Clinical examination in musculoskeletal disorders

Clinical examination in musculoskeletal disorders

what are the aims it is very important to know how you can examine the musculoskeletal system which include the whole bone joint skin soft tissue nerve and the tests done for it which will be discuss here also
To understand the three major types of history, their functions and the different ways in which they are obtained as 

• To understand the three zones of abnormality that a history should address

• To know a simple system for examining the musculoskeletal system

• To learn the specific features to be sought in each area of the body

HISTORY Orthopaedic history

The history in trauma and orthopaedics is different from the rest of surgery in that there are some specific areas which need to be covered. The three main areas are Pain, Dys­function and Deformity ,

Pain

Patients should be asked to define in what way the pain troubles them. Their answer may give the clue as to how the pain can best be managed if it cannot be alleviated. For example, if it is pain at night that is preventing sleep, then a combination of pain-killers and sleeping tablets might offer the best option if no other option is available. If,however,the pain occurs in a joint on weight-bearing a splint might stabilize the joint and make the pain manageable also Ask about onset- speed and cause of
Ask about consequences - duration,radiation, type,constancy Things that make it better or worse

Disability

Loss of function may be a result of pain stiffness,weakness,instability or even locking. In the first instance, the patient should be ­. allowed to describe in his or her own words what the problem is, for example the inability to reach up to hang clothes on the washing line. This problem will later be translated into a clinical diagnosis, but at this stage it should be reported in the patient's own words also ask for what are the effects on activities of daily work and recreation

Deformity

What is the cosmetic problem? When is it important? Most patients want to look normal. Patients may want bunions corrected because they are unsightly not because they are painful although they may initially claim this. It is important to be clear about patients' real reasons for seeking treatment, and what it is
they hope you will be able to do about it

MUSCULOSKELETAL EXAMINATION

System of musculoskeletal examination

Musculoskeletal examination works on a simple system designed by Apley it consists of four letter words divided into three sets of three. to perform orthopaedic examination must assessed the following points

The main structure is look or inspected, feel or palpated and move. Each of these is divided into three as well
Look and feel each separate into skin, soft tissue and bone.
Move is divided into active, passive and resisted movement.

Look or Inspection

Make sure that you can see enough of the patient's body. This means exposing at least one joint above and one below the area in question. It also means exposing the opposite side. It is said by some that the human body was made bilaterally symmetrical to help orthopaedic surgeons distinguish abnormal from normal. Do not spurn such ready-made help

It is not always necessary to lay the patient down in order to perform an orthopaedic examination. It may he easier if the patient remains standing, provided this is comfortable. In this position it is easier to look at the patient's back as well as his or her front. It is important to inspect all sides of the patient to make sure that no lesion is missed

Skin

Look for:

bruising and wounds - evidence of recent injury

redness - signs of inflammation

scars - the archaeology of superficial injury

sweating -loss of sweating may indicate nerve damage.

Soft tissues

Look now at the soft tissues. You are looking for:

swelling - a cardinal sign of injury and inflammation

wasting - signs of disuse and nerve damage, the archaeology of deep injury

Bones

Finally look at the bones (shape of the skeleton). Look for:

deformity - unusual angles or joints held in unusual positions. You have now looked at skin, soft tissue and bone. Summarize these in your mind and make a record of what you have found.

Feel or Palpation

Skin

Temperature Stroke the patient's limbs with the back of your hand; it is more sensitive than the front. Use the patient's other side for comparison. Warmth may indicate inflammation. A cold limb may indicate nerve or vascular damage.

Sensation Stroke first the normal limb then the other limb lightly. Ask if the touch on the two limbs feels the same. By comparing the two sides the patient should be able to detect any change in sensation, however slight.

Soft tissue
 
When you feel the soft tissues, you must be very careful to avoid hurting the patient. The best way to do this is to place your hands on the area under examination, then look up and watch the patient's face as you palpate.

Feel for:

Tenderness. As you press with your fingers try to describe to yourself the actual anatomical structure that you are palpat­ing: subcutaneous fat, bursae, muscle bodies, tendons, nerves, arteries and ligaments.

Lumps and effusions. Each time you feel an abnormality under the skin you should be able to run through a check­ list of features of a lump

Distal circulation. Feel for peripheral pulses and check capil­lary filling. When checking pulses, take the patient's pulse elsewhere at the same time this should ensure that it is the patient,s pulse you are feeling not your own pulse

 bone outlines and joint margins

Feel the bone and joint margins gently for areas of tenderness, steps and lumps. Again, try to work out what anatomical struc­ture your fingers arc touching as you palpate.

Review your findings. Try to decide what structures are tender, what structures are swollen, wasted or displaced, and whether the circulation and sensation to the distal limb is normal. If not, where is the likely damage

Move

Once again there are three phases of the examination, but this time they are active, passive and stability

Active movement The patient should move his or her own joints within the limits of pain. Use simple language to explain what you want the patient to do, and if necessary demonstrate the movement

passive movement

Do not take the range of movement beyond the active range without watching the patient's face

Stability

There are two types of stability: dynamic and static. Dynamic sta­bility is provided by muscle power; static stability by ligaments and int;y:t joint surfaces

Dynamic stability Measure the force that the patient can develop by showing the movement and then asking the patient to repeat it while you try to stop It. For each movement, try to work out which muscles are the drivers of that movement, which nerves supply them and the nerve root values

Static stability Static stability tests the integrity of the ligaments and the joint surface. The joint should be gently stressed in each direction controlled by a ligament, while watching the patient's face to make sure that he or she is not in pain. You do not need to use any force. Indeed, the tests will not work if you do, as the patient

History and Examination of a lump

Start Did it appear after trauma or just gradually on its own

Where? Anatomical site. Does it lie in skin fat or muscle? Will it move in relation to these

External features Size, surface and definition of margins

Lymph nodes are the local ones enlarged

Liquid is it fluctuant ?can it be transilluminated

Internal features is it hard ? is it tender

Noise is there a thrill'? is there a bruit

General Examination of the whole patient for other lumps and general health

EXAMINATION GENERAL PRINCIPLES OF LOWER LIMB EXAMINATION
Ask the patient to walk up and down before getting on the exam­ination couch. Observe the patient's gait, note particularly any limp.

