MSK OSCE

Question 1

Please carry out a GALS examination.

Answer 1

1. introduction
2. screening questions - any pain or stiffness in muscles, joints or back? can you dress yourself completely without any difficulty? can you walk up and down the stairs without any difficulty
3. GAIT - walk few steps and turn quickly, in anatomical position, inspect for - bulk and symmetry, limb / spine / iliac crest alignment, inspect spine from behind for scoliosis and from the side for lordosis or kyphosis, ability to extend elbows and knees, abnormalities in the feet
4. ARMS - patients puts arms behind head, hands help out (palms down + fingers outstretched) - observe back of hands, look at palms, make a fist, squeeze my fingers, pincer grip of each finger on thumb, squeeze MCP joints (watch face)
5. LEGS- patient lying on couch - asses full flexion and extension of both knees (feel for crepitus), hip and knee flexed to 90 degrees - holding the knee and ankle to guide the movement, assess internal rotation of each hip in flexion, patellar tap, from end of bed inspect feet, squeeze MTP joints (watch for discomfort)
6. SPINE - standing - tilt head to each side, touch toes (put 2 or 3 fingers on lumbar vertebrae - fingers should move apart)

Question 2

Please carry out a hip examination.

Answer 2

1. introduction etc
2. expose patient - only underwear below waist
3. patient standing - quads/ hamstring muscle mass, trendeleberg test
4. gait - pace, symmetry, gross gait abnormalitites, walking aids
5. patient lying on couch - inspection of hip, ask about swelling, bruising, scars or hair changes
6. altitude of limb
7. limb lengths - ASIS to medial malleolus and xiphoid sternum to medial malleolus
8. palpation - one side only (greater trochanter - lateral to groin)
9. move - flexion (active and inactive) bend knee, further passive flexion (patient pulls on their own knee)
10. internal/ external rotation- lift leg over other than outwarads
11. thomas test - one side only, hand is placed under lumbar lordosis whilst lifting, lift other leg
12. summarise exam findings

Question 3

Please carry out a knee examination.

Answer 3

1. inspection
   patient standing - limb alingnment, quads/ hamstring muscle mass, popliteal fossae
   gait - pace, symmetry, walking aids
   patient on couch - local inspection of knee for erythema, bruising, scars, hair changes + swelling
2. palpation - temperature
3. straight leg raise - ensures extensor mechanism is intact (dorsiflex ankle)
4. effusion tests - medial gutter (small) or patellar tap (large)
5. appropriate patellar tests
   - apprehension test (move patellar laterally)
   - patellar grind test (push down and move it side to side) - for OA
   - patello-femoral crepitation - for OA
6. medial and lateral joint line test
   - flex knee to 90degrees, palpate tibial tuberosity and patellar tendon
   - palpate medial + lateral joint lines using single finger - looking for arthritis or meniscal tear
7. +- steimanns test for acute meniscal tear (isolate tenderess and rotate foot away from sore side)
8. MCL and LCL
   - palpation in medial and lateralleral collaterals in 3 places
   - legs off couch - stress medial and lateral
9. Cruciate ligament testing
   - both legs bent on couch with feet together
   - assess symmetry
   - PCL - sit on foot and pull from under knee / push behind knee
   - ACL - patient relates, passovely flex knee to 20 degrees, thumb over tibial tuberosity and pull knee
10. move
    - flexion (active and passive)
    - extension (active passive +- heel height testing for locked knee - lie prone with heels off the bed)

Question 4

Please carry out a shoulder examination.

Answer 4

1. introduction, bare above waist
2. inspection
   anterior - contour, muscle bulk, joints
   laterally - contour, joints
   posterior - muscle wasting, scapula
   axilla - swelling or scars
3. palpation - sternoclavicular joint (medially), clavicle, acromio-clavicular joint (laterally onto shoulder), acromion, long head of biceps (spine and body)
4. move
   external rotation - elbows flexed to 90degrees and locked, ask patient to move arms away from each other as if they were going to give you a hug
   forward flexion - arms straight up
   abduction - arms out to side, up to head, painful arc
   internal rotation - face away, hand behind back and reach upwards to neck
   - scapular winging - palms against wall and draw chest into wall, do it again with palms at waist height
5. rotator cuff power
   supraspinatus - arms out and thumb point to floor, push down on patients forearm
   infraspinatus - external rotation against resistance
   subscapularis - hand behind bum
6. special tests
   impingement - painful arc on abduction, hawkins kennedy test, jobes (supraspinatus) thumb down, scarf - ACJ pathology, hand round neck

instability - sulus sign (shoudler relaxed, stabilise shoulder girlde and pull down on arm)
anterior and posterior drawer tests - hold and pull on shoudler as patient is lying on couch
anterior apprehension and relocation test
posterior apprehension tet