Module 11: Musculoskeletal System Flashcards
1
Q
MSK
-Terminology
A
- Articulation — Where 2 bones come together — I.e Joint
- Synovial Joints — Freely movable
- Spheroidal — Ball and socket
- Hinge — Elbow and Knee
- Condyloid — knuckles - Cartilaginous — Slightly moveable — Bones of spine, Sternum
- Fibrous — NOT moveable — Sutures in skull
2
Q
MSK
-Terminology Cont..
A
- Tendons — Connect muscles to bone — Tendon contracts - muscle moves - bone moves
—Ex: Achilles’ tendon calf attaches to the calcaneus (Heel) - Ligaments — Connect bones to other bones for stability
—Ex: ACL connect femur to tibia - Bursa — Pouches of synovial fluid that cushion movement of tendon, muscles, and skin over bony prominences.
—Occurs near joints that perform frequent repetitive motions
—Ex: Hip & Elbow (Bursa covers the greater trochanter — keeps skin from rubbing the bony prominence
3
Q
MSK
-Subjective
A
- HPI — OLD CARTS
—Previous Tx — RICE, Meds, therapy? - Past medica, Family, Surgical and social Hx
-Fam Hx - Arthritis, auto-immune disorders
-Surgical Hx - Previous surgeries to the affected body part
-Social Hx - Particularly alcohol, tobacco, drug use/abuse - Meds and allergies
- ROS
4
Q
MSK
-Objective
A
- General Exam
- IPPA
- Inspection — Alignment, color, swelling, deformity
- Palpation/Percussion — Warmth, tenderness, crepitus pulses
- Passive ROM — Mobility, stability
- Active ROM — Mobility, stability, strength, reflexes
5
Q
MSK
-Assessment & Plan
A
- Differential Dx
- Use pain codes when unsure of dx — Ex. Pain in the wrist
Plan
- RICE
- Activity Level
- NSAIDs and other meds
- PT
- Wait and watch (Time is a good medication)
- Labs — Uric acid, Rheumatoid factors
- Imaging (X-ray)
- Referrals
6
Q
Shoulder Exam
-Joints info
A
- Clavicle and Acromion articulate at the acromoioclavicular joint
- Acromion is an extension of posterior scapula (Ie Shoulder blade) - Glenoid & Humerus articulate at the glenohumeral joint (Shoulder)
7
Q
Shoulder Exam
-Muscles TEST
A
- Infraspinatus
- Subscapularis
- Teres Minor
- Supraspinatus — Most common site of injury in rotator cuff injury — responsible for abduction
8
Q
Shoulder Muscles
-Supraspinatus
A
- Responsible for abduction of the shoulder
- Think of a supraspinatus muscle tear IF patient CANNOT lift their arm
9
Q
CC: Shoulder Pain
A
- HPI
—Point to the pain. Anatomy helps guide Dx. Onset? - Joints swell for 3 reasons — Infection, Injury, or Inflammation **TEST
- PMH — Joint surgery?
- Fam Hx — Any arthritis, auto-immune disorders
5 .Surgical Hx — Any surgery performed on that body part or around - Social Hx — ETOH, tobacco, illicit drug use (IV Drug user injecting near joints)
- ROS
10
Q
Shoulder Exam (IPPA)
A
- Inspection (Anterior and posterior)
—Alignment (deformity) and symmetry
—Scapular winging and Sulcus Sign
-Look for redness, ecchymosis, swelling, wounds, skin
—Eccymosis can mean a fracture or torn bicep tendon
-Guarding and non-use - Palpation/Percussion
- Warmth, tenderness, crepitus, pulses (especially distal) - Passive ROM
- Movement in all planes. Abduction, abduction, flexiona, and extension, internal & external rotation
11
Q
Shoulder Assessment
-Scapular Winging
A
- Leads to limited functionality of upper extremity — Resulting in a nerve injury or paralysis of the Serratus anterior, Trapezius or the rhomboid muscle
- Most commonly the Serratus muscle**
- Dx is made on inspection! REFER to Ortho or neurology for the nerve issue
12
Q
Shoulder Assessment
-Sulcus Sign
A
- Divot in the lateral shoulder — DISLOCATION — Needs ER for reduction
13
Q
Shoulder Assessment
-Neer Sign
A
- Test for suspected subacromial impingement
- Press on scapula to prevent motion w/ one hand, and raise the patient’s arm w/ the other
—Pain is a + test for (1) rotator cuff tendinitis (2) Impingement syndrome of the supraspinatus
Sensitivity and specificity aren’t great — couple with other test for dx
14
Q
Shoulder Assessment
-Hawkin’s Kennedy Test
A
- Test for Supraspinatus impingement — Usually caused by overuse (overhead sports, Ie. Volleyball, baseball, basketball
- Shoulder in 90 degree abduction and elbow flexed to 90 degrees.
