Musculoskeletal Examination Todd Milbrandt, MD, MS Pediatric Orthopaedic Surgeon

Musculoskeletal Exam There are so many moving parts-how am I going to remember them all?

Musculoskeletal Exam I was once a first year medical student, too. I was once a first year medical student, too. That may have been a long time ago….but That may have been a long time ago….but Consider yourself lucky. Consider yourself lucky.

Musculoskeletal Exam We never had standardized patients. We never had standardized patients. MSK information was a big black box. MSK information was a big black box. No one taught it because no-one felt comfortable doing it. No one taught it because no-one felt comfortable doing it.

Musculoskeletal Exam The best part about the MSK examination is that you really can touch all the parts. The best part about the MSK examination is that you really can touch all the parts. And you have a “normal” to compare it too (the other side). And you have a “normal” to compare it too (the other side).

Musculoskeletal Exam We will divide the examination into regions: We will divide the examination into regions: Spine, Upper Extremity and Lower Extremity. Spine, Upper Extremity and Lower Extremity. We will progress through inspection, palpation, range of motion, stability testing, and finally “special” tests We will progress through inspection, palpation, range of motion, stability testing, and finally “special” tests

Musculoskeletal Exam Remember Anatomy? Remember Anatomy? This is where you need it. This is where you need it. I have a list of students and I am not afraid to use it!! I have a list of students and I am not afraid to use it!! Ward learning=Active engagement of participants! Ward learning=Active engagement of participants!

Functional Anatomy Name the bones of the upper extremity Name the bones of the upper extremity

Functional Anatomy Name bones within the axial skeleton and pelvis Name bones within the axial skeleton and pelvis

Functional Anatomy Name bones within the lower extremity Name bones within the lower extremity

Spine Inspection Inspection –Shoulder asymmetry –Prominent scapula –Hairy patches –Dimples

Spine examination Inspection Inspection –Kyphosis –Lordosis Palpation Palpation –Spinous processes –Paravertebral muscles –Percussion of spine (??)

Spine examination Palpation Palpation –Spinous processes –Paravertebral muscles –Percussion of spine (??)

Spine examination-Range of Motion Modes Modes –Passive (all planes) –Active (all planes) Anatomical areas Anatomical areas –Cervical, thoracic, lumbar

Spine examination-Range of Motion Cervical Cervical –Flexion –Extension –Rotation –Side bend

Spine examination-Range of Motion Thoracic Thoracic –Flexion –Extension –Rotation –Side bend

Spine examination-Range of Motion Thoracic Thoracic –Flexion –Extension –Rotation –Side bend

Spine examination- Special tests Axial compression Axial compression It called the Lhermites test It called the Lhermites test Don’t do if suspect C-spine injury! Don’t do if suspect C-spine injury!

Spine examination- Special tests Axial compression with head tilted Axial compression with head tilted Spurling’s maneuver Spurling’s maneuver Don’t do if suspect C-spine injury Don’t do if suspect C-spine injury

Spine examination- Special exam Adam’s forward bend test Adam’s forward bend test

Shoulder-Cartoon Anatomy

The Shoulder- X-ray Anatomy

Shoulder-Inspection Name those areas when inspecting Name those areas when inspecting Deltoid Deltoid Acromion Acromion Clavicle Clavicle AC joint AC joint Spine of the scaplua Spine of the scaplua

Shoulder-Inspection Name those areas when inspecting Name those areas when inspecting Deltoid Deltoid Acromion Acromion Clavicle Clavicle AC joint AC joint Look for muscle wasting Look for muscle wasting

Shoulder: Palpation Acromioclaviular Joint

Shoulder: Palpation Acromion

Shoulder: Palpation

Shoulder-Range of Motion Must do both Active and Passive!!! Must do both Active and Passive!!! Must do each side separate Must do each side separate Flexion and Extension Flexion and Extension Internal and External rotation Internal and External rotation Abduction Abduction Adduction Adduction

Shoulder-Range of Motion Must do both Active and Passive!!! Must do both Active and Passive!!! Must do each side separate Must do each side separate Flexion and Extension Flexion and Extension Internal and External rotation Internal and External rotation Abduction Abduction Adduction Adduction

