Week 10: Musculoskeletal

Question 1

What are the four key features of the MSK exam?

Answer 1

1. Inspect: visually evaluate any signs of deformity, swelling, scars, inflammation or muscle atrophy
2. Palpate: use surface anatomy landmarks (bony contours and structures) to localize points of tenderness or fluid collection
3. Range of motion: have patient actively move involved joints then move them passively as the examiner
4. Special maneuvers: perform stress maneuvers if indicated to evaluate joint stability and integrity of ligaments, tendons and bursae particularly if pain or trauma is present

Question 2

How is joint pain classified? (3)

Answer 2

1. # of joints involved - monoarticular, oligoarticular/pauciarticular or polyarticular
2. articular or extra-articular
3. acute (days to weeks) vs. chronic (months to years)

Question 3

Define monoarticular, oligoarticular/pauciarticular and polyarticular

Answer 3

Monoarticular: 1 joint (localized)

Oligoarticular or pauciarticular: 2-4 joints

Polyarticular: more than 4 (diffuse)

Question 4

Define articular vs. extra-articular. How do these present on exam?

Answer 4

Articular: includes the joint capsule & articular cartilage, synovium & synovial fluid

• Presentation: usually involves swelling & tenderness of the entire joint

Extra-articular: includes peri-articular ligaments, tendons, bursae, muscle, fascia & overlying skin

• Presentation: involves point or focal tenderness in regions adjacent to the articular structure

Question 5

Which are some examples of monoarticular (7) disease processes? Polyarticular? (8)

Answer 5

• · Monoarticular
  
  • Injury
  • Monoarticular arthritis
  • Monoarticular osteoarthritis
  • Tendinitis
  • Bursitis
  • Soft tissue injury
  • Acute gout
• Polyarticular
  
  • Rheumatic fever
  • Rheumatoid arthritis
  • Connective tissue disease
  • Osteoarthritis
  • systemic lupus erythematosus
  • Psoriatic arthritis
  • Scleroderma
  • Gonococcal arthritis

Question 6

What is crepitus? What does it indicate?

Answer 6

Audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss

Question 7

What are the four cardinal signs of inflammation?

Answer 7

1. Redness
2. Swelling
3. Warmth
4. Pain or tenderness

Question 8

What history and exam findings are consistent with rheumatoid arthritis?

Answer 8

History: chronic inflammation of synovial membranes with secondary erosion of adjacent cartilage and bone and damage to ligaments and tendons

Exam findings: tender, often warm but seldom red swollen joints, hands most often affected but may see symptoms in the feet, wrists, knees, elbows and ankles; stiffness in the morning and after inactivity

Question 9

What history and exam findings are consistent with osteoarthritis?

Answer 9

History: degeneration and loss of joint cartilage from mechanical stress

Exam findings: tender joints usually knees, hips, hands, cervical and lumbar spine, wrists; heberden’s & bouchard’s nodes

Question 10

How would the FNP perform a preparticipation sports physical? What would be abnormal findings and what would these finding indicate? (12 steps)

Answer 10

Step 1: stand straight facing forward, note any asymmetry or joint swelling

Step 2: move neck in all directions, note any loss of range of motion

Step 3: shrug shoulders against resistance, note for any weakness of shoulder, neck or trapezius muscles

Step 4: hold arms out to the side against resistance and actively raise arms over the head; note any loss of strength in the deltoid muscle

Step 5: hold arms out to the side with elbows bent at 90 degrees, raise and lower arms; note any loss of external rotation and injury of glenohumeral joint

Step 6: hold arms out, completely bend and straighten elbows; note any reduced ROM of the elbow

Step 7: hold arms down, bend elbows 90 degrees and pronate and supinate forearms; note any reduced ROM from prior injury to forearm, elbow or wrist

Step 8: make a fist, clench and then spread fingers; note any protruding knuckle, reduced ROM

Step 9: squat and duck-walk four steps forward; note inability to fully flex knees and difficulty standing up from prior knee injury

Step 10: stand straight with arms at sides facing back, assess for symmetry, leg length and weakness

Step 11: bend forward with knees straight and touch toes; note asymmetry

Step 12: stand on heels and rise to toes; note any wasting of calf muscles

Question 11

Which muscle groups make up the rotator cuff? (4)

Answer 11

Scapulohumeral group (SITS): supraspinatus, infraspinatus, teres minor & subscapularis

Axioscapular group: trapezius, rhomboids, serratus anterior, levator scapulae

Axiohumeral group: pectoralis major and minor; latissimus dorsi

Biceps & triceps

Question 12

What exam findings would be consistent with a clavicle fracture in the newborn?

