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Approach To The Musculoskeletal Patient Flashcards

(81 cards)

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1
Q

MSK complaints account for what percent of primary care visits

A

10-20%

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2
Q

What are common MSK chief complaints?

A

Pain/stiffness
Instability/dysfunction
Deformity
Weakness

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3
Q

What historical questions about location would you want to ask about?

A

Joint: bilateral or unilateral
Bone: midshaft, joint involvement
Soft tissue: muscle, tendon, ligament

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4
Q

What quality/character of pain questions would you want to ask about a MSK complaints

A

-Catching/locking in joint?
-instability/giving way?
-burning
-aching vs sharp
-radiating

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5
Q

What associated signs and symptoms would you want to ensure you ask about with an MSK complaint?

A

-Systemic symptoms
-neurogenic symptoms
-inflammatory symptoms

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6
Q

MSK physical exam goals

A

Determine structures involved
Determine nature of underlying pathology
Determine functional consequences of the process
Determine the presence of systemic or extraarticular manifestations

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7
Q

Key physical exam principles in the MSK physical exam

A

Inspection
Palpation
Range of motion
Neurovascular status
Muscle testing
Motor and sensory evaluation
Special tests

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8
Q

How should inspection of a MSK complaint be performed?

A

Expose the area of concern
Have patient point to area of maximal pain/tenderness
SEADS: swelling, erythema, atrophy, deformity, scars/skin

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9
Q

When palpating an MSK complaint, what are you trying to locate?

A

Point of maximal tenderness

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10
Q

What does hard palpation of a MSK complaint indicate? Boggy?

A

Hard —> bone
Spongy/boggy —> synovial thickening

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11
Q

What does palpation of fluctuance indicate? Position?

A

Fluctuance —> effusion
Position —> joint or periarticular (bursa)

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12
Q

What are types of ROM?

A

Active (AROM)
Passive (PROM)
Active assistive range of motion (AAROM)

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13
Q

How can range of motion be measured more accurately?

A

Goniometer

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14
Q

What is goniometer preferred for evaluating?

A

Elbow
Wrist
Digits
Knee
Ankle
Great toe

Typically less useful for hip and shoulder ROM evaluation (overlying soft tissue structures don’t allow for as much precision)

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15
Q

How do you use a goniometer?

A

1) Start by placing the joint in the zero starting position (most joints this is an anatomic position of 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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16
Q

Manual muscle testing grades

A

5/5: normal (complete ROM against gravity with full resistance)
4/5: good (complete ROM against gravity with some resistance)
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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17
Q

When would vascular status be performed?

A

Trauma patient

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18
Q

How do you assess neurovascular status in each area of the body?

A
  • One muscle/nerve at a time
  • Neck and back: nerve root function
  • Extremity: peripheral nerve testing
  • Digits: 2-point discrimination
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19
Q

How would you perform neurovascular assessment on the axillary nerve?

A
  • Muscle: deltoid- shoulder abduction
  • Sensory: lateral aspect, arm
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20
Q

How would you perform evaluation of musculocutaneous nerve?

A
  • Muscle: biceps- elbow flexion
  • Sensory: lateral proximal forearm
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21
Q

How would you perform evaluation of the median nerve?

A
  • Muscle: flexor pollicis longus- thumb flexion
  • Sensory: tip of thumb, volar aspect
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22
Q

How would you perform evaluation of ulnar nerve?

A
  • First dorsal interosseous- abduction
  • Sensory: top of little finger, volar aspect
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23
Q

How would you perform radial nerve evaluation?

A
  • Muscle: extensor pollicis longus- thumb extension
  • Sensory: dorsum thumb web space
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24
Q

How would you perform obturator nerve testing?

