msk assessment level 6

Assessment of the musculoskeletal system

Professor Rebecca Jester 2013

Aims of the day

Recap on applied anatomy and physiology History taking practice Principles of MSK examination Practice of MSK examination Falls risk assessment

3 elements essential for mobility

The ability to move The motivation to move The environment to permit and facilitate

mobility.

Causes of impaired mobility

Intolerance to activity, decreased strength and endurance.

Pain/discomfort Perceptual/cognitive impairment Musculoskeletal impairment Psychological impairment

(Davis, 2005)

What is involved in mobility – musculoskeletal system

Axial skeleton (skull, VC, ribs, sternum) & appendicular (upper and lower limbs, pelvic and pectoral girdles).

Cartilage – hyaline covers articulating surfaces, fibrocartilage – shock absorber, elastic cartilage e.g. larynx & epiglottis

musculoskeletal system (contd)

Joints – fibrous, cartilaginous, synovial Types of synovial-hinge, ball and socket,

plane, pivotal, condyloid, saddle Tendons – connect muscle to bone Ligaments – join bones together at joints Muscles – insertion and origin

Bone is living tissue

Osteocytes, osteoblasts, osteoclasts Haversian systems Compact and cancellous bone Diaphysis Epiphyses periosteum

Nervous system

Function to coordinate and control all parts of the body.

Central nervous system (brain and spinal cord)

Peripheral system (spinal and cranial nerves) Voluntary (somatic) and Involuntary

(autonomic)

Stages of Assessment

History – 10 steps Examination – observation, inspection,

palpation, auscultation, percussion, measurement e.g. ROM, limb length, muscle strength, gait analysis

PROMS Clinical Investigations

ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM

HISTORY TAKING Pain is the commonest orthopaedic complaint

Pain is a symptom and is not the same as tenderness, which is a physical sign

Pain is often referred – eg pain in the hands may be referred from the neck (cervical spondylosis or prolapsed cervical disc) or knee, hip pain from lesions in the lumbo-sacral spine. Therefore examination of joints above and below is essential


Assessment – Nature of Pain Localised or diffuse Unilateral or bilateral Aching or sharp Present only with use Present constantly Worse at night or at rest Associated with sensory symptoms Use of pain assessment tools

Other chief complaints

Loss of or reduced function, mobility, range of movement.

Joint stiffness, joint instability, joint laxity Inflammation of joints, deformity


Landmarks Limbs and joints can be grossly distorted by trauma or

disease. So identification of known landmarks is essential.Examples – ant. Sup,Iliac spine, greater trochanter, ischial tuberosity and symphysis pubis for the hip.

Range of active and passive movement Temperature of joints Measurement of limbs Muscle power- MRC scale Neurological – reflexes, sensitivity to sharp/blunt


ExaminationBoth limbs should always be compared

Gait Common gait abnormalities include:- Trendelberg, toe

catching due to drop foot, stiff legged gait (knee disorders)

Muscle wasting local or generalized eg wasting of thena muscles associated with median nerve compression

Gait abnormalities

Common gait abnormalities include:- Trendelberg, toe catching due to drop foot, stiff legged gait (knee disorders).

Observation of patients’ gait, stride pattern and their footwear are important.

Goniometry

Comes from two Greek words – gonia (angle) and metron (measure)

If performed correctly goniometry provides a very accurate measure of joint motion.

The movement should be free of any muscle contraction. The measurement of ROM of a particular patient should be

taken 3 times and the average ROM recorded to 5 degree increments.

The measurements are obtained by placing the parts of the measuring instrument along the proximal and distal bones adjacent to the joint concerned.

Assessing muscle power

MRC Scale for Recording Muscle Power

0 No muscle power1 Flicker of activity2 Movement with effect of gravity eliminated i.e. in a place at

right angles to gravity but not against resistance3 Movement against gravity but not against applied resistance4 Movement against applied resistance but less than full power5 Normal power


Measuring Leg Length

Measure from the anterior superior iliac spine to the medial malleolus, then extend the measurement down to the bottom of the heel with the ankle in the neutral position.

Remember to check that the patients pelvis is flat and square on the bed before measuring.

The Bony Spine

Back pain is extremely common and if it becomes chronic and unrelieved can lead to significant psychological and social issues for the patient and their family. It is therefore important to include assessment of patients' stress, coping and depression status, social circumstances as well physical examination.

The Bony Spine

Back pain may be localized to the back, but often radiates into the buttocks, legs and feet due to sciatica. Back pain may also be indicative of problems not associated with the bony spine such as lower intestine, genitourinary or renal problems and these should be excluded during the assessment process.

The Bony Spine

Areas of the spine included in the assessment will depend on the patient's presentation and history. Causes include: sprains and strains, osteoarthritis, spondylosis, spinal stenosis, ankylosing spondylitis, osteoporotic fractures and less commonly tumours/spinal metastases and infection

Bony Spine

Detailed history of what specific movements, activities and positions bring on or exacerbate the pain e.g. sitting or standing for long periods, occupational activity, coughing or sneezing, bowel movements. Also determine what alleviates the pain.

Bony spine

Elicit if there is a history of trauma does the patient report twisting their spine, whiplash or any locking. Its important to elicit if there is any neurological symptoms such as sciatica, erectile dysfunction or loss of bladder or bowel sensation which if reported require urgent investigation (MRI)by a spinal specialist.

