Muskoloskeletal System Flashcards
3 Components of the Muskoloskeletal System
Bones, Joints & Muscles
Provide a frame (shape) to keep the body supported. Help to produce movement with the aid of the muscles.
Bones
It provides a cushion between bones and tendons and/or muscles around a joint (i.e, shoulder or patella).
Bursa
A layer of resilient layer in the synovial joints that covers the surface of opposing bones.
- Cushion of Bones
Cartilage
Is the place of union of two or more bones.These are functional units because they permit ADLs.
Joints
Freely movable joints because they have bones that are separated from each other and enclosed in a joint cavity. The cavity is filled with a lubricant called synovial fluid, the principal role of synovial fluid is to reduce friction between the articular cartilage of synovial joints during movement.
Synovial Joints
Muscles that are attached to bone by a tendon.
Skeletal
Is a tough band of fibrous connective tissue that usually connects muscle to bone.
Tendon
Fibrous bands running directly from one bone to another bone that strengthen the joint and help prevent movement in undesirable directions.
Ligaments
The movements possible with synovial joints are: (5)
- Abduction
- Adduction
- Extension
- Flexion
- Rotation
Bending a limb at a joint
1.Flexion:
Straightening a limb at a joint
2.Extension:
Moving a limb away from the midline of the body
3.Abduction:
Moving a limb toward the midline of the body
4.Adduction:
Turning the forearm so that the palm is down
5.Pronation:
Turning the forearm so that the palm is up
6.Supination:
Moving the arm in a circle around the shoulder
7.Circumduction:
Moving the sole of the foot inward at the ankle
8.Inversion:
Moving the sole of the foot outward at the ankle
9.Eversion:
10.Rotation: Moving the head around a central axis
10.Rotation:
Moving a body part forward and parallel to the ground
11.Protraction:
Moving a body part backward and parallel to the ground
12.Retraction:
Raising a body part
13.Elevation:
Lowering a body part
14.Depression:
Widespread musculoskeletal pain lasting 3 months or longer and associated with fatigue is suggestive of _______
fibromyalgia
____ is usually felt as cramping or aching of muscles.
Myalgia
_____ cause sharp pain that increases with movement (other bone pain usually feels “dull” and “deep” and is unrelated to movement).
Fractures
A fractured bone may also be _____. Report findings immediately. Never attempt to realign broken bones.
Misaligned
Monitor _____ and peripheral vascular circulation distal to the injury until the patient’s care is transferred.
vital signs
Preparation for the Physical Exam (2)
Screening musculoskeletal examination
Complete musculoskeletal examination
Needed equipment for physical exam
Tape measure
Goniometer, to measure joint angles
Skin marking pen
- Inspect (2)
Size and contour of joint
Skin and tissues over joint
Abnormal Findings
_____ may be due to excess joint fluid (effusion), thickening of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement.
Swelling
_____ include dislocation (one or more bones in a joint being out of position), subluxation (partial dislocation of a joint), contracture (shortening of a muscle leading to limited ROM of joint), or ankylosis (stiffness or fixation of a joint).
Deformities
Partial dislocation of a joint
subluxation
Shortening of a muscle leading to limited ROM of joint
contracture
stiffness or fixation of a joint
ankylosis
Ask for active ROM while stabilizing the body area proximal to that being moved. If you see a limitation, gently attempt passive motion. Anchor the joint with one hand while your other hand slowly moves it to its limit. The normal ranges of active and passive motions should be the same.
If any limitation or any increase in ROM occurs, use a goniometer to measure the angles precisely
- Range of Motion
Abnormal Findings
_____ is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened, as with rheumatoid arthritis
Crepitation
- Test the strength of the prime mover muscle groups for each joint. Repeat the motions you elicited for active ROM. Now ask the person to flex and hold as you apply opposing force. Muscle strength should be equal bilaterally and should fully resist your opposing force. (Note: Muscle status and joint status are interdependent and should be interpreted together.
- A wide variability of strength exists among people. You may wish to use a grading system from no voluntary movement to full strength, as shown.