A
  • Adductors - hip adduction
  • Sensory: medial aspect, midthigh
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25
How would you perform femoral nerve testing?
* Quadriceps - knee extension * Sensory: proximal to medial malleolus
26
How would you perform deep branch peroneal nerve testing?
* Extensor hallucis longus - great toes extension * Sensory: dorsum first web space
27
How would you perform superficial branch nerve testing?
* Peroneus brevis - foot eversion * Dorsum lateral foot
28
How would you perform tibial nerve testing?
* Flexor hallucis longus - great toe flexion * Sensory: plantar aspect, foot
29
What are special tests?
Tests specific to individual anatomic injuries
30
What is the first line imaging in bone and joint imaging, especially for initial evaluation?
Radiography
31
What are advantages to radiography?
* Fast * Inexpensive * Readily available * Easily interpreted * Plain x-ray often needed prior to more detailed imaging
32
What are disadvantages to radiography?
* Poor soft tissue contrast * 2D * Quality is technician dependent * Some radiation exposure (small), lead shields used to protect radiation sensitive areas
33
If you are concerned about an injury on x-ray, how should the x-ray be performed
* Joint above and below * At least 2 planes perpendicular to each other should be performed
34
Indications for radiography
* History of trauma * Deformity of a bone or joint * Inability to use the joint or extremity * Unexplained pain and localized tenderness to a bone or joint * Abnormal asymmetry or mass * Evaluation of foreign bodies
35
Advantages of CT
* Offers 3D images of bone, muscle, and fat tissues with multiplanar image reconstruction * Highest bony detail * Rapid process: few seconds to several minutes to capture non-contrasted image * Often completed without contrast but addition of contrast can further evaluate soft tissue, tumors, nerves
36
Indications for CT
* Pre-operative planning * Complex or intraarticular fracture patterns * Evaluation of bone tumors * Bone and joint aspirations/infections
37
Disadvantages to CT
* Expensive * Greater amount of radiation * Risk of motion/metal artifact * Closed in space (claustrophobia/limited body habitus): average CT weight limit = 450 lbs
38
What is the advantage of MRI
* Soft-tissue detail: muscle, tendons, menisci, and discs * Superior contrast resolution * Beneficial for evaluation of tumors, osteonecrosis, stress fracture * Open MRI available
39
Indications for MRI
* Spinal column pathology * Tendon and ligament injuries * Meniscal and cartilaginous injuries * Stress and occult fractures * Osteomyelitis/necrosis * Soft tissue and bony tumors
40
Disadvantages to MRI
* Expensive * Loud * Small spaces (although open MRI is an option) * Length - scans last from 30 minutes up to 2 hours * CI with certain types of metal
41
What is an ultrasound?
Interprets echoes produced when a transducer bounces sound waves off of specific anatomic structures creating an image
42
Indications for ultrasound
* Joint effusions * Tendinopathy * Ligament pathology * Soft-tissue masses * Infantile hip dysplasia
43
Advantages of ultrasound
* Safe * Inexpensive * Readily accessible
44
Disadvantages of ultrasound
Technician dependent
45
What is scintigraphy?
* Examines blood flow and metabolic activity of bone to assess bone formation/destruction * Sensitive but not specific * Able to scan entire skeleton
46
Indications for scintigraphy
* Infection of the bones/joints * Fractures * Metastatic bone disease * Tumors * Metabolic bone disease * Bone death
47
What is myelography
* Involves injection of a contrast medium into the spinal subarachnoid space followed by continuous x-rays (fluoroscopy)
48
What is indication for myelography?
* Detect pathology of the spinal cord * Level of injury, infection, tumor, cysts, or herniated disk * Beneficial in patients who cannot undergo MRI
49
What is arthrography?
* Imaging (CT/MRI/fluoroscopy) of a joint following the injection of contrast medium
50
What is arthrography used for?
* Clear image of the soft tissue border of the joint * Most commonly used on shoulder, elbow, wrist * Hip, knee, ankle
