MSK Flashcards
Hip and knee exam
Look Feel Movement Function Measure
NB to always compare both sides
Require: Gonio-meter Tape measure Skin marker Tendon hammer
1) Gait - rhythmical motion of limbs to propagate body forward efficiently
Consider - stance and swing phase
Most common deficiencies:
a) Antalgic - decrease time in stance phase (in order to decrease the pressure on the affected leg)
• can be due to pain in any part of the leg
b) Short limb - >1cm, whole trunk goes up and down
• compensation:
- Equinus of the affected foot
- Flexion of the knee on the unaffected side
c) Trendelenburg - abductor issue
• Power issue - glutimus medius or minimus
• Lever issue - neck of the femur
• Fulcrum issue - hip joint
Leads to contra-lateral pelvis drop
[Ask the patient to stand on one leg]
2) Spine abnormality
• Kyphosis (
• Lordosis )
NB that it is in the right place
3) Hip
Note if flexed and externally rotated:
• optimal joint movement to allow for accumulation of effusion and maximal comfort
- this will exaggerate lumbar lordosis
Mark • ASIS • Greater trochanter • Medial joint line of the knee • Medial malleolus • PSIS
Feel for tenderness
• mid-inguinal
• just above the greater trochanter
• point 2/3 from PSIS to greater trochanter
Measure • Flexion of hip deformity - Thomas test • Length - Apparent - Actual - Segmental
Movement range • Flexion - 120 degrees • Extension - 15-20 degrees • Abduction - 45-50 degrees • Adduction • Ext. rotation - more in extension • Int. rotation - more in flexion
Special tests
Teloscopy
Trendelenburg
4) Knee Inspect for varus or valgar deformity Ligaments: • ACL [most common] - Anterior Drawer (90 degrees) or Lachman's (20 degrees) • PCL - Posterior Drawer • MCL - Valgus force • LCL - Varus force • Medial meniscus [most common] - bend knee, ext. rotate at knee and then extend • Lateral meniscus - vice versa
Hand exam
WIPER
Look, feel, move
Skin: • Colour • Consistency - tight -> sclerodactyly - thick -> DM, acromegaly • Characteristic lesions - rash - pulp infarct - purpura - spider naevi - telangiectasia - tophi (gout) - scars
In generals, sign of inflammation: • Calor • Dalor • Rubor • Tumor
Nails • Pitting and onycholysis • Clubbing • Splinter haemorrhages • Beau's lines • Koilonychia • Leuconychia
Muscles - wasting and fascicultions
• Thenar
- median nerve
• Generalised, especially dorsal interossei
- ulnar nerve
Also look for Dupuytren’s and carpal tunnel:
Tinel’s - percuss over the flexor wrist tendons
Phalen’s - reverse prayer
Positive if tingling suggests carpal tunnel
Joints - inflammation and deformities • ulnar deviation • Z deformity (thumb) • Swan neck (flex DIP, hyperext PIP) • Boutonniere (opposite) • Heberden's nodes (DIP) • Bouchard's nodes (PIP)
Move & Feel • Prayer • Reverse prayer • Fist • Claw • Supination and pronation • Check elbows • Pincer and power grip • Spread fingers • Froment's Sign - not holding paper with flat thumb
Function
• Button
• Write something
Sensation
• Little finger = ulnar
• Index finger = median
• Snuffbox = radial
Palpate each joint methodically for:
• tenderness
• effusions
• crepitus
Shoulder
Frozen - restricted capsule use
Dislocated - trauma
Rotator cuff tendonopathy
Joint pain felt distal to joint - upper arm, in bed, above head
Early morning stiffness - think inflammatory
Nb rotator cuff activating on deltoid activation to allow for abduction
Stages of frozen shoulder:
Freezing - painful and increasingly restrictive
Frozen - restricted
thawing - ameliorate
First movement that goes is external rotation - still able to do this in rotator cuff
Look:
• Anterior and acromioclav, sternoclav prominences.
• Posterior, muscle wasting (scalloping) mainly supraspinatus.
• Redness
Feel:
• Tenderness, over joints, capsule and clavicle.
Movement
• External rotation, if negative passive movement could perform the movement
• Test other movements - int rotation, flex, ext, adductions.
• Arc of abduction - out to the side, let them relax onto your hand and then the pain should go
Tests for each of the rotator cuffs:
• Supraspinatus - empty cans and push against resistance to the ceiling (pain, weakness and wasting).
• Infraspinatus and teres minor - external rotation.
• Subscapularis - lift off test, hands behind back and lift off
Function
• throwing
• putting coat on
Special tests
• Impingement - push humoral head under acromium
• Scarf test - acromioclavicular
Causes
• Hyper mobility disorder - apprehension test (<40)
• Acromioclavicular osteofite - bony prominence
Management
• Physio
• Orthopaedic surgery
Joint pain
Q:
Is there morning stiffness?
Is the pain localised or diffuse?
No early morning stiffness • Diffuse pain - chronic pain syndrome - malignancy • Localised pain - OA/arthropathy - Tendinopathy - Bursitis
Early morning stiffness • Diffuse pain - polymyalgia rheumatica - inflammatory myositis • Localised pain Monoarticular - sepsis - crystals - reactive - spondyloarthritis Polyarticular - rheumatoid - viral <6wk - SLE - spondyloarthritis - crystals
