Applied Muscularskeletal Flashcards by Chris Caangay

Clues for muscle disease in older infants and children (11)

Floppy baby
Delayed milestones 
Trouble walking/running
Trouble climbing stairs/Getting up from sitting
Tripping and falling 
Fatigue
Double vision at the end of the day 
Muscle Pain 
Difficulty swallowing
Garbled speech after eating cold food (myotonia?)
Trouble letting go of objects

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Perinatal clues for muscle disease (4)

Reduced Intra-uterine movement
Neonatal respiratory distress
Poor Suck
Reduced limb activity

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Congenital absence of ____ is associated with _____

- Pectoralis major

Isolated

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Congenital absence of ____ is associated with _____

- Depressor labii oris

Congenital heart disease

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Congenital absence of ____ is associated with _____

- Pectoralis muscle

leukemia

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Congenital absence of ____ is associated with _____

- Temporalis

Myotonia

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Wasting 1’ muscle degeneration

Disuse

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Wasting 2’ (2)

Anterior horn cell dse

Peripheral nerve dse

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T/F Genital hemihypertrophy involves _____% of the body and is considered ________

50%

SERIOUS

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Isolated hypertrophy of calf muscles

Duchenne Dystrophy

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Type of hypertrophy seen in congenital adrenal hyperplasia

Generalized

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Fasciculation of muscle bundles is seen in conditions associated with irritation of

Anterior horn cell

Polio
Werdnig-Hoffmann

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Palpation of an induration over muscle is seen in (3)

Dermatomyositis
Infectious myositis
Pyomyositis

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Tenderness on palpation of muscles is seen in

Dermatomyositis

Trichinosis

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Percussion
Contraction on percussion + delayed relaxation

Best tested on _____ muscle

Myotonia congenita

Biceps

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Testing Muscle strength

Ant neck flexors

Get up from supine

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Testing Muscle strength

Trapezius

Shrug shoulders

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Testing Muscle strength

Deltoids

Elevate arms over head

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Testing Muscle strength

Biceps

Flex elbow

Palm facing upwards

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Testing Muscle strength

Quadriceps

Sit on edge of table w/popliteal space flush

Extend knee

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Testing Muscle strength

Gluteus medius

R lateral side
Flex knee
Abduct hip on L side

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Testing Muscle strength

Gluteus maximus

Prone
Knees flexed
Lift hip off table

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Testing Muscle strength

Gastrocnemius and soleus

Using sole of foot, push down on examiner’s palm

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Pattern of weakness

Dermatomyositis

Proximal

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Pattern of weakness | Peripheral neuritis

