MSK Examination Flashcards
What is the patient positioning for a hand and wrist exam? (Intro –> consent, exposure and position)
Sitting, elbows out, Hands on pillow
What is the patient positioning for an elbow exam? (Intro –> consent, exposure and position)
standing in anatomical position
What is the patient positioning for a shoulder exam? (Intro –> consent, exposure and position)
Standing
What observations are looked at in H&W exam DORSUM of hand?
Dorsum (palms down) scars or swelling skin colour (erythema/pallor) Skin changes (thinning, bruising, psoriatic plaques) Muscle wasting nail changes (vasculitis, pitting, onycholysis) Hand posture (contractures) deformities (heberdens or bouchards nodes)
NB: if there are any clinical signs indicated note if they are symmetrical or not e.g. affecting both limbs or not
What observations are looked at in H&W exam SIDES of hand?
Swan neck deformity Boutonnieres deformity (opp of swan neck)
From thumb side: Z-thumb deformity
[all of these are assoc. with RA]
What observations are looked at in H&W exam PALM of hands?
NB: looking at both hands hand posture (symmetry, contractures,) Scars or swelling Colour - erythema/pallor Thenar/hypothenar wasting (Ul or med nerve lesion; thenar only ~carpal tunnel)
What observations are looked at in H&W exam elbow?
Psoriatic plaques or rheumatoid nodules
What do you FEEL for in a H&W exam?
First: temp palms and forearm, wrist, MCPs), R&U pulse, {tendons, joints and bones}
Palm up:
thenar and hypothenar eminence bulk
palmar thickening
assess median and ulnar nerve sensation [thenar and index for M.nerve and hypothenar and little finger for U.nerve]
Dorsum:
radial nerve sensation (over first dorsal web space)
Palpate anatomical snuffbox
Squeeze MCP joints (tenderness=?active inflamm arthropathy)
Bimanually palp DIPs, PIPs, MCPs and CMC [comparing joints for tenderness, irregularities and warmth]
Palpate wrists (irregularities and tenderness)
Palpate elbow (from arm along ulnar boarder = rheum nodules or psoriatic plaques)
How do you move the patient in a H&W exam?
Do active, then passive (- for crepitus)
Finger extension/flexion (open/fist)
Wrist extension/flexion (prayer and ~phalens)
ALSO in H&W do motor (like power movements) assesment:
Radial nerve –> wrist/finger extension resisted
Ulnar nerve - index finger abduction
Median - thumb abduction
What are the special tests in H&W exam?
(as well as motor assessment of U,R &M nerve in H&W) also do a function assessment:
Power grip,
pincer grip
and pick up small object
Then
Tinnels
Phalens
What is the overall order for a H&W examination?
Consent, exposure, position
around bed
Look: palms down, sides, up
Feel: Palms up, down, MCP squeeze, bimanual palp of DIPs,PIPs,MCP,CMC, anatomical snuffbox, wrists and elbows
Move: active and passive; finger ext/flex and wrist ext/flex
Motor assessment (radial, ulnar and median)
Function assessment (power, pincer, pick up a small object)
ST: Tinnels; phalens
What do you look at in an elbow examination?
Around the bed
inspect from front: scars, swelling / erythema; carrying angle (cubitus valgus/varus)
Side: fixed flexion deformity, olecranon bursitis, scars / swelling / erythema
Behind: rheumatoid nodules, psoriatic plaques
What do you feel for in an elbow examination?
Temperature
Radial head - capitellum -lateral epicondyle, olecranon, medial epicondyle
Biceps tendon
How do you do “move” in an elbow examination?
- Do both active and passive (p-to feel for crepitus) Elbow: Flexion Extension Pronation Supination
What are the special tests in elbow examination?
Medial epicondylitis (golfers elbow) A.K.A. active wrist flexion against resistance (while firmly feeling the medial epicondyle)
Lateral epicondylitis (tennis elbow) A.K.A active wrist extension against resistance
What do you look at in a shoulder examination?
Around bed (aids and adaptations- slings)
Front (scars, scoliosis, arthritis, trauma, swelling, muscle wasting)
Side (scars)
Behind (scars, asymmetry/deformity/ muscle bulk of traps and deltoids and para-vertebrals)
What do you “feel” in a shoulder exam?
Assess temp, shoulder girdle components for swellings tenderness
SC->clav->acromio-clavicular joint-coracoid process->humerous head-greater tuberosity and scapular spine
What do you “move” in a shoulder exam?
Active:
Hands behind head (external rotation and abduction)
Hands as far up back as you can
(internal rotation)
Ask them to move arms: forwards, back, away from sides, across trunk, int and ext rotation
Scapula movement on abduction
Passive:
Repeat above movements passively and feel for any crepitus during the movement of the joint
What are the special tests in a shoulder exam?
Supraspinatus tests: empty can and painful arc
Infraspinatus: external rotation against resistance
Subscapularis – internal rotation against resistance
Teres minor – external rotation in abduction
What consent and position do you do for ankle and foot examination?
position pt upright
“I’d like to examine your ankles and feet. This will involve having a look and feel of these joints, in addition to assessing the joints’ movement”
What do you do for “look” in an ankle and foot exam?
