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Musculoskeletal 1 > Phys Di - MSK System > Flashcards

Phys Di - MSK System Flashcards

1
Q

What are the keys to a good ortho history?

A
  • location
  • PMT: point of maximal tenderness
  • unilateral vs. bilateral
  • acute description of associated sx: pain, swelling, loss of ROM, weakness, clicking/locking, etc.
  • insidious onset: progression, change
  • acute onset: if known injury, ask the mechanism, sensation at time of injury
  • **above and below rule: knee pain can be d/t hip, etc.
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2
Q

Instead of using a 1-10 scale for severity, what questions should you ask to grade severity?

A
  • does the complaint interrupt daily life?
  • what does your (e.g. knee pain) keep you from doing that you enjoy?
  • does your (e.g. shoulder pain) disrupt your sleep?
  • can you transfer yourself from bed to toilet?
  • do you require an assistive device?
  • is it affecting your ability to work?
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3
Q

What should you ask about aggravating/alleviating factors?

A

-Aggravating Factors?
Weight bearing, exercise, stair climbing, sleeping position, carrying their baby, new job, sitting in a car, getting up from chair

-Alleviating Factors?
Rest, moving around, NSAIDs, bracing, toddler holding arm, sleeping position, stretching, massage, ice/heat

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4
Q

Pertinent questions to ask about pain complaint

A
  • character: dull vs. sharp, aching, radiating
  • location: uni- or bilateral, get the PMT
  • associated sxs: fatigue weakness?
  • timing: frequency, time of day, worse in am, progressive, constant or intermittent, injury, related to activity
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5
Q

Pertinent questions to ask about joint complaint

A
  • swelling
  • subjective stiffness vs. true ↓ROM,
  • warmth/erythema
  • instability or “giving way”
  • mechanical sx (click, catching, locking, etc)
  • morning or activity related pain
  • loss of function
  • crepitus
  • deformity
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6
Q

Pertinent questions to ask about back complaint

A

-onset: abrupt or gradual
-location:
Midline vs. paravertebral
Unilateral vs. bilateral
Radiation to leg
-associated/aggravating:
Worse with cough/strain
Postural changes?
Night pain?
Paresthesias
Bowel or bladder changes

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7
Q

MSK ROS

-joint

A
  1. Joint Pain/Stiffness
  2. Joint Swelling/Redness
  3. Joint Instability
  4. Decreased ROM
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8
Q

MSK ROS

-muscle

A
  1. Muscle Pain
  2. Muscle Weakness
  3. Muscle Atrophy
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9
Q

MSK ROS

-miscellaneous

A
  1. Gait changes
  2. Use of Assistive Devices
  3. Back Pain
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10
Q

MSK ROS

-history of

A
  1. History of Arthritis

12. History of Gout

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11
Q

What PMG and surgeries should you ask about?

A
  • prior orthopedic surgeries
  • history of prior fractures
  • history of osteoporosis
  • childhood MSK issues
  • any issues with healing
  • risks for falling
  • hypercoaguable states
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12
Q

Importance of social history

A
  • employment: lifting, standing, how long have you been at your current job?
  • exercise
  • functional abilities: housework, bathing, toileting, etc.
  • recent weight gain/loss
  • nutrition: calcium, vitamin D, calories, protein
  • cigarette smoking delays healing
  • ETOH use can contribute to accidents and injuries
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13
Q

Family history

A
  • osteoarthritis
  • rheumatoid arthritis
  • family member with history of total joint replacements
  • fractured hips
  • osteoporosis
  • congenital abnormalities of hip or foot
  • scoliosis or back problems
  • ankylosing spondylitis, gout
  • genetic disorders: osteogenesis imperfecta, Ehlers-Danlos, Charcot
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14
Q

What comprises a good MSK Exam?

