Exam 3- Musculoskeletal

Question 1

What are the four key features to evaluate musculoskeletal disorders?

Answer 1

Articular or extra-articular

Acute or chronic

Inflammatory or non-inflammatory

Localized (monoarticular) or diffuse (polyarticular)

Question 2

What are the three types of joints? Give examples of each

Answer 2

Synovial - freely movable (knee, shoulder)

Cartilaginous - Slightly movable (Vertebral bodies of the spine)

Fibrous- immovable (skull structures)

Question 3

What are the three types of synovial joints? What are their articular shapes? What is their movement? Give examples of each.

Answer 3

Spheroidal (ball and socket)- Convex surface in concave cavity. Wide ranging: flexion, extension, abduction, abduction, rotation, circumduction. EX: Shoulder, hip

Hinge- Flat, planar. Motion in one plane; flexion, extension. EX: Inter-phalangeal joints of hand and foot, elbow

Condylar- Convex or concave. Movement of 2 articulating surfaces not dissociable. EX: Knee, TMJ

Question 4

In articular joint pain, is there:

A. Decreased active ROM

B. Decreased passive ROM

C. Morning stiffness or “gelling”

D. All of the above

Answer 4

D. All of the above

Question 5

What kind of joint pain has periarticular tenderness and passive ROM remains intact?

Answer 5

Non-articular joint pain

Question 6

What are the four cardinal features of inflammation?

Answer 6

1. Swelling
2. Warmth
3. Redness
4. Pain

Question 7

What are examples of symmetric joint pain?

Answer 7

• RA
• SLE
• Ankylosing spondylitis

Question 8

What are examples of asymmetric joint pain?

Answer 8

• Psoriatic arthritis
• Reactive (Reiter) arthritis
• IBD-associated arthritis

Question 9

What are red flags for low back pain from underlying systemic disease?

Answer 9

• Age less than 20 or greater than 50
• Hx of cancer
• Unexplained weight loss, fever, or decline in general health
• Pain lasting more than one month or not responding to treatment
• Pain at night or at rest
• Hx of IV drug use, addiction, or immunosuppression
• Presence of active infection or HIV
• Long term steroid therapy
• Saddle anesthesia, bladder or bowel incontinence
• Neurologic symptoms or progressive neurologic deficit

Question 10

What is this maneuver and what would a positive result indicate?

Answer 10

Crossover or crossed body adduction test.

• Cross arm in front of body
• Acromioclavicular joint tenderness and compression tenderness

Question 11

What is this maneuver and what would a positive result indicate?

Answer 11

Apley scratch test

(overall shoulder rotation)

• Ask patient to touch opposite scapula using the 2 motions
• Pain during maneuvers suggest rotator cuff disorder or adhesive capsulitis

Question 12

What is this maneuver and what would a positive result indicate?

Answer 12

Painful arc test

(pain provocation test)

• Fully abduct patient’s arm from 0-180 degrees
• Shoulder pain from 60-120 degrees = subacromial impingement/rotator cuff tendinitis disorder.

Question 13

What is this maneuver and what would a positive result indicate?

Answer 13

Neer impingement sign

(pain provocation test)

• Press on scapula to prevent scapular motion with one hand, & raise the patient’s arm w the other. This compresses the greater tuberosity of the humerus against the acromion.
• Pain during maneuver indicates subacromial impingement/ rotator cuff tendinitis disorder.

Question 14

What is this maneuver and what would a positive result indicate?

Answer 14

Hawkins impingement

(pain provocation test)

• Flex patient’s shoulder & elbow to 90º w palm facing down. Then w one hand on the forearm & one on the arm, rotate the arm internally. Compresses the greater tuberosity against the supraspinatus tendon & coracoacromial ligament
• Pain during maneuver rotator cuff sprain or tear suggests Subacromial impingement, Supraspinatus impingement/rotator cuff tendinitis

Question 15

What is this maneuver and what would a positive result indicate?

Answer 15

External rotation lag test

(strength test)

• With patient’s arm flexed to 90º w palm up, rotate the arm into full external rotation
• Inability of patient to maintain external rotation suggests supraspinatus & infraspinatus disorders.

Question 16

What is this maneuver and what would a positive result indicate?

