Abstract
The clinical examination is an important part of any patient consultation. After the primary survey and taking the patient history, a more in-depth examination is sometimes required to aid making a working diagnosis and help negate other differential diagnoses. The extent of this depends on the stability of the patient and may not be possible in time-critical circumstances. However, clinical examination is an increasing part of paramedic practice owing to the continued expansion of the scope of the paramedic role in both urgent and emergency care. Education on clinical examination concerning each of the main body systems is now an integral part of undergraduate paramedic curricula.
This clinical examination series provides a step-by-step overview for each of the main body systems. Continuing professional development (CPD) is an essential requirement for all clinicians to maintain and to demonstrate that they are staying up to date and advancing in their roles.
This series gives an overview of each type of examination to support students, newly qualified paramedics and paramedics wishing to use these articles as a CPD development activity and an aide-memoire for clinical practice. This article, which explores the the upper musculoskeletal system, gives an overview of initial examination considerations.
How to use these guides
The articles in this series, which can be torn out for use in practice, are intended to support clinician development and to assist in the overall assessment of patient presentations. The information should be used to aid consideration of differential diagnoses in situations where life-threatening conditions have been ruled out.
The extent and explanation of each examination will not be to the depth of those provided in core literature texts, so further reading and consolidation are advised to support understanding supplemental to these articles. Key questions are included for reader consideration and to direct further study.
Most examinations are taught in a rigid format. However, in clinical practice, practitioners need to be flexible and adapt their approach depending on the presenting condition and circumstances. While there is no single set way to carry out each of these examinations, a good structure will reduce omissions and errors, and support the gathering of information to inform patient care.
Contemporary texts provide the underpinning reference sources throughout this series, as many of the examination processes and techniques are universally applied; however, differences will be highlighted. Readers will be signposted to these key texts for each clinical examination.
The series will cover the following systems:
Cardiovascular system
Peripheral vascular system
Neurological system (upper and lower limbs)
Cranial nerves
Gastrointestinal system
Respiratory system
Musculoskeletal system
Musculoskeletal examination
This article sets out a structured approach to aid with the assessment of the upper musculoskeletal (MSK) system, with assessment of the lower MSK following next month.
The joints of the upper MSK system are examined in turn, according to the ‘look, feel, move and function’ structure outlined below. Familiarity with the techniques and processes for each joint will foster confidence in patient assessment and form a foundation for further research and knowledge with regard to diagnosis and treatment.
This examination comprises a mixture of observation and physical assessment, and should always be carried out in conjunction with the patient's history-taking. Taking a history from the patient will allow you to gauge their normal levels of movement through information they provide regarding their activities of daily living (Bickley and Szilagyi, 2017).
A general survey of the patient will provide an overview and, alongside specific information regarding the mechanism of injury, will help to inform the MSK examination as you proceed (Innes et al, 2018). No specific equipment is required for the examination of the MSK joints unless specific data are being collected (e.g. a range of movement or test of power).
General observations
The examination of the joints of the body can be structured using: look; feel; move; and function (Bickley and Szilagyi, 2017).
Look
Observe posture, symmetry, skin changes, scars and swelling.
Look for changes in the patient's posture. This should be considered from different angles, i.e. the front, side and back
Consider the area in symmetry; for example, what does the patient's left wrist look like in comparison to the right? Look for scars, swelling and skin changes
Although reddening is a classic sign of inflammation, its presence is less reliable in joints and less likely to be present except in the fingers, toes and knees where the joint is more superficial (Bickley and Szilagyi, 2017)
If there is pain in the joint or the degree of movement is reduced, imaging should be considered before movement (Innes et al, 2018). Local guidelines should be followed for pain relief.
REFLECTION
Consider bedside items that may indicate a chronic or ongoing musculoskeletal illness or injury
Feel
Feel for temperature, tenderness and swelling at the joint and around it.
Look for evidence of temperature changes
Check for swelling, which may indicate the presence of arthritis or inflammation
Note any crepitus, where a crunching is heard or felt during the movement of tendons or ligaments over bones or areas of cartilage loss (Bickley and Szilagyi, 2017); this may be found during the examination but should not be actively sought during movement or palpation
Maintain an index of suspicion for possible fractures, which would indicate that support and immobilisation are needed, rather than a movement assessment
Observing and communicating with the patient during palpation will help to identify areas of tenderness.
REFLECTION
What aspects of your bedside manner would be important in establishing a rapport with the patient before and during the palpation of a joint?
Consider why it may be important to examine the joint above or below the one initially indicated
Move
Consider the range of movement for the limb being examined, including extension, flexion, abduction and adduction as appropriate.
Try to begin each movement with the patient facing forward with their hands at their sides as demonstrated by the anatomical position (Agur and Dalley, 2019). This will ensure there is no confusion regarding the location of any abnormality identified
If the patient can mirror your actions, this may help with communication
Special function tests are specific to the joint being examined and common injuries to that joint
The examination of range of movement involves active and passive movements. The purpose of this is to determine the degree of movement in the joint being examined. Passive examination should follow active so the patient's own range of movement can be observed first (Innes et al, 2018)Active movement is where the patient moves independently, with no help from the clinician (Innes et al, 2018)Passive movement is where the patient relaxes and the clinician makes the movement. Relaxation is important; if the patient is tense, more rigidity in the limbs will make passive movement more difficult.
