MSk

Musculoskeletal Assessment for Nurse Practitioners

  • Comprehensive study guide for advanced health assessment and NP certification exam preparation.

  • Focuses on high-yield musculoskeletal examination techniques, diagnostic maneuvers, and clinical decision-making for common orthopedic conditions across the lifespan.

Knee Examination: Essential Special Tests

Ligamentous Stability Tests

  • Anterior Drawer Test:

    • Purpose: Assesses anterior cruciate ligament (ACL) integrity.

    • Technique: With the knee flexed at 90°, pull tibia forward.

    • Positive Test: Excessive anterior translation compared to the opposite knee indicates ACL tear.

  • Lachman Test:

    • Purpose: More sensitive test for ACL injury.

    • Technique: Knee flexed at 20-30°, stabilize femur and pull tibia anteriorly.

    • Positive Test: Soft or absent endpoint suggests ACL injury; considered the gold standard for ACL assessment.

  • Posterior Drawer Test:

    • Purpose: Evaluates posterior cruciate ligament (PCL).

    • Technique: Push tibia posteriorly with the knee at 90°.

    • Positive Test: Excessive posterior movement indicates PCL rupture.

Meniscal Injury Tests

  • McMurray Test:

    • Purpose: Detects meniscal tears.

    • Technique: Flex the knee maximally, externally rotate tibia and extend knee for medial meniscus; internally rotate for lateral meniscus.

    • Positive Test: Palpable click or pop with pain suggests a tear.

  • Apley Compression Test:

    • Purpose: Distinguishes meniscal pathology from ligamentous injury.

    • Technique: Patient prone, knee flexed at 90°. Apply downward pressure while rotating tibia.

    • Positive Test: Pain indicates meniscal injury.

  • Bulge Sign (Ballottement):

    • Purpose: Assesses for knee effusion.

    • Technique: Stroke medial side of the knee upward, then tap lateral side.

    • Positive Test: Fluid wave returning to the medial side confirms small effusion; critical for early joint inflammation detection.

Hip Assessment and Pediatric Conditions

Legg-Calvé-Perthes Disease

  • Age: 4-8 years, male predominance (4:1).

  • Presentation: Insidious limp, hip/knee pain, limited abduction and internal rotation.

  • Pathophysiology: Avascular necrosis of the femoral head.

  • Exam Findings: Antalgic gait, decreased range of motion (ROM), especially abduction.

  • Action: Requires orthopedic referral and imaging; X-ray shows femoral head flattening.

Slipped Capital Femoral Epiphysis (SCFE)

  • Age: 10-16 years, often in obese adolescents.

  • Presentation: Hip, thigh, or knee pain; limping.

  • Key Finding: Affected leg externally rotated and shortened; limited internal rotation and flexion.

  • Emergency: Acute slips require immediate orthopedic referral to prevent avascular necrosis; X-ray shows posterior/inferior displacement of the femoral epiphysis.

Osgood-Schlatter Disease

  • Age: Active adolescents 10-15 years during growth spurts.

  • Presentation: Anterior knee pain over tibial tuberosity, worsened by running, jumping, kneeling.

  • Exam Findings: Tenderness, prominent tibial tubercle; pain with resisted knee extension.

  • Management: Usually self-limiting; treatment includes rest, ice, NSAIDs, quadriceps stretching; resolves with skeletal maturity.

Pediatric Lower Extremity Alignment

Genu Varum (Bowlegs)

  • Definition: Outward bowing of legs with knees apart when ankles together.

  • Normal Range: Birth to 18-24 months due to intrauterine positioning.

  • Concerning Findings:

    • Persistence beyond age 2,

    • Unilateral bowing,

    • Worsening deformity,

    • Intercondylar distance >6cm suggests pathologic causes (e.g., Blount disease, rickets).

  • Referral: If asymmetric, progressive, or beyond normal age range.

Genu Valgum (Knock-Knees)

  • Definition: Inward angulation with knees touching, ankles apart.

  • Normal Range: Peaks at ages 3-4 years; gradually resolves by age 7-8.

  • Concerning Findings:

    • Intermalleolar distance >8cm,

    • Asymmetry,

    • Pain,

    • Persistence beyond age 8 years.

  • Assessment: Measure distance between medial malleoli with knees together and monitor growth curves.

Pediatric Gait Development

  • 12-15 months: Wide-based gait, arms in high guard position, feet flat.

  • 18 months: Narrower base, initiation of reciprocal arm swing.

  • 2-3 years: Mature heel-to-toe pattern emerges; improved balance.

  • 4 years: Adult-like gait pattern established.

  • Red Flags: Persistent toe-walking beyond age 2, asymmetric gait, regression of milestones require further evaluation.

Scoliosis Screening and Assessment

Screening Importance

  • Essential during adolescence, particularly for girls ages 10-14 during peak growth velocity.

Adams Forward Bend Test

  • Standard Screening Maneuver: Reveals rib humps or paraspinal prominences indicative of vertebral rotation.

Visual Inspection

  • Patient standing for assessment:

    • Shoulder height symmetry,

    • Scapular prominence,

    • Waist crease asymmetry,

    • Overall spinal alignment.

  • Note any obvious lateral curvature or trunk shift.

Scoliometer Measurement

  • Technique: Place scoliometer across apex of rib hump or paraspinal prominence during forward bend.

  • Readings: ≥7° angle of trunk rotation (ATR) warrants orthopedic referral and radiographic evaluation; document measurement location (thoracic vs. lumbar).

Referral Needs

  • Refer if:

    • ATR ≥7°,

    • Rapidly progressive curve,

    • Presence of pain (suggests non-idiopathic causes),

    • Neurological findings,

    • Curve noted before age 8.

  • Confirmation: Cobb angle >10° on X-ray confirms scoliosis diagnosis.

Juvenile Idiopathic Arthritis and Gower Sign

Juvenile Idiopathic Arthritis (JIA)

  • Definition: Most common chronic rheumatic disease in children, onset before age 16.

  • Presentation: Joint swelling, morning stiffness lasting >15 minutes, decreased ROM, warmth without erythema; systemic symptoms may include fever, rash, lymphadenopathy.

  • Exam Findings: Boggy joint swelling, limited ROM, growth disturbances, leg length discrepancy.

  • Action: Immediate rheumatology referral for diagnosis, initiation of DMARDs, and monitoring; uveitis screening is essential.

Gower Sign

  • Classic Indicator: Proximal muscle weakness, indicative of muscular dystrophy (e.g., Duchenne).

  • Behavior: Child