Musculoskeletal assessment

Upper limb examination

Look

• Give analgesia before the examination.
• Look at the movement and position of the painful limb.
• Look for deformity, swelling, breaks in the skin and bruising.
• Compare findings with the non-injured side.

Feel

• Examine the non-injured, painless side first.
• Examine the injured limb from clavicle to fingertips, assessing the painful area last.
• Palpate along the bone, feeling for deformity and assess for point of maximal tenderness.
• Palpation may be unnecessary if the deformity is obvious.
• Complete a neurovascular assessment of the limb:
• Assess for compartment syndrome.
• Compare skin temperature and capillary refill time to the opposing limb.
• Palpate the radial and ulna pulses.
• Assess motor and sensory function of the radial, ulna, and median nerves (see table below).
• Assess the unaffected side and compare the findings. In case of abnormal neurovascular findings, follow the local CERS protocol for escalation.

Move

• Look for reduced movement in one limb and compare it to the other.
• Assess the range of movement of the affected joint and the joint above and below the injury, including flexion, extension, abduction adduction, pronation and supination.

Lower limb examination

Look

• Give analgesia before the examination.
• Look at the movement and position of the painful limb.
• Look for deformity, swelling, breaks in the skin and bruising.
• Compare findings with the non-injured side.

Feel

• Assess the non-injured, painless side first.
• Palpate the length of the bone from the proximal femur to the distal tibia, feeling for deformity and point of maximal tenderness.
• Palpation may be unnecessary if the deformity is obvious.
• Complete a neurovascular assessment of the limb:
• Assess for compartment syndrome.
• Compare skin temperature and capillary refill time to the opposing limb.
• Palpate the popliteal and tibial pulses.
• Assess motor and sensory function of the peroneal and tibial nerves (see table below).
• Assess the unaffected side and compare the findings. In case of abnormal neurovascular findings, follow the local CERS protocol for escalation.

Move

• Assess the range of movement of the affected joint and the joint above and below the injury, including flexion, extension, abduction, adduction, dorsiflexion, plantarflexion, inversion and eversion.
• Assess gait if possible.
• Assess ability to straight leg raise.

Knee injuries

Use Ottawa knee rules (appendix) to determine if radiology is required.

Foot and ankle injuries

The 5 most important bones to consider for injury are:

• lateral malleolus
• medial malleolus
• calcaneus
• navicular
• the base of 5th metatarsal.

Common mechanisms of foot and ankle injuries

Injuries of the foot or ankle are most commonly caused by:

• forceful inversion or eversion
• adduction or abduction
• forced dorsiflexion
• falls from a height
• crush injuries
• landing directly on the heels.

Physical assessment

• Look for swelling, inflammation, deformity and skin changes. Compare with the unaffected side. Observe whether the patient can weight bear.
• Feel for bony tenderness to the fibula head, medial/lateral malleoli, base 5th metatarsal and calcaneus. Check pulses and sensation.
• Note the degree of movement within the patient's pain limits.

Use Ottawa ankle rules (appendix) to determine if x-rays are required. Findings suggestive of ankle sprain can be treated without the need for imaging.

Radiology tips

• Only registered nurses who have completed the required education and training may request medical imaging.
• Complete a full patient assessment and consider a patient’s presenting complaint, history, pregnancy status and signs and symptoms prior to requesting medical imaging.
• At the beginning of the clinical history the requesting nurse must document ‘requested under ECAT Protocol (Protocol Name)’ e.g., ‘requested under ECAT Protocol (Isolated Limb Injury)’.
• Minimum documentation of the request must include a succinct and specific description of:
  • Patient details and demographics, including pregnancy status for females
  • History, mechanism of injury
  • Assessment findings
  • Site of pain, region of interest
  • Clinical question, provisional diagnosis
  • Signature, or electronic signature as well as contact details of requesting nurse.

• X-ray the area of maximal tenderness or deformity.
• Consider x-raying the joints above and below the injury.
• All imaging requested under ECAT protocols must be reviewed by the attending medical or nurse practitioner or physiotherapist when they take over care of the patient.