Exam 3- Musculoskeletal Flashcards
What are the four key features to evaluate musculoskeletal disorders?
Articular or extra-articular
Acute or chronic
Inflammatory or non-inflammatory
Localized (monoarticular) or diffuse (polyarticular)
What are the three types of joints? Give examples of each
Synovial - freely movable (knee, shoulder)
Cartilaginous - Slightly movable (Vertebral bodies of the spine)
Fibrous- immovable (skull structures)
What are the three types of synovial joints? What are their articular shapes? What is their movement? Give examples of each.
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
In articular joint pain, is there:
A. Decreased active ROM
B. Decreased passive ROM
C. Morning stiffness or “gelling”
D. All of the above
D. All of the above
What kind of joint pain has periarticular tenderness and passive ROM remains intact?
Non-articular joint pain
What are the four cardinal features of inflammation?
- Swelling
- Warmth
- Redness
- Pain
What are examples of symmetric joint pain?
- RA
- SLE
- Ankylosing spondylitis
What are examples of asymmetric joint pain?
- Psoriatic arthritis
- Reactive (Reiter) arthritis
- IBD-associated arthritis
What are red flags for low back pain from underlying systemic disease?
- 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
What is this maneuver and what would a positive result indicate?
Crossover or crossed body adduction test.
- Cross arm in front of body
- Acromioclavicular joint tenderness and compression tenderness
What is this maneuver and what would a positive result indicate?
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
What is this maneuver and what would a positive result indicate?
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.
What is this maneuver and what would a positive result indicate?
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.
What is this maneuver and what would a positive result indicate?
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
What is this maneuver and what would a positive result indicate?
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.
What is this maneuver and what would a positive result indicate?
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
What is this maneuver and what would a positive result indicate?
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
What is this maneuver and what would a positive result indicate?
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.
What is this maneuver and what would a positive result indicate?
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.
What are Heberden nodes? What condition are they seen in?
- 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
What are Bouchard nodes? What condition are they found in?
- Nodes on the PIP (proximal interphalangeal joint) joints
- Common in OA (but less common than Heberden nodes)
What symptoms are consistent with carpel tunnel syndrome?
- 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
How do you test Thumb Abduction? What does a postive test indicate?
- 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.
How do you test Tinel sign? What does a positive test indicate?
- 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
How do you test Phalen sign? What does a positive test indicate?
- 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.
How do you assess grip strength? What does a postive test indicate?
- 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.
How do you test opposition of the thumb? What does a positive test indicate?
- 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
What is snuffbox tenderness? What does this indicate?
- 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.
What are Dupuytren flexion contractures?
- 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.
How would the FNP perform the Barlow test?
What are positive finding and what do they indicate?
- 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