Answer 12

Lumps, tenderness or crepitus along the clavicle

Question 13

In considering the elbow, what history and exam findings are consistent with lateral epicondylitis?

Answer 13

• pain and tenderness 1cm distal to the lateral epicondyle and sometimes in extensor muscles close by
• can elicit pain when extending the wrist against resistance

Question 14

In considering the elbow, what history and exam findings are consistent with medial epicondylitis?

Answer 14

• tenderness maximal just lateral and distal to the medial epicondyle
• wrist flexion against resistance increases pain

Question 15

In considering the elbow, what history and exam findings are consistent with olecranon bursitis?

Answer 15

• swelling and inflammation of the olecranon bursa
• superficial to the olecranon process and may reach 6cm in diameter

Question 16

What symptoms are consistent with carpal tunnel syndrome? (5)

Answer 16

• noctural hand or arm numbness
• dropping objects
• inability to twist lids off jars
• aching at the wrist and forearm
• numbness of the first 3 digits

Question 17

What is snuffbox tenderness? What does this indicate?

Answer 17

= tenderness with the wrist in ulnar deviation and pain at the scaphoid tubercle

• indicative of occult scaphoid fracture

Question 18

What are Dupuytren flexion contractures? Stenosing tenosynovitis? Colles fracture?

Answer 18

• Dupuytren flexion contractures: thickened band overlying flexor tendon of the fourth finger and possible little finger near distal palmar crease; thickened fibrotic cord develops between palm and finger; extension is limited but flexion is normal
• Stenosing tenosynovitis: trigger digits, catching or locking of affected finger
• Colles fracture: tenderness over distal radius after a fall

Question 19

What are the muscle groups of the hips? (4)

Answer 19

• Flexor group: iliopsoas
• Extensor group: gluteus maximus, hamstring muscles, adductor magnus, gluteus medius
• Adductor group
• Abductor group: gluteus medius and gluteus minimus

Question 20

How would the FNP perform the Barlow and Ortolani tests. What are positive finding and what do they indicate?

Answer 20

• Barlow: pull the leg forward and adduct with posterior force, feel for any movement of the femur head laterally
  
  • Positive finding: palpable movement of the femur head
• Ortolani: supine with legs pointing towards you - flex legs to form right angles at the hips and knees, abduct both hips simultaneously until the lateral aspect of each knee touches the exam table
  
  • Positive finding: palpable movement of the femur head back into place

Question 21

How would the FNP assess for leg shortening? Tibial torsion?

Answer 21

• Leg shortening: inspection of gait, patient supine - assess for symmetry, ,measure distance between anterior superior iliac spine and medial malleolus
• Tibial torsion: have toddler lie prone on the examination table with knees flexed to 90 degrees, assess for internal or external rotation past 10 degrees either way

Question 22

What is a SCFE? In whom might this occur?

Answer 22

• SCFE: slipped capital femoral epiphysis
• Associated with limp in an obese child

Question 23

What exam techniques can you use to assess for an effusion? What is a positive result? (3)

Answer 23

• Bulge sign: with knee extended, place left hand above the knee and apply pressure on the suprapatellar recess to displace fluid downward, stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area; tap the knee being the lateral margin of the patella with the R hand
  
  • Positive sign: bulge on medial side between patella and femur
• Balloon sign: place thumb and index finger of the R hand on each side of the patella, with left hand, compress the suprapatellar recess against the femur; palpate for fluid ejected or ballooning into spaces next to the patella and under the right thumb and index finger
  
  • Positive: palpable fluid wave
• Balloting of the patella: compress suprapatellar push and ballotte or push the patella sharply against the femur
  
  • Positive: palpable fluid wave

Question 24

What are symptoms and exam findings consistent with prepatellar bursitis?

