Musculoskeletal System 1 Flashcards
What are the 2 stages in screening for MSK problems?
3 screening questions followed by a 2 minutes GALS screening examination
What does GALS stand for?
G gait
A arms
L legs
S spine
What are the 3 screening questions that are asked in an MSK exam?
- 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 stairs without any difficulty?
When inspecting gait, what should you ask the patient to do?
ask them to walk to the end of the room, turn around and comeb back
What should the doctor observe during the gait exam, whilst the patient is walking around the room?
- inspect the gait cycle (heel strike, toe-off) and coordination
- when the patient reaches the end of the room, are they able to turn without any issues?
- is there any evidence of pain?
- are the foot arches normal or absent?
what does assessing gait screen for?
it screens for pathology in the ankles, subtalar, midtarsal and small joints of the feet and toes
When looking at the patient from the front, what should be noted about posture and body habitus?
posture:
- any obvious asymmetry/scoliosis
body habitus:
- obesity can be associated with joint pathology
- a thin malnourished adult may be at increased risk of fractures of osteomalacia
Why should skin rashes be observed on the patient?
salmon-coloured plaques with silvery scales over extensor surfaces is typical of psoriasis
psoriatic arthritis is associated with psoarisis
How should the shoulders be assessed when examining the patient from the front?
assess shoulder bulk:
- muscle wasting suggests chronic joint disease
asymmetry of the shoulders:
- may be due to unliateral wasting or scoliosis of the spine
How should elbow extension and leg length alignment be observed when assessing the patient from the front?
elbow extension:
- assess patient’s carrying angle (normal 5-15 degrees)
- joint contractures can result in inability to extend the elbow at rest
leg length and alignment:
- note any leg length inequality
- a valgus or varus deformity of the hip or knee may result in misalignment of the limb
How are the quadriceps muscles assessed when viewing the patient from the front?
assess muscle bulk and symmetry
muscle wasting suggests chronic joint disease
How are the knees assessed when viewing a patient from the front?
swelling and erythema of a knee joint suggests inflammatory arthritis or sepsis
- note any deformity of the knee joints (valgus or varus)
- note any asymmetry that can be caused by joint effusion
- note any hyperextension of the knee joints
When observing a patient from the front, how should the feet and ankles be assessed?
ankles:
- swelling and erythema of the ankle joint may suggest inflammatory arthritis or joint sepsis
- note any deformity of the ankle joints (valgus/varus deformity)
feet:
- note any midfoot/forefoot deformity (e.g. flat feet)
- note any asymmetry between the feet (e.g hallux valgus)
How is the spine assessed when observing a patient from the side?
cervical spine:
- inspect for hyperlordosis - excessive spine curvature
thoracic spine:
- inspect degree of thoracic kyphosis (normal 20-45 degrees)
- hyperkyphosis =/> 45 degrees
lumbar spine:
- assess degree of lordosis
- loss of lumbar lordosis may suggest sacroiliac joint disease
How should the knee joints, foot arches and toe clawing be assessed when observing a patient from the side?
knee joints:
- note the degree of flexion
- look for evidence of hyperextension
foot arches:
- a low arch profile suggests pes planus (flat feet)
- a high arch profile suggests pes cavus - e.g charcot marie tooth disease
toe clawing:
- may indicate plantar fascial fibromatosis
How are the shoulder muscles assessed when observing a patient from behind?
shoulder bulk:
muscle wasting suggests chronic joint disease
asymmetry of the shoulders:
this may be due to unilateral wasting or scoliosis of the spine
How is spinal and iliac crest alignment assessed when observing a patientfrom behind?
spinal alignment:
look for evidence of scoliosis
iliac crest alignment:
pelvic tilt may suggest hip abductor weakness
How are gluteal muscle bulk, popliteal swellings and hind-foot abnormalities detected when observing a patient from behind?
gluteal muscle bulk:
wasting of gluteal muscles suggests reduced mobility
popliteal swellings:
- baker’s cyst is non-pulsatile
- popliteal aneurysms are pulsatile
hind-foot abnormalities:
thickening of the Achille’s tendon may suggest tendonitis
What is the first stage in the arms examination?
