Musculoskeletal Review Flashcards
What connects bone to bone?
Ligaments
What connects muscle to bone?
Tendons
What is affected with a sprain?
Joints
What is affected with a strain?
Muscles
What is the 3-4 rule?
3-4 tabs of ibuprofen, 3-4 times per day for 3-4 days
Ibuprofen - 400-800 mg TID-QID
naproxen 250-500 mg QD in divided doses
According to the WHO Bone Density Criteria, what score is diagnostic of osteoporosis?
T score 2.5 standard deviations from the mean for young adult white women)
According to the WHO Bone Density Criteria, what score is diagnostic of osteopenia?
T score -2.5 to 1.5 (1 to 2.5 SDs below the mean for young adult white women)
How do you best measure bone density?
A DEXA (dual energy x-ray absorptiometry) scan. Also used to diagnose osteoporosis and guiding treatment decisions.
Where does the median nerve innervate?
To the palm and palmar surface of most of the middle finger, index finger, and thumb, and half of the fourth/ring finger digit. It innervates the thumb to flex, abduct, and opposition.
What are the two primary tests to evaluate for carpal tunnel and how are they performed?
What is the treatment?
-Tinel’s sign and Phalen’s sign.
-Treatment: a “cock up” splint to prevent dorsiflexion and
flexion.
What is the McMurray test?
How do you perform it and what are positive findings?
-Tests for medial meniscal injury
-An audible/palpable click when the knee is raised slowly
with one foot externally rotated (knee is flexed and then
quickly straightened), NP’s hand rests on the joint line
What is the Lachman’s test?
How do you perform it and what are positive findings?
-Drawer test to assess for ACL/PCL tear
-Most sensitive and easy to perform test on a swollen,
painful knee
-+Anterior drawer suggests ACL tear
-+Posterior drawer suggests PCL tear
How are ankle sprains classified?
Stretched, partially torn, or completely torn ligaments
Grade 1 - mild, localized tenderness, with normal ROM
and no disability
Grade 2 - moderate to severe pain with weight bearing;
difficulty walking, swelling, ecchymosis; pain
immediately after injury
Grade 3 - impossible to ambulate; resists any motion of
feet; “egg-shaped” swelling within 2 hours of injury
What is bursitis?
How is it treated?
-Inflammation of the bursa
-Caused by trauma, sepsis/infection
-Most common locations:
oleecranon
subdeltoid
ischial
prepatellar
-S/S - pain, swelling, tenderness, erythema
-Aspirate with C&S, WBD, plain x-rays
-Splinting, RICE, heat, aspirin or NSAIDs, steroids (max 3 per year)
What are some defining characteristics of Osteoarthritis?
-It is a degenerative joint disease with slow destruction of
the articular cartilage
-Asymmetrical
-Gets worse throughout the day
-Mostly affects knees, hips, DIPs (Herbeden’s nodes), and
PIPs (Bourchard’s nodes), wrists
-Swelling and edema, NO REDNESS OR HEAT
-Better in the AM, worse as the day goes on
-X-Rays reveal joint space narrowing, osteophytes
-Aspirated synovial fluid is normal, yellow/clear
What are some defining characteristics of Rheumatoid Arthritis?
-Most common in younger females
-Autoimmune inflammation of connective tissue
-Symmetrical
-Worse in the morning, better throughout the day
-Mostly affects PIPs, MCPs/wrists
-Swelling and edema with redness and heat
-Elevated ESR, ANA+ in 1/5 patients
-Aspirated synovial fluid with inflammatory changes and
WBCs
-X-ray reveals progressive cortical thinning, osteopenia,
joint space narrowing, joint swelling
-DMARDS - Must check LFTs
What is the straight leg raisetest?
How do you perform it and what are positive findings?
- have patient lay supine and raise leg off table.
- Radiating or sciatic pain reproduced is a positive finding.
What is the pelvic rock test?
How do you perform it and what are positive findings?
Screens for sacroiliac joint dysfunction.
-with patient laying supine, place hands on each of the
anterior superior iliac spines and attempt to “open and
close” the pelvis.
-The test is positive if the patient feels pain in either or
both sacroiliac joints.
Your patient comes in complaining of lower back pain that radiates to the medial maleolus and he also reports numbness behind his knee. On exam you find diminished patellar reflexes. What is the next test you perform and why?