Types of limp

The limp caused by any specific diagnosis is usually a complex mixture of several pathological processes, which can be divided simply into the following groups to produce an easily remembered if miss-spelled
mnemonic, LIMPS

Common causes of a limps and their features are

Long limp characterized by The gait is even in cadence but when looked at from in front the patient bobs upwards on stepping off the shorter onto the longer leg

Incoordinated limp characterized by There is no regularity. Arms and legs may fly in all directions as the patient struggles to maintain balance

Muscle weakness limp characterized by1- Hip The body sways over sideways as the patient steps on the weak hip 2-Knee. The patient locks the knee with a hand on the thigh as the heel strikes 3-Ankle. Hip·stepping gait to bring the floppy foot through

Pain limp characterized by The gait is uneven in cadence. The patient spends a short time on the painful limb and the centre of gravity also falls as the patient takes weight on it

Stiffness limp characterized by A stiff hip may make the patient stoop if it is flexed

A flexed knee has to be swung out sideways in the swing phase

Long

If one limb is short then the other is long in relation to it. The patient bobs up and down when walking, when looked at from the front. However, the cadence (rhythm) of the gait is normal. Equal time is spent on each limb.

Incoordinated

Walking has been described as controlled falling (AlexanderMcNeil). In patients with neuromuscular disorders, the falling is less controlled and so the patient's limp is similar to the normal person who has tripped or who is drunk. The arms are swung around to act as counterbalances. The legs frequently scissor across each other and the gait has no rhythm to it

Muscle weakness

Hip Trendelenburg gait

The patient's body sways sideways to and fro when looked at from the front. The patient uses the trunk muscles to lift the pelvis enough to swing the leg through, as it is not possible to pelvis any other way.

Knee

Patients with weak quadriceps (often seen after polio) use a trick manoeuvre to lock the knee. As they swing the leg forward flick the lower leg forward so that the knee extends fully well locked straight by keeping their hand in their pocket and pushing back on the front of the thigh as the foot comes down ( strike. If they do not do this then the knee will buckle into flexion as they start to take weight on the leg

Ankle

With weak ankle dorsiflexors the patient lifts the foot very high in order to ­ swing the leg through without catching the toe

The painful limp antalgic gait

The patient spends less time on the painful limb than the painless one. When looked at from the front, the patient appears to bob up ­and down, dropping down when taking the weight on the limb, and rising back up again on transferring the weight the good limb. This gait can be confused with the 'long' leg gait but' there is a major difference. The cadence is abnormal. The gait is dot-dash-dot-dash because so much less time is spent on the painful limb than on the painless one

The stiff limp

Hip

The patient tends to sway forwards and backwards when looked at from the side. There is also a tendency to hoist the pelvis up as the hip is brought through to stop it dragging on the ground.

Knee

Patients with a stiff knee often swing the leg out to the side as they walk.This is because you need to be able to lift the knee to avoid catching your toe on the ground as you bring the leg forward for the next stride.

Ankle

Patients with a stiff ankle walk with a foot that rocks forward from heel to toe in a very pronounced way

THE FOOT AND ANKLE

Look

Watch the patient walking.Look at the shoes for signs of abnormal wear.Wear on the shoe is an indicator of rubbing. not pressure. In the normal wear pattern a comer is worn off the posterolateral side of the heel (the normal point for heel strike). There may then be a circular wear pattern under the ball of the big toe (where toe-off occurs as the foot provides its final drive and then lifts oft).

Skin

Look for calluses. corns. bunions and scars. A bunion is a red swelling on the medial side of the metatarsophalangeal joint con­sisting of inflamed skin. a subcutaneous bursa and an osteophyte on the joint margin of the medial side of the metatarsal head . In patients with gout. the whole metatarsophalangeal joint will be red and swollen.

In patients with rheumatoid arthritis, the fat pad under the metatarsal heads becomes thin. and the heads become prominent and tender immediately beneath the skin of the sole of the foot. The patient complains of pain in the sole of the foot when walk­ing. as If walking barefoot on pebbles. Areas of thickened callous skin form over the metatarsal heads.

Feet do not fit easily into most shoes, even when they are nor­mal. If the toes have started to claw then the pulp of the toe will be driven into the floor of the shoe. while the dorsum of the inter­phalangeal joints will be driven into the top of the shoe (a sort of contrecoup injury) .The counter of shoes (the part that wraps around the heel) can rub on the calcaneum. producing a bunion on the Insertion of the Achilles tendon into the bone.

Soft tissues swelling and wasting

Swelling Swelling in the foot is commonly seen on the dorsum only. In the ankle joint it is commonly seen at the front of the ankle.

Wasting This is seen in neurological conditions. and there may be wasting in the clefts between the metatarsals. Wasting may be associated with clawing of the toes

Bone

Check for clawing and hammering of the toes, and for a foot which cannot rest that on the ground

Feel

Skin

Inflammation This may be indicated by heat in the skin.

Sensation Feeling may be lost distally in neuropathies. such as that caused by diabetes. and the toes may be numb. In nerve compression there may be numbness over a dermatome

Soft tissue

Pulses The easiest foot pulses to feel are the posterior tibial artery behind the medial malleolus and the dorsal pedis artery between the proximal end.of the first and second metatarsals The toes should also be tested for capillary fillings.