GAIT- heel strike/toe off gait, step height normal? smooth and symmetrical; asymmetrical shoe wearing; walk on tip toes then on heels (arthritis, muscle strength in calves for DF and PF and anterior leg muscles for DF)
Front- symmetry - toe allignment (?valgus e.g. point out), MTP bunions, toe deformities, scars, calluses, swelling or erythema of foot/anke
Side - foot arches pes planus/pes cavus, stand on tiptoes to see if rigid or supple flat feet
Behind - foot/ankle symmetry - heel alignment (?var/val) achillies tendonitis (deformity/discontinuity/swelling/ery– ?tendonitis)
What do you feel for in an ankle and foot exam?
Temp Pulse (post tibial and dorsalis pedis) Tendons - achilles, gastronomicnemius muscle- ?focal tenderness or swelling (tendonitis)/apparent tendon gaps - ?rupture Joints and bones (Dist-->prox); tenderness, swelling, irregularity; Squeeze MTPJ; metatarsal and tarsal bones, tarsal joint, ankle joint, subtalar joint, calcaneum, medial/lateral malleoli/distal fibula
what do you move in an ankle and foot exam?
Active
Passive (feeling for crepitus excluding toe flexion/extension)
Foot plantar/dorsi
toe flexion (curl)
toe extension (towards head)
Ankle/foot eversion and inversion
Passive assessment only: ankle joint, subtalar, mid-tarsal, MP and IP joints [bend toes]
What special test do you do in an ankle and foot exam?
Simmonds test
e.g. calf squeeze while kneeling to see Achilles tendon rupture
What is the intro and consent for a knee exam?
Intro
(Consent exposure and position pt standing upright)
“Today I need to examine your knee joint, this will involve looking, feeling and moving the joint.”
What do you “look” at in a knee exam?
GAIT Heel strike/toe off gait? High stepping gait? Smooth and symmetrical? ?antalgia / waddling / broad based Front Scars Swellings Asymmetry/leg discrepancy Valgus or varus deformity Quads wasting Side Behind Scars Asymmetry Popliteal swellings e.g. bakers cyst or popliteal aneurysm
What do you feel for in a knee exam?
Straight knee: Temp Quad-->patella tendon Patella tap Sweep test Patella (bent to 90*) Tendons, bones, ligs and popliteal fossa Measure quads circum 20cm above tibal tuberosity
What movement do you do in a knee exam?
Active Flexion/extension (140*) Passive Same as above + feel for crepitus lift legs by heel for hyperextension (<10* norm)
What special tests are there in a knee exam?
Anterior/posterior draw test Ant move ?ACL dam Post move ?PCL dam Lachmans test Collateral ligaments (medial and lateral) Lateral apprehension test McMurrays Childress Apleys
What intro do you do for hip exam?
?hip replacement (no >90*)
“Today I need to examine your hip joints, this will involve looking, feeling and moving the joints.”
What do you “look” at in a hip exam?
Front: Scars, pelvic tilt, quadriceps wasting, foot deformity Side: normal or hyperlordosis Behind: Scoliosis, gluteal wasting, pelvic tilt GAIT: Assess speed, smoothness, turning, note any evidence of antalgic gait or Trendelenburg gait, assess the patients footwear
What do you feel for in a hip exam?
(Pt lying down)
Palpate the tissues overlying the hip joint for tenderness/warmth
palpate greater trochanter (tenderness ?GT bursitis)
ASIS and mid-inguinal point
Assess leg length
apparent (umbillicus –> MM)
True (ASIS –> MM)
What do you move in a hip exam?
Supine--. Active: flexion Passive: internal and external rotation abduction (45*) and adduction (30*) Prone--> Passive hip extension (10-20*)
What special tests are there in hip exam?
Thomas’ and trendelenburgs
and FABER and FAIR
What do you look for in spine exam?
Look for adaptations e.g. walking stick wheelchair
position patient standing
Front: Posture of head and neck (symmetry, abnormality)
Side:
Cervical lordosis (hyper, spondylolisthesis, osteoporosis, discitis),
thoracic kyphosis (20-45*); vertebral fracture
Lumbar lordosis - assess for hyperlordosis - obesity, tight lower back muscles
behind: Scars, wasting (paraspinal muscles etc- chronic immobility), scoliosis, abnormal hair growth (spina bifida)
GAIT: foot drop, antalgic gait (may indicate spinal pathology)
What should you feel for in a spinal exam?
(tenderness, irregularities and alignment) - spinal processes and sacroiliac joints
Palpate paraspinal muscles - tenderness or muscle spasms (looking at pts face)
What should you “move” in a spinal exam?
Cervical -
active: flexion, extension (down/up) lateral flexion and rotation
Do passive if reduced movement on active; assess if pain/stiffness/muscle spasm is the restricting factor
Lumbar:
Flexion/extension/lateral flexion (toes, back, outer leg(s))
Thoracic spine:
pt sit down and turns with arms across chest (10-20*)
What are the special tests in a spine exam?
Schobers test
5 below PSIS and 10 above PSIS, full lumbar flexion should be >20cm; reduced = ind ankylosing spondylitis etc
Sciatic stretch test - straight leg raise (passively flex hip, norm:80-90* then once as far as poss, Dorsiflex the foot)
Femoral nerve stretch test:
Prone pt, flex knee, extend hip, plantar-flex the foot
