Pediatric Musculoskeletal Examination PDF

Pediatric Musculoskeletal Examination Prof. Dr. Tuncay Duruöz Marmara University School of Medicine, PMR Department, Rheumatology Division Istanbul [email protected] The majority of causes of MSK presentations in child-hood are benign, selflimiting and often trauma related; referral to sp...

Pediatric Musculoskeletal Examination Prof. Dr. Tuncay Duruöz Marmara University School of Medicine, PMR Department, Rheumatology Division Istanbul [email protected] The majority of causes of MSK presentations in child-hood are benign, selflimiting and often trauma related; referral to specialist care is not always necessary, and in many instances reassurance alone may suffice. However, MSK symptoms can be presenting features of Juvenile Idiopathic Arthritis (JIA), and potentially life-threatening conditions such as malignancy, infection, vasculitis and non-accidental injury. Inflammatory arthritis is an associated feature of many chronic paediatric conditions such as inflammatory bowel disease, cystic fibrosis, and psoriasis pGALS is an evidence-based approach to basic pMSK assessment and is aimed at the non-specialist in pMSK medicine to discern normal from abnormal When to perform pGALS Unwell child with pyrexia. Child with limp. Delay or regression of motor milestones. The ‘clumsy’ child in the absence of neurological disease. Child with chronic disease and known association with musculoskeletal presentations (such as with inflammatory bowel disease). When inflammatory joint disease is suspected ? The lack of reported pain does not exclude arthritis There is need to probe for symptoms such as ○ gelling (e.g. stiffness after long car rides) ○ altered function (e.g. play, handwriting skills, writing, regression of milestones) ○ deterioration in behaviour (irritability, poor sleeping) There is need to examine all joints as often joint involvement may be ‘asymptomatic’ RED FLAGS (to raise concern about infection, or malignancy or non-accidental injury) Fever, systemic upset (malaise, weight loss, night sweats) Lymphadenopathy, hepatosplenomegaly Bone pain Persistent night waking Incongruence between history and presentation/ pattern of physical findings Practical tips in performing pGALS: Use a 'copy me' approach. Look for verbal and non-verbal clues of discomfort (e.g., facial expression, withdrawal). Do the full assessment as the extent of joint involvement may not be obvious from the history. Look for asymmetry (e.g., muscle bulk, joint swelling, range of joint movement). Remember to interpret the findings in the context of the general examination and the clinical presentation (see the example below). Consider clinical patterns for example: non-benign hypermobility with a Marfanoid habitus or abnormal skin elasticity. association of leg length discrepancy and scoliosis. widespread joint contractures and trigger fingers (see below). Use of pGALS to distinguishing normal from abnormal Normal variants in gait patterns and leg alignment Habitual toe walking is common in young children up to 3 years. In toeing can be due to: Persistent femoral ante version (characterised by child walking with patellae and feet pointing inwards and is common between ages of 3–8 years) Internal tibial torsion (characterized by child walking with patella facing forward and toes pointing inwards and is common from onset of walking to 3 years) Metatarsus adductus (characterized by a flexible ‘C shaped’ lateral border of the foot and most resolve by 6 years). Bow legs (genu varus) are common from birth to early toddler, often with out-toeing (maximal at approximately 1 year of age), and most resolve by 18 months. Knock knees (genu valgus) are common and are often associated with in-toeing (maximal at approximately 4 years of age) and most resolve by age of 7 years. Flat feet – most children have a flexible foot with normal arch on tiptoeing and resolve by 6 years Crooked toes – most resolve with weight bearing. Normal variants: indications for referral Persistent changes (beyond the expected age ranges) Progressive/asymmetrical changes Short stature or dysmorphic features Painful changes with functional limitation Regression or delayed motor milestones Abnormal joint examination elsewhere Suggestion of neurological disease/developmental delay History THANKS