Exam 3: Musculoskeletal Flashcards
Temperomandibular Joint:
What CN is it associated with?
How do you palpate it?
CN V
Place tips of index fingers just in from of tragus of each ear and ask pt to open mouth. Fingertips should drop into joint spaces as mouth opens. Check for smooth range of motion. Note any swelling or tenderness. Snapping or clicking may be felt or heard in normal people.
ROM for neck
We seem to use extension instead of hyperextension
When you palpate joints, what are you feeling for?
crepitus, tenderness, inflammation/swelling
UE Joints to palpate
Shoulders, elbows (olecranon and epicondyles), wrists, fingers
Where are the olecranon & epicondyles?
Olecranon is bony point of elbow
Bones of wrist/hands
Joints of wrist/hands
Shoulder ROM
No hyperextension in Bates
Flexion: “Raise your arms in front of you and overhead”
Extension: “Raise your arms behind you”
Abduction: “Raise your arms out to the side and overhead”
Adduction: “cross your arm in front of your body”
Internal Rotation: “Place one hand behind yoru back and touch your shoulder blade” (could also be as pictured)
External Rotation: “Raise your arm to shoulder level; bend your elbow and rotate your forearm to the ceiling” OR “Place one hand behind your neck or head as if you are brushing your hair”
Elbow ROM
Flexion, extension, supination, pronation
Supination: “have some soup”
Wrists ROM
Fingers: ROM
Flexion: Make a tight fist with each hand, thumb across knuckles
Extension: Extend and spread the fingers
Abduction: spread fingers apart
Adduction: Bring fingers back together
Thumbs: ROM
Flexion: move thumb across palm, touch base of 5th finger
Extension: move thumb back across palm and away from fingers
Abduction: place fingers and thumb in neutral position with palm up, then have patient move thumb anteriorly away from the palm
Adduction: bring thumb back to palm
Opposition: touch thumb to each of fingertips
Grading Muscle Tone & Strength
0 - No muscular contraction detected
1 - A barely detectable flicker or trace of contraction
2 - active movement of body part with gravity eliminated
3 - Active movement against gravity
4 - Active movement against gravity and some resistance
5 - Active movement against full resistance without evident fatigue. This is normal muscle strength
Tinel’s Test
Positive suggests carpal tunnel
For median nerve compression. Lightly tap overcourse of median nerve in carpal tunnel. Positive: aching & numbness in median nerve distribution
Phalen’s Test
For carpal tunnel
ask pt to hold wrists in flexion 60 seconds. OR backs of both hands together to form right angles (compresses median nerve)
Brudzinski’s Sign
For meningitis
pt lies flat and provider passively flexes head up, noting no nuchal rigidity, neck stiffness, hip or knee flexion
B for “bend neck”
Kernig’s Sign
For meningitis
w/ pt supine, provider bends knee to 90 degrees and then straightens, noting there is no resistance from pt
K for “knee”
Lower Extremities to Palpate
Hips, Knees, ankles, toes
Hip ROM
+ internal & external rotaton
Knee ROM
Flexion, extension
Knee anatomy
Ankle ROM
Straight leg raise
provider passively elevates straight leg to see if any pain is produced in back and down leg. Seated or supine.
Positive for lumbar radiculopathy if pain radiates down leg in radicular pattern
Thomas Test
with full hip flexion, look for full extension of opposite hip and flattening of lumbar lordosis; repeat w/ other leg
Measure distance between affected thigh and table
Physiologic in first 3mths of life
Checking for hip flexion contractures
Bulge Test
With your dominant hand, milk down towards the patella and then hold pressure. Now press the medial aspect of the knee to force any fluid within the joint laterally. Now, take your hand and press quickly along the lateral (i.e., opposite) aspect of the knee. If you see a fluid wave medially, that is a positive bulge sign.
if bulge present, you would check for ballottment.
Ballottement: knee
For larger effusions
compress suprapatellar pouch and “ballotte” or push the patella
sharply against the femur. Watch for fluid returning to the
suprapatellar pouch.
Collateral ligament assessment: Valgus Test
MCL
abduction. With patient supine and knee slightly flexed, move thigh about 30 degrees laterally to the side of the table. Place one hand against lateral knee and stabilize the femur and the other hand around the medial ankle. Ush medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress). Pain or gap in medial joint line points to ligamentous laxity and a partial tear of the medial collateral ligament. Most injuries on medial side.
* genovalgum: “gum between your knees”*
Collateral ligament assessment: Varus stress
LCL
adduction. With thigh and knee in same position, change your position so you can place one hand against medial surface of the knee and push other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side
* genovarum: bow-legged*
McMurray Test
Hold heel. Trap meniscus between tibia and femoral condyle. Knee hyperflexed and go back and forth w/ ankle to trap meniscus. To test medial meniscus, feel medial side w/ fingers. Keep knee hyperflexed with ankle inversion and extend in varus position. To test lateral meniscus, feel lateral side w/ fingers. Knee hyperflexed with ankle eversion. Leg in valgus position and extend. Feel for pop/click. If pain with pop/click, this is a positive McMurray. (Tests Meniscus)
Click or pop along medial joint w/valgus stress, external rotation and leg extension suggests a probably tear of posterior portion of medial meniscus. Tear may displace meniscal tissue, causing “locking” on full knee extension. McMurray + locking: medial meniscus tear 8.2 and 3.2 times more likely
ACL/PCL assessment: Drawer Test: (Anterior and Posterior)
w/ pt’s knees bent and feet flat on table
Cup hands around knee w/thumbs on medial and lateral joint line and fingers on medial and lateral insertion of hamstrings.
pull lower leg forward (anterior test) and push it back (posterior test)
Lachman Test
Place knee in 15 degrees of flexion and external rotation. Grasp distal femur on lateral side w/one hand and proximal tibia on medial side w/other. With thumb of tibial hand on joint line, simultaneously pull the tibia forward and the femur back. Estimate degree of forward excursion.
ACL Tear
Back ROM
Spinal Curvature Disorders
Crossover test
Acromioclavicular joint: palpate and compare both joints for swelling or tenderness. Adduct patient’s arm across chest.
Localized tenderness or pain suggests inflammation or arthritis of the acromioclaviular joint
Apley scratch test
Rotator cuff d/o or adhesive capsulitis
Neer’s impingement SIgn
Press on scapula to prevent scapular motion w/one hand and raise patient’s arm w/other. This compresses the grater tuberosity of the humerus against the acromion.
Pain –> inflammation or rotator cuff tear
Hawkin’s impingement
Flex patient’s shoulder and elbow to 90 degrees w/palm facing down. Then, with one hand on forearm and one on arm, rotate arm internally. This compresses greater tuberosity against coracoacromial ligament.
pain: inflammation or rotator cuff tear
Nerve distribution to hands
Hands of those with chronic rheumatoid arthritis
ulnar deviation, swollen thickened metacarpophalangeal and proximal interphalangeal joints, boutonniere deformity, swan neck defomity
Signs of osteoarthritis in hand
Heberden’s node, bouchard’s node, radial deviation of distal phalanx
(metacarpophalangeal joints uninvolved)
