Question

Discuss the assessment of the musculoskeletal system of a high school student, focusing on the spine and include one usual abnormal finding.

For each assessment, please be sure to name the instruments that would be used in the process. Please limit answer to 4 paragraphs only.

Answer 1

In examining the musculoskeletal system it is important to keep the concept of function in mind. Note any gross abnormalities of mechanical function beginning with the initial introduction to the patient. Continue to observe for such problems throughout the interview and the examination.

On a screening examination of a patient who has no musculoskeletal complaints and in whom no gross abnormalities have been noted in the interview and general physical examination, it is adequate to inspect the extremities and trunk for observable abnormalities and to ask the patient to perform a complete active range of motion with each joint or set of joints.

If the patient presents complaints in the musculoskeletal system or if any abnormality has been observed, it is important to do a thorough musculoskeletal examination, not only to delineate the extent of gross abnormalities but also to look closely for subtle anomalies.

To perform an examination of the muscles, bones, and joints, use the classic techniques of inspection, palpation, and manipulation. Start by dividing the musculoskeletal system into functional parts. With practice the examiner will establish an order of approach, but for the beginner it is perhaps better to begin distally with the upper extremity, working proximally through the shoulder. Then, beginning with the temporomandibular joint, pass on to the cervical spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, in the lower extremity, again begin distally with the foot and proceed proximally through the hip.

Use the opposite side for comparisons: it is easier to spot subtle differences as well as identify symmetrical problems. If there is any question, use your own anatomy as a control.

Glean the maximum information from observation. Concentrating on one area at a time, inspect the area for discoloration (e.g., ecchymoses, redness), soft tissue swelling, bony enlargement, wasting, and deformity (abnormal angulation, subluxation). While noting these changes, attempt to determine whether they are limited to the joint or whether they involve the surrounding structures (e.g., tendons, muscles, bursae).

Observe the patient's eyes while palpating the joints and the surrounding structures. A patient's expression of pain depends on many factors. For this reason the verbalization of pain often does not correlate directly with the magnitude of the pain. The most objective indicator of the magnitude of tenderness produced by presence on palpation is involuntary muscle movements about the eyes. Therefore, the examiner should observe the patient's eyes while palpating the joints and surrounding structures. With practice the examiner will become skilled in evaluating the magnitude of pain produced by the examination and will be able to do a skillful evaluation without producing excessive discomfort to the patient. Note areas of tenderness to pressure, and if possible identify the anatomic structures over which the tenderness is localized.

One should also note areas of enlargement while palpating the joints and surrounding structures. By noting carefully the consistency of the enlargement and its boundaries, one can decide whether this is due to bony widening, thickening of the synovial lining of the joint, soft tissue swelling of the structure surrounding the joint, an effusion into the joint capsule, or nodule formation, which might be located in a tendon sheath, subcutaneous tissue, or other structures about the joint.

While palpating the joints, note areas of increased warmth (heat). A method for doing this that will help even the most inexperienced to perceive subtle increases in heat is to choose the most heat-sensitive portion of the hand (usually the dorsum of the fingers) and, beginning proximally, lightly pass this part of your hand over all portions of the patient's extremity several times. As you proceed from proximal to distal, the skin temperature gradually cools. If you find an area becoming slightly warmer, this represents increased heat.

Have the patient perform active movements through an entire range of motion for each joint. Defects in function can be most rapidly perceived by having the patient perform active functions with each region of the musculoskeletal system. This reduces examination time and helps the examiner to identify areas in which there is poor function for more careful evaluation.

Manipulate the joint through a passive range of motion only if the patient is unable actively to perform a full range of motion, or if there is obvious pain on active motion. In passively manipulating a joint, note whether there is a reduction in the range of motion, whether there is a pain on motion, and whether crepitus is produced when the joint is moved. Note also whether the joint is stable or whether abnormal movements may be produced.

Spine

Inspect the cervical spine for loss of the normal lordotic curve. Palpate for local areas of tenderness and crepitation. Next, ask the patient to put the chin on the chest to check flexion, to put first the right ear on the right shoulder and the left ear on the left shoulder for lateral flexion, and to extend the neck as far as possible by looking back over the ceiling as far as possible. Rotation is then checked by asking the patient to put the chin on the right shoulder and then the left shoulder.

Examine the thoracic and lumbar spine together. Examine the back and palpate for areas of muscle spasm and tenderness. Lightly percuss over the spinous processes throughout the spine to check further for tenderness. Observe the patient both standing and sitting from behind and from the side to check for kyphosis (an abnormal forward flexed position) and scoliosis (an abnormal curvature of the spine on one side or the other). The presence of scoliosis can best be judged by determining if a list is present. If the first thoracic vertebra is not centered over the sacrum, the patient is said to have a list. This can easily be measured by dropping a perpendicular from the first thoracic vertebra and measuring how far to the right or left of the gluteal fold it falls. If a list is demonstrated, scoliosis must be present. Also observe whether the lumbar lordosis is present in increased amount or abnormally absent.

Check for forward flexion in the sitting position by asking the patient to place the nose on the knee, and in the standing position by asking the patient to touch the toes. To check for lateral flexion, ask the patient to hyperextend the spine as much as possible and then to pass the hand straight down the thigh, first on the right and then on the left, keeping the hips straight. Ask the patient to maintain the pelvic girdle in a flexed position and rotate the shoulders first to the right and then to the left to check for rotation. With the patient standing, check for a pelvic tilt by placing your hands on the iliac crests and observing if these are parallel. Angles of motion can be estimated from an imaginary line passing straight up through the spine, perpendicular to the floor or to the table. It is very difficult to measure these accurately or to list accurate normal measurements. The most accurate parameter of measurement is the amount of lengthening of the spine in forward flexion. The normal spine should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area on forward flexion.

Costovertebral joint motion can be measured by placing the hands with fingers spread on the thorax and having the patient inspire and expire fully. If there is an abnormality, an accurate measurement of chest expansion at the nipple line should be recorded as a baseline.

For straight leg raising tests, ask the patient to lie with the spine on the table and to relax completely. With the knee fully extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced. If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve root irritation. The angle of elevation of the leg from the table at the point where pain is produced should be recorded.

The sacroiliac joints are examined by palpation and by light fist percussion for tenderness. Other maneuvers that might produce pain in a sacroiliac joint when inflammation is present are:

Compression of the iliac crests: This is performed by asking the patient to lie on his or her side, placing firm downward pressure on the upper iliac crest. If pain is produced by this maneuver in a sacroiliac joint, this can aid diagnosis; but the absence of pain does not rule out involvement of the sacroiliac joint.

Jarring the sacroiliac joint: The patient is asked to lie on his or her side, facing the examiner. The inferior leg is flexed at the hip and knee, and the upper leg is fully extended. Place your hand on the upper iliac crest and produce a sharp jar on the patient's flexed knee with the palm of your hand. Again, pain in a sacroiliac joint is considered a positive test, but a negative test does not rule out possible involvement of a sacroiliac joint.

Passive hyperextension of the lower extremity: Ask the patient to move close to the edge of the examining table in the supine position. With the patient fully relaxed, the examiner supports a lower extremity and slowly allows it to hyperextend passively over the side of the examining table.

PLEASE DO LIKE??