What is assessed?
Ask the patient to put their hands behind their head
This assesses shoulder abduction and external rotation as well as elbow flexion
Restricted range of movement suggests shoulder or elbow pathology
Excessive range of movement suggests hypermobility
What is the second stage in the arms examination, after the patient has put their hands behind their head?
Ask the patient to hold their hands out in front of them, with their palms facing down and fingers outstretched
This assesses forward flexion of the shoulders, elbow extension, wrist extension and extension of the small joints of the fingers
Inspect the backs of the hands for asymmetry, joint swelling and deformity
Inspect the nails for signs associated with psoriasis (e.g. nail pitting)
What is the third stage of the hand examination, after the patient has put their hands out in front of them?
Ask the patient to turn their hands over (supination)
This assesses wrist and elbow supination
Inspect the muscle bulk of the palms (thenar / hypothenar eminences) for evidence of wasting
Restriction of supination suggests wrist or elbow pathology
What is the fourth stage of the hand examination, after the patient has performed supination?
Ask the patient to make a fist whilst observing hand function
This assesses flexion of the small joints of the fingers and hand function
The patient may be unable to make a fist if they have joint swelling or deformities of the small joints of the hands
What is the fifth stage of the hand examination, after the patient has made a fist?
Ask the patient to squeeze your fingers and assess grip strength and compare between the hands
Grip strength may be reduced due to pain (e.g. swelling of joints in the hand) or due to nerve pathology (e.g. carpal tunnel syndrome)
What is the sixth stage of the hand examination, after the patient has squeezed your fingers?
Ask the patient to touch each finger in turn to their thumb (precision grip)
this assesses coordination of the small joints of the fingers and thumb
it also assesses overall manual dexterity
reduced manual dexterity may suggest inflammation or joint contractures of the small joints in the hand
What is the seventh and final stage of the hand examination?
Gently squeeze across the metacarpophalangeal joints
observe for non-verbal signs of discomfort
inspect for symmetry of the MCP joints
tenderness indicates active inflammatory arthropathy
When the patient is lying down on the examination couch, what is the first stage of the leg examination?
assess passive knee flexion and extension
assess one limb at a time
flex and then extend the knee whilst feeling for crepitus over the patella
note the range of movement and any asymmetry between knee joints
What is the second stage of the leg examination, whilst the patient is lying down on the examination couch?
assess passive internal rotation of the hip joint
the hip and knee joint should be flexed to 90 degrees for assessment
internal rotation is often the first movement to be reduced in hip pathology
note the range of movement and any asymmetry between the hip joints
What is the third stage in the leg examination?
What can it detect?
patellar tap
it can detect large effusions, but small effusions may not be detected using patellar tap alone
What are the 3 stages involved in assessing patellar tap?
- empty the suprapatellar pouch by sliding your left hand down the thigh to the patella
- keep the left hand in position and use the right hand to press downwards on the patellar with your fingertips
- if there is fluid present you will feel a distinct tap as the patella bumps against the femur
What is the fourth and final stage in the leg examination?
squeeze across metatarsophalageal joints (MTP)
observe for non-verbal signs of discomfort
tenderness indicates active inflammatory arthropathy
What else should be performed during the leg examination?
Inspect the feet
Look for any deformities, callosities or swelling
What is the first stage in the spinal examination?
Inspect the patient’s spine
look from behind for evidence of scoliosis (asymmetrical shoulders and pelvic girdle)
look from the side for abnormalities of lordosis or kyphosis
What is the second stage of the spine inspection, after the spine has been inspected?
assess lateral flexion of the cervical spine
ask the patient to tilt their head to each side, moving their ear towards their shoulder
What is the third stage in the spinal examination, after lateral flexion of the cervical spine?
