(FE) MSK Flashcards
1
Q
What is the anatomical landmark for the temporomandibular area?
A
Tragus of each ear
2
Q
What is the anatomical landmark of the hips?
A
iliac crests and greater trochanters
3
Q
How does normal gait look like?
A
- Upright posture
- Ambulates with smooth, even and painless gait
4
Q
How does a normal spine look like?
A
- Concave curve of the cervical (1) and lumbar (3) spine
- Convex curvature of the thoracic (2) and sacral (4) spine
5
Q
What are some alterations in spine curvature?
A
1) Lordosis
- Inward curvature of lumbar (3) spine
- Often seen in pregnant clients
2) Kyphosis
- Top spine seems more rounded than normal
- Often seen in elderly
3) Scoliosis
- Lateral curvature of spine
- Usually discovered in childhood
6
Q
How should limbs normally present upon inspection?
A
- Bilaterally symmetric in length, circumference and position
7
Q
What are the unexpected findings of muscles upon inspection?
A
1) Fasciculations
- Muscle twitching
- Occurs if motor neuron is damaged
2) Muscle wasting
- Can occur after an injury or muscle disease
8
Q
What are some alterations in knee anatomy?
A
- Outward deviation: genu varum (bow leg)
- Inward deviation: genu varus (knock knees)
9
Q
What are some foot variations?
A
- Pes planus (flat feet)
- Pes cavus (higher than normal instep)
10
Q
What are some toe variations?
A
- Hammertoe (middle joint is bent)
- Claw toe
- Hallux valgus (bunion)
- Hallus varus (great toe deviates from other toes)
11
Q
What are the normal and abnormal findings upon palpitation of bones, joints, tendons and muscles?
A
Normal:
-Aligned, symmetrical and nontender
Abnormal:
- Crepitus
- Grating sensation
~ Usually in tendonitis or bones rubbing against each other
- Edema
~ Usually in gout, arthritis, or injury
12
Q
When is the normal finding upon palpation of the temporomandibular joint?
A
- Uneventful when opening and closing mouth, or a slight popping sound/sensation
13
Q
What are the abnormal findings upon palpation of the elbows?
A
- Nodule along ulnar surface
~ Rheumatoid nodule
~ Gouty tophi
14
Q
What are the abnormal findings upon palpation of the wrist and hands?
A
- Mass over dorsum of wrist
~ Ganglion cyst - Tender swelling of proximal interphalangeal joints
~ Rheumatoid arthritis
~ Deviates into swan neck/boutonniere deformities - Bony growths in distal interphalangeal joints
~ Heberden nodes
~ Associated with osteoarthritis - Bony growths in proximal interphalangeal joints
~ Bouchard nodes
~ Associated with osteoarthritis
15
Q
What are the abnormal findings upon palpation of the hips and knees?
A
- Swelling and tenderness
~ Injury or joint effusion - Tenderness or edema in popliteal space
~ Popliteal cyst
16
Q
What are the abnormal findings upon palpation of the ankles and feet?
A
- Thick achilles tendon
~ Tendonitis secondary to spondyloarthritis or xanthelasma (yellow eyelid corners) of hyperlipidemia - Localised warmth, pain or inflammation
~ Joint inflammation from RA, septic joint, fracture or tendonitis
17
Q
What is the normal results of ROM?
A
- Normal muscle strength and tone that feels soft and nontender
- 0-5 rating (0 is paralysis)
~ <3 may be due to neuromuscular, skeletal, neurological disorder or overstretching
~ May need assistive devices to promote mobility
18
Q
What is the difference between osteomyelitis, osteoarthritis and rheumatoid arthritis?
A
1) Osteomyelitis
- Infx of bone
2) OA
- Local disease/Wear and tear so it usually affects one joint at a time
- Has varying levels of synovitis
- Bone ends rub together due to loss of articular cartilage
- Morning stiffness lasts <30 mins
3) RA
- Systemic disease so it affects both joints
- Constant inflammation in synovial membrane
- Bone is eroded
- Morning stiffness lasts >30 mins
19
Q
What is osteomyelitis?
A
- Inflammation of the bone
- Usually due to infection
~ Commonly S. aureus
~ M. tuberculosis
~ Pseudomonas aeruginosa
~ Streptococcus spp
~ Salmonella spp
~ Pasteurella spp
20
Q
What is the structure of bone?
A
- Outer surface covered by periosteum (dense layer of connective tissue)
~ Where muscles, tendons and ligaments are attached - Below periosteum, is compact bone
~ Has blood vessels and nerves - Center of the bone has medullary canal, lined by spongy bone
~ Spaces in spongy bone are occupied by bone marrow
21
Q
What are the risk factors for osteomyelitis?
