Musculoskeletal SystemMusculoskeletal SystemHistory and Physical History and Physical

ExaminationExaminationSalah FallatahSalah Fallatah

Mar 12/2011Mar 12/2011

HistoryHistory

Similar to other medical histories in that Similar to other medical histories in that you need to identify:you need to identify: AgeAge Chief complaintChief complaint History of presenting illnessHistory of presenting illness Past medical history especially prior injuries Past medical history especially prior injuries

or operationsor operations

HistoryHistory MedicationsMedications

NSAIDsNSAIDs steroidssteroids narcoticsnarcotics

Other treatments for this injuryOther treatments for this injury InjectionsInjections BracingBracing PhysiotherapyPhysiotherapy Chiropractic careChiropractic care

AllergiesAllergies

Social HistorySocial History OccupationOccupation

Working / RetiredWorking / Retired Manual labor / Desk jobManual labor / Desk job

Living situationLiving situation Alone / Spouse / Other supportsAlone / Spouse / Other supports Two storey house / ApartmentTwo storey house / Apartment

Ambulatory statusAmbulatory status How far can they walkHow far can they walk Do they use a walker / cane Do they use a walker / cane

Smoking/ Alcohol/ Drug UseSmoking/ Alcohol/ Drug Use

Specifics to the HPISpecifics to the HPI

Precipitating incidentPrecipitating incident trauma (macrotrauma) trauma (macrotrauma) repetitive stress (microtrauma)repetitive stress (microtrauma) is this a work related injury?is this a work related injury? is there a lawsuit ongoing?is there a lawsuit ongoing?

Specifics to the HPISpecifics to the HPI

For MVAs For MVAs driver/passengerdriver/passenger belted/non-beltedbelted/non-belted location of impact and severity of crash location of impact and severity of crash

(required jaws of life, if anyone died in (required jaws of life, if anyone died in the crash, thrown from the car, etc)the crash, thrown from the car, etc)

speed at impactspeed at impact position of the patient and the limb in position of the patient and the limb in

question at impactquestion at impact

Specifics of the HPISpecifics of the HPI

for pain or presenting problemfor pain or presenting problem OnsetOnset DurationDuration CharacterCharacter CourseCourse Aggravating and relieving factorsAggravating and relieving factors LocationLocation RaditionRadition Associated symptoms Associated symptoms

Associated Associated SSymptomsymptoms

In addition to pain do they have:In addition to pain do they have: ClickingClicking SnappingSnapping CatchingCatching LockingLocking Sensation of giving way (including prior falls Sensation of giving way (including prior falls

or dislocations)or dislocations) SwellingSwelling WeaknessWeakness

TTemporality or emporality or TTimingiming

Is it worse when they wake up in the Is it worse when they wake up in the morning?morning?

Does it gradually get worse over the course Does it gradually get worse over the course of the day?of the day?

Does the pain ever wake them up at night?Does the pain ever wake them up at night?

Red flagsRed flags

Pain at night or restPain at night or rest Associated weight loss and loss of appetiteAssociated weight loss and loss of appetite Hx. Of cancerHx. Of cancer Steroids useSteroids use Hx. Of traumaHx. Of trauma Extreme ageExtreme age Bowel or bladder symptomsBowel or bladder symptoms

General Considerations for General Considerations for ExaminationExamination

When taking a history for an acute problem When taking a history for an acute problem always inquire about the always inquire about the mechanism of mechanism of injuryinjury, loss of function, onset of swelling (< , loss of function, onset of swelling (< 24 hours), and initial treatment 24 hours), and initial treatment

When taking a history for a chronic problem When taking a history for a chronic problem always inquire about past injuries, past always inquire about past injuries, past treatments, effect on function, and current treatments, effect on function, and current symptoms. symptoms.

General Considerations for General Considerations for ExaminationExamination

The patient should be gowned and exposed The patient should be gowned and exposed as required for the examinationas required for the examination

Some portions of the examination may not Some portions of the examination may not be appropriate depending on the clinical be appropriate depending on the clinical situation (performing range of motion on a situation (performing range of motion on a fractured leg for example)fractured leg for example)

General Considerations for General Considerations for ExaminationExamination

The musculoskeletal exam is all about The musculoskeletal exam is all about anatomyanatomy

Think of the underlying anatomy as you Think of the underlying anatomy as you obtain the history and examine the patientobtain the history and examine the patient

