Life-threatening conditions
Malignancy (leukaemia, lymphoma, bone tumour)
Sepsis (septic arthritis, osteomyelitis)
Non-accidental injury
Joint pain with minimal or no swelling
Hypermobility syndromes
Orthopaedic syndromes (e.g. Osgood–Schlatter disease, Perthes’ disease)
Idiopathic pain syndromes (reflex sympathetic dystrophy, fibromyalgia)
Metabolic (e.g. hypothyroidism, lysosomal storage diseases)
Tumour (benign and malignant)
Joint pain with swelling
Trauma (haemarthrosis)
Infection
Septic arthritis and osteomyelitis (viral, bacterial, mycobacterial)
Reactive arthritis (postenteric, sexually acquired)
Infection related (rheumatic fever, post-vaccination)
Juvenile idiopathic arthritis
Arthritis related to inflammatory bowel disease
Connective tissue diseases (SLE, scleroderma, dermatomyositis, vasculitis)
Metabolic (e.g. osteomalacia/rickets, cystic fibrosis)
Haematological (e.g. haemophilia, haemoglobinopathy)
Tumour (benign and malignant)
Chromosomal (e.g. Down’s-related arthritis)
Auto-inflammatory syndromes (e.g. periodic syndromes, chronic recurrent multifocal osteomyelitis)
Sarcoidosis
Developmental/congenital (e.g. achondroplasia)
Accurate interpretation of MSK assessment needs appreciation of normal growth and development (Table 9.2), recognition of normal variants (Table 9.3) and knowledge of patterns of pathology that occur at different age groups. This is exemplified in the context of the limping child; interpretation of the gait pattern must take into account the changing gait with age. This then needs to be interpreted with the knowledge that causes of limp vary with age (Table 9.4), e.g. slipped upper femoral epiphysis often in the older, overweight child, Perthes’ disease which may follow a transient synovitis or ‘irritable hip’ in the school-aged child and developmental dysplasia of the hip which may present in the toddler if not detected in early baby checks. Life-threatening conditions such as acute leukaemia or bone and joint infection can present with limp, non-specific limb, joint or muscle pain or pyrexia without apparent focus.
Table 9.2
Normal gait and musculoskeletal development
Sit without support | 6–8 months |
Creep on hands and knees | 9–11 months |
Cruise or bottom shuffle | 11–12 months |
Walk independently | 12–14 months |
Climb upstairs on hands and knees | ~15 months |
Run stiffly | ~16 months |
Walk down steps (nonreciprocal) | 20–24 months |
Walk up steps, alternate feet | 3 years |
Hop on one foot, broad jump | 4 years |
Skipping | 5 years |
Balance on one foot for 20 s | 6–7 years |
Adult gait and posture | 8 years |
Table 9.3
Normal variants of lower limb development
Indications for concern and referral to physiotherapy or pediatric orthopaedics unless specified | Comments | |
|---|---|---|
Tiptoe walking Common in healthy young children and usually resolves by 3 years of age | Toe walking is persistent or asymmetrical Associated developmental delay Child unable to squat or stand with heels on the floor (tightness of calf muscles) Child >3 years old and unable to stand from floor sitting without using hands | Can associate with club foot or neurological disease be associated with (e.g. muscular dystrophy, cerebral palsy, poliomyelitis). Careful neuromuscular/assessment required. Check for gastrocnemius contracture and shoes for sole wear. Physiotherapy can often help in mild cases but surgery may be required |
Flat feet Common and normal for babies and toddlers, resolves with development of longitudinal arch usually by 4–6 years of age | Signs of pressure on the foot, e.g. blistering Longitudinal arch does not form normally when the child stands on tiptoe The foot is stiff (i.e. the normal arch does not form when the child stands on tiptoe or the big toe is passively extended) | Persistence often familial, more common in hypermobility Insoles may help but should not be worn all the time – walking in bare feet help promote foot development A non-flexible flat foot may indicate tarsal coalition (often teens) In newborn, exclude vertical talus |
Pes cavus Not common, the opposite of flat feet; the arch is extremely pronounced | Often associated with toe clawing, calluses, heel varus and pain, with footwear difficult to fit May be physiological (familial – so check parents’ feet), residual from club foot abnormality or associated with neurological abnormalities – pediatric neurology/orthopaedic referral usually needed | Careful neuromuscular/musculoskeletal assessment required. Neurological conditions to consider include spina bifida, spinal dysraphism, poliomyelitis, Charcot–Marie–Tooth, Friedreich’s ataxia Insoles may help and surgery may be required |
Curly toes Mostly resolve by 4 years of age | Surgery rarely needed | Check shoes are well fitting |
Knock knees Usually resolve by 6 years of age | Associated with pain or asymmetrical Extreme (>6 cm intermalleolar distance at ankles) or persistent (>6 years) | A gap of 6–7 cm between the ankles is normal (between 2 and 4 years) Late feature of arthritis of the knee (e.g. JIA) |