- Internally rotate the shoulder by pushing downward on the hand - Sensitivity and specificity aren’t great — couple with other test for dx
15
Q
Shoulder Assessment
-Drop Arm Test
A
- A Positive test would indicate a rotator cuff tear within the supraspinatus
- A + test is when the shoulder is abducted to 90 degrees then let go of. If it drops, test is +
16
Q
Shoulder Pain
-ACUTE Differential Dx
A
- Shoulder impingement - Rotator cuff tendinitis
—Differential for people doing things they don’t normally do (ie The weekend warrior or starting a new exercise routine
—Test w/ NEER, HAWKINS sign — Often overuse - Sprain/strain
- Rotator cuff Tear
—Pt will have weakness/pain w/ abduction. DROP ARM test - Infection — Usually through previous wound near joint — Puncture wound w/ redness visible
- Dislocation — Visible deformity w/ recent hx of trauma — SULCUS SIGN
- Fracture — Usually humerus or clavicle — Usually direct trauma — Often ecchymosis
17
Q
Shoulder Pain
-CHRONIC Differential Dx
A
- Shoulder Osteoarthritis — Gradual Pain and stiffness, Sometimes has crepitus
- Adhesive Capsulitis (FROZEN shoulder) — Capsule around shoulder is tight w/ minimal motion
- Can be idiopathic and last 1-3 years d
18
Q
Shoulder Treatment (Plan)
A
- Rest
- NSAIDs
- Imaging - Prior to PT
- PT
- Referral
19
Q
Elbow Anatomy
-Joints
A
- Distal humerus articulates w/ the proximal ulna and radius
- Distal end of the humerus contains — Medial and lateral epicondyle — Flexors and extensors of the arm are attached here for elbow movement TEST
20
Q
CC: Elbow Pain
A
- HPI — OLD CARTS
- Age? Gradual Onset? Previous injury? - Look at other joints around injury site. For a wrist injury, look at the elbow. Vice versa
21
Q
Elbow Pain Examination (IPPA)
A
- Inspection
-Alignment (Deformity) and symmetry
—Shortening and bowing of the arm
-Redness, ecchymosis, swelling, wounds, skin
-Guarding and non-use - Palpation/Percussion
- Warmth, tenderness, crepitus
- ULNAR NERVE aka “funny bone” — Palpate w/ hammer to check for CUBITAL tunnel syndrome = tingling in the 4th and 5th fingers is positive
- Inspect and palpate the medial and lateral epicondyles - Passive ROM
- Flexion, extension, pronation, supination — Elbow should be able to do all 4
- Hyper-mobility “Double Jointed” It’s OK but joint is LESS Stable = MORE INJURIES
22
Q
Elbow Pain
-ACUTE Differential Dx
A
- Medial/Lateral Epicondylitis — Pain worsens w/ engagement of flexors or extensors
—Golfers (Medial) / Tennis Elbow (Lateral) - Think Fracture if unable to flex/bend
- Dislocation — REFER to ER
- Olecranon Bursitis (D/t Trauma or infection of the elbow)
23
Q
Elbow Pain
-CHRONIC Differential Dx
A
- Cubital tunnel syndrome — Persistent paresthesias in the 4th and 5th digits - REFER
- Arthritis -Osteoporosis (ONE elbow) & Rheumatoid (Both elbows at the same time)
24
Q
Elbow Pain
-Plan: Tx
A
- Rest - SLINGS should only be used for 2 days — REFER — Immobilization can lead to elbow locking
- NSAIDs / Tylenol
- Imaging (radiographs) Prior to therapy
- Therapy
- Referral
25
Wrist and Hand
| -Joints
1. Distal end of the radius and ulna articulate the radiocarpal joint along w/ 8 other small bones
2. The hand is comprised of — (1) Middle hand bones (2) Metacarpals (3) Phalanges
3. Phalanges are comprised of — (1) Metacarpophalangeal joints (MCP) (2) Proximal interphalangeal joint (PIP) (3) Distal interphalangeal joint (DIP)
26
CC: Hand or Wrist Pain
1. HPI — OLD CARTS
- Gradual vs acute are worked up different
- Repetitive motion? Usually chronic — Think of occupational risks
- IV drug use? Spider/insect bite?
