musculoskeletal: part 1 Flashcards
which plane passes through body vertically parallel to median plane?
sagittal plane
which plane passes vertically through midline of body dividing it into right and left sides
median plane
which plane passes horizontally through body at right angles to frontal and sagittal planes?
transverse plane
which plane passes longitudinally through body dividing into front and back?
frontal (coronal) plane
which plane? “sections are slices of the body or any of its parts that are not cut along the previously listed anatomical planes”
oblique plane
ipsilateral vs contralateral
Ipsilateral-occurring on the same side of the body
Contralateral-occurring on the opposite side of the body
flexion vs extension
Flexion-bending or decreasing the angle between bones or parts of the body
Extension- straightening, increasing the angle between the bones or parts of the body.
what is “circumduction”?
circular movement that involves sequential flexion, abduction, extension, and adduction (or in the opposite order) in such a way that the distal end of the part moves in a circle
medial rotation vs lateral rotation
Medial rotation (internal rotation) brings the anterior surface of a limb closer to the median plane Lateral rotation (external rotation) takes the anterior surface away from the median plane.
pronation vs supination
Pronation- elbows flexed, palms facing down
Supination- elbows flexed, palms facing up.
plantar flexion vs dorsiflexion
Plantar flexion- of the foot, extension of the ankle joint, distal foot is pointed
Dorsiflexion- flexion of the ankle joint, distal foot moves up
eversion vs inversion
Eversion-moves the sole of the foot away from the median plane, turning the sole laterally
Inversion-moves the sole of the foot toward the median plane, facing the sole medially
articular vs extra-articular structures
Articular structures
Joint capsule and articular cartilage, synovium/synovial fluid, intra-articular ligaments, juxta-articular bone
Extra-articular structures
Periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin
Ligaments + tendons
ligaments vs tendons
Ligaments – bone to bone
Tendons – muscle to bone
joint articulation: what is the mobility differences between synovial, cartilaginous, + fibrous
synovial- freely move
cartilaginous - slightly move
fibrous- immovable
examples of synovial, cartilaginous + fibrous joints
Synovial – Knee, shoulder * Bones do not touch
Cartilaginous –Vertebral bodies *Discs with nucleus pulposus
Fibrous – Skull sutures * Bones almost in direct contact
3 types of synovial joints
ball + socket (spheroidal), hinge, condylar
describe the 3 synovial joints (ball+socket, hinge, condylar) +examples of each
Ball+socket: Flexion, extension, abduction, adduction, rotation, circumduction (wide-ranging)
ex/ Shoulder, hip
Hinge: Flat, planar – move in one plane (flex/extend)
ex/ IP joints, elbow
Condylar: Convex or concave
ex/ Knee, TMJ
define bursae
a synovial sac that allow adjacent muscles or muscles and tendons to glide over each other during movement.
what two places can bursae be found?
- between the skin and the convex surface of a bone or joint
- In areas where tendons or muscles rub against bone, ligaments or other tendons or muscles
2nd most common reason for office visits
low back pain
low back pain that is midline vs off midline: what things could it be from?
Midline: Musculoligamentous injury, disc herniation, vertebral collapse, spinal cord mets, epidural abscess (rare)
Off Midline: Sacroiliitis, trochanteric bursitis, sciatica, hip arthritis
low back pain w/ radiation (paresthesias/numbness) could be cause by what?
-Radicular pain arises from spinal nerve compression
Low back- herniated disc
Neck – degenerative changes
low back pain w/ bowel/bladder disruption is likely from what?