51
What is positron emission tomography scan (PET)?
* Imaging test that uses a radioactive glucose tracer to look for disease in the body * Indicated to identify metastatic malignant lesions * Provides full body image
52
Arthrocentesis indications
* Patients who have an effusion or signs suggesting inflammation or infection within the joint * Pain relief * Drainage * Injection of medications
53
Goals of arthrocentesis
* Determine source of effusion: inflammation, infection, induced, hemorrhage * Improve joint ROM and comfort in joint effusions
54
Risks of arthrocentesis
* Bleeding * Bruising * Septic arthritis * Iatrogenic infection * Osteonecrosis and joint instability
55
What is the typical synovial fluid color on arthrocentesis?
oily clear
56
What are relative CI to knee arthrocentesis?
* Bacteremia * Adjacent osteomyelitis * Coagulopathy * Prosthetic joint * Overlying cellulitis/dermatitis
57
Approaches for knee arthrocentesis
* Parapatellar * Suprapatellar * Infrapatellar
58
Complications of knee arthrocentesis
* Iatrogenic infection * Damage to tissues * Osteonecrosis * Joint instability
59
What is synovial fluid tested for?
* Cell count and differential * Crystals * Culture and sensitivity * Cytology
60
Techniques for muscle biopsy
* Needle (MC) or open
61
Indications for muscle biopsy
* Muscle weakness and low muscle tone * Distinguish between myopathies and neuropathies
62
Risks of muscle biopsy
* Infection * Bleeding * Bruising * Muscle damage
63
When is a PT, PTT, platelet count indicated in MSK complaints?
* If bloody effusion and no evidence of trauma
64
When are blood cultures indicated for MSK complaints?
Indicated if fever/joint erythema
65
When is ESR/CRP indicated for MSK complaints?
* Nonspecific indicators of inflammation * Useful in patients iwth a non-specific joint exam
66
When is ANA lab indicated in MSK complaints?
High sensitivity for lupus and other rheumatological problems
67
When would serum rheumatoid factor be ordered in MSK complaints?
Moderate suspicion of RA
68
When would CBC and LFTs be ordered in MSK complaints?
When multisystem process suspected
69
When would HLA-B27 be ordered?
* Clinical suspicion high for ankylosing spondylitis (young adults 20-30 years old M>F)
70
What is ordered for lyme serology in MSK complaints?
* ELISA * Western Blot
71
General goals for treatment of an MSK complaint
* Reduce pain * Improve, preserve, or restore function * Modify disease progression * Reduce number of recurrences
72
Conservative treatment for MSK complaint
* Patient education * Activity modification/restriction * Assistive devices * Rehab/physical therapy * Pain management
73
74
Pain control options for MSK complaint
* NSAIDs, acetaminophen, or opioids * Muscle relaxants * Neuropathic agents * Topical analgesics (capsaicin cream, lidocaine patches) * Joint injection with corticosteroids and analgesics
75
Non-medication mannagement options for MSK complaint
* Immobilization with casting, slings, and braces * Alternative therapies: chiropractice manipulation, massage therapy, acupuncture * Surgery: when benefit outweighs risk
76
Indications for emergency/immediate referral for MSK complaint
* Neurovascular injury (pain out of proportion to exam findings, ps) * Open or unstable fractures * Unreduced joint dislocations * Septic arthritis
77
What are signs/symptoms of neurovascular injury?
* Numbness * Decreased pulse * Changes in color * Pain * Pallor * Paresthesia * Pulselessness * Paralysis (compartment syndrome)
78
What are signs/symptoms of septic arthritis?
* Swelling * Warmth * Redness * Increased WBC * CRP/ESR
79
Indications for urgent referral (within 7 days)
* Closed and stable fractures * Reduced joint dislocation * Locked joint * Tumor
80
Indications for early referral to ortho (2-4 weeks)
* Motor weakness * Constitutional symptoms (not due to other conditions) * Multiple joint involvement
81
Indications for routine referral (beyond 4 weeks) to ortho
* Failure of conservative treatment: persistent symptoms >3 months * Persistent numbness and tingling in an extremity

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