Distal extremity weakness

Pattern of weakness | One sided weakness

Unilateral cerebral insult

Pattern of weakness | Unequal lower limb weakness

Myelomeningocele

Pattern of weakness | Equal lower limb weakness

Paraplegia

``` Activities of Daily living I - II - III - IV - ```

I Fully independent II Most independent, minimal help required III Wheelchair bound IV Totally dependent

Clues in diagnosing muscle weakness | Myotonia

Mental retardation

Clues in diagnosing muscle weakness | Exaggerated reflexes

CNS dse

Clues in diagnosing muscle weakness | Fasciculations

Anterior horn cell disease

Clues in diagnosing muscle weakness | Rashes

Collagen vascular disease

Clues in diagnosing muscle weakness | Sensory changes

Peripheral nerve disease

Clues in diagnosing muscle weakness | Dark urine

Myoglobinuria

Gait | Waddling

Proximal muscle weakness around the hip

Gait | Toe walking

Duchenne or | Tight heel cord

Gait | Slapping gait

Peripheral neuropathy

Gait | High stepping gait

Posterior column lesion

History and PE (+) Joint pain (-) Swelling

Arthralgia

History and PE (+) Joint Pain (+) Swelling

Arthritis

History and PE: Etiology | Pain: Acute onset in 1 joint

Trauma or | Inflammation

History and PE: Etiology | Slow onset of pain

Collagen vascular disease

History and PE: Etiology | Generalized pain

Polyarticular

History and PE: Etiology | Pain in a joint for 1-2 days

Trauma | Infection

History and PE: Etiology | Pain in a joint for days or months

Collagen disease

History and PE: | Intense acute pain

Acute rheumatic fever or Septic arthritis (Acute onset could also be trauma or inflammation)

History and PE: | Extreme grades of pain

Vasomotor disease

History and PE: | Moderate pain

Juvenile Rheumatoid Arthritis

History and PE: | Arthritis w/no pain

Neuropathic joint

History and PE: | True migrating pain (Flitting-fleeting)

Acute rheumatic fever | Gonococcemia

History and PE: | Non-migrating pain

Collagen vascular disease

History and PE: | Pain worse on activity

Destructive joint dse | i.e. acute cartilaginous necrosis

History and PE: | Pain and stiffness early in the morning

Suggests JRA

History and PE: | Pain that interferes w/sleep

Vasomotor dse | Joint Bleeding

History and PE: | Growing pain

Septic arthritis Osteomyelitis Osteoid osteoma

Inspection | Involves 1 side of the joint

Peri-articular

Inspection | Swelling extends above and below joint

Cellulitis | Peri-articular swelling involves 1 side of joint

Inspection | True swelling w/_____ defined edges suggests __________

ill-defined | effusion in the joint

Inspection | ___________ __________ = swelling of joint w/clear defined edges

Synovial thickening

Inspection Sterno-clavicular swelling - Acute: ? - Chronic: ?

Acute - Gonococcemia | Chronic - Juvenile arthritis

Inspection: Etiology? | Obliteration of dimples of olecranon

Swelling of elbow

Inspection: Manifestation | Swelling of carpal joints

Limitation of wrist extension (seen dorsally)

Inspection: Etiology? | Clear, distal, oblique transverse edge

Swelling of extensor tendon sheath

Inspection: Etiology? | Diffuse swelling of dorsum of hand

Sickle cell disease | Tenosynovitis w/lymphedema or serum sickness

Inspection: Etiology? | Flexed, claw-like fingers

Flexor teno-synovitis Clawhand - paralysis of ulnar nerve Bifid Claw-like hand - Thalidomide

History and PE: | Swelling of plantar aspect w/tenderness

Ankylosing spondylitis

History and PE: Swelling of sole and dorsum of feet (-) Tenderness

Serum sickness

History and PE: Palpation | Heat and tenderness over the joint

Inflammatory arthritis

History and PE: Palpation | Flexor tendon tenderness upon percussion

Flexor tenosynovitis

History and PE: Palpation | Percussion of flexor aspect of wrist --> tingling sensation along outer 3 fingers

Carpal tunnel syndrome

T/F | Tenderness along femoral tibial edges of knee is a feature of arthritis

FALSE | NOT a feature

Most important point in testing for tenderness

Exclude tenderness of peri-articular structures

History and PE: | Test to elicit tenderness of sacro-iliac joint

Prezel Hold and cross one lower limb over the other while crossing the opposite upper limb across the trunk. Hold the shoulder and knee, and do quick spring-like stretching

History and PE: | (+) Cashmere velvet feeling =

Hypertrophic synovium

History and PE: (+) Crepitus on auscultation - Along flexor tendons = - Over tempero-mandibular joint =

Flexor tendons - Teno-synovitis of scleroderma | TMJ - JRA

Range of motion: How to test | Inferior cervical spine

Chin on chest

Range of motion: How to test | Atlanto-axial joint

Look up | Side to side

Range of motion: How to test | Lower cervical spine

Ear to shoulder

Range of motion: How to test | Abduction and internal rotation of shoulder

Arms above shoulders | Touch palms

Range of motion: How to test | Indian greeting tests what

Wrist ext | Elbow flexion

Range of motion: How to test/What are you testing | Distal and proximal interphalangeal joints

Bend fingers (scratching)

Range of motion: How to test/What are you testing | Metacarpo-phalangeal joints

Close the fist

Range of motion: How to test/What are you testing | Hip and knee flexion

Squat DOWN if rising from squatting, test of strength (DUH!)

Range of motion: How to test/What are you testing Trouble getting up? Suspect Trouble sitting down? Suspect

Muscle | Joint

Range of motion: Hip | At rest, flexion + external rotation =

Effusion into hip joint

Range of motion: How to test/What are you testing | Hip rotation is best tested in what position

Prone

Range of motion: Etiology | Limitation of internal rotation of hip

Slipped epiphysis | Legg-Perthes disease

Range of motion: | Excessive external rotation of hip is normal up to _____

18 months

Range of motion: Etiology/Manifestation | Loss of full extension of knee

Arthritides

Range of motion: Etiology/Manifestation | Osgood-Schlatter disease

Pain below knee causing limitation of flexion

Torsional deformities of lower limb: Hip In-toeing: Out-toeing:

Femoral anteversion | Physiologic (infancy)

Torsional deformities of lower limb: Tibia In-toeing: Out-toeing:

Internal torsion | External torsion

Torsional deformities of lower limb: Foot In-toeing: Out-toeing:

Metatarsus adductus | Flat-foot or curved foot

Straight lateral border of foot =

Normal

Convexity of the lateral border of the foot =

Metatarsus adductus

Tibial torsion is best observed when child is in _____ position and thigh _________

Prone | Flexed to 90'

Normal Thigh foot angle =

10-30'

Thigh foot angle =

Internal tibial torsion (normal first 2 years of life)

Excessive external rotation and limitation of internal rotation is normal up to

18m of life

Internal rotation normally:

Internal rotation >70'

Femoral anteversion