Assess the temporomandibular joint (TMJ):
ask the patient to open their mouth wide and put three of their fingers into their mouth
this assesses the temporomandibular joint’s range of movement and screens for deviation of jaw movement
restricted jaw opening may be due to temporomandibular joint disease
What is the fourth and final stage of the spinal examination?
assess for lumbar flexion
place 2 fingers on the lumbar vertebrae and ask the patient to bend forward and touch their toes
observe your fingers as the patient’s lumbar spine flexes (they should move apart)
observe your fingers as the patient extends their spine to return to standing (they should move back together)
During the lumbar flexion exam, what does it suggest if the patient is able to place their hands flat on the floor?
joint hypermobility
When taking an MSK history, what are the 7 areas that need to be covered?
- Pain - SOCRATES
- stiffness
- joint swelling
- patterns of joints affected - number, large v. small, symmetry
- acute v. chronic (> 6 weeks)
- associated systemic symptoms
- impact on functioning/daily life
What are the basic priniciples of joint examination?
look, feel, move, function
During the look stage of the hand examination, what features should be observed on the dorsum?
hand posture:
note any abnormal posture e.g. contracture
scars or swelling:
scars may suggest previous surgery
compare the hands and wrists to note any areas of swelling
skin colour
deformities
skin changes
muscle wasting
nail changes
when looking at skin colour on the dorsum of the hand, what should be looked for?
erythema of soft tissue may indicate cellulitis or joint sepsis
pallor of the hands may indicate peripheral vascular disease and/or anaemia
What deformities should be looked for when examining the dorsum of the hand?
- Bouchard’s nodes
- Heberden’s nodes
- swan neck deformity
- Z-thumb
- Boutonnières deformity
What is the difference between Bouchard’s and Heberden’s nodes?
Bouchard’s nodes:
occur at the proximal interphalangeal joint (PIP)
Heberden’s nodes:
occur at the distal interphalangeal joint (DIP)
They are both associated with osteoarthritis
What is swan neck deformity?
it occurs at the distal interphalangeal joint (DIPJ)
features include DIPJ flexion with PIPJ hyperextension
associated with rheumatoid arthritis
What is Z-thumb?
hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint
associated with rheumatoid arthritis
What is Boutonnières deformity?
PIPJ flexion with DIPJ hyperextension
associated with rheumatoid arthritis
When lookin
What skin changes can be observed when looking at the dorsum of the hand?
skin thinning or bruising:
this is associated with long-term steroid use, which is common in patients with inflammatory arthritis
psoriatic plaques:
psoriasis and psoriatic arthritis are closely associated
When looking at muscle wasting in the dorsum of the palm, what should be observed?
muscle wasting can occur secondary to chronic joint pathology
consider lower motor neurone lesions (e.g. carpal tunnel syndrome)
When looking at nail changes on the dorsum of the hand, what should be observed?
nailfold vasculitis:
this is small vessel vasculitis that is a feature of rheumatoid arthritis
nail pitting and ocycholysis:
these are associated with psoriasis and psoriatic arthritis
When inspecting the palms of the hand, what areas should be observed?
- inspect hand posture
- scars or swelling
- skin colour
- deformity
- thenar/hypothenar wasting
- elbows
What common deformity is looked for in the palm of the hand?
Dupuytren’s contracture
presents as a thickening or painless nodule in the palm
the most common finger to be affected in the ring finger
in advanced disease, there is a loss of range of motion in the affected fingers
Why are the elbows and thenar/hypothenar eminence looked at on the palms?
isolated wasting of the thenar eminence is suggestive of carpal tunnel syndrome
the elbows are inspected for psoriatic plaques or rheumatoid nodules
During the feel stage of the hand examination, what areas are looked at?