Bowel/bladder function
cauda equina syndrome
health history: red flags for serious underlying condition causing BACK PAIN
<20 years or >50
Hx of Cancer
unexplained weight loss
pain > 1 year, or not responding to treatment
pain at night or present at rest
Hx of IV drug use
Presence of active infection or HIV infection
Long-term steroid use
Saddle anesthesia, bowel or bladder incontinence
Neurologic symptoms or progressive neurologic deficit
joint pain: monoarticular, polyarticular, vs extra articular
- Monoarticular – localized to one joint
- Polyarticular – several joints
Pattern? Migrating? Symmetric? - Extraarticular
Myalgias – muscle pain
Arthralgia – pain but no evidence of arthritis
Can assume it is _______ if they have swelling, stiffness or decreased range of motion
articular
_________pain- loss of active but not passive range of motion (always from patient’s perspective)
nonarticular
what is “inspected” for in exam
Joint symmetry, alignment, deformities, surrounding tissues, nodules, atrophy
what is “palpated” for in exam ?
Skin changes, nodules, muscle atrophy, crepitus, tenderness
how is ROM/joint fxn and stability tested in exam?
Active vs. passive ROM (always from patient’s perspective)
Ligaments, tendons, bursae
signs of inflammation in exam
Swelling, warmth, tenderness, redness (least common sign of inflammation)
most active joint in the body
TMJ
what type of joint is TMJ? what muscles does it involve? nerve?
Condylar synovial joint
External (lateral) pterygoids (open mouth) and masseter, temporalis, and internal pterygoids
- nerve: trigeminal
how do you palpate for swelling of TMJ?
Tips of index fingers just in front of tragus of each ear
“Open and close your mouth several times.”
Smooth? Tenderness?
TMJ ROM- (4)
Glide and hinge
Open and close mouth
Protrude and retract jaw
Lateral side-to-side motion
glenohumeral joint: contact less than ___ of surface area of glenoid fossa. attached by what?
Contact less than 1/3 of surface area of glenoid fossa
Attached by joint capsule, intra-articular capsular ligaments, glenoid labrum, and meshwork of muscles and tendons
shoulder girdle: dynamic stabilizers vs static stabilizers
Dynamic stabilizers (move): Rotator cuff (SITS) – moves humerus, stabilizes humeral head within glenoid fossa Static stabilizers (do not move): Labrum, articular capsule, glenohumeral ligaments
what is the labrum?
fibrocartilaginous ring, surrounds glenoid to deepen socket
what anchors the shoulder joint to the axial skeleton ?
sternoclavicular joint and scapulothoracic articulation (inserting muscles, not true joint)
shoulder: structures you need to ID on exam (6)
Manubrium Sternoclavicular joint Clavicle Tip of acromion Greater tubercle of humerus Coracoid process
shoulder: ___ joints, ___large bones ____ principle muscle groups
Interconnection of 3 joints, 3 large bones, 3 principal muscle groups
what are the 3 joints within the shoulder?
Glenohumeral
Sternoclavicular
Acromioclavicular (AC)
what is each like? Glenohumeral, Sternoclavicular, Acromioclavicular (AC)
Glenohumeral: Deep, not normally palpable
(Ball-and-socket)
Sternoclavicular: Convex medial end of clavicle articulates with concave hollow in upper sternum (manubrium)
Acromioclavicular (AC): Lateral end of clavicle articulates with acromion of scapula
what 3 muscle groups are involved in the shoulder?
scapulohumeral, axioscapular, axiohumeral
*biceps + triceps as well
scapulohumeral muscle group: what does it do? what 4 muscles are included?
rotate shoulder laterally and depresses and rotates the head of the humerus
-supraspinatus, infraspinatus+ teres minor, subscapularis
axioscapular muscle group: what does it do? what 4 muscles are included
Attaches trunk to scapula + rotates scapular
trapezius, rhomboids, serratus anterior, and levator scapulae
axiohumeral muscle group: what does it do? what 3 muscles are included?
Attaches trunk to humerus + internal rotation of shoulder pectoralis major and minor and latissimus dorsi
how to find to biceps tendon on exam
Rotate arm externally and find tendinous cord that runs just medial to greater tubercle = tendon of long head of biceps that runs in bicipital groove between greater and lesser tubercles
(can also start at elbow and track up)
subacromial bursa: where is it? what action compresses it? when might it be palpable?
