Exam 3: Musculoskeletal

Question 1

Temperomandibular Joint:

What CN is it associated with?

How do you palpate it?

Answer 1

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.

Question 2

ROM for neck

Answer 2

We seem to use extension instead of hyperextension

Question 3

When you palpate joints, what are you feeling for?

Answer 3

crepitus, tenderness, inflammation/swelling

Question 4

UE Joints to palpate

Answer 4

Shoulders, elbows (olecranon and epicondyles), wrists, fingers

Question 5

Where are the olecranon & epicondyles?

Answer 5

Olecranon is bony point of elbow

Question 6

Bones of wrist/hands

Answer 6

Question 7

Joints of wrist/hands

Answer 7

Question 8

Shoulder ROM

Answer 8

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”

Question 9

Elbow ROM

Answer 9

Flexion, extension, supination, pronation

Supination: “have some soup”

Question 10

Wrists ROM

Answer 10

Question 11

Fingers: ROM

Answer 11

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

Question 12

Thumbs: ROM

Answer 12

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

Question 13

Grading Muscle Tone & Strength

Answer 13

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

Question 14

Tinel’s Test

Answer 14

Positive suggests carpal tunnel

For median nerve compression. Lightly tap overcourse of median nerve in carpal tunnel. Positive: aching & numbness in median nerve distribution

Question 15

Phalen’s Test

Answer 15

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)

Question 16

Brudzinski’s Sign

Answer 16

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”

Question 17

Kernig’s Sign

Answer 17

For meningitis

w/ pt supine, provider bends knee to 90 degrees and then straightens, noting there is no resistance from pt

K for “knee”

Question 18

Lower Extremities to Palpate

Answer 18

Hips, Knees, ankles, toes

Question 19

Hip ROM

Answer 19

+ internal & external rotaton

Question 20

Knee ROM

Answer 20

Flexion, extension

Question 21

Knee anatomy

Answer 21

Question 22

Ankle ROM

Answer 22

Question 23

Straight leg raise

Answer 23

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

Question 24

Thomas Test

Answer 24

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

Question 25

Bulge Test

Answer 25

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.

Question 26

Ballottement: knee

Answer 26

For larger effusions compress suprapatellar pouch and “ballotte” or push the patella sharply against the femur. Watch for fluid returning to the suprapatellar pouch.

Question 27

Collateral ligament assessment: Valgus Test

Answer 27

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"*

Question 28

Collateral ligament assessment: Varus stress

Answer 28

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*

Question 29

McMurray Test

Answer 29

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

Question 30

ACL/PCL assessment: Drawer Test: (Anterior and Posterior)

Answer 30

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)

Question 31

Lachman Test

Answer 31

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

Question 32

Palpate spinal process

Answer 32

C1-C7, T1-T12, L1-L5, sacral curve Walk your fingers down, "tell me if you have pain"

Question 33

Back ROM

Answer 33

Question 34

Spinal Curvature Disorders

Answer 34

Question 35

Cerebellar function tests

Answer 35

* Finger to nose * Heel down shin - length of knee to great toe * RAMS w/each hand (pronation, supination) or thumb finger to finger * Romberg * Pronator Drift * Tandem Walking * Heel walking * Toe Walking * Gait

Question 36

Romberg

Answer 36

Feet together, eyes open. Close them 30 to 60 seconds. Excessive swaying/falling. Guard patient!

Question 37

Pronator Drift

Answer 37

20 to 30 seconds, arms straight forward, palms up. Eyes closed. Tap briskly telling them to maintain horizontal position.