A
Local:
- Trauma and open wounds
Systemic:
- Weak immune system
- Poor circulation
~ Due to uncontrolled diabetes or peripheral vascular disease
- Bacterial infections in other sites of the body
- IV drug use
- Periodontal disease
- IDC
- Prosthetic joint
22
Q
What is the pathology of osteomyelitis?
A
Direct invasion:
- Trauma or surgery (bone is exposed to environment)
Indirect invasion:
- Hematogenous spread (distant spread through bloodstream)
- Contiguous spread (nearby infection)
Followed by:
- (Acute) Pathogens proliferate and initiate an inflammatory response
~ Causes local destruction of bone
~ Phase resolves within a few weeks
- (Chronic)
~ Bone becomes necrotic and separates itself from healthy bone to form a sequestrum
23
Q
What are the local and systemic symptoms of osteomyelitis?
A
Local:
- Bone pain, redness, swelling, warmth and restricted movement around site of infection
Systemic:
- Fever, malaise
- Nausea
- Restlessness
- Night sweats/chills
24
Q
Diagnosis of osteomyelitis?
A
- CBC
~ ^ in WBC
~ ^ in ESR
~ ^ in CRP - Imaging tests
~ Thickening of cortical bone and periosteum and elevation of periosteum
~ Osteopenia (loss of bone mass) - Bone biopsy
25
Treatment of osteomyelitis?
Acute:
- Antibiotics (oral, irrigation, acrylic bead chains implanted onto bone)
- Surgical debridement
Chronic:
- Incision and drainage
- Wound debridement
- Surgical removement of dead tissue
- Extended antibiotics therapy and hyperbaric oxygen therapy (^ pressure)
- Amputation of limb
- Bone graft
26
Nursing care for osteomyelitis?
- Contact precaution
- Vital signs + pain score
- Administer analgesics
- Note dec. or absent pulses, prolonged capillary refill, dusky or pale, cool skin, numb feeling/reduced sensation and pain that does not improve with medication
- Look out for signs of sepsis
~ ^ WBC with left shift
~ ^ serum lactate
~ ^ procalcitonin
~ Altered level of consciousness
~ Hypotension
~ Tachycardia
~ Tachypnea
27
What is osteoarthritis?
- Degenerative joint disease
~ Gradual wear and tear of joint cartilage and underlying bone + inadequate repair
- Chronic, non-inflammation condition
28
What are the types joints?
1) Fibrous/synoarthrodial joints
- Bones which do not move at all
- Skull bones
2) Cartilaginous/amphiarthrodial joints
- Some movement
- Spine
3) Synovial/diarthrodial joints
- Freely movable
- Wrists, elbows etc
29
What are the risk factors of osteoarthritis?
- > 50 y/o
- Obesity
- Joint overuse/injury
- Altered walking patterns (can increase joint stress)
- Family history of OA
- Female
- Associated medical conditions
~ Diabetes, multiple sclerosis, hematological disorders
30
What is the pathophysiology of OA?
- Articular cartilage (connective tissue with a lubricated surface that acts as a protective cushion for bones to smoothly glide against) wears away from repetitive stress
~ Weakens and loses elasticity
- Since cartilage has limited repair capacity, areas of maximal stress start developing fibrillations (cracks or clefts) in cartilage
- Over time, cartilage continues to erode until bones are exposed
~ Bones start to rub against each other
- At joint edges, bone grows outward to form osteophytes/bone spurs
31
Symptoms of OA?
- Joint pain
~ Pain worsens with activity (early stages) and at rest (late stages)
~ Worse in the evening
- Joint stiffness w/ limited ROM
~ Worse in the morning
~ Typically lasts up to 30 mins
~ Stiffness improves with activity
- Osteophytes visible as single subcutaneous nodes
~ Bouchard nodes (proximal interphalangeal)
~ Heberden nodes (distal interphalangeal)
32
Diagnosis of OA?
- X-rays
~ Cartilage loss and narrowing of joint space
- Blood tests
~ Typically normal (used to rule out other types of arthritis)
- Arthrocentesis
~ Synovial fluid usually clear and no inflammation in OA
~ Used to rule out other types of arthritis
33
Treatment of OA?
