Musculoskeletal Flashcards
Function of the Musculoskeletal System
Protects vital organs
Provides storage space for minerals
Produces blood cells (hematopoiesis)
Function of the Musculoskeletal System
Protects vital organs
Provides storage space for minerals
Produces blood cells (hematopoiesis)
Synovial Membrane
Lines and secretes lubricating synovial fluid
What is an articulation?
Also called a joint
Synovial Membrane
Lines and secretes lubricating synovial fluid
Bursae
Develop in the spaces between connective tissue, tendons, ligaments, and bones to promote ease of motion at points where friction would occur
What is an articulation?
Also called a joint
Radiocarpal joint (wrist)
Articulation of radius and carpal bones
Articular disc between ulna and carpal bones and is protected by ligaments and fibrous capsules
Movements of the wrist
Flexion, extension and rotation
Forearm joint
Articulation between radius and ulna at both proximal and distal locations.
Allow for supination and pronation
Elbow
Articulation at humerus, radius and ulna
Bursa located at olecranon and the skin
Flexion and extension
Glenohumeral Joint
Shoulder
Articulation between humerus and glenoid fossa of scapula
Acromion and coracoid proces protect and surround the joint
Ball-and-socket joint
TMJ
Mandible and temporal bone in the cranium
Temporal bone found anteriorly to tragus of ear \
Hinge joint - lateral movement, protrusion and retraction
Function of Rotator Cuff
reinforces glenohumeral joint
stabilize shoulder and position humeral head
Acromioclavicular Joint
Comprises acromion process and the clavicle
Sternoclavicular
Manubrium and clavicle
TMJ
Mandible and temporal bone in the cranium
Spine
Cervical, Thoracic, lumbar and sacral
All but sacral are separated from each other by firbocariliginous disks for cushion
Suprapatellar Bursae and type of joint that is the knee
Bursa separates the patella, quadriceps tendon, and muscle from the femur
Knee is a hinge joint - flexion and extension
Hip joint
between acetabulum and the femur
Depth of acetabulum stabilize and protect the head of femur in a joint capsule
Three bursae surround the hip
Ball-and-socket
Knee Joint
Femur, tibia and patella Fibrocartilenginous discs (medial and lateral menisci) cushion the tibia and femur
Ligaments of the knee
Collateral - give medial and lateral stability to knee
Two Cruciate ligaments - cross obliquely in knee, adding anterior and posterior stability
Anterior Cruciate Ligament - Protects from hyperextension
Suprapatellar Bursae and type of joint that is the knee
Bursa separates the patella, quadriceps tendon, and muscle from the femur
Knee is a hinge joint - flexion and extension
Tibiotalar joint
Ankle
Tibia, fibula and talus
Hinge joint - dorsi and plantar flextion
Additional joints of the ankle
Talcalcaneal joint (subtalar) and transverse tarsal joint allow for supination or pronation
Musculoskeletal in Infants and Children
Skeletal system first emerges from embryologic connective tissue to from cartilage that calcifies and becomes bone
Bone growth during childhood
Increased length of long bones
Proliferation of cartilage at growth plates (epiphyses)
Smaller bones, ossification centers form in calcified cartilage
Injuries to long bones and joints more likely to cause fracture then sprain b/c ligaments are stronger than bone until adolescence
Changes in structure in older adults
Equilibrium shifts to favor bone resorption dominates over deposition
Loss of bone density in entire skeleton
Long bones and vertebrae particularly vulnerable
Weight-bearing bones increased fracture risk
Bony prominences become apparent due to loss of subcu fat
Cartilage around joints deteriorates
When is bone growth completed
By age 20
Last epiphysis closes and becomes firmly fused to shaft
Bone growth stops; bone density and strength continue to increase
Peak bone mass achieved at 35 y/o
Muscle mass in older
Increased collagen
Fibrosis of connective tissue
Tendons lose elasticity
Reduction of total muscle mass, tone and strength
Decreased reaction time, speed of movement, agility and endurance
Growth of fetus causes changes in pregnant women
