed, bare footed and preferably in presence of a parent. ‘Top to toe’ examination including assessment of mobility of different axial and peripheral joints. Forward bending test – mobility and symmetry. Assessment of gait, Trendelenberg’s test. Evaluation of the arch of the foot with toe walking. Look for limb length discrepancy by Coleman Block Test. Evidence of signs of any acute or chronic inflammation. YUVA CME, W.B.A.P. 14

15. P-GALS While only a few decades ago where we were in a desperate search of a comprehensible schedule for MSK examination in children, pGALS has turned out to be the one to look forward for the purpose since the earlier part of this century. It has come out of age to its’ present state from the adult counterpart of this scheme. The clinical scheme has been validated through different multicentric study and has shown to have formidable sensitivity as a screening tool in detecting various joint pathologies. YUVA CME, W.B.A.P. 15

16. Paediatric Gait, Arms, Leg and Spine ( pGALS ) assessment is a simple and rapid scheme of MSK examination. It helps in quick detection of musculoskeletal problems in a child and warrants for in detail examination of the afflicted joint or region. The clinical tool comprises of a set questionnaires and some sequential steps to perform. YUVA CME, W.B.A.P. 16

17. SCREENING QUESTIONS: Do you have any pain or stiffness in your joints, muscles or your back? Do you have any difficulty getting yourself dressed without any help? Do you have any difficulty going up and down stairs? GAIT: Observe the child standing (front, side and back). Observe the child walking. “Walk on your heels / walk on your tip-toes ” YUVA CME, W.B.A.P. 17 Figure 6. Foster HE, Jandial S. pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol . 2013;11:1-7.

18. ARMS: “Put your hands out in front of you” “Turn your hands over and make a fist” “Pinch your index finger and thumb together” “Touch the tips of your fingers with your thumb” Squeeze the metacarpophalangeal joints. “Put your hands together and back to back” “Reach up and touch the sky” “Look at the ceiling” “Put your hands behind your neck” YUVA CME, W.B.A.P. 18 Figure 7.

19. LEGS: Feel for effusion at the knee. “Bend and then straighten your knee” (Active movement of knees while examiner feels for crepitus) Passive flexion of 90 º with internal rotation of hip YUVA CME, W.B.A.P. 19 Figure 8.

20. SPINE: “Open your mouth and put 3 of your (child’s own) fingers in your mouth” Lateral flexion of cervical spine – “Try and touch your shoulder with your ear” Observe the spine from behind. “Can you bend and touch your toes?” Observe curve of the spine from side and behind YUVA CME, W.B.A.P. 20 Figure 9.

21. For the ease of executing the pGALS examination: Check that the child is comfortable, ask about pain, and explain what you intend to do. Observe the child walking in the room, getting undressed, & at play with adequate exposure. Get the child to copy you doing the manoeuvres . Look for verbal and non-verbal clues of discomfort. Look for asymmetry and consider clinical patterns YUVA CME, W.B.A.P. 21

22. Red flag signs: Fever and systemic signs Lymphadenopathy Organomegaly Bone pain Persistent night waking Dysmorphic features Incongruence between history and physical findings YUVA CME, W.B.A.P. 22

23. YUVA CME, W.B.A.P. 23 Growing pain in pMSK screening Inclusion criteria Exclusion criteria Frequency and duration Intermittent pains once or twice per week, individual episodes lasting for 30 min to 2 hours Persisting pain or increasing in severity with time Site Usually in the calf muscles, sometimes anterior thigh muscles, shins and popliteal fossa and affects both the limbs Pain involving joints Or occurring only in one limb Time Evening and nights Day time pain and persisting nocturnal pains Physical examination Normal Signs of inflammation

24. YUVA CME, W.B.A.P. 24 M/C pMSK complaint: Growing pain M/C functional abnormality: Hypermobility Sabui TK, Samanta M, Mondal RK, Banerjee I, Saren A, Hazra A. Survey of musculoskeletal abnormalities in school‐going children of hilly and foothill regions of Eastern Himalayas using the pediatric Gait, Arms, Legs, Spine screening method. Int J Rheum Dis. 2018;21:1127-34.

25. Beighton Score One point if while standing forward bending you can place palms on the ground with legs straight One point for each elbow that bends backwards One point for each knee that bends backwards One point for each thumb that touches the forearm when bent backwards One point for each little finger that bends backwards beyond 90 degrees. Can you now (or could you ever) place your hands flat on the floor without bending your knees? Can you now (or could you ever) bend your thumb to touch your forearm? As a child did you amuse your friends by contorting your body into strange shapes OR could you do the splits? Dislocation of shoulder or kneecap on more than one occasion? Do you consider yourself double-jointed? YUVA CME, W.B.A.P. 25 Total score: 0-9; Cut-off score: 4 Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413–8.