``` Toddler gait: When child walks in straight line, feet make an angle of ____ in external rotation ____ in-toeing ____ out-toeing ```

10' >10' >30'

Testing genu varum, valgum, flat foot and pronated foot | With medial malleoli touching, there must be _________ space between medial condyles

(5cm)

Testing genu varum, valgum, flat foot and pronated foot Genu varum Space between medial condyles: Normal until

Bowleg >2 inches Physiologic until 2.5 years old

Testing genu varum, valgum, flat foot and pronated foot Genu valgum Space between medial condyle: Normal at what age

Knock knee Normal betwee 2-5 years

Testing genu varum, valgum, flat foot and pronated foot Pronated feet: definition - Where is weight

Outward curvature of tendo-achilles | Inside edge of sole

Functional test for joint problems: | Duration of morning stiffness

Rheumatic dse

Functional test for joint problems: | Grip strength of 6-10 y/o

120 mmHg

Spine: Inspection Young child w/ Short neck or Elevated shoulder + Scholiosis

Hemi-vertebrae

Spine: Inspection | Child walking extremely to avoid pain suggests

Intervertebral disc inflammation

Spine: Inspection | Bunch of hair over lower end of spine suggests

Lipo-meningocele | Spina bifida occulta?

Spine: Inspection | Dimple at lower end of spine (2)

Sacrococcygeal dimple | Pilonidal sinus

``` Spine: Inspection Curves - Cervical - - Thorax - - Lumbar ```

C curve Convex C Curve

Loss of C curve in cervical spine = (2)

JRA | Tuberculosis of the spine

Spine: Inspection | Prominent thoracic curve

Kyphosis | i.e. morquio disease

Spine: Inspection Distinct angle at apex of kyphosis = Indicates:

Gibbus | Fracture/collapse of vertebrae

Spine: Inspection | Loss of lumbar lordosis seen in

Ankylosing spondylitis

Spine: Inspection | Prominent lordosis is d/t (3)

Familial Developmental (N up to 7-8 yo) Hip flexion

Spine: Scoliosis | Five (5) physical clues

``` Elevated shoulder on one side Unequal bra cup size Family history of scoliosis Prominent scapula Leg length discrepancy ```

Spine: Scoliosis | How to perform Hump Test

Bend fwd

Spine: Scoliosis | Modified Schober's tests for

Mobility of lumbar spine Mark midline over spine 10cm above 1st point Another mark 5cm below first point. Patient bends forward and points should be at least 7cm apart

Hand: Handedness established at What if earlier?