27
Hand and Wrist Exam?
1. Inspection
- Alignment (deformity) & Symmetry of fingers
- Redness, ecchymosis, swelling, wounds, Purulence (Think fracture)
- Guarding & Non-use
- Muscle wasting (Suspect nerve injury
2. Palpation/Percussion
- Warmth, tenderness, crepitus, pulses, & A1 pulley (for trigger finger)
3. Passive ROM
- Flexion and extension — Coordination
28
Arthritis
1. Osteoarthritis —Wear and tear — Takes several years —Gradual loss of joint space
2. Rheumatoid Arthritis — Effects both hands MCP, DIP joints
3. Septic Arthritis — Single joint — animal bite, IV drug use
29
Arthritis
| -NODES?
1. Heberden node — Bony overgrowth of the distal phalanges (DIP)
2. Bouchard Node — Bony overgrowth of the Proximal Phalanges (PIP)
30
Hand Pain
| -Inspection
1. FELON - Puncture wound of distal finger — Swollen, tender, dusky red —REFER to Hand surgeon
2. Trigger Finger — finger gets stuck in bent position — Surgery or steroids is the Tx
31
Hand and Wrist Pain
| -Tinel’s Test
1. Percuss over the median nerve on the volar (palm) side of the wrist
2. Test is positive if increased numbness, tingling or radiating pain in fingers 3, 4 and half of 5
32
Hand and Wrist Pain
| -Phalen’s Test
1. Reverse prayer hands
2. Hold back of hands together for 20-30 seconds (May need longer)
3. Positive result if causes increased numbness, tingling , or radiating pain (fingers 3, 4, or 5)
33
Hand and Wrist Pain
| -Ganglion Cyst
1. Harmless unless it causes pain. This can be surgically drained if over a nerve
34
Hand & Wrist Pain
| -Finkelstein Test
1. Enclose thumb into a closed fist. Move wrist laterally in a downward motion
+ Test is pain with the maneuver = DeQuervain’s Tenosynovitis
—Pain is on lateral side of wrist at the Radial styloid — Repetative motions
35
Hand & Wrist Pain
| -ACUTE Differential Dx
1. Fractures, dislocation (FOOSH) — Fall on outstretched hand
2. Tendon Ruptures - REFER
3. Inflammation — Gout
4. Infection — Paronychia (Close to nail bed), VS Felon (Finger tip)
5. DeQuervain’s Syndrome — Pain at the radial styloid
36
Hand & Wrist Pain
| -CHRONIC Differential Dx
1. Arthritis — Most common at the carpal metacarpal joint (CMC joint) — Base of the thumb
—Starts at the distal most part and works the way upward — Aggravated by CELL PHONE USAGE
2. Carpal Tunnel Syndrome — D/t repetitive motions — Worse at night
3. Neuropathy — DM - Starts at the distal most part and works its way upward
4. Trigger finger
5. Ganglion Cyst
37
Hip
| -Anatomy Joints
1. Acetabulum meets femoral head
38
CC: Hip Pain
1. HPI
- Point to pain — some hip pain comes from the back — Assess both back and hip when one is the CC
- Lateral hip pain — Bursitis