Shoulder-Range of Motion Must do both Active and Passive!!! Must do both Active and Passive!!! Must do each side separate Must do each side separate Flexion and Extension Flexion and Extension Internal and External rotation Internal and External rotation Abduction Abduction Adduction Adduction

Shoulder-Range of Motion Must do both Active and Passive!!! Must do both Active and Passive!!! Must do each side separate Must do each side separate Flexion and Extension Flexion and Extension Internal and External rotation Internal and External rotation Abduction Abduction Adduction Adduction

Shoulder-Stability Testing Sulcus sign Sulcus sign Apprehension Sign Apprehension Sign

Shoulder-Stability testing Sulcus sign Sulcus sign Apprehension sign Apprehension sign

Elbow-Cartoon Anatomy

Elbow-X-ray Anatomy

Elbow-Inspection

Elbow-Inspection

Elbows: Palpation Lateral epichondyle Medial epichondyle

Elbows: Palpation

Elbow: Range of Motion Flexion and Extension Flexion and Extension Pronation and Supination Pronation and Supination

Elbow: Range of Motion Flexion and Extension Flexion and Extension Pronation and Supination Pronation and Supination Pronation

Elbow: Range of Motion Flexion and Extension Flexion and Extension Pronation and Supination Pronation and Supination Pronation

Elbow: Range of Motion Flexion and Extension Flexion and Extension Pronation and Supination Pronation and Supination Supination

Elbow: Range of Motion Flexion and Extension Flexion and Extension Pronation and Supination Pronation and Supination Supination

Elbow: Stability testing Varus Varus Valgus Valgus

Elbow: Stability testing Varus Varus Valgus Valgus

Wrists-Cartoon Anatomy

Wrists-Xray Anatomy

Wrist-Palpation Distal radus and radial styloid Distal radus and radial styloid Distal ulna and ulnar styloid Distal ulna and ulnar styloid

Wrist-Palpation Anatomical “Snuffbox” Anatomical “Snuffbox”

Wrist: Range of Motion Flexion Flexion Extension Extension

Wrist: Range of Motion Flexion Flexion Extension Extension

Wrist: Range of Motion Radial- deviation Radial- deviation Ulnar deviation Ulnar deviation

Wrist: Range of Motion Radial- deviation Radial- deviation Ulnar deviation Ulnar deviation

Wrist: Special Test Tinel’s Sign Tinel’s Sign –This is a tapping over any area over any nerve. –Most commonly associated with wrist Phalen’s sign Phalen’s sign

Wrist: Special Test Tinel’s Sign Tinel’s Sign Phalen’s sign Phalen’s sign –Hold wrists for seconds –What nerve are we compressing? –What area will become numb?

Hands-Carton Anatomy Profundus or superficialis?

Hands: Inspection

Hands: Palpation Metacarpal Phalangeal joints (MCP joints) Metacarpal Phalangeal joints (MCP joints) Proximal Interphalangeal Joints (PIP) Proximal Interphalangeal Joints (PIP) Distal Interphalangeal Joints (DIP) Distal Interphalangeal Joints (DIP)

Hands: Palpation Metacarpal Phalangeal joints (MCP joints) Metacarpal Phalangeal joints (MCP joints) Proximal Interphalangeal Joints (PIP) Proximal Interphalangeal Joints (PIP) Distal Interphalangeal Joints (DIP) Distal Interphalangeal Joints (DIP)

Hand and Finger: Range of Motion Flexion Flexion Extension Extension Abduction Abduction Adduction Adduction Thumb opposition Thumb opposition

Hand and Finger: Range of Motion Flexion Flexion Extension Extension Abduction Abduction Adduction Adduction Thumb opposition Thumb opposition

Hand and Finger: Range of Motion Flexion Flexion Extension Extension Abduction Abduction Adduction Adduction Thumb opposition Thumb opposition

Hand and Finger: Range of Motion Flexion Flexion Extension Extension Abduction Abduction Adduction Adduction Thumb opposition Thumb opposition

Hand and Finger: Range of Motion Flexion Flexion Extension Extension Abduction Abduction Adduction Adduction Thumb opposition Thumb opposition

Hip-Cartoon anatomy

Hip: X-ray anatomy

Hip: Gait pattern

Hip:Surface Anatomy

Hip: Palpation

Hip: Range of Motion Flexion Flexion Extension Extension Internal Internal External External Abduction Abduction Adduction Adduction

