What special musculoskeletal screening techniques should be used for a comprehensive assessment in adults and children?

Special Musculoskeletal Screening Techniques

Comprehensive Musculoskeletal Ultrasound Protocol

For comprehensive musculoskeletal assessment in both adults and children, standardized ultrasound examination using high-frequency transducers (≥10 MHz) should be performed as the primary screening technique, following established anatomical scanning protocols for the shoulder, elbow, wrist, and hand. 1

Shoulder Examination Protocol

The shoulder requires multiple standardized views to detect inflammatory lesions, tendon pathology, and joint effusions 1:

• Patient positioning: Sitting with 90° elbow flexion, hand supinated on thigh 1
• Required scans: Nine standard views including anterior transverse (neutral and maximal internal rotation), anterior longitudinal (neutral and maximal internal rotation), lateral longitudinal (neutral and maximal internal rotation), posterior transverse, axillary longitudinal with raised arm, and acromioclavicular joint scan 1
• Dynamic assessment: Active and passive external/internal rotation through full range of motion with 90° flexed elbow 1
• Key detection: The axillary longitudinal scan is most sensitive for detecting even very small shoulder effusions, though arm elevation may not be possible in advanced disease 1

Elbow Examination Protocol

Inflammatory lesions are most easily detected early through ventral longitudinal scans 1:

• Patient positioning: Sitting with full extension and supination for ventral scans; 90° flexion for dorsal scans with hand on hip or thigh 1
• Target areas: Humeroradial and humeroulnar joints ventrally, olecranon fossa dorsally 1

Wrist and Hand Examination Protocol

High-frequency transducers (≥10 MHz) detect even minor synovitic lesions and differentiate synovial from tenosynovial pathology 1, 2:

• Patient positioning: Sitting with hand on thigh or examining table 1, 2
• Dynamic examination: Active flexion/extension of fingers during scanning 1, 2
• Wrist standard scans: Volar transverse, volar longitudinal, dorsal transverse (radial and ulnar), dorsal longitudinal (radial, median, and ulnar) 1, 2
• Hand/finger standard scans: Dorsal longitudinal, dorsal transverse, palmar longitudinal, and palmar transverse views 2
• Additional assessment: Volar transverse scan at carpal tunnel for median nerve evaluation (77-79% sensitivity, 94-98% specificity for entrapment) 2

Pediatric-Specific Skeletal Screening

Radiological Skeletal Survey for Suspected Abuse

In children under 2 years with suspected physical abuse, perform systematic radiological skeletal survey as the initial imaging modality, consisting of 17-32 views including oblique rib views. 1

• Age indication: Systematically recommended up to age 2 years (one guideline extends to 1.5 years) 1
• Standard views: 17-32 views depending on protocol, with oblique rib views mandatory in all but one guideline 1
• Follow-up survey: Perform between 7-14 days after initial survey if doubt remains, using 9-17 views 1
• Adjunctive bone scintigraphy: Consider on case-by-case basis if skeletal survey negative but suspicion remains high, particularly for detecting occult rib fractures 1

Pediatric Back Pain Evaluation

For children with persistent back pain (≥4 weeks), constant pain, night pain, radicular pain, or abnormal neurologic examination, obtain plain radiographs (frontal and lateral views only) as initial imaging. 1

• Clinical red flags requiring imaging: Persistent pain ≥4 weeks, constant pain, night pain, radicular pain, abnormal neurologic examination 1
• Conservative approach: Children with short-duration back pain, normal physical examination, and minor/no trauma history require no imaging 1
• Radiographic technique: Standard frontal and lateral views only—oblique lumbar views double radiation dose without additional diagnostic value 1
• Advanced imaging: Reserve MRI without contrast for red-flag presentations; SPECT bone scan superior to MRI for detecting active spondylolysis 1

Comprehensive Physical Examination Components

Diabetes-Related Musculoskeletal Assessment

Perform comprehensive foot examination at every visit for patients with sensory loss, previous foot ulcers, or amputations, including visual inspection, 10-g monofilament testing, and pedal pulse assessment. 1, 3

• Annual comprehensive foot exam components: Visual inspection for skin integrity, callous formation, foot deformity, ulcers, and toenail abnormalities; screen for peripheral arterial disease via pedal pulses (refer for ankle-brachial index if diminished); determination of temperature, vibration/pinprick sensation, and 10-g monofilament examination 1, 3
• Functional performance assessment: Consider at age ≥65 years 1
• Bone pain screening: Consider assessment for bone pain annually 1

General Musculoskeletal Inspection

Visual inspection and palpation remain fundamental screening techniques but require same-examiner consistency for reliability. 4

• Reliability: Good intra-rater reliability (ICC = 0.782-0.901) but only moderate inter-rater reliability (ICC = 0.481-0.681) for visual inspection and palpation 4
• Clinical implication: Same examiner should perform serial assessments for accurate comparison 4

Critical Pitfalls to Avoid

• Do not use oblique lumbar spine views in children—they double radiation exposure without diagnostic benefit 1
• Do not skip dynamic examination during ultrasound—static imaging misses tenosynovitis and functional pathology 1, 2
• Do not use transducers <10 MHz for wrist/hand examination—lower frequencies miss minor synovitic lesions 1, 2
• Do not delay imaging in children with neurologic abnormalities or clinical red flags—these require immediate evaluation 1
• Do not rely on visual inspection or pulse palpation alone for vascular assessment—only 3 of 18 significant technical problems were detected by these methods in one study, compared to completion arteriography 5
• Do not perform skeletal surveys in children >2 years for abuse screening—yield decreases dramatically after 18 months of age 1