Examination skills of the musculoskeletal system Dr ARIANNIA

Competencies  Elicit a health history from a patient with a musculoskeletal chief complaint.  Perform inspection and palpation of the musculoskeletal system.  Describe the range of motion movements of the major joints. Copyright 2002, Delmar, A division of Thomson Learning (continues)

Health History  Family history  Rheumatoid arthritis  Paget’s disease  Osteoporosis  Social history  Alcohol or tobacco use  Work environment: role of repetitious movements  Home environment: physical layout/barriers Copyright 2002, Delmar, A division of Thomson Learning (continues)

Common Chief Complaints  Pain  Weakness  Limited movement  Stiffness  Deformity Copyright 2002, Delmar, A division of Thomson Learning

Normal Findings  Normal muscle tone  No crepitus or masses  Joints without pain, tenderness, or swelling  Full ROM  Normal muscle strength  Muscle strength is equal bilaterally  No lordosis, kyphosis, or scoliosis Copyright 2002, Delmar, A division of Thomson Learning

General Assessment  Overall appearance  Posture  Gait and mobility  Weight-bearing status  Gait patterns  Transfer ability Copyright 2002, Delmar, A division of Thomson Learning (continues)

deformity

Red hot joint

DIP joint arthritis

Acute gout with desquamation of the skin

Sausage finger

Psoriatic dactylitis and arthropathy

Swollen hand

PIP palpation

MCP palpation

KNEE palpation

Inspection  Muscle size and shape  Hypertrophy  Atrophy  Involuntary muscle movements  Limb circumference  Joint contour and periarticular tissue Copyright 2002, Delmar, A division of Thomson Learning (continues)

ARTHRITIS

Severe rheumatoid arthritis of the hands. Progressive and longstanding disease may result in deformity, subluxation, or ankylosis of the joints. Ulnar deviation of the fingers is typical of the later stage of the disease, and severe muscle wasting with large tendon sheath effusions may also be seen.

severe muscle wasting IN RA

Tenderness and swelling ofthe metatarsophalangeal joints: the feet are usually affected early. Fibular deviation of the toes may occur at a later stage.

episcleritis. This is a common ocular complication of rheumatoid arthritis and generally indicates a poor prognosis. It is often associated with skin nodules, a high titre of rheumatoid factor, and sometimes vasculitis. The incidence of iritis in rheumatoid arthritis is no greater than that found in the general population.

Rheumatoid scleritis is more serious and may eventually lead to involvement of the whole uveal tract with risk of eventual glaucoma. Blue discolouration of the sclera may eventually occur.

Early psoriasis of the nails ('thimble pitting‘)

Advanced nail psoriasis shows dystrophy of the nails, discolouration and sub-ungual separation. Note the swelling of several terminal interphalangeal joints associated with the neighbouring nail dystrophy. It would seem that nail involvement in some way enhances liability to develop arthropathy, since 80% of patients with psoriatic arthritis have both skin and nail lesions.

PSORIATIC LESION

Keratodennia blennorrhagica occurs in more severe relapsing cases, and is often confined to the feet and lower legs

Nail dystrophy in Reiter's syndrome with inflammatory changes in the distal interphalangeal joints of the toes.

Advanced Heberden's nodes affecting all the terminal interphalangeal joints. Lateral deviation of the terminal phalanx may occur as seen in the left index and middle fingers.

Involvement of the proximal interphalangeal joints by osteoarthrosis is less common, the associated swellings being known as Bouchard's nodes, as seen here particularly affecting the fingers of the right hand. Early Heberden's nodes are also present in the thumbs and index fingers.

Hallux rigidus. The hallux is the most commonly affected joint, resulting in valgus deformity.

'Butterfly rash' is the most common skin manifestation of SLE. This is a sunlight sensitive rash occurring over the bridge of the nose and cheeks. Note the bullous eruption around the lips.

Early scleroderma of the fingers. The skin is thickened, waxy in appearance, and bound down to underlying tissue.

Widespread scleroderma affecting hands, trunk and face. There is widespread telangiectasia, and thickened skin around the mouth.

photosensitivity

Oral ulcer

DLE lesion

dermatomyositis

Periungual erythema

Mechanical hand

Raynaud phenomenon

Pitting ulcer

calsinosis

Salt and paper appearance

Hyperextension of little finger to at least 90°.

Hyperextension of wrist enabling the thumb to touch the forearm.

Hyperextension of elbows (and of the knees) is another feature.

Hyperflexion of the lumbar spine and hips.

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