26. Focussed assessment A through inspection shall be done relevant to the clues obtained from the pMSK screening examination. Observation of the child from - Front: Posture, Symmetry (limb length discrepancy) - Sides: Curvature of spine - Back: Posture, Symmetry (Shoulder level, Scapula, Iliac crest, Sacral dimples), Central abnormalities The child is asked to squat on the floor and then to stand up. Assessing the gait and mechanics of walking : Push off, follow through & heel strike. YUVA CME, W.B.A.P. 26

27. Measuring limb length: Δ Apparent leg length – Umbilicus → Medial malleolus/heel Δ Actual leg length – ASIS → Medial malleolus/heel Δ Arm length – Acromion process → Olecranon process Δ Total (Upper) limb length – Acromion process → Tip of middle finger Δ Arm span, US:LS Δ Proximal segment of upper limb – Asking the child to touch the shoulder with the thumb with flexed elbow YUVA CME, W.B.A.P. 27

28. Examination of hand and wrist: All the small joints of hand (PIP, DIP, MCP joints) including wrist joint shall be examined Δ Look – Nail changes, muscle wasting, swelling and effusion of joint, deformity. Δ Feel – Skin temperature, eliciting tenderness, tendon thickening and bulk of thenar and hypothenar eminences, nodules, crepitations on joint movement. Δ Move – ROM (active & passive), Restriction of movement, stress pain. Δ Functional assessment - Grip and pinch, picking up small object, writing or drawing, testing individual muscle power, hypermobility assessment. YUVA CME, W.B.A.P. 28 *nail fold capillaroscopy

29. Examination of elbow: Δ Look – Carrying angle, scars, rashes, deformity , muscle wasting, contracture, swelling and effusion of joint. Δ Feel – Skin temperature, tenderness, tendon thickening, nodules, crepitations on joint movement. Palpate joint line, head of radius, ulnar border, medial and lateral epicondyles. Δ Move – ROM (active & passive), Restriction of movement. Δ Functional assessment - Hand to nose or mouth, hands behind head, testing power of individual muscle groups. YUVA CME, W.B.A.P. 29

30. Examination of shoulder: Δ Look (front & back) – Normal contour, scars, rashes, muscle wasting, swelling and joint effusion, shoulder height, position of scapula. Δ Feel – Skin temperature, tenderness, bony landmarks, nodules, crepitations on joint movement. Palpate clavicle, costochondral, sternoclavicular and acromioclavicular joint, axilla. Δ Move – ROM (active & passive), Restriction of movement. Δ Functional assessment – Raise arms over the head, hands behind the neck, hands behind the back, abduction against resistance, testing power of individual muscle groups. YUVA CME, W.B.A.P. 30

31. Examination of temporomandibular (TM) joint and spine: Δ Look – Swelling anterior to the tragus of ear, normal curvatures of spine from side and behind, lumber hollow, symmetry, scars, sinus, swelling and muscle wasting, natal cleft, breach in continuity of skin and deformities. Δ Feel – Skin temperature, tenderness, crepitations on joint movement, paraspinal muscles spasm. Palpate mandibular condyles, spinal processes, sacroiliac joint and other bony landmarks. Δ Move – ROM (active & passive), Restriction of movement. Δ Functional assessment – Putting child’s own three fingers into mouth, look at the celling, bend the neck laterally to touch the shoulder with ear, thoracic rotation, touch the toes with finger, stork test. YUVA CME, W.B.A.P. 31

32. Examination of hip: Δ Look (front, side & back) – Scars, sinus, rashes, muscle wasting, contracture, swelling, asymmetry, sub gluteal skin crease, fixed deformity. Δ Feel – Skin temperature, tenderness, muscle bulk, crepitation on joint movement, muscle spasm. Palpation of grater trochanter, sacroiliac joint and other bony landmarks. Δ Move – ROM (active & passive), Restriction of movement. Δ Functional assessment – Straight leg rising test, Trendelenberg test, Thomas test, gait with turning and running, ancillary movements. YUVA CME, W.B.A.P. 32 *Ortolani test for new-born

33. YUVA CME, W.B.A.P. 33 External rotation of hip Internal rotation of hip Figure 10. Figure 11. Available from: https://musculoskeletalkey.com/examination-of-the-pediatric-patient/

34. Examination of knee: Δ Look – Scars, sinus, rashes, muscle wasting, contracture, swelling, joint effusion, fixed deformity. Δ Feel – Skin temperature, joint line tenderness, muscle bulk, crepitation on joint movement, synovial thickening, joint stability. Palpation of patellar border, tibial tuberosity, popliteal fossa. Δ Move – ROM (active & passive), Restriction of movement. Δ Functional assessment – Drawyer test, patellar tap and cross fluctuation. YUVA CME, W.B.A.P. 34

35. Examination of ankle and feet: Δ Look – Skin changes, muscle wasting, contracture, swelling, joint effusion, arch of the foot, fixed deformity. Δ Feel – Skin temperature, elicit tenderness, nodules, crepitation on joint movement, muscle bulk, tendon thickening and bony landmarks. Palpation of ankle joint line, subtalar, mid-tarsal, metatarsophalangeal (MTP) joints and Achilles tendon at the insertion. Δ Move – ROM (active & passive), Restriction of movement. Δ Functional assessment - Thigh-foot angle, G ait cycle (heel strike, stance, toe off or push off), running and turning, ancillary movement. YUVA CME, W.B.A.P. 35

36. YUVA CME, W.B.A.P. 36 Thigh-foot angle Figure 12.

37. Limitations Age appropriate pMSK examination scheme Appearance of secondary ossification centres Overlap in mode of presentation of diseases Subtle signs and symptoms Apprehensive parents YUVA CME, W.B.A.P. 37 Kay LJ, Baggott G, Coady DA, Foster HE. Musculoskeletal examination for children and adolescents: do standard textbooks contain enough information?. Rheumatol (Oxford). 2003;42:1423-5.

38. Conclusion Hints from pMSK examination Joint involvement Nails, skin & mucosal changes Muscle & tendon affliction Systemic involvement YUVA CME, W.B.A.P. 38 Duration & episodes Number: Mono/Oligo/Poly Type: Large/Small Distribution: Axial/Peripheral Symmetry Nature: Static/Additive/Migratory Deforming/non-deforming Precipitating/reliving factors

39. Thank you [email protected] YUVA CME, W.B.A.P. 39 - Practice is the best of all instructors -