Lordosis occurs in an effort to shift the center of gravity back over to the lower extremities
Ligaments and muscles of lower back become strained, leading to low back pain
Changes in structure in older adults
Equilibrium shifts to favor bone resorption dominates over deposition
Loss of bone density in entire skeleton
Long bones and vertebrae particularly vulnerable
Weight-bearing bones increased fracture risk
Bony prominences become apparent due to loss of subcu fat
Cartilage around joints deteriorates
Risk factors for osteoporosis
Race (white, asian, native american)
Light body frame, thin
FH
Nulliparous - never given birth to a child
Amenorrhea or menopause before 45, postmenopause
Sedentary lifestyle
Constant dieting - lack of calcium and vitamin D
Scoliosis, rheumatoid arthritis, cancer, MS, chronic illness, previ fracture
Metabolic disorder (DM, hyperthyroidism, hypogonadism, hypercorticsolism)
Drugs that decrease bone density - thyroxine, steroids, heparin, litihum, anticonvulsants, antacids
Cigarette smoking, heavy alcohol use
Muscle mass in older
Increased collagen
Fibrosis of connective tissue
Tendons lose elasticity
Reduction of total muscle mass, tone and strength
Decreased reaction time, speed of movement, agility and endurance
Bone resorption
Osteoclasts break down bone tissue, release minerals and transfer calcium to blood
Risk factors for osteoarthritis
Obesity, FH, hypermobility syndromes, aging (older than 40), injury, high level of sports activities, occupation requiring overuse of joints
Inspect extremities
Overall size, gross deformity, bony enlargement, alignment, contour and symmetry of length and position
Symmetry of length, circumference, alignment, and position and # of skinfolds
First steps of examination
Inspect gait, sitting position, rises from sit to standing, takes off coat, responds to directions
Look for asymmetry
Look for: muscular strength and function, joint function
Inspection
Observe symmetry, alignmen of extremities
Note lordosis, kyphosis (thoracic), scoliosis
Inspection of skin
Subcu tissue over muscles, cartilage, bones and joints for discoloration, swelling and masses
Crepitus
Bony surfaces rubbing together as a joint moves
Two edges of broken bone rubbing
Movement of tendon inside a tendon sheath in tenosynnovitis
Inspect muscles
Atrophy or hypertrophy, fasculations or spasms
Fasculation occurs after muscle injury to a muscle’s motor neuron
Muscle wasting is d/t injury as a result of pain, disease to muscle, or damage to motor neuron
Palpation
Bones, joints and surrounding muscles if symptomatic
Palpate inflamed joints last
Note heat, tenderness, swelling, crepitus, pain, and resistance to pressure
No discomfort should occur to bones or joints
Muscles should be firm, not hard or doughy
Synovial thickening
Can be felt in joints close to the skin
When edemetous or hypertrophied because of inflammation
Crepitus
Bony surfaces rubbing together as a joint moves
Two edges of broken bone rubbing
Movement of tendon inside a tendon sheath in tenosynnovitis
ROM
Examine active and passive
Muscle tone evalulated simultaneously
Watch for pain, limited ROM, spastic movement, joint instability, deformity or contracture
Assessing muscle strength
0 - no evidence of movement
1 - trace of movement
2 - Full ROM, but not against gravity
3 - Full ROM against gravity, but not resistance
4 - Full ROM against gravity, but little resistance
5 - Full ROM against gravity and resistance
Less than 3 is considered a disability and may require support
Weakness results from disuse atrophy, pain, fatigue or overstretching
Discrepencies of active and passive ROM
may indicate true muscle weakness or joint dx
No crepitation or tenderness c movement
Note specific location of tenderness
Goniometer
Measure angle of joint
Begin at neutral position and flex joint as far as possible
Compare angle of greatest flexion or extension c expected angle
Muscle strength expectations
Should be bilaterally symmetric c full resistance to opposition
Muscle strength requires full active ROM
Palpation of hands and wrists
Palpate each joint
Joint surfaces should be smooth and without nodules, swelling, bogginess or tenderness
Firm mass over dorsum of wrist may be ganglion
