MSK EXAM Flashcards
Discuss the principles of a joint examination
LOOK
- Compare right with left
- looking at all sides front back and the sides
- Skin – erythema, atrophy, scars and rashes (psoriasis)
- Swelling/oedema over the joint
- Obvious deformity - trauma or chronic detructive arthritis
- Muscle wasting
- Look at joint above and below
FEEL
-Skin warmth - increased warmth can be associated with active synovitis, infection or crystal arthritis
-Tenderness- this can be graded as follows
GRADE 1: patient complains of pain
GRADE 2: patients complains of pain and winces
GRADE 3; Patient complains of pain and winces +withdraws
GRADE 4: patient does not allow palpation
MOVE
1) passive movement
- look for range of motion reduction
2) Active movement
3) stability of the joint
4) joint crepitus
Measure/special test
1)
Describe an approach to examination of the hands
LOOK
1) skin for erythema or atrophy scares and rashes
-Ulnar deviation and volar subluxation of the fingers -
-Swan neck deformity - hyperextension at the PIP and fixed flexion of the DIP
and boutonneire
2) look for characteristic finding of OA
- Heberden’s nodes - caused by marginal osteophytes
-Sausage shaped fingers indicative of psoriatic arthritis
-Nails - pitting impressions, onycholysis and less commonly hyperkeratosis.
-spinter haemorrahge
Describe an approach to examination of the elbow
Expose upper arm completly
LOOK
- Joint effusions
- Rheumatoid nodules, gouty tophi and enlarged bursa
FEEL
- Tenderness particularly over the lateral and medial epicondyles which may indicate tennis or golfer elbow.
- Feel for effusions and nodules
MOVE
-Assess ROM of motion passive initially then actively
Discuss approach to the examination of the shoulder
Watch the patient undressing and not fowards backward and upward movement of the shoulders and whether these seem limited or cause the patient pain. - Stand back and compare the two sides
LOOK
- Asymmetry of the shoulder and scars
FEEL
-Tenderness and swelling
MOVE
- Shrug shoulders – testing trapezoid and accessory nerve
- Internally rotate - please place you hand behind you back and scratch as high up as possible – test terres major
- Externally rotation - infraspinatus
- abduction - supra spinatus
- seratus anteiror push against a wall
- Deltoid abduction of arm after 15 degrees
MEASURE/SPECIAL
1) NEER - passively extend/elevate the pronated arm above the level of the shoulder - pain at the anteriolateral aspect indicates subacromial impingement
2) HAWKINS - Sitting or standing upright with shoulder adducted and thearm fully flexed and the elbow flexed - one arm on shoulder other applies internal rotation - pain indicates subacromial impingement
3) drop arm test - hold the effected arm in abduction at the level of the shoulder - rotator cuff pathology - not able to hold in abuction or perform slow and measuered adduction - supraspinatus
4) lift of test – effected arm internally rotated so that the dorsum of the hand is resting on the lumbar region - passive pulled away from the back if unable to maintain indicates subscapularis tear
5) Adduction external rotation test – adduct arm and fully externally rotate inability to keep in this position indicates infraspinatus tear
6) drop can test – fully pronate the arm + abudction to 90degrees – inability to resist downward pressure or pain indictates supraspinatus injury
Descriibe an approach to the examination of Thoracolumbar spine and SI joint
LOOK
- deformity inspecting from both the back and the side -loss of kyphosis or lordosis
- scoliosis
FEEL
-each vertebral body for tenderness and para spinal tenderness
MOVE
- Bending movements take place in the L spine
- Rotational in the T spine
- Flexion - touch toes - looks for degree of flexion in those with advanced ankylosing spondylitis all movement occurs at the hips
- Extension - ask the patient to bend backwards
- Lateral movememtn
- Rotation
Measures
- SCHOBERS test - amrak is made at the level of the posterior iliac spine on the vertbral column - a one finger is placed 5cm below and the other 10 cm above an increase of less than 5 cm indicates limitation of lumbar flexion
- Straight leg raising -with the patient lying flat passively lift the straightened leg if sciatica is sucpected this will be limited by pain (<60 degrees is positive)
- Lie on stomach look for gluteal wasting - SI joint tenderness
Discuss DDX for back pain
NON SPECIFIC or MSK (although said to be due to disc herniation there is little correlation between MRI scan detected disc herniation and pain - it is found in 30% of asymptomatic people )
1) gradual onset
2) nil neuro symptoms or signs
3) recent minor injury or strain
ANKYLOSING SPONDYLITIS
1) Systemic symptoms
2) Pain at rest
MALIGNANT
1) Worse at rest keeps patient awak
2) present for more than 4 weeks
3) weight loss
4) known other malignancy
ABCESS
1) worse at rest
2) Fever
3) immunosupression
4) recent instrumentation
CAUDA
1) Severe pain
2) urinary retention or incontinence
3) faecal incontinence
4) saddle anaethesia
5) leg weakness
Describe Examination of the hip
WATCH - watch the patient walking asseess the gait
LOOK
- Wasting, scores, erythema
- Compare
MOve
- Flexion
- THOMAS test – laying supine fully flexion both hips then extend one by one
- Rotation - knee and hip flexed
- ABDUCTION and Adduction
- extension tested supine
MEASURE
-leg lencth
Describe examination for the knee
LOOK
- Patient lying down on the back with both knees and thighs exposed
- Quads wasting
- Skin chnges - including recent arthroscopy ports
- Compare the sides
- Effusion
FEEL
- Quads wasting
- Patella tap for joint effusion - one hand reset over the lower part of the quad and compresses the suprapatellar extension of the joint space. the other hands pushes the patella downwards - the signs i positive if the patella is felt to skin and then comes to rest with a tap as it touches the femur
- Buldge sign
MOVE
- Passive movement flexion and extension
- Active range
Measures/special test
1) Collateral ligament via valgus and varus stressing
2) ACL with anterior draw and PCL with posterior draw -
- ACL can also be tested with Lachmans - knee flexed to 20-30 degrees patient lying supine grasp the femur to steady it then grab the lower leg below the knee and give it a quick tug foward
3) patellar aprehension test - push the patella firmly in a lateral direction while slowly flexing the knee
4) supine look for Baker cyst which is a diverticulum of the synovial membrane that occurs through a hitaus in the knee capsule. rupture is often associated with a cresent sign that may mimic signs of DVT
5) apleys grind - patient leg is flexed to 90 degrees the examine stabilises teh thigh by kneeling lightly on it while pressing on the foot rotates the leg backwards and fowards
6) Mcmurray
