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Clin Med III: MSK > Approach to the Musculoskeletal Patient > Flashcards

Approach to the Musculoskeletal Patient Flashcards

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1
Q

Common musculoskeletal chief complaints include:

A
  • Pain/Stiffness
  • Instability/Dysfunction
  • Deformity
  • Weakness
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2
Q

4 Goals for Evaluating Patients with Musculoskeletal Complaints

A
  1. Develop accurate diagnosis
  2. Provide timely care
  3. Avoid unnecessary testing
  4. Identify “red flag” conditions
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2
Q

Keys to Success In Evaluating MSK Complaints

A
  1. appropriate, thorough hx
  2. PE
  3. DDX - Considering MC disorders first
  4. Consider need for diagnostic testing
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2
Q

what is often the most important factor in diagnosing musculoskeletal problems

A

history!

  1. Obtain a complete ROS
  2. Thorough past medical history
    - Review medications and allergies
    - Family history
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2
Q

Key Historical MSK Considerations

A

LOCATES

  1. Onset
  2. Location
  3. Quality/Character
  4. Timing/Duration
  5. Aggravators/relievers
  6. Associated signs & symptoms
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3
Q

Onset questions when taking hx?

A
  1. When?
  2. Activity at onset?
    - Was there an injury?
    - What was the MOI?
  3. Timing of onset?
    - Sudden vs insidious
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4
Q

location questions when taking hx?

A
  1. Joint
    - Unilateral vs Bilateral
  2. Bone
    - Midshaft
    - Joint involvement
  3. Soft tissue
    - Muscle, tendon, ligament
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5
Q

Quality/character of pain when taking hx?

A
  • Catching/locking in the joint
  • Instability/giving way
  • Burning
  • Aching vs. sharp
  • Radiating
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6
Q

associated s/s of MSK compliant when taking hx?

A
  1. Systemic Symptoms
  2. Neurogenic Symptoms
  3. Inflammatory Symptoms
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7
Q

MSK/Orthopedic complaints classification

A
  1. Traumatic vs. atraumatic
  2. Articular vs. nonarticular
  3. Localized/Monoarticular vs. widespread/polyarticular
  4. Acute vs. chronic
  5. Inflammatory vs. non-inflammatory
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8
Q

MSK Physical Exam Goals

A
  1. Determine structures involved
  2. Determine the nature of the underlying pathology
  3. Determine the functional consequences of the process
  4. Determine the presence of systemic or extraarticular manifestations
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9
Q

Key Physical Exam Principles

A
  1. Inspection
  2. Palpation
  3. Range of motion
  4. Neovascular status
  5. Muscle testing
  6. Motor and Sensory evaluation
  7. Special tests
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10
Q

Inspection components of MSK PE

A
  • Expose area of concern
  • Have pt point to area of maximal pain/tenderness
  • REMEMBER “SEADS” - Swelling, erythema, atrophy, deformity, scars/skin
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11
Q

When examining the extremities, it is IMPERATIVE to examine how?

A

BILATERALLY

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12
Q

For palpation what are you assessing

A
  1. Assess for tenderness, masses, fluctuance, temperature changes, crepitus - Locate point of maximal tenderness
  2. Imagine the anatomy as you are palpating
    - Hard → bone
    - Spongy/Boggy → synovial thickening
    - Fluctuance → effusion
    - Position→ joint or periarticular (bursa)

pain SHOULD NOT discourage you from palpating the affected area

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13
Q

How to assess ROM during MSK exam?

A
  1. Provides info on severity and progression of disorder
  2. Always compare sides!
  3. Types of ROM:
    - Active (AROM)
    - Passive (PROM)
    - Active Assistive Range of Motion (AAROM)
  4. Measuring ROM
    - Can be estimated
    - More accurate assessment utilizing a goniometer
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14
Q

Goniometer are preferred for evaluating these specific joints:

A
  • Elbow
  • Wrist
  • Digits
  • Knee
  • Ankle
  • Great toe
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15
Q

Goniometers are less useful for ___ and ___ ROM evaulation

A

Hip and shoulder
Overlying soft tissue structures don’t allow for as much precision

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16
Q

how to use a goniometer?

