MSK - Clinical assessment

Question 1

GALS Screening Questions for Musculoskeletal History as part of Systematic Enquiry?

Answer 1

> 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?

Question 2

Cardinal presenting complaints in orthopaedics?

Answer 2

> Something FEELS wrong:
- pain, dysaesthesiae, weakness

> Something MOVES wrong:
- stiffness, reduced RoM (eg. locking), limp, instability / collapsing, crepitus

> Something LOOKS wrong
- swelling, deformity, wasting, shortening, discolouration (eg. redness, pallor, bruising), wounds

Question 3

Question to ask in orthopaedics - sleep?

Answer 3

wake at normal time or woken by pain, etc.?

Question 4

Question to ask in orthopaedics - morning?

Answer 4

How are they first thing in morning?

• is pain/ swelling/ stiffness at its worst?
• how long does it take to get going?
• have to do exercises?

Question 5

Question to ask in orthopaedics - dressing?

Answer 5

dressing - socks & shoelaces?

Question 6

Question to ask in orthopaedics - toenails?

Answer 6

cut own toenails?

Question 7

Question to ask in orthopaedics - keeping clean?

Answer 7

Can they get in and out of a bath?

Question 8

Question to ask in orthopaedics - walking?

Answer 8

Walking distance on flat - (“How far can you walk?” “Oh not very far, etc., etc.”):
- (Union St = 1 mile long)

• Stopped by what? (n.b. crushing central chest pain?!)
• Use of walking aids
  stairs (up vs. down), rough ground

Question 9

Question to ask in orthopaedics - driving

Answer 9

Yes or no or used to

Question 10

Question to ask in orthopaedics - shopping?

Answer 10

Does own shopping? (good indicator of prognosis after hip fracture – physically able to get out of house (mobility), mentally able to do shopping, medical co-morbidities not so severe as to keep housebound, and more likely to be living independently and not in an institution

Question 11

Question to ask in orthopaedics - day to day?

Answer 11

work, hobbies – does it stop them doing anything?

Question 12

Red flag is orthopaedics history?

Answer 12

“Red Flags” from the history suggesting serious pathology (infection, tumour, etc.)
> 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 13

Past medical history orthopaedics?

Answer 13

MISTI THREAD
> MI
> Stroke
> Thrombosis (DVT/PE)
> Icterus

> TB
> Hypertension
> Rheumatic fever
> Epilepsy
> Asthma
> Diabetes

Question 14

Allergies in orthopaedics?

Answer 14

Any known allergies: 
> previous penicillin
> Iodine
> general anaesthetic 
> Latex
> elastoplast/ S.A.T

Question 15

Drug history in orthopaedics?

Answer 15

> Current, recent (when started?, when stopped?)

> On any Rx from own doctor?

> Taking any other drugs? (proprietary e.g. Paracetamol, recreational, hard) – Ever been an IV drug user? – n.b. Incidence of high risk cases presenting to Trauma Unit (RIE study) – duty to self and colleagues (nursing & medical)

> Oral contraceptive pill
aspirin / warfarin / clopidogrel (why are they on it? Is it safe to stop?)

> NSAIDs (had them?, did they work?, side effects?)
steroids (life-saving & quality-of-life-saving drugs, but side effects!)

Question 16

THE GALS SCREEN?

Answer 16

(Gait, Arms, Legs, Spine)

a rapid screen for musculoskeletal and neurological deficits, and functional ability

Question 17

REMS (Regional Examination of the Musculoskeletal System)?

Answer 17

Starting with lower limb examination

hips, knees, ankles and feet

Question 18

Principles of a before starting MSK examination?

Answer 18

> Quiet private room, +/- chaperone (low threshold), well-lit, warm

> Space to observe gait, examination couch

> Adequate exposure! + position

> Always compare R & L; examine normal side first

Question 19

Principles of a MSK examination?

Answer 19

> Convention for description of deformity

• “distal part has moved with respect to supposedly stationary proximal part”
• valgus & varus (knee & hip)

> Anatomical position = 0 degrees for all joints
- extended elbow = 0 degrees, not 180 degrees)

> Knee deformities - Genu?

Question 20

Name fingers?

Answer 20

> Thumb
> Index
> Long or middle
> Ring
> Small or little 

Never number!

Question 21

Talking about different aspects of the hand?

Answer 21

> Ulnar border
Radial border
Volar or palmar aspect

Try to refrain from using lateral, medial, posterior or anterior

Question 22

What is important in a local MSK examination?

Answer 22

KISS = Keep it systematic, stupid:
> LOOK
> FEEL
> MOVE 
> (X-RAY)

Question 23

MSK Clinical examinations - Look?

Answer 23

observe, esp. when not formally examining (often more valuable information) n.b. front & back & sides!:

> posture – patient, limb (esp. lower limb when weight-bearing)

> note relevant negatives, and obvious positives e.g. amputation

> gait – limp?

> skin - scars , wounds, sinuses, ulcers

> skin - colour - redness, bruising, pallor, cyanosis, blae, black (gangrene, melanoma), etc.; shiny? hairless? thin/atrophic skin?

> vascular markings (venous varicosities, haemosiderin deposition)?
swelling

> wasting (hip problem, look at gluteal muscles; knee problem, look at thigh; foot or ankle problem, look at calf) – disuse, neurological, cachexia

> deformity -asymmetry?, palpate for normal anatomical landmarks - are they all there and in the right place?

> limb lengths –

> real (ASIS/ greater trochanter/ tibial tuberosity to medial malleolus) – legs in same position

> apparent (midline marker e.g. xiphisternum or umbilicus to medial malleolus)

Question 24

MSK Clinical examinations -Feel?

Answer 24

Systematic anatomical palpation; relationship of bony landmarks & surface anatomy; start away from painful area (examine last):
> skin - temperature, sweating (tactile adherence), capillary filling

> tenderness (localised, diffuse) n.b. pain = symptom, tenderness = sign – not synonymous

> swelling (vide infra)

> deformity - palpate for normal anatomical landmarks - are they all there and in the right place and non-tender?

Question 25

MSK Clinical examinations - Move?

Answer 25

active (lag?) - “Would you > bend your left elbow, please, Mr Smith?”

> passive- “Would you relax and let me bend your left elbow, please, Mr Smith?”

> special tests abnormal movement, joint laxity, tests, etc., e.g. on stressing joint/ limb

> range, rate, rhythm

> RoM’s - degrees, or % vs. normal side, comparisons (heel-to-buttock distance, fingertip to palm, etc.)

> accompanied by pain, crepitus, stiffness?

> rhythm/ smoothness, laxity/hypermobility, tenodesis

> muscle tone

> power/ strength

> joint laxity/ hypermobility

Question 26

MSK Clinical examinations - general priniciples?

Answer 26

(1) in any joint examination, must examine joints above and below (e.g. examine hips if c/o knee pain); and examine spine for any limb symptoms
(2) + neurovascular examination of whole limb
(3) consider other relevant systematic examination – chest, abdomen, neurological

Record findings

Re-examine & compare
(X-RAY)

Question 27

Orthopaedic examination overview?

Answer 27

> General examination first – sick or well? distress? well nourished/hydrated? behaviour? Face, neck, hands!

> LOOK – skin scars/wounds/sinuses, colour, swelling, wasting, deformity

> FEEL – temperature, tenderness, swelling, deformity, sensation

> MOVE – active (range, power), passive, special tests (stability)