A
  1. inspection
  2. palpation
  3. ROM testing
  4. muscle strength testing
  5. quick sensory and vascular check
  6. special tests
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15
Q

Physical exam - inspection

A
  • standing posture, sitting posture
  • compare the extremities visually: look for atrophy, asymmetry, gross deformity
  • spinal deformities, check symmetry (look from anterior or posterior), check contour (look from lateral)
  • watch the gait
  • inspect the PMT, ask patient to use 1 finger to localize it
  • note the skin: swelling? redness?
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16
Q

Physical exam - palpation

A
  • tenderness
  • abnormal masses
  • effusion
  • temperature changes
  • crepitus
  • alignment
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17
Q

Physical exam - ROM testing

A
  • parameters for rating MSK disability are based on the degree of motion impairment
  • can be guesstimated visually, but a goniometer enhances accuracy
  • documented in degrees of whatever motion you are evaluating
  • active vs. passive ROM
  • Know the ACCEPTED ZERO STARTING POSITIONS for each joint: for most joints it is anatomical position
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18
Q

Should you start with active or passive ROM? What is the difference?

A
  • if the joint is injured or painful, observe ACTIVE motion first
  • active motion is the patient physically moving the joint
  • passive motion is you moving the joint
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19
Q

What is the key to quantifying muscle strength?

A
  • **testing bilaterally
  • you are looking for a gross weakness on one side
  • place the muscle being tested in a shortened position
  • ask patient to perform a motion that lengthens the muscle as the examiner resists the movement
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20
Q

Muscle strength scale

A

5 - Normal - Complete ROM against gravity with full resistance

4 - Good - Complete ROM against gravity with some resistance

3 - Fair - Complete ROM against gravity

2 - Poor - Complete ROM with gravity eliminated

1 - Trace - Muscle contraction but limited joint motion

0 - Zero - No evidence of muscle function

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21
Q

Testing muscle strength also indirectly assesses…

A

the function of that nerve or nerve root that innervates it

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22
Q

Physical Exam – Motor and Sensory Evaluation

A
  • if patient presents with a neck or back complaint, MUST assess nerve root function
  • if patient presents with an extremity complaint, MUST assess peripheral nerve function
  • evaluate ONE muscle and ONE area of sensation for each nerve in question
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23
Q

On physical exam, how to you perform the vascular check?

A

**a quick vascular check is vital, especially if s/p injury or s/p surgery

Ask…

  • is capillary refill present and normal?
  • are pulses present in the limb being evaluated?
  • is there pallor in extremities?
  • what is the temperature of skin, “cool to touch” or “warmth”?
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24
Q

Shoulder inspection

A
  • symmetry
  • deformity
  • effusion
  • warmth
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25
Q

Shoulder palpation

A
  • AC joint
  • proximal humerus
  • insertion of biceps tendon
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26
Q

Shoulder ROM and strength

A
  • forward flexion
  • abduction
  • internal/external rotation
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27
Q

Shoulder special tests (4)

A
  1. Neer Impingement Sign
  2. Jobe Test
  3. Crossover Test
  4. Apprehension Test
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28
Q

Shoulder

-Neer Impingement Sign

A

**to test for rotator cuff tear, tendonitis, or impingement

  • grasp patient’s extended arm at the wrist, internally rotate the arm
  • use other hand to stabilize the scapula
  • lift the arm into full flexion
  • positive test = pain
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29
Q

Shoulder

-Jobe “empty can” test

A

***tests for pain or weakness in the
supraspinatus muscle of the rotator cuff

  • abduct arm to 90°
  • angle forward 30° (bringing it into the scapular plane)
  • and internally rotate (empty the can)
  • press down on arm while patient resists
  • positive test = pain or inability to rotate shoulder
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30
Q

Shoulder

-crossover test

A

***evaluates for AC joint pathology

  • forward flex the arm to 90⁰
  • horizontally adduct the arm across the body
  • positive test = pain

“the scarf test”

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31
Q

Shoulder

-apprehension test

A

***tests for anterior shoulder instability

  • correct technique is pt supine
  • elbow flexed to 90⁰
  • arm abducted to 90⁰
  • slowly apply external rotation and watch for apprehension in patient’s face, some may ask you to stop
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32
Q