- temperature
- radial and ulnar pulse
- thenar/hypothenar eminence bulk
- palmar thickening
- assess median and ulnar nerve sensation
Why is temperature of the palm assessed during the feel stage of the hand examination?
the temperature of the wrists and small joints of the hand is assessed and compared
increased warmth in a joint is suggestive of inflammatory arthritis or joint sepsis
Why is the radial and ulnar pulse palpated when feeling the palm?
to confirm that there is adequate blood supply to the hand
Why is the muscle bulk of the thenar/hypothenar eminence assessed when feeling the palm?
wasting of these areas is often noted in ulnar/median nerve lesions
Why are the palms palpated when feeling the hand?
to look for evidence of palmar thickening
this is caused by Dupuytren’s contracture
How is median and ulnar nerve sensation assessed in the feel stage of the hand examination?
median nerve sensation:
assessed over the thenar eminence and index finger
ulnar nerve sensation:
assessed over the hypothenar eminence and little finger
During the feel stage of the hand examination, which features are assessed on the dorsum of the hand?
- assess radial nerve sensation
- assess and compare temperature using the back of your hand
- gently squeeze over metacarpophalangeal joints
- bimanually palpate joints of the hand
- palpate anatomical snuffbox
- bimanually palpate the wrists
How is radial nerve sensation assessed on the dorsum of the hand?
over the first dorsal web space
When assessing and comparing temperature of the dorsum of the hand, which 3 areas are looked at?
forearm, wrist and MCP joints
Why are the MCP joints gently squeezed over during the feel part of the hand exam?
to observe for non-verbal signs of discomfort
tenderness may indicate active inflammatory arthropathy
Which joints are bimanually palpated during the feel stage of the hand exam?
joints are assessed and compared for tenderness, irregularities and warmth:
- metacarphophalangeal joint
- proximal interphalangeal joint
- distal interphalangeal joint
- carpometacarpal joint of thumb
Why are the wrists and anatomical snuffbox palpated during the feel stage of the hand exam?
anatomical snuffbox:
- tenderness may suggest scaphoid fracture
wrists:
- palpated for evidence of joint line irregularities or tenderness
How is the patient’s elbow palpated during the feel stage of the hand exam?
palpate the patient’s arm along the ulnar border to the elbow
note any rheumatoid nodules or psoriatic plaques
What is the general rule for joint movement during the move stage of the hand exam?
each movement is assessed actively first - the patient does the movements independently
the movement is then assessed passively, feeling for crepitus and noting any pain
During the move stage of the hand exam, how is finger extension assessed?
by asking the patient to open their fist and splay their fingers
During the move stage of the hand examination, how is finger flexion assessed?
by asking the patient to make a fist
During the move stage of the hand exam, how is wrist extension assessed?
by asking the patient to put the palms of their hands together and fully extend their wrists
this is the “prayer sign”
During the move stage of the hand exam, how is wrist flexion assessed?
by asking the patient to put the backs of their hands together and flex their wrists fully
“inverse prayer sign”
How is passive wrist flexion and extension assessed?
How is the motor function of the radial nerve assessed?
by asking the patient to extend their fingers against resistance
How is the motor function of the ulnar nerve assessed?
by asking the patient to abduct their index finger against resistance
How is the motor function of the median nerve assessed?
by asking the patient to abduct their thumb against resistance
What are the 3 screening tests for hand function?
power grip:
“squeeze my fingers with your hands”
pincer grip:“squeeze my finger between your thumb and index finger”
pick up a small object or undo a shirt button
When is Tinel’s test used?
it is used to identify nerve irritation
it can be useful in diagnosis of carpal tunnel syndrome
What are the stages in Tinel’s test?
- tap over the carpal tunnel with your finger
- if the patient develops tingling in the thumb and radial 2 1/2 fingers, this is suggestive of medial nerve compression and irritation
When is Phalen’s test used?
if history or examination findings are suggestive of carpal tunnel syndrome, Phalen’s test further supports the diagnosis
How is Phalen’s test conducted?
- ask the patient to hold their wrist in complete and forced flexion for 60 seconds
- if the patient’s symptoms of carpal tunnel syndrome are reproduced, then the test is positive
(e. g. burning, tingling, numb sensation in the thumb, index, middle and ring fingers)
