Week 6 - Musculoskeletal and Neuro Flashcards
Synovial joints
Freely movable, no direct contact between bones
- hip
- elbow
Cartilaginous joints
slightly moveable
- symbus pubus (pelvic joint)
- intervertebral joints
Fibrous joints
immovable
- sutures of the skull
Synovial joint capsules
Joints where the bones don’t actually touch
- spheroidal (hip, shoulder)
- hinge (hands, feet, elbow)
- Condylar (wrist, knee, TMJ)
Monoarticular
one joint
Oligoarticular
2-4 joints
Polyarticular
More than 4 joints
Condylar joints
Must move on coronal plane (half moon and cup) (anterior/posterior)
- wrist
- TMJ
- knee
Articular structures
- joint capsule
- articular cartilage
- synovium
- synovial fluid
- intraarticular ligaments
- juxta articular bone
Abnormal findings in articular structures
- swelling
- tenderness
- crepitus
- instability
- locking sensation
- deformity
- limited active/passive ROM
Nonarticular structures
- periarticular ligaments
- tendons
- bursae
- muscle
- fascia
- nonarticular bone
- nerves
- overlying skin
Abnormal findings in nonarticular structures
- point or focal tenderness of adjacent regions
- limited active ROM
- rarely causes swelling, instability and deformity
What acronym helps you assess joints?
IPROMS
I - inspect - look for signs of deformity, swelling, scars, inflammation, atrphy
P - palpation - feel bony joint and soft tissue structures or fluid collection
R - assess active and passive ROM
S - special maneuvers - test specific movements to assess joint stability
Acute pain
Less than 6 weeks
Chronic pain
Greater than 12 weeks
What should you consider with joint pain in those under 60?
- repetitive strain/overuse
- crystal induced arthritis
- RA
- Psoriatic arthritis
- reative arthritis
- infectious arthritis
What should you consider with joint pain in those over 60?
- OA
- gout and pseudogout
- polymyalgia rheumatica
- osteoporitic fracture
- septic bacterial arthritis
How is muscle strength rated?
0 - no contraction (flacid)
1 - barely detectable movement
2 - movement, not against gravity, not against resistance
3 - movement against gravity, not against resistance
4 - movement against gravity, some resistance
5 - full movement with full resistance
Osteoarthritis
- age over 60
- wear and tear –> degenerative joint disease resulting from the breakdown of joint cartilage and underlying bone affecting the major joints
- Heberden nodes
- Bouchard nodes
- wide base stance
- pain worse with activity
- intermittent stiffness/swelling that worsens over the course of the day
- look for crepitus over inflamed joints
Heberden nodules
in DIP (distal interphalangeal joint - close to fingernail) with buldging or inflammation of the joint
Bouchard nodes
In the PIP (proximal interphalangeal joint - closer to wrist) - joint enlargement
Rhumatoid Arthritis
Chronic inflammatory disorder that affects the lining of the joints causing painful swelling resulting in bone erosion and deformity
- stiffness early in the morning that improves with activity
- polyarticular and symmetrical
- look for SQ nodules
- often persistent bilateral swelling and tenderness
- family history of autoimmune disease
- swan neck deformity of hands
Gout
Uric acid buildup resulting in crystal deposition at joints.
- causes severe pain
- pain usually unilateral
- erythema
- deformities
- monitor uric acid levels
- commonly found in distal locations
- big toe, knee, elbow
Pseudogout
Same symptoms as gout but with calcium crystals
Myalgia
muscle aches which may involve ligaments, tendons and fascia
Arthralgia
Joint pain without arthritis
4 Cardinal Signs of Inflammation
- redness
- swelling
- warmth
- pain
Ankylosing Spondylitis
Type of autoimmune arthritis that causes inflammation of the joints and ligaments of the spine. Inflammation causes spine stiffness and in severe cases can cause the vertebrae to fuse together.
Tenderness over the scaroiliac joint is common.