Question 38

Gait descriptions

Answer 38

even ataxia (jerky, unsteady) dystonia antalgic (limping b/c hurts)

Question 39

Types of Joints

Answer 39

**Synovial**: freely movable (e.g., knee, shoulder) **Cartilaginous**: slightly moveable (e.g., vertebral bodies of the spine **Fibrous**: immovable (e.g., skull sutures)

Question 40

Articular Structures

Answer 40

include joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone. Articular disease typically involves swelling and tenderness of entire joint and limits both active and passive ROM d/t either stiffness or pan

Question 41

Extra-articular structures

Answer 41

**LIgaments**: collagen fibrils, rope-like, connect bone to bone **Tendons**: collagen fibers connecting muscle to bone **Bursae**: pouches of synovial fluid that cushion movement of tendons and muscle over bone or other joiint structures extra-articular disease typically involves selected regions of joint and types of movement

Question 42

Types of synovial joints

Answer 42

**Spheroidal** (ball & socket): e.g., shoulder and hip **Hinge**: IP joints of hand and foot, elbow **Condylar**: knee, TMJ

Question 43

Low back pain

Answer 43

85% is idiopathic. Usually d/t muculoligamentous injuries and age-related degenerative processes

Question 44

Back pain: midline or off the midline

Answer 44

midline: musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metasteses, and rarely, epidural abscess off the midline: muscle strain, sacroiliitis, trochanteric bursitis, sciatica, hip arthritis; also renal conditions e.g., pyelonephritis or stones

Question 45

Cauda equina syndrome

Answer 45

from S2-4 midline disc or tumor consider if patient c/o bowel or bladder dysfunction (usually urinary retntion w/overflow incontinence), especially if saddle anesthesia or perineal numbness

Question 46

Pain in one joint, consider...

Answer 46

injury, monoarticular arthritis, possible tendinitis, or bursitis. Lateral hip pain near greater trochanter suggsts trochanteric bursitis

Question 47

polyarticular pain: always ask about *pattern of involvement* Migratory or steadily spreading? Symmetric?

Answer 47

Migratory: consider rheumatic fever, cgonococcal arthritis Progressive additive & symmetric: rheumatoid arthritis

Question 48

Severe pain, rapid onset in a red swollen joint, consider...

Answer 48

acute septic arthritis or gout. In children, consider osteomyelitis in bone contiguous to a joint

Question 49

Joints: pain swelling, loss of active and passive motion, or "locking", consider....

Answer 49

articular joint pain

Question 50

Joints: loss of active but not passive motion + tenderness outside the joing, consider...

Answer 50

nonarticular pain

Question 51

At what age is peak bone mass reached and what is the speed of age related bone degeneration?

Answer 51

30 yo Age related declines in estrogen and testosterone cause initially rapid bone loss which later becomes slow and continuous

Question 52

Palpable bogginess or doughiness of synovial membrane, often accompanied by effusion, consider...

Answer 52

synovitis

Question 53

joint fluid + tenderness over tendon sheaths, consider

Answer 53

tendinitis

Question 54

Crossover test

Answer 54

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

Question 55

Apley scratch test

Answer 55

Rotator cuff d/o or adhesive capsulitis

Question 56

Neer's impingement SIgn

Answer 56

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

Question 57

Hawkin's impingement

Answer 57

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

Question 58

Testing Supraspinatus Strength

Answer 58

Empty can test elevate arms to 90 degrees adn internall rotate arms, w/thumbs pointed down, as if emptying a can. Ask pt to resist you as you place downward pressure on arms weakness: possible rotator cuff tear

Question 59

Testing infraspinatus Strength

Answer 59

Ask patient to place arms at side and flex elbows to 90 degrees with thumbs turned up. Provide resistance as patient presses the forearms outward Weakness: rotator cuff tear, bicipital tendinitis

Question 60

Drop-arm sign

Answer 60

Ask ptient to fully abduct the arm to shoulder level (or up to 90 degrees - not above, then it's deltoid) and lower it slowly. If can't hold arm out or control lowering the arm, positive for rotator cuff tear

Question 61

Nerve distribution to hands

Answer 61

Question 62

Hands of those with chronic rheumatoid arthritis

Answer 62

ulnar deviation, swollen thickened metacarpophalangeal and proximal interphalangeal joints, boutonniere deformity, swan neck defomity

Question 63

Signs of osteoarthritis in hand

Answer 63

Heberden's node, bouchard's node, radial deviation of distal phalanx (metacarpophalangeal joints uninvolved)

Question 64

Chronic tophaceous gout - hands

Answer 64

can mimic rheumatoid and osteo-arthritis BUT, not usually symmetrical like rheumatoid is. And knobby swellings ulcerate and discharge white chalklike urates.