Musculoskeletal PE Flashcards
Hand Examination - Arthritis
A 50 year old lady has presented with a complaint of bilateral hand pain. You are suspecting Osteoarthritis.
Tasks:
1. Explain how to assess functional tests of the hand - urine jar, clip, key, paper folded in half (camera pointed to the patient’s hands)
2. Explain further relevant hand examination
OA: Heberden, Bouchard nodes
RA: Z deformity, swan neck, boutonnieres
Ulnar/radial deviation
Wasting of thenar, hypothenar, small muscles of the hand
Subcutaneous nodules in elbow in RA
Palpation: each and every joint; how to properly do it
Wrist Cut Examination
Your next patient is a 25 year old lady who has presented to the ED for a self-inflicted wrist cut on the volar aspect of the wrist. (Vitals are stable. Dressing has been done.)
Task:
1. Explain physical examination to the medical student with anatomical landmarks.
Wrist flexors (FCR, FCU, PL)
- Ask the patient to flex the wrist
Finger flexors (FCS, FCP) - I want to check the superficial and deep flexors of the fingers
- Ask the patient to rest the hand on the table, use the other hand to block the PIPJ of all fingers, then ask to bend the fingers. This flexes the DIPJ and checks the integrity of the deep flexors of the fingers.
- Ask the patient to rest the hand on the table, use the other hand to block the MCPJ, then ask to bend the fingers. This flexes both the DIPJ and PIPJ . This checks the integrity of the combination of the superficial and deep flexors.
- Ask the patient to rest the hand on the table, use the other hand to hold down all fingers except the middle finger, then ask to flex the middle finger. This checks the integrity of the superficial flexor of the finger.
Thumb flexor (FDP)
- Hold the thumb at the MCPJ and ask the patient to bend the IPJ
Radial Fracture Examination
Your next patient is a 4 year old boy who is brought in by his father after a fall. He injured his forearm. An x-ray has been done.
Task:
1. Explain physical examination to the medical student with anatomical landmarks.
Visible deformity, open wounds
Skip parts that may injure the fracture site but still explain how you want to examine it if there was no injury
Palpate other anatomical landmarks in the hand, wrist and forearm
Skip passive movements, but check active movements of the fingers and thumb
Neurological exam
Scaphoid Fracture Examination
Your next patient is a 20 year old man who has presented to the ED after a fall on an outstretched arm and he is complaining of pain in his wrist. You are suspecting a scaphoid fracture.
Task:
Explain your physical examination to the medical student with anatomical landmarks
Palpate the snuff box and scaphoid tubercle
Active movement: thumb
Grip strength
Pincer grip
Axial compression test of the thumb
Boxer’s Fracture (Hand pain after a punch)
30 year old man who presents to your general practice complaining of swelling and pain in his right hand after a fight in a bar. He was injured after punching someone.
Task:
1. Explain physical examination to the medical student with anatomical landmarks
Loss of knuckle contour and step deformity
Pseudoclawing: hyperextension of the MCPJ and flexion of PIP on attempting finger extension
Palpate the head, shaft, base of the metacarpals
Extensor tendon movements
Elbow Examination
Your next patient is a 27 year old hockey player who has presented to you complaining of elbow locking.
Task:
Explain your physical examination to the medical student with anatomical landmarks
Inspection: carrying angle, cubitus varus and valgus
Palpate for tenderness:
- I will be palpating the medial epicondyle, olecranon process, lateral epicondyle, joint line
- In the arm I’ll try to palpate the biceps tendon and muscle, and the triceps tendon
- In the forearm, I’ll also try to palpate the head of the radius, and the soft tissues of the forearm
Palpate for crepitations
Special tests:
Osteochondritis - Radiocapitellar compression test
Resisted active and passive stretching
- Lateral epicondylitis
- Medial epicondylitis
Varus and valgus stress tests
Back Examination
40 year old man presented with lower back pain for 3 days. His pain started after lifting a heavy box. Pain is radiating to her left thigh.
Tasks:
1. Explain back physical examination to the medical student
Neurological Exam: Motor, sensory, reflexes
Special tests: SLR, crossed SLR, Braggards
Hip Examination
Patient comes in already diagnosed with osteoarthritis.
