Diagnosis of Musculoskeletal Disorders and Injuries

The investigation to make diagnosis of musculoskeletal disorders and injuries

proceeds in the following order : 1) history taking (symptomps), 2) physical

examination (signs), 3) diagnostic imaging (imaging signs), and 4) laboratory

investigation (including examination of various body fluid as well as examination

of a specimen, or biopsy of diseased tissue). Symptoms provide subjective data,

whereas phisical signs, imaging signs, and the result of laboratory test provode

objective data.(1)

The Patient’s Story (Clinical History)

In the current era of dramatic technological advances in a wide variety of

diagnostic methods, it is more important than ever to appreciate that in most

cases, a carefull and accurately obtained clinical history from the patient or the

patient’s relkatives (or both) still contributes significantly more to a correct

diagnosis than do the physical examination, diagnostic imaging, and laboratory

investigation combined.(1)

Important Data in the Patient’s History

Preliminary Data

The patient’s name, sex, date of birth and present age, occupation, and family

responsibilities are the first items of information obtained.(1)

The Presenting Problem of Chief Complaint

The chief complaint is the main symptom, or group of symptoms, that have

prompted the patient to seek help and advice. Your opening inquiry about this

should not be “What is wrong with you?” because such question invites the

obvious reaction, either silent or expressed : “That is what I have come to find out

from you!” A preferrable beginning is, “What have you noticed or felt that does

not seem tight to you?” Having listened to your patient describe the chief

complaints in his or her own words, you need to obtain more precise information

by asking further questions to determine the following : time of onset, type of

onset (sudden or gradual), severity, constancy (constant or intermittent),

progression, activities that aggravate it and those that relieve it, relation to any

injury or other incident, and any associated symptoms.(1)

Common Musculoskeletal Symptoms or Complaints

The following are the main reasons why a patient with a musculoskeletal

condition seeks consultation with a medical practitioner : (1)

1. Pain. By far the most important presenting symptom is pain, and you must

inquire about it in great detail with respect to its onset, precise location,

character (dull, sharp, burning), severity, duration, factors that relieve the pain

as well as those that aggravate it, and its variation with day and night. Most

musculoskeletal pain is aggravated by intermittent local movement and is

relieved by local rest; this suggest that during movement, such pain is caused

by sudden increase in either tension or pressure in sensitive soft tissues such

as periosteum (mevement at a fracture site) or joint capsule and ligaments

(movement in a joint). Pain that persist inspite of local rest suggests

progressively increasing pressure in closed space, such as occurs with an

increasing amount of purulent exudate within the confines of a bone

(osteomyelitis) or within a joint cavity (septic arthritis) and also with a

progressively expanding bone neoplasm. Pressure on a nerve, or nerve root,

produces radiating pain in the sensory area of that nerve or nerve root; the ost

common example is sciatica, pain radiating down the lower limb in the

distribution of the sciatic nerve from pressure of a protruded intervertebral

disc on a nerve root. Remember also, the phenomenon of referred pain, the

most important example of which is pain felt in the knee (referred to the knee)

but arising from a painful lession in the hip cause by the obturator nerve

pattern of hip pain. Neurological lession may produce alterations in skin

sensation, including increased or painful feeling (hyperesthesia), decreased

feeling (hyposthesia), or peculiar feeling, for example, “pins and needles”

(paresthesia).

2. Decrease in function. Decreased ability to use a body part is also a common

presenting complaint (chief complaint) of patients with musculoskeletal

conditions. The patient may be concerned about decreased ability (disability)

caused by muscle weakness or fatigue, giving away (isntability) of a joint, or

stiffness of a joint.

3. Physical appearance. The patient’s chief complaint may be the physical

appearance of a deformity such as a crooked limb or limbs (angulatory

deformity), twisted limb (torsional or rotational deformity), a wasted limb

(atrophy), a short leg (leg length discrepancy), or a crooked back (scoliosis).

He or she may be concerned about the physical appearance of an abnormal

way of walking (limp or abnormal gait). You must determine when the

problem first noticed, its character, clinical course (getting better, getting

worse, or remaining unchanged), and the extent of any associated disability.