Tenderness If the extensor tendons of the toes in the dorsum of the foot and up the from of the tibia are tender ask the patient to move his or her toes and you may feel crepitus under your fingers a characteristic of tenosynovitis

Bone

tenderness palpate for tenderness down the length of the fibula to its tip (the lateral malleolus) and then

over the ligament as it passes from there to the calcaneum the palpate down the medial side of the leg, down the tibia to the tip of medial malleolus and on til the medial deltoid ligament feel the talus and navicular, on the dorsomedial side of the forefoot feel the fifth metatarsal head on the lateral side of midfoot (a common site for a fracture after an inversion injury) After a fall from a height. check for tenderness in the calcaneum as this may be fractured . If the forefoot has been crushed then check for tenderness in the bones of the forefoot which may be both fractured and dislocated

Move

Active

The Windlass test

Make the patient stand on his or her toes while, front and from behind. Some patients' feet look very flat when at rest. This can simply be a physiological flat foot. As soon as these patients stand on their toes. the arch forms In patho­logical flat foot the arch does not form

::other movements

you should also ask the patient to move the toes. and move the ankle through a full range of movement (flexion. extension.-inversion and eversion

Passive

The Apley test

if you hold the heel in one hand and the forefoot in the other.ankle subtalar and metatarsal mobility can be tested one after the other without moving your hands

Rocking the ankle by moving your hands in opposite directions. like a see-saw. tests ankle mobility.Tilting the foot outwards and inwards using both hands together tests subtalar movement. Twisting the forefoot while holding the hindfoot still tests midtarsal mobility

The metatarsophalangeal joint of the big toe is stiff in hallux rigidus. In claw toes the metatarsophalangeal joint is commonly dislocated. with the phalanx riding dorsally over the metatarsal head 

Stability

Stability of the ankle and foot joints is not easy to test. especially after acute trauma.

Resisted

Test for power of extensor hallucis longus . Remember that this muscle is specifically served only by the L5 nerve root and is a key test for damage to this nerve in a prolapsed intervertebral disc
In patients with polio and other neurological disorders, each mus­cle will need to be tested in turn. One way to do this is to put the tips of your fingers over the muscle body, or its tendon, while holding the limb still with the other hand. The patient is asked to try to move the limb against the resistance that you have created. Your fingertips will detect whether there is any activity in the muscle, as the movement itself might be produced by alternative muscles, the so-called 'trick manoeuvres'. The power of each muscle can be graded using the Medical Research Council (MRC) power scale .

MRC muscle power scale can be divided into five grades

Grade 1 Description flicker of movement

Grade 2 Description moves but not against gravity

Grade 3 Description moves just against gravity

Grade 4 Description not quite full power

Grades 5 Description full power

Simmonds test

The patient lies face down, feet over the end of the bed. Squeeze the calf and the foot should passively dorsiflex .If does not, the tendoachilles is likely to be ruptured

THE KNEE

Look from in front or behind to see whether the knees are alignec in the sagittal plane. In patients with varus knees (or bow legs) clear space is visible between the knees when the ankles are together

Valgus knees tend to brush together as the patient walks even though the ankles may be wide apart

Look

Skin

check for redness scars and lacerations

Soft tissue

Look for an effusion in the knee. The dimple on the medial side of the knee will be lost compared with the other side if there is an effusion

Vastus medialis wastes within days of a knee injury and will fail to bulge when contracted compared with the other side

Bone

Check for knock-knee. bow legs and fixed flexion. and for the position of the patella Fixed flexion is the position of comfort in the knee and tends to develop secondary to any acute infection or inflammation

The patella almost always dislocates laterally . If not reduced. it may remain jammed outside the lateral femoral condyle

Feel

Skin

Temperature inflammation of the knee will produce a knee hot to the touch compared with the other side
Sensation Damage to nerves at or around the knee will produce disturbance of sensation mainly in the foot.

Soft tissue

Check for a knee effusion.

Stroke test

With the patient lying supine, empty the medial side of the knee joint by stroking any fluid up into the suprapatellar pouch. Then, watching the medial side of the knee carefully,stroke down the front of the thigh, squeezing any fluid lying in the suprapatellar pouch back into the medial side of the knee. As the fluid returns the dimple on the medial side of the knee pops out 

Boker's cyst

This is an outpouching of the synovium through a defect in the capsule posteriorly. It can be difficult to feel. As soon as the knee is flexed the cyst disappears, but it reappears in full exten­sion. It is associated with osteoarthritis of the knee. The patient will guide your fingers to the lump if you are having difficulty finding it.

Circulation

The distal pulses and capillary filling should be checked in the same way as during examination of the foot

Bone

The margins of the patella, the femoral condyles and the margins of the tibial plateau are all easy to feel as they are sub­cutaneous

Move

Active

Flexion

The knee should be able to flex until the heel touches the buttock. Loss of flexion can be measured by the number of centimetres that the heel stops short of the buttock, rather than by actually measuring the angle of the knee. Comparison with the other side gives a sensitive guide to loss of range of movement

Extension

The patient should be asked to force the knee into the bed. Most knees hyperextend at least by a few degrees

Passive

Flexion

The knee can be bent up passively, but be sure to watch the patient's face, especially if you push the knee beyond the active range of flexion. It may be limited because of pain

Extension

With the patient lying supine and relaxed, the feet can be raised off the bed by lifting under the heels. Any loss of extension will be visible because one knee will remain higher (in fixed flexion) than the other

Log test

A subtle test for quadriceps weakness is to ask the patient to lift the leg straight off the bed. Most patients can do this and, indeed, even if the quadriceps mechanism is completely rup­tured this manoeuvre is still possible because the patient uses the lateral retinaculum to lock the knee in extension. The patient is then asked to bend the knee 20 degree and straighten it a patient who has a quadriceps lag will not able to return the knee to its original extension , this loss of flexion is not a fixed flexion deformity as the extension if the knee has already been demonstrated it is caused by weakness in the quadriceps

Stability

Collateral ligaments

The integrity of the collateral ligaments can be tested only when the knee is slightly flexed. In full extension the stability of the posterior capsule masks any collateral ligament instability. However, if the knee is flexed more than a few degrees, the knee rotates when stress is put on the knee to test medial and lateral stability,and it is not possible to check integrity of the ligaments. The leg should be rested on the bed with the patient supine. One of your hands should be put behind the knee to lift it slightly into flexion, hold it stable and feel with thumb and fingers over the joint line. Your other hand should grasp the patient's ankle, and gently stress the lower leg into varus (putting load on the lateral collateral ligament) then into valgus (stressing the medial collateral ligament) . Knee ligaments vary in their laxity between patients, and it is a difference between the two legs which once again gives a clue to instability

Cruciate ligaments

There are several tests for cruciate disruption, but one simple method is as follows.The patient lies supine with both knees bent up to a right angle and the feet resting on the bed. The examiner looks from the side to see whether one tibial tubercle is lying further back than the other. If the tubercle on the injured side is lying further back, then the knee has a posterior sag suggestive of a posterior cruciate ligament injury

The examiner then grasps the uninjured knee with fingers meeting in the popliteal fossa and thumbs side by side over the tibial tubercle. Sit on the patient's foot to keep it still and then rock the upper tibia gently backwards and forwards against the femur, feeling for the amount of laxity in the joint. Now repeat the manoeuvre with the injured limb, comparing the amount of 'play' in the injured knee with that in the normal one. If there is more play and the injured knee had a posterior sag then the posterior cruciate is ruptured. If there is laxity but no sag then the problem is rupture of the anterior eructate .