Shoulder

-other special tests

A
  1. Speed’s Test for proximal biceps
  2. Hawkin’s Impingement Sign for RTC
    - lift elbow to 90 degrees, try to impinge the shoulder
  3. lift off test for subscapularis MM
    - place back of hand on small of back then lift off
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33
Q

The elbow

-inspection

A
  • identify PMT
  • look for deformity
  • bruising
  • note carrying angle
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34
Q

The elbow

-palpation

A
  • for tenderness, crepitus, warmth, effusion
  • palpate the radial head, olecranon (ulna), distal humerus, the epicondyles

in a non-verbal kid with a negative x-ray who protects elbow, gently palpate the radial head, the distal humerus

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35
Q

What are the different carrying angles of the elbow?

A
  • normal
  • excessive cubilus valgus
  • cubilus varus
  • gunstock deformity
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36
Q

The elbow

-ROM and strength

A
  • check pronation/supination for radius injury

- extension/flexion for olecranon or humerus injury

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37
Q

What are the special tests for the elbow?

A
  • elbow flexion test

- stability testing

38
Q

How should you document ROM of the elbow?

A

***by amount of
flexion

“Right elbow with full
flexion from 0-140 degrees” or
“Right elbow flexes from 0-150 degrees.”

39
Q

How do you document hyperextension in the elbow?

A

“full elbow
ROM with 10 degrees of hyperextension
present” or “full flexion of right elbow
present from -10 to 150 degrees”

**common in children

40
Q

How do you document an elbow without full ROM?

A

“lacks the last 10⁰ of extension” or “flexion from 10-150 degrees”

41
Q

Inspection of the hand and wrist

A
  • know the nodes: Bouchard and Heberden (common in OA)
  • look for ulnar deviation (common in RA)
  • look for thenar atrophy
42
Q

Hand and wrist

-palpation

A
  • MP
  • PIP
  • DIP
  • first CMC joints
  • radiocarpal joint
  • ulna styloid
  • distal radius
  • anatomical snuffbox

You’re looking for tenderness, temperature, crepitus, effusion.

43
Q

Hand and wrist

-ROM and strength

A
  • fingers
  • hand grip
  • wrist flexion
  • extension
  • supination
  • pronation
44
Q

Why do you palpate the anatomical snuffbox?

A

A scaphoid fracture can result in avascular necrosis d/t damage to the radial A.

Radial N also runs here.

45
Q

Instead of using anterior/posterior to describe the hand, use…

A

Volar/dorsal

46
Q

Instead of using medial/lateral to describe the hand, use…

A

Ulnar/radial

47
Q

What parts of the hand are innervated by median N?

A

Thumb, index, long, and 1/2 of ring.

48
Q

What parts of the hand are innervated by ulnar N?

A

other 1/2 of ring and pinky.

49
Q

Special tests for hand and wrist (4)

A
  1. Durkan’s Compression Test
  2. Phalen’s Test
  3. Tinel’s Sign
  4. Finkelstein’s Test
50
Q

Hand and wrist

-Durkan’s compression test

A

***evaluation of median N for carpal tunnel syndrome (better than Phalen’s)

-hold compression over the CT for 30 sec

51
Q

Hand and wrist

-Phalen’s test

A

***evaluates CTS also by impinging median N

  • hold wrists in flexion (reverse prayer) for 60 seconds
  • not as sensitive as a good compression test
52
Q

Hand and wrist

-Tinel’s Sign

A

***evaluates median N

-lightly tap the median N at the wrist flexion crease in line with long finger

53
Q

Hand and wrist

-Finkelstein’s test

A

***to evaluate wrist pain for DeQuervain’s tenosynovitis

  • have patient make a fist with thumb inside the fingers
  • then apply ulnar deviation
  • positive test = pain elicited at the radial wrist (1st dorsal compartment)
  • reproduces their pain complaint
54
Q

