(FE) MSK Flashcards
What is the anatomical landmark for the temporomandibular area?
Tragus of each ear
What is the anatomical landmark of the hips?
iliac crests and greater trochanters
How does normal gait look like?
- Upright posture
- Ambulates with smooth, even and painless gait
How does a normal spine look like?
- Concave curve of the cervical (1) and lumbar (3) spine
- Convex curvature of the thoracic (2) and sacral (4) spine
What are some alterations in spine curvature?
1) Lordosis
- Inward curvature of lumbar (3) spine
- Often seen in pregnant clients
2) Kyphosis
- Top spine seems more rounded than normal
- Often seen in elderly
3) Scoliosis
- Lateral curvature of spine
- Usually discovered in childhood
How should limbs normally present upon inspection?
- Bilaterally symmetric in length, circumference and position
What are the unexpected findings of muscles upon inspection?
1) Fasciculations
- Muscle twitching
- Occurs if motor neuron is damaged
2) Muscle wasting
- Can occur after an injury or muscle disease
What are some alterations in knee anatomy?
- Outward deviation: genu varum (bow leg)
- Inward deviation: genu varus (knock knees)
What are some foot variations?
- Pes planus (flat feet)
- Pes cavus (higher than normal instep)
What are some toe variations?
- Hammertoe (middle joint is bent)
- Claw toe
- Hallux valgus (bunion)
- Hallus varus (great toe deviates from other toes)
What are the normal and abnormal findings upon palpitation of bones, joints, tendons and muscles?
Normal:
-Aligned, symmetrical and nontender
Abnormal:
- Crepitus
- Grating sensation
~ Usually in tendonitis or bones rubbing against each other
- Edema
~ Usually in gout, arthritis, or injury
When is the normal finding upon palpation of the temporomandibular joint?
- Uneventful when opening and closing mouth, or a slight popping sound/sensation
What are the abnormal findings upon palpation of the elbows?
- Nodule along ulnar surface
~ Rheumatoid nodule
~ Gouty tophi
What are the abnormal findings upon palpation of the wrist and hands?
- Mass over dorsum of wrist
~ Ganglion cyst - Tender swelling of proximal interphalangeal joints
~ Rheumatoid arthritis
~ Deviates into swan neck/boutonniere deformities - Bony growths in distal interphalangeal joints
~ Heberden nodes
~ Associated with osteoarthritis - Bony growths in proximal interphalangeal joints
~ Bouchard nodes
~ Associated with osteoarthritis
What are the abnormal findings upon palpation of the hips and knees?
- Swelling and tenderness
~ Injury or joint effusion - Tenderness or edema in popliteal space
~ Popliteal cyst
What are the abnormal findings upon palpation of the ankles and feet?
- Thick achilles tendon
~ Tendonitis secondary to spondyloarthritis or xanthelasma (yellow eyelid corners) of hyperlipidemia - Localised warmth, pain or inflammation
~ Joint inflammation from RA, septic joint, fracture or tendonitis
What is the normal results of ROM?
- Normal muscle strength and tone that feels soft and nontender
- 0-5 rating (0 is paralysis)
~ <3 may be due to neuromuscular, skeletal, neurological disorder or overstretching
~ May need assistive devices to promote mobility
What is the difference between osteomyelitis, osteoarthritis and rheumatoid arthritis?
1) Osteomyelitis
- Infx of bone
2) OA
- Local disease/Wear and tear so it usually affects one joint at a time
- Has varying levels of synovitis
- Bone ends rub together due to loss of articular cartilage
- Morning stiffness lasts <30 mins
3) RA
- Systemic disease so it affects both joints
- Constant inflammation in synovial membrane
- Bone is eroded
- Morning stiffness lasts >30 mins
What is osteomyelitis?
- Inflammation of the bone
- Usually due to infection
~ Commonly S. aureus
~ M. tuberculosis
~ Pseudomonas aeruginosa
~ Streptococcus spp
~ Salmonella spp
~ Pasteurella spp
What is the structure of bone?
- Outer surface covered by periosteum (dense layer of connective tissue)
~ Where muscles, tendons and ligaments are attached - Below periosteum, is compact bone
~ Has blood vessels and nerves - Center of the bone has medullary canal, lined by spongy bone
~ Spaces in spongy bone are occupied by bone marrow
What are the risk factors for osteomyelitis?