- You have the patient squat and rise to assess quadriceps muscle strength.
- You are confirming L3-L4 disk pathology.
Your patient comes to see you for pain that radiates to lateral calf and causes numbness on the bottom of her foot. What test do you do in your exam room and why?
- You have the patient walk on her heels to assess her ability to dorsiflex her foot and great toe. This should also elicit pain in her calf.
- You suspect L4-L5 disk pathology.
What do you expect to find with L5-S1 disk pathology?
85% of herniated disks
- Pain along buttocks, lateral leg and lateral malleolus.
- Numbness to lateral aspect of foot and in posterior calf
- Diminished achilles reflex
- Inability to walk on toes (this will elicit pain to calf and butt)
In addition to bracing, rest, PT, heat/ice, NSAIDs, and education on proper body mechanics, what else should the NP assess for in someone with lower back pain?
- Psychosocial assessment of stress management strategies
- Refer if not better in 3 days
A patient comes in complaining of pain from heel to toes and is worse when he first wakes up and takes a few steps. What do you advise?
- You tell him he most likely has plantar fasciitis, which is inflammation of the plantar fascia/the bottom of his foot probably from overuse.
- You tell him to take NSAIDs and he may possibly need steroid injections if not better with NSAIDs
- He needs to rest and use orthotics and wear a night splint
Your patient comes to saying she thinks she might have a rock stuck in her foot. She reports some numbness and tingling in her toes. What do you advise?
- You tell her she most likely does not have a rock in her foot but a condition called Morton’s Neuroma which means she has a benign mass between her 3rd and 4th intermetatarsal spaces that causing a compression neuropathy.
- You can do a US to confirm
- You encourage her to ear orthotics and she can try corticosteroid injections if she wants
- She may need surgery
What is polymyalgia rheumatica and how do you treat it?
It is an inflammatory disorder involving pain and stiffness of neck, shoulders and hip.
- It may be associated with temporal arteritis.
- Treatment is with corticosteroids and symptom management
You suspect your patient has Osgood-Schlatter Disease, what do you expect to find?
- An adolescent male who is going through his growth spurt
- Pain with high impact sports
- Enlarged tibial tuberosity on affected side
- You tell him to scale back on the sports and wear a neoprene sleeve for comfort. His pain will go away at the end of his growth spurt.
What do you expect to find with toxic synovitis?
- insidious onset of hip pain, elicited by internal rotation of hip
- recent viral illness, maybe a low grade temp
- treat with analgesics as it is usually benign and self-limiting
- osteomyelitis or septic arthritis are on your differential
What differentiates Slipped Capital Femoral Epiphysis from Legg-Calves-Perthes Disease?
- In SCFE, the femoral head become dislocated spontaneously; acute onset
- Often one leg is shorter than the other as a result of displacement
- Requires immediate referral to the orthopedist and the patient cannot ambulate
- more common in males and AA; incidence greater among obese males with sedentary lifestyles and seems to occur during growth spurt or prior to menarche for females
For what condition do you perform the Adam’s Forward Bend Test?
Scoliosis. You ask the patient to bend forward to touch their toes and you assess for assymmetry of the shoulders, ribs, hips, and waistline.
-If you find more than 25 degrees curvature, refer to orthopedics
What are the three classifications of an ankle sprain?
Grade I: Stretching but no tearing of the ligament. Local
tenderness but only minimal swelling and usually no
ecchymosis. Maintains full range of motion and is able
to bear weight.
Grade II: Partial tear of ligament. Pain immediately upon
injury. Significant pain with weight bearing and limited
ROM. Localized edema and ecchymosis.
Grade III: Complete ligamentous tearing. Unable to bear
weight. Severe pain immediately upon injury with
profound ecchymoses and edema. Unable to bear
weight.
According to the Ottawa Ankle Rule, when is an X-Ray indicated?
If there is
Pain at or near the malleoli
OR
Bone tenderness at the posterior edge of the distal 6 cm or the tip of either malleolus
OR
The patient is unable to bear weight for at least 4 steps at the time of injury and evaluation
What is a fat pad sign?
Suggests an occult elbow fracture even if not seen on X-Ray -often occurs from a fall that occurred with outstretched arms
What is a “nursemaid elbow”?
A dislocated elbow, often resulting from a child swinging their arms or pulling child’s arm.
- pain present with supination
- Supportive care with NSAIDs
What is cartilage?
Denise connective tissue with no blood supply
What is the Apley’s Grind test?
How do you perform it and what are positive findings?
-Pain or click is positive for medial or lateral collateral
ligament damage and/or meniscus injury
-Testing MCL/LCL
What is the most frequent sports-related injury?
Lateral ankle sprain
Treatment of ankle sprains
- RICE
- Nonweightbearing
- High-dose NSAIDs
- Refer Grade 3 for possible casting
What is the leading cause of lost work days in America?
Low back pain
What is the Spurling test?
- Helps diagnose cervical radiculopathy
- Positive if pain radiates down the arm
-Pt is sitting, bend head towards affected side of the
body, then apply some pressure to the top of your head
What is proprioception?
Decreased position sense
What is ataxic gait?
Limp, pt is twisted to one side and bent forward
L3-L4 Disk Pathology
What is the screening exam?
-Quadriceps muscles weak and/or atrophic
-Pain radiating into medial malleolus; numbness along the
same path, especially medial aspect of knee
-Diminished or absent patellar reflexes
-Have patient squat and rise
L4-L5 Disk Pathology
What is the screening exam?
-Weakness of the dorsiflexion mechanism of the great toe
and foot
-Pain radiating into lateral calf; numbness of dorsum of
the foot and lateral calf
-Have patient walk on heels
L5-S1 Disk Pathology
What is the screening exam?
-Weakness of plantar flexion of great toe and foot
-Pain radiating into lateral calf; numbness of dorsum of
foot and lateral calf
-Diminished or absent Achilles reflex
-Have patient walk on toes
Low back pain diagnostics and management
- X-rays, AP and lateral of the spine
- CT or MRI
-NSAIDS, ibuprofen 400-800 TID x3-4 days
-Psychosocial assessment with stress management
strategies
What is Morton’ Neuroma?
Causes?
S/S?
Treatment?
-Benign neuroma causing a compression neuropathy of
an inter-metatarsal plantar nerve, most commonly of
the 3rd and 4th inter-metatarsal spaces
-High heels with narrowed toe, high impact activity, flat
feet, bunions, and hammer toes may contribute
-Feels like standing on a pebble
-Shooting pain affecting the contiguous halves of 2 toes
-Tingling or numbness in the toes
-Ultrasound/MRI for lesions
-Refer to orthotics, corticosteroid injection, surgery
What is plantar fasciitis?
Causes?
S/S?
Treatment?
-Inflammation of plantar fascia, thick tissue on the bottom
of the foot that connects the heel bone o the toes and
creates the arch of the foot
-Arch pain/problems, obesity, common in runners, more common in men age 40-70 yo
-Pain and stiffness in the bottom of the heel
Heel pain, dull or sharp, radiates from heel to toes
Bottom of foot may ache or burn
Pain is worse in the AM (first few steps) or after
standing/sitting for a while
-PE, X-rays, NSAIDs, corticosteroids, orthotics, night splints, PT, referral
What is Osgood-Schlatter Disease?
Causes?
S/S?
Treatment?
-Rupture of the growth plate at the tibial tuberosity as a
result of stress on the patellar tendon
-Painful limp with pain below the patella
-Can occur in one or both legs
-Pain exacerbated with running, jumping, climbing stairs
-Swelling ranges from mild to severe
-PE, X-rays, RICE, NSAIDs, refer
What is costochondritis?
Causes?
S/S?
Treatment?
-Inflammation of the cartilage that connects the rib to the
sternum
-Cause may be unknown, strain, URI, fibromyalgia,
infection
-Pain and tenderness where ribs attach to the sternum
Pain with deep breath or coughing
-PE, X-rays
-Usually resolves on its own, heat/ice, NSAIDs
What is polymyalgia rheumatica?
Causes?
S/S?
Treatment?
-Inflammatory disorder involving pain and stiffness in the
shoulder and usually the hips
-Etiology unknown, almost always >50 yo, may be
associated with temporal arteritis
-Stiffness in neck, shoulders, and hips
Loss of ROM in affected areas
Fatigue, anemia, and mild fever
-ESR, X-ray
-Corticosteroids, symptomatic managementWhat is sarcopenia?
- Decreased muscle mass and strength
- Gerontological concern
- Risk of disability, falls, unstable gait