Considerations for assessing neck pain
- ask about any possibly injury
- radiation may indicate involvement of the spinal cord
- radiculation (pain radiation from the back or spine into the leg) suggests nerve compression
- tenderness at C1/C2 indicate possible subluxation and high cervical cord compression (requires prompt additional assessment)
Back pain warning signs
Infection
- duration for more than 6 weeks
- fever
- weight loss
- injection drug use
- immune comprimised
- unremitting pain
Tumor
- duration over 6 weeks
- under 18 or over 50
- history of cancer
- fever
- weight loss
Spinal cord compression
- incontinence
- saddle anesthesia
- severe or rapidly progressing neurological deficit
Red flags for low back pain
- Age <20 yrs or >50 yrs
- History of cancer
- Unexplained weight loss, fever, or - decline in general health
- Pain lasting more than 1 mo or not responding to treatment
- Pain at night or present at rest
- History of intravenous drug use, addiction, or immunosuppression
- Presence of active infection or human immunodeficiency virus (HIV) infection
- Long-term steroid therapy
- Saddle anesthesia
- Bladder or bowel incontinence
- Neurologic symptoms or progressive neurologic deficit
- Lower extremity weakness
Epicondylitis
Painful condition that occurs when tendons in elbow are overloaded usually by repetitive movements of the wrist and arm
Tennis elbow
Pitcher or golfer’s elbow
Nervous System Assessment includes what steps…
- Mental status - level of alertness, language function, memory, calculation, visuospatial processing, abstract reasoning
- Speech and language
- Cranial nerve assessment
- Motor system - body position, involuntary movements, muscle tone, bulk and strength, coordination
- Sensory - pain, temperature, vibration, position, light touch and discrimination
- Reflexes - deep tendon
What comprises the central nervous system?
brain and spinal cord
Peripheral nervous system
Peripheral nerves and cranial nerves
Autonomic nervous system
Involuntary. Connects to internal organs to control autonomic functions like digestion and BP
Sympathetic nervous system
Mobilizes organs during times of stress and arousal
Parasympathetic nervous system
Conserves energy during times of rest and relaxation
Somatic
voluntary muscle movements in response to pain
Tension headaches
Most common. Banding sensation around the crown of the head.
- gradual onset
- mild to moderate
- bilateral
- lasts a few hours
Migraine
- with or without aura
- 3 of 5 POUND symptoms
- pulsatile
- One day duration
- unilateral
- N/V
- Disabling
Additional photo/phonophobia
Pain is throbbing, may have aura, moderate to severe, unilateral
Lasts 4-72 hours
Cluster Headache
Localized to periorbital, orbital, supraorbital, temporal
- unilateral
- more common in men
- severe pain
- occur multiple times per day
Characteristics of subarachnoid hemorrhage
- worse headache of my life
- thunderclap/instantaneous
Headache from mass/lesion
- compression type pain
- worse with cough or sneezing
SNOOP
Red flag detection tool for high risk features in secondary headaches
S - systemic symptoms/secondary risk factor
- (systemic) fever, weight loss, fatigue
- (secondary) - HIV, cancer, immune suppresion, infection, inflammation
N - neurologic s/s
- altered consciousness/local deficits
- encephalitis, mass lesion, stroke
O - onset
- thunderclap and abrupt
- subarachnoid hemorrhage
O - order
- new s/s over 50
- temporal arteritis
P - positional, prior headache, papilledema
- upright/lying down
-prior headache, progressive
worsening
- intercranial hypotension,
dysautonomia,
Nuchal rigidity
Nuchal rigidity (neck stiffness with resistance to flexion) is found in patients with acute bacterial meningitis and subarachnoid hemorrhage.
Brudzinski Sign
As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally they should remain relaxed and motionless.
Flexion of both the hips and knees is a positive Brudzinski sign.
Kernig sign
Flex the patient’s leg at both the hip and the knee, and then slowly extend the leg and straighten the knee (Fig. 24-63). Discomfort behind the knee during full extension is normal but should not produce pain.
Pain and increased resistance to knee extension are a positive Kernig sign.
Joints Accentuation of Headache (JAH)
have the patient rotate their head side to side at a speed of 2 to 3 times per second. The test is positive at this maneuver worsens headache. A positive JAH strongly increases the possibility of meningitis, a negative result is not able to rule out the presence of a cute meningitis
Intracranial pressure
- cough, sneezing, position change may worsen headache.
- valsalva maneuvers and leaning forward may increase pain from acute sinusitis’
- Valsalva and lying down may increase pain from mass lesions due to changing intracranial pressure.
- Examine the fundi carefully.
- Examine closely for papilledema, an important sign of elevated intracranial pressure
Grading reflexes
0: absent
1: somewhat diminished, requires reinforcement
Reinforcement: contraction of muscles for 10 seconds, reassess
2: average response
3: brisker than average
4: very brisk with clonus
Red flags for secondary headache syndrome
- recent hx head trauma
- headache awakens patient from sleep
- acute onset over a few minutes
- headaches after age 50
- new onset in patient with risk factors for HIV, CA
- signs of systemic illness
- focal neurological signs other than aura
- papilledema
How is migraine diagnosed?
- headache lasts 4-72 hours
- have at least two of the following:
- pulsating
- unilateral
- moderate or severe
- aggravation or caused by avoidance of routine activity - Pt has n/v or photo/phonophobia
Diagnosis with 5 attacks that meet the above criteria