- Muscle Testing
Full ROM against gravity, full resistance, 100, Normal
Grade: 5
Full ROM against gravity, some resistance, 75, Good
Grade: 4
Full ROM with gravity, 50, Fair
Grade: 3
Full ROM with gravity eliminated (passive motion)
, 25, Poor
Grade: 2
Slight contraction, 10, Trace
Grade: 1
No contraction, 0, Zero
Grade: 0
- Inspect: Joint area
- Palpate: As person opens mouth
Motion and expected range
Open mouth maximally
Protrude lower jaw and move side to side
Stick out lower jaw - Palpate: Muscles of mastication
Temporomandibular Area
- Inspect: Alignment of head and neck
- Palpate: Spinous processes and muscles
Motion and expected range
Chin to chest
Lift chin
Each ear to shoulder
Turn chin to each shoulder
Cervical Spine
- Inspect: Joint
- Palpate: Shoulders and axilla
Motion and expected range
Arms forward and up
Arms behind back and hands up
Arms to sides and up over head
Touch hands behind head
Shoulders
- Inspect: Joint in flexed and extended positions
- Palpate: Joint and bony prominences
Motion and expected range
Bend and straighten elbow
Pronate and supinate hand
Muscle Strength
Elbow
- Inspect: Joints on dorsal and palmar sides
- Palpate: Each joint
Motion and expected range
Bend hand up, down
Bend fingers up, down
Turn hands out, in
Spread fingers, make fist
Touch thumb to each finger
Phalen’s Test
Tinel’s Sign
Wrist and Hand
Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.
Phalen’s Test
Abnormal Findings
Phalen’s test reproduces numbness and burning in a person with ________ syndrome.
carpal tunnel syndrome
Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand.
Tinel’s Sign
Abnormal Findings
In carpal tunnel syndrome, percussion of the median nerve produces ___ & ___along its distribution, which is a positive Tinel’s sign.
burning and tingling
- Inspect: Person stands
- Palpate: Person supine
Motion and expected range
Raise leg
Knee to chest
Flex knee and hip; swing foot out, in
Swing leg laterally, medially
Stand and swing leg back
Hip
- Inspect: Joint and muscle
- Palpate
- Bulge Sign
- Ballottement of Patella
Motion and expected range
Bend knee
Extend knee
Check knee during ambulation
McMurray’s Test
Muscle Strength
Knee
For swelling in the suprapatellar pouch, the bulge sign confirms the presence of small amounts of fluid as you try to move the fluid from one side of the joint to the other. Firmly stroke up on the medial aspect of the knee two or three times to displace any fluid.
- Tap the lateral aspect. Watch the medial side in the hollow for a distinct bulge from a fluid wave. Normally none is present.
Bulge Sign
Abnormal Findings
The bulge sign occurs with very small amounts of _____, 4 to 8 mL, from fluid flowing across the joint.
effusion
This test is reliable when larger amounts of fluid are present. Use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint. With your right hand, push the patella sharply against the femur. If no fluid is present, the patella is already snug against the femur.
Ballottement of the Patella
Abnormal Findings
If fluid has collected, your tap on the patella moves it through the fluid, and you will hear a tap as the patella bumps up on the _____.
femoral condyles
- Continue palpation, and explore the _______
- Note smooth joint margins and absence of pain.
- Palpate the infrapatellar fat pad and the patella.
tibiofemoral joint.
- Check for ____ by holding your hand on the patella as the knee is flexed and extended.
Note: Some of these in an otherwise-asymptomatic knee is not uncommon.
crepitus
Abnormal Findings
- Irregular bony margins occur with _____.
- Pain at joint line.
osteoarthritis
_______ is significant and occurs with degenerative diseases of the knee.
Pronounced crepitus
Perform this test when the person has reported a history of trauma followed by locking, giving way, or local pain in the knee. Position the person supine as you stand on the affected side. Hold the heel and flex the knee and hip. Place your other hand on the knee with fingers on the medial side. Rotate the leg in and out to loosen the joint. Externally rotate the leg and push a valgus (inward) stress on the knee. Then slowly extend the knee. Normally the leg extends smoothly with no pain.
Meniscal Tear = McMurray’s Test
Abnormal Findings
If you hear or feel a “click,” McMurray’s test is positive for a torn _______.
meniscus
- Inspect: Person sitting, standing, and walking
- Palpate: Joints
Motion and expected range
Point toes down, up
Turn soles out, in
Flex and straighten toes
Muscle Strength
Ankle and Foot
- Inspect: While person stands
- Palpate: Spinous processes
Motion and expected range
Bend sideways, backward
Twist shoulders to each side
Straight Leg Raising or LaSegue’s Test
Measure Leg Length Discrepancy
Spine
These manoeuvres reproduce back and leg pain and help confirm the presence of a herniated nucleus pulposus. Straight leg raising while keeping the knee extended normally produces no pain. Raise the affected leg just short of the point where it produces pain. Then dorsiflex the foot. Raise the unaffected leg while leaving the other leg flat. Inquire about the involved side.