Bony spine

The symmetry of the spine should be observed and any abnormal curvature such as lordosis, scoliosis or kyphosis noted. Observe for limb length inequality when standing and gait pattern should be noted. Check for protrusions, redness, swelling and any scars which indicate previous surgery or trauma.

Bony spine

Palpation and Percussion - The spine should be palpated with the patient in the sitting and standing positions and any tenderness, heat, misalignment, protrusions noted. The spine should also be gently percussed with the patient bending forward from the root of the neck to the sacrum noting any pain.

Bony spine

Specific assessment of motor and sensory function will depend on the level of the presenting spinal problem and if the patient reports any altered sensation or motor function during the history. E.g. patients presenting with lumbar/sacral pain who report sciatica will need to have the sensation and motor function of their lower limbs assessed.

Bony spine

Movement - The amount of flexion/extension, lateral bend and rotation of the spine should be measured. If prolapsed intervertebral disc is suspected then the patient's ability to straight leg raise should be included in the assessment.

Bony spine- clinical investigations

NICE guidelines for management of non-specific LBP(2009) recommend not to offer X-ray of the lumbar spine for the management of non-specific low back pain and only to consider MRI when a diagnosis of spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing spondylitis or another inflammatory disorder is suspected.

Bony spine- clinical investigations

If ankylosing spondylitis is suspected blood tests for inflammatory markers should be taken (CRP, ESR,PV and HLA-B27 antigen)

Psyco/social aspects of assessment

There are a number of valid and reliable indices to assess depression and anxiety including Becks Depression Inventory (BDI) and Hospital Anxiety and Depression Score (HADS). The nurse should also ascertain how the patient's back pain is impacting on their social and occupational activities.

Disease specific measures

There are a number of assessment indices specifically designed for assessing back pain including the Oswestry low back pain score (full and modified versions) and the Back Pain Index see orthopaedic.scores.com for further detail.

Examination of the Shoulder

Total shoulder movement comprises 2 separate movements: 1 at the gleno-humeral joint and 1 between the scapula and chest wall. You should fix the scapula before assessing ROM of GH joint.

External rotation and adduction by asking patient to touch the back of the head.

Internal rotation and adduction by asking patient to reach as high up his back as possible.

Normal – patient can touch fingertips of both hands together. Record any limitation due to pain.

ROM of the Shoulder

Circumduction (200 ) Elevation through abduction (180) Elevation through forward flexion (160-180) External/lateral rotation (90) Internal/medial rotation (60-90) Adduction (50-75%) Horizontal adduction/abduction (cross-flexion/cross

extension 130) Extension (50-60) Elevation through the plane of the scapula (170-180)

Examination of the hip

Range of active movement should include: Flexion (110-120° ) Abduction (30-50°) Aduction (30°) Extension (10-15°) Lateral rotation (40-60°) Medial rotation (30-40°)

HIP

A patient with tight adductors or weak abductors will have a +ve Trendelburg sign. Stand on good leg, the pelvis tilts up on the opposite side appropriately. When standing on bad leg not possible to tilt the pelvis so opposite side sags down.

Fixed flexion deformity of hip – often hidden by exaggerated lumbar lordosis, Fully flexing opposite hip flattens lordosis and the fixed flexion contracture becomes apparent (Thoma’s test)

Examination of the Knee

Flexion 0-140 degrees / Hyperextension possible 5-0-90. There should not be a great deal of internal/external rotation of the knee.

Anterior Draw Test – tibia is pulled forward on the femur to check the integrity of the anterior cruciate – knee should be in 90 degree flexion (sit on foot to stabilise).

Lachman Test – still for anterior cruciate instability – knee is not flexed (suitable for acutely injured knee). Pull tibia forward on the femoral condyle.

Radiography

Radiographic images are created by short bursts of radiation which pass through the body and interact with photographic film or a fluorescent screen. The extent to which the film is blackened depends on the number of x-rays reaching the film which, in turn, depends on the densities of the tissue. X-rays pass easily through soft tissue but are less able to pass through bone which is more dense.

Radiography

Radiographs provide images of bony structures, the density of bones, the relationships between bones, their continuity and contour and the shape of spaces within joints. They are used in all cases of suspected fracture and are commonly used in the diagnosis of musculo-skeletal conditions such as osteoarthritis.

Radiography

Long shot. A general overview of the radiograph, standing well back, considering the shape, size and contour of the bones and joints as a whole.

Medium Shot. Noting bone texture, areas of new bone or bone destruction and deformity

Close-up. Tracing methodically around the contours of the bone and noting any abnormalities of the continuity of the outline and structure of the bone.

CT scans

CT scans are created using radiation beams passing through the tissue from different angles of rotation to provide cross-sectional slice images of a segment of the body. This enables more detailed views of bony structures from many angles as well as greater definition of different types of tissue. In most situations CT scans have now been superseded by MRI. The risks of CT are the same as those for normal radiographs although the scan will take much longer so the dose of radiation may be greater.

MRI

MRI is increasingly being used to diagnose musculo-skeletal problems

No radiation is involved and the process is harmless to the patient (although can be quite lengthy and noisy)

Suggested Reading

Jester R, Santy J & Rogers J (2011) Oxford Handbook of Orthopaedic & Trauma Nursing. OUP. Oxford

Magee D (2006) Orthopaedic Physical Assessment. 4th Ed. Saunders Elsevier. St Louis

McRae R (2005) Clinical Orthopaedic Examination. 5th ed. Churchill Livingstone. Edinburgh

msk assessment level 6

Health & Medicine