Musculoskeletal Clinical Assessment

Question 1

What tools are used to make a diagnosis?

Answer 1

History
Examination
Investigations

Question 2

What categories can orthopaedic symptoms be broken down into?

Answer 2

Something looks wrong
Something feels wrong
Something moves wrong

Question 3

List orthopaedic symptoms:

Answer 3

Cardinal presenting complains marked by *:

Something looks wrong:

• Swelling*
• Deformity*
• Wasting
• Shortening
• Discolouration* (redness, pallor, bruising)
• Wounds

Something feels wrong:

• Pain*
• Dysaesthesiae
• Weakness

Something moves wrong:

• Stiffness*
• Reduced Range of Movement
• Limp
• Instability/collapsing
• Crepitus

Question 4

What is the GALS screening questions?

Answer 4

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 the stairs without any difficulty?

Question 5

What questions need to be asked about a typical day?

Answer 5

Wake at normal time or woken by pain?
How do they feel first thing in the morning?
Dressing - socks and shoelaces
Cut own toenails?
Can they get in and out of the bath?
Walking distance on flat, what stops them?
Driving?
Does own shopping?
Work, hobbies - does it stop them?

Question 6

What are the red flags from a history suggesting serious pathology?

Answer 6

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

Question 7

What needs to be asked about allergies?

Answer 7

Any known allergies?
History of penicillin use
Iodine
General anaesthetic
Blood transfusion
Elastoplast
Asthma/eczema/hay fever
Mental sensitivity
Latex
Family history of allergies

Question 8

What needs to be asked about a drug history?

Answer 8

Current, recent (when started/stopped)
Prescribed medications
Recreational/over-the-counter/herbal drugs
Oral contraceptive pill
Aspirin/warfarin/clopidogrel
NSAIDs
Steroids

Question 9

What are the principles of a musculoskeletal examination?

Answer 9

Quiet private room +/- chaperone, well-lit, warm
Space to observe gait, examination couch

Adequate exposure + position
Always compare L/R - examine normal side first

Convention for description of deformity
Name fingers
Use ‘radial/ulnar’ and ‘dorsal/volar’ rather than ‘lateral/medial’ and ‘anterior/posterior ‘ in the hand and forearm
Anatomical position = 0° for all joints
Do not overwhelm children - examine on mother’s lap, divert attention (admire clothes or something)

Question 10

What should be covered in the general inspection of a patient?

Answer 10

Look around the bed - equipment, walking aid, prosthetics etc.
Age and health
Distress - position/posture, movement
Nutrition - size
Hydration - mucous membranes, skin turgor
Behaviour/affect

Question 11

What should be covered in the head and neck section of a general examination of a patient?

Answer 11

Eyes - pallor of conjunctivae, icterus of sclerae, Marcus seniles, xanthalesma, conjunctivitis/iritis
Face - rash
Mouth - central cyanosis, glossitis, angular stomatitis, dental sepsis, ulcers
Neck - lymphadenopathy
Temperature
BMI

Question 12

What should be covered in the hands section of the general examination?

Answer 12

Nails - clubbing, koilonychia, leuconychia, splinter haemorrhages, vasculitic lesions, pitting
Colour - peripheral cyanosis, jaundice, palmar erythema, pallor (Raynaud’s), pink fingers (CO2 retention), tar staining, spider naevi
Deformity - rheumatoid arthritis (ulnar deviation, swan neck, boutonniere, Z thumb etc.), Dupuytren’s
Swellings - Bouchard’s and Heberden’s nodes, ganglion, nodules, joints
Wasting - nerve specific
Pulse

Question 13

What is done in a local musculoskeletal examination?

Answer 13

Look - skin scars/wounds/sinuses, colour, swelling, wasting, deformity
Feel - temperature, tenderness, swelling, deformity, sensation
Move - active (range/power), passive, special tests (stability)
X-Ray

Question 14

What is done in the looking section of the musculoskeletal examination?

Answer 14

Limb lengths:

• Real (ASIS/greater trochanter/tibial tuberosity-medial malleolus) - legit in same position
• Apparent (midline marker) - legs lying as they will
• Galleazzi Test (Hips flexed 45°, knees 90°)

Measure and record

In any joint examination must examine joints above and below and examine spine for any limb symptoms
Neurovascaular exam of whole limb
Consider other relevant systematic examination - chest, abdomen, neurological

Record findings, re-examine and compare