Straight Leg Raising or LaSegue’s Test
Abnormal Findings
LaSegue’s test is positive if it reproduces ______.
sciatic pain
If lifting the affected leg reproduces sciatic pain, it confirms the presence of a _________.
herniated nucleus pulposus.
Perform this measurement if you need to determine whether one leg is shorter than the other. For true leg length, measure between fixed points, from the anterior iliac spine to the medial malleolus, crossing the medial side of the knee. Normally these measurements are equal or within 1 cm, indicating no true bone discrepancy.
Abnormal Findings
Unequal leg lengths > 1 cm.
Measure Leg Length Discrepancy
Risk for Osteoporosis (6)
Gender Age Post-menopausal Ethnocultural background Lifestyle choices Family history
Osteoporosis Canada Recommendations:
______ over age of 50 years
Risk assessment
Bone Mineral Density testing (BMD) (4)
All women >65 years old
Fragility fractures after age 40
Family history
Systemic glucocorticoid therapy>3months
Treatment of Osteoporosis (2)
HRT(↑ risk for breast cancer & myocardial infarction)
Alternative therapies-exercise & diet
Recommendations for Bone Health (5)
Diet Exercise Lifestyle Medical options Supplements
This is a chronic, systemic inflammatory disease of joints and surrounding connective tissue. Inflammation of the synovial membrane leads to thickening; then to fibrosis, which limits motion; and finally to bony ankylosis. The disorder is symmetrical and bilateral and is characterized by heat, redness, swelling, and painful motion of the affected joints. Rheumatoid arthritis is associated with fatigue, weakness, anorexia, weight loss, low-grade fever, and lymphadenopathy.
Rheumatoid Arthritis
Chronic progressive inflammation of spine, sacroiliac, and larger joints of the extremities, leading to bony ankylosis and deformity. A form of rheumatoid arthritis, this affects primarily men by a 10 : 1 ratio, starting in late adolescence or early adulthood. Spasm of paraspinal muscles pulls the spine into forward flexion, obliterating cervical and lumbar curves. The thoracic curve is exaggerated into a single kyphotic rounding. Manifestations also include flexion deformities of the hips and knees
Ankylosing Spondylitis
Noninflammatory, localized, progressive disorder involving deterioration of articular cartilages and subchondral bone and formation of new bone (osteophytes) at joint surfaces. It is a degenerative disease.
- Affected joints have stiffness; swelling with hard, bony protuberances; pain with motion; and limitation of motion.
Osteoarthritis
Decrease in skeletal bone mass occurring when rate of bone resorption is greater than that of bone formation. The weakened bone state increases risk for stress fractures, especially at wrist, hip, and vertebrae. Occurs primarily in postmenopausal women of European descent. Osteoporosis risk also is associated with smaller height and weight, younger age at menopause, lack of physical activity, and lack of estrogen replacement therapy.
Osteoporosis
Abnormalities of the Shoulder (6)
Atrophy Dislocated Shoulder Joint Effusion Tear of the Rotator Cuff Frozen Shoulder—Adhesive Capsulitis Subacromial Bursitis
Loss of muscle mass is exhibited as a lack of fullness surrounding the deltoid muscle. It also occurs from disuse, muscle tissue damage, or motor nerve damage.
Atrophy
Anterior dislocation (95%) is exhibited when hunching the shoulder forward and the tip of the clavicle dislocates. It occurs with trauma involving abduction, extension, and rotation (e.g., falling on an outstretched arm or diving into a pool).
Dislocated Shoulder:
Characteristic “hunched” position and limited abduction of arm. Occurs from traumatic adduction while arm is held in abduction, or from fall on shoulder, throwing, or heavy lifting. Positive drop arm test: if the arm is passively abducted at the shoulder, the person is unable to sustain the position and the arm falls to the side.
Tear of Rotator Cuff:
Abnormalities of the Elbow (4)
Olecranon Bursitis
Gouty Arthritis
Subcutaneous Nodules
Epicondylitis—Tennis Elbow
- Joint effusion or synovial thickening, seen first as bulge or fullness in grooves on either side of olecranon process.
