Exam 3: Musculoskeletal Flashcards
Adduction
the movement of a limb or other part toward the midline of the body or toward another part.
abduction
the movement of a limb or other part away from the midline of the body, or from another part
Flexion
the action of bending or the condition of being bent, especially the bending of a limb or joint.
Extension
It occurs when muscles contract and bones move the joint from a bent position to a straight position. It is a posterior movement for joints that move backward or forward, such as the neck
Pronation
person shifts their weight from the heel to the forefoot, it is termed pronation
Suppination
weight is placed on the outside of the foot while walking or running
3 major bones of ankle
Tibia, fibula, talus
Weight bearing bone of ankle
Talus
Sprain
Ligament injury (bone to bone) Occurs due to abnormal rotation such as a sudden change in direction or a misstep on an uneven surface
Clinical presentation of ankle sprain
Swollen and painful joint, ecchymosis and decreased ROM. weight bearing causes pain
Immediate swelling or ecchymosis is suspicious for
Fracture
Treatment of sprain
RICE
Rest, ice, compression elevation
NSAIDs
Passive and active exercises
Achilles tendon
Responsible for flexion and extension of the ankle
Clinical presentation of achilles tendinopathy
Intermittent symptoms, pain that subsides during exercise but increases while at rest
Can be local at heel or along th elength of tendon
Severe pain climbing stairs
Abnormal gait
Haglund deformity
Bony prominence at the heel
Achilles tendinopathy
Gold standard for achilles tendinopathy
MRI
Tx of achilles tendinopathy
Cessation of sports, tendon rest, NSAIDs, ice massage
May take 8 weeks to heal
Achilles tendon rupture
Sudden event; feel like you were shot in the calf; sudden weakness in the ankle and inability to rise up on toes; pain not common
PE of achilles tendon rupture
Visible and palpable gap overlying the tendon where the rupture occurred
Thompson test
Achilles tendon is in tact if th efoot plantar flexes when the calf is squeezed
Tx of achilles tendon rupture
Long leg cast with foot in plantar-flexed position for 6 weeks or surgical repair
Plantar fasciitis
Pain in the bottom of the foot and along the arch and in the heel
Due to high impact running/jumping or shoes with inadequate support
Pain with weight bearing first thing in the morning and point tenderness
Morton neuroma
Result of perineural fibrosis of the plantar nerve at the point where the medial and lateral branches of the plantar nerve converge
Usually due to high heeled shoes
severe pain and burning in the region of the third web space; barefoot and foot massages relieves discomfort; elevation of foot aggravates
Tx of morton neuroma
Wide toe shoes, NSAIDs, separation of toes with pad
Sarcoma
Malignant tumor of mesenchymal or neuroectodermal origin
Most common malignant tumor that originates in bone
Multiple myeloma
Pain management for bone tumors
Biphosphanates
Gabapentin, amitriptyline, benzos
Bursa
Sac lined with synovial fluid, which provides lubrication and facilitates smooth movement between tissues of an extremity
Clinical features of bursitis
Pain at motion and rest, regional loss of ROM, visible swelling, tenderness to palpation
Shoulder bursitis
Anterior/lateral shoulder pain exacerbated by overhead activities
Deep aching interrupts sleep
Tenderness below the acromion
Signs for shoulder bursitis
NEER and Hawkins
Olecranon bursitis
Elbow
Visible posterior elbow swelling
1/3 cases are septic–antibiotics should cover S Aureus
Ballottement test
For knee effusion
Valgus stress
Force on medial elbow from throwing or axial compression
Golf
Varus stress
Force on lateral elbow
Tennis
Tx of fibromyalgia
Amitriptyline, cyclobenzaprine, SSRI, gabapentin, trazadone, zolpidem, lidocaine IM
4 stages of gout
Asymptomatic hyperuricemia
Acute gouty flare
Intercritical gout
Chronic tophaceous gout
Most common inflammatory arthritis in adults
gout
Predominant cause of hyperuricemia
Undersecretion of urate by the kidneys
Definitive dx of gout achieved by
Needle aspiration of inflamed joint
Tx of acute gout flare
NSAIDs, colchicine, steroids
higher doses of NSAIDs in first 24-48 hours
Urate lowering therapy
Start 6-8 weeks after acute flare has resolved
Start at low dose and increase slowly every 4-6 weeks
Allopurinol, prebencid, pegloticase
Tinnel sign
For carpal tunnel syndrome