Inspection of Hands and Wrists
Dorsal and palmar
Contour, position, shape, number and completeness of digits
Note presence of palmar and pharyngeal creases
Expect fingers to fully extend and to be aligned c forearm
Lateral finger surfaces should gradually taper from the proximal to distal aspects
Thenar eminence
Palmar surface of each hand should have a central depression c a prominent, rounded mound on the thumb side of the hand and a less prominent hypothenareminence on the little finger side of the hand
Indications of rheumatoid arthritis in the hands
Deviation of the ulnar side
Swan neck
Boutonniere deformities
Ganglia
Cystic, round, nontender swellings along tendon sheaths or joint capsules
Evaluation of hand strength
Have patient grip two of your fingers
finger extension, abduction, adduction and thumb opposition
Heberden nodes
Bony overgrowths along distal interphalangeal joints
Bouchard
Bony overgrowths proximal interphalangeal joints
Painful swelling of the proximal interphalangeal joints causes spindle-shaped fingers, associated c acute stages of rheumatoid arthritis
Epicondylitis or tendonitis
Suspected if boggy, soft or fluctuant swelling; point tenderness at lateral epicondyle, or along grooves of olecranon process and epicondyles; and increased pain with pronation of supination are found
Inspection of Elbows
Subcu nodules along pressure points of ulnar surface indicate rheumatoid arthritis or gouty tophi
Carrying angle between radius and ulnar should be 5 to 15 degrees laterally
Variations in angle are cubitus valgus (lateral angle) exceeding 15 degrees, cubitus varus is a medial angle
Palpation of elbows
Flex elbow 70 degrees and palpate extensor surface of ulna, olecranon process and the medial and lateral epicondyles
Palpate groove on either side of olecranon process for tenderness, swelling and thickening of synovial
Epicondylitis or tendonitis
Suspected if boggy, soft or fluctuant swelling; point tenderness at lateral epicondyle, or along grooves of olecranon process and epicondyles; and increased pain with pronation of supination are found
Inspection of the shoulders
Contour of shoulder, shoulder girdle, the clavicles, scapula and the surrounding musculature
Assymetric contour or hollows could be shoulder dislocation
A winged scapula or outward prominence indicates injury to the nerve of the anterior serratus muscle
Palpation of shoulder
Sternoclavicular joint, clavicle, AC joint, scapula, coracoid process, greater tubercle of humerus biceps groove and area muscles
Palpating bicep groove
Rotate the arm and forearm externally
Locate biceps muscle near the elbow and follow the muscle and its tendon into the biceps groove along the anterior aspect of the humerus
Palpation of cervical spine
posterior neck, cervical spine and paravertebral trapezius and SCM muscles
Look for tone, symmetry and no tenderness or spasm
Palpation of TMJ
Place fingertips just anterior to the tragus of each ear. Space is palpable when pt opens mouth
Audible or palpable snapping or clicking is not unusual, but pain, crepitus, locking or popping may be dysfunction
Abnormal curvatures of the spine
Kyphosis may be observed in older
Lordosis occurs in patients who are obese or pregnant
Gibbus - collapsed vertebrae from osteroporosis
Palpation of cervical spine
posterior neck, cervical spine and paravertebral trapezius and SCM muscles
Inspection for Thoracic and Lumbar spine
C7 and T1 are usually most prominent, examine scapulae, iliac crests, and paravertebral muscles
Head is to be positioned over gluteal cleft and vertebrae to be straight as indicated by symmetric shoulder, scapular and iliac crest heights
Thoracic spin should be convex, while lumbar is concave. Knees and feet should be in alignment
Inspection of hips
Inspect anterior and posterior while standing. Use major landmarks of iliac crest and greater trochanter of femur, note any symmetry in the iliac crest height, size of the buttocks or the number and level of gluteal folds
Palpation of Thoracic and Lumbar
Pt standing erect, palpate along spinal process and palpate paravertebral muscles. Note any muscle spasms or spinal tenderness.