A
  1. Start by placing the joint in the “Zero Starting Position”
    - In most joints this is in the anatomic position of the extremity in extension
  2. Place the center of the goniometer at the joint
  3. Have patient actively perform ROM
  4. Move the distal end of the goniometer to align with the distal extremity
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17
Q

Manual Muscle Testing Grades

A
  • 5/5: Normal (complete ROM against gravity w/full resistance)
  • 4/5: Good (complete ROM against gravity w/some resistance) - Sometimes subdivided into 4-, 4, and 4+
  • 3/5: Fair (ROM against gravity, but not with resistance)
  • 2/5 : Poor (ROM only if gravity eliminated)
  • 1/5: Trace (twitch/muscle contraction but no joint motion)
  • 0/5: Absent (muscle does not contract)
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18
Q

what is the Neurovascular Assessment

A
  1. Assess vascular status in trauma patient
  2. Assess one muscle/nerve at a time
  3. Neck and Back - Assess nerve root function
  4. Extremity - Peripheral nerve testing
  5. Digits - 2-point discrimination
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19
Q

First line in bone and joint imaging, especially for initial evaluation

A

Radiography

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20
Q

advantages of Radiography

A
  • fast, inexpensive, readily available, easily interpreted
  • Plain x-ray is often needed (by insurance) prior to more detailed imaging
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21
Q

disadvantages of radiography

A

poor soft tissue contrast, 2D, quality is technician dependent, some radiation exposure (small)