Inspection of the hip

A
  • is PMT anterior or lateral?
  • symmetry of limb length
  • look at iliac crest height
  • note any muscle atrophy
55
Q

Palpation of the hip

A
  • tenderness
  • masses
  • greater trochanter
  • anterior superior iliac spine (ASIS)
56
Q

The hip

-ROM and strength

A
  • test with patient supine
  • flexion (normal = 0-130⁰)
  • abduction (normal is up to 35⁰ to 50⁰) *away
  • adduction (normal is up to 25⁰ to 35⁰) *toward
  • internal and external rotation (with patient in hip flexion)
57
Q

The hip

-special tests

A

TRENDELENBURG TEST:

  • tests for ABductor strength, examiner behind
  • patient stands on one leg
  • a positive test = pelvic tilts/drops on contralateral side = weak hip abductors on stance leg
58
Q

What 3 joints/articulations are you evaluating in the knee?

A
  • knee (tibiofemoral) joint
  • patellofemoral joint
  • tibiofibular articulation
59
Q

What is full motion of the knee? Hyperextension?

A
  • full motion is 0-150⁰

- hyperextension to -10⁰ is considered normal, called recurvatum

60
Q

What are the special tests for stability?

A
  • Lachman’s
  • anterior drawer
  • posterior drawer
61
Q

What are the special tests for the meniscus?

A

McMurray’s

62
Q

Inspection of the knee

A
  • effusion
  • erythema
  • deformities
  • muscle atrophy
  • patellar position/tracking
  • gait
63
Q

Palpation of the knee

A
  • for effusion (milk it down)
  • tenderness (patella, joint line)
  • crepitus
  • patellar tracking
  • temperature
64
Q

What are valgus knees commonly called?

A

knock-kneed

65
Q

What are varus knees commonly called?

A

bow-legged

66
Q

Name the special tests for the knee (5)

A
  1. McMurray Test
  2. Valgus/Varus Stress Test
  3. Lachman Test
  4. Anterior Drawer Test
  5. Posterior Drawer Test
67
Q

Knee special test

-McMurray

A
  • flex knee to maximum pain free position (must be >90⁰ for test to work)
  • hold that flexed position
  • and stress meniscus by…
  • externally rotate tibia to evaluate medial meniscus
  • internally rotate tibia to evaluate lateral meniscus

-then gradually extend knee and feel/watch for localized click and/or pain

68
Q

Knee specialty test

-valgus/varus stress test

A

knee must be flexed to 30⁰, tests collateral ligaments

69
Q

Knee specialty test

-Lachman test

A
  • flex knee to 30⁰, stabilize femur from lateral side
  • attempt to translate the tibia anteriorly with other hand
  • abnormal test if NO firm end point and increased tibial “translation” compared to the contralateral knee
70
Q

Knee specialty test

-anterior drawer test

A
  • not as sensitive as Lachman’s but easier to do
  • flex knee to 90⁰
  • stabilize tibia by sitting on patient’s foot
  • grasp to proximal tibia with both hands
  • attempt to translate the tibia anteriorly
71
Q

Knee specialty test

-posterior drawer test

A
  • same position as above
  • inspect for gravity sag sign
  • attempt to push tibia posteriorly
  • “flush” is abnormal (the anterior tibial plateaus sit 10mm anterior to the femoral condyle in a normal position)
  • abnormal posterior drawer test can cause a false + anterior drawer test
72
Q

Inspection of foot and ankle

-deformities

A
  • Pes planus (flat feed)
  • hammer toes
  • hallux valgus (bunion)
73
Q

Inspection of foot and ankle

-location

A
  • FOREFOOT (metatarsals, phalanges, sesamoids)
  • MIDFOOT (navicular, cuboid, cuneiforms)
  • HINDFOOT (talus, calcaneous)
  • BONES and JOINTS: Hallux, First MTP joint, Navicular, and Calcaneous…
74
Q

Palpation of anterior ankle

  • bones/joints
  • soft tissue structures
A
  • ankle (tibiotalar) joint

- anterior talofibular ligament (ATFL)

