A disjointed effort: paediatric musculoskeletal examination
- Correspondence to Dr Irwin Gill Department of Paediatrics, Midlands Regional Hospital, Mullingar, Co Westmeath, Ireland;
Contributors IG and FS are the only contributors to this audit.
- Received 11 October 2011
- Accepted 12 January 2012
- Published Online First 3 February 2012
Background Musculoskeletal (MSK) symptoms are a frequent cause of emergency department attendance for children, and while most often indicative of benign or self-limiting disease, such symptoms can occasionally be the first presentation of serious illness such as leukaemia or juvenile idiopathic arthritis. MSK examination, however, is often not included as part of the routine paediatric examination. The authors aimed to evaluate how often and how thoroughly MSK examination was performed during admissions to the paediatric ward and to compare it with the examination of other symptoms in relation to the presenting complaint and eventual diagnosis.
Results Medical records for 100 consecutive patients were reviewed. A poster campaign to increase awareness was then commenced along with oral and written presentations to staff regarding MSK examination. A further 100 consecutive patients were then reviewed. Only 9% of children in the initial group had routine MSK examination, rising to 32% in the second group. Where performed, MSK examination was often incomplete. Frequent errors included only examining the reported site of injury and only examining a single limb or single joint when limpness/stiffness was the presenting complaint. Non-limb joints were very rarely examined.
Conclusions MSK examination is not performed routinely during paediatric admissions in contrast to the examination of other symptoms regardless of the presenting complaint. This may need to be addressed by local audit and increased undergraduate teaching.
In children, many disease processes can present in a similar and non-specific fashion. Eventual diagnoses are often not obvious at the outset and need to be teased out through a detailed history, examination and appropriate use of investigations. The assessing physician cannot rely on a young child to articulate his or her symptoms accurately, if at all. For this reason, a thorough physical examination is arguably more crucial in paediatrics than in other medical disciplines.
Musculoskeletal complaints in children are common and often represent benign, self-limiting conditions.1 They can, however, also represent the first presentation of many more concerning conditions including juvenile idiopathic arthritis, malignancy, haemophilia, connective tissue disorders, bone and joint infections and non-accidental injury to mention just a few. In such situations, prompt recognition of the pathology at play and timely initiation of appropriate care can have a lasting impact on long-term morbidity. In juvenile idiopathic arthritis in particular, delayed diagnosis leads to increased disability due to joint destruction.2
Existing research from other centres has documented that musculoskeletal examination is often neglected during routine paediatric examinations.1 3 4 Whereas cardiovascular, respiratory, abdominal and ear, nose and throat (ENT) examinations are likely to be performed routinely regardless of the presenting complaint, musculoskeletal examination is often omitted or performed incompletely despite strong evidence for its inclusion as a valuable tool in assessing the sick child.2 3 Many screening examinations have been suggested, including the pGALS (paediatric gait, arms, legs and spine) screening tool which can be conducted quickly by the non-specialist in an examination of school-age children.3 5 The incorporation of a brief but detailed musculoskeletal examination into the routine examination of all children could improve the rate of detection of muscle, bone and joint disease, improve the speed with which appropriate referral in made and thus could improve the burden of disease in affected patients.
We aimed to evaluate the frequency with which musculoskeletal examination was documented for children admitted to the paediatric ward and to compare it with the frequency of examination of other systems in relation to the presenting complaint and eventual diagnosis.
A total of 200 patients were included in the audit. Assessment of 100 consecutive admissions was made by a retrospective chart review in stage 1. Basic demographic information was recorded, as well as information regarding the presenting complaint and eventual diagnosis. The examination of any system at any stage of the admission was documented, as were the individual components of the musculoskeletal examination on the occasions when it was performed.
