Orthopedic/Musculoskeletal Disorders Flashcards
Parts of the musculoskeletal system
Bones
Muscles
Joints
Cartilage
Ligaments
Tendons
Nerves
Skin/scars
Joints
space between 2 articular surfaces
Types:
- Synarthrosis
- Amphiarthrosis
- Diarthrosis
* ball and socket (greatest degree of freedom)
* condyloid
* gliding
* hinge
* pivot
* saddle
Cartilage
Lines articular bones
Protects against impact and friction
Gets blood through osmosis, so it doesn’t easily heal, if at all
No nerves, so it doesn’t hurt when you tear it
Thickening of cartilage in the knee - meniscus or disc
Types:
- Hyaline cartilage: most common; found in nose and ribs
- Fibrocartilage: found in intervertebral disks, joint capsules, and ligaments
Ligaments
Connect articulating bones
Prevent movement
Have very little vascular supply
Take a long time to heal
Ulnar collateral ligament of MP joint of thumb
- Gamekeeper’s thumb or skier’s thumb
- AKA medial collateral ligament
Grades of ligament sprains
Grade I: stretch the ligament causing mild swelling and pain with stress testing, but no laxity
Grade II: partial tear resulting in more moderate swelling and pain along with some laxity on stress testing; have definitive endpoint with stress testing
Grade III: complete tear with a lot of pain, swelling, and gross laxity on stress testing without any definitive endpoint
Grade IV: not really a sprain; avulsion fracture
Types of muscle movement
Isotonic
- eccentric: lengthening of muscle
- concentric: shortening of muscle
Isometric
- muscle contraction, not shortening or lengthening
- happens with co-contraction of flexors and extensors
Energy metabolism of muscles
METS (metabolic equivalent task score)
Primary engine that burns calories
What to muscles do?
Move the body
Energy metabolism
Generate body heat
Atrophy and hypertrophy
What is muscle atrophy?
muscle wasting, often with age
Muscle fibers
All or none
- motor unit: motor neuron and its end plate
- recruitment
Muscle spasm or cramp
Painful condition of muscle contraction (temporary)
Reason is varied and unknown
Muscle spasticity
Involuntary, intense, and sometimes painful contraction due to inappropriate CNS neural signs
Not strength
Ashworth’s scale
Muscle contracture
Muscle shortening from being stationary
Muscle fatigue
Decreased blood supply
Exhaustion of ACT
Accumulation of lactic acid (most common)
Myalgia
Muscle strain
RICE
Bleed and bruise
Chronic fatigue syndrome
Extreme fatigue lasting for at least 6 months and can’t be explained by any other medical cause
Symptoms:
- Post-exertional malaise
- Unrefreshing sleep
- Brain fog
- Muscle and joint pain
- Headache and light sensitivity
- Chills
- Stomach pain, bloating, nausea
- Sinus problems, swollen glands, tender lymph nodes, sore throat
No known cause or cure
Fibromyalgia
Often triggered by physical or emotional stress
If you have lupus or rheumatoid arthritis (RA), you are more likely to develop fibromyalgia.
Symptoms:
- Fatigue, cognitive and memory problems, headaches, diziness, trouble sleeping
- Vision problems
- Tender points
- Nausea
- Urinary problems, dysmenorrhea in women
- Restless leg syndrome
- Joint pain and stiffness
- Skin problems
- Muscle pain
- Jaw pain
Medication and stress reduction can help symtoms.
Bones
Provide structure
Reservoir of calcium and phosphate
Site of hematopoiesis
- RBC creation
Haversian canals (blood vessels in bones)
- avascular necrosis
- Kienbock’s disease: lunate (high risk for avascular necrosis)
Epiphyseal plates
- harden at 18 for women and 22 for men
- bone mass decreases at 40-60
Constant rate of uptake and production
- osteoblasts and osteocytes produce
- osteoclasts absorb
Wolfe’s law
What is Wolfe’s law?
Soft tissue (musculoskeletal tissue and bone) responds to the forces placed on it.
- Weight bearing can decrease the affect of the disease
- Osteoporosis can begin 6 weeks after spine injury
Rickets (Osteomalacia)
- bad bones
- due to vitamin D and E deficiency
- common in children outside the US
- bowing is caused by bodyweight
- can be corrected
Nerves
Get impinged or compressed by soft tissue or neuromuscular structures
- can get compressed against humerus when sleeping funny
Radial nerve
Innervates extensor wad
Responsible for wrist, thumb, and MP extension
Clinical presentation:
- Weakness of wrist dorsiflexion and finger extension, causing wrist drop and MP drop
What happens if there is damage to the axilla?
All radial-innervated muscles are involved
- anconeus and triceps
Decreased sensation
Arm drop
Limp and uncoordinated self-feeding
Very jerky
What happens if there is damage to the spiral groove?