Bow legs Common and normally seen in children until the age of 2 years | Associated with pain or asymmetrical, or the child is short in stature or has other medical problems Extreme (>6 cm intercondylar distance at knees) or persistent (>6 years) | Conditions to exclude include rickets, skeletal dysplasias, syndromes associated with dwarfism (e.g. achondroplasia), Blount’s disease Late feature of arthritis of the knee (e.g. JIA) |
Out–toeing Feet point outwards, usually resolves by 4 years | Recent onset in a teenager – check hips for a slipped upper femoral epiphysis | |
Intoeing Feet turning inwards – ‘pigeon toed’ Normal development for many toddlers when just learning to walk, usually resolved by 10 years | Persistence (>10 years) Affecting mobility and function (clumsy, prone to falling) Femoral anteversion and medial tibial torsion, usually resolve by 10 years of age Metatarsus adductus, usually resolve by 5 years of age | Check child’s leg alignment when standing Femoral anteversion (90 % of cases), patellae pointing inwards Medial tibial torsion (patellae point straightforward) Metatarsus adductus (forefoot abnormal only) Insoles and exercises will not help. Surgery rarely required |
Table 9.4
Significant causes of limp, by age
0–3 years | 4–10 years | 11–16 years | |
|---|---|---|---|
Most common | Trauma (including toddler’s fracture) | Trauma Transient synovitis Perthes’ disease | Trauma Osgood–Schlatter disease |
Conditions requiring urgent intervention | Osteomyelitis Septic arthritis | Osteomyelitis Septic arthritis | Osteomyelitis Septic arthritis |
Non-accidental injury Malignancy (e.g. neuroblastoma) | Non-accidental injury Malignant disease (e.g. acute lymphocytic leukaemia) | Slipped upper femoral epiphysis Malignancy (e.g. bone tumours) | |
Testicular torsion Inguinal hernia | Testicular torsion Appendicitis Inguinal hernia | Testicular torsion Appendicitis Inguinal hernia | |
Other important conditions to consider | Developmental dysplasia of the hip Juvenile idiopathic arthritis | Juvenile idiopathic arthritis | Juvenile idiopathic arthritis |
Metabolic (e.g. rickets, mucopolysaccharidoses) Haematological disease (e.g. sickle cell anaemia) Reactive arthritis Lyme arthritis | |||
The concept of referred pain should not be overlooked; in the context of limp for example, pain in the thigh or knee may be referred pain from the hip, and also extra-articular causes from the testis or hernia must be considered. Accurate interpretation of MSK assessment also requires appreciation of normal motor milestones; delay may indicate neurological disease (especially where there is global developmental delay), whereas regression (of achieved motor milestones) is more likely in acquired MSK disease, such as inflammatory muscle or joint disease (e.g. the child who was happy to walk unaided but has recently refused to walk or resorted to crawling again).
Taking a History
Clinical assessment usually starts with taking a history, with key features described in Table 9.5. The questions in the history will help to discern if the presentation suggests an inflammatory or non-inflammatory cause, if there are any ‘red flags’ to suggest a sinister cause, if the problem is acute or chronic and the pattern of joint involvement (e.g. monoarticular or polyarticular) and if there are features to suggest a multisystem disease. There are, however, several challenges in the history taking, as listed below:
Table 9.5
Key open questions to ask when taking a musculoskeletal history
Questions to parent/carer (and to the child as appropriate) | Points to check for | Comments |
|---|---|---|
What have you or anyone else noticed? | Behaviour, mood, joint swelling, limping, bruising History of trauma | Limping, whether intermittent or persistent, always warrants further assessment. Deterioration in school performance (e.g. sport, handwriting) or avoidance of previously enjoyed activities is always significant Joint swelling is always significant but can be subtle and easily overlooked by the parent (and even healthcare professionals!), especially if the changes are symmetrical. Rather than describing stiffness, the parents may notice the child is reluctant to weight bear, limps in the mornings or ‘gels’ after periods of immobility (e.g. after long car rides or sitting in a classroom) Trauma – can be misleading as trauma is a common event in the lives of young children and not necessarily the appropriate explanation for a child’s MSK symptoms. Conversely, not all trauma is witnessed by a parent or carer. Significant trauma usually results in the child being no longer able to continue the activity or weight bear Repeated episodes of trauma, pattern of injury or incongruous circumstances or explanation raises concerns about non-accidental injury |
What is the child like in him-/herself? | Irritability, grumpy, ‘clingy’, reluctant to play, systemic features (e.g. fever, anorexia, weight loss) | Young children in pain may not verbalise pain but may present with behavioural changes or avoidance of activities previously enjoyed Systemic features including red flags to suggest malignancy or infection |