- Lifestyle modifications
~ Weight loss
~ Physical therapy
~ ROM and local muscle strengthening
- For px with joint instability, joint can be immobilized using supportive or orthotic devices
~ Ilizarov apparatus
~ Braces, splints
- Acupuncture, meditation, massage
- Oral analgesics
- Total joint replacement, arthroplasty
- Osteotomy (less common)
~ Cut and realign bones to relieve pressure and pain
34
Nursing care for OA?
- Perform mobility assessment
~ Evaluate for joint enlargement, swelling, stiffness, crepitus and ROM
- Assess joint pain
~Onset, quality, severity, relieving or aggravating factors and duration of pain
- For joint instability
~ Apply heat pack
~ Immobilize joint with splint or brace until inflammation subsides
- Analgesics
- Ensure physical therapy
35
What is rheumatoid arthritis?
- Autoimmune disease that causes bone erosion and a swollen, inflamed synovial membrane
36
What is gout?
- Inflammatory disease
- Urate crystals deposit in a joint and cause damage
- Caused by hyperuricemia
~ Uric acid is a waste product from purines (building blocks of RNA/DNA) and is excreted by the kidneys to urine
37
What are the risk factors/causes of gout?
1) Overproduction
- Overconsumption of purine-rich food
~ Red meat, shellfish, anchovies
~ Alcohol
~ Sodas
~ Mayonnaise
~ Aged cheese
- Cells die at faster rate -> ^ breakdown of purines into uric acid
~ Chemo, radiotherapy, surgery
2) Decreased excretion
- Dehydration
- Diabetes
- CKD
- Medications
~ Thiazide diuretics
~ Aspirin
3) Genetic predisposition
- ^ age, male gender, obesity
- Family history
38
What is the pathophysiology of gout?
1) Hyperurecemia + presence of urate crystals in joints causes:
- Complement activation
- Phagocytosis of crystals by monocytes
2a) In complement activation, neutrophil chemotaxis causes attempted (but failed) phagocytosis of neutrophils
- Causes neutrophil lysis
~ Releases lysosomal enzymes which lead to tissue injury and inflammation
2b) Successful phagocytosis of crystals by monocytes causes IL-1, IL-6 and TNF to be released
- Proteases are released by the cartilage and synovium
~ Leads to tissue injury and inflammation
39
Presentations of gout?
- Joint becomes red, warm, tender and swollen in a few hours
- Mostly affects the first metatarsal joint of big toe (podagra)
- Joint feels like it is on fire
- Discomfort and swelling can last for a few days w/ treatment, or weeks w/o treatment
- Repeated attacks leads to chronic gout
~ Type of arthritis with permanent joint destruction and deformity
~ Permanent deposits of urate crystals (tophi) alone bones beneath the skin
- ^ risk of developing kidney stones and urate nephropathy (urate deposition in kidney tubules)
40
Diagnosis of gout?
- Lab tests
~ Hyperuricemia (>6.8 mg/dL)
~ ^ CRP
~ ^ ESR
- Joint aspiration
~ Presence of monosodium urate crystals in the synovial fluid (normal plasma urate levels is 2-7mg/dL)
~ Kidney stones from urate crystals
- Imaging tests (eg X-rays)
~ Tophi
41
Treatment of gout?
- Decreased pain and swelling
~ NSAIDs
~ Corticosteroids
~ Antigout agents (colchicine)
- Decrease uric acid levels
~ Allopurinol
~ Uricosuric medication to ^ excretion of uric acid by kidneys
- Lifestyle modifications
~ Modify diet to reduce purine-rich food
~ Exercise
~ Stay hydrated (helps kidneys to flush out toxins)
~ Managing underlying comorbidities
~ Avoiding thiazide diuretics
~ Elevate his foot and keep his toe open to air
42
What is acute compartment syndrome and its pathophysiology?
- Rapid increase in pressure within an enclosed compartment that contains muscles, nerves and blood vessels, and surrounded by fascia (fibrous connective tissue)
- As fascia is non-elastic, it will not stretch much when pressure increases
~ Blood supply gets cut off -> tissue damage due to hypoxia and ischemia
43
What are the causes of acute compartment syndrome?
- Bleeding
~ Especially in long bone fractures and penetrating injuries
- Limb compression
- Circumferential burns -> tissue edema
- Reperfusion injury
~ In clients with prolonged tissue hypoxia, sudden restoration of blood supply can lead to massive inflammation and edema
- Receiving large amounts of IV fluids
~ May extravasate and infiltrate tissues
~ Eg in clients with bleeding disorders
44
What are the symptoms of acute compartment syndrome?
6Ps:
1) Severe pain out of proportion to injury
2) Paresthesia (numbness)
3) Pallor
4) Pulselessness
5) Poikilothermia (coolness of limb)
6) Paralysis
- Swollen and very stiff
45
What are the complications of acute compartment syndrome?