Task:
1. Explain physical examination to the medical student with anatomical landmarks
Walking aids
Gait: antalgic gait, able to bear weight, ask to squat to check power of proximal muscles and ROM of hip joint
Trendelenburg test
Inspection: asymmetry or tilting of hip, leg length discrepancy
Palpate for tenderness: ASIS, iliac crest, PSIS, greater trochanter, joint line, quadriceps muscles and adductor muscles
Movements: palpate for crepitations
flexion, extension, abduction, adduction, internal and external rotation
True leg length, apparent leg length
Special test: FABER test, adductor tendonitis, Thomas test, FADIR test
Knee Examination
Inspect: genu varum & genu valgum
Tenderness: quadriceps, patella, medial and lateral joint lines, patellar tendon, tibial tuberosity, head of the fibula
Movement: palpate for crepitations
Special tests:
1. Anterior and posterior drawer (ACL & PCL)
2. Varus and Valgus stress tests (LCL & MCL)
3. McMurray & Apley’s grind test (Meniscus)
4. Clarke’s test (Chondromalacia patella)
5. Patellar tendinitis
6. Apprehension test (patellar subluxation)
7. Tap test (effusion)
8. Sweep test (effusion)
Compartment Syndrome Examination
Your next patient is a 25 year old man who presented to the ED complaining of excruciating leg pain. You have made the diagnosis of compartment syndrome.
Tasks:
1. Explain your PE to the medical student and explain the anatomical landmarks
Explain specific findings you are looking for
6 P’s of Compartment syndrome:
1. Pallor
2. Paresthesia
3. Pulselessness
4. Pain
5. Paralysis
6. Poikilothermia
4 compartments of the leg: anterior, lateral, superficial and deep posterior
Palpation: temperature, CRT, pulse, tenderness
Movements: ankle passive movements - pain on passive movement
Wiggle toes: inability to do active movement
Tibial fracture Examination
Your next patient has been brought to the ED after a motor vehicle accident and has been diagnosed with an open comminuted tibial fracture. Primary management has been done. He is being transferred to a tertiary center for Orthopedic management.
Tasks:
1. Explain how to assess a similar patient to the medical student
2. Explain procedures necessary before the transfer
PE to check integrity of neurovascular, musculoskeletal and skin
Rule out compartment syndrome
Management:
Irrigation, debridement, antibiotics, tetanus booster
Immobilize with splint, ice, analgesics, elevate, handover
Ankle/Hindfoot Examination
40 year old lady presented to you complaining of hindfoot pain/ankle pain. Pain has been worse on walking. She also gives a history of an ankle injury/fracture 10 years ago.
Task:
1. Explain your physical examination the medical student with anatomical landmarks
Can weight bear
If pain is worse on stance or swing phase
Inspection: pes planus, pes cavus, ankle varus and valgus deformity, Achilles tendon swelling, redness, thickening, “too many toes sign”
Palpation: tenderness - tibial tendonitis, peroneal tendonitis
Movement: passive inversion: peroneal tendonitis, passive eversion: tibial tendonitis
Crepitations on movement
Special tests:
Wind lass test (plantar fasciitis)
Thompson test (ruptured Achilles)
Ankle Telehealth Examination
Ottawa ankle rules
Ability to bear weight immediately after injury and on assessment
Pain on medial malleolus and 6cm above it
Pain on lateral malleolus and 6cm above it
Pain on navicular
Pain on base of 5th metatarsal
Special test:
Syndesmosis squeeze test
Thompson test
Anterior drawer test
Talar tilt test
Shoulder Examination
I. Introduction
- Introduce yourself
- Explain steps: I’ll be looking and feeling the shoulders, ask you to do some movements and do some special tests
- Take shirt off to expose both shoulders
- Offer pain killers
- Get consent
- Wash hands before starting examination
II. General Appearance - Distress due to pain - Protective posture III. Inspection - Look at the shoulder from the front, side and back - Anterior view: asymmetry of shoulders, deltoid wasting, deformity of the biceps tendon (Popeye deformity) - Lateral view: swelling, redness (bursitis) - Posterior: supra and infraspinatus wasting, scoliosis, asymmetry of scapula, winging of scapula (ask the patient to place hands against the wall and push, looking for elevation of the medial border of the scapula - serratus anterior muscle) IV. Palpation - Temperature - CRT - Pulse - Tenderness: palpate each joints and compare both sides ○ Sternoclavicular joint ○ Clavicle ○ Acromioclavicular joint ○ Coracoid process ○ Head of humerus/biceps tendon ○ Spine of scapula ○ Border of scapula ○ Supra & infra spinatus V. Movement of shoulder - I'll check both passive and active movements, active movements give you an idea if there is pain or limitation of movement, while passive movements give you an idea about the range of movement - Flexion/extension: raise your arm