Where is the pain? (ask the child to point) and what is it like? | Take a pain history and focus on locality, exacerbating/relieving factors, timescale, pattern | Asymmetrical persistent site of pain is invariably a cause for concern Referred pain from the hip may present with non-specific pain in the thigh or knee |
How is he/she in the mornings and during the day? | Diurnal variation and daytime symptoms (e.g. limping, difficulty walking, dressing, toileting, stairs?) | Pain on waking or daytime symptoms suggestive of stiffness or gelling (after periods of inactivity) are indicative of inflammatory joint (or muscle) disease |
What is he/she like with walking and running? Has there been any change in his activities? | Motor milestones and suggestion of delay or regression of achieved milestone, including speech and language. Avoidance of activities previously enjoyed (e.g. sport, play) is noteworthy. Mechanical problems may be suggested by locking or giving way | Regression of achieved motor milestones, functional impairment or avoidance of activity (including play, sport or writing) is more suggestive of acquired joint or muscle disease (and especially inflammatory causes). An assessment of global neurodevelopment is indicated with delay or regression in speech, language or motor skills ‘Clumsiness’ is a non-specific term but may mask significant musculoskeletal or neurological disease |
How is he/she at school or nursery? | School attendance (any suggestion of school avoidance, bullying) | Behavioural problems in the young child may manifest as non-specific pains (headaches, tummy aches or leg pains). Sensitive questioning may reveal stressful events at home or school |
Does he/she wake at night with pain? | Pattern of night waking | Night waking is a common feature of growing pains (usually intermittent and often predictable). Conversely, persistent night waking, especially if there are other concerns (such as unilaterality, limping, unusual location or systemic features), is of concern and invariably necessitates further investigation |
Can you predict when the pains may occur? | Relationship to physical activity (including during or after sporting activities) | Mechanical pains tend to be worse later in the day, evenings and often after busy days. Growing pains often follow busy days and are often predictable in their occurrence |
What do you do when he/she is in pain? | Response to analgesics, anti-inflammatory medication, massages and reaction of the parent | Lack of response to simple analgesia is a concern. Vicious circle of reinforced behaviour can occur |
What is your main concern? | Sleep disturbance, cosmesis, anxiety about serious disease (arthritis, cancer, family history), pain control | A family history of muscle disease, arthritis or autoimmune disease may indicate a predisposition to muscle or joint disease. Observed ‘abnormalities’ (such as flat feet, curly toes) may be part of normal development. The parent or carer will undoubtedly have anxieties and concerns about the child and may often fear severe illness, and both child and parent have an expectation of investigations (e.g. blood tests) |
- (i)
Young children may have difficulty in localising or describing pain, and ‘symptoms’ may manifest with non-verbal signs such as withdrawal of a painful limb, crying or distress.
- (ii)
The history is often obtained from a parent or carer and may be rather vague with non-specific complaints such as ‘my child is not walking right’ or observations of altered behaviour (e.g. irritability, poor sleeping); this means that the physical examination needs to include all joints and bodily systems.
- (iii)
It is important to ask open questions to enquire about concerns and what has been observed and describe patterns of pain, stiffness (diurnal variation) and functional problems at school (e.g. handwriting), home, sport or play.
- (iv)
The pGALS (see below) basic MSK assessment [5] includes three questions (Fig. 9.1); a negative response to these questions does not exclude significant MSK disease as in children, especially the very young, it is not uncommon to find joint involvement that has not been mentioned as part of the presenting complaint [6]. In some clinical contexts, the pGALS questions may not be socioculturally relevant (e.g. walking up and downstairs in environments without steps or getting dressed and undressed in hot climates where few clothes are worn) [7], and in such circumstances modification of the questions is required (e.g. rise from a squatting position). In the absence of overt MSK complaints, it is advised that all children, irrespective of the presenting complaint, have, as a minimum, a pGALS assessment performed.
Fig. 9.1
The components of the pGALS musculoskeletal assessment (Table and photos taken with permission, from Hands On pGALS – a pediatric musculoskeletal assessment for children (www.arthritisresearchuk.org/~/media/Files/Education/Hands-On/HO15-June-2008.ashx)) (and can source better image of the table) More information available- http://www.pmmonline.org/page.aspx?id=342Related posts:
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