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

• Assess the non-injured, painless side first.
• Palpate the injured limb from clavicle to fingertips, assessing the painful area last.
• Palpate along the bone, feeling for deformity and assessing for point of maximal tenderness. Palpating may be unnecessary if the deformity is obvious.
• Complete a neurovascular assessment of the limb:
  • Assess for compartment syndrome.
  • Palpate the radial and ulna pulses. Evaluate the motor and sensory function of the radial, ulna and median nerves.
  • Pain and anxiety may limit the examination in a child. Complete the assessment of basic motor function by showing the child a movement and asking them to copy on the uninjured side first, followed by the injured side.
  • Abnormal neurovascular findings require escalation as per local CERS protocol.

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 patient's movement and position of the painful limb.
• Position the child to maintain comfort.
• 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 limb from hip to toes, assessing the painful area last. Palpating 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 the motor and sensory function.
  • Escalate abnormal neurovascular findings as per local CERS protocol.

Move

• Look for reduced movement in one limb compared to the other.
• Assess the range of movement of the affected joint, including flexion, extension, abduction adduction, pronation and supination.
• Assess gait if possible.

Physical assessment

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

Foot and ankle assessment

Foot injuries

• Phalangeal (toe) fractures are the most common foot fracture in children. They generally occur from stubbing or catching the toe or being crushed by a falling object.
• Foot fractures are often due to falls from a height, sport related injuries, inversion injuries of the ankle, crush injuries or repetitive stress injuries.
• Plain films of the foot should be performed if the patient has tenderness:
  • at the navicular
  • and/or at the base of the 5th metatarsal.

Ankle injuries

• Most ankle injuries result from inversion, eversion or twisting of the ankle.
• Plain films of the ankle looking for an ankle fracture should be performed if the patient has any one of:
  • tenderness of the medial malleolus
  • tenderness at the posterior aspect of the lateral malleolus
  • inability to bear weight both at the time of the injury and for four steps at the time of evaluation.

• All other patients presenting with findings suggestive of ankle sprain can be treated without the need for imaging.
• Ottawa ankle rules (appendix) can be used in ambulant patients, provide they can communicate clearly and could walk normally before the injury.

Paediatric tips

• Severe pain and restricted movement to the limb may indicate infection. If the pain appears to be out of proportion, escalate as per local CERS protocol.
• Knee pain: examine the hip as well, as pain may be referred.
• If the patient can weight bear on the knees, i.e. crawl but not walk, an injury to the lower leg or foot should be suspected.

Non-accidental injury

Consider non-accidental injury (NAI) if:

• no history to account for the injury
• unreasonable delay in seeking medical attention
• injury incompatible with mechanism or developmental capabilities
• vague or varying history, e.g. one parent contradicting the other
• inappropriate parental attitude or behaviour, e.g. lack of concern, over-concern or aggression
• inappropriate parent-child interaction
• features of failure to thrive or neglect
• history of family violence
• allegation of assault
• femoral shaft fracture less than two years old
• injury in non-ambulant infants.

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.
• X-ray the area of maximal tenderness or deformity.
• Consider x-raying the joints above and below the injury.
• 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.
• 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.