Answer 16

Internal rotation lag test

(strength test)

• Ask the patient to place the dorsum of the hand on the low back with the elbow flexed to 90°. Then you lift the hand off the back, which further internally rotates the shoulder. Ask the patient to keep the hand in this position.
• Inability to hold hand in this position suggests subscapularis disorder

Question 17

What is this maneuver and what would a positive result indicate?

Answer 17

Drop arm test

(strength test)

• Fully abduct arm to shoulder level (90º) & then slowly lower down
• Note abduction above shoulder level, from 90-120 degrees, reflects action of the deltoid muscle
• Weakness during this maneuver for a supraspinatus rotator cuff tear or bicipital tendinitis
• Rotator cuff sprain, partial tear, or full tear
• >60yo w + drop arm test likely degenerative rotator cuff tear

Question 18

What is this maneuver and what would a positive result indicate?

Answer 18

External rotation resistance test

(composite test)

• Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pres-sure proximal to the patient’s wrist as the patient presses the wrist outward in external rotation.
• Pain or weakness during this maneuver = infraspinatus disorder.
• Limited external rotation points to glenohumeral disease or adhesive capsulitis.

Question 19

What is this maneuver and what would a positive result indicate?

Answer 19

Empty can test

(composite test)

• Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms.
• Direct testing of SITS muscles
• Assess supraspinatus
• Inability of pt to hold arm fully abducted at shoulder level or control lower arm suggests supraspinatus rotator cuff tear.

Question 20

Which muscle groups make up the rotator cuff?

Answer 20

Scapulohumeral group

• Supraspinatus
• Infraspinatus & Teres minor
• Subscapularis

“SITS”

Question 21

What is lateral epicondylitis? What are exam findings?

Answer 21

• “Tennis elbow”
• Tenderness distal to epicondyle
• Repetitive extension of the wrist or pronation–supination of the forearm.
• Increased pain when extend wrist against resistance .
• Pain and tenderness develop 1 cm distal to the lateral epicondyle and possibly in the extensor muscles close to it.
• Treat w rest & NSAID

Question 22

What is medial epicondylitis? What are exam findings?

Answer 22

(“pitcher’s or golfer’s elbow”)

• Tenderness lateral and distal to medial epicondyle
• Due to Repetitive wrist flexion (throwing)
• Wrist flexion against resistance increases pain
• Treat w rest & NSAID

Question 23

What is olecranon bursitis? What are exam findings?

Answer 23

• Nodules or swelling when inspecting & palpating
• The swelling is superficial to the olecranon process and may reach 6 cm in diameter.
• May result from trauma, gout, or RA.
• Consider aspiration for both diagnosis and symptomatic relief.

Question 24

What are Heberden nodes? What condition are they seen in?

Answer 24

• Hard dorsolateral nodules on the DIP joints.
• On the dorsolateral aspects of the DIP joints from bony overgrowth of OA.
• Usually hard and painless, they affect middle-ages or older adults;
• Common in OA

Question 25

What are Bouchard nodes? What condition are they found in?

Answer 25

* Nodes on the PIP (proximal interphalangeal joint) joints * Common in OA (but less common than Heberden nodes)

Question 26

What symptoms are consistent with carpel tunnel syndrome?

Answer 26

* Numb first 3 digits * Thenar atrophy - from median nerve compression. * Nocturnal hand or arm numbness (paresthesias) * Dropping objects * Inability to twist lids off jars * Aching at the wrist or even the forearm

Question 27

What tests can use to assess for carpel tunnel syndrome?

Answer 27

1. Thumb Abduction 2. Tinel Test (not reliable) 3. Phalen Test for Median Nerve Compression (not reliable) Others: * Grip strength * Opposition of the thumb

Question 28

How do you test Thumb Abduction? What does a postive test indicate?

Answer 28

* Ask the patient to raise the thumb straight up as you apply downward resistance * **Weakness** on thumb abduction is a positive test. * The abductor pollicis longus is innervated only by the median nerve. Combined use of a hand symptom diagram, median nerve territory hypalgesia, and thumb abduction weakness are most consistent with **nerve conduction diagnoses of carpal tunnel syndrome**.

Question 29

How do you test Tinel sign? What does a positive test indicate?

