Musculoskeletal Lower Extremity Flashcards
Important factors that can point you toward a differential diagnosis
. Chief complaint
. Age
. Biological sex
. Vital signs
Septic joint
. Acute onset of mono articular joint pain, erythema, heat, and immobility
. Fever, chills rigor
. Failure to start antibiotics in first 24-48 hrs causes subchondral bone loss and permanent joint dysfunction
Most common route of entry in a joint for infection
. Contiguous, direct inoculation, and hematogenous
Risk factors for contiguous spread of infection in joint
. Cellulitis . Cutaneous ulcers . Osteomyelitis . Septic bursitis . Abscess
Risk factor for direct inoculation of joint infection
. Previous intraarticular injection . Prosthetic joint . Recent surgery . Arthrocentesis . Trauma
Risk factors for hematogenous spread in joint infection
. DM . HIV . Bacteremia . Immunosuppressive meds . IV drug abuse . OA
Synovial fluid analysis
. Helpful to distinguish crystal arthropathy from infectious arthritis
. Synovial fluid sent for WBC count (usually over 50,000 per mm3)
. Isolation of causative agent of sepsis is essential for selecting antibiotic therapy
Arthalgia
. Joint pain
. Discomfort form w/in or surrounding joint
What to inspect for in musculoskeletal examination
. Joint symmetry, alignment, or bony deformities
. Surrounding tissues for skin changes, nodules, muscle atrophy, or crepitus
. Assess any degenerative or inflammatory changes, especially swelling, warmth, tenderness, or redness
Psoas syndrome
. Muscular strain, spasm, or flexion contracture
. Caused from being in position that allows prolonged shortening of psoas following sudden lengthening (desk work, road trip, trauma)
. Stooped posture, back/butt pain
. Tests: pos. Thomas test, non-neutral upper lumbar somatic dysfunction
Trendelenberg sign
. Weak abductor
. Could be caused by bone length, position (internal/externally rotated), gross deformity
Iliac crest anatomical landmark
L4
Pubic tubercle anatomical landmark
. Find greater trochanter then move thumbs medially at same level as trochanter
Antalgic
. Shortened stance phrase on affected side
Important bony structure to palpate on lower extremity exam
. Joint line
. Paella
. Tibial tubercle
Soft tissue structures to palpate in lower extremity exam
. Pes anserine bursa . Patellar tendon . Quad tendon . Iliotibial band . Collateral ligaments
Patellar tendon tear results from ___
. Direct impact from a fall/blow and jumping
. Patellar tendinitis
. Chronic disease
. Steroid use
Patellar tendon tear symptoms
. Tearing/popping sound . Pain, swelling . Unable to straighten knee . Indentation where tendon tore . Displacement of patella . Difficulty walking due to knee buckling
Ankle sprain
. Inversion sprains 75% of the time
. Occur in plantar flexion most of the time (dec. ankle stability because ant. Aspect of talus is no longer wedged btw malleoli increasing mobility)
Spine
. Central supporting structure of trunk and back
. Can cave curves of cervical spine and lumbar spine
. Convex curves of thoracic and sarcococcygeal spine
. Help to distribute body weight to pelvis and lower extremities
Cervical lordosis
Abnormal straightening of the concavity
Thoracic hyperkyphosis
Hyper-convexity of thoracic curvature
Lumbar hyperlordosis
Hyper-concavity of lumbar curvature
Spine ROM and muscles that caus it
. Muscles: psoas, quad lumborum, internal and external obliques, abs
. As flexion proceeds, lumbar concavity flattens
. Fl/extension, side Bending, rotation
Muscles in charge of spine extension
. Erector spinae and transversospinalis mm.
