Results
Table 1 describes patient demographics and MSK diagnoses with MSK abnormalities presented in Table 2.
Case-note Review
The referral letters of 152 patients were reviewed with 303 abnormal joints found on examination, of which 92 (30.4%) were elicited in the history, and 211 (69.6%) were only detected on subsequent examination. Of the 152 referrals, 54 patients (35.5%) had ≥1 joint abnormalities detected on examination but not mentioned in the history. Limited range of movement was the most common abnormality missed (38% of abnormal joints) and mostly affected the lower limb. Other significant MSK abnormalities not elicited in the history included active arthritis, biomechanical abnormalities and joint hypermobility.
Prospective Study Paediatric Rheumatology Clinics
Forty-five patients, predominantly with juvenile idiopathic arthritis, were included, with 135 abnormal joints detected: 53 (39.3%) identified by history and 82 (60.7%) only found on subsequent examination, including 24/82 with restricted movement (11 patients), 37/82 with active arthritis (12 patients) and one patient with enthesitis and low back pain consistent with sacroiliitis. A further 10 patients had features of hypermobility and various biomechanical problems. There were a number of 'false positives' (n=38) where patients complained of pain in a joint with no abnormality found on examination. Sensitivity of history compared with clinical examination was 53% and specificity 98%; positive predictive value 64%; and negative predictive value 97%.
Acute General Paediatric Assessment Unit
Fifty children participated; 29 abnormal joint findings were recorded in 17 children, 62% identified on history and 38% on examination alone. Abnormal findings included biomechanical abnormalities, active synovitis, restricted movement and bone tenderness. The pGALS screening questions (pain, ability to manage stairs and ability to dress/undress) had a sensitivity of 62%, specificity of 100%, positive predictive value 100% and negative predictive value 85%. Pain was the most sensitive question with all patients complaining of joint pain being found to have abnormality in ≥1 joints. The sensitivity of history taking did not differ significantly between younger (3–10) and older (11–18) children, although the small numbers precluded further subgrouping (data not shown).