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pGALS Arms

It is often best to sit the child on an examination couch facing you. Start with the hands and take a few moments to scan the hands and up the arms for any evidence of rashes such as psoriasis, not forgetting to check the nails as well. And look for any evidence of joint swelling, deformity and the muscle bulk again. Looking for asymmetry can be helpful.

Ask about any pain anywhere and as you go through your examination check for facial expression of discomfort. It is often easier if the child is able to copy your movements so standing in front of them allows you to demonstrate the various manoeuvres. Ask them to turn their hands over as far as they can go. Check again for asymmetry, and lack of full supination may indicate joint disease at the wrist or elbow or a combination of the two.

A full finger tuck is an excellent screen for the small joints of the fingers and hands. Check manual dexterity and small joint movement. Turn the hands back over and gently squeeze the metacarpophalangeal joints.

Then ask the child to put their hands together, first of all with their hands palm to palm with their elbows held horizontal. Then ask the child to put the backs of their hands together, again with the elbows horizontal. Check for symmetry of movement. This is a good way to screen for wrist extension and flexion, finger extension and elbow flexion.

Then ask them to raise their arms straight above their head. This screens the shoulders and elbows for extension. Asking them to look at the ceiling screens neck extension. Ask them to put their hands behind their head and elbows right back and this screens the shoulders and the elbows. Check for lateral flexion of the cervical spine.

Observing the child from the front may show some asymmetry of the face. Ask them to open their mouth. Check for asymmetry of movement which may suggest temporomandibular joint disease. A child should be able to insert easily three of their own fingers into their mouth.

In the normal child all these manoeuvres are very easy. You may see clues for hypermobility with excessive ranges of movement and this is very common in children. Always check for asymmetry of range of movement which may help localise joint disease.

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