Musculoskeletal

Chapter 22: Musculoskeletal System

Inspection

Note any lordosis, kyphosis (overcurvature of the thoracic vertebrae), or scoliosis (curved from side to side) of the spine.
Fasciculation (muscle twitching) occurs after injury to a muscle's motor neuron.
Muscle wasting occurs after injury as a result of pain, disease of the muscle, or damage to the motor neuron.

Inspection of overall body posture. Note the even contour of the shoulders, level scapulae and iliac crests, alignment of the head over the gluteal folds, and symmetry and alignment of extremities. The occiput, shoulders, buttocks, and heels should be able to touch the wall the patient stands against.

A, Anterior view.

B, Posterior view.

C, Lateral view.

Palpation

Palpate any bones, joints, tendons, and surrounding muscles if symptomatic.
Palpate inflamed joints last.

Range of Motion and Muscle Tone

When a join appears to have an increase or limitation in its range of motion, a goniometer is used to precisely measure the angle.
Measure the angles of greatest flexion and extension, comparing these with the expected join flexion and extension values.

Use of goniometer to measure joint range of motion.

Muscle Strength

Evaluation of muscle strength: flexion of the elbow against opposing force.

Specific Joints and Muscles

Hands and Wrists

A, Bony structure of the right hand and wrist; note the alignment of the fingers with the radius.

B, Features of the palmar aspect of the hand; note creases, thenar eminence and hypothenar eminence, and gradual tapering of the fingers.

Unexpected findings of the hand.

A, Ulnar deviation and subluxation of metacarpophalangeal joints.

Usually indicates rheumatoid arthritis.

B, Swan neck deformities.

C, Boutonnière deformity.

Palpation of Hands and Wrists

Joint surfaces should be smooth and without nodules, swelling, bogginess, or tenderness.
A firm mass over the dorsum of the wrist may be a ganglion.

Palpation of joints of the hand and wrist.

A, Proximal interphalangeal joints.

B, Metacarpophalangeal joints.

C, Radiocarpal groove and wrist.

Unexpected findings of the fingers

When located along the distal interphalangeal joints, they are called Heberden nodes.
Those along the proximal interphalangeal joints are called Bouchard nodes.
Painful swelling of the proximal interphalangeal joints causes spindle-shaped fingers, which are associated with the acute stage of rheumatoid arthritis.
Cystic, round, nontender swellings along tendon sheaths or joint capsules that are more prominent with flexion may indicate ganglia.

Unexpected findings of the fingers.

A, Fusiform swelling or spindle-shaped enlargement of the proximal interphalangeal joints.

B, Degenerative joint disease; Heberden nodes at the distal interphalangeal joints and Bouchard nodes at the proximal interphalangeal joints.

C, Telescoping digits with hypermobile joints.

Range of Motion of the Hand and Wrist

A, Metacarpophalangeal flexion and hyperextension.

B, Finger flexion: thumb to each fingertip and to the base of the little finger.

C, Finger flexion: fist formation.

D, Finger abduction.

E, Wrist flexion and hyperextension.

F, Wrist radial and ulnar movement.

Carpal Tunnel Syndrome

Several procedures are used to evaluate the integrity of the median nerve, which innervates the palm of the hand and the palmar surface of the thumb, index and middle fingers, and half of the ring finger.

Assessment for carpal tunnel syndrome.

A, Katz hand diagram.

B, Classic and probable patterns of pain, tingling, and numbness using the Katz hand diagram.

Additional procedures for assessment of carpal tunnel syndrome.

A, Thumb abduction test isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve.

Full resistance to pressure is expected.

Weakness is associated with carpal tunnel syndrome.

B, Phalen maneuver.

Ask the patient to hold both wrists in a fully palmar-flexed position with the dorsal surfaces pressed together for 1 minutes.

Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome.

The reverse Phalen test is performed by placing the palms and fingers together with full wrist extension.

C, Elicitation of Tinel sign.

A tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign and is suggestive of carpal tunnel syndrome.

Elbows

Subcutaneous nodules on the extensor surface of the forearm near the elbow.

Expected carrying angle of the arm, at 5 to 15 degrees.

Palpation of the olecranon process grooves.

Range of motion of the elbow.

A, Flexion and extension.

B, Pronation and supination

Shoulders

Contour changes of the shoulder

A, With dislocation.

When the shoulder contour is asymmetric and one shoulder has hollows in the rounding contour, suspect a shoulder dislocation.

B, Winging of the scapula with abduction of the arm.

Observe for a winged scapula, an outward prominence of the scapula, indicating injury to the nerve of the anterior serratus muscle.

Range of motion of the shoulder:

A, Forward flexion and hyperextension.

B, Abduction and adduction.

C, Internal rotation.

D, External rotation.

E, Shrugged shoulders.

Assessment for rotator cuff inflammation or tear:

Several procedures are used to evaluate the rotator cuff for impingement (tendonitis or overuse injury from repetitive overhead activities) or a tear

A, Neer test.

Increased sholder pain is associated with rotator cuff inflammation or a tear.

B, Hawkins test.

Increased shoulder pain is associated with rotator cuff inflammation or a tear.