Answer 24

Swelling around the prepatellar bursa - typically due to excessive kneeling

Question 25

What are the following gait abnormalities and what do they indicate? Spastic hemiparesis Steppage gait Cerebellar ataxia

Answer 25

* Spastic hemiparesis - corticospinal tract lesions * affected arm is flexed, immobile, held close to the side with elbow, wrists and interphalangeal joints flexed * Affected leg extensors are spastic; ankles are plantar-flexed and inverted * Patients may drag toe, circle leg stiffly outward and forward or lean trunk to contralateral side to clear affected leg while walking * Steppage gait - foot drop, secondary to peripheral nervous system disease * Drag the feet or lift them high * Cannot walk on heels * May involve one or both legs * Tibialis anterior and toe extensors are weak * Cerebellar ataxia- disease of the cerebellum or associated tracts * Staggering and unsteady gait with feet wide apart and exaggerated difficulty on turns * Cannot stand steadily with feet together with eyes open or closed * Dysmetria, nystagmus and intention tremor may be present

Question 26

What are the following gait abnormalities and what do they indicate? Scissors gait Parkinsonian gait Sensory ataxia

Answer 26

* Scissors gait - spinal cord disease that causes spasticity * Stiff gait, advance each leg slowly and thighs cross forward on each other with each step * Short steps * Patients appear to be walking through water, may be compensating sway of the trunk * Parkinsonian gait - basal ganglia defects of Parkinson disease * Posture stooped with flexion of the head, arms, hips and knees * Slow to get started * Short and shuffling steps with involuntary hesitation (festination) * Arm swings decreased and patients turn around stiffly * Postural control is poor * Sensory ataxia - polyneuropathy or posterior column damage * Unsteady gait, wide based * Throw their feet forward and outward and bring them down, first on the heels then on the toes * Watch the ground for guidance when walking * With eyes closed, patients cannot stand steadily with feet together (positive Romberg sign), staggering gait worsens

Question 27

What are some abnormalities of the toes and soles? (6)

Answer 27

1. Ingrown toenail: tender, reddened overhanging nail fold with granulation tissue and purulent discharge 2. hammer toe: hyperextension of the metatarsophalangeal joint with flexion at the proximal interphalangeal joint 3. Corn: painful conical thickening of the skin due to recurrent pressure on normally thin skin 4. Callus: area of thickened skin in a region of recurrent pressure on normally thick skin, usually painless 5. Plantar wart: hyperkeratotic lesion caused by human papillomavirus; characteristic small dark spots; normal skin lines stop at the wart's edge, tender if pinched from side to side 6. Neuropathic ulcer: deep, infected, indolent and painless due to sensory disruption

Question 28

What are some common foot abnormalities of the young child?

Answer 28

* Flat feet * Inversion of the foot * Metatarsus adductus * Pronation

Question 29

What are some spine abnormalities the FNP should assess for during infancy? (4)

Answer 29

1. Pigmented spots 2. Hairy patches 3. Deep pits 4. Deformities of vertebrae

Question 30

How would the FNP assess for scoliosis? What findings would be indicative of scoliosis?

Answer 30

* Adams test: have child bend forward with knees straight and head hanging straight down between extended arms * Positive test: asymmetry in positioning * Use a scoliometer to detect for the degree of scoliosis if detected with Adams test * Can also use a plumb line to determine symmetry

Question 31

Shoulder ROM (in order from L to R)

Answer 31

1. Flexion: raise your arms in front of you and overhead 2. Extension: raise your arms behind you 3. Abduction: raise your arms out to the side and overhead 3. Adduction: cross your arm in front of your body

Question 32

What is the test pictured? What do positive results indicate?

Answer 32

Crossover/crossed body adduction test: adduct patient's arm across chest Positive results: acromioclavicular joint tenderness and compression tenderness

Question 33

What is the test pictured? What do positive results indicate?

Answer 33

Apley scratch test: ask patient to touch opposite scapula from above and below with the same arm Positive results: rotator cuff disorder or adhesive capsulitis

Question 34

What is the test pictured? What do positive results indicate?

Answer 34

painful arc test: fully abduct patient's arm from 0-180 degrees Positive: pain from 60-120 degrees indicates subacromial impingement/rotator cuff tendinitis

Question 35

What is the test pictured? What do positive results indicate?

Answer 35

Neer impingement sign: press on scapula to prevent scapular motion with one hand and raise the patient's arm with the other Positive: subacromial impingement/rotator cuff tendinitis disorder

Question 36

What is the test pictured? What do positive results indicate?