The pivot shift test

This test relies on the fact that an anterior cruciate-deficient knee frequently has some rotatory instability in extension. In this position the femoral condyles rolling on the tibia do not control rotation well. With the patient lying supine and the examiner sit­ting at the patient's foot facing up the bed, one hand is used to lift the leg off the bed by the ankle and to rotate the tibia inwards on the femur. The examiner's other hand presses against the lateral side of the knee, pushing it into valgus,so that the lateral femoral condyle is engaged firmly with the tibial plateau. This hand now gently pushes the knee into flexion If there is anterior cruciate instability the knee starts to bend under the guidance of the examiner's hand, but then jams at about l0 degree of flexion. The tibia has rotated so much on the femur (because of the absent anterior cruciate ligament) that the knee will no longer work as a hinge, and jams as soon as it tries to do so. As the examiner's hand pushes the knee on into flexion,the tibia has to come out of inter­nal rotation so that the jammed joint can continue to flex. The jolt as the tibia derotates under the examiner's hand is clearly pal­pable to the examiner and to the patient. It is even easier to feel if the examiner's thumb lies tucked behind the fibula head. It is then forced smartly back when the de-rotation occurs. This test should be done very gently.If it is not the patient will be hurt and the test will be inconclusive because muscle spasm will mask the pivot shift.

The patella apprehension test

If patients have ever dislocated their patella they will be anxious about dislocating it again. If the knee is placed in extension and the patella pushed laterally, flexing the knee will encourage the patella to dislocate over the lateral femoral condyle . As soon as this starts to happen the patient will become very apprehensive. Do not continue - just note the apprehension; you do not want actually to dislocate the patella.

THE HIP

The hip is rarely involved in extrinsic trauma but is commonly affected by intrinsic trauma (fractured neck of femur) and by chronic conditions [osteoarthritis}. The examination of the joint is made more difficult by the fact that it is covered by muscles. It is also likely to present With pain referred to the knee, and can be the site of pain referred from the spine

look

Limp

Watch the patient walk and look for a limp. The limp of a stiff hip is difficult to spot as the patient rocks the pelvis with the femur on the affected side, but fixed flexion deformity is common and lead) to the patient walking with a characteristic stooped gait

Skin

The scars from surgery on the hip are usually on the lateral side of the hip

Soft tissue

Gluteal wasting can occur if the superior gluteal nerve was dam­aged after hip surgery, but beware of confusing gluteal wasting with loss of lumbar lordosis caused by back problems. The tile of the pelvis may make It look as if there is bilateral gluteal wasting,if there is a leg length discrepancy, the pelvis will be tilted and the spine curved when the patient stands. The spinal curvature then disappears as soon as he or she sits on the side of the couch

Bone

There is little to see because the hip is so deeply buned, but a limp may give a clue to underlying bony deformity. If there is a leg length discrepancy, the pelvis will be tilted and the spine curved when the patient stands. The spinal curvature then disappears as soon as he or she sits on the side of the couch

Feel

Skin

As the joint is so deeply buried the only item that needs to be checked is distal sensation. Damage to the femoral nerve pro­duces numbness over the front of the thigh. Damage to the sciatic nerve will produce numbness in the lower leg

Soft tissue

Peripheral pulses should be tested in the foot

Bone

The hip can be palpated anteriorly in the groin beneath the femoral pulse, but it is deep and difficult to feel. Tenderness on the lateral side of the hip arises from the greater trochanter or is referred from the spine. Pain posteriorly usually arises from the sciatic nerve or, once again, has been referred from the spine

Leg length discrepancy

Leg length discrepancy can be caused by bones in the two Limbs being of unequal length, such as might occur after a malunited fracture. It can also be caused by deformity such as a fixed flexion deformity of the hip. Leg length discrepancy caused solely by short bones is known by convention as 'true' leg length discrepancy That caused by joint deformity is known as 'apparent' shortening. Most leg length discrepancy is caused by a mixture of the two

True leg length discrepancy

It is usual to measure the 'true' leg length discrepancy first by purring both legs as straight as possible, and then measuring the leg which can­ not be put straight. The other leg is then put into an identical posit­ion, so that the deformity has no effect on leg length discrepancy. If the end of the tape measure is held firmly between the pulp of the thumb and the side of the index finger, the tip of the thumb can be wed to trace the inguinal ligament upwards until it catches in the notch immediately below the anterior superior iliac crest. A similar manoeuvre can be used at the lower end of the leg. The tip of the examiner's other thumb is traced up the calcaneus, until it Jams in the notch immediately below the medial malleolus. The measure is repealed on the other limb, which is first put in the identical position. In order to decide which bone(s) are responsible for the short­ening, the patient should Lie supine and the Knees should be bent up to a right angle. The examiner can then look at the knees from the side. If the femur on the short side lies lower then the shortening below the knee. If the tibia lies further back then the shortening tlit's above the knee. If the shortening is above the knee then palpation of the greater trochanters will reveal whether the shortening is in the femoral neck or in the femoral shaft. If the shortening is below the knee then palpation of the medial and lateral malleollus will reveal whether the shortening is above or below the ankle