- Redness and heat can extend beyond area of synovial membrane. Soft, boggy, or fluctuant fullness to palpation. Limited extension of elbow.
Olecranon Bursitis
- Chronic, disabling pain at lateral epicondyle of humerus, radiates down extensor surface of forearm. Pain can be located by touching with one finger. Resisting extension of the hand will increase the pain. Occurs with activities combining excessive pronation and supination of forearm with an extended wrist (e.g., racket sports or using a screwdriver).
Epicondylitis—Tennis Elbow
_____epicondylitis is rarer and is caused by activity of forced palmar flexion of wrist against resistance.
Medial
Abnormalities of the Wrist and Hand (11)
- Ganglion Cyst
- Colles’ Fracture
- Carpal Tunnel Syndrome
- Ankylosis
- Dupuytren’s Contracture
- Swan-Neck and Boutonniere Deformities
- Ulnar Deviation or Drift
- Degenerative Joint Disease or Osteoarthritis
- Acute Rheumatoid Arthritis
- Syndactyly (Webbed Finger)
- Polydactyly (Extra Digit)
Caused by chronic repetitive motion; occurs between 30 and 60 years of age and is five times more common in women than in men. Symptoms of this syndrome include pain, burning and numbness, positive findings on Phalen’s test, positive indication of Tinel’s sign, and often atrophy of thenar muscles.
carpal tunnel syndrome
Wrist in extreme flexion, due to severe rheumatoid arthritis. This is a functionally useless hand because when the wrist is palmar flexed, a good deal of power is lost from the fingers, and the thumb cannot oppose the fingers.
Ankylosis
- Chronic hyperplasia of the palmar fascia causes flexion contractures of the digits, first in the fourth digit, then the fifth digit, and then the third digit.
- The hyperplasia bands extend from the midpalm to the digits and the puckering of palmar skin.
The contracture is painless but impairs hand function. - Condition occurs commonly in men past 40 years of age and is usually bilateral.
- Occurs with diabetes, epilepsy, and alcoholic liver disease and as an inherited trait.
Dupuytren’s Contracture
Webbed fingers are a congenital deformity, usually necessitating surgical separation. The metacarpals and phalanges of the webbed fingers are different lengths, and the joints do not line up. Not correcting fused fingers would therefore limit their flexion and extension.
Syndactly
Extra digits are a congenital deformity, usually occurring at the fifth finger or the thumb. Surgical removal is considered for cosmetic reasons. The sixth finger shown here was not removed because it had full range of motion and sensation and a normal appearance.
Polydactly
Abnormalities of the Knee (6)
- Mild Synovitis
- Prepatellar Bursitis
- Swelling of Menisci
- Osgood-Schlatter Disease
- Postpolio Muscle Atrophy
- Chondromalacia Patellae
Abnormalities of the Ankle and Foot
- Achilles Tenosynovitis
- Chronic/Acute Gout
- Hallux Vagus with Bunion and Hammer Toes
- Callus
- Plantar Wart
- Ingrown Toenail
Localized swelling on anterior knee between patella and skin. A tender fluctuant mass indicates swelling; in some cases, infection spreads to surrounding soft tissue. The condition is limited to the bursa, and the knee joint itself is not involved. Overlying skin may be red, shiny, and either atrophic or coarse and thickened.
Prepatellar Bursitis
Leg and foot muscle atrophy as a result of childhood polio. Poliomyelitis epidemics peaked in North America in the 1940s and 1950s. The development of the oral polio vaccine (1962) has almost eradicated the disease. However, thousands of polio survivors have this muscle atrophy. Also, if a client had a cast on to support a fractured extremity, this is what the outcome could look like but it would only be temporary.
Postpolio Muscle Atrophy
Localized soft swelling from cyst in lateral meniscus shows at the midpoint of the anterolateral joint line (right leg in illustration). Semiflexion of the knee makes swelling more prominent.
Medial Meniscus Tear
Acute episode of gout usually involves first the metatarsophalangeal joint. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. It occurs primarily in men over 40 years of age.
Acute Gout
Hard, painless nodule (tophi) over metatarsophalangeal joint of first toe. ____ are collections of sodium urate crystals due to chronic gout in and around the joint that cause extreme swelling and joint deformity. They sometimes burst with a chalky discharge.