- Groin pain
2. Consider age — Child hip issues — Pain radiates to the knee
39
Hip Exam (IPPA)
1. Inspection
- Alignment (Deformity), Symmetry and stance
- Redness, ecchymosis, swelling, wounds, skin
- Station and gain — walk and watch the gait
2. Palpation/Percussion
- Include lower back, posterior hip, and greater trochanter
- Push on the greater trochanter to assess for bursitis**
3. Passive ROM
- Flexion and Extension - Abduction & Adduction. Internal & External Rotation
4. Active ROM
- Same as above but w/ resistance
40
Hip Pain
| -ACUTE Differential Dx
1. Groin strain (Usually sports injury)
2. Greater Trochanteric Bursitis
3. Pelvic or femur fracture
41
Hip Pain
| -CHRONIC Differential Dx
1. Hip Osteoarthritis (R/o w/ internal & External rotation with patient lying on their back)
2. A vascular necrosis of the hip or femur — Multiple steroid injections — sickle cell
3. Trochanteric Bursitis
42
Knee
| -Anatomy & Joints
1. Osteoarthritis is a progressive loss of cartilage in the joint
—D/t loss of cartilage or meniscus
43
CC: Knee Pain
1. Young Patient — Examine both the KNEE and the HIP w/ Hip pain cc
2.
44
Knee Pain Examination (IPPV)
1. Infection
- Alignment (Vargus/valgus deformity) & Symmetry
- Redness, ecchymosis, swelling/effusion, wounds, skin
- Guarding & Non-use
2. Palpation/Percussion
-Warmth, joint line tenderness, crepitus, bakers cyst
—If warm, it’s NOT OSTEOARTHRITIS** — Consider gout or septic arthritis w/ WARMTH / Acute injury
3. Passive ROM
- Flexion and Extension
4. Stability/Laxity testing — Strength Testing
EFFUSION — Enlargement of a pocket of fluid** DOCUMENT
Swelling — Enlargement of the tissue
45
Effusion Vs Swelling
1. EFFUSION — Enlargement of a pocket of fluid** DOCUMENT
| 2. Swelling — Enlargement of the tissue
46
Knee Pain
| -ACL Stability Test
1. Anterior Drawer Test
- Sensitivity & Specificity (92 & 91%)
- Rule out PCL injury FIRST to avoid false positive results
- Test is + if Tibia translates anteriorly > 6mm or it is soft and mushy — Test leg at 45 degrees
2. Lachman Test (MOST ACCURATE)
- Sensitivity & Specificity (85 & 94%)
- 30 degrees, slight external rotation of the tibia. Try to translate tibia anterior
- Test is + if there is a soft/mushy feel or if anterior tibial translation is more than 3mm compared to normal leg
BEST for CHRONIC condition not Acute
47
Knee Pain
| -PCL Stability Test
1. Posterior Drawer test
- Sensitivity & Specificity (90 & 96%)
- Put leg at 45 degrees. Push tibia forward in explosive movement
- Test is + if tibia translates positive more than 6 mm or Soft/mushy feel
48
Knee Pain
| -Meniscal Damage Test
1. McMurray’s Test
49
Calf Pain
| -Homan’s Test?
