MSK - Clinical assessment Flashcards
GALS Screening Questions for Musculoskeletal History as part of Systematic Enquiry?
> Do you have any pain or stiffness in your muscles, joints or back?
> Can you dress yourself completely without any difficulty?
> Can you walk up and down stairs without any difficulty?
Cardinal presenting complaints in orthopaedics?
> Something FEELS wrong:
- pain, dysaesthesiae, weakness
> Something MOVES wrong:
- stiffness, reduced RoM (eg. locking), limp, instability / collapsing, crepitus
> Something LOOKS wrong
- swelling, deformity, wasting, shortening, discolouration (eg. redness, pallor, bruising), wounds
Question to ask in orthopaedics - sleep?
wake at normal time or woken by pain, etc.?
Question to ask in orthopaedics - morning?
How are they first thing in morning?
- is pain/ swelling/ stiffness at its worst?
- how long does it take to get going?
- have to do exercises?
Question to ask in orthopaedics - dressing?
dressing - socks & shoelaces?
Question to ask in orthopaedics - toenails?
cut own toenails?
Question to ask in orthopaedics - keeping clean?
Can they get in and out of a bath?
Question to ask in orthopaedics - walking?
Walking distance on flat - (“How far can you walk?” “Oh not very far, etc., etc.”):
- (Union St = 1 mile long)
- Stopped by what? (n.b. crushing central chest pain?!)
- Use of walking aids
stairs (up vs. down), rough ground
Question to ask in orthopaedics - driving
Yes or no or used to
Question to ask in orthopaedics - shopping?
Does own shopping? (good indicator of prognosis after hip fracture – physically able to get out of house (mobility), mentally able to do shopping, medical co-morbidities not so severe as to keep housebound, and more likely to be living independently and not in an institution
Question to ask in orthopaedics - day to day?
work, hobbies – does it stop them doing anything?
Red flag is orthopaedics history?
“Red Flags” from the history suggesting serious pathology (infection, tumour, etc.)
> Severe and worsening pain
> Night pain disturbing sleep
> Non-mechanical pain
> General malaise, febrile, rigors
> Unexplained weight loss, anorexia, night sweats
> Past history of malignant disease
Past medical history orthopaedics?
MISTI THREAD > MI > Stroke > Thrombosis (DVT/PE) > Icterus
> TB > Hypertension > Rheumatic fever > Epilepsy > Asthma > Diabetes
Allergies in orthopaedics?
Any known allergies: > previous penicillin > Iodine > general anaesthetic > Latex > elastoplast/ S.A.T
Drug history in orthopaedics?
> Current, recent (when started?, when stopped?)
> On any Rx from own doctor?
> Taking any other drugs? (proprietary e.g. Paracetamol, recreational, hard) – Ever been an IV drug user? – n.b. Incidence of high risk cases presenting to Trauma Unit (RIE study) – duty to self and colleagues (nursing & medical)
> Oral contraceptive pill
aspirin / warfarin / clopidogrel (why are they on it? Is it safe to stop?)
> NSAIDs (had them?, did they work?, side effects?)
steroids (life-saving & quality-of-life-saving drugs, but side effects!)
THE GALS SCREEN?
(Gait, Arms, Legs, Spine)
a rapid screen for musculoskeletal and neurological deficits, and functional ability
REMS (Regional Examination of the Musculoskeletal System)?
Starting with lower limb examination
hips, knees, ankles and feet
Principles of a before starting MSK examination?
> Quiet private room, +/- chaperone (low threshold), well-lit, warm
> Space to observe gait, examination couch
> Adequate exposure! + position
> Always compare R & L; examine normal side first
Principles of a MSK examination?
> Convention for description of deformity
- “distal part has moved with respect to supposedly stationary proximal part”
- valgus & varus (knee & hip)
> Anatomical position = 0 degrees for all joints
- extended elbow = 0 degrees, not 180 degrees)
> Knee deformities - Genu?
Name fingers?
> Thumb > Index > Long or middle > Ring > Small or little
Never number!
Talking about different aspects of the hand?
> Ulnar border
Radial border
Volar or palmar aspect
Try to refrain from using lateral, medial, posterior or anterior
What is important in a local MSK examination?
KISS = Keep it systematic, stupid: > LOOK > FEEL > MOVE > (X-RAY)
MSK Clinical examinations - Look?
observe, esp. when not formally examining (often more valuable information) n.b. front & back & sides!:
> posture – patient, limb (esp. lower limb when weight-bearing)
> note relevant negatives, and obvious positives e.g. amputation
> gait – limp?
> skin - scars , wounds, sinuses, ulcers
> skin - colour - redness, bruising, pallor, cyanosis, blae, black (gangrene, melanoma), etc.; shiny? hairless? thin/atrophic skin?
> vascular markings (venous varicosities, haemosiderin deposition)?
swelling
> wasting (hip problem, look at gluteal muscles; knee problem, look at thigh; foot or ankle problem, look at calf) – disuse, neurological, cachexia
> deformity -asymmetry?, palpate for normal anatomical landmarks - are they all there and in the right place?
> limb lengths –
> real (ASIS/ greater trochanter/ tibial tuberosity to medial malleolus) – legs in same position
> apparent (midline marker e.g. xiphisternum or umbilicus to medial malleolus)
MSK Clinical examinations -Feel?
Systematic anatomical palpation; relationship of bony landmarks & surface anatomy; start away from painful area (examine last):
> skin - temperature, sweating (tactile adherence), capillary filling
> tenderness (localised, diffuse) n.b. pain = symptom, tenderness = sign – not synonymous
> swelling (vide infra)
> deformity - palpate for normal anatomical landmarks - are they all there and in the right place and non-tender?
MSK Clinical examinations - Move?
active (lag?) - “Would you > bend your left elbow, please, Mr Smith?”
> passive- “Would you relax and let me bend your left elbow, please, Mr Smith?”
> special tests abnormal movement, joint laxity, tests, etc., e.g. on stressing joint/ limb
> range, rate, rhythm
> RoM’s - degrees, or % vs. normal side, comparisons (heel-to-buttock distance, fingertip to palm, etc.)
> accompanied by pain, crepitus, stiffness?
> rhythm/ smoothness, laxity/hypermobility, tenodesis
> muscle tone
> power/ strength
> joint laxity/ hypermobility
MSK Clinical examinations - general priniciples?
(1) in any joint examination, must examine joints above and below (e.g. examine hips if c/o knee pain); and examine spine for any limb symptoms
(2) + neurovascular examination of whole limb
(3) consider other relevant systematic examination – chest, abdomen, neurological
Record findings
Re-examine & compare
(X-RAY)
Orthopaedic examination overview?
> General examination first – sick or well? distress? well nourished/hydrated? behaviour? Face, neck, hands!
> LOOK – skin scars/wounds/sinuses, colour, swelling, wasting, deformity
> FEEL – temperature, tenderness, swelling, deformity, sensation
> MOVE – active (range, power), passive, special tests (stability)