Push down on radial nerve
Phalen test
For carpal tunnel syndrome
Back of hands pressed together
What should always be ruled out for hip pain caused by trauma
Avascular necrosis
Primary fx of hip
locomotion and weight bearing
Leg-Calve-Perthes
Avascular necrosis of the femoral head found in 4-8 year old boys
Pain at rest in hip indicates
inflammatory, infection or neoplasm
OA clinical presentation
Worsening pain with activity and improvement with rest
Stiffness on first rising and after long eperiods of inactivity
2 tests of hip function
gait and ROM
Most common cause of acute bacterial arthritis
Staph aureus
Triad of sx in gonococcal arthritis
dermatitis, tenosynovitis, migratory polyarthritis
Most important dx exam for infectious arthritis
Synovial fluid aspiration
Tx of infectious arthritis
Older children + adults: nafcillin, oxacillin, cefazolin
Elderly/immuno compromised: cefepime
Gonococcal: ceftriaxone IM
MRSA: Vanco
Cartilage of knee
Meniscus
Medial collateral ligament injury
Externally rotating wrenching motion of the knee or a blow to the lateral side of the knee with a firmly planted foot
Valgus stress
Lateral collateral ligament injury
Internal rotation or a blow to the medial side of the knee with a firmly planted foot
Varus stress
Anterior cruciate ligament injury
Typically injured in sports during rapid deceleration or quickly changing direction
Usually occurs with ruptures of MCL and medial meniscus
Hear a pop or feel snap
Lachman test, anterior drawer test
Medial meniscus injury
When weight bearing knee is twisted while in flexed position; femur compresses against the tibia and grinds against the meniscus
McMurray test
Activity modification for 6-12 weeks
Lumbar spinal stenosis
Back pain and neurogenic claudication; feel as though legs are heavy or wooden
Walk with shopping cart helps
Cauda equina
Saddle anesthesia, urinary retention or incontinence, lower extremity weakness, recent onset ED
Due to compression of multiple lumbosacral nerve roots below the termination of the spinal cord
Straight leg test
For herniated disk
Osteoporosis
Increased bone fragility and susceptible to fracture due to decrease in bone mass due to estrogen deficiency and aging
Most common metabolic bone disease
Bone mineral density of 2.5 below mean
Bone formation
Osteoblasts
Most common cause of secondary osteoporosis
Steroids
Causes osteoblast death, prolongs life of osteoclast and decreases estrogen levels
Indication for DEXA scan
women >65, men >70
Prevention of osteoporosis
Calcium 1000-1200mg, vitamin D 800-1000IU daily, weight bearing exercise, normal body weight, avoid smoking and alcohol
Biphosphanates
Alendronate, zoledronic acid
Reduce bone resorption and bone loss by binding to bone and poisoning osteoclasts
Biphosphanates CI in
esophageal dismotility, active GI bleeding, renal disease
Denosumab
Monoclonal antibody that inhibits RANK ligant and potently reduces bone resorption
Given SC every 6 months
For osteoporosis
Calcitonin
Decreases osteoclastic activity
Paget disease
Localized increase in bone turnover and blood flow; osteoclasts increased in number and size; osteoblasts try to keep up but the newly formed bone is disorganized and lacks integrity
Result is mechanically weak, highly vascular bone prone to deformity and fractures
Clinical presentation of paget disease
Bone pain most common
Painful at rest and motion; deep ache pain and becomes worse with weight bearing and warmed
PE in paget disease
Affected area tender to touch and warm; may have increased pulsatility and enlarged
Dx tests for paget disease
serum alkaline phosphatase, urinary n-telopeptide cross links level
How to take biphosphanates
Empty stomach at least 30 mins before a meal
Muscle relaxants
Tizanidine, cyclobenzaprine, baclofen
Most common pathogen of osteomyelitis
staph aureus
Rotator cuff consists of attachments of 4 muscles
supraspinatus, infraspinatus, teres minor, subscapularis muscles
PE for shoulder pain
Palpate for any tenderness
Active ROM: forward flexion, extension, external rotation, internal rotation, abduction, adduction
Apprehension test
abduct to 90 degrees and slowly externally rotate patient’s arm to position where it might dislocate
Drop arm test
have patient hold arm in fully abducted position, then ask patient to slowly lower arm to side
Empty can test
hold affected arm as if offering examiner can of soda (abduct to 90 degrees), then have patient turn arm to empty contents