Local:
- Trauma and open wounds
Systemic:
- Weak immune system
- Poor circulation
~ Due to uncontrolled diabetes or peripheral vascular disease
- Bacterial infections in other sites of the body
- IV drug use
- Periodontal disease
- IDC
- Prosthetic joint
What is the pathology of osteomyelitis?
Direct invasion:
- Trauma or surgery (bone is exposed to environment)
Indirect invasion:
- Hematogenous spread (distant spread through bloodstream)
- Contiguous spread (nearby infection)
Followed by:
- (Acute) Pathogens proliferate and initiate an inflammatory response
~ Causes local destruction of bone
~ Phase resolves within a few weeks
- (Chronic)
~ Bone becomes necrotic and separates itself from healthy bone to form a sequestrum
What are the local and systemic symptoms of osteomyelitis?
Local:
- Bone pain, redness, swelling, warmth and restricted movement around site of infection
Systemic:
- Fever, malaise
- Nausea
- Restlessness
- Night sweats/chills
Diagnosis of osteomyelitis?
- CBC
~ ^ in WBC
~ ^ in ESR
~ ^ in CRP - Imaging tests
~ Thickening of cortical bone and periosteum and elevation of periosteum
~ Osteopenia (loss of bone mass) - Bone biopsy
Treatment of osteomyelitis?
Acute:
- Antibiotics (oral, irrigation, acrylic bead chains implanted onto bone)
- Surgical debridement
Chronic:
- Incision and drainage
- Wound debridement
- Surgical removement of dead tissue
- Extended antibiotics therapy and hyperbaric oxygen therapy (^ pressure)
- Amputation of limb
- Bone graft
Nursing care for osteomyelitis?
- Contact precaution
- Vital signs + pain score
- Administer analgesics
- Note dec. or absent pulses, prolonged capillary refill, dusky or pale, cool skin, numb feeling/reduced sensation and pain that does not improve with medication
- Look out for signs of sepsis
~ ^ WBC with left shift
~ ^ serum lactate
~ ^ procalcitonin
~ Altered level of consciousness
~ Hypotension
~ Tachycardia
~ Tachypnea
What is osteoarthritis?
- Degenerative joint disease
~ Gradual wear and tear of joint cartilage and underlying bone + inadequate repair - Chronic, non-inflammation condition
What are the types joints?
1) Fibrous/synoarthrodial joints
- Bones which do not move at all
- Skull bones
2) Cartilaginous/amphiarthrodial joints
- Some movement
- Spine
3) Synovial/diarthrodial joints
- Freely movable
- Wrists, elbows etc
What are the risk factors of osteoarthritis?
- > 50 y/o
- Obesity
- Joint overuse/injury
- Altered walking patterns (can increase joint stress)
- Family history of OA
- Female
- Associated medical conditions
~ Diabetes, multiple sclerosis, hematological disorders
What is the pathophysiology of OA?
- Articular cartilage (connective tissue with a lubricated surface that acts as a protective cushion for bones to smoothly glide against) wears away from repetitive stress
~ Weakens and loses elasticity - Since cartilage has limited repair capacity, areas of maximal stress start developing fibrillations (cracks or clefts) in cartilage
- Over time, cartilage continues to erode until bones are exposed
~ Bones start to rub against each other - At joint edges, bone grows outward to form osteophytes/bone spurs
Symptoms of OA?
- Joint pain
~ Pain worsens with activity (early stages) and at rest (late stages)
~ Worse in the evening - Joint stiffness w/ limited ROM
~ Worse in the morning
~ Typically lasts up to 30 mins
~ Stiffness improves with activity - Osteophytes visible as single subcutaneous nodes
~ Bouchard nodes (proximal interphalangeal)
~ Heberden nodes (distal interphalangeal)
Diagnosis of OA?
- X-rays
~ Cartilage loss and narrowing of joint space - Blood tests
~ Typically normal (used to rule out other types of arthritis) - Arthrocentesis
~ Synovial fluid usually clear and no inflammation in OA
~ Used to rule out other types of arthritis
Treatment of OA?
- Lifestyle modifications
~ Weight loss
~ Physical therapy
~ ROM and local muscle strengthening - For px with joint instability, joint can be immobilized using supportive or orthotic devices
~ Ilizarov apparatus
~ Braces, splints - Acupuncture, meditation, massage
- Oral analgesics
- Total joint replacement, arthroplasty
- Osteotomy (less common)
~ Cut and realign bones to relieve pressure and pain
Nursing care for OA?