. Dec/ mobility common in OA and other inflammatory processes
Muscles in charge of sidebending and rotation
. Combo of flexion and extension muscle groups
Stance
. When foot is on ground and bears weight 960% walking cycle)
. Hip problems appear during this phase
Swing
. When foot moves forward and doesn’t bear weight (40% walk cycle)
Width of the base when walking
. 2-4 inches heel to toe
Hip
. Ball and socket
. High strength and stability
. Essential for weight bearing
. Rounded femur head articulates w/ cup-like cavity of acetabulum
. Muscles crossing joint and inserting below femoral head provide leverage for femur movement
FABER test
. Evaluates hip and SI joint
. Pos: post. Pain in SI joint, lumbar spine, or hip
. Groin pain w/ this is sensitive for intra-articular pathology
Hamstrings motions
. Flexors of knee joint
. Extensors of hip joint
Seven structure of knee important to examine
. Med. and lat. menisci
. Med., lat., ant., and post. Collateral ligaments
. Patellar tendon
Bursas of the knee
. Suprapatellar
. Prepatellar (beneath patella)
. Infrapatellar
. Pes anserine (on med. side at distal attachment of med. collateral ligament)
Baker’s cyst
. Large accumulation of fluid in popliteal fold (behind knee joint)
Bulge sign
. Test for knee joint effusions
. Milk patella and fluid downward
. Apply med. pressure.
. Tap and watch for fluid wave
Allotment of patella
. Compress suprapatellar pouch and push patella sharply against femur
. Palpable fluid wave returning into pouch is pos. For major effusion
Patellar grind test
. Pt supine w/ knees extended and relaxed
. Apply downward force onto patella and move in all directions
. Pos if pain and/or crepitus
Valgus
. Distal part deviated more lateral from midline
Varus
Distal part deviated for med. from midline
Valgus stress test
. Tests MCL
. Pt supine, grip ankle w/ one hand and put other hand on lat. aspect on knee
. Apply valgus force
. Pos: joint laxity in medial aspect
Varus stress test
. tests LCL
. Pt supine, grip ankle w/ other hand on med. aspect of knee
. Apply varus force
. Pos: joint laxity in lat. aspect
Mcmurray’s for lat. meniscus
. Start with knee flexed
. Internally rotate for and apply varus stress at knee
. Slowly extend knee
. Pos: click at joint or tenderness along joint line in lat. aspect
McMurray for med. meniscus
. Pt. Supine w/ knee flexed
. Externally rotate foot and apply valgus stress at knee
. Slowly extend knee
. pos: clicking or tenderness at med. joint line
Ant. And post. Drawer test
. Knee bent
. Fingers behind knee, thumbs on tibial plateau
. Either pull tibia ant. Or push post.
. Pos: laxity in a direction compared w/ opposite knee
Lachman test
. Knee bent
. Grab calf w/ dominant hand, thumb over ant. Joint line
. Other hand stabilizes distal femur
. Pull tibia ant. In sudden firm motion
. Pos: laxity (>6-8mm shift) compared w/ opposite knee
Sag sign
. Injury to PCL causes inc. post. Knee laxity
. Drop back in pos. Direction upon femur
Accessory motions of foot
. Side-to-side glide
. Rotation
. Ab/duction
. Only occur when joint is in plantar flexion
Lateral longitudinal arch of ankle
. Firm osteoid structure
. Formed by calcaneous, cuboid, and 4th-5th metatarsals
. Limited mobility and built to transmit weight
Medial longitudinal arch of ankle
. Higher and more mobile (calcaneous, talus, navicular, cuneiform, and 1st 3 metatarsals)
. No firm osseous support
. Can be inc. or reduced to meet needs of motion and terrain
Medial ligaments of ankle
. Deltoid ligament: fans out from med. malleolus to talus and prox. Tarsal bones
. Protects against stress from eversion
Lateral ankle ligaments
. ATF
. Calcaneofibular ligament
. Post. Talofibular ligament
. Protects against stress from inversion
Thompson test
. For Achilles rupture
. Have patient get up on knees w/ feet hanging off table
. Squeeze gastroc and soleus
. Plantarflexion should occur, if not Achilles is ruptured
Diagnostic tests for lower extremity injuries
. Labs: CBC, erythrocyte sedimentation ate
. Radiography: suspect fracture/dislocation
. MRI for soft tissue issues
. Ultrasound: bursitis, joint effusion, image guided injections
. Arthrocentesis: joint fluid looks at for cell count, glucose and protein, bacterial culture, and crystals
Salter-Harris fractures
/ pediatric fractures involving growth plate
. S: straight across (type I): complete break
. A: above (type II): break above physis and prox. Through metaphysis
. L: (III): break through physis and distally through epiphysis
. TE: (IV): break through everything
. R: cRush injury