Relevant Past History

It is important to obtain a history of previous illness, injuries, and related

treatment, including vaccinations and operations.(1)

Functional Inquiry

Patients with disorders of the musculoskeletal system may have coexistent

disorders of some other body system, or systems, and hence the reason for

inquiring into function of all system s (functional inquiry). Some of the more

important conditions to include are heart disease, diabetes, kidney disease,

respiratory conditions, and psychogenic disturbances with either exaggeration or

falcification of symptoms.(1)

Social, Economic, and Work History

Since orthopaedic problems and their treatment frequently extend over long

periods, you must obtain the relevant details of the patient’s social, economic, and

work history so that the proposed plan of treatment will be feasible for the

particular patient.(1)

Family History

Because some musculoskeletal conditions (both congenital and acquired) show a

distinct tendency to appear in members of the same damily (either in the same or

in different generations), it is important to obtain such data concerning relatives

by means of a family history.(1)

Physical Examination

In a sense, the physical examination begins the moment the patient comes in

sight. Certain striking features about the patient – body build (habitus), facial

appearance (facies), way of walking (gait) as he or she approaches you, or the

sitting or lying position if you are approaching him or her (body language) – may

have already provided you with useful clues almost before you have had time to

say “How do you do”. The examination is conducted in a systematic order : 1)

looking (inspection); 2) feeling (palpation); 3) moving (assessment of joint

motion), both active and passive; 4) listening (auscultation) over joints and

vessels; 5) special physical tests to elicit or exclude specific physical signs; and 6)

the neurological examination.(1)

Figure 1 – Equipment for musculoskeletal examination : stethoscope (1), pocket flashlight (2),

skin marker (3), pins and cotton wool (4), tape measurement (5), reflex hammer (6), and

goniometer (to measure angles) (7). (1)

Looking (Inspection)

Confirm your earlier observations of the patient’s habitus and facies. Observe the

skin (redness, cyanosis, pigmentation), looking for atrophy, hypertrophy, and

scars of previous injury or operation. Look for any deformity, swelling, or lumps.

Measure any limb shortening or atrophy, always comparing the abnormal limb

with the ooposite limb. If the patient is able to walk, request him or her to do so,

back and forth in an unobstructed area, at least 20 feet long, because careful

observation of the patient’s gait may provide many important clues. Many of the

abnormal physical sign that are apparent on inspection are described and depicted

in subsequent chapters.(1)

Figure 2. Left – The areas of ight brown skin pigmentation (café au lait spots) in this boy are a

clue to the diagnosis of neurofibromatosis (Von Recklinghausen’s disease) (1)

Figure 3. Right – The cubitus varus deformity of this boy’s left arm is the result of an old

supracondylar fracture of the humerus that had been allowed to heal with varus angulation (1)

Figure 4. Left – The diffuse swelling of this boy’s left leg results from chronic edema secondary to

lymphatic vessel obstruction (1)

Fugire 5. Right – The lump on the medial side of this woman’s knee is a bony prominence caused

by a type of benign bone lesion, an osteochondroma (osteocartilaginous exostosis), arising from

the upper end of the tibia (1)

Feeling (Palpation)

By palpation you will obtain data concerning skin temperature, pulse, tenderness,

the nature of any swelling (indurated or edematous “pitting”), the characteristics

of a lump or mass (consistency, fluctuation, size, relationship to adjacent

structures), muscle bulk, and abnormal relationships of bones at their joints

(dislocations). With the combination of joint movement and palpation, you will

also detect joint crepitus as well as muscle tone.(1)

Moving (Assessment of Joint Motion)

Active movement of a joint by the patient should be assesed first; it may be

limited by pain nad associated muscle spasm, muscle weakness, ruptured muscle

or tendon, joint stiffness or joint contracture, or bony block. Passive movement of

joint by you, the examiner, should be assessed gently; it may be decreased for any

of the reasons already mentioned (except muscle weakness and ruptured muscle

or tendon) or it may be increased as in joint instability caused by a lax capsule or

torn ligaments. Abnormal ranges of joint motion, both active and passive, should

be recorded.(1)

Listening (Auscultation)

Sounds arising from bones (fracture crepitus), joints (joint crepitus), or muscle

action (snapping tendons) are sometimes sufficiently loud that they can be heard

by both you and the patient without any effort.(1)

PATHOLOGICAL FRACTURE

A pathologic fracture is one that occurs when the normal integrity and strength of

bone have been compromised by invasive disease or destructive processes. Causes

include neoplasm (primary tumor or metastatic disease), necrosis, metabolic

disease, disuse, infection, osteoporosis, or iatrogenic causes (e.g., surgical defect).(2)

Mechanism of Injury (2)

Pathological fractures may occur as a result of minimal trauma or even during

normal activities.