Between acromion and head of humerus and overlying supraspinatus tendon
Compressed by abduction
Bursa may be palpable if inflamed
inspection of shoulder: what do inspect anteriorly vs posteriorly?
Inspect shoulder/shoulder girdle anteriorly
Inspect scapulae and related muscles posteriorly
what are you inspected shoulder muscles FOR? what do you want to inspect about the general appearance of the shoulder?
Look for swelling, deformity, muscle atrophy, fasciculations, abnormal positions
Inspect upper extremity for color, skin changes, unusual bony contours
palpation of bony landmarks of shoulder
- Trace clavicle laterally
- Bony spine of scapula from behind laterally and up to acromion and ID anterior tip
- Pointer finger on acromion, press medially with thumb to find elevated ridge of distal clavicle at AC joint
- Move thumb down and medial to next bony prominence, coracoid process
- Leave thumb on coracoid process and allow fingers to locate lateral aspect of humerus to palpate greater tubercle (SITS insertion site)
palpation of subacromial + subdeltoid bursae + SITs muscles: how do you want to position the arm?
Passively extend humerus by lifting elbow posteriorly to rotate structures anterior to acromion. Then palpate bursae + SITS muscles
what are the locations of the SITS muscles?
Supraspinatus – directly under acromion
Infraspinatus – posterior to supraspinatus
Teres minor – posterior and inferior to supraspinatus
Subscapularis inserts anteriorly and is not palpable
what is included in ROM of the shoulder?
Flexion + Extension
Abduction + Adduction
Internal rotation + External rotation
extra tests for shoulder: what does the “crossover test” and “apley scratch test” each look for?
crossover test : compression of AC joint
apley scratch test: shoulder Rotation
what are the two signs for impingements of the rotator cuff?
Neer’s impingement sign: stabilize pts shoulder while putting in max elevation (shoulder near ear). pain = positive
Hawkin’s impingement sign: flex arm at 90 degrees + medially rotate shoulder (forward flex + horizontal adduct). pain = positive
test for supraspinatus vs infraspinatus strength
- Suprapinatus strength “empty can test”
- Infraspinatus strength – arms at side at 90 degrees with thumbs up, provide resistance as patient presses forearms outward (rotator cuff or bicipital tendonitis)
forarm supination test
Provide resistance as patient tries to rotate wrist from pronation to supination (elbows at 90 degrees) (rotator cuff or bicipital tendonitis)
what is the “drop arm test” for?
rotator cuff tear
what are the 3 articulations in the elbow ?
Humeroulnar joint
Radiohumeral joint
Radioulnar joint
All 3 in large common articular cavity with extensive synovial lining
muscles of the elbow?
Biceps Brachioradialis (flexion) Triceps (extension) Pronator teres (pronation) Supinator (supination)
olecranon bursa : where is it? is it palpabe?
between olecranon process and skin
Usually not palpable (May become swollen, inflamed, and tender)
3 nerves of the elbow
Ulnar nerve – posterior in ulnar groove between medial epicondyle and olecranon process
Median nerve – ventral forearm just medial to brachial artery
Radial Nerve – Anterior medial aspect at elbow
elbow exam: inspection
Support forearm and flex elbow to about 70°
ID medial and lateral epicondyles and olecranon process
Inspect for abnormal contours, nodules, swelling
elbow exam: palpation (4)
- Olecranon process – note tenderness, swelling, inflammation, displacement
- Epicondyles – note tenderness, swelling
- Grooves between epicondyles and olecranon – note tenderness, swelling, thickening
- Ulnar nerve between olecranon process and medial epicondyle (SENSITIVE!)
elbow ROM (4)
Flexion + Extension . (radial + ulnar deviation)
Pronation+ Supination
how many carpal bones? what are they?
