1. Musculoskeletal Examination Todd Milbrandt, MD, MS Pediatric Orthopaedic Surgeon

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

3. 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.

4. 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.

5. 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).

6. 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

7. 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!

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

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

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

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

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

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

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

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

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

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

18. 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!

19. 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

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

21. Shoulder-Cartoon Anatomy

22. The Shoulder- X-ray Anatomy

23. 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

24. 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

25. Shoulder: Palpation Acromioclaviular Joint

26. Shoulder: Palpation Acromion

27. Shoulder: Palpation

28. 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

29. 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

30. 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

31. 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

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

33. Shoulder-Stability testing Sulcus sign Sulcus sign Apprehension sign Apprehension sign

34. Elbow-Cartoon Anatomy

35. Elbow-X-ray Anatomy

36. Elbow-Inspection

37. Elbow-Inspection

38. Elbows: Palpation Lateral epichondyle Medial epichondyle

39. Elbows: Palpation

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

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

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

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

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

45. Elbow: Stability testing Varus Varus Valgus Valgus

46. Elbow: Stability testing Varus Varus Valgus Valgus

47. Wrists-Cartoon Anatomy

49. Wrists-Xray Anatomy

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

51. Wrist-Palpation Anatomical “Snuffbox” Anatomical “Snuffbox”

52. Wrist: Range of Motion Flexion Flexion Extension Extension

53. Wrist: Range of Motion Flexion Flexion Extension Extension

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

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

56. 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

57. Wrist: Special Test Tinel’s Sign Tinel’s Sign Phalen’s sign Phalen’s sign –Hold wrists for 30-60 seconds –What nerve are we compressing? –What area will become numb?

58. Hands-Carton Anatomy Profundus or superficialis?

59. Hands: Inspection

61. 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)

62. 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)

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

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

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

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

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

68. Hip-Cartoon anatomy

69. Hip: X-ray anatomy

70. Hip: Gait pattern

71. Hip:Surface Anatomy

72. Hip: Palpation

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

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

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

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

77. 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

78. Hip: Stability examination Barlow test Barlow test Ortolani test Ortolani test

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

80. Knees: Cartoon anatomy

81. Knees: X-ray anatomy

84. Knees: Surface anatomy and inspection

85. VarusValgus

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

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

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

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

90. Knees: Palpation Medial joint line Medial joint line Lateral joint line Lateral joint line

91. Knees: Palpation Medial joint line Medial joint line Lateral joint line Lateral joint line

92. Knees: Range of Motion Flexion Flexion Extension Extension

93. Knees: Range of Motion Flexion Flexion Extension Extension

94. Knees: Stability Examination Varus Varus Valgus Valgus

95. Knees: Stability Examination Varus Varus Valgus Valgus

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

97. 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

98. 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

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

100. 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

101. 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

102. Ankles and Feet: Cartoon Anatomy

103. Ankles and Feet: X-ray Anatomy

104. 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

105. 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

106. 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

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

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

109. Foot: palpation Palpate: Metatarsal heads Metatarsal heads

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

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

112. Whew!!!! You made it!!! Thanks for listening Thanks for listening Watch the videos on the knee exam and shoulder examination Watch the videos on the knee exam and shoulder examination My contact info My contact info Phone 859 266 2101 Email: tmilbrandt@shrinenet.org