Apparent leg length discrepancy

Apparent leg discrepancy is that caused by joint deformity and is best calculated from the difference in true leg length, as measured above, and the difference in leg length when both legs are put as straight as possible

Measurement and correction or leg length discrepancy

Leg length discrepancy is very difficult to measure accurately using clinical methods but can be measured very precisely, when necessary from radiographs with grids superimposed. An alterna­tive method clinically is to ask the patient to walk over raised blocks, The blocks are raised under the sole of the shorter leg until the patient feels that the short leg is now too long. Reduction (If the height by 5 mm usually produces a measure that can be used as a shoe lift to correct leg length Inequality. Discrepancies (If 1 cm or less can usually be accommodated by lifts hidden inside the shoe. Lifts of up to 2 -3 cm can be put on the heel only, so keeping the shoe light. If the discrepancy is more than this, the sole and the heel will usually need to be raised

Move

Active and passive

Active and passive movements are measured together in the modified Thomas's test, which is described below

Modified Thomas's test

The patient actively pulls up both the knees and hips, into a ball. The examiner can then carefully (watching the patient face) push the hips Into further flexion (passive flexion'. the flexion of the two hips can now be checked and compared patient is now asked to keep the normal hip 'flexed by holding the shin. This fixes the pelvis in full flexion. The other leg is now carefully extended as far as is comfortable and a note made of the angle that the femur makes to the couch in full extension. The affected leg is now flexed back up again as far as possible, and held there by the patient. The abnormal hip is now allowed to extend( carefully watching the patient's face) until it too will extend no further .Again, the angle that the femur makes with the couch is noted and compared with the recording made on the other side

Abduction

lays your forearm across the patient's pelvis with the tips of your fingers resting on one anterior superior iliac spine and your fore­arm resting on the other one nearer to you. Abduct first one hip and note the angle when you feel the pelvis starting to move under your hands. Return that leg to its original position and repeat the

manoeuvre with the other leg

Adduction

still leaving one hip abducted, adduct the other hip across until pelvis starts to move. Put that hip back in
abduction and adduct the other hip, noting the range of movement of abduction and adduction on both side

Rotation

Rotation of the hip will always be limited in extremes of extension and flexion, as the capsule of the hip is already tight. It is therefore important to test the range of movement of the hip in the mid range­ with the thigh flexed at '45 degree. If the knee is flexed to 90 degree the tibia can be used as a lever and a protractor. Watch the patient's face, and test internal and external rotation, comparing the two sides Note that when the foot comes across the body you are testing­ external rotation , and when the foot comes out to. the side you are testing internal rotation

Stability

The Trendelenburg test

This is a test of stability of the hip joint or of weakness of the gluteal muscles, such that the patient has difficulty taking all of their. weight on t.he affected leg. The most sensitive way of per­forming this test is to ask the patient to stand on both legs facing you, and to place the patient's hands palm downwards on your hands held palm upwards. First ask the patient to stand on the healthy leg, then repeat the manoeuvre on the affected leg. 1f the test is positive the examiner will feel a firm push downwards from the patient's hand on the affected side as the patient tries to trans­fer his or her weight on to the affected limb

Tests for referred pain

Pain in the hip can be referred down from the spine, while pathology in the hip can produce pain in the knee. A simple test that can help distinguish pathology in the hip from pathology elsewhere is the 'pastry rolling test'. With the patient lying supine on the couch start with the unaffected side. Place the palm of one of your hands the patient's shin and the other on the thigh. Keep your hands flat with the fingers straight, and roll the leg as one to and fro under your hands as if you were rolling pastry. If there is no problem in the hip, the patient will relax completely after a couple of roils, and the foot will flop to and fro at the end of the leg . . Repeat the test on the affected. side. If there is pain and/or stiffness in the hip joint the patient will not relax, the foot will not flop to and fro. and there will be a distinct resistance to movement at the end of internal and
external rotation. Pathology causing pain in the knee joint does not produce resistance because the knee joint is being rolled as one. Similarly, the sciatic nerve is not irritated by internal and external rotation of the hip so pathology in the spine has no effect on this test

LUMBAR SPINE

The lumbar spine is another part of the anatomy which can be best examined. initially with the patient standing up. Exposure is important and the back must be visible as far down as the natal cleft. The key to the examination of the lumbar spine is a full examination of the lower limbs. Irritation of nerves in the spine can mimic problems in the lower limb. Whenever you see a patient with problems in the lower limb, keep in the back of your mind that this problem could be referred from the spine

Look

Skin

Look for hairy tufts and dimples at the base of the spine which may indicate an underlying spina bifida.
Soft tissue
look at the muscles on each side of the spine if they are very prominent hey may be in spasm
Bone
the lumbar spine should have a smooth concavity (lumbarordosis). Loss of lordosis and flattening of the buttocks go wit muscle spasm

If the spine is curved laterally (scoliosis) then there are three common causes. The legs may be unequal in length (postural scoliosis). this scoliosis will disappear when the patient sits down. Second, there may be a fixed scoliosis in the thoracic spine, with a compensatory scoliosis in the lumbar region below It. This produces a rib hump as the patient tries to touch his or her toes.Third, there may be spasm in the muscles around the lumbar spine caused by pain

Feel

Skin Sensation Test sensation in both legs. Sensory loss is most likely to be detectable distally, so Simply compare touch on the lateral and medial side of both feet if this is abnormal then continue to a full
neurological examination. Test for any loss of sensation in the perineal area if the patient complains of sudden onset of pain and numbness in both legs cauda equina syndrome.

