6 Locomotion
Introduction
History
Table 6.1 Important features of a ‘locomotor’ or ‘musculoskeletal’ history
| Presenting symptom | |
|---|---|
| Joints | Pain – where, when is it worst, does it wake the child at night, what brings it on, is there anything that improves it? Swelling Morning stiffness (this is different from pain) – ‘It takes her an hour to get going and then she loosens up’ Function – unable to weight bear, cannot do up buttons Joint distribution |
| Extra-articular | Fever Rash, hair loss, mouth ulcers Poor appetite Weight gain and growth Vision |
| Past history | Any precipitating or preceding illness Development |
| Family history | Complete family tree Ask especially about arthritis, psoriasis, systemic lupus erythematosus, maternal miscarriages, inflammatory bowel disease |
| Social | Functional ability – dress, feed, walk, etc. ‘Is there anything that you want to do but can’t?’ School – ability and progress ‘What are you into?’ – can the child still do everything they wish to do, and as well as their peers? |
Examination
Table 6.2 lists important features of the musculoskeletal examination. Remember the mnemonic GALS (gait, arms, legs, and spine).
| Gait | The child must be in underwear/minimal clothing to observe lower limbs and spine fully Preserve dignity Look at position of knees, ankles and feet, freedom of movement |
| Joint (any) | Inspect – skin colour, muscle bulk, resting position Palpate – skin warmth, joint swelling (soft tissue, bone, intra-articular effusion), site of maximal tenderness, tendons Move – range of active and passive movement |
| Hands | Pattern of joint involvement, rashes, nails (pitting in psoriasis, nail fold infarcts in vasculitis) Can she make a fist with the distal phalanges tucked perpendicular to the palm? What is the grip like? Does the thumb oppose to the base of the fifth finger? |
| Arms (sitting up) | ‘Put your arms out straight, now turn your hands over’ (elbow extension, supination/pronation), ‘put your hands behind your head’ (glenohumeral and sternoclavicular movement), ‘stretch your hands to the ceiling’ (proximal muscle strength) Move joints passively through their full range |
| Feet (lying down) | ‘Point your toes down, then bend them up’ (ankle joint) Squeeze the metatarsophalangeal joints (gently) – for synovitis pain Test eversion and inversion of the heel and forefoot (subtalar and mid-tarsal joints) |
| Legs (lying down) | Normal muscle bulk? Any swelling, deformity? Equal leg length? – measure real and apparent shortening ‘Hug your right knee into your chest’ (knees and hips) then the left Check for knee effusion: compressing the bursa above the patella, gently press the patella with the other hand – does it bounce off the distal femur? If you stroke up the medial side of the knee, down the lateral side, can you see fluid bulging from side to side? (effusion) |
| Legs (standing) | Any valgus or varus deformity? (valgus – the distal part of the limb is angled away from the midline; varus – the limb is angled towards the the midline) Flat feet (loss of the medial longitudinal arch)? If so, get the child to stand on tip-toe – can you see the arch now? |
| Spine (standing) | Stand behind the child and look at how straight the spine is and whether the normal curves are present ‘Bend forward to touch your toes’ – this should result in a smooth curve with no lateral deviation (scoliosis) Observe the neck movements (forward and lateral flexion, extension, rotation) |
Principles of management
You should work towards recovery with appropriate therapy, including medication, physiotherapy, occupational therapy, orthotics and psychological support. The child and family need education and support about the condition, the impact on school and family life, and, very often, financial support (disability living allowance). Social services and voluntary organizations may be able to help (see also Chapter 3).