- Necrosis and gangrene
- ^ risk of infection
- Rhabdomylosis
~ Leads to muscle scarring and contractures that restrict movement
~ Can result in acute kidney injury
- Irreversible nerve damage
~ Permanent motor and sensory deficits
46
Diagnosis of acute compartment syndrome?
- Measure compartment pressure using a handheld manometer
~ Diagnosis if >30mmHg
- Imaging techniques (X-rays, CT, MRI)
~ Locates bone, muscle and blood vessel injuries
- CBC
~ ^ WBC
~ ^ ESR
~ ^ CK and myoglobin (if rhabdo is present)
- Urinalysis
~ Tea-coloured urine
47
Treatment of acute compartment syndrome?
- Fasciotomy
~ Skin and fascia are cut open to relieve pressure and restore normal blood flow
- Amputation if limb is already necrotic and gangrenous
- Pain medications
- Elevate extremity but not above the heart
~ Could decrease perfusion and worsen condition
- NVA every 30 mins
~ Report if numbness, cyanosis/necrosis, absent pulses or if limb does not improve within 4 hours of cast removal
48
What are the 2 types of hip fractures?
- Intracapsular fractures
~ Within the capsule of the hip joint
~ Caused by (minimal)trauma and osteoporosis
-Extracapsular fractures
~ Happens outside the capsule
~ Usually caused by severe direct trauma
49
What are the types of fractures?
- Closed / simple fractures
~ Bone breaks but skin is intact
- Open / compound fractures
~ Fractured end pierces through the skin
- Greenstick fracture
~ One side of bone breaks, other side bends
~ Common in children
- Impacted fracture
~ Piece of bone gets dislodged into another bone
- Comminuted fractures
~ Shattered into many pieces
~ Great and sudden trauma
- Spiral fractures
~ Fracture line follows the projection of a small, twisting force
~ Usually non-accidental
50
What are the risk factors for fractures?
- Old age
- Female
- Family history of osteoporosis
- Low vit D
- Smoking, alcohol
- Glucocorticoid use
- Malabsorption problems (affects absorption of nutrients like vitamin D)
51
Why are women more at risk of osteoporosis than men?
- Women tend to have smaller, thinner bones
- Estrogen (hormone that protects bones) decreases during menopause
52
What are the complications of fractures?
- Avascular necrosis of femoral head (if circumflex artery is compromised)
- Slower healing and longer periods of immobility and hospitalisation (due to reduced blood flow)
- DVT and pulmonary emboli, infx
- Severe pain and tenderness around affected area (difficult to bear weight on affected leg)
- Compartment syndrome
- Fat embolism
- Mobility complications (joint stiffness, instability)
~ Contractures (shortened muscles and tendons causing shorter ROM)
- Healing abnormalities that result in bone deformity
~ Malunion (fractured ends are not properly aligned)
~ Delayed union (bone requires more time to complete healing process)
~ Non-union (bone fails to connect)
53
Diagnosis of fractures?
Imaging tests
- Anteroposterior and lateral plain X-rays
- Only need to be taken from 2 angles
- 3 angles needed if fracture is near a joint
54
Treatment of fractures?
- Controlling pain using
~ Regional nerve block
~ Immobilization of hip joint
- Surgical repair and stabilization of displaced bones
- Anticoagulants (prevent thrombosis and avascular necrosis)
- Rehabilitation
55
Nursing care for fractures?
- Institute fall precautions
- Maintain bed rest
- Affected extremity to be immobilized and abducted in the prescribed position
- Head of the bed <45deg to prevent excessive hip flexion (for hip fractures)
- Continue IV fluids and antibiotics
- Reduce risk of pressure injuries
- Monitor for signs of delirium
- Perform full NVA
~ Cool, pale skin
~ Diminished distal pulses
~ Prolonged capillary refill
~ Impaired sensation or motor function
- If px is on anticoagulants, monitor for excessive bleeding or presence of clots
56
What is the healing process of a fracture?
1) Inflammatory phase
- Immune cells go to area of fracture and remove dead cells and damaged tissue
2) Reparative phase
- Osteoblasts activated to form a callus (new bone tissue that connects fractured ends)
3) Remodeling phase
- Callus is replaced by regular bone
57
What is the treatment for osteoporosis?
- Calcium + Vitamin D
- Bisphosphonates
- RANK ligand/inhibitor
- Selective estrogen receptor modulator
- Parathyroid hormone
- Calcitonin