Hip: Range of Motion Flexion Flexion Extension Extension Internal Internal External External Abduction Abduction Adduction Adduction

Hip: Range of Motion Flexion Flexion Extension Extension Internal Internal External External Abduction Abduction Adduction Adduction

Hip: Range of Motion Flexion Flexion Extension Extension Internal Internal External External Abduction Abduction Adduction Adduction

Hip: Range of Motion Flexion Flexion Extension Extension Internal Internal External External Abduction Abduction Adduction Adduction One hand should be on leg and the other on the iliac crest

Hip: Stability examination Barlow test Barlow test Ortolani test Ortolani test

Hip: Stability examination Barlow test Barlow test Ortolani test Ortolani test You cannot dislocate a normal child’s hip!!!!

Knees: Cartoon anatomy

Knees: X-ray anatomy

Knees: Surface anatomy and inspection

VarusValgus

Knees: Palpation Patella Patella Patella tendon Patella tendon Quad tendon Quad tendon Tibial Tubercle Tibial Tubercle

Knees: Palpation Patella Patella Patella tendon Patella tendon Quad tendon Quad tendon Tibial Tubercle Tibial Tubercle

Knees: Palpation Patella Patella Patella tendon Patella tendon Quad tendon Quad tendon Tibial Tubercle Tibial Tubercle

Knees: Palpation Patella Patella Patella tendon Patella tendon Quad tendon Quad tendon Tibial Tubercle Tibial Tubercle

Knees: Palpation Medial joint line Medial joint line Lateral joint line Lateral joint line

Knees: Palpation Medial joint line Medial joint line Lateral joint line Lateral joint line

Knees: Range of Motion Flexion Flexion Extension Extension

Knees: Range of Motion Flexion Flexion Extension Extension

Knees: Stability Examination Varus Varus Valgus Valgus

Knees: Stability Examination Varus Varus Valgus Valgus

Knees: Stability Examination Anterior drawer (at 90 degrees flexion) Anterior drawer (at 90 degrees flexion) –Lachman’s maneuver Posterior drawer Posterior drawer

Knees: Stability Examination Anterior drawer (at 90 degrees flexion) Anterior drawer (at 90 degrees flexion) –Lachman’s maneuver (at 30 degrees of flexion) Posterior drawer Posterior drawer

Knees: Stability Examination Anterior drawer (at 90 degrees flexion) Anterior drawer (at 90 degrees flexion) –Lachman’s maneuver (at 30 degrees of flexion) Posterior drawer Posterior drawer

Knees: Special Tests Bulge sign or Balloon sign Bulge sign or Balloon sign

Knees: Special Tests McMurray’s test- medial McMurray’s test- medial –While Palpating medial joint line, axially load and externally rotate the foot –This “loads” the medial meniscus

Knees: Special Tests McMurray’s test- Lateral McMurray’s test- Lateral –While Palpating lateral joint line, axially load and internally rotate the foot –This “loads” the lateral meniscus

Ankles and Feet: Cartoon Anatomy

Ankles and Feet: X-ray Anatomy

Ankles: palpation of ankle Palpate: Anterior aspect of joint Anterior aspect of joint Achilles tendon Achilles tendon Medial and lateral malleoli Medial and lateral malleoli

Ankles: palpation of ankle Palpate: Anterior aspect of joint Anterior aspect of joint Achilles tendon Achilles tendon Medial and lateral malleoli Medial and lateral malleoli

Ankles: palpation of ankle Palpate: Anterior aspect of joint Anterior aspect of joint Achilles tendon Achilles tendon Medial and lateral malleoli Medial and lateral malleoli

Ankles: palpation of ankle Palpate: Plantar Fascia Plantar Fascia Anterior Talo- Fibular Ligament Anterior Talo- Fibular Ligament

Ankles: palpation of ankle Palpate: Plantar Fascia Plantar Fascia Anterior Talo- Fibular Ligament Anterior Talo- Fibular Ligament

Foot: palpation Palpate: Metatarsal heads Metatarsal heads

Foot and Ankle: Range of Motion Flexion Flexion Extension Extension Inversion Inversion Eversion Eversion

Foot and Ankle: Range of Motion Flexion Flexion Extension Extension Inversion Inversion Eversion Eversion

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