Musculoskeletal
examination
Learning
objectives
1. To understand a simple system for examining the musculoskeletal
system.
2. To learn the specific features to be sought in each area of the body.
The
first stem is:
• look;
• feel;
• move.
• skin;
• soft (tissue);
• bone.
• active;
• passive;
• stability.
You cannot look with your hands. Once you let your hands on to the
patient, your ability to notice things with your eyes seems to be lost. While
looking, it may be better to put your hands behind your back to remind you to
look first, and to show the examiner what you are doing.
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 for an orthopaedic
examination. It may be easier if the patient remains standing, provided that
they are comfortable to do this. In this position it is easier to look at the
patient’s back as well as their front. It is important to inspect all sides of
the patient to make sure that no lesion is missed.
Skin
Look once at the skin for:
• bruising and wounds — evidence of recent injury;
• redness — signs of inflammation;
• scars — the archaeology of injury;
• sweating — loss of sweating may indicate nerve damage.
Soft
tissues
Look a second time at the soft tissues. Now you are looking for:
• swelling — a cardinal sign of injury and inflammation;
• wasting — signs of disuse and nerve damage, the archaeology
of injury.
Bones
Look a third time at the bones (shape of the skeleton). Look for:
• deformity — unusual angles or joints held in unusual
positions.
Summarise
You have now looked at three zones. Summarise these in your mind and
make a record of what you have found.
Feel
Once again you will test in three zones: skin, soft tissue and bone.
Skin
(temperature, sensation)
• 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 — if you ask the patient to shut their eyes and
then test whether their feeling is normal, you are in danger of missing nerve
damage. Patients do not always close their eyes when asked (especially if they
are drunk). The question ‘Is that normal?’ is a closed question which
invites the answer ‘Yes’. A better system is to leave the patient with their
eyes open and then 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 (tenderness, lumps and circulation)
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.
This way you will be certain to spot immediately that you are causing discomfort
or even pain. You will then be able to stop what you are doing immediately to
prevent further suffering. If you fail to do this in an examination and then
cause pain to a patient, the examiner will regard this as a serious
transgression.
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 checklist of features of a lump. A
simple system is shown in Table 20.5.
• 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.
For
capillary filling, simply press in on the tip of a digit and say under your
breath ‘capillary filling’. If the blanching has not disappeared by then,
there is diminished capillary filling. Before diagnosing local vascular damage,
check whether the circulation is reduced generally (as it might be in shock).
Bone
(bone outlines and joint margins)
Watch the patient’s face, feel the bone and joint margins gently for
areas of tenderness, steps and lumps. Again, try to work out what anatomical
structure your fingers are touching as you palpate.
Summary
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
The patient should move their own joints within the limits of pain. Use
simple language to explain what you want them to do, and if necessary
demonstrate the movement.
Passive
Don’t 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 intact joint
surfaces.
Dynamic
stability. Measure the force that the patient can develop by showing them the
movement, then asking them to repeat it while you try to stop them. 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 you don’t hurt
the patient. You do not need to use any force. Indeed, the tests will not work
if you do, as the patient’s muscles will go into spasm and hide the underlying
static instability.