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pGALS complete

Introduction

Musculoskeletal complaints in children are very common and a frequent reason for consultation with healthcare professionals. Taking a history and performing an examination of the musculoskeletal system is a very important part of the process of making a diagnosis. The purpose of this short video is to demonstrate a simple, quick and effective way to screen the musculoskeletal system in school-aged children that can be done in a few minutes. Examination of a younger child is likely to require a quite different approach and is not covered in this demonstration.

We have called this screen pGALS, which stands for Paediatric Gait, Arms, Legs and Spine. This screening examination has been developed from the adult GALS and this is now routinely taught to medical students. The amendments to GALS are all simple manoeuvres that are commonly used in clinical practice by doctors and therapists who are experienced in the assessment of children.

Taking the history from the child and the parent is very important in the assessment process and gives you the opportunity to establish a rapport with the child.

As part of your general systematic enquiry you should include the following key questions relating to the musculoskeletal system. These are:

  • Do you have any pain or difficulty in moving your arms, legs, neck or back?
  • When you get dressed, are you able to do this yourself without any help?
  • Can you walk up and down the stairs without any problems?

A positive response to any of these questions will alert you to the possibility of significant problems in the musculoskeletal system.

When examining a girl, we would suggest that she wears a sleeveless top and shorts.

Before going through the components of pGALS in detail it is worthwile taking a few moments to observe the child standing upright and ask them to be as straight as possible. It is helpful to scan the child from head to toe looking from the front, the side and behind the child. This takes a few seconds but can give very important clues. For example, does the child look generally well?

Check for rashes such as psoriasis, check for asymmetry such as muscle bulk including muscle wasting and the presence of joint swelling. Check for a knock-knee or a bow-leg deformity and, from the side, check for a flexion deformity perhaps at the knee or the hip. Check the child’s face from the front and the side. For example, a small jaw or facial asymmetry may suggest temporomandibular joint disease.

Remember that you may see more from the back of the child than from the front, for example, swelling of the ankles is often more obvious from behind the child. Check the back of the child, looking for asymmetry of skin creases or shoulder level which may suggest a scoliosis.

Gait

With the child undressed it is possible to screen gait effectively by watching the child walk across the room and back. Look out for any suggestion of limping, look at the rhythm of gait, look for difficulty in turning around, and ask the child about any discomfort. Look for any expression of pain as the child walks. Check for the normal pattern of heel strike, stance phase, and then toeing off as the child walks. You can also look for evidence of flat feet and excessive pronation when walking as this is a feature of hypermobility. Then ask the child to walk on their heels, and then on their tiptoes.

Arms

It is often best to sit the child on an examiation 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.

Legs

You need to scan the legs from the top down to the feet so make sure you’ve exposed the legs appropriately.

Check for muscle bulk and wasting, leg alignment problems such as knock-knee or bow-leg deformity. Ask yourself if the legs look the same length. Does there appear to be a flexion contracture at the knee? Look for swelling of the knees. Check the feet, including the soles of the feet, for local causes of a limp such as a verruca or a foreign body. And always scan the nails and skin for features of psoriasis.

Check the knees for warmth, comparing one side with the other. When assessing for an effusion, ask about discomfort and scan for facial expression. Gently press down over the distal thigh to move fluid into the joint from the suprapatellar pouch. Compare each side. A patellar tap suggests an effusion, but for a small effusion a patellar tap may be absent. It may be helpful to milk fluid from one side to the other. Again, compare one side with the other.

Normally a child of school age is able to reach their heel to their buttock. Compare both sides and check that the knees fully extend. It is very helpful to compare each side for symmetry as normal ranges of movement vary with the child’s age. Firstly check full flexion, then flex the hip to 90o and check for external, and then internal rotations. Check also for full extension at the knee.

Spine

You will have already observed the child from the side and from behind as part of your general assessment. It is important to assess forward flexion and look for a smooth curve of the spine from the side and from the back.

PGALS is a quick screening examination of the musculoskeletal system and applicable to the school-aged child. It is an important part of your assessment of the child and the findings need to be considered in the context of your history and an overall assessment. A normal screening examination suggests there is no significant abnormality of the child’s musculoskeletal system. If the screening examination is abnormal this will help you to focus your more detailed regional examination which is not covered here in this video.

Recording your findings

How do you record your findings in the case notes? We suggest the following way. For your screening questions, if the child reports no pain, no difficulty in dressing themselves and no difficulty with walking then you could write this as follows:
[table is displayed showing normal result]
If, however, the child does report pain, for example, in their right knee and difficulty in walking then you could write this as follows:
[table showing abnormal findings is displayed]
To record your examination we suggest the following, entering a cross or a tick depending on your findings. For an abnormal screening examination, for example a swollen knee with limited range of movement, you could record this in the notes as follows:
[table showing how to record swollen knee with limited movement is displayed]

Summary

  • Observe the patient walking.
  • ‘Walk on your heels.’
  • ‘Walk on your tip-toes.’
  • ‘Put your hands out in front of you.’
  • ‘Turn your hand over and make a fist.’
  • ‘Touch the tips of your fingers.’
  • Squeeze MCPJs.
  • ‘Put your hands out in front of you.’
  • ‘Turn your hand over and make a fist.’
  • ‘Touch the tips of your fingers.’
  • Squeeze MCPJs.
  • ‘Put your hands and wrists together.’
  • ‘Put your hands back to back.’
  • ‘Reach up as far as you can.’
  • ‘Look at the ceiling.’
  • ‘Put your hands behind your neck.’
  • ‘Place your ear on your shoulder.’
  • ‘Open your mouth wide and place 3 fingers inside.’
  • Feel for effusion at the knee.
  • ‘Bring your ankle up to your bottom.’
  • Passive movement of hip and knee including rotation of hip.
  • Observe curvature of spine from the side and behind.
  • ‘Bend forwards.’

pGALS versus GALS

Q: How does pGALS differ from adult GALS?
A: pGALS is the same as adult GALS with the following additions:

  • ‘Walk on your heels.’
  • ‘Walk on your tip-toes.’
  • ‘Put your hands and wrists together.’
  • ‘Put your hands back to back.’
  • ‘Reach up as far as you can.’
  • ‘Look at the ceiling.’
  • ‘Open your mouth wide and place 3 fingers inside.’

Common/significant findings

[No soundtrack: still photographs are displayed of hypermobility, swollen wrists and PIPJs, swollen knees and quadriceps wasting, swollen ankles, knock knee deformity, quadriceps wasting, swollen ankles and knees, swollen knee and flexion contracture, nail pitting, scoliosis, psoriasis, wrist swelling, flexion deformity of fingers, swollen knee and leg length inequality, micrognathia]

pGALS: a screening examination of the musculoskeletal system in school-aged children

For a full illustrated discussion of pGALS see our Hands On report (published June 2008)

pGALS checklist

Download our printable pGALS checklist (Word doc)

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