OHCEPS - The Locomotor System Flashcards
Fibrous joints?
- Held together by fibrous (collagenous) connective tissue and are “fixed” or “immoveable”.
- They do not have a joint cavity. Examples include the connections of the skull bones.
Cartilagenous joints?
- Held together by cartilage, are slightly moveable and again have no cavity.
- An example is the vertebral joints.
Synovial joints?
- Covered by cartilage with a synovial membrane enclosing a joint cavity.
- These joints are freely moveable and are the most common type of joint functionally, being typical of nearly all the joints of the limbs.
Role of the inner synovial membrane of a synovial joint?
Secretes synovial fluid –> number of functions:
- Lubrication
- Supply of nutrients to the cartilage
Synovial fluid contains?
Phagocytic cells that remove microbes and debris within the joint cavity.
Types of synovial joints?
- Hinge
- Ball and socket
- Pivot
- Gliding
- Saddle
Hinge synovial joint?
Movement occurs primarily in a single plane (eg elbow, knee, and interphalangeal joints.
Ball and socket synovial joint?
Allows movement around 3 axes (flexion/extension, abduction/adduction, and rotation).
Examples are the shoulder and hip.
Pivot synovial joint?
A ring of bone and ligament surrounds the surface of the other bone allowing rotation only.
Examples –> Atlanto-axial joint at C1 and C2 vertebrae and the connection between the radius and ulna.
Gliding synovial joint?
Flat bone surfaces allow side-to-side and backwards and forwards movements.
Examples –> Between carpals, tarsals, sternum and clavicle and the scapula and clavicle.
Saddle synovial joints?
Similar to a hinge joint but with a degree of movement in a second plane (eg base of thumb).
Special movements - Inversion?
Tilting the soles of the feet inwards to face each other.
Special movement - Eversion?
Tilting the soles of the feet outwards away from each other.
Special movements - Protraction?
Moving the mandible forward.
Special movements - Retraction?
Moving the mandible backwards.
Character of pain in the locomotor system?
- Bone pain is typically experienced as boring, penetrating and often worse at night.
- Pain associated with a fracture is usually sharp and stabbing in nature and often exacerbated by movement.
- Shooting pain is suggestive of nerve entrapment (eg disc protrusion).
Bone pain - etiology?
- Tumor
- Chronic infection
- Avascular necrosis
- Osteoid osteoma
Acute onset of bone pain leads us to?
Manifestation of infection such as septic arthritis or crystal arthropathies (eg gout).
Chrondromalacia patellae?
This arises due to softening of the patellar articular cartilage and is felt as a patellar ache after prolonged sitting.
Usually seen in young people.
Osteochrondritis dissecans?
Usually associated with trauma resulting in an osteochondral fracture which forms a loose body in the joint with underlying necrosis.
Osgood-Schlatter’s disease?
Arises as a result of a traction injury of the tibial epiphysis which is classically associated with a lump over the tibia.
Etiology of arthralgia in adults - Knee?
- Osteoarthritis
- Referred from the hip
- Chondomalacia patellae
- Trauma
- Osteochrondritis dissecans
- Bursitis
- Tendonitis
- Osgood-Schlatter’s disease
- RA
- Infection
- Malignancy
Etiology of arthralgia in adults - Hip?
- Osteoarthritis
- Referred pain - eg from a lumbar spine abnormality
- Trauma
- RA
- Infection
- Hernia
- Tendonitis
- Bursitis
Etiology of shoulder pain in adults?
- Rotator cuff disorders (eg tendonitis, rupture, adhesive capsulitis/frozen shoulder).
- Referred pain - eg cervical, mediastinal, cardiac.
- Arthritis - glenohumeral, acromioclavicular.
Etiology of elbow arthralgia in adults?
- Lateral epicondylitis (tennis elbow)
- Medial epicondylitis (golfer’s elbow)
- Olecranon bursitis
- Referred pain from neck/shoulder (eg cervical spondylolysis)
- Osteoarthritis
- RA
Etiology of mechanical/degenerative back pain in adults?
- Arthritis
- Trauma
- Disc prolapse
- Osteoporosis
- Infection
- Ankylosing spondylitis
- Spondylolisthesis
- Lumbar spinal/lateral recess stenosis
- Spinal tumors - Especially metastases from lung, breast, prostate, thyroid, kidney.
- Metabolic bone disease.
Stiffness is?
A subjective symptom which must be explored in detail to establish exactly what the patient means.
–> It is the inability to move the joints after a period of rest. It may be due to mechanical dysfunction, local inflammation of a joint or a combination of both.
If stiffness predominates over pain, consider?
Spasticity or tetany.
Look for hypertonia and other motor neuron signs.
Stiffness - what to ask the patient?
- When is the stiffness worst? (early morning etc…)
- Which joints are involved? Is the stiffness generalized?
- How long does it takes them to “get going” in the morning?
- How is the stiffness related to rest and activity?
Locking is?
This is the sudden inability to complete a certain movement and suggests a mechanical block or obstruction usually caused by a loose body or torn cartilage within the joint (often secondary to trauma).
