DEBREBIRHAN UNIVERSITY

SCHOOL OF MEDICINE
PCD ON MUSCULOINTEGUMENTARY
SYSTEM FOR PC1 MEDICAL STUDENTS
BY Dr. GETACHEW A.

Dr. Getachew A. 1
 Outline of presentation
• Introduction
• Principle of history taking
• Physical examination
• Modalities of investigations

Dr. Getachew A. 2
 Introduction
• Musculoskeletal symptoms are a major cause
of pain and disability
• single most important cause of disability,
requiring considerable health and social
service resources in later life

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 objectives of performing a musculoskeletal
assessment
• To make an accurate diagnosis
• To assess the severity and consequences of
the condition
• To construct a clear management plan.

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 GALS’ locomotor screen

• Gait
• Arms
• Legs
• Spine

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 Screening Hx
1. pain or stiffness in your muscles, joints or
back?
2. ever had gout or arthritis?
3. dress yourself completely without difficulty
4. Can you walk up and down stairs without
difficulty?

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 Screening examination
• Gait
• Watch the patient walking and turning back
• symmetry, smooth movement, arm swing, no
pelvic tilt,
• normal stride length, ability to turn quickly.

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 Spine

• scoliosis, symmetrical paraspinals, normal

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ARMS

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Con..

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 LEGS
• swelling
• deformities or limb shortening.
• knee deformity: anterior or popliteal swelling,
• muscle-wasting,
• hind foot swelling or deformity.

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 Specific locomotors history
• General demographic: age, sex and occupation.
• Pain: severity, duration, constancy, associated
symptoms(red flags), radiation, aggravating and
relieving factors
• Deformity and swelling
• Mass
• Disability
• Co-morbidy illness

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 Joint diseases
• monoarticular (single joint),
• pauciarticular (up to four joints)
• polyarticular (many joints)
• axial (spinal involvement).

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 Flitting or migratory joint pains
• inflammation beginning in one joint and then
involving others, usually one at a time for
about 3 days each.
• Eg. Gonococcal, rheumatic fever arhtritis

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 EXAMINATION OF BONES
• Inspection/look/observation
• Feel/palpation
• Move
• Measure

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 look
• shape or outline
• Deformity: osteo-chondral enlargement
(rickety rosary).
• Localized swellings :infections, cysts or
tumours.

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JOINTS

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 LOOK
Sign of Inflammation : redness, swelling and
warmth.
swelling or deformity
 distribution of jt inv’t: is
symmetrical{ rheumatoid arthritis} or
asymmetrical-psoriatic arthropathy or gout
 seronegative spondyloarthropathies
predominantly the joints of the lower limb.

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 Palpation

 tenderness.
 swelling
Deformity
Tenden creptus

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 Score for joint tenderness
• Grade 1: patient says joint is tender
• Grade 2: patient winces
• Grade 3: patient winces and withdraws the
affected part
• Grade 4: patient will not allow the joint to be
touched Eg. gout, septic arthritis, rheumatic
fever

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EXAMINATION OF SPECIFIC JOINTS
The shoulder
• Flexion.
• Extension.
• Abduction.
• Rotation in abduction.
• Rotation in neutral position.
• Elevation ( scapular movement).

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TESTS ABDUCTION AND TESTS ADDUCTION AND
EXTERNAL ROTATION INTERNAL ROTATION

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 Clinical importance
• Limitation of external rotation is a good sign of
true glenohumeral disease, adhesive capsulitis
(frozen shoulder) or erosive damage from
inflammatory arthritis
• If patient cannot hold arm fully abducted at
shoulder level, possible rotator cuff tear

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 The elbow
• Flexion.
• Hyperextension
• Medial (golfer’s elbow) and lateral (tennis
elbow) epicondylitis are the most common
causes of elbow pain.

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Dr. Getachew A. 26
 The wrist
• Dorsiflexion (extension).
• Palmar flexion.
• Ulnar deviation.
• Radial deviation

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Dr. Getachew A. 28
 Metacarpophalangeal joint
• Proximal nodules in rheumatoid arthritis
(Bouchard’s nodes),
• distal nodules in osteoarthritis (Heberden’s
nodes)
• Tenderness on anatomic snuffbox suggests
scaphoid fracture

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 The hip

• Flexion: measured with knee bent.

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 PATELLA
• Swelling over the patella in prepatellar
bursitis (“housemaid’s knee”)
• Tenderness or inability to extend the leg in
partial or complete tear of the patellar
tendon
• Pain, crepitus, and a history of knee pain in
patellofemoral disorder

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 KNEE
• Bulge sign (minor effusions): Compress the
suprapatellar pouch, stroke downward on
medial surface, apply pressure to force fluid to
lateral surface, and then tap knee behind
lateral margin of patella.
• A fluid wave returning to the medial surface
after a lateral tap confirms an effusion—a
positive “bulge sign.”

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Dr. Getachew A. 35
• Balloon sign (major effusions): Compress
suprapatellar pouch with one hand; with
thumb and finger of other hand, feel for fluid
entering the spaces next to the patella.

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• Ballotte the patella (major effusion): Push the
patella sharply against the femur; watch for
fluid returning to the suprapatellar space.