Alternatively, pathologic fractures may occur during high-energy trauma

involving a region that is predisposed to fracture.

History

When obtaining the patient history, consider : (3)

Prior symptoms. Pain present for a prolonged periode proir to fracture may

actually be a positive. It suggests a slow-growing lesion. In pediatric patients

in particular, there may have been no symptoms from an active bone tumor

prior to the fracture. In older patients, the fracture may be the latest

manifestation of a long history of metastatic bone disease.

Known primary cancer or symptoms that may suggest a primary

malignancy. If an adult patient has a known primary malignancy, determine

whether he or she has received or is receiving systemic therapy, and whether

he or she is known to suffer from extensive bone or visceral metastases.

Prior radiation to the site of fracture.

Extent of metastatic disease, if surgery is being considered to manage a

metastatic pathologic fracture.

Symptoms related to cervical spine involvement; lung, liver, and CNS

metastatic disease; and possible symptoms of hypercalcemia.

Suspicion of pathologic fracture should be raised in patients presenting with

fracture involving : (2)

Normal activity or minimal trauma

Excessive pain at the site of fracture prior to injury

Patients with a known primary malignant disease or metabolic disease

A history of multiple fractures

Risk factors such as smoking or environmental exposure to carcinogens

Physical Examination

In assessing the local site of a pathologic fracture : (3)

Ensure that the skin is intact and that there is no evidence of distal

neurovascular impairment. Open pathologic fractures and pathologic fractures

with neurovascular impairment are rare because these are generally not high-

energy injuries.

Evaluate the stability of the fracture.

Determine the extent of physiological impairment caused by the injury.

Evidence of articular involvement should be evaluated, especially in

pathologic fractures occurring through aggressive or malignant primary tumor,

which commonly effect the epiphyseal-metaphyseal portion of the bone. As a

result, they more commonly affect the joint than metastatic pathologic

fractures.

Complete a general examination in older patients. If there is no known

primary malignancy elsewhere, the common sites of tumors that metastasize

to bone should be evaluated (thyroid, breast, lungs, kidney and prostate).

Evidence of widespread metastases should be assessed by examining for

hepatic or splenic enlargement, CNS signs, and changes of pulmonary

osteoarthropathy.

Investigations

In discussing investigations of pathological fractures, it is also necessary to

describe management goals since in many cases, biopsy of the pathological

fracture is combined with stabilization of the fracture. However, appropriate

investigation should precede surgery.(3)

Order routine blood work, including complete blood count, erythro

sedimentation rate,  (CBC, ESR, Ca2+, PO4, alkaline phosphatase, serum

immune electrophoresis, and PSA) if there is no known primary cancer in an

adult patient.

Obtain liver function and coagulation tests in a patient expected to have

surgery.

Obtain a total body bone scan to identify wide spread bony metastases if

there is no known primary cancer and the patient is not confined to traction as

a result of an unstable lower extremity fracture

Order chest CT, mammogram, and abdominal ultrasound or CT as

appropriate to evaluate the patient for an occult primary cancer. If the patient

is known to have metastatic bony disease, routine and flexion/extension views

of the cervical spine are necessary prior to intubation.

Obtain plain radiographs. The interpretation of the radiographic features of

the underlying lesion that caused the fracture is critical to the diagnosis of the

condition and planning of further management.

Order MRI or CT imaging of the local site of fracture for patients without a

known cancer diagnosis, especially if the fracture has occurred through a

solitary bony lesion. Imaging may demonstrate a soft tissue mass or matrix

formation that suggests that the lesion is likely a primary aggressive or

malignant tumor.

REFERENCES

1. Salter RB. Chapter 5 - Diagnosis of Musculoskeletal Disorders and Injuries. In: Johnson EP. Textbook of Disorders and Injuries of the Musculoskeletal System - Third Edition. Maryland, USA: Lippincott Williams & Wilkins; 1999.

2. Chapter 5 - Pathologic Fractures. In: Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures Fourth Edition. Philadelphia, USA: Lippincott Wittiams & Witkins; 2010.

3. Pathologic fracture [Internet]. Orthopaedics One Articles - The Orthopaedic Knowledge Network. 20 September 2011. [cited 29 January 2015]. Available from: http://www.orthopaedicsone.com/x/vw0CAg.