Soft tissue

Feel the muscles on each side of the spine for spasm

Bone

Trace the line of the spine with your fingers,checking for scoliosis

Feel the spine of the L5 and the S1 vertebrae. A step between

the two may indicate a spondylolisthesis (a slip forward of one vertebra on the one below, caused by a fracture through the pedicles

Move

Active

Flexion/extension Place the tip of your thumb over the T12-Ll junction, and the tip of your index finger of the same hand over the lumbosacral junction. Ask the patient to reach forward to try to touch the toes. Note the distance that your thumb and tip of finger separate as the patient bends forward This distance is a measure of lumbar flexibility. Lateral deviation Ask the patient to slide first one hand and then the other down the side of the thigh, bending laterally.The spine should bend smoothly from top to bottom. Total mobility can be recorded by noting the distance that each hand can move down the side of that thigh

Rotation Stand behind the patient and hold their pelvis still with both hands. Ask the patient to twist round and look over his or her shoulder, first in one direction and then the other, Note the angle that the shoulder girdle can form with the pelvis For these last three tests record whether any of the manoeu­vres is limited by pain, and if so where

Passive

The Lasegue or straight-leg raise test

This test can be painful and so should only be performed slowly while watching the patient's face at all times. It is a test of sciatic nerve irritability and relies on the fact that when the straight leg is flexed fully at the hip the roots of the sciatic nerve move as much as 2 cm through the vertebral foraminae. If the nerve is compressed and/or inflamed this movement will cause pain

Pick up the leg least affected by the pain and gently bend the hip and the knee until both joints are fully flexed.Note the range of movement of the hip.gradually straighten the knee, while allowing the hip to
extend only as much as the patient feels is necessary for com­fort. All patients will experience some discomfort in the back of the thigh during this manoeuvre as the hamstring muscles are put on full stretch. While keeping the knee straight, let the hip drop 10 degree into extension so that any pain from tight hamstrings is relieved. Then take the foot and dorsiflex the ankle fully. This stretches the sciatic nerve. Pain in the back radiating down the full length of the affected leg indicates sciatic nerve irritation. This is called the cross-over test and is highly suggestive of nerve root compression. The test is then repeated with the leg affected by the pain. If the test is positive this too is suggestive of nerve root irritation, but it is not as specific as the 'cross-over test'. If the test is positive on either side you should record the angle of the hip at which the test was found to be positive

Resisted

Extensor hallucis longus is served purely by lumbar nerve root 5 (L5). It can be tested by comparing resisted extension of the hip of the big toenails Stand at the feet of the patient and press down on the big toenails of each foot while asking the patient to resist this pressure. If one distal phalanx drops into flexion easily compared with the other toe despite the best efforts of the patient, there is likely to be an L5 lesion

Testing for motor weakness

The simplest test for compromise of L4 motor function is loss - the knee reflex and weakness in the quadriceps (demonstrated by quads lag' in the section 'The knee'). The ankle reflex is lost in S1 damage, but beware; it is commonly missing in elderly patients even without nerve root damage but beware it is commonly missing in elderly patients even without nerve root damage


THORACIC SPINE look
Skin and soft tissues

There are no common lesions in the thoracic spine which can be seen in the skin or soft tissues.

Bone

The thoracic spine is normally convex, and straight in the sagittal plane.If it is very convex and painful the patient may have Scheuer­mann's disease, a condition of unequal growth of the front and back of the spine that presents in adolescence.Lateral curvature of the thoracic spine accompanied by rota­tion is called scoliosis. As the patient bends forward to touch the toes, the associated rib hump increases in size. This is diagnostic of idiopathic thoracic scoliosis, a buckling rotatory deformity of the spine apparently caused by faster growth of the anterior spinal elements compared with the posterior during adolescence

Feel

Skin, soft tissues and bone

In cases of possible trauma to the thoracic, spine. the patient should be immobilized on a spine board. A full check of distal neurology should be performed if the patient is alert enough to cooperate. When the time comes to examine the thoracic spine, the patient should be log-rolled using at least three trained staff working as a team. The whole length of the spine should be pal­pated for tenderness and steps. If any are found the patient should be kept on a spine board until all the necessary investigations have been performed. The spinal cord lies in the thoracic spine so neurological damage may appear as an upper motor neuron lesion in the lower limbs and/or a lower motor neurone lesion in the nerve roots originating from the thoracic spine. Any sensory loss may spread progressively (the apparent level of the lesion rise) in the hours after the injury, A very careful examination of perineal sen­sation should be performed. Preservation of function in these sacral roots (central sparing) is a good prognostic sign that some recovery may occur over the next months

Move

Active, passive and stability

There are no simple tests for mobility or stability of the thoracic spine and. indeed, if stability is in doubt the thoracic spine should not be moved. It should be immobilized while investigations are performed to avoid the risk of causing further neurological damage

CERVICAL SPINE

The cervical spine can be difficult to see, particularly in women. It is important to get the hair up out of the way, but patients should not use their own arms to do this. a theatre nurse's cap may be helpful. Just as the key to examination of the lumbar spine is a neurological examination of the lower limbs, the key to the examination of the cervical spine is a neurological examination of the upper limbs

Look

Skin

Look for scars and sinuses, particularly around the cervical lymph node area. Surgical approach to the neck can be made from the front. the side or the back

Soft tissue

Look for spasm of the trapezius muscles and the sternomastoid muscles. Look also for wasting in the hands.

Bone

The cervical spine normally has a lordosis like the lumbar spine. If this is lost there is probably muscle spasm caused by pain.

Feel

Skin

Test for sensory loss in hands and feet.

Soft tissue

Feel for spasm in the trapezius muscles.

Bone

Palpate down the contour of the cervical spine feeling for gaps(caused by ligament damage) or for tender areas

Move

Active

Flexion/extension The patient should be asked to bend the neck forward and put the chin on the chest. He or she should then extend the neck by looking up at the ceiling. Note the angle that the face makes with the ceiling as a measure of extension
Lateral rotation Ask the patient to look over each shoulder, keeping the thorax still. Note the angle that the chin makes with the shoulders on each side

Lateral deviation Ask the patient to lay one ear on the shoulder, then the other ear on the other shoulder. Note how closely they can bring each ear to its shoulder Without shrugging the shoulder upwards. Note whether any of these manoeuvres is painful. Comparing sides is much more useful than any attempt at measuring actual degrees

Neurological testing

The neurology of both upper and lower limbs should be tested. For testing motor power in the upper limb it is probably only ne­cessary to test grip and the power to spread the fingers apart. Grip serves to test power of the finger flexors as well as the wrist exten­sors. so the one test covers most of the middle cervical nerve roots. Abduction of the fingers is supplied by the lower cervical roots including Tl By testing grip and finger spreading, most of the motor roots from the cervical spine have been tested apart from the uppermost ones

Passive and stability
These do not contribute much to diagnosis of problems in the cer­vical spine

THE SHOULDER

The examination of the shoulder is most easily performed if the patient is standing with shirt and vest removed

look

Skin

Look for scars. Check in the axilla for sinuses.

