musculoskeletal part 2 Flashcards
spine: which parts are concave? convex?
Concave – cervical and lumbar
Convex – thoracic and sacrococcygeal
describes the joints of the vertebral spine
Slightly movable cartilaginous joints between vertebral bodies and articular facets
Cushion movement between vertebrae and allow column to curve, flex, and bend
describe intervertebral discs
– soft mucoid central core (nucleus pulposus) rimmed by tough fibrous tissue of annulus fibrosis
what are the muscle groups of the spine
Trapezius and latissimus dorsi – large outer layer of muscles attach to each side of spine and overlie two deeper muscle layers attaching to head, neck, and spinous processes (splenius capitis, splenius cervicis, and sacrospinalis)
Muscles that attach to anterior aspect of vertebrae such as psoas and abdominal wall muscles assist in what?
flexion
inspection of the spine (4)
- Observe posture (position of neck and trunk)
- Expose entire back, preferably upright in natural standing position with feet together and arms at sides
- View from behind
- View from side noting spinal curvatures
what three things do you want to observe about posture (inspection)
(Erect, coordinated and smooth movement/gait)
what things do you want to note in the view of the spine from behind? ( inspection) (4)
- spinous processes (C7 and T1 usually more prominent, more prominent on forward flexion)
- spinal curvature;
- paravertebral muscles;
- iliac crests; posterior superior iliac spines (dimples)
Line drawn above posterior iliac crests crosses ___ spinous process
L4
palpation of spine (4)
- Spinous processes of each vertebrae with thumb
- Facet joints of neck between cervical vertebrae about 1 inch lateral to spinous processes (deep to trapezius so may not palpate if muscle tensed)
- Check for vertebral step-offs, especially in lower vertebral area (spondylolisthesis)
- Palpate SI joint (dimple over posterior iliac spine)
* and any tender areas
how can you percuss the spine?
May percuss by thumping for tenderness with ulnar surface of fist
what do you inspect and palpate paraverbetral muscles for?
tenderness or sign of spasm (firm, knotted, ? visible)
how do you palpate for the sciatic nerve? (spine exam)
hip flexed and patient lying on opposite side (nerve roots of L4-S3) – lies midway between greater trochanter and ischial tuberosity
ROM of the neck: which cervical vertebrae do flexion/extension, rotation, lateral bending?
Most mobile part of spine
flexion, extension (C1), rotation (C1-C2), lateral bending (C2-C7)
ROM spinal column (4)
Flexion, extension, rotation, lateral bending
what joint is strong, stable with a wide range of motion?
hip
Hip below ______ _______ of inguinal ligament but deeper plane
middle third
4 muscle groups of the hip
Flexor group (anterior) – iliopsoas (1° hip flexor) Extensor group (posterior)gluteus maximus (1°) Adductor group (medial) Abductor group (lateral) – gluteus medius and minimus
3 bursae of the hip
- Psoas or iliopectineal or iliopsoas
- Trochanteric
- Ischial or ischiogluteal
where are the 3 bursae of the hip? psoas/iliopectineal/iliopsoas
trochanteric
ischial/ischiogluteal
- Psoas or iliopectineal or iliopsoas (anterior to joint) – overlies articular capsule and psoas
- Trochanteric on posterior surface of greater trochanter (mulitlocular)
- Ischial or ischiogluteal – not always present, under ischial tuberosity
inspection of the hip (4)
- Gait
- Lumbar spine for slight lordosis
- Asses length of legs for symmetry with patient supine
- Anterior and posterior inspection for muscle atrophy or bruising
gait inspection: what % of stance is the walking cycle, width of base should be what? when should the knee be flexed?
– stance (60% of walking cycle) and swing
Also observe width of base (2-4 inches from heel to heel), shift of pelvis, flexion of knee (should be flexed throughout stance except when heel strikes)
what 3 things do you palpate for in the hip?
surface landmarks (anterior + posterior) inguinal structures bursae
palpation: anterior (5) and posterior (4) landmarks in the hip
Anterior: ID iliac crest (level of L4), iliac tubercle (widest point of crest) and downward to ASIS, greater trochanter, pubic symphysis
Posterior: PSIS (level of S2) under visible dimples, greater trochanter at level of gluteal fold, ischial tuberosity, SI joint (not always palpable)
what inguinal structures do you palpate for in the hip?
Supine with heel to opposite knee – palpate along inguinal ligament from ASIS to pubic tubercle.