Answer 36

Hawkins impingement sign: flex patient's shoulder and elbow to 89 degrees with the palm facing down, rotate the arm internally Positive: subacromial impingement/rotator cuff tendinitis disorder

Question 37

What is the test pictured? What do positive results indicate?

Answer 37

external rotation lag test: with arm flexed at 90 degrees with the palm up, rotate the arm into full external rotation Positive: inability to maintain external rotation is indicative of supraspinatus and infraspinatus disorders ​

Question 38

What is the test pictured? What do positive results indicate?

Answer 38

internal rotation lag test: bring dorsum of the hand behind the low back with the elbow flexed at 90 degrees, grip the wrist and lift the hand off the back, which further internally rotates the shoulder Positive: indicative of subscapularis disorder

Question 39

What is the test pictured? What do positive results indicate?

Answer 39

drop arm test: abduct arm to shoulder level up to 90 degrees then lower slowly Positive: indicates supraspinatus rotator cuff tear or bicipital tendinitis

Question 40

What is the test pictured? What do positive results indicate?

Answer 40

external rotation resistance test: adduct and flex the arm to 90 degrees with the thumbs turned up, stabilize elbow and apply pressure as the patient presses the wrist outward in external rotation Positive: pain or weakness indicates infraspinatus disorder; limited external rotation indicates glenohumeral disease or adhesive capsulitis

Question 41

What is the test pictured? What do positive results indicate?

Answer 41

empty can test: elevate arms to 90 degrees and internally rotate the arms with the thumbs pointing down, resist as you place downward pressure on the arms Positive: inability to hold arm fully abducted at shoulder level or control lowering the arm is indicative of supraspinatus rotator cuff tear

Question 42

Where/how do you assess for sensory change in median, radial and ulnar nerves? What are the tests to assess for carpal tunnel?

Answer 42

* Assess median, radial and ulnar sensory innervations of the wrist and hand * Median: pulp of index finger * Ulnar nerve: pulp of fifth finger * Radial nerve: dorsal web space of the thumb and index finger * Thumb abduction with resistance (top L) * Positive test: weakness * Thumb opposition with resistance * Positive test: weakness * Tinel sign: tapping over median nerve (top R) * Positive test: shooting pain, aching or worsening numbness * Phalen sign: hold wrists in full flexion with elbow fully extended, press backs of hands together to form right angles (bottom) * Positive test: numbness and tingling within 60 seconds

Question 43

Hand/thumb ROM

Answer 43

1. Finger flexion 2. Finger extension 3. Thumb abduction & adduction 4. Thumb flexion 5. Thumb extension 6. opposition

Question 44

What is the test pictured? What do positive results indicate?

Answer 44

McMurray: grasp the heel and flex the knee, cup your other hand over the knee joint with fingers and thumb along the medial joint line; externally rotate the lower leg from the heel then push on the lateral side of apply a valgus stress on the medial side of the joint while slowly extending the lower leg in external rotation Positive test: palpable click or pop is a positive test for a tear in the posterior portion of the medial meniscus

Question 45

What is the test pictured? What do positive results indicate?

Answer 45

Abduction stress test (Valgus): move the thigh 30 degrees laterally to the side of the table; place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle; push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side Positive test: pain or gap in the medial joint line is indicative of MCL injury

Question 46

What is the test pictured? What do positive results indicate?

Answer 46

Adduction stress test (Varus): place one hand against the medial surface of the knee and the other around the lateral ankle; push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side Positive test: pain or gap in the lateral joint line is indicative of LCL injury

Question 47

What is the test pictured? What do positive results indicate?

Answer 47

Anterior drawer test: cup hands around the knee with thumbs on medial and lateral joint line, hold patient's foot down; draw tibia forward and observe if it slides forward under the femur Positive test: forward jerk showing contours of upper tibia indicative of ACL tear

Question 48

What is the test pictured? What do positive results indicate?

Answer 48

Lachman test: place knee in 15 degrees of flexion and mild external rotation; grasp distal femur on the lateral side with one hand and proximal tibia on the medial side with the other forcefully and simultaneously pull tibia forward and femur back Positive test: significant forward excursion is indicative of ACL tear

Question 49

What is the test pictured? What do positive results indicate?

Answer 49

Posterior drawer sign: push tibia posteriorly and observe degree of backward movement in the femur Positive test: if proximal tibia falls back indicative of PCL injury