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22
What are used to protect radiation sensitive areas?
Lead shields
23
Long bone x-rays should be taken how?
**include joint above and below** At least 2 planes perpendicular to each other should be obtained
24
indications for radiography?
1. History of trauma 1. Deformity of a bone or joint 1. Inability to use the joint or extremity 1. Unexplained pain and localized tenderness to a bone or joint 1. Abnormal asymmetry or mass 1. Evaluation of foreign bodies
25
Advantages of a CT
1. Offers a 3D images (axial imaging) of bone, muscle and fat tissues - Multiplanar image reconstruction 2. Highest bony detail 3. Rapid process - Few seconds to several minutes to capture non-contrasted image 4. Often completed w/o contrast - contrast can further evaluate soft tissue, tumors, nerves
26
indications for CT
1. Pre-operative planning 1. Complex or intraarticular fracture patterns 1. Evaluation of bone tumors 1. Bone and joint aspirations/infections
27
Disadvantages of CT
1. $$ 1. Greater amount of radiation 1. Risk of motion/metal artifact 1. Closed in space (claustrophobic/limited body habitus) - avg CT weight limit: 450 lbs
28
advantages for MRI
1. Advantage of soft-tissue detail - Muscle, tendons, menisci and discs 1. Superior contrast resolution 1. Beneficial for evaluation of: Tumors, osteonecrosis, osteomyelitis, stress fracture 1. Open MRI available
29
indications for MRI
1. Spinal column pathology 1. Tendon and ligament injuries 1. Meniscal and cartilaginous injuries 1. Stress and occult fractures 1. Osteomyelitis/-necrosis 1. Soft tissue and bony tumors
30
disadvantages for MRI
1. $$$ 1. Loud 1. Small spaces (although open MRI is an option) 1. Length – scans last from 30 minutes up to 2 hours. 1. CI with certain types of metal
31
Interprets echoes produced when a transducer bounces sound waves off of specific anatomic structures creating an image
US
32
indications for US
1. Joint effusions 1. Tendinopathy 1. Ligament pathology 1. Soft-tissue masses 1. Infantile hip dysplasia
33
advantages and disadvantages of an US
* Advantages: safe, inexpensive, readily accessible * Disadvantage: technician dependent
34
Examines blood flow and metabolic activity of bone to assess bone formation/destruction Sensitive but not specific Able to scan the entire skeleton
Scintigraphy (Bone Scan)
35
Indications for scintigraphy
1. Infection of the bones/joints 1. Fractures 1. Metastatic bone disease 1. Tumors 1. Metabolic bone disease 1. Bone death
36
Involves injection of a contrast medium into the spinal subarachnoid space followed by continuous x-rays (fluoroscopy)
Myelography
37
indications for myelography
1. Indicated to detect pathology of the spinal cord - Level of injury, infection, tumor, cysts or herniated disk 2. Beneficial in patients who cannot undergo MRI Invasive!
38
Imaging (often CT/MRI/fluoroscopy) of a joint following the injection of contrast medium Provides a clear image of the soft tissue borders of the joint
Arthrography invasive!
39
Arthrography Procedure most commonly used on the following joints:
* Shoulder, elbow, wrist * Hip, knee, ankle
40
Imaging test that uses a radioactive glucose tracer to look for disease in the body Provides full body image
Positron Emission Tomography Scan (PET)
41
indications for a PET scane
Indicated to identifymetastatic malignant lesions
42
arthocentesis indications
patients who have an effusion or signs suggesting inflammation or infection within the joint
43
main goals of arthrocentesis
1. Determine the source of the effusion - Inflammation, infection, crystal-induced, hemorrhage 2. Improve joint ROM and comfort in joint effusions
44
indications for a muscle bx?
Indicated in muscle weakness and low muscle tone to **distinguish between myopathies and neuropathies** technique: needle (MC) or open
45
risks with muscle bx?
infection, bleeding, bruising, muscle damage
46
Common Laboratory Studies Used In MSK Complaints
* PT, PTT, Platelet Count * Blood Cultures * Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) * Antinuclear Antibody (ANA) * Serum Rheumatoid Factor (RF) * CBC and LFTs * HLA-B27 * Lyme Serology *
47
this lab study is indicated if bloody effusion and no evidence of trauma
PT, PTT, Platelet Count
48
this lab study is indicated if fever/joint erythema
Blood Cultures
49
this lab study has Nonspecific indicators of inflammation Useful in patients with a non-specific joint exam
Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)
50
this lab study has High sensitivity for Lupus and other rheumatological problems
Antinuclear Antibody (ANA)
51
this lab study is ordered when there is a moderate suspicion of RA
Serum Rheumatoid Factor (RF)
52
this lab study is ordered when a multisystem process is suspected
CBC and LFTs
53
this lab study is ordered when clinical suspicion is high for ankylosing spondylitis (young adults 20-30 years old M > F)
HLA-B27
54
ELISA and Western Blot are indicated for what condition/what lab study?
Lyme serology
55
General Goals for MSK Treatment:
* Reduce pain * Improve, preserve, or restore function * Modify disease progression * Reduce number of recurrences
56
conservative tx for MSK
1. Patient education 1. Activity modification/restriction - Assistive devices 1. Rehab/physical therapy 1. Pain management
57
pain control management for MSK
* NSAIDS, acetaminophen, or opioids * Muscle relaxants * Neuropathic agents * Topical analgesics (capsaicin cream, lidocaine patches) * Joint injection with corticosteroids and analgesics
58
management options for MSK
1. Immobilization with casting, slings and braces 1. Alternative therapies including: - Chiropractic manipulation - Massage therapy - Acupuncture 2. Surgery - Indicated when the benefit outweighs the risk
59
Indications for EMERGENCY/IMMEDIATE referral
1. Neurovascular injury 1. Open or unstable fractures 1. Unreduced joint dislocations 1. Septic Arthritis
60
Common s/s of a neurovasular injury?
* Numbness, decreased pulse, changes in color * Pain, Pallor, Paresthesia, Pulselessness, Paralysis (Compartment Syndrome)
61
septic arthritis s/s that indcates for emergency referral?
Swelling, warmth, redness, increased WBC, CRP and ESR
62
Indications for URGENT referral (within 7 days)
1. Closed and stable fractures 1. Reduced joint dislocation 1. “Locked” joint 1. Tumor
63
Indications for EARLY referral (2-4 weeks)
1. Motor weakness 1. Constitutional symptoms (not due to other conditions) 1. Multiple joint involvement
64
Indications for ROUTINE referral (beyond 4 weeks)
1. Failure of conservative treatment - Persistent symptoms >3 months 1. Persistent numbness and tingling in an extremity

Clin Med III: MSK (14 decks)

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