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.Musculoskeletal examination works on a simple system originally designed by Apley. It consists of four-letter words divided into threes.
The first stem is:
The second stem branching off from each of these first two stems is:
- soft (tissue);
Finally, ‘move’ is divided into:
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.
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.
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.
Look a third time at the bones (shape of the skeleton). Look for:
- deformity — unusual angles or joints held in unusual positions.
You have now looked at three zones. Summarise these in your mind and make a record of what you have found.
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.
- 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.
- 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.
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?
Once again there are three phases of the examination, but this time they are active, passive and stability.
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.
Don’t take the range of movement beyond the active range without watching the patient’s face.
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.