- Perform mobility assessment
~ Evaluate for joint enlargement, swelling, stiffness, crepitus and ROM - Assess joint pain
~Onset, quality, severity, relieving or aggravating factors and duration of pain - For joint instability
~ Apply heat pack
~ Immobilize joint with splint or brace until inflammation subsides - Analgesics
- Ensure physical therapy
What is rheumatoid arthritis?
- Autoimmune disease that causes bone erosion and a swollen, inflamed synovial membrane
What is gout?
- Inflammatory disease
- Urate crystals deposit in a joint and cause damage
- Caused by hyperuricemia
~ Uric acid is a waste product from purines (building blocks of RNA/DNA) and is excreted by the kidneys to urine
What are the risk factors/causes of gout?
1) Overproduction
- Overconsumption of purine-rich food
~ Red meat, shellfish, anchovies
~ Alcohol
~ Sodas
~ Mayonnaise
~ Aged cheese
- Cells die at faster rate -> ^ breakdown of purines into uric acid
~ Chemo, radiotherapy, surgery
2) Decreased excretion
- Dehydration
- Diabetes
- CKD
- Medications
~ Thiazide diuretics
~ Aspirin
3) Genetic predisposition
- ^ age, male gender, obesity
- Family history
What is the pathophysiology of gout?
1) Hyperurecemia + presence of urate crystals in joints causes:
- Complement activation
- Phagocytosis of crystals by monocytes
2a) In complement activation, neutrophil chemotaxis causes attempted (but failed) phagocytosis of neutrophils
- Causes neutrophil lysis
~ Releases lysosomal enzymes which lead to tissue injury and inflammation
2b) Successful phagocytosis of crystals by monocytes causes IL-1, IL-6 and TNF to be released
- Proteases are released by the cartilage and synovium
~ Leads to tissue injury and inflammation
Presentations of gout?
- Joint becomes red, warm, tender and swollen in a few hours
- Mostly affects the first metatarsal joint of big toe (podagra)
- Joint feels like it is on fire
- Discomfort and swelling can last for a few days w/ treatment, or weeks w/o treatment
- Repeated attacks leads to chronic gout
~ Type of arthritis with permanent joint destruction and deformity
~ Permanent deposits of urate crystals (tophi) alone bones beneath the skin - ^ risk of developing kidney stones and urate nephropathy (urate deposition in kidney tubules)
Diagnosis of gout?
- Lab tests
~ Hyperuricemia (>6.8 mg/dL)
~ ^ CRP
~ ^ ESR - Joint aspiration
~ Presence of monosodium urate crystals in the synovial fluid (normal plasma urate levels is 2-7mg/dL)
~ Kidney stones from urate crystals - Imaging tests (eg X-rays)
~ Tophi
Treatment of gout?
- Decreased pain and swelling
~ NSAIDs
~ Corticosteroids
~ Antigout agents (colchicine) - Decrease uric acid levels
~ Allopurinol
~ Uricosuric medication to ^ excretion of uric acid by kidneys - Lifestyle modifications
~ Modify diet to reduce purine-rich food
~ Exercise
~ Stay hydrated (helps kidneys to flush out toxins)
~ Managing underlying comorbidities
~ Avoiding thiazide diuretics
~ Elevate his foot and keep his toe open to air
What is acute compartment syndrome and its pathophysiology?
- Rapid increase in pressure within an enclosed compartment that contains muscles, nerves and blood vessels, and surrounded by fascia (fibrous connective tissue)
- As fascia is non-elastic, it will not stretch much when pressure increases
~ Blood supply gets cut off -> tissue damage due to hypoxia and ischemia
What are the causes of acute compartment syndrome?
- Bleeding
~ Especially in long bone fractures and penetrating injuries - Limb compression
- Circumferential burns -> tissue edema
- Reperfusion injury
~ In clients with prolonged tissue hypoxia, sudden restoration of blood supply can lead to massive inflammation and edema - Receiving large amounts of IV fluids
~ May extravasate and infiltrate tissues
~ Eg in clients with bleeding disorders
What are the symptoms of acute compartment syndrome?
6Ps:
1) Severe pain out of proportion to injury
2) Paresthesia (numbness)
3) Pallor
4) Pulselessness
5) Poikilothermia (coolness of limb)
6) Paralysis
- Swollen and very stiff
What are the complications of acute compartment syndrome?