Answer 29

* By tapping lightly over the course of the median nerve in the carpal tunnel * **Aching and numbness** in the median nerve distribution is a positive test for **Carpal Tunnel Syndrome**

Question 30

How do you test Phalen sign? What does a positive test indicate?

Answer 30

* Ask the patient to hold the wrists in flexion for 60 seconds with the elbows fully extended. * Alternatively, ask the patient to press the backs of both hands together to form right angles. * These maneuvers compress the median nerve. * **Numbness and tingling in the median nerve distribution** within 60 seconds is a positive test and indicates **carpal tunnel syndrome**.

Question 31

How do you assess grip strength? What does a postive test indicate?

Answer 31

* Ask the patient to squeeze grasp your second and third fingers as hard as possible and not let them go * **Decreased grip strength** is a + test for weakness of the finger flexors and/or intrinsic muscles of the hand. * It also results from **inflammatory or degenerative arthritis, carpal tunnel syndrome, epicondylitis, and cervical radiculopathy**. * Grip weakness plus wrist pain are often present in **de Quervain tenosynovitis**.

Question 32

How do you test opposition of the thumb? What does a positive test indicate?

Answer 32

* Ask the patient to touch the tip of the little finger with the thumb, against your resistance. * Inspect for **weak opposition** of the thumb in median nerve disorders such as **carpal tunnel syndrome**

Question 33

What is snuffbox tenderness? What does this indicate?

Answer 33

* The anatomic snuffbox = a hollowed depression just distal to the radial styloid process formed by the abductor and extensor muscles of the thumb. The “snuffbox” is more visible with lateral extension of the thumb away from the hand (abduction). * “Snuffbox” tenderness with the wrist in ulnar deviation and pain at the scaphoid tubercle are suspicious for occult **scaphoid fracture**. * Poor blood supply increases risk of _scaphoid bone avascular necrosis._

Question 34

What are Dupuytren flexion contractures?

Answer 34

* **Thickening of the flexor tendons or flexion contractures in the in the 3rd, ring, and 5th fingers**, arise from thickening of the palmar fascia. * The first sign is a thickened band overlying the flexor tendon of the 4th finger and possibly the little finger near the distal palmar crease. * The skin puckers, and a thickened fibrotic cord develops between the palm and finger. * Finger extension is limited, but flexion is usually normal. * Flexion contracture of the fingers may gradually develop.

Question 35

What is Stenosing tenosynovitis?

Answer 35

* Inflamed, tenderness & swelling tendon sheaths * Loss of grip strength * Trigger digits

Question 36

What is Colles fracture?

Answer 36

Tenderness over the distal radius after a fall

Question 37

What exam findings would be consistent with a clavicle fracture in the newborn?

Answer 37

* Palpate along the clavicle noting any **lumps, tenderness, or crepitus**; these may indicate a fracture. * A fracture of the clavicle can occur during a difficult birth.

Question 38

What is crepitus? What does it indicate?

Answer 38

* Audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss * May occur in joints without pain but is more significant when associated with s/s * Could indicate roughened undersurface

Question 39

What are the muscle groups of the hips?

Answer 39

* Ilopsoas * Gluteus maximus * Adductor group * Abductor group

Question 40

How would the FNP perform the Barlow test? What are positive finding and what do they indicate?

Answer 40

* Pull the leg forward & ADDUCT with posterior force (opposite direction with your thumbs moving down toward the table & outward). * You are feeling for any movement of the femur head laterally. Feel for a “clunk”. * Children \< 3 mo may have a negative exam but still have a dislocated hip d/t tightening of the hip muscles & ligaments. * Postive is you feel head of femur slip out

Question 41

How would the FNP perform the Ortolani test? What are positive finding and what do they indicate?

Answer 41

* Tests for posteriorly dislocated hip * Flex the leg to form right angles @ the hips & knees, place your fingers @ the greater trochanter of each femur & thumbs over lesser trochanter. ABDUCT HIPS simultaneously until the lateral aspect of each knee touches the examining table * With a developmental dysplasia of the hip, you feel a “clunk” as the femoral head, which lies posterior to the acetabulum, enters the acetabulum. * A palpable movement of the femoral head back into place = a + Ortolani sign.