Msk Flashcards
Key points in MSK history
Inflammatory or not?
Acute or chronic - when did it start, how has it changed, sudden onset or gradual, onset due to an event eg infection or trauma, what treatments has it responded to?
Are symptoms from joint or soft tissues - eg left shoulder pain can be referred cardiac pain - if no abnormality in joint think of this.
Nerve pain associated with tingling and goes to their areas of the nerve eg sciatica.
Mechanical symptoms - clicking or locking
Sig previous problems
Family history
Affect on patient’s life
Severity of symptoms
Mobility
Can they carry out ADLs
Differentiate inflammatory or not
Non is more related to use and may be relieved by rest.
Localised, short-lasting stiffness.
Inflammatory is often present at rest and has flares and is tender. Gets better with use.
There is prolonged morning stiffness - more than 1hr- duration is rough guide to activity of inflammation. Intermittent joint swelling - Exceptions - swelling of knee as it can occur with trauma and OA. Ankle swelling = usually due to oedema. Nodal OA causes bony swelling in PIPJ and DIPJ.
Other systems involved including skin, eyes, lungs, kidneys. Systemic symp such as malaise, weight loss, fevers, night sweats.
Severe bone pain (suggesting malignancy) disturbs sleep
Pattern of affected areas and type of arthiritis
Monoarticular - possibly septic
Oligo - psoriatic - asymmetrical
Poly - rheumatoid - symmetrical
Axial - usually spine - ankylosing spondylitis
OA - weight bearing joints - lumbar and cervical
GALS screening
Prior to focused exam
First 3 questions:
Any pain, swelling, stiffness in muscles, joints or back
Any difficulty in dressing yourself?
Any difficulty walking up and down the stairs?
Gait - smooth, symmetry and can turn quickly
Spine - Inspect back for muscle bulk. Look at shoulders, spinal alignment, gluteal muscle bulk, popliteal fossa and hindfoot.
Normal cervical lordosis, thoracic kyphosis and lumbar lordosis.
Put fingers on lumbar and ask them to touch toes - makes sure lumbar spine is moving, not just hips.
Touch ear to shoulder - lateral flexion of cervical spine.
Open jaw and move side to side - tempomandibular joint.
Arms - inspect for muscle bulk
Put hands behind head
Bring elbows down then pronate
Supinate
Make fist
Pinch fingers together
Grip strength - squeeze my fingers
Squeeze metacarpophalangeal joints for inflammation - ask any pain
Legs - hip flexion, internal and external rotation
Patellar tap
Squeeze toes
Look at feet for callouses
Emergency MSK conditions
Serious pathology if:
• escalating pain that do not respond to management as expected
• systemically unwell (fever, weight loss)
• night pain that prevents sleep due to escalating pain lying flat.
Cauda equina syndrome: People presenting with spinal and leg pain (bilateral sciatica) and any suggestion of changes in bladder or bowel function or saddle sensory disturbance.
• Metastatic spinal cord compression:
metastatic bone disease in the spine. It can lead to irreversible neurological damage. Symptoms can include spine pain with band-like referral, escalating pain and gait disturbance.
• Spinal Infection: May present with spinal pain, fever and worsening neurological
symptoms. Consider risk factors (e.g. immunosuppressed, primary source of
infection, personal or family history of tuberculosis).
• Septic arthritis: If the person presents unwell, with or without a temperature, with a sudden onset of a hot swollen painful joint and multidirectional restriction in movement, septic arthritis should be expected until proven otherwise. This is
particularly important in children, who may present with a painful limp or loss of
function in the upper limb, and not as a hot, swollen, painful joint.
• Giant Cell Arteritis: Presents with new-onset headache predominantly in temples
with or without associated symptoms such as jaw claudication, shoulder or pelvic pain girdle pain, visual symptoms and accompanied by a raised acute phase
response (ESR or CRP) in people usually aged over 50.
Urgent MSK conditions
Urgent referral
Primary or secondary cancers - Primary cancers such as breast, prostate and lung can metastasise to the spine. Present with escalating pain and night pain. May become systematically unwell.
Insufficiency fracture - sudden onset pain, mostly located in thoraco-lumbar region following low impact trauma. Pain severe and localised to area of fracture. Consider risk factors associated with osteoporosis.
Major spinal-related neurological deficit - spinal pain. Progressively worsening limb weakness, present for day/weeks, less than grade 4 on Oxford scale.
Cervical spondylotic myelopathy- cervical spondylosis can progress to this condition. Worsening pain, lack of co-ordination, weakness in arms or legs, loss of bladder and bowel control.
Persistent synovitis - hot swollen joints, particularly if MCP and PIP or feet affected. Early morning joint stiffness lasting more than 30mins - rheumatoid/psoriatic arthritis.
New onset autoimmune connective tissue disease - rash, Raynaud’s, mouth ulcers etc
Myalgia - worsens proximally, worse in the morning, more than 30mins of stiffness and raised CRP - polymyalgia rheumatica or myosytis
Hand exam
Look - dorsal and palmar
Feel
Palms up
Temperature - compare the temperature of the joints of the hand and elbow using the back of your hands.
Radial and ulnar pulse
Thenar and hypothenar eminence bulk - Palpate the muscle bulk of the thenar and hypothenar eminences
Palmar thickening - Support the patient’s hand and palpate the palm to detect the typical bands of thickened palmar fascia associated with Dupuytren’s contracture.
Median and ulnar nerve sensation
1. Assess median nerve sensation over the thenar eminence and index finger.
2. Assess ulnar nerve sensation over the hypothenar eminence and little finger.
Palms down
Radial nerve sensation - over the first dorsal webspace.
Temperature
Metacarpophalangeal joint squeeze - observe for verbal and non-verbal signs of discomfort.
Bimanual joint palpation - assessing and comparing for tenderness, irregularities and warmth:
Metacarpophalangeal joint
Proximal interphalangeal joint
Distal interphalangeal joint
Carpometacarpal joint
Anatomical snuffbox - scaphoid fracture.
Bimanual wrist palpation
Move
Active movement
Finger extension - make a fist and open and splay your fingers
Finger flexion - make a fist
Wrist extension - palm of your hands together
Wrist flexion - back of your hands together
Passive movement
Radial nerve - palms facing down, extend fingers and don’t let me push them down. Testing extensors of wrist and fingers.
Ulnar nerve - splay fingers outwards. Push your index finger against the patient’s. Testing abduction. Muscle assessed first dorsal interosseous.
Median nerve - palm facing upwards. Position thumb rewards the ceiling. Apply downward resistance with your own thumb. Thumb abduction against resistance.
Function
Power grip
Instructions: “Squeeze my fingers with your hands.”
Pincer grip
Instructions: “Squeeze my finger between your thumb and index finger.”
Pick up a small object
Instructions: “Could you please pick up the coin off the table.”
Special tests
Tinel’s test - identify median nerve compression - carpal tunnel - tap over the carpal tunnel with your finger - If the patient develops tingling in the thumb and radial two and a half fingers this is suggestive of median nerve compression.
Phalen’s test - Phalen’s test to further support carpal tunnel.
Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.
If the patient’s symptoms of carpal tunnel are reproduced then the test is positive (e.g burning, tingling or numb sensation in the thumb, index, middle and ring fingers).