After the results from stage 1 were available, a poster campaign was commenced in our centre to increase the awareness among paediatric medical staff of the importance of musculoskeletal examination in children. Posters were placed in strategic locations in the hospital to act as an aide-mémoire. An oral presentation on the subject was made to medical staff, and written information on the importance of the musculoskeletal examination was circulated to all team members with specific reference made to pGALS as a useful screening tool in school-age children. A further 100 consecutive admissions were then reviewed in stage 2, with an interval of 30 days between stages.
Forty-six female and 54 male patients were included in stage 1, with an age range of 2 weeks to 13 years. All patients were seen by a consultant during their admission. One hundred per cent of children had cardiovascular, respiratory and abdominal examination performed, regardless of the presenting complaint. Eighty-nine per cent of patients underwent ENT examination, 51% had a skin examination and 31% had a neurological examination performed. Nine per cent of children had a musculoskeletal assessment. Three of these presented with head injury and had no examination beyond the site of injury, with another patient with a radial fracture also only having the site of injury examined. Two patients presented with joint pain, with only the reported painful joints being examined.
While musculoskeletal examination is a valuable tool for all patients, there were 22 patients in stage 1 in whom musculoskeletal examination was especially notable for its absence. The majority of these were patients admitted with pyrexia of unknown origin (n=17), but the group also included two patients admitted with failure to thrive and discharged without a definitive diagnosis. We concluded from stage 1 that musculoskeletal examination was not being routinely performed on children and when performed was often incomplete. This was in stark contrast to the approach to examination of other systems.
Following our campaign to increase the rate of musculoskeletal examination, we reviewed the notes of 100 further admissions in stage 2. Fifty-four female and 46 male patients were included with an age range of 1 day to 13 years, and all were seen by a consultant during their admission. Again, 100% of children underwent cardiovascular, respiratory and abdominal examination. Eighty-nine per cent had an ENT exam, 73% had a skin examination and 32% had a neurological examination. The rate of musculoskeletal examination increased to 32% in stage 2. In four patients the examination was notably incomplete, with only the reported site of stiffness or injury examined. Eight additional patients were specifically notable for having been admitted without musculoskeletal examination: all presented with fever of unknown origin.
In total, 41 patients underwent musculoskeletal examinations. In only 18 of these were specific joints documented as being examined; in the remainder, notes such as ‘joints normal’ or ‘no musculoskeletal signs on examination’ were documented. Hips were the most frequently examined joint (n=15) followed by knees (n=11), while non-limb joints were examined in only four cases (C-spine n=2, lumbosacral spine n=1, temporomandibular joint n=1).
Notably, of the 178 patients (89%) who underwent ENT examination, only 91 (51%) had symptoms suggestive of possible ENT disease (fever: n=44 (24.7%), cough: n=39 (21.9%), sore throat: n=5 (2.8%), reluctant feeding: n=3 (1.6%)), while the remaining 87 (49%) underwent ENT examination as a part of routine assessment in the absence of any specific clinical indication.
The results from this audit support existing research which suggests musculoskeletal examination is not included routinely in the examination of children. Although the rate of examination increased greatly between stage 1 and stage 2, the majority of musculoskeletal examinations performed were incompletely documented; this may reflect either time constraints in a busy hospital or a lack of confidence and experience in the specifics of musculoskeletal examination in children among paediatricians and trainees. Physicians at all levels report poor confidence in their own abilities to conduct a thorough musculoskeletal examination and other authors have outlined the deficit in undergraduate and postgraduate training in this area.4
In our study, no patients have yet represented with worsening signs of bone or joint disease. We made no life-altering diagnoses of juvenile idiopathic arthritis, leukaemia or other severe systemic diseases; this is in keeping with the fact that the majority of children presenting with musculoskeletal complaints will have self-limiting illnesses such as transient synovitis or minor soft tissue injuries. This should not lead us to be complacent in our approach to the examination of such children. A physician who does not regularly examine a child's joints may be slow to identify the child with subtle features of early joint problems. Increased teaching at all levels and introduction of local audit could improve the frequency of joint examination in children, thus better serving the occasional patient for whom it makes a real difference.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.