Soft tissue

Check for wasting of the deltoid (increased angularity of the shoulder) . This is commonly caused by damage to the axillary nerve during an anterior dislocation of the shoulder Wasting of the supraspinatus and infraspinatus (hollows above and below the spine of the scapular) occurs with a tear of the rota­tor cuff muscules

Bone

The commonest deformity is a subluxed acromioclavicular joint, which appears as a prominent lump on the distal end of the clavicle An anterior dislocation of the shoulder itself is first noticeable because of the loss of the rounded contour of the shoulder. The bulge in front of the shoulder (the humeral head lying anteriorly) can be masked by the swelling of the acute injury

Feel

Problems in the shoulder can be referred from the neck or arise from the shoulder complex itself

The epaulette sign

Before starting the examination, ask the patient to show you where the pain is. If the patient can localize the pain with the tip of one finger then the pathology is probably in the shoulder. If, however, the patient rubs the whole hand over the top of the shoulder then this indicates that the pain is likely to be referred from a lesion in the neck. In the case of pain referred from the neck, the patient rubs the hand over the position an epaulette on a soldier's uniform, hence the name of the test

Localization in the shoulder

Within the shoulder complex, problems commonly arise from the acromioclavicular joint, from problems in the rotator cuff includ­ing the subacromial bursa, or from the glenohumeral joint itself
The examination should be designed to distinguish between these three possibilities

Skin

Test distally for loss of sensation, comparing touch on the two sides. Test the outer and inner side of the upper and lower arm, then the medial and lateral side of the hand

Soft tissue

Feel the trapezius muscle for tenderness (common in referred pain from the neck). Tenderness under the margin of the acromion suggests problems with the rotator cuff complex

Bone

Feel along the clavicle starting at the sternoclavicular joint palpat­ing for tenderness, particularly at the junction of the clavicle with the acromion. Palpate the outlines of the acromion and feel for tenderness immediately beneath the acromion in the subacromial bursa. starting anteriorly, moving laterally and finishing posteriorly

Move

Active

Ask the patient to put the hands first behind the head and then behind the back. These two movements effectively test the func­tional range of movement in the shoulder. Record how far he or she can reach towards the back of the head and up the back.

Stand behind the patient and ask him or her to extend both arms laterally and then to raise them 30 degree forward (in the plane of the scapula and vertically above the head. Watch the movement of the scapula in relation to the humerus. There should be a scapulohumeral rhythm.In the first part of abduction the scapula moves very little. perhaps only 1 degree for every 2degree that the humerus moves. In the second part of
movement the scapula and humerus tend to move almost together That is a normal rhythm. Note if there is a catch in this movement, and if there is ask the patient to indicate the area of any pain.

Passive

With the arms at the sides, flex the forearms to 90 degree pointing the hands straight forward. Put one hand on the shoulder joint and use the other hand gently to turn the forearm outwards, exter­nally rotating the shoulder. Crepitus in the shoulder suggests arthritis in the glenohumeral joint. Pain and stiffness in all directions is associated with adhesive capsulitis (frozen shoulder

Stability

Thumb-down test

This test is specific for problems of impingement and inflammation in the subacromial bursa. The patient is asked to flex the shoulder to just under 90degree in the plane of the scapula (laterally and 30 degree forward). With the patient holding the arm straight out in this position,push down gently on the arm so that the patient has to maintain the posi­tion against resistance If sharp pain is experienced in the subacromial area there is an impingement problem

Apprehension sign

The shoulder commonly dislocates anteriorly when the arm is above the head and externally rotated. If the patient has ever experienced a previous dislocation, putting the patient in that position makes it feel as if the shoulder is about to dislocate Be gentle, and watch the patient's face. You do not want to dislocate the shoulder

Sulcus test

In patients who have previously dislocated the shoulder, the joint tends to be lax. Drawing down on the patient's arm when it is relaxed allows the humerus to drop away from the acromion, pro­ducing a sulcus(groove) in the unstable shoulder that is more prominent than on the normal side

THE ELBOW

The elbow is a subcutaneous joint and is quite simple to examine. Exposure should include the whole of both arms. It is not suffi­cient just to roll up the sleeves

Look

Skin

Look for scars and for redness, especially over the olecranon.

Soft tissue

Swelling This can be seen mainly in the dimples either side of the olecranon

Wasting Soft-tissue wasting as a result of a problem at the elbow is commonly the result of an ulnar nerve palsy. There will therefore be wasting in the hypothenar eminence and of the intrinsic mus­cles in the hand.

Bone

Look at the carrying angle of the elbow, the angle that the forearm makes with the upper arm as the arm lies by the patient's side with the hands facing forward.Fixed flexion can be seen in comparison with the other arm if the arms are held out horizontally in front with the palms upwards

Skin
if thee elbow joint is inflamed it will feel hot as it is a subcutaneous joint
Sensation The sensation in the hand should he checked. The dis­tribution of the ulna nerve is the lateral line and a half fingers of the hand. The median nerve supplies the front and most of the back of the other fingers and the thumb

Soft tissue
Cross fluctuation in the elbow joint between the posteromedial and posterolateral pouches can be elicited if there is an effusion in the elbow.The ulnar nerve can be felt by rolling it under your fingers between the medial epicondyle and the olecranon. If it is tender it is probably inflamed.

Bone

Tenderness over the lateral epicondyle is found in tennis elbow.

The radial head can best be felt by passively pronating and supinating the forearm while feeling for the radial head. It is slightly lumpy and can be felt under the tip of your finger as it rotates. Tenderness indicates a fracture if it is acute, or arthritis if it is chronic.