Swelling of the joint - Etiology?
A variety of factors - Including:
- Inflammation of the synovial lining.
- Incr. in the volume of synovial fluid
- Hypertrophy of bone
- Swelling of structures surrounding the joint.
Swelling is particularly significant when?
In the presence of joint pain and stiffness.
Swelling - what is essential to be established?
- Which joints are affected (small or large)?
- Is the distribution symmetrical?
- What was the nature of onset of swelling?
- Are the joints ALWAYS swollen or does it come and go (and when)?
- Is there any associated pain?
- Do the joints feel hot to touch?
- Is there erythema? (common in infective, traumatic and crystal arthropathies)
- Have the joints in question sustained any injuries?
Deformity - What is essential to be established?
- The time frame over which the deformity has developed.
- Any associated symptoms such as pain and swelling.
- Any resultant loss of function? (What is the patient now unable to do with the joint in question?)
Acute deformity usually associated with?
Fracture or dislocation.
Chronic deformity usually associated with?
Bone malalignment and may be:
- Partial/subluxed
- Complete/dislocated
Weakness - what to ask?
Always enquire about the presence of localized or generalized weakness which suggests a peripheral nerve lesion or a systemic cause, respectively.
–> Consider that the weakness may be neurogenic or myopathic in origin.
Sensory distribution - what to ask?
Ask about the exact distribution of any numbness or paresthesia as well as documenting any exacerbating and relieving factors.
Some major extra-articular features of several locomotor disorders?
- Systemic symptoms - fever, weight loss, fatigue, lethargy.
- Skin rash
- Raynaud’s
- GI (eg diarrhea and resultant reactive arthritis or enteropathic arthritis secondary to inflammatory bowel disease).
- Urethritis (Reiter syndrome)
- Eye symptoms
- Cardiorespiratory –> Breathlessness (pulm. fibrosis?), pericardial and pleuritic chest pain, AV regurgitation, and spondyloarthropathies.
- Neurological –> Nerve entrapment, migraine, depression, stroke.
Joint deformity - Valgus?
The bone or part of limb distal to the joint is deviated LATERALLY.
Joint deformity - Varus?
The bone or part of limb distal to the joint is deviated MEDIALLY.
PMH - What to ask about?
Ask about ALL previous medical and surgical disorders and enquire specifically about any previous history of trauma or musculoskeletal disease.
The rest of the history - FHx?
It is important to note any FHx of illness, especially those locomotor conditions with a heritable element:
- Osteoarthritis
- RA
- Osteoporosis
- -> The seronegative spondyloarthropathies (eg ankylosing spondylosis) are more prevalent in patients with the HLA-B27 haplotype.
The rest of the history - DHx?
- Full DHx including all prescribed and OTC medications.
- Attempt to assess the efficacy of each treatment including those past and present.
- Ask about any side effects of any drugs taken for locomotor disease.
- Ask also about medication with known adverse musculoskeletal effects.
- Drugs that may increase the risk of developing TB, HIV, hep –> All of which can cause musculoskeletal complaints.
Long-term side effects of steroid therapy?
- Osteoporosis
- Myopathy
- Infections
- Avascular necrosis
Statins - Adverse effects?
- Myalgia
- Myositis
- Myopathy
ACEIs - Side effects?
Myalgia
Anticonvulsants - Side effects?
Osteomalacia
Quinolone - Side effects?
Tendinopathy
Diuretics - Side effects?
- Aspirin
- Alcohol
- Gout
SLE drugs?
- Procainamide
- Hydralazine
- Isoniazid
Social history - Certain occupations?
- Repetitive strain injury
- Hand-vibration syndrome
- Fatigue fractures
- -> Dancers + Athletes.
Social history - Ethnicity?
Relevant as there is an overrepresentation of lupus and TB in the Asian population, both of which are linked to a variety of locomotor complaints.
The rest of the history - Sexual history?
Where appropriate, take a sexual history. This is important because reactive arthritis, or Reiter’s syndrome may be cause by STDs (Chlamydia, gonorrhoeae).
The locomotor system - Outline examination?
- Elbow
- Shoulder
- Spine
- Hip
- Knee
- Ankle
- Foot
Examination framework?
Examination of each joint should follow the standard format:
- Look
- Feel
- Move (passive, active)
- Measure
- Special tests
- Function
The GALS screen?
G = Gait A = Arms L = Legs S = Spine
GALS screen - Role?
Was devised as a quick screen for abnormality in the absence of symptoms.
GALS screen - Gait?
- Watch the patient walk.
- There should be symmetry and smoothness of movements and arm swing with no pelvic tilt and normal stride length.
- Patient should be able to start, stop and turn quickly.
GALS - Arms (sitting on couch) - Inspection?
- Look for muscle wasting and joint deformity at the shoulders, elbows, wrists and fingers.
- Squeeze across the 2nd-5th metacarpals - there should be no tenderness.
Arms - Shoulder abduction?
“Raise your arms out sideways, above your head”. Normal range 170-180degrees.
Arms - Shoulder external rotation?