NAVEL – (lateral to medial); nerve-artery-vein-empty space-lymph node
what bursae do you palpate for in the hip? (3)
psoas and trochanteric;
ischiogluteal only palpable if inflamed
ROM for the hip
Flexion+ extension
abduction + adduction
external rotation + internal rotation
testing for flexion + extension of hip
flexion- Hand behind back, flex knee to chest, when lumbar lordosis flattens then hip is flexing – note degree of flexion as well as if other thigh is fully extended
Extension – supine or edge of table-pull leg back
testing abduction + adduction of the hip
Abduction – STABILIZE PELVIS by pressing on opposite ASIS with one hand and grasp ankle with other hand and abduct leg until iliac spine moves to mark limit of abduction
Adduction – STABILIZE PELVIS, hold one ankle and move leg medially across body over opposite extremity
testing internal and external rotation of the hip
Flex 90° at hip and ankle; swing lower leg medially for external rotation and laterally for internal rotation
(like a runner’s dynamic stretch)
what is the largest joint in the body ?
knee
what type of joint is the knee? involving what bones?
Hinge joint involving femur, tibia, and patella
* No inherent stability so depends on ligaments
Highly vulnerable to injury
what are the articular surface of the knee?
3 total: two between femur and tibia and one between femur and patella
what are the 2 joints in the knee?
Tibiofemoral (2) – convex curves of medial and lateral condyles of femur articulating on concave condyles of tibia
Patellofemoral joint – patella slides in trochlear groove (anterior groove of distal femur) on flexion and extension
muscle groups of the knee
Quadriceps femoris extend leg (cover anterior, medial, and lateral thigh)
Hamstring on posterior flex knee
what are the discs/ligaments of the knee?
- Medial and lateral menisci (crescent-shaped fibrocartilaginous discs – make flat surface cup-like)
- Medial and lateral collateral ligaments (MCL/LCL)
- cruciate ligaments (ACL + PCL)
where is the MCL vs LCL ?
MCL – medial femoral epicondyle to medial tibial condyle, also attaches to medial meniscus
LCL – lateral femoral epicondyle to fibular head
cruciate ligaments: ACL vs PCL - where are they? what is their function?
**Not palpable
(ACL) – crosses obliquely from anterior medial tibia to lateral femoral condyle; prevents forward slippage of tibia on femur
(PCL) – crosses from posterior tibia and lateral meniscus to medial femoral condyle; prevents backward slippage of tibia on femur
concavities on either side of the patella, swollen/tender with inflammation- what is this referring to?
synovial cavity
2 bursae of the knee? which is not palpable?
- Prepatellar – between patella and overlying skin
- Anserine – 1-2 inches below knee on medial surface proximal and medial to attachments of medial hamstring muscles on proximal tibia
* * Not palpable due to overlying tendons
people who kneel a lot get inflammation of which bursae? what about runners?
prepatellar- kneelers
anserine - runners
inspection of the knee: (5)
- Gait –
- Alignment and contours of knee: Genu varum vs valgum
- Atrophy of quadriceps
- Loss of hollows around patella
- Other swelling
what are you looking for with gait inspection of the knee?
smooth, rhythmic, knee extended with heel strike only
genu varum vs genu valgum
genu varum (bowlegs) and genu valgum (knock-knees) *gum sticks the knees together *
knee palpation: why do you want them on the edge of the table w/ knees flexed?
Bony landmarks more visible; muscles tendons and ligaments more relaxed
paplation of tibiofemoral joint
thumbs in soft tissue depression on either side of patellar tendon, ID groove (patellar lies just above), press thumbs downward to feel tibial plateau; move fingers medially and laterally then upward in articular surface of femur
Note irregularities
palpation of medial and lateral meniscus
Medial meniscus – press on medial soft tissue depression along upper edge of tibial plateau – easier if slightly internally rotated at knee
Lateral meniscus – knee in slight flexion
knee: palpation of medial joint compartment (4 things to palpate)
knee flexed to 90°; move thumbs upward to palpate medial femoral condyle;
adductor tubercles is posterior to medial femoral condyle; palpate medial tibial plateau (downward)
MCL (broad flat ligament)
knee: palpation of lateral joint compartment (3)
Lateral to patellar tendon move thumbs upward to palpate 1. lateral femoral condyle + downward to palpate 2. lateral tibial plateau
3. Lateral collateral ligament – patient asked to cross legs so ankle rests on opposite knee;
palpating the patellofemoral compartment
Trace patellar tendon distally until palpate tibial tuberosity; ask pt to extend to test if intact
patellofemoral grind test
Pt supine with knee extended, compress patella against femur and ask pt to tighten quads checking for smooth sliding motion
palpating the suprapatellar pouch
palpate for thickening or swelling along patellar margins starting 10 cm above superior border of patella; feel for soft tissues between thumb and fingers moving hand distally progressively to ID pouch; note tenderness or warmth
knee palpation : palpate the Prepatellar bursa, anserine bursa, and medial aspect of popliteal fossa with pt leg ______ for _____ or _______
extended
bogginess or swelling
knee: what the the signs for a minor, moderate and major effusion ?
