The aim of examination in patients with a musculoskeletal swelling is to identify the exact location, size, anatomical extent, biological nature and the effects of the swelling and to plan its treatment. Method of treatment depends on the nature of swelling, its anatomic location, its relation to adjacent anatomic structures and its effects on the patient and adjacent tissues.
Swellings may either be due to normal variants (muscle hernias, anomalous muscle), normal tissue (rupture of long head of biceps), non-neoplastic (ganglions, bursa, infection, hematoma or cysts) or neoplastic. Neoplastic swellings may be benign or malignant. An important aim of examination is to rule out malignancy and to rule out any limb threatening or life threatening complications. Malignant swellings generally have a short duration, grow rapidly and show features of invasion either locally or distantly. Once the clinical examination is over; the examiner should be able to answer the following questions.
- Is there a swelling or is it just an anatomical variant?
- Is it a neoplastic or non-neoplastic swelling?
- If neoplastic; is it benign or malignant?
- If malignant; is there any local infiltration and is there any metastasis?
- What is the site of the swelling?
- What is the plane of the swelling?
- What is its relation to nearby anatomic structures?
- Are there any complications due to the swelling?
- What is the probable tissue diagnosis?
- How long since the swelling was found?
- How was it found?
It might be noticed accidently, detected by someone else or detected because of pain.
- What has happened to the swelling since it was detected?
It may change in size, shape, consistency or associated symptoms. So it is better to ask whether there was any change in the size, shape or symptoms after the swelling was first noted.
- Is the swelling enlarging?
- How rapidly is it enlarging?
- Is the any associated pain?
- Duration of pain?
- How pain started? It may start suddenly or gradually.
- How did it progress?
- Is the pain remaining the same, worsening, improving or fluctuating.
- Site of pain? This is the most valuable factor. The exact site should be noted. Ask the patient to point it out with a single finger. Also note the patient’s perception of the depth of pain; whether superficial or deep.
- Severity of pain? As the tolerance to pain vary between individuals, it is better to note the effect of pain on the patient. Ask for any interference to daily routine, recreational activities, work, sleep and need for analgesics.
- Character of pain?
- Any radiation?
- Is there rest pain?
- Is the pain interfering with sleep?
- Which came first; pain or swelling? Pain appears before the swelling in malignant swellings as rapid growth increases the tissue pressure.
- What are the aggravating factors and relieving factors?
- Any other swellings in the body?
- Is there any history of trauma?
- Is there any history of recent loss of weight and appetite?
- Is there any associated fever?
- Is there any numbness or weakness in the distal part of the limb?
- Is there any swelling of the distal part of the limb?
- Previous illnesses, operations, accidents and hospital admissions.
- Hypertension, diabetes mellitus, coronary artery disease.
- Tuberculosis, bronchial asthma, allergies.
- Bleeding disorders.
- Sexually transmitted disease.
- Marital status.
- Sexual habits.
- Eating habits.
- Recreational habits.
- Smoking, drinking, substance abuse.
- Occupation. Occupational exposure to industrial toxins.
- Travel abroad.
- Family tree.
- Age and health status of close relatives and companions.
- Similar illness in the family.
- Cause of death of close relatives.
- Any drugs taken regularly; particularly steroids, antidiabetics, antihypertensives, antipsychotics, blood thinners, contraceptives.
- What was the treatment taken for the swelling so far?
- What all investigations were done?
To be Continued
Inspection of the limb.
Inspection of swelling.
The site of swelling should be noted in exact anatomic terms. It’s relation to adjacent joint or bony landmarks should be identified. Identify whether the swelling is at a joint, proximal or distal juxta-articular region or the middle of a limb segment. Identify which aspect of the limb it is located such as anterior, posterior, medial or lateral.
Remember that the swelling is three dimensional; it has a length, width and depth. Often the swelling size may be discernible only in 2 dimensions and the third dimension especially the depth may not be identifiable on inspection; then it should be clearly mentioned.
As a swelling is three dimensional, it cannot be round, square or oval. It may be described as hemispherical, spherical or ovoid.
Surface on inspection may be smooth, irregular or mixed. Irregular surface may be bosselated, lobulated or rough. Smooth surface on inspection is seen in deep seated swellings and fluid filled swellings such as bursa or ganglion.
5. Skin over the swelling.
It may be normal, inflamed, ulcerated, infected, adherent, infiltrated with peau de orange appearance or perforated by the tumor tissue.
Borders may be well defined or indistinct. In deep seated swellings, margins may be indistinct on inspection but may be clearly defined on palpation.
Swelling may be solitary or multiple. Multiple swellings may be either within the same anatomic region or in other anatomic regions. Multiple swellings may be identical or dissimilar.
TO BE CONTINUED…… Please visit again