Percuss for tenderness, first by tapping each spinal process with one finger and then by percussing each side of the spine along the paravertebral muscles with the ulnar aspect of your fist.
No muscle spasm or spinal tenderness with palpation or percussion should be elicited
Ask patient to bend over and touch toes
Inspect for curvature of spine
Pt’s back should remain symmetrically flat as the concave curve of lumbar spine becomes convex with forward flexion
Lateral curvature or rib hump should make you suspect scoliosis
Have pt rise but bend at waist to observe full extension of back. Reversal of lumbar curve should be apparent.
Inspection of hips
Inspect anterior and posterior while standing. Use major landmarks of iliac crest and greater trochanter of femur, note any symmetry in the iliac crest height, size of the buttocks or the number and level of gluteal folds
Testing hip flexion strength
Apply resistance while the patient maintains flexion of the hip when the knee is flexed and then extended
Can be abducted or adducted as well by resistance to uncrossed legs while seated
Inspection of legs and knees
Inspect popliteal spaces during flexion and extension
Note tibial tuberosity, medial and lateral tibial condyles, medial and lateral epicondyles of femur, adductor tubercle of the femur and patella
Inspect the extended knee for its natural concavities on the anterior aspect, on each side, and above the patella. Loss of cavities may be knee effusion.
Observe lower leg allignment
Angle between femur and tibia is expected to be less than 15 degrees Genu valgum (knock-knees) Genu varum (bowlegs) Genu recurvatum (hyperextension of knee c weight-bearing) - indicates weak quad muscles
Contour of feet
position, size and number of toes
alligned c tibias
pes varus (in-toeing)
pes valgus (out-toeing)
weight bearing should be midline of foot or from heel midline to between the second and third toes
Deviations in forefoot alignment (metatarsal varus or valgus) heel pronation, and pain or injury often cause a shift in weight-bearing position
Palpation of the knee
Palpate popliteal space noting any swelling or tender
Fullness may be baker cyst
Tibiofemoral joint, identify patella, suprapatellar pouch, and the infrapatellar fat pad
Joint should feel smooth and firm, without tenderness, swelling or bogginess, nodules or crepitus
Inspection of feet and ankles
Inspect weight-bearing and non-weight bearing
Medial malleolus, lateral malleolus and the achilles
Expect smooth and round malleoluses, prominent heels, and prominent metatarsophalangeal joints
Calluses and corns indicate chronic pressure or irritation
Foot arch
Longitudinal arch is normal
Foot may flatten c weight bearing
Pes planus - flat foot
pes cavus - high instep or claw toes
Toe contour
Straight, forward, flat and aligned
Hyperextension of the MTP joint c flexion of the toes proximal joint is hammertoe
Mallet toe - flexion of distal interphalangeal joint
Hallux valgus - lateral deviation of great toe, possible overlapping of second toe
Claw toe is hyperextension of the metatarsalphalangeal joint c flexion of toe’s proximal and distal joints
Bunion is caused by inflammed bursa at a pressure point
Signs of inflammed joint
Heat, redness, swelling and tenderness
Possible rheumatoid arthritis, gout, septic joint, fracture, or tendonitis
Palpation of the achilles tendon
Anterior surface of the ankle and the medial and lateral malleoli
Thickened achilles is tendonitis that can develop c spondyloarthritis or from xanthelasma of HLD.