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 Diagnostic tests
• CBC
• ESR: affected by haemoglobin, globulins and
fibrinogen,Age
• CPR
• Plasma viscosity.
• Serum complement: low in SLE

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• rheumatoid factor: 80% of RA, and others like
SLE, Sjogren’s syndrome, or other
inflammatory disorders such as subacute
bacterial endocarditis and some viral
• Antinuclear antibody (ANA) or antinuclear
factor (ANF),
• Anti- double-stranded DNAase

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• Uric acid
• Synovial fluid examination/analysis:bacterial
infections and crystal synovitis
• Biopsies useful in differential diagnosis

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 Radiological examination
 General principles:
• Use a systematic approach
• Age, sex and clinical information are essential in
interpretation
• Radiographs reveal bones and soft tissues
• Always obtain two views, at right angles, in trauma patients
• Radiographs may be normal even in the presence of
disease
• Diffuse abnormalities are difficult to detect
• Bone-based and joint-based disease must be differentiated
• Normal variants can be confused with pathology

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 Con..
• X-ray
• CT SCAN
• MRI: best for joint diseases

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Bone density of metastatic tumors
• Expansile – thyroid, kidney, breast, bronchus,
melanoma and myeloma
• Sclerotic – prostate and breast
• Lytic – breast, bronchus, kidney, thyroid and
melanoma
• Mixed – breast, bladder, or previously treated
(irradiated) bone lesions

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 Con..
• Isotopic scanning (scintigraphy) can be used in
the diagnosis of acute (e.g. infection or stress
fracture) or multiple (e.g. metastases) bone
lesions

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INTEGUMENTARY SYSTEM

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 INTRODUCTION
o Skin is the largest organ.
o Covers an area of approximately 2 m
o Weighs about 4 kg.
o The structure of human skin is complex
o dermatology is predominantly a visual
speciality

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 SKIN Fun
• Protection : physical, chemical, infection
• Physiological: homoeostasis of electrolytes, water and
protein
• Thermoregulation
• Sensation: specialized nerve endings
• Lubrication and waterproofing: sebum
• Immunological: Langerhans’ cells, lymphocytes,
macrophages
• Vitamin D synthesis
• Body odour: apocrine glands
• Psychosocial: cosmetic
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 Hx
 Site of onset
 Mode of spread and duration of the disorder
 Personal history or family history of skin disease,
including skin cancer and atopy (an allergic skin
reaction)
 Previous medical conditions
 Full drug history
 The social and occupational history
 Environmental exposure, especially sunshine(UV)
 Sexual activity
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 PHYSICAL EXAMINATION
• Color: Cyanosis, jaundice, carotenemia,
changes in melanin
• Moisture: Dry, oily
• Temperature: Cool, warm
• Texture: Smooth, rough
• Mobility
• Turgor

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 Any skin lesion
• Anatomical location and distribution:
Generalized, localized
• Patterns and shapes: Linear, clustered,
dermatomal
• Type: Macule, papule, pustule, bulla, tumor
• Color: Red, white, brown, heliotrope

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 PRIMARY SKIN LESIONS
1.Macule Non-palpable
area of altered colour
• Eg. Hemangioma
Vitiligo
• 2. Papule Palpable
elevated small area of
skin (<0.5 cm)
• Eg. Elevated nevus

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 Con..
3. Plaque Palpable flat-
topped discoid lesion (>2
cm) Eg. psoriasis

4. Nodule Solid palpable

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 Cont…
5. Vesicle Small fluid-filled
blister (<0.5 cm) eg.
herpes
6. Bulla Large fluid-filled
blister (>0.5 cm) eg. Insect
bite
7. Pustule Blister
containing pus eg. acne

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 Con..
8.Petechiae Pinhead-sized 12. Erythema Redness of
macules of blood the skin
9. Purpura Larger 13. Burrow Linear or curved
petechiae which do not elevations of the superficial
blanch on pressure skin due to infestation by
female scabies mite
1o. Ecchymosis Large
extravasation of blood in 14. Comedo Dark horny
skin (bruise) keratin and sebaceous
plugs within pilosebaceous
11.Haematoma Swelling openings
due to gross bleeding
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 Secondary skin lesions
• Scale—A thin flake of
dead,exfoliated
epidermis
Eg: Ichthyosis vulgaris
• Crust—The dried
residue of skin exudates
such as serum, pus, or
blood
• Eg: Impetigo

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 Con..
• Scars—Increased
connective tissue that
arises from injury or
disease Eg:
Hypertrophic scar
• Keloids—Hypertrophic
scarring that extends
beyond the borders of
the initiating injury Eg:
Keloid—ear lobe
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 Con…
• Erosion Partial loss of
epidermis which heals
without scarring Eg.
Aphthous stomatitis,moist
area after the rupture of
avesicle, as in chickenpox
• Ulcer At least the full
thickness of the epidermis
is lost. Healing occurs
with scarring Eg. Stasis
ulcer of venous
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 INVESTIGATIONS
• Microscopic examination: Dermoscopic
and/or microscopic examination is useful in
the diagnosis of scabies, pediculosis (lice) and
fungal infection (tinea and candidiasis).
• Skin biopsy
• FNAC
• KOH

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REFERENCES

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THANK YOU

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