All radial-innervated muscles distal to the triceps are weak
- extensor wad in forearm
What happens if there is damage to isolated posterior interosseous lesions (PIN)?
Sensation is spared and motor involvement occurs in radial muscles distal to the supinator
Lose a little bit of thumb and sensation
Innervation of the radial nerve
The radial n. innervates motor outside the hand in the extrinsic muscles of the forearm. Once it crosses over into the hand, it only functions in sensory.
Posterior interosseous nerve coarse
Ulnar nerve
Ulnar n. in ulnar groove - funny bone
- innervates adductor pollicis long head
- flexes intrinsic and ulnar half of lumbricals
- Guyon’s tunnel
- when power comes from
Ulnar nerve palsy
Occurs due to compression at the elbow (cubital tunnel) or at the wrist (Guyon’s tunnel)
Muscle weakness and atrophy predominate the clinical presentation
If it gets trapped at the cubital tunnel, there will be numbness and tingling
Can cause ulnar claw hand
- caused by an imbalance between strong extrinsic muscles and weakened intrinsic muscles
- MCP hyperextension
- PIP and DIP flexion
Ulnar innervated muscles
Forearm:
- flexor carpi ulnaris (C7, C8, T1)
- flexor digitorum profundus III and IV (C7, C8)
Thenar:
- hypothenar muscles (C8, T1)
- adductor pollicis (C8, T1)
- flexor pollicis brevis (C8, T1)
Fingers:
- palmer interosseous (C8, T1)
- dorsal interosseous (C8, T1)
- III and IV lumbricles (C8, T1)
Digiti minimi:
- abductor digiti minimi (Quinti) (C8, T1)
- opponens digiti minimi (C8, T1)
- flexor digiti minimi (C8, T1)
Median nerve
Injury at elbow or wrist
Commonly compressed at the wrist causing carpal tunnel syndrome
Deformity or ape-like hand
- flat thenar eminence and adducted thumb
Opposition and abduction aren’t possible leading to loss of pincer-like action of hand
- difficulty with fine motor tasks like buttoning
Cause:
- paralysis and wasting of the muscles of the thenar eminence
- adductor pollicis is unopposed since it is supplied by ulnar n.
- opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis
Big driver of thumb flexion and adduction, except for deep adductor pollicis
If anterior interosseous n. injury is present, the patient will be unable to bring together the distal phalanx or thumb and index finger to make the OK sign.
Carpal tunnel
Carpal tunnel syndrome (CTS) occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist.
Causes numbness and tingling
Tendons
Connect muscle to bone
Covered in a sheath which provides nutrients
Tendonitis
Micro tear from lifting off the bone
Types:
- Epicondylitis
- Lateral: tennis
- Medial: golfers
DeQuervain’s Tenosynovitis
Affects abductor pollicis longus and extensor pollicis brevis
Use the Finklestien’s test
Intersections Syndrome
Abductor pollicis longus and extensor pollicis brevis cross over the extensor carpi radialis longus and the extensor carpi radialis brevis
Trigger finger
Affects the pulleys of the finger
- Annular (A 1-5)
- Cruciate (C 1-3)
If caught at or before 30 days, can be treated with injection and splinting.
Dupuytrens’ disease
Non cancerous tumor that grows around tendons and causes contractures
30º contracture at MP joint
Any contracture at PIP joint
Flat hand test
Z plasty to prevent straight line scar the pulls into flexion
Bursitis
Potential space filled with fluid
Found in areas where bone approaches another surface
May be removed or drained
Ganglion cysts
A fluid filled sac that grows out of the tissues surrounding a joint or tendon.
Ganglion cysts are common in the soft tissue along the back of the wrist, as 60% to 70% develop along the front or back of the wrist.
Can be associated with rheumatoid arthritis or osteoarthritis
Usually right on the carpal bones
If you pop it, theres a 50% chance it won’t grow back.
Joint disorders
Osteoporosis
Osteopenia
Heterotropic Ossification
Arthrogryposis multiplex congenita
Ankylosing spondylitis
Osteoporosis
Decreased bone density
Silent disease until there is a fracture
Loss of balance between production and uptake
Kyphosis
Dowager’s hump
- not fixable by a therapist
Frequently a comorbidity or RSD/CRPS, spinal cord injuries, or astronauts
Causes:
- age (over 50)
- hereditary
- poor diet
- alcohol
- prolonged steroid use
- cigarettes
- vitamin D (rickets)
- non weight bearing
Symptoms: none, fractures, shrinking
Dual energy x-ray obsorptiometry (DEXA)
Treatment:
- weight bearing
- medication
- diet
Osteopenia
Reversible weakening of the bone
- fracture without trauma (standing while washing dishes and hip suddenly just breaks)
“Pre” osteoporosis
- pathological fracture
Heterotopic ossification
Growing bone where you shouldn’t be growing bone
- more likely to happen where there’s already bone on bone (elbow)
- burns
- head injury
- spinal cord
Fracture vs. break
SAME THING
Break is the lay term for fracture
Fractures
Can be open (bone sticking out) or closed
Complete or partial
Compression
Pathological
- osteoporosis, rickets
What is a “bad” fracture?