8 carpal bones
Trapezium , Trapezoid, Capitate, Hamate
pisiform, Triquetrum, Lunate, Scaphoid
wrist- includes what? hand?
wrist: carpals
hand: metacarpals + phalanges (proximal, middle, distal)
3 joints of the wrist
- Radiocarpal – note groove on dorsal aspect of wrist; provides most of flexion and extension at wrist
- Distal radioulnar
- Intercarpal
3 joints of the hand
- Metacarpophalangeal (MCPs) – flex hand and find groove distal to knuckle, felt best on either side of extensor tendon
- PIPs
- DIPs
how many muscles are involved in wrist flexion, extension, supination/pronation?
Two carpal muscles on radial and ulnar surfaces = flexion
Two radial and one ulnar muscle = wrist extension
Forearm muscle contraction = supination/pronation
muscles involved in flexion, abduction, opposition, + extension
Three muscles form thenar eminence and provide flexion, abduction, and opposition of the thumb
Muscle base of thumb along radial margin = thumb extension
muscles of digit movement
Flexor and extensor tendons of muscles in forearm and wrist = digit movement
Intrinsic hand muscles that attach to metacarpals provide digit flexion (lumbricals), abduction (dorsal interossei), and adduction (palmar interossei)
what is the carpal tunnel?
Channel beneath palmar surface of wrist and proximal hand containing sheath and 2 flexor tendons of forearm muscles and median nerve
where is the flexor retinaculum and median nerve?
Flexor retinaculum – hold tendons and tendon sheath in place (over carpal tunnel)
Median nerve between sheath and retinaculum
inspection of the wrist and hand (5)
- Observe position, motion
Rest = slightly flexed fingers aligned almost parallel - Palmar and dorsal surfaces for joint edema
- Deformities / Radial or ulnar deviation
- Contours of palm (thenar and hypothenar eminences)
- Flexor tendon thickening, flexion contractures in fingers
which nerve is damaged for thenar atrophy vs hypothenar atrophy?
Thenar atrophy – median nerve
Hypothenar atrophy – ulnar nerve
palpation of the wrist: 1st three parts. what 3 things do you palpate grooves of joints for?
- Palpate distal radius and ulna laterally and medially
- Palpate grooves of joints placing thumbs on dorsum of wrist and fingers on ventral aspect
(Swelling, boggy, tender) - Palpate radial styloid and anatomical snuffbox (hollow distal to radial styloid )
palpation of wrist: last 4 parts
- Palpate eight carpal bones and then each metacarpal and proximal, middle, and distal phalanges
- Palpate suspected abnormality
- MCP Compression –
- Palpate medial and lateral PIP and DIP
- Palpate along tendons of each digit especially if inflammation noted
MCP compression
squeeze hand from each side between thumb and fingers and palpate MCP
Note swelling, boggy, tender
palpation of PIP and DIP for what?
PIP + DIP: Swelling, boggy, tender and bony enlargement
3 part test for sensation of nerves in the hand/wrist (which hand to check for which nerve)
Pulp of index finger (median)
pulp of 5th finger (ulnar)
dorsal web space of thumb and index finger (radial)
3 maneuvers to test for hand/wrist
- Hand grip
- Thumb movement (Finkelstein’s test) – DeQuervain’s tenosynovitis
- Carpal tunnel
what are the 3 tests for carpal tunnel?
thumb abduction: pt raises thumb as you apply resistance
Tinel’s test: tapping over course of median nerve
Phalen’s test (60 sec): hold wrists at flexion for 60 seconds
* for all: numbness/weakness = positive
what is finkelstien’s test for?
deQuervain’s tensynovitis- hold thumb into palm and ulnar deviate. pain = positive
what is the distribution of nerves in the hand?
dorsal hand + lateral thumb: radial nerve
palm + distal ventral/dorsal fingers: median nerve
pinky + 1/2 ring finger: ulnar nerve
ROM of fingers and thumb
ROM of fingers: Flexion, extension, abduction, adduction
ROM of thumbs: Flexion, extension, abduction, adduction, opposition