Temporomandibular Joint

Palpation of the temporomandibular joint.

Lateral range of motion in the temporomandibular joint.

Cervical Spine

Range of motion of the cervical spine:

A, Flexion and hyperextension.

B, Lateral bending.

C, Rotation.

Examining the strength of the sternocleidomastoid and trapezius muscles:

A, Flexion with palpation of the sternocleidomastoid muscle.

B, Extension against resistance.

C, Rotation against resistance.

Thoracic and Lumbar Spine

Landmarks of the back.

Palpation of the spinal processes of the vertebrae.

Deviations in spinal column curvatures.

A, Expected spine curvatures.

B, Kyphosis.

Kyphosis may be observed in aging adults.

C, Lordosis.

Lordosis is common in patients who are obeser or pregnant.

D, Gibbus.

A sharp angular deformity, a gibbus, is associated with a collapsed vertebra from osteoporosis.

Inspection of the spine for lateral curvature and lumbar convexity.

Range of motion of the thoracic and lumbar spine.

A, Flexion.

B, Hyperextension.

C, Lateral bending.

D, Rotation of the upper trunk.

Femoral stretch test for high lumbar nerve root irritation.

The presence of pain on extension is a positive sign of nerve root irritation.

Hips

Range of motion of the hip:

A, Hip flexion, knee extended.

B, Hip extension, knee extended.

C, Hip flexion, knee flexed.

D, Abduction.

E, Internal rotation.

F, External rotation.

Test for the Trendelenburg sign to detect weak hip abductor muscles.

Ask the patient to stand and balance first on one foot and then the other.
Observe from behind , note any asymmetry or change in the level of the iliac crests with weight bearing.
When the iliac crest drops on the side of the lifted leg, this indicates the hip abductor muscles on the weight-bearing side are weak.

Procedures for examination of the hip with the Thomas test.

The Thomas test is used to detect flexion contractures of the hip that may be masked by excessive lumbar lordosis.
Have the patient lie supine, fully extend one leg flat on the examining table and flex the other leg with the knee to the chest.
Observe the patient's ability to keep the extended leg flas on the examining table.
Lifting the extended leg off the examination table indicates a hip flexion contracture in the extended leg.

Legs and Knees

Range of motion of the knee: flexion and extension.

Procedure for ballottement examination of the knee.

Ballottement is used to determine the presence of an effusion in the knee from excess fluid.
With the knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then push the patella quickly downward against the femur with a finger of your other hand. If an effusion is present, a tapping or clicking will be sensed when the patella is pushed against the femur.
Release the pressure against the patella, but keep your finger lightly touching it. If an effusion is present, the patella will float out as if a fluid wave were pushing it.

Testing for the Bulge sign in examination of the knee to determine the presence of excess fluid in the knee.

With the patient's knee extended, milk the medial aspect of the knee upward two or three times, and then milk the lateral side of the patella.
Observe for a bulge of returning fluid to the hollow area medial to the patella.

B, Tap the lateral side of the patella.

Procedure for examination of the knee with the McMurray test to detect a torn medial or lateral meniscus.

Have the patient lie supine and flex one knee.
Position your thumb and fingers on either side of the joint space.
Hold the heel with your other hand, fully flexing the knee, and rotate the foot and knee outward (valgus stress) to a lateral position.
Extend and then flex the patient's knee.
- Any palpable or audible click, pain, or limited extension of the knee is a positive sign of a torn medial meniscus.
Repease the procedure, rotating the foot and knee inward (varus stress).
- A palpable or audible click, pain, or lack of extension is a positive sign of a torn lateral meniscus.

Examination of the knee with the drawer test.

The anterior and posterior drawer test is used to identify instability of the anterior and posterior cruciate ligaments.

Have the patient lie supine and flex the knee 45 to 90 degrees, placing the foot flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity.
Draw the tibia forward, forcing the tibia to slide forward of the femur.
Then push the tibia backward.
- Anterior or posterior movement of the knee greater than 5 mm in either direction is an unexpected finding.

The Lachman test is used to evaluate anterior cruciate ligament integrity.

With the patient supine, flex the knee 10 to 15 degrees with the heel on the table.
Place one hand above the knee to stabilize the femur and place the other hand around the proximal tibia.
While stabilizing the femur, pull the tibia anteriorly.
Attempt to have the patient relax the hamstring muscles for an optimal test.
- Increased laxity, greater than 5 mm compared with the uninjured side, indicates injury to the ligament.

Valgus stress test of the knee with knee extended.

The varus (abduction) and valgus (adduction) stress tests are used to identify instability of the lateral and medial collateral ligaments.

Have the patient lie supine and extend the knee.
Stabilize the femur with one hand and hold the ankle with your other hand.
Apply varus force against the ankle (toward the midline) and internal rotation.
- Excessive laxity is felt as joint opening.
- Laxity in this position indicates injury to the lateral collateral ligament.
Then apply valgus force against the ankle (away from the midline) and external rotation.
- Laxity in this position indicates injury to the medial collateral ligament.
Repease the movements with the patient's knee flexed to 30 degrees.
No excessive medial or lateral movement of the knee is expected.