Impingement test
have patient elevate arm slowly into overhead position
Hawkin test
forward flex the shoulder and elbow to 90 degrees, apply force to the forearm to internally rotate the shoulder
Spurling test
have patient flex cervical spine laterally toward the ipsilateral shoulder; apply downward axial force on the head
Most commonly injured tendon in rotator cuff tear
Supraspinatus tendon
Labral tear
o Deep shoulder pain with specific shoulder positions, pain during overhead maneuvers
Subacromial impingement syndrome
Edema, hemorrhage, inflammation and fibrosis occur
Grade 1 sprain
: involves minimal injury with stretched fibers or a few microscopic tears of a ligament resulting from overstretching; causes pain and edema
Tx: RICE, non-weight bearing activity, return to sports in 2-3 weeks
Grade 2 sprain
incomplete tear of a ligament and includes some functional impairment, ecchymosis, discomfort or pain with weight bearing
Tx: RICE, partial weight bearing, return to sports in 4-8 weeks
Grade 3 sprain
full or complete tear of the ligament with loss of ligament integrity
May have swelling, discoloration and pain with movement
Tx: referral to orthopedics, cast for 10-14 days, rehab before returning to sports
Strain
Overstretching or overuse o muscles and/or tendons (muscle to bone)
No actual muscle damage occurs
Most common site for bursitis
subacromial (shoulder)
CI to aspiration and injection in bursitis
cellulitis at the injection site, primary coagulopathy or uncontrolled anticoagulant therapy, septic effusion of a bursa or periarticular structure, more than three previous injections at the same site in the previous 12 months or lack of improvement after two prior injections, suspected bacteremia from another site, unstable joints (for corticosteroid injection), tumors, fractures, joint prosthesis, and inaccessible joints.
Primary weight bearing bone of ankle
talus
Risk factors for osteoporosis
alcohol, RA, menopause
Typical sites of fracture in osteoporosis
vertebrae, distal wrist, proximal femur, ribs
If osteoporosis is present in premenopausal or men
Should consider secondary cause–hyper parathyroidism or hyperthryoidism
Dx labs for osteoporosis
Serum electrolyte levels, fasting serum calcium and phosphorus, serum glucose, BUN, Cr, PTH, TSH, vit D
Most common sites of Pagets disease
pelvis, femur, tibia, spine, skull
Labs for bone tumors (multiple myeloma)
Calcium, alkaline phosphatase, Bence jones protein, ESR and CRP, WBC,
NEER impingement sign
Raise and pull on straightened arm forcibly from the side to full abduction above the head.
• The maneuver causes pain in patients with impingement.
Hawkins impingement sign
Flex the elbow to 90 degrees and raise the upper arm to 90 degrees of abduction (parallel to the floor). Then rotate the arm internally across the front of the body, causing compression of the rotator cuff and subacromial bursa between the head of the humerus and coracoacromial ligament.
• The maneuver causes pain in patients with impingement
Neuropathic agents for fibromyalgia pain
Gabapentin (neurontin), pregabalin (lyrica), amitriptyline (elavil)
Increasing prevalence of gout due to
Greater use of diuretics and low dose aspirin
Podagra
Acute synovitis of the first MTP joint of the big toe
Risk factor for avascular necrosis
Chronic steroid use
Ballotment
Push down on patella
Patella springs upward suggesting large effusion
McMurray test
Foot everted, knee varus position, flex/extend while palpating medial joint line, then invert fot, knee valgus, palpate lateral joint line
Pain or palpable click with hand on joint line suggests meniscal injury
Appley grind test
Patient supine, knee flexed 90 degrees, examiner rotates foot while providing downard pressure
Pain suggests meniscal injury along side being palpated
Lachman test
Stabilize femur with one hand and pull anteriorly on tibia with other
Excessive laxity suggests ACL tear
Posterior drawer test
Knee 90 degrees, examiner sits in patient’s foot and pushes posteriorly on tibia
Excessive laxity suggests PCL tear
Subacromial palpation pain
Suggests bursitis or impingement
Hawkins test
Elbow 90 degrees, arm forward flexed 90 degrees, examiner internally rotates
Pain suggests bursitis/impingement
Neers test
Thumb down, elbow straight, examiner raises arm through forward flexion
Pain suggests bursitis/impingement