75
Q

Palpation of medial ankle

  • bones/joints
  • soft tissue structures
A
  • medial malleolus (tibia)

- deltoid ligament

76
Q

Palpation of lateral ankle

  • bones/joints
  • soft tissue structures
A
  • lateral malleolus (fibula)

- calcaneofibular ligament

77
Q

Palpation of posterior ankle

-soft tissue structures

A

achilles tendon

78
Q

Palpation of forefoot

-bones/joints

A

-metacarpalphalangeal (MP) joints

79
Q

Ankle and foot

-ROM testing and strength

A
  • dorsiflexion
  • plantar flexion
  • inversion
  • eversion
  • great toe extension
80
Q

What are the special tests focused on stability for the ankle? (3)
-name the ligament

A
  1. anterior drawer test (tests ATFL)
  2. inversion stress test (tests CFL)
  3. eversion stress test (tests deltoid ligament)
81
Q

Thompson test for foot and ankle

A
  • tests Achilles tendon function
  • have patient prone
  • flex knee to 90⁰, make sure muscles relaxed
  • squeeze the calf to make the foot plantar flex
  • positive test = NO plantar flexion = ruptured Achilles
82
Q

Overview of the spine

-patient standing

A
  • inspection/palpation: feel spinous processes to help determine alignment
  • evaluate for scoliosis
  • check thoracolumbar ROM (flexion, extension, rotation, lateral bending)
83
Q

Overview of the spine

-patient seated

A
  • inspection/palpation:
  • cervical Spinous processes
  • muscles (sternocleidomastoid, trapezius, paraspinal muscles)

cervical spine ROM and strength:
-special test = SPURLING TEST

84
Q

Overview of the spine

-patient seated

A

Watch for discomfort as you lay patient back.

2 special tests in supine position:

  • -straight leg raise
  • -FABER Test
85
Q

Evaluating for scoliosis

A
  • inspect/palpate spinous processes of thoracolumbar spine for alignment
  • if lateral deviation noted, have patient forward flex the spine and look for one side of the back higher than the other
  • check from behind the patient
86
Q

In scoliosis, a slight posterior asymmetry becomes ______ with forward flexion.

A

A very slight posterior asymmetry becomes VERY apparent with the forward flexion.

**asymmetry due to muscle spasm goes away with forward flexion

87
Q

The spine

-cervical ROM and strength testing

A
  • flexion (chin to chest)
  • extension (look up)
  • lateral flexion (ear to shoulder)
  • rotation (look left, look right)
88
Q

the spine – special tests

A
  • straight leg raise: to determine if back pain is due to nerve root irritation
  • FABER test: use to check if “back” pain is truly hip or SI pain
89
Q

Straight leg raise test

A
  • common provocative test to evaluate low back pain
  • patient supine, passively elevate the fully extended leg of the affected side to 30-60⁰; you will usually need to extend >60⁰
  • positive test = pain in the region of the original complaint of back pain, often with radiation down the leg
  • test contralateral leg too, if nerve root irritation is severe enough this will cause pain on the affected side as well
90
Q

How do you elicit the tripod sign?

A
  • with pt seated (don’t announce that you are checking the back pain), extend the leg on affected side
  • a positive sign = pain in the back (again often radiating down the leg) accompanied by the patient’s natural tendency to ↓ the pain by leaning back and resting both arms on the table for support, creating a tripod
91
Q

The tripod sign is a good test for…

A
  • malingering!
  • failure to lean back and rest both arms on the table may suggest the pain is NOT present or NOT related to irritation of a nerve root
92
Q

What are the other 2 tests for malingering patients?

A

Nonorganic tenderness: lightly touch lower lumbar spine - this should NOT cause pain. A positive test is marked pain behavior.

Axial stimulation: apply light downward pressure on top of head which should not cause pain in the lower back. A positive test is the patient grimacing or reporting pain in the back.

Musculoskeletal 1 (14 decks)

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