General Considerations for General Considerations for ExaminationExamination

The cardinal signs of musculoskeletal The cardinal signs of musculoskeletal disease are:disease are: PainPain Redness (erythema)Redness (erythema) SwellingSwelling Increased warmthIncreased warmth DeformityDeformity Loss of functionLoss of function

General Considerations for General Considerations for ExaminationExamination

Always begin with inspection, palpation and Always begin with inspection, palpation and range of motion, regardless of the region range of motion, regardless of the region you are examining you are examining (LOOK,FEEL, MOVE(LOOK,FEEL, MOVE))

Specialized tests are often omitted unless a Specialized tests are often omitted unless a specific abnormality is suspectedspecific abnormality is suspected

A complete evaluation will include a focused A complete evaluation will include a focused neurological examneurological exam of the effected area of the effected area

InspectionInspection

Look for scars, rashes, or other lesions like Look for scars, rashes, or other lesions like abrasions/open woundsabrasions/open wounds

Look for asymmetry, deformity, or atrophy Look for asymmetry, deformity, or atrophy Always compare with the other sideAlways compare with the other side Look for swellingLook for swelling Look for erythema (redness)Look for erythema (redness) Posture/position of the joint or limbPosture/position of the joint or limb

PercussionPercussion

Typically, we don’t percuss things in orthopedics Typically, we don’t percuss things in orthopedics however the one exception is however the one exception is nervesnerves

If tapping over a nerve causes pain or electric If tapping over a nerve causes pain or electric shock sensations, this is called Tinel’s sign shock sensations, this is called Tinel’s sign

Present when nerves are compressed or irritatedPresent when nerves are compressed or irritated Also used to monitor nerve recovery after injury Also used to monitor nerve recovery after injury

(in the form of an “advancing Tinel’s sign”)(in the form of an “advancing Tinel’s sign”)

AuscultationAuscultation

We don’t really listen to anything in We don’t really listen to anything in orthopedicsorthopedics

PalpationPalpation Examine each major joint and muscle group in Examine each major joint and muscle group in

turnturn Identify any areas of tendernessIdentify any areas of tenderness Joint lineJoint line Tendinous insertionsTendinous insertions Palpate for any crepitus Palpate for any crepitus Identify any areas of deformityIdentify any areas of deformity Always compare with the other side Always compare with the other side

PalpationPalpation

Warm or cold including pulses Warm or cold including pulses Fluctuation/fluid collectionFluctuation/fluid collection Compartments – soft or firm and painfulCompartments – soft or firm and painful Sensation Sensation

Range of MotionRange of Motion

ActiveActive PassivePassive

Active ROMActive ROM

Ask the patient to move each joint through a Ask the patient to move each joint through a full range of motionfull range of motion

Note the degree and type of any limitations Note the degree and type of any limitations (pain, weakness, etc.) (pain, weakness, etc.)

Note any increased range of motion or Note any increased range of motion or instability instability

Always compare with the other side Always compare with the other side Proceed to passive range of motion if Proceed to passive range of motion if

abnormalities are foundabnormalities are found

Passive ROMPassive ROM Ask the patient to relax and allow you to Ask the patient to relax and allow you to

support the extremity to be examinedsupport the extremity to be examined Gently move each joint through its full Gently move each joint through its full

range of motionrange of motion Note the degree and type (pain or Note the degree and type (pain or

mechanical) of any limitationmechanical) of any limitation If increased range of motion is detected, If increased range of motion is detected,

perform perform special tests special tests for instability as for instability as appropriateappropriate

Always compare with the other sideAlways compare with the other side

Vascular StatusVascular Status

PulsesPulses Upper extremityUpper extremity

Check the radial pulses on both sidesCheck the radial pulses on both sides If the radial pulse is absent or weak, check If the radial pulse is absent or weak, check

the brachial pulsesthe brachial pulses Lower extremityLower extremity

Check the posterior tibial and dorsalis pedis Check the posterior tibial and dorsalis pedis pulses on both sides - if these pulses are pulses on both sides - if these pulses are absent or weak, check the popliteal and absent or weak, check the popliteal and femoral pulses femoral pulses

Vascular StatusVascular Status

Capillary RefillCapillary Refill Press down firmly on the patient's finger or Press down firmly on the patient's finger or

toe nail so it blanchestoe nail so it blanches Release the pressure and observe how long it Release the pressure and observe how long it

takes the nail bed to "pink" up takes the nail bed to "pink" up Capillary refill times greater than 2 to 3 Capillary refill times greater than 2 to 3

seconds suggest peripheral vascular disease, seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock arterial blockage, heart failure, or shock

Special testsSpecial tests