forward, then back as far as you can - Abduction/adduction: raise your arm to the side, then back close to the body - Internal/external rotation: touch your back and reach as high as possible with your thumb; flex your elbow at 90 degrees, keep it close to your body then move your hand backwards VI. Neurological Exam - I'll be checking the motor and sensory functions of the upper limb using myotomes and dermatomes ○ C5: shoulder abduction / upper outer arm ○ C6: elbow flexion/ lateral side of forearm ○ C7: elbow extension/ middle finger ○ C8: grip strength / little finger ○ T1: finger spread / medial side of forearm VII. Special Tests a. Hawkins-Kennedy Test (Impingement syndrome): - Elevate the arm to 90 degrees, angle 30 degrees anteriorly (scapular plane), then flex elbow to 90 degrees - Do internal rotation of the shoulder - Positive pain: impingement syndrome b. Empty can Test (Supraspinatus tear) - Elevate the arm to 90 degrees, angle 30 degrees anteriorly (scapular plane) - Ask the patient to internally rotate the shoulder by pointing the thumb down - Apply downward force as the patient attempts to resist - Positive pain/weakness: supraspinatus tear c. Drop arm Test (supraspinatus tear) - Hold the arm in 90 degrees abduction - Explain to the patient that you'll be removing the support and try to hold the same position - Pain/dropping: supraspinatus tear d. Apley's Scratch Test (rapid assessment of the ROM of the shoulder) - Ask the patient to bring hands together on the bag while one hand comes from the back and one from below - Switch arms, then check for difference on both sides e. Apprehension Test (labral tear: shoulder instability) - Hold the arm in 90 degrees abduction with 90 degree flexion of elbow - Put one hand behind the shoulder, hold the wrist with the other hand then bring the shoulder in more and more external rotation - Positive test: patient reports fear of subluxation in greater degrees of external rotation
Differential Diagnoses
- Rotator cuff injury
- Impingement syndrome
- Bursitis
- Fracture: clavicle, acromion
- Acromioclavicular separation
- Shoulder dislocation
- Labral tear
- Biceps tendonitis
- Cervical radiculopathy
- OA/RA
Frozen shoulder
Numbness in Hands Examination
Your next patient isa 35 year old man who presented to you complaining of pins and needles in his right hand. His symptoms are worse in the night and wakes him up. He is a factory worker.
Task:
1. Explain hand examination to the medical student
Differential Diagnosis:
- Carpal tunnel syndrome
- Cubital tunnel syndrome
- Cervical radiculopathy
I. Introduction - Introduce yourself - Explain steps: looking and feeling his hands, asking to do some movement, checking the sensation of the hands - Position: place hand on pillow - Get consent - Wash hands and start examination II. Flagging - Today I'll be doing a complete hand examination and I'll be considering different differentials like carpal tunnel syndrome cubital tunnel syndrome, and cervical radiculopathy III. General Appearance - Distress due to pain IV. Inspection - Thenar (carpal tunnel) and hypothenar (cubital tunnel) wasting - Wasting of small muscles of the hand - Tremor - Fasciculations: irregular, non-rhythmic contraction of the muscles V. Palpation - Temperature: compare both sides - CRT - Pulse: radial pulse - Tenderness: fingers, metacarpals, wrist (palmar surface), elbow VI. Movement - I'll be doing both passive and active movements ○ Finger § Flexion: making a fist § Extension: opening fist § Abduction: spreading fingers § Adduction: opposite ○ Thumb § Abduction: point thumb towards the ceiling § Adduction § Flexion § Extension § Opposition ○ Wrist § Flexion § Extension § Radial deviation § Ulnar deviation ○ Elbow § Flexion § Extension VII. Neurological Examination - Motor ○ Median: thumb abduction ○ Ulnar: finger abduction ○ Radial: wrist extension - Sensory ○ Median: index finger ○ Ulnar: little finger ○ Radial: snuffbox VIII. Special Tests a. Carpal Tunnel Syndrome - Phalen sign: push the dorsal aspect of the hands together for 30 seconds, and look for reproduction of symptoms - Tinel sign: tap over the palmar surface of the wrist, look for reproduction of symptoms b. Cubital Tunnel Syndrome - Elbow flexion test: hold the elbow in full flexion with wrist extended for 1 minute, reproduction of symptoms - Tinel sign: tap on the medial groove of the elbow (between olecranon and medial epicondyle), reproduction of symptoms c. Cervical radiculopathy - Spurling test/Axial compression test: ask the patient to do lateral flexion of the neck to the affected side, then apply axial compression, reproduction of symptoms IX. Neck Examination - Inspection: kyphoscoliosis, normal cervical lordosis - Palpation: spinous processes in the neck, paraspinal muscles, trapezius Movement: flexion, extension, lateral bending, rotation