Position: if it doesn’t stay by the other piece of bone; if it moves and causes tissue damage
Age
Fragments
Soft tissue
Fat emboli: fat escapes from marrow and can result in a stroke
Other diseases: like osteoporosis
Volkman’s ischemia
Volkmann contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This occurs when there is increased pressure due to swelling, called compartment syndrome.
Types of union after a fracture
Delayed union: couldn’t put the bone back together quickly, possibly because of an infection
Malunion: poorly healed
Non Union: ends of the bones heal, but not together
Types of fractures
Greenstick: almost always in children; most don’t need surgery, just a cast; pressure on one side, break on the other
Spiral: only way it can occur is by twisting really hard, so if this happens in a child, CPS will be called
Comminuted: crush, shattered; non-stable
Transverse (oblique): complete or partial
Compound: total
Compression: bone is stable; will heal on its own
Delayed union: complete; a midshaft humeral fracture is inherently unstable and will result in surgery
When to start AROM vs PROM
AROM first so you don’t sheer soft callus. Pt will know when to stop on their own. If PROM the OT may cause more damage.
Dislocation vs subluxation
Shoulder
- sulcus sign, you can see the separation
Nursemaid’s elbow
- reduction: apply pressure at radial head, grasp wrist and apply slight traction, supinate wrist while flexing elbow to 90º
Apprehension test
- abduction and external rotation
Compartmental syndrome
Excessive inflammatory response
Volkman’s ischemia or ischemic contracture
- any place there is a compartment
* shin splings
- treated with fasciotomy if excessive
Osteoarthritis vs. rheumatoid arthritis
Interventions for osteoarthritis
Joint protection
Replacement
Symptom mangagement
- edema control
- heat/ice
- modalities
- meicine
Rheumatoid arthritis
System, RH factor
- severe joint inflammation, changes in the synovial lining
* pannus: corrosive agent that breaks down cartilage in bone
- more than just joints
- autoimmune
- leading cause of disability worldwide
- any age (JRA), adults 40-70
- all races and ethnic groups
- hereditary component
Swan neck deformity
Hyperextension of PIP and flexion of DIP
Points palmar
LB - dorsal
Injury outside of RH:
- injury to terminal ligament (mallet or jersey finger)
Boutonnière deformity
Flexion of PIP, hyperextension of DIP
Points dorsal
LB - anterior
Injury outside of RH:
- injury to central slip (buttonhole deformity)
Classification criteria for rheumatoid arthritis
Criterai:
1. morning stiffness (at least 1 hour)
2. arthritis in 3+ joint areas
3. arthritis of hand joints (1+ swollen)
4. symmetric arthritis
5. rheumatoid nodules
6. serum RF
7. radiographic changes (erosions) on x-rays of hands
Applicable for: all arthritis patients
Results in: classification of RA (yes/no)
Positive in case: 4/7 criteria must be present; criteria 1-4 must have been present for at least 6 weeks
Test characteristics: sensitivity of 79-80% and specificity of 90-93% for established RA; 77-80% and specificity of 22-77% for early RA
Complex regional pain syndrome
Used to be called reflexive sympathetic dystrophy (RSD)
Cardinal signs: pain outside the norm associated with that injury, swelling outside the norm associated for that injury, temperature change, stiffness or motor changes
Complete overreaction of the system to an injury
Can occur anywhere in the body, but most commonly in the arm after a distal radial fracture
Many different symptoms associated with it
Narcotics don’t affect the pain
Extremely hypersensitive to ice
6-12 weeks in, an x-ray will show osteoporotic changes in the affected limb
Spinal issues
Lordosis
Kyphosis
Scoliosis
- any lateral deviation, even 1º
- anything 15º+ needs intervention like bracing or surgery
- can be postural or birth
- 30º-40º can impact respiratory status, child bearing ability, liver and digestive function
Ankylosing Spondylitis
Spondylolisthesis: occurs when there’s bilateral defects in the vertebral pars intrarticulariss which permit the vertebral body to slip anteriorly; usually occurs at level L5, S1
Spondylolysis: the most common cause for spondylolisthesis; it’s a unilateral or bilateral defect in the vertebral pars interarticularis result from stress fracture
Weight bearing status on the operated leg
NWB
TDWB
PWB
WBAT
FWB
New and old terminology for amputations
The terms long and short refer to the residual limb
Scapula and shoulder amputation is forequarter
The terms in ( ) are new