REFLECTION
Ensure you are clear about each directional movement by documenting the location of injuries using directional terms such as lateral, medial and superior
Shoulder
The shoulder consists of three joints: the sternoclavicular, acromioclavicular and glenohumeral (Agur and Dalley, 2019). Movement and stability of the shoulder is aided by the rotator cuff muscles of the supraspinatus, subscapularis, teres minor and infraspinatus (Innes et al, 2018).
Look
Consider muscle wasting around the shoulder joint including the supraspinatus, trapezius, pectoralis and deltoid muscles
Inspect the patient from the front and back, observing any asymmetry. Is there an obvious dislocation of the humerus or winging of the scapula (Innes et al, 2018)?
Feel
Feel for temperature changes, swelling and tenderness around the joint.
Work from the front at the superior aspect of the sternum along the clavicle to the humeral head and round the back to the scapula or shoulder blade
Further anatomical features, such as the acromion process and coracoid process, should also be checked. A process is an area of bone that protrudes (Agur and Dalley, 2019).
Move
Observing movement of the joint should begin with the patient facing forward with their hands at their sides and palms to the front. The following movements may be with the patient's arm straight or bent at the elbow
The patient should attempt to move their arm forward in flexion and back in extension of the shoulder. Shoulder abduction could be up to 90° or 180°
Any area of discomfort or difficulty felt during this movement should be noted as different muscles contribute to stages or degrees of the movement, and this could help identify the area affected (Innes et al, 2018)
Shoulder adduction can be achieved by crossing the arms in front of the torso
Internal and external rotation starts with the arm at the patient's side and the elbow flexed at 90°The hand and arm should be in a forward position to begin with, and move laterally for external rotation and medially for internal rotationThe arm should be kept in the same position throughout the movements
Asking the patient to place their hands behind their head allows for external rotation and abduction to be observed; moving the hand up the spine shows the degree of internal rotation and adduction
Difficulty with these movements may suggest a rotator cuff disorder (Bickley and Szilagyi, 2017)
Any crepitus during movement should be noted although not actively sought.
REFLECTION
Consider the muscles used in the rotator cuff movement of the shoulder as this is a common area of a shoulder injury
Elbow
The elbow is the joint between the humerus above, and the radius and ulna below (Agur and Dalley, 2019).
Look
Look at the carrying angle of the elbow, as the position in which the arm is resting may indicate asymmetry. A deformity in the carrying angle may indicate the need for further assessment to determine whether this is reducible or fixed (Innes et al, 2018)
Examine for swelling around the olecranon and epicondyle
Skin changes could indicate psoriasis, bursitis or nodules under the skin (Innes et al, 2018).
Feel
The bones in the elbow joint are relatively easy to palpate as the musculature tends to be distal and proximal to the articulating surface (Bickley and Szilagyi, 2017)
At the base of the humerus, there are two epicondyles: a lateral and medial epicondyle (Agur and Dalley, 2019)
The epicondyles can be palpated either side of the olecranon process, which is the medial prominence felt at the base of the ulna when the arm is fully flexed at the elbow
Palpating the radius bone from the thumb side of the wrist to the elbow will determine the position of the radial head
Having the arm in different positions may assist with palpating the bony landmarks.
Move
Testing movement begins with the patient facing forward with palms front and arms straight and by their sides
Consider asking the patient to mirror your movements for ease of explanation
Bringing the hand up to the shoulder with bending at the wrist will produce flexion; fully straightening the arm will show extension
The brachioradialis and the bicep aid flexion at the elbow and the tricep aides extension
Supination and pronation are achieved by bending the arm at 90°, with the forearm palm up for supination and palm down for pronation
The movements with the elbow flexed at 90° with palm up (supination) and palm down (pronation) are produced by the supinator and pronator muscles
Passive movement will require the clinician to support the limb above the elbow
Supporting the limb helps to prevent the patient from using the shoulder joint during active movement (Bickley and Szilagyi, 2017).
REFLECTION
Consider golfer's and tennis elbow and, using the above examination techniques; think about the differing presentations of medial and lateral epicondylitis
Hand and wrist
For this examination, the patient may sit with their arms resting on a pillow.
Look
Look for any deformities of the fingers such as Z deformities or deviation of the hand's position from the ulnar side (Bickley and Szilagyi, 2017)
There may be muscle wasting around the thenar and hypothenar eminences
As well as symmetry and swelling at the joints, look for any skin changes such as bruising, scars or thinning
Look for carpal tunnel scars medially to the radial pulse.
Feel
Palpating the joints of the fingers and wrist may reveal inflammatory swelling such as that found in arthritis
Begin with the distal, middle and proximal phalanges of the fingers, then palpate the metacarpal bones of the hand and wrist
A bimanual palpation will help to identify abnormalities through asymmetry.
Movement
In flexion, the fingers are closed in a grip; in extension, the fingers are straightened
In abduction, the fingers are spread open and adducting the fingers closes them
The movement of individual or all digits may be assessed depending on the presenting condition
As a function test, you can ask the patient to grip your forefinger and index finger in their hand or to pick up a small object, such as a coin (Bickley and Szilagyi, 2017)
These tests will help to determine weakness within the hand and wrist muscles.
REFLECTION
Consider the different types of arthritis and how they may present
The forthcoming article in this series will continue with this assessment, moving on to the lower MSK system.
