Paediatric musculoskeletal screening examination

What it is

This is the pGALS musculoskeletal screen: gait, arms, legs and spine, used as screening for joints. If it points to a specific joint, a full examination of that joint follows, on the pattern of posture, gait, look, feel, move.

The screening questions come first:

• Do you, or does your child, have any pain or stiffness in your joints, muscles or back?
• Do you, or does your child, have any difficulty getting yourself dressed without any help?
• Do you, or does your child, have any problem going up and down stairs?

Then the screening manoeuvres, and each one has a joint or a movement behind it.

• Observe the child standing, from front, back and sides: posture and habitus; skin rashes such as psoriasis; deformity such as leg length inequality, leg alignment with valgus or varus at the knee or ankle, scoliosis, joint swelling, muscle wasting, flat feet.
• Observe the child walking, and "walk on your heels" and "walk on your tiptoes": ankles, subtalar, midtarsal and the small joints of the feet and toes, and foot posture, where the note is whether the normal longitudinal arches of the feet are present when on tiptoes.
• "Hold your hands out straight in front of you" tests forward flexion of the shoulders, elbow extension, wrist extension and extension of the small joints of the fingers.
• "Turn your hands over and make a fist" tests wrist supination, elbow supination and flexion of the small joints of the fingers.
• "Pinch your index finger and thumb together" tests manual dexterity and the coordination of the small joints of the index finger and thumb, and the functional key grip.
• "Touch the tips of your fingers" tests manual dexterity and the coordination of the small joints of the fingers and thumbs.
• The metacarpophalangeal joints are squeezed for tenderness.
• "Put your hands together palm to palm" and "Put your hands together back to back" test extension of the small joints of the fingers, wrist extension and elbow flexion.
• "Reach up, touch the sky" and "look at the ceiling" test elbow extension, wrist extension, shoulder abduction and neck extension.
• "Put your hands behind your neck" tests shoulder abduction, external rotation of the shoulders and elbow flexion.
• "Try and touch your shoulder with your ear" tests cervical spine lateral flexion.
• "Open wide and put three of your own fingers in your mouth" tests the temporomandibular joints, and the jaw movement is watched for deviation.
• "Bend forwards and touch your toes" tests forward flexion of the thoracolumbar spine, and the back is watched for scoliosis.

The knee is felt for effusion by patella tap or cross-fluctuation; a small effusion may be missed by patella tap alone. Active movement of the knees in flexion and extension is then checked, with feel for crepitus; and passive movement of the hip with the knee flexed to 90° tests hip flexion and internal rotation of the hip.