“Touch your back between your shoulder blades”.
Arms - Shoulder internal rotation?
“Touch the small of your back”. Should touch above T10.
Arms - Elbow extension?
“Straighten your arms out”. Normal is 0 degree.
Arms - Wrist and finger extension?
The prayer sign.
Arms - Wrist flexion and finger extension?
The reverse prayer sign.
Arms - Power grip?
“Make a fist” - Should hide fingernails.
Arms - Precision grip?
“Put your fingertips on your thumb”
GALS - Legs (lying on couch) - Inspection?
- Look for swelling or deformity at the knee, ankle and foot as well as quadriceps muscle wasting.
- Squeeze across the metatarsals - there should be no tenderness.
Legs - Hip and knee flexion?
- Test passively and actively.
2. Normal hip flexion is 120, normal knee flexion is 135.
Legs - Hip internal rotation?
Normal is 90 at 45 flexion.
Legs - Knee?
Bulge test and patellar tap.
Legs - Ankle?
Test dorsiflexion (normal 15) and planarflexion (normal 55).
GALS screen - Spine (standing) - Inspection?
From behind –> Look for scoliosis, muscle bulk at the paraspinals, shoulders and gluteals, level iliac crests.
From the side –> Look for normal thoracic kyphosis and lumbar and cervical lordosis.
Spine - Tenderness?
Feel over the mid-supraspinatus –> there should be NO tenderness.
Spine - Lumbar flexion?
“Touch your toes”.
Normal is finger-floor distance Schober’s test.
Spine - Cervical lateral flexion?
“Put your ear on your shoulder”.
Elbow - Look?
- Any mobility aids or other clues.
- Ask the patient to stand, make sure both upper limbs are exposed and look at the patient from top to toe.
- Inspect the elbow from side to side and note:
a. Malalignment of the bones
b. Scars
c. Skin changes (eg psoriatic plaques)
d. Skin or subcutaneous nodules
e. Deformities
f. Muscle wasting
g. Swelling
Elbow - Look - Deformities?
Varus (cubitus varus): can be caused by a supracondylar fracture.
Valgus (cubitus valgus): can be caused by non-union of a lateral condylar fracture.
Elbow - Feel?
- Always ask about PAIN before getting started.
- Palpate the joint posteriorly and feel for:
a. Temperature
b. Subcutaneous nodules
c. Swelling
d. If fluid is present, attempt to displace it on either side of the olecranon.
e. Carefully palpate the joint margin for tenderness and note if it is localized to the medial epicondyle (golfer’s elbow) or the lateral epicondyle (tennis elbow).
Elbow - Feel - Swelling?
- Soft swelling may be due to olecranon bursitis.
- Hard swellings suggests a bony deformity
- Boggy swelling suggests synovial thickening (secondary to RA).
Elbow - Move?
- Check that there is good shoulder function before attempting to assess elbow movements.
- Remember to test passive movements (you do the moving) and active movements (patient does the moving) at each stage.
- Ask the patient to place their arms on the back of their head.
- Next assess elbow flexion and extension with the upper arm fixed –> Remember to compare with the opposite side.
- With the elbows tucked into the sides and flexed to a right angle, test the radio-ulnar joints for pronation (palms towards floor) and supination (palms towards the sky).
Elbow - Measure?
Measure elbow flexion and extension in degrees from the neutral position (ie consider a straight elbow joint to be 0).
Elbow - Function?
Observe the patient pour a glass of water and then put on a jacket.
Shoulder - Look?
- Any aids or adaptations.
- Ask patient to remove covering clothing and expose both upper limbs, neck, chest.
- Scan the patient from top to toe. Inspect from the front, side, behind.
- Look especially for:
a. Contours
b. Joint swelling
c. Scars
d. Bruising
e. Position of both shoulders looking for dislocation
- -> Remember to inspect the axillary regions.
Shoulder - Look - Contours?
Make note of any obvious asymmetry or deformity such as:
- Winging of the scapula.
- Prominence of acromioclavicular joint.
- Wasting of the deltoid or short rotators, which overlie the upper and lower segments of the scapula.
Shoulder - Look - Joint swelling?
This is more obvious from the front and may be a clue to:
- Acute bleeds
- Rheumatoid effusions
- Pseudogout
- Sepsis
Shoulder - Look - Evidence of dislocation?
- Posterior dislocation can be seen when the arm is held in an internally rotated position.
- Anterior dislocation can be seen easily when the arm is displaced in a forward and downward position.
Shoulder feel?
- Always ask about PAIN before getting started.
- Make note of any temperature changes, tenderness, or crepitus. Standing in front of the patient:
a. Palpate the soft tissues and bony joints.
b. Check the interscapular area for pain.
c. Palpate the supraclavicular area for LYMPHADENOPATHY.
Shoulder - Feel - Palpitation of the soft tissues and bony points in WHAT ORDER?
- Sternoclavicular joint
- Clavicle
- Acromioclavicular joint
- Acromial process
- Head of humerus
- Coracoid process
- Spine of scapula
- Greater tuberosity of humerus