Approach To The Musculoskeletal Patient Flashcards
MSK complaints account for what percent of primary care visits
10-20%
What are common MSK chief complaints?
Pain/stiffness
Instability/dysfunction
Deformity
Weakness
What historical questions about location would you want to ask about?
Joint: bilateral or unilateral
Bone: midshaft, joint involvement
Soft tissue: muscle, tendon, ligament
What quality/character of pain questions would you want to ask about a MSK complaints
-Catching/locking in joint?
-instability/giving way?
-burning
-aching vs sharp
-radiating
What associated signs and symptoms would you want to ensure you ask about with an MSK complaint?
-Systemic symptoms
-neurogenic symptoms
-inflammatory symptoms
MSK physical exam goals
Determine structures involved
Determine nature of underlying pathology
Determine functional consequences of the process
Determine the presence of systemic or extraarticular manifestations
Key physical exam principles in the MSK physical exam
Inspection
Palpation
Range of motion
Neurovascular status
Muscle testing
Motor and sensory evaluation
Special tests
How should inspection of a MSK complaint be performed?
Expose the area of concern
Have patient point to area of maximal pain/tenderness
SEADS: swelling, erythema, atrophy, deformity, scars/skin
When palpating an MSK complaint, what are you trying to locate?
Point of maximal tenderness
What does hard palpation of a MSK complaint indicate? Boggy?
Hard —> bone
Spongy/boggy —> synovial thickening
What does palpation of fluctuance indicate? Position?
Fluctuance —> effusion
Position —> joint or periarticular (bursa)
What are types of ROM?
Active (AROM)
Passive (PROM)
Active assistive range of motion (AAROM)
How can range of motion be measured more accurately?
Goniometer
What is goniometer preferred for evaluating?
Elbow
Wrist
Digits
Knee
Ankle
Great toe
Typically less useful for hip and shoulder ROM evaluation (overlying soft tissue structures don’t allow for as much precision)
How do you use a goniometer?
1) Start by placing the joint in the zero starting position (most joints this is an anatomic position of extremity in extension)
2) Place the center of the goniometer at the joint
3) Have patient actively perform ROM
4) Move the distal end of the goniometer to align with the distal extremity
Manual muscle testing grades
5/5: normal (complete ROM against gravity with full resistance)
4/5: good (complete ROM against gravity with some resistance)
3/5: fair (ROM against gravity, but not with resistance)
2/5: poor (ROM only if gravity eliminated)
1/5: trace (twitch/muscle contraction but no joint motion)
0/5: absent (muscle does not contract)
When would vascular status be performed?
Trauma patient
How do you assess neurovascular status in each area of the body?
- One muscle/nerve at a time
- Neck and back: nerve root function
- Extremity: peripheral nerve testing
- Digits: 2-point discrimination
How would you perform neurovascular assessment on the axillary nerve?
- Muscle: deltoid- shoulder abduction
- Sensory: lateral aspect, arm
How would you perform evaluation of musculocutaneous nerve?
- Muscle: biceps- elbow flexion
- Sensory: lateral proximal forearm
How would you perform evaluation of the median nerve?
- Muscle: flexor pollicis longus- thumb flexion
- Sensory: tip of thumb, volar aspect
How would you perform evaluation of ulnar nerve?
- First dorsal interosseous- abduction
- Sensory: top of little finger, volar aspect
How would you perform radial nerve evaluation?
- Muscle: extensor pollicis longus- thumb extension
- Sensory: dorsum thumb web space
How would you perform obturator nerve testing?
- Adductors - hip adduction
- Sensory: medial aspect, midthigh
How would you perform femoral nerve testing?
- Quadriceps - knee extension
- Sensory: proximal to medial malleolus
How would you perform deep branch peroneal nerve testing?
- Extensor hallucis longus - great toes extension
- Sensory: dorsum first web space
How would you perform superficial branch nerve testing?
- Peroneus brevis - foot eversion
- Dorsum lateral foot
How would you perform tibial nerve testing?
- Flexor hallucis longus - great toe flexion
- Sensory: plantar aspect, foot
What are special tests?
Tests specific to individual anatomic injuries
What is the first line imaging in bone and joint imaging, especially for initial evaluation?
Radiography
What are advantages to radiography?
- Fast
- Inexpensive
- Readily available
- Easily interpreted
- Plain x-ray often needed prior to more detailed imaging
What are disadvantages to radiography?
- Poor soft tissue contrast
- 2D
- Quality is technician dependent
- Some radiation exposure (small), lead shields used to protect radiation sensitive areas
If you are concerned about an injury on x-ray, how should the x-ray be performed
- Joint above and below
- At least 2 planes perpendicular to each other should be performed
Indications for radiography
- History of trauma
- Deformity of a bone or joint
- Inability to use the joint or extremity
- Unexplained pain and localized tenderness to a bone or joint
- Abnormal asymmetry or mass
- Evaluation of foreign bodies
Advantages of CT
- Offers 3D images of bone, muscle, and fat tissues with multiplanar image reconstruction
- Highest bony detail
- Rapid process: few seconds to several minutes to capture non-contrasted image
- Often completed without contrast but addition of contrast can further evaluate soft tissue, tumors, nerves
Indications for CT
- Pre-operative planning
- Complex or intraarticular fracture patterns
- Evaluation of bone tumors
- Bone and joint aspirations/infections
Disadvantages to CT
- Expensive
- Greater amount of radiation
- Risk of motion/metal artifact
- Closed in space (claustrophobia/limited body habitus): average CT weight limit = 450 lbs
What is the advantage of MRI
- Soft-tissue detail: muscle, tendons, menisci, and discs
- Superior contrast resolution
- Beneficial for evaluation of tumors, osteonecrosis, stress fracture
- Open MRI available
Indications for MRI
- Spinal column pathology
- Tendon and ligament injuries
- Meniscal and cartilaginous injuries
- Stress and occult fractures
- Osteomyelitis/necrosis
- Soft tissue and bony tumors
Disadvantages to MRI
- Expensive
- Loud
- Small spaces (although open MRI is an option)
- Length - scans last from 30 minutes up to 2 hours
- CI with certain types of metal
What is an ultrasound?
