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Flashcards in Week 10: Musculoskeletal Deck (49)
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1

What are the four key features of the MSK exam?

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

2

How is joint pain classified? (3)

1. # of joints involved - monoarticular, oligoarticular/pauciarticular or polyarticular

2. articular or extra-articular

3. acute (days to weeks) vs. chronic (months to years)

3

Define monoarticular, oligoarticular/pauciarticular and polyarticular

Monoarticular: 1 joint (localized)

Oligoarticular or pauciarticular: 2-4 joints

Polyarticular: more than 4 (diffuse)

4

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

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

5

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

  • · 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

6

What is crepitus? What does it indicate? 

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

7

What are the four cardinal signs of inflammation?

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

8

What history and exam findings are consistent with rheumatoid arthritis?

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

9

What history and exam findings are consistent with osteoarthritis?

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

10

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

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

11

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

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

12

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

Lumps, tenderness or crepitus along the clavicle

13

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

  • 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

14

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

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

15

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

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

16

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

  • 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

17

What is snuffbox tenderness? What does this indicate? 

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

  • indicative of occult scaphoid fracture

18

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

  • 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

19

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

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

20

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

  • 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

21

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

  • 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

22

What is a SCFE? In whom might this occur?

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

23

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

  • 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

24

What are symptoms and exam findings consistent with prepatellar bursitis?

Swelling around the prepatellar bursa - typically due to excessive kneeling

25

What are the following gait abnormalities and what do they indicate?

Spastic hemiparesis

Steppage gait

Cerebellar ataxia

  • 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

26

What are the following gait abnormalities and what do they indicate?

Scissors gait

Parkinsonian gait

Sensory ataxia

  • 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

27

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

  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

28

What are some common foot abnormalities of the young child?

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

29

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

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

30

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

  • 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