1. Forced dorsiflexion (Reverse gas pedal)
- Pain can indicate a DVT
2. Follow up a positive Homan’s test w/ a Doppler ultrasound.
50
Knee Pain
| -ACUTE Differential Dx
1. Contusion
2. Sprains/strains
3. Fracture
4. Meniscus tear (steps and squatting hurts)
5. Bursitis
6. Gout — WAKE UP in pain
7. DVT
8. Septic Arthritis (Occurs over several days vs gout is OVERNIGHT
51
Knee Pain
| -CHRONIC Differential Dx
1. Chondromalacia (aka Runners Knee) / Osteoarthritis
| 2. Gout
52
Knee Pain
| -Plan
1. NSAIDs
2. PT
3. X-rays or other imaging
4. Immobilization (Not used too much)
5. Labs — Check for RA
6. Dietary changes
7. Referral
53
Foot and Ankle
| -Joints & Anatomy
1. Distal Tibia and fibula sits on the talus
| 2. Lateral Malleolus is the distal part of the fibula — COMMON site of fractures
54
Gout
| -S/Sx
1. Hot, red, tender and swollen
2. VERY abrupt onset
3. High Purine diet — Red meats and alcohol
55
Foot & Ankle Pain
| -ACUTE Differential Dx
1. Sprain/Strain (Most common)
2. Fracture — Lateral Malleolus is MOST COMMON site
3. Achilles Rupture — Posterior ankle or foot pain — Divot
4. Gout
5. Septic Arthritis (knowing how GOUT and SA present (onset) will help differentiate
56
Foot & Ankle Pain
| -CHRONIC Differential Dx
1. Achilles Tendinitis — Usually worse after activity
2. Osteoarthritis (Stiffening of the joint)
3. Plantar Fasciitis — Bottom of the foot pain
MOST COMMON fracture in the foot is the FIFTH Metatarsal fracture**TEST
57
Cervical Spine
| -Anatomy
1. C1 - C7 — 7 vertebral bodies (aka vertebrae)
2. Atlas and Axis sit on top — Responsible for rotation of the head
3. Intervertebral discs — cushion the disks
4. Foramen— Nerves exit the spine
58
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Neck Pain (Cervicalagia)
-Examination of Cervical Spine (IPPA)
```
1. Inspection
- Alignment and symmetry (as symmetry indicates musculature)
- Redness, ecchymosis, swelling, skin
- Guarding and non-use
2. Palpation/Percussion (both sides of spine)
- Trigger points or spasms (Make note of any)
- Deep tendon reflexes (TEST)
3. Passive ROM — Flexion and extension - Ear to shoulders, rotation
4. Active ROM — Strength testing - Same as above w/ resistance
59
```
Neck Pain (Cervicalagia)
-Spurling’s Test
```
1. Used to Diagnose Cervical Radicular Syndrome**
| - Sensitivity & Specificity 50 & 83%
60
Cervical Nerve Roots Examination
C5 = Elbow Flexion, shoulder abduction
C6 = Elbow Flexion, Wrist extension, Sensory thumb and radial hand
C7 = Wrist Flexion, finger extension, Elbow Extension
C8 = Finger Flexion
T1 = Abduction of the fingers
61
Neck Pain
| -ACUTE Differential Dx
1. Sprain/Strains & Whiplash — MOST Common
2. Fracture — Immobilize when possible
3. Disc Displacement — If pt has positive Spurlings Sign or Radiculopathy
62
Neck Pain
| -CHRONIC Differential Dx
1. Spondylitis — Arthritic changes that occur; involves Degenerative Disc disease DDD
2. Radiculopathy — Numbness/tingling
3. Post-laminectomy syndrome — Pt suffers persistent pain following back surgery
—Tx w/ nerve blocks & Joint injection
63
Thoracic Spine
| -Scoliosis
1. S curvature of the spine — Refer to ortho
| 2. Have patient bend over and observe spine with shirt off
64
Thoracic Spine
| -Differential Dx
1. Acute
- Strains
- Compression Fractures (elderly patient falling on coccyx)
2. Chronic
- Spondylosis
- Scoliosis
There are 12 vertebrae in the thoracic spine
65
Lumbar spine
| -Info
1. 5 lumbar vertebrae — Spinal chord terminates at L1
| 2. L4 L5 is the most common area for disc ruptures
66
Low Back Pain
| -Differential Dx
1. Acute
- Strains
- Vertebral Fractures — Commonly from slips and falls
- Sciatica —Compression of sciatic nerve from lumbar spine
2. Chronic
- Spondylosis — Arthritis from wear and tear — Discs and joints degenerate
- Radiculopathy — aka sciatica
- Post-laminectomy syndrome
- Chronic pain syndrome