Palpate each metatarsophalangeal joint for tenderness or swelling
Median Nerve
Innervates the palm of the hand and palmar surface of the thumb, index and middle fingers and half of the ring finger
Ask pt to mark location of pain, tenderness or tingling on Katz hand diagram
Patterns of pain, numbness or tingling associated c carpal tunnel syndrome
Thumb abduction test
Tests for carpal tunnel
Have pt abduct thumb, perpedicular to hand
Apply downward pressure to thumb. A weakness is carpal tunnel
Tests strength of pollicis brevis muscle, innervated by median nerve
Phalen Test
Hold both wrists in fully palmar-flexed position with dorsal surfaces presssed together for 1 minute
Note any numbness or paresthesia
Can be done in the reverse as well
Tinel Sign
Strike pt wrist c index or middle finger
Positive Tinel sign is a tingling sensation radiating from wrist to the hand
Classic pattern of carpal tunnel
Symptoms affect two of digits 1, 2 or 3
Classic pattern permits in the fouth and fifth, wrist pain and radiation of pain proximal to the wrist
No symptoms of palm or dorsum of hand
Probable Pattern of carpal tunnel
Same symptoms as classic, but also includes ulnar aspect
Possible pattern effects one of digits 1,2 and 3
Neer test
Forward flex pt’s arm up to 150 degrees while depressing scapula
Increased shoulder pain is associated c rotator cuff inflammation or tear
Hawkins Test
Abduct shoulder to 90 degrees, flexing elbow to 90 degrees and then internally rotating arm to its limit
Increased shoulder pain is rotator cuff inflammation or tear
Assess supraspinatus muscle
Pt places arm in 90 degrees of abduction, 30 degrees of forward flexion and internally rotated so thumbs are pointing down
Apply downward pressure on the arm against pt resistance
Assess subscapularis muscle
Hold arm to side and flex 90 degrees and rotate forearm medially against resistance
Assess infraspinatus and teres minor
hold at at side, elbow flexed 90 degrees and rotate arm laterally against resistance
Straight leg raising test
Test nerve root irritation or lumbar disc herniation at L4, L5 and S1
Lay supine c head flexed
Raise leg and keep knee extended
Pain below the knee is disc herniation
Repeat in unaffected leg
Crossover pain in affected leg could be sciatic nerve impingement
Femoral Stretch Test
Checks inflammation of nerve root at L1, L2, L3 and sometimes L4
Lie prone and extend hip
Pain is nerve root irritation
Thomas Test
Detect flexion contractures of the hip
Can be masked by excessive lumbar lordosis
Fully extend one leg flat and flex the other leg with the knee to the chest
Observe ability to keep extended leg flat
Lifting the extended leg off the examining table indicates a hip flexion contracture in the extended leg
Trendelenburg Test
Detects weak hip abductor muscles
Pt must stand and balance first on one foot then the other
Note any asymmetry or change in level of iliac crests
Hip abductor muscles on weight-bearing are weak if iliac crest drops on the side of lifted leg
Ballottement
Tests excesss fluid or effusion in the knee
Extend knee and apply downward pressure on suprapatellar pouch
Push patella sharply downward against the femur
A tapping or clicking will be sensed when the patella is pushed against the femur
Release pressure against patella, but keep your finger lightly touching it
If effusion present, patella will float out as if fluid wave were pushing it
Bulge Sign
Detect excess fluid in knee
Extend knee, milk medial aspect of the knee upward two or three times
Milk lateral side of patella
Observe for bulge of returning fluid to the hollow area medial to the patella
McMurray Test
Detect torn medial or lateral meniscus
Lay pt supine and flex knee
Position fingers around joint space and hold the heel with your other hand, fully flexing the knee and rotate the foot and knee outward (valgus stress) to a lateral position
Extend and then flex pt knee
Palpable or audible click, grinding pain, or limited extension of the knee is positive sign of torn medial meniscus
Repeat procedure, rotating the foot and knee inward (varus stress)
Drawer test
Used to identify instability of the ACL and PCL
Anterior or posterior movement of the knee greater than 5mm in either direction is abnormal
Lachman Test
Evaluates ACL integrity
Increased laxity, greater than 5mm compared to uninjured side indicates injury
Varus (abduction) and valgus (adduction) stress test
Instability of the lateral and medial collateral ligaments
Laxity is indicative of injury `
Limb measurement
Athletes may have a discrepancy in circumference if there is use of a dominant arm
No more than a 1-cm discrepancy in circumference and length in matching extremities should be found
