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pipi&pi2 > (FE) MSK > Flashcards

(FE) MSK Flashcards

1
Q

What is the anatomical landmark for the temporomandibular area?

A

Tragus of each ear

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2
Q

What is the anatomical landmark of the hips?

A

iliac crests and greater trochanters

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3
Q

How does normal gait look like?

A
  • Upright posture
  • Ambulates with smooth, even and painless gait
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4
Q

How does a normal spine look like?

A
  • Concave curve of the cervical (1) and lumbar (3) spine
  • Convex curvature of the thoracic (2) and sacral (4) spine
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5
Q

What are some alterations in spine curvature?

A

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

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6
Q

How should limbs normally present upon inspection?

A
  • Bilaterally symmetric in length, circumference and position
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7
Q

What are the unexpected findings of muscles upon inspection?

A

1) Fasciculations
- Muscle twitching
- Occurs if motor neuron is damaged

2) Muscle wasting
- Can occur after an injury or muscle disease

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8
Q

What are some alterations in knee anatomy?

A
  • Outward deviation: genu varum (bow leg)
  • Inward deviation: genu varus (knock knees)
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9
Q

What are some foot variations?

A
  • Pes planus (flat feet)
  • Pes cavus (higher than normal instep)
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10
Q

What are some toe variations?

A
  • Hammertoe (middle joint is bent)
  • Claw toe
  • Hallux valgus (bunion)
  • Hallus varus (great toe deviates from other toes)
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11
Q

What are the normal and abnormal findings upon palpitation of bones, joints, tendons and muscles?

A

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

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12
Q

When is the normal finding upon palpation of the temporomandibular joint?

A
  • Uneventful when opening and closing mouth, or a slight popping sound/sensation
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13
Q

What are the abnormal findings upon palpation of the elbows?

A
  • Nodule along ulnar surface
    ~ Rheumatoid nodule
    ~ Gouty tophi
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14
Q

What are the abnormal findings upon palpation of the wrist and hands?

A
  • 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
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15
Q

What are the abnormal findings upon palpation of the hips and knees?

A
  • Swelling and tenderness
    ~ Injury or joint effusion
  • Tenderness or edema in popliteal space
    ~ Popliteal cyst
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16
Q

What are the abnormal findings upon palpation of the ankles and feet?

A
  • 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
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17
Q

What is the normal results of ROM?

A
  • 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
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18
Q

What is the difference between osteomyelitis, osteoarthritis and rheumatoid arthritis?

A

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

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19
Q

What is osteomyelitis?

A
  • Inflammation of the bone
  • Usually due to infection
    ~ Commonly S. aureus
    ~ M. tuberculosis
    ~ Pseudomonas aeruginosa
    ~ Streptococcus spp
    ~ Salmonella spp
    ~ Pasteurella spp
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20
Q

What is the structure of bone?

A
  • 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
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21
Q

What are the risk factors for osteomyelitis?

A

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

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22
Q

What is the pathology of osteomyelitis?

A

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

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23
Q

What are the local and systemic symptoms of osteomyelitis?

A

Local:
- Bone pain, redness, swelling, warmth and restricted movement around site of infection

Systemic:
- Fever, malaise
- Nausea
- Restlessness
- Night sweats/chills

24
Q

Diagnosis of osteomyelitis?

A
  • 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
25
Q

Treatment of osteomyelitis?

A

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

26
Q

Nursing care for osteomyelitis?

A
  • 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
27
Q

What is osteoarthritis?

A
  • Degenerative joint disease
    ~ Gradual wear and tear of joint cartilage and underlying bone + inadequate repair
  • Chronic, non-inflammation condition
28
Q

What are the types joints?

A

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

29
Q

What are the risk factors of osteoarthritis?

A
  • > 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
30
Q

What is the pathophysiology of OA?

A
  • 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
31
Q

Symptoms of OA?

A
  • 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)
32
Q

Diagnosis of OA?

A
  • 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
33
Q

Treatment of OA?

A
  • 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
34
Q

Nursing care for OA?

A
  • 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
35
Q

What is rheumatoid arthritis?

A
  • Autoimmune disease that causes bone erosion and a swollen, inflamed synovial membrane
36
Q

What is gout?

A
  • 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
37
Q

What are the risk factors/causes of gout?

A

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

38
Q

What is the pathophysiology of gout?

A

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

39
Q

Presentations of gout?

A
  • 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)
40
Q

Diagnosis of gout?

A
  • 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
41
Q

Treatment of gout?

A
  • 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
42
Q

What is acute compartment syndrome and its pathophysiology?

A
  • 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
43
Q

What are the causes of acute compartment syndrome?

A
  • 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
44
Q

What are the symptoms of acute compartment syndrome?

A

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
45
Q

What are the complications of acute compartment syndrome?

A
  • 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
46
Q

Diagnosis of acute compartment syndrome?

A
  • 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
47
Q

Treatment of acute compartment syndrome?

A
  • 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
48
Q

What are the 2 types of hip fractures?

A
  • 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

49
Q

What are the types of fractures?

A
  • 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
50
Q

What are the risk factors for fractures?

A
  • Old age
  • Female
  • Family history of osteoporosis
  • Low vit D
  • Smoking, alcohol
  • Glucocorticoid use
  • Malabsorption problems (affects absorption of nutrients like vitamin D)
51
Q

Why are women more at risk of osteoporosis than men?

A
  • Women tend to have smaller, thinner bones
  • Estrogen (hormone that protects bones) decreases during menopause
52
Q

What are the complications of fractures?

A
  • 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)
53
Q

Diagnosis of fractures?

A

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

54
Q

Treatment of fractures?

A
  • Controlling pain using
    ~ Regional nerve block
    ~ Immobilization of hip joint
  • Surgical repair and stabilization of displaced bones
  • Anticoagulants (prevent thrombosis and avascular necrosis)
  • Rehabilitation
55
Q

Nursing care for fractures?

A
  • 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
56
Q

What is the healing process of a fracture?

A

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

57
Q

What is the treatment for osteoporosis?

A
  • Calcium + Vitamin D
  • Bisphosphonates
  • RANK ligand/inhibitor
  • Selective estrogen receptor modulator
  • Parathyroid hormone
  • Calcitonin

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