- Necrosis and gangrene
- ^ risk of infection
- Rhabdomylosis
~ Leads to muscle scarring and contractures that restrict movement
~ Can result in acute kidney injury - Irreversible nerve damage
~ Permanent motor and sensory deficits
Diagnosis of acute compartment syndrome?
- Measure compartment pressure using a handheld manometer
~ Diagnosis if >30mmHg - Imaging techniques (X-rays, CT, MRI)
~ Locates bone, muscle and blood vessel injuries - CBC
~ ^ WBC
~ ^ ESR
~ ^ CK and myoglobin (if rhabdo is present) - Urinalysis
~ Tea-coloured urine
Treatment of acute compartment syndrome?
- Fasciotomy
~ Skin and fascia are cut open to relieve pressure and restore normal blood flow - Amputation if limb is already necrotic and gangrenous
- Pain medications
- Elevate extremity but not above the heart
~ Could decrease perfusion and worsen condition - NVA every 30 mins
~ Report if numbness, cyanosis/necrosis, absent pulses or if limb does not improve within 4 hours of cast removal
What are the 2 types of hip fractures?
- Intracapsular fractures
~ Within the capsule of the hip joint
~ Caused by (minimal)trauma and osteoporosis
-Extracapsular fractures
~ Happens outside the capsule
~ Usually caused by severe direct trauma
What are the types of fractures?
- Closed / simple fractures
~ Bone breaks but skin is intact - Open / compound fractures
~ Fractured end pierces through the skin - Greenstick fracture
~ One side of bone breaks, other side bends
~ Common in children - Impacted fracture
~ Piece of bone gets dislodged into another bone - Comminuted fractures
~ Shattered into many pieces
~ Great and sudden trauma - Spiral fractures
~ Fracture line follows the projection of a small, twisting force
~ Usually non-accidental
What are the risk factors for fractures?
- Old age
- Female
- Family history of osteoporosis
- Low vit D
- Smoking, alcohol
- Glucocorticoid use
- Malabsorption problems (affects absorption of nutrients like vitamin D)
Why are women more at risk of osteoporosis than men?
- Women tend to have smaller, thinner bones
- Estrogen (hormone that protects bones) decreases during menopause
What are the complications of fractures?
- Avascular necrosis of femoral head (if circumflex artery is compromised)
- Slower healing and longer periods of immobility and hospitalisation (due to reduced blood flow)
- DVT and pulmonary emboli, infx
- Severe pain and tenderness around affected area (difficult to bear weight on affected leg)
- Compartment syndrome
- Fat embolism
- Mobility complications (joint stiffness, instability)
~ Contractures (shortened muscles and tendons causing shorter ROM) - Healing abnormalities that result in bone deformity
~ Malunion (fractured ends are not properly aligned)
~ Delayed union (bone requires more time to complete healing process)
~ Non-union (bone fails to connect)
Diagnosis of fractures?
Imaging tests
- Anteroposterior and lateral plain X-rays
- Only need to be taken from 2 angles
- 3 angles needed if fracture is near a joint
Treatment of fractures?
- Controlling pain using
~ Regional nerve block
~ Immobilization of hip joint - Surgical repair and stabilization of displaced bones
- Anticoagulants (prevent thrombosis and avascular necrosis)
- Rehabilitation
Nursing care for fractures?
- Institute fall precautions
- Maintain bed rest
- Affected extremity to be immobilized and abducted in the prescribed position
- Head of the bed <45deg to prevent excessive hip flexion (for hip fractures)
- Continue IV fluids and antibiotics
- Reduce risk of pressure injuries
- Monitor for signs of delirium
- Perform full NVA
~ Cool, pale skin
~ Diminished distal pulses
~ Prolonged capillary refill
~ Impaired sensation or motor function - If px is on anticoagulants, monitor for excessive bleeding or presence of clots
What is the healing process of a fracture?
1) Inflammatory phase
- Immune cells go to area of fracture and remove dead cells and damaged tissue
2) Reparative phase
- Osteoblasts activated to form a callus (new bone tissue that connects fractured ends)
3) Remodeling phase
- Callus is replaced by regular bone
What is the treatment for osteoporosis?
- Calcium + Vitamin D
- Bisphosphonates
- RANK ligand/inhibitor
- Selective estrogen receptor modulator
- Parathyroid hormone
- Calcitonin
