OSCE - MSK

Question 1

Examination - General Principles

Answer 1

• Expose & Assess the limb/affected area - ensure you can see the whole area on both sides.
• Compare & Contrast injured anatomy with uninjured equivalent - always test the ‘good’ side first.

Question 2

Examination - Look

Answer 2

• Deformity - may include spinal asymmetry, leg length discrepancy, obvious deformity of bony or joint contours post-trauma could indicate fracture/dislocation.
• Swelling - indicates presence of inflammation caused by trauma/overuse such as bursitis, or arthritis. Swelling that presents immediately indicates bleeding in the area.
• Symmetry - note any differences from ‘the good side’. Any obvious muscle wastage noted is likely to have a neurological origin. Any scars/rashes?
• Pallor - redness may indicate acute inflammation(redness, heat, swelling, pain). Any signs of bruising post-trauma, or pallor/reddening associated with circulatory/sympathetic involvement.
• Wounds - thorough assessment necessary, as could be an indication of an open fracture.

Question 3

Examination - Feel

Answer 3

An explanation for the patient is always necessary:

• Tenderness - indicates inflammation and therefore tissue damage.
• Crepitus - common sign of bone fractures, but also of degenerative conditions such as osteoarthritis. Gain a history!
• Distal Pulse - absence indicates a circulatory disturbance and can be limb-threatening.
• Capillary Refill - over 2 seconds can indicate circulatory disturbance.
• Distal Sensation - abnormal/absent distal sensation indicative of neurological involvement.

Question 4

Examination - Move

Answer 4

An explanation for the patient is always necessary:

• Range of motion &/or ability to mobilise - an indication of a patients willingness to move and any pain experienced.
• Active Movement - ask the patient to move the joint on their own, request that they complete all movements associated with the specific joint(flexion, extension, internal rotation, external rotation, pronation, supination, inversion, eversion, plantar & dorsiflexion, etc). Note the following:
  
  • Range - reduced range could be an indication of pain or structural obstruction. patients with pre-existing injuries may have historical reduced range of movement.
  • Pain - evoked by active movement indicates MSK injury.
  • Power - loss could indicate muscle weakness or neurological involvement.
  • Willingness - is the patient afraid to move the limb? Are they guarding?
• Passive Movement - guide the patient through an appropriate range of movements, ensuring their limb is relaxed and that you control the movement. Assess pain & range, note abnormalities. Passive movements test the inert structures, including:
  
  • joint capsule
  • menisci
  • ligaments
  • fascia
  • bursae
  • nerve root sleeves
• Resisted Movement - resist the patient carrying out an appropriate range of motions. Assess pain & power. Resisted tests may produce several findings, each of which has different implications:
  
  • strong & painless - normal
  • strong & painful - contractile lesion
  • weak & painless - neurological weakness
  • weak & painful - partial rupture/serious pathology such as fracture/tumour
  • painful on repetition - an overuse injury

Question 5

Examination - Further Tests

Answer 5

• BM
• BP