Move

Active

Flexion/extension The range of movement of elbows can be com­pared by moving both elbows together with the shoulders forward flexed 90 degree. The normal elbow hyperextends slightly,but the variation is large.

Pronation and supination This is tested with the elbows at a right angle and with the fingers out straight or with a pencil or any other straight rod gripped in the fist to act as a protractor

Passive

Repeat the above movements holding the patient's wrist in one hand and the elbow clasped between the thumb and index finger on the epicondyles. Watch the patient's face to avoid causing pain.

Stability

The stability of the elbow can be tested in extension, stressing the collateral ligaments

THE WRIST look
Skin

Look for scars, particularly over the palmar side of the wrist. The thin scar of a carpal tunnel release may be almost invisible unless carefully looked for.

Soft tissue

Swelling Swelling is visible mainly on the dorsal side, or over the radial styloid (de Quervain's tenosynovitis.

Wasting Wasting can occur in the thenar or hypothener emi­nence. It can also be seen between the metacarpals in the dorsum of the hand. Thenar eminence wasting can best be seen by putting the two hands side by side, thumb upwards, and looking down at the thumbs from above. Any slight difference in shape can then be clearly seen .

Bone

Look for prominence of the ulnar styloid and for radial drift of the wrist, which is characteristic of rheumatoid arthritis

Feel

Skin

Test sensation in the hand by comparing the sides.The median nerve can be tested over the palmar surface at the thumb and the index finger, the ulnar nerve over the little finger.The sensory distribution of the radial nerve is a patch over the dorsum of the base of the thumb.

Soft tissue

Feel for the radial pulse and capillary filling at the fingertips.

Tinel's test

This is a test for inflammation in the median nerve. This is usually caused by compression in the carpal runnel. Lay the patient's hand on the table, palm upwards, and tap with the tip of your index finger over the median nerve at the wrist crease. Tingling or lightning pains into the fingers suggest that the median nerve is being compressed

de Quervoin's tenosynovitis
The extensor tendons to the thumb can become inflamed from overuse.The tendon sheath is tender and It is sometimes possible to feel crepitus in the tendon if it is moved gently while palpating over it

Bone

Scaphoid fracture The waist of the scaphoid can be felt in the anatomical snuff box and the proximal pole can be felt anteriorly at the front of the base of the thumb

Move

Active

Extension is tested by the patient pushing their two hands together into a prayer position but with the elbows raised so that the forearms are in line with each other . If there is loss of extension the palms will not be able to meet together and/or one forearm will tend to be dropped. Palmar flexion is per­formed in the same way,but With the hands pointing down and the backs of the hands in contact

Passive

Ulnar and radial deviation are tested by taking the patient's hand in your own and forcing the hand into these positions, comparing the two sides

Stability and resisted movement

The stability of the wrist is not easy to test, but checking power grip rests the power of the grip test the power of the finger flexors, the wrist extensors and the stability of the wrist

THE HAND

Look

Skin

Look 

for tight bands in the palm leading up to the fingers or even thumb Dupuytren's contracture

Soft tissue

Check for thenar and hypothenar wasting  but also check for wasting in the clefts between the fingers dorsally (damage to the ulnar nerve or T I

Bone

Look for Heberden's nodes  over the distal interpha­langeal joints dorsally (associated with osteoarthritis). Look for swan neck and boutonniere deformities. Swan neck deformities have an extension at the middle interphalangeal joint with flexion at the distal interphalangeal joint. Boutonniere deformity is extension at the distal interphalangeal joint with flexion at the middle interphalangeal joint  Both of these are associated with rheumatoid arthritis. Look also for dropped fin­gers. If one finger lies lower than the others when the hands are held out, test for rupture of the extensor tendon by asking the patient to extend the finger against resistance. Look for subluxa­tion of the metacarpophalangeal joints and for ulnar drift of the fingers also associatedwith rheumatoid arthritis

Feel

Skin

Feel for loss of sensation in the tips of the fingers.Review the sen­sory distribution of the median, ulnar and radial nerves. If there is any doubt about the sensation then proceed to test two-point dis­crimination

Soft tissues

Check for capillary filling in the fingertips.Feel for wasting in the first dorsal interosseous on the radial side of the first metacarpal. This muscle is plump and easily palpable. Damage to the ulnar nerve or to the Tl nerve root can be detected from wasting in this muscle

Bone

Feel for swelling and tenderness over the metacarpophalangeal and interphalangeal joints.

Move

Active

Test roll-up of the fingers from full extension to full flexion. Test flexion of the metacarpophalangeal joints in isolation while keeping the proximal and distal interphalangeal joints extended. This tests the patient's control of the intrinsic muscles. Test abduction of the fingers (a further test of small muscles in the hand

Passive stability and resisted

Test the power of the extensors, individually pushing down on each finger.

Superficialis tendon test

Flexor digitorurn profundus usually has only one muscle belly supplying the tendons to all of the fingers. Profundus can there­ fore be immobilized by holding all the fingers bar the one being tested in full extension. grasping them in your hand. If the test finger is still able to flex. then superficialis to that finger is active

Profundus test

Flexor digitorum profundus is the only tendon that inserts in the distal phalanx. If the finger is held by the middle phalanx. the power of the profundus tendon can be tested ).

 
Intrinsics test
The power of the intrinsic muscles of the hand is tested by asking the patient to abduct the fingers against resistance. and feeling for contraction in the first dorsal interosseous muscle on the index finger side of the web space 

Froment's test

The patient is asked to grip a sheet of paper between the index finger and thumb of both hands. If the intrinsic muscles of the hand are normal, the patient can grip firmly with the thumb in extension. However. if there is weakness. particularly of the adductor pollicis, the thumb cannot remain straight while flexor hallucis longus contracts hard. so the thumb flexes .

Abductors of thumb

The abductors of the thumb are supplied by the median nerve. Power is tested by asking the patient to raise the thumb from the palm against resistance

SUMMARY
The examination of musculoskeletal system follow standard pattern whichever part of the body is being examined the system is quick and simple and ensures that no critical physical signs are missed

tags:examination,musculoskeletal,disorders,clinical