Interprets echoes produced when a transducer bounces sound waves off of specific anatomic structures creating an image
Indications for ultrasound
- Joint effusions
- Tendinopathy
- Ligament pathology
- Soft-tissue masses
- Infantile hip dysplasia
Advantages of ultrasound
- Safe
- Inexpensive
- Readily accessible
Disadvantages of ultrasound
Technician dependent
What is scintigraphy?
- Examines blood flow and metabolic activity of bone to assess bone formation/destruction
- Sensitive but not specific
- Able to scan entire skeleton
Indications for scintigraphy
- Infection of the bones/joints
- Fractures
- Metastatic bone disease
- Tumors
- Metabolic bone disease
- Bone death
What is myelography
- Involves injection of a contrast medium into the spinal subarachnoid space followed by continuous x-rays (fluoroscopy)
What is indication for myelography?
- Detect pathology of the spinal cord
- Level of injury, infection, tumor, cysts, or herniated disk
- Beneficial in patients who cannot undergo MRI
What is arthrography?
- Imaging (CT/MRI/fluoroscopy) of a joint following the injection of contrast medium
What is arthrography used for?
- Clear image of the soft tissue border of the joint
- Most commonly used on shoulder, elbow, wrist
- Hip, knee, ankle
What is positron emission tomography scan (PET)?
- Imaging test that uses a radioactive glucose tracer to look for disease in the body
- Indicated to identify metastatic malignant lesions
- Provides full body image
Arthrocentesis indications
- Patients who have an effusion or signs suggesting inflammation or infection within the joint
- Pain relief
- Drainage
- Injection of medications
Goals of arthrocentesis
- Determine source of effusion: inflammation, infection, induced, hemorrhage
- Improve joint ROM and comfort in joint effusions
Risks of arthrocentesis
- Bleeding
- Bruising
- Septic arthritis
- Iatrogenic infection
- Osteonecrosis and joint instability
What is the typical synovial fluid color on arthrocentesis?
oily clear
What are relative CI to knee arthrocentesis?
- Bacteremia
- Adjacent osteomyelitis
- Coagulopathy
- Prosthetic joint
- Overlying cellulitis/dermatitis
Approaches for knee arthrocentesis
- Parapatellar
- Suprapatellar
- Infrapatellar
Complications of knee arthrocentesis
- Iatrogenic infection
- Damage to tissues
- Osteonecrosis
- Joint instability
What is synovial fluid tested for?
- Cell count and differential
- Crystals
- Culture and sensitivity
- Cytology
Techniques for muscle biopsy
- Needle (MC) or open
Indications for muscle biopsy
- Muscle weakness and low muscle tone
- Distinguish between myopathies and neuropathies
Risks of muscle biopsy
- Infection
- Bleeding
- Bruising
- Muscle damage
When is a PT, PTT, platelet count indicated in MSK complaints?
- If bloody effusion and no evidence of trauma
When are blood cultures indicated for MSK complaints?
Indicated if fever/joint erythema
When is ESR/CRP indicated for MSK complaints?
- Nonspecific indicators of inflammation
- Useful in patients iwth a non-specific joint exam
When is ANA lab indicated in MSK complaints?
High sensitivity for lupus and other rheumatological problems
When would serum rheumatoid factor be ordered in MSK complaints?
Moderate suspicion of RA
When would CBC and LFTs be ordered in MSK complaints?
When multisystem process suspected
When would HLA-B27 be ordered?
- Clinical suspicion high for ankylosing spondylitis (young adults 20-30 years old M>F)
What is ordered for lyme serology in MSK complaints?
- ELISA
- Western Blot
General goals for treatment of an MSK complaint
- Reduce pain
- Improve, preserve, or restore function
- Modify disease progression
- Reduce number of recurrences
Conservative treatment for MSK complaint
- Patient education
- Activity modification/restriction
- Assistive devices
- Rehab/physical therapy
- Pain management
Pain control options for MSK complaint
- NSAIDs, acetaminophen, or opioids
- Muscle relaxants
- Neuropathic agents
- Topical analgesics (capsaicin cream, lidocaine patches)
- Joint injection with corticosteroids and analgesics
Non-medication mannagement options for MSK complaint
- Immobilization with casting, slings, and braces
- Alternative therapies: chiropractice manipulation, massage therapy, acupuncture
- Surgery: when benefit outweighs risk
Indications for emergency/immediate referral for MSK complaint
- Neurovascular injury (pain out of proportion to exam findings, ps)
- Open or unstable fractures
- Unreduced joint dislocations
- Septic arthritis
What are signs/symptoms of neurovascular injury?
- Numbness
- Decreased pulse
- Changes in color
- Pain
- Pallor
- Paresthesia
- Pulselessness
- Paralysis (compartment syndrome)
What are signs/symptoms of septic arthritis?
- Swelling
- Warmth
- Redness
- Increased WBC
- CRP/ESR
Indications for urgent referral (within 7 days)
- Closed and stable fractures
- Reduced joint dislocation
- Locked joint
- Tumor
Indications for early referral to ortho (2-4 weeks)
- Motor weakness
- Constitutional symptoms (not due to other conditions)
- Multiple joint involvement
Indications for routine referral (beyond 4 weeks) to ortho
- Failure of conservative treatment: persistent symptoms >3 months
- Persistent numbness and tingling in an extremity
