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What are the articular structures?
- joint capsule
- articular cartilage
- synovium and fluid
- intra-articular ligaments
- juxta-articular bone
What are the extra-articular structures?
- periarticular ligaments
- overlying skin
What are the 3 primary types of joints and what are their relative degrees of motion?
- Synovial (freely movable)
- Cartilaginous (slightly movable)
- Fibrous ("immovable")
What type of join has bones that do not touch each other, are covered by articular cartilage and separated by a synovial cavity in which synvoial membrane lines the cavity and secretes synovial fluid? What surrounds the synovial membrane?
What type of joint has bones that are connected by fibrocartilaginous discs that separate the bony surfaces and contain a necleus pulposus in the center? What are examples of these joints?
- Intervetebral discs, ribs-sternum, epiphyseal plates of long bones
What type of joint has bones that are connected by fibrous connective tissue with intervening layers of fibrous tissue that hold the bones together? What are examples of these joints?
- Sutures, distal talofibular joint, teeth/socket
What are the 5 types of synovial joints?
- 1) ball and socket
- 2) condylar
- 3) saddle
- 4) hinge
- 5) pivot
What type of joints are the tibiofibular and skull joints? What else are they labeled as?
- tibiofibular: fibrous (syndesmosis)
- skull: fibrous (suture)
What type of joints are the vertebral and rib joints? What else are they labