MSK Flashcards
What is this movement
Flexion
What movement is this
Extension
What is this movement
ABDuction
“Raise your arms out to the side and overhead”
Whats this movement
ADDuction
“Cross your arm infront of your body”
What is this movement?
Internal rotation
“Place one hand behind your back and try to touch your shoulder blade”
What is this movement
External rotation
“Raise your arm to shoulder level; bend your elbow and rotate your forearm toward the ceiling”
What is this maneuver
Crossover or crossed body test
Adduct the patients arm across the chest (AC joint)
What is this maneuver
Apley scratch test (overall shoulder rotation)
Ask the patient to touch the opposite scapula using these 2 motions
Pain: could suggest rotator cuff disorder or adhesive capsulitis
What is this maneuver
Painful arc test
Fully ABDuct the patients arm from 0-180 degrees
If painful: suggestive of subacromial impingement syndrome/rotator cuff tendonitis)
What is this maneuver
Neer Impingement sign
Examiner presses on the patient’s scapula to prevent scapular motion with one hand, and raises the patients arm with the other hand.
+ test for a subacromial impingement syndrome/rotator cuff tendonitis disorder)
When both neer and hawkins tests are negative
Very LOW likelihood of rotator cuff disorder
What is this maneuver
Hawkins impingement
Flex the patients shoulder and elbow to 90 degrees with the palm facing down. Then with one hand on the forearm and one on the arm rotate the arm internally
+ sign for supraspinatus impingement syndrome/rotator cuff impingement
What is this maneuver
External rotation lag test
With the patients arm flexed to 90 degrees and palm up rotate the arm into full external rotation and ask the patient to keep their arm in this position
INABILITY TO MAINTAIN: positive test suggestive of tears to the supraspinatus and infraspinatus muscles/ shoulder impingement syndrome
Whats this maneuver
Internal rotation lag test (lift off test)
With you standing to the patients rear, bring the dorsum of the hand behind the low back with the elbow flexed to 90 degrees. Then grip the wrist and lift the hand off the back which further internally rotates the shoulder. Ask the patient to keep the hand in the position as you release the wrist.
Inability to maintain = + tests indicates subscapularis tendinopathy or torn muscle
What is this maneuver
Drop arm test
Ask the patient to fully Abduct the arm to the shoulder level up to 90 degrees and lower it slowly (after you release your hand)
The abduction above the shoulder level from 90-120 degrees reflects action of the deltoid muscle
+ sign: if they are unable to slowly lower the arm (itll just DROP)
This suggests supraspinatus rotator cuff tear or bicipital tendinitis
What is this maneuver
External rotation resistance test
Ask the patient to flex the arms to 90 degrees with the thumbs turned up. Stabilize the elbow with one hand and apply pressure to proximal to the patients wrist as the patient presses the wrist outward in external rotation.
+ if mobility is limited OR it illicits pain
Suggests infraspinatus disorder
Limited extension suggests glenohumeral disease or adhesive capsulitis
Whats this maneuver
Empty can test
Elevate the arms to 90 degrees 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.
+test: inability of the patient to hold the arm fully abducted at the shoulder or control lowering the arm
Suggests supraspinatus rotator cuff tear
NOT a stand alone test less specificity
What are the four key features for the MSK exam?
IPROMS
INSPECTION: evaluate visually for signs of deformity, swelling, scars, inflammation or atrophy
PALPATE: use surface anatomy landmarks to localize points of tenderness or fluid collection
Range of motion: have the patient actively move the involved joints, then passively move them as the examiner.
Special maneuvers: perform stress maneuvers (if indicated) to evaluate joint stability and the integrity of ligaments, tendons or bursae especially if pain or trauma is present.
Acute vs chronic joint pain
Acute: last from days to weeks
Chronic: lasts months to years
Whats a monarticular disease?
Pain localized to ONE joint
Ie, injury, monoarticular arthritis
What is a polyarticular disease
More than 4 joints
Ie. RA, systemic lupus and OA
What is crepitus? What does it indicate?
Crepitus is audible or palpable crunching during the movement of tendons or ligaments over bone or areas of cartilage loss.
What are the 4 cardinal signs of inflammation
Swelling
Warmth
Redness
Pain
Swelling
Palpable swelling may involve
1. Synovial membrane may feel boggy or doughy
2. Effusion from excess synovial fluid in the joint space
3. Soft tissue structures, such as bursae, tendons, and tendon sheaths
Warmth
Use the backs of your fingers to compare the involved joint with its unaffected joint or with nearby tissues if both joints are affected
Redness
Redness of the overlying skin the LEAST common sign of inflammation near the joints and is usually seen in superficial joints like fingers, toes and knees.
Pain
Try to identify the anatomic structure that is tender.
“Can you point to exactly where the pain is”
Rheumatoid arthritis
Chronic inflammation of the synovial membranes with secondary erosion of adjacent cartilage and bone and damage to the ligaments and tendons.
SYMMETRICAL
Frequent swelling of synovial tissue in joints
Tender, often warm seldom red
Stiffness (especially in the morning) with inactivity IMPROVES with movement
Common locations for RA
Hands feet ankles wrists elbows and knees
Generalized symptoms of RA
Weakness, fatigue, weight loss and low grade fever are common
Osteoarthritis
Degenerative and progressive loss of joint cartilage from mechanical stress with damage to the underlying bone and formation of new bone at the cartilage margins
Activity increases pain
Rest improves pain
Intermittent stiffness or “gelling” throughout the day
Brief stiffness after inactivity or in the morning lasting (5-10 min)
No generalized symptoms
Locations for OA
Knees hips hands
Cervical and lumbar spine
Wrists
And joints previously injured or diseased
Which muscle groups make up the rotator cuff?
- Supraspinatus
2.infraspinatus
3.tres minor - Subscapularis
The SITS muscles
Lateral epicondylitis
(Tennis elbow)
Follows repetitive extension of the wrist of pronation-supination of the forearm
Pain and tenderness develop 1cm distal to the lateral epicondyle and possibly in the extensor muscles close to it.
Pain most commonly caused by chronic tendonitis of the extensor carpi and radialis brevis.
when a patient tried to extend the wrist against resistance, pain increases
Medial epicondylitis
(Pitchers, golfers or little league elbow)
Follows repetitive wrist flexion such as throwing
Tenderness is maximal just lateral and distal to the medial epicondyle
Wrist flexion against resistance increases the pain
Pain is most often caused by tendonitis of the pronator teres or flexor carpi radialis
Olecranon bursitis
Swelling and inflammation of the olecranon bursa may result from; trauma, gout, or RA. The swelling is superficial to the olecranon process and may reach 6cm in diameter.
Consider aspiration for both diagnosis and symptom relief
Heberden nodes
Hard dorsolateral nodules on the DIP joints
Bouchard nodes
Hard dorsolateral nodules on the PIP joints
Heberden nodes and bouchard nodes are common findings in a patient with what condition?
Osteoarthritis
What is this
Heberden nodes
What is the examiner doing
Palpating MCP joints
What is this exam
Palpation of the snuff box
What symptoms are associated with carpal tunnel?
Starts with a dull ache, but can increase to sharp pins and needles “parasthesias”
This pain can also extend up the arm
Patients may also have muscle weakness
Difficulty holding small objects
Turning doorknobs or holding keys
Or fine motor tasks like buttoning a shirt
Difficulty opening a jar
What are the 3 carpal tunnel assessments?
- Reduced thumb abduction
- Tinel sign
- Phalen
What is this test
Reduced thumb abduction
Ask the patient to touch the thumb to the fifth fingertip as you apply outward pressure against the base of the thumb
Positive test: weakness is present
What is this test
Tinel sign
To test: repeatedly tap over the course of the median nerve in the carpal tunnel
Positive test: shooting pain, aching, or worsening numbness in the median nerve distribution
What is this exam
Phalen sign
Ask the patient to hold the wrists in full flexion and juxtaposing the dorsum of each hand against eachother for 60 seconds
Positive test: numbness and tingling in the median nerve distribution in the 60s seconds
Tinel and phalen signs do or do not predict carpal tunnel syndrome?
DO NOT reliably predict the electrodiagnosis of carpal tunnel syndrome
What exam is this?
The finkelstein test
Grasp the thumb and move wrist down to midline
Positive test: pain with ulnar deviation (tilt wrist down)
What is snuffbox tenderness? What does it indicate?
Tenderness in the wrist with ULNAR deviation and pain at the scaphoid tubercle
Suspicious for occult scaphoid fracture
Poor blood supply increases risk of scaphoid bone avascular necrosis
Dupuytren flexion contractures
First sign: a thickened band overlying the flexor tendon of the fourth finger and possibly the little finger near the distal palmar crease.
SUBSEQUENTLY, the skin in this area puckers and a thickened fibrotic cord develops between the palm and finger.
Finger EXTENSION is limited but FLEXION is usually normal.
This usually develops gradually
Colles fracture
Tenderness over the distal radius after a fall
Stenosing tenosynovitis
“Trigger finger”
Caused by a painless nodule in a flexor tendon in the palm, near the metacarpal head.
The nodule is too big to enter easily into the tendon.
With extra effort and assistance the finger extends and flexes with a palpable or audible snap as the nodule pops into the tendon sheath.
(Watch listen and palpate the nodule as the patient flexes and extends the fingers)
What is this exam
Testing for scoliosis
Have the patient bend at the waist and look for lateral bending
What are the muscle groups of the hips?
1.flexor group
2.extensor group
3. Adductor group
4. Abductor group
Whats do the Ortolani and Barlow tests assess for?
Development of hip dysplasia
Barlow assessment
Flex the leg to form right angles @the hips and knees
Place your fingers at the greater trochanter of each femur and thumbs over the lesser trochanter
Pull the leg forward and ADDUCT with posterior force
(Opposite direction with your thumbs moving down toward the table and outward)
Positive test: palpable dislocation
What is this assessment?
Ortolani assessment
Ortolani assessment
Hands in the same position, ABDUCT hips simultaneously until the lateral aspect of each knee touches the examination table
Positive ortolani: an audible clunk
What is this assessment?
Barlow assessment
For the barlow and ortolani exams kids over 3 months may have what result?
A negative exam but STILL have a dislocated hip d/t tightening of the hip muscles and ligaments.
In children great than 3 months with limited hip ABDUCTION be concerned for hip dysplasia.
When do you stop hip exams for babies?
When they start walking
What maneuver is this and what is it testing?
McMurray
Testing: medial meniscus and lateral meniscus
Positive test: a palpable click or pop along the medial or lateral joint line is a positive test for a tear of the posterior portion of the medial meniscus
What is this maneuver? What is it testing?
Abduction (or valgus) stress test
Positive test: pain or a gap in the medial joint line (medial collateral ligament injury)
What is this maneuver and what is it testing?
Adduction (or varus) stress test
Positive test: pain in the lateral joint line (indicates an LCL injury)
What is this maneuver? What is it testing?
Anterior drawer sign
Positive test: anterior jerk showing the contours of the upper tibia (indicating ACL tear)
What is this maneuver? What is it testing?
Lachman test
Positive test: significant forward excursion is a positive test for an ACL tear
What is this maneuver? What is it testing?
Posterior drawer sign
Positive test: if the proximal tibia falls back + for pcl injury
What is the NP assessing?
Bulge sign
Step1: displace or “milk the fluid down”
Step2: force fluid to lateral area by applying pressure on the medial knee
Step 3: tap the bulge formed by the fluid
+ test: a fluid wave (positive for effusion)
What is this test
Balloon sign (for major effusions)
Displacing fluid while compressing both sides of the knee to observe the patella “ballooning up”
Positive sign: palpable fluid wave (confirms major effusion)
What is this exam?
Balloting of the patella (for major effusions)
Pushing sharply (balloting) the patella against femur in a fluid filled knee
Positive test: palpable fluid wave (indicates major effusion)
What symptoms and exam findings indicate prepatellar bursitis?
An inflammation of the bursa infront of the kneecap.
It occurs when the bursa becomes irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the knee.
Often triggered by extensive kneeling
Pt complaining about pain in the toe. The sharp edge of the toenail has dug into the lateral nail fold, is red and tender with purulent discharge.
Ingrown toenail
A patient reports their second toe is hyperextended, with a corn over it causing the toe to be flexed.
Hammer toe
A patient has painful thickening of the skin on the fifth toe.
A corn
A diabetic patient has a wound on the bottom of their food. They have little to no sensation on that foot and the wound is infected.
Neuropathic ulcer
Plantar warts
Lesion caused by hpv located on the sole
It may look like a callus but has a dark spot
It hurts if pinched side to side
Callus
An area of greatly thickened skin that develops in an area of recurrent pressure:
Unlike a corn a callus involves skin that is normally thick such as the sole and is usually painless
Articular
Within the joint
Extraarticular
Outside the joint
Osteoarthritis is a ______ aging process
Normal
We lose the synovial fluid as we get older
Snuffbox tenderness is suspicious for what type of fracture?
Scaphoid fracture
Tenderness over the distal radius after a fall is suspicious for what
Colles fracture
A joint that is RED and swollen is usually
Infectious or gout
Mcp joints are commonly inflammed with what type of arthritis?
RA
During the painful arc test pain in which degrees of movement is positive for a subacromial impingement/rotator cuff tendonitis?
60-120 degrees
Deformity of the thorax on forward bending, especially when the height of the scapulae is unequal suggests what condition?
Scoliosis
When measuring scoliosis with a scoliometer when would you refer the patient to ortho?
A curvature greater than or equal to 7 degrees
Ortolani and barlow
B comes before O
Barlow you want to dislocate the hip
Ortolani to relocate the hip
What type of joint is the hip?
Ball and socket
What type of joint is the knee?
Hinge joint
What is an example of a fibrous joint?
Sutures of the skull
What is this pedi foot
Metatarsus adductus
What are these pedi feet?
Pronation
What is this pedi foot
Inversion of the foot
Varus
What is this pedi foot
Pes plantus or flat feet
What is this testing for
Sports exam
Any prior knee or ankle injury
Ortolani test
Adducts the hips (brings em back in)
Barlow test
Abducts the hips dislocates then
What signs may indicate a clavicle fracture in a bebe
While palpating if theres any lumps, tenderness or crepitus
(This can happen with a difficult birth)
Most newborns are
Bowlegged
Torsion of the tibia in an infant
The babies usually toeing in or toeing outward
Usually corrects itself within the second or third year of life
Suprling test
Have patient look over their shoulder then up at the ceiling next position yourself behind the patient and carefully apply downward pressure on the patient’s head and check if the maneuver reproduces the neck pain with radiation to the same side
+ test suggest cervical root compression
If an infant has a lil tuft of hair or dimpling above their bum what should the NP do?
Get a spinal ultrasound
What are the two phases of gait?
- Stance
- Swing
Most hip problems appear during what phase?
The weight bearing stance phase
Trendelenburg gait
Waddling gait
The pelvis drops to the opposite side while in the swing phase
The width of the base while ambulating should be
2-4 inches from heel to heel
Uneven or asymmetric hips can be a sign of
Leg shortening
Their legs arent the same length:)
What is this testing
Hip ADDuction
What is this testing?
External rotation of the hip
What is this test and what is it testing for?
FARBER or patrick test
For groin strain
If an old lady has leg shortening what are we concerned about?
Hip fracture!
Inability to bear weight for 4 steps is indicative of
An ankle fracture
Valgus
Knock knees
Knees point in
Verus
Knees point out of bowlegged
Nurse maids elbow
Radial head dislocation
Happens frequently to kids when swinging and stuff
They guard the arm and wont use it
Slipped caital femoral epiphysis
SCFE
Happens in pre teens early adolescence
Sublaxation of the femoral head with issues with the growth plate
Common in obese kids
Might have a painful hip or limp
Requires surgical intervention
Adams test
Bending over and touching toes
Test for scoliosis
How to assess for gait strength and coordination in a child?
Gait: observe the child walking
Strength: have the child lie on the floor and then stand up and closely observe. Most normal kids will first sit up then flex the knees and extend the arms to the side to push off from the floor and stand up.
Coordination: heel to toe walking
Gower sign
Present in certain forms of muscular dystrophy w/ weakness of the pelvic girdle muscles
Children will rise to standing by rolling over prone and pushing off the floor with their arms while the legs remain extended