2.5-3 years old | Earlier suggests hemiplegia

Hand: | Tremors at rest (2)

Essential | Wilson's

Hand: | Tremor in sustained posture (4)

Anxiety Fatigue Thyrotoxicosis Cerebellar dse

``` Hand: Intention tremor (2) ```

Cerebellar dse | Stress

Hand: | Inability to sustain grasp =

Chorea

Hand: | Writhing movements in distal part of body =

athetosis

Hand: Flopping movement of outstretched hand = Seen in

Asterixis (liver flap) | Seen in hepatic failure (Reye's syndrome)

Hand: | Loss of abduction and extension of thumb d/t

Radial nerve paralysis

Hand: | Loss of ADduction of thumb

Ulnar nerve paralysis

Hand: | Apposition of thumb d/t

Median nerve paralysis

Hand: Size | Achondroplasia

Small

Hand: Size | Gigantism

Large

Hand: Size | Long hands w/spidery fingers (2)

Arachnodactyl | Homocystinuria

Hand: Size | Hypoplasia of radial aspect of hand (2)

Holt-Oram syndrome | Fanconi Syndrome

Hand: Shape | Mitten hand + Fused fingers

Apert

Hand: Shape | Apert syndrome =

Mitten hand w/fused fingers

Hand: Shape | Bifid claw-like hand

Thalidomide syndrome

Hand: Position | Policeman receiving tip d/t

Brachial plexus paralysis

Hand: Position | Wrist drop

Radial nerve paralysis

Hand: Position | Claw hand

Ulnar nerve paralysis Bifid clawlike = thalidomide Claw-like fingers = flexor tenosynovitis

Hand: Position Ulnar deviation of hand + Volar subluxation of the wrist

JRA

Rashes and Nodules: | Vesicular lesions are seen in: (6)

``` Scabies Herpes simplex Chicken pox Epidermolysis bullosa Congenital Syphilis Gonococcemia ```

Rashes and Nodules: | Pustules are seen in (2)

Impetigo | Infected scabies

Rashes and Nodules: | Lesion in Rheumatoid arthritis

Nodular

Rashes and Nodules: | Purpuric (2)

Rocky Mountain spotted fever | Meningococcemia

Rashes and Nodules: | Tips of fingers in scleroderma

Vasculitic

Fingers: | Short fingers of equal length are seen in (2)

Hypothyroidism | Achondroplasia (banana bunch fingers)

Fingers: | Trident sign

Acondroplasia

Fingers: | Polydactyl is seen in (2)

Ellis-Van Creveld syndrome | Trisomy 13

Fingers: | Syndactyl is seen in (3)

Apert Syndrome de Lange syndrome Prader Willi Syndrome

Fingers: Uniformly swollen Slight flexion Tender along tendon sheaths

Acute tenosynovitis

Fingers: | Triggering (locking) of fingers suggests

Nodules along flexor tendons

Fingers: Flexion deformity of little finger Seen in (3) Inherited via

Camptodactyl Down Carpenter Aarskog Simple dominant gene

Fingers: Shortening of radial aspect of middle phalanx resulting to radial deflection of terminal phalanx Seen in: M/F? Normal: ?

Clindodactyl Females 0.3% of normal population

Fingers: | Hypoplasia of metacarpal bones of all fingers is seen in (2)

Coffin-siris syndrome | Cri-du-chat

Fingers: | Hypoplasia of 4th metacarpal causes dimple. Seen in

Pseudo-hypo-parathyroidism

Fingers: Patient clenches fist w/thumb inside palm. Tip of thumb protrudes past ulnar border of palm. (+) in (-) in

THUMB SIGN (+) Marfan (-) Homocystunuria

Thumb: Abnormality: Triphalangeal thumb Associated Syndrome:

Holt-Oram

Thumb: Abnormality: Thumb Aplasia Associated Syndrome:

13q syndrome

Thumb: Abnormality: Broad thumb Associated Syndrome:

Rubinstein-Taybi

Thumb: Abnormality: Proximal placement of thumb Associated Syndrome:

18q syndrome

Thumb: Abnormality: Flexed thumb Associated Syndrome:

Arthrogryposis

Thumb: Abnormality: Bifid thumb Associated Syndrome:

Translocation 3/13

Dermatoglyphics: | Three components

Flexion creases Ridge arrangement of palms Finger patterns

Dermatoglyphics: 2 distal creases fuse and run as single crease along entire palm to ulnar border of palm = Seen in

Simian crease Down (NOT pathonomonic)

Dermatoglyphics: 2 transverse creases Proximal runs across entire palm Seen in:

Sydney line Congenital rubella syndrome

Dermatoglyphics: 2-3 creases over proximal interphalangeal joints 1 over distal interphalangeal joints

Normal

Dermatoglyphics: | 2 creases over palmar aspect of distal interphalangeal joints are seen in

Sickle cell disease

``` Ankylosing Spondylitis: Arthritis of the ______ _______ disease Early symptoms: (2) Age: ```

``` Arthritis of spine Immune disease (auto?) Early: Back pain + Stiffness Late adolescence or early adulthood Fuse vertebrae together ```

_______ ________ Disease | Idiopathic Osteo-necrosis of capital femoral epiphysis of femoral head

Legg Perthes Disease

Legg Perthes - Cause - Location (2), referred to (1) - Pain (2) - Quality of pain (2) - History of trauma?

Idiopathic osteo-necrosis of capital femoral epiphysis of femoral head Hip/Groin --> Thigh Mild/Intermittent in Ant thigh or knee NO history of trauma

MC cause of knee pain in adolescent | Prognosis:

Osgood-Schlatter (Osteo-chondritis) Dis-ecans | Benign/Self limited

Pain + Edema in tibial tubercle Associated w/traction apophysitis of _____ tubercle Due to __________ on the ___________ ossification center

Osgood-Schlatter (Osteo-chondritis) Tibeal Repetitive strain on 2' ossification center of tibial tubercle

``` ____________ Mucopolysaccharidosis type ____ INC clumsiness Mild coarsening of facial features Corneal clouding Hepatomegaly Odontoid hypoplasia Exercise intolerance ```

Morquio Disease

_____________ Disease Inheritance Liver dse manifestations (jaundice, varices, spider angiomas, palmar erythema) Neuro-psychiatric ___________ rings Arthropathy ressembles premature osteo-arthritis ________ anemia

Wilson's Rare AR Kayser-Fleischer rings Hemolytic anemia

``` Fanconi Syndrome ________ of kidneys excrete ____(3)_____ into urine Evidenced by ___(4)_____ in urine INC or DEC? Potassium INC or DEC? in Vit. D ```

``` Fanconi Syndrome Proximal tubules secrete ______ into urine - Glucose - AA - Phosphate ``` Evidenced by: Glucose, Citrate, AA, Phosphate in urine Hypokalemia Vit D deficiency

``` ____________ and _________ Syndrome X-linked Ocular hyper-telorism Anteverted nostrils Broad ________ lip Scrotal "Shawl" _______ the penis ________ hands ```

Carpenter and Aarskog Syndrome Broad upper lip Shawl Above penis Small hands

______________ Syndrome - rare congenital - Sex predilection (?) - Delay: mental or developmental - Coarse facial features - Incompletely formed or absent ______ - Absent 5th finger

Coffin-Siris Syndrome Females BOTH Mental and developmental 5th fingernails

_____________ syndrome - Multisystem - Growth retardation & and delayed ______ age - Mental retardation - Craniofacial dysmorphism - Hyper-telorism - ___________ nose - ___________ thumbs and toes - Breathing and swallowing difficulties

Rubinstein-Taybi - Delayed bone age - Broad nasal bridge - Abnormally large or "beak-shaped" nose - Broad thumbs and toes

__________________ Progressive or non-progressive? Multiple joint contractions present at birth Extremities are ________ or _________ in shape Thin SQ Tissues and absent skin creases Deformities are (symmetric or asymmetric?) Severity increases (distally or proximally?) _________ and ______ are most deformed Joint rigidity and dislocation (esp ____ and _____) Atrophy Sensation (+/-? ) DTR (+/-?)

- Arthrogryposis - Non-progressive - Extremities are fusiform or cylindrical - Deformities are symmetric - Severity increases distally - Hands and feet most deformed - Sensation intact - DtR diminished or absent

Applied Muscularskeletal Flashcards

(182 cards)