Tophi with Chronic Gout:
A common deformity from rheumatoid arthritis. It is a lateral or outward deviation of the great toe with medial prominence of the head of the first metatarsal.
Hallux Valgus
The ______ is the inflamed bursa that forms at the pressure point. The great toe loses power to push off while walking; this stresses the second and third metatarsal heads, and they develop calluses and pain. Chronic sequelae include corns, calluses, hammertoes, and joint subluxation (refer to next slide for images).
- Structural Bunion = First Metatarsal (base of the great toe)
- Tailor’s Bunion = Fifth Metatarsal (base of the little toe)
bunion
Abnormalities of the Spine(3)
Kyphosis
Scoliosis (Structural/Functional)
Herniated Nucleus Pulposus
Postural changes include a decrease in height, more apparent in the eighth and ninth decades. “Lengthening of the arm–trunk axis” describes this shortening of the trunk with comparatively long extremities. This is common, with a backward head tilt to compensate. This creates the outline of a figure “3” when you view this older adult from the left side. Slight flexion of hips and knees is also common.
Kyphosis:
Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of involved vertebral bodies
Scoliosis:
is flexible; it is apparent on standing and disappears on forward bending. It may be compensatory for other abnormalities such as leg length discrepancy.
Functional scoliosis
is fixed; the curvature shows both on standing and on bending forward. Note rib hump with forward flexion. When the person is standing, note unequal shoulder elevation, unequal scapulae, obvious curvature, and unequal hip level. At greatest risk are females 10 years of age through adolescence, during the peak of the growth spurt.
Structural scoliosis
Note: The Canadian Task Force on Preventative HealthCare concluded that there was insufficient evidence to recommend the routine screening of __________ adolescents.
asymptomatic adolescents
The nucleus pulposus (at the centre of the intervertebral disc) ruptures into the spinal canal and puts pressure on the local spinal nerve root. Usually occurs from stress, such as lifting, twisting, continuous flexion with lifting, or fall on buttocks. Occurs mostly in men 20 to 45 years of age.
- Note sciatic pain, numbness, and paresthesia of involved dermatome; listing away from affected side; decreased mobility; low back tenderness; and decreased motor and sensory function in leg. Straight leg raising tests reproduce sciatic pain.
Herniated Nucleus Pulposus
______ hernations occur mainly in interspaces L4 to L5 and L5 to S1.
Lumbar herniations
Common Congenital or Pediatric Abnormalities(4)
Congenital Dislocated Hip – Thomas Test
Talipes Equinovarus (Clubfoot)
Spina Bifida
Coxa Plana (Legg-Calvé-Perthes Syndrome)
- Head of the femur is displaced out of the cup-shaped acetabulum. Occurs due to subluxation…stretched ligaments allow partial displacement of the femoral head, and acetabular dysplasia may develop because of excessive laxity of the hip joint capsule.
- Occurrence is 1 : 500 to 1 : 1000 births; more common in girls (7 : 1 ratio). Signs include limited abduction of flexed thigh, positive findings of Ortolani manoeuvre and positive Barlow’s sign, asymmetrical skin creases or gluteal folds, limb length discrepancy, and positive indication of the Trendelenburg sign in older children.
Congenital Dislocated Hip – Thomas Test
Congenital, rigid, and fixed malposition of foot, including:
(a) inversion
(b) forefoot adduction
(c) foot pointing downward (equinus)
- A common birth defect, with an incidence of 1 : 1000 to 3 : 1000 live births. Boys are affected twice as frequently as girls.
Talipes Equinovarus (Clubfoot)
Incomplete closure of posterior part of vertebrae results in a neural tube defect. Seriousness varies from skin defect along the spine to protrusion of the sac containing meninges, spinal fluid, or malformed spinal cord.
The most serious type is myelomeningocele (shown here), in which the meninges and neural tissue protrude. In these cases, the child is usually paralyzed below the level of the lesion.
Spina Bifida:
- Chronic disorder of unknown cause.
- Widespread musculoskeletal pain lasting 3 months or longer, associated with fatigue, insomnia, and psychosocial distress.
- Most patients (90%) are women.
- There are two major diagnostic criteria:
(a) pain on both sides of the body, above and below the waist, and axial skeletal pain (cervical, thoracic, lumbar spine, or anterior chest)
(b) point tenderness on digital palpation in 11 of 18 specific sites - The burden of illness is high: 25% to 33% of affected patients receive disability compensation.
Fibromyalgia Syndrome