Bulge sign (minor effusion) Balloon sign (major effusion) Ballotting patella (large effusion)
for the ballotting patella (large effusion test) - look for what?
look for fluid returning to suprapatellar pouch
testing achilles tendon fxn
patient supine or kneeling on chair with ankle at 90°, squeeze calf (gastroc+soleus) for plantar flexion
ROM of knee
Flexion + extension
internal rotation + external rotation
4 maneuvers for the knee exam
McMurray Test
Valgus and Varus Stress
Anterior/Posterior Drawer Sign
Lachman Test
mcmurry test
for presence of meniscal tear w/in the knee:
position of maximal flexion
lateral meniscus: extend the knee with internal rotation (IR) of the tibia and a VARUS stress
medial meniscus: extend the knee with external rotation (ER) of the tibia and a VALGUS stress.
varus vs valgus stress
Varus: LCL: pressure to medial side of knee, lateral side of ankle
Valgus: MCL: pressure to lateral side of knee, medial side of ankle
anterior/posterior drawer tests for what?
Test for dysfunction of the anterior and posterior cruciate ligaments.
lachman test
for ACL tear:
stabilizes the thigh, pull tibia anterior and posterior against femur
what type of joint is the ankle
hinge
what is the ankle “mortise” ?
Tibia and fibula; talus is braced like inverted cup. *compared to the woodworking “mortise” joint that is a small rectangular socket fitting into a large rectangular hole.
what are the other two joints within the ankle?
Tibiotalar joint – tibia and talus Subtalar joint (talocalcaneal)
where are the medial and lateral malleolus?
medial malleolus (tibia), lateral malleolus (fibula),
dorsiflexion vs plantar flexion- which muscles are involved in each? where do the tendons (extensors/flexors) run?
Dorsiflexion - anterior tibial muscle and toe extensors (tendons on anterior surface or dorsum of ankle, anterior to malleoli)
Plantar flexion – gastrocnemius, posterior tibial muscles, and toe flexors (tendons run behind malleoli)
heads of metatarsals are palpable where in the foot?
in ball of foot
what is the forefoot?
MTP joints proximal to webs of toes, DIP and PIP joints
deltoid ligament of the foot: what is it? fxn?
triangular fanning out from inferior surface of medial malleolus to talus and proximal tarsal bones;
protect against eversion stress
three less substantial ligaments of the foot (laterally). which is most at risk for injury from inversion?
Anterior talofibular ligament – most at risk from inversion
Calcaneofibular ligament
Posterior talofibular ligament
Achilles attaches _____ + ______ to calcaneus
Plantar fascia insertion on what?
gastroc + soleus
medial tubercle of calcaneus
inspection of ankle + foot
ALL SURFACES
Deformity, nodules, swelling, calluses, corns
palpation of ankle + foot
- Anterior ankle joint with thumbs: Boggy? Swollen? Tender?
- Achilles tendon – Nodules, tender?
- Heel, especially posterior inferior calcaneus, and plantar fascia for tenderness
- Medial and lateral malleoli for tenderness (especially due to trauma)
- MTP joints for tenderness
- Metatarsal heads and grooves between with thumb and pointer finger
how do you check MTP joints for tenderness?
Compress forefoot between thumb and fingers exerting pressure just proximal to heads of 1st and 5th metatarsals
4 joints to check ROM for in ankle/foot?
tibiotalar
subtalar
transverse tarsal joint
metatarsalphalangeal joints
ROM for tibiotalar, subtalar, transverse tarsal, metatarsalphalangeal joints
Tibiotalar: Flexion and extension (plantar flexion and dorsiflexion)
Subtalar joint: Foot inversion and eversion
Stabilize ankle with hand, grab heel with other hand and invert and evert foot
Transverse Tarsal Joint: Stabilize heel, invert and evert forefoot
Metatarsophalangeal Joints: Flex/extend toes
describe limited range of motion how?
in degrees, measure with a geniometer
measuring leg length- how should pt be positioned? measure where to where?
Supine with symmetrical alignment and legs fully extended
Tape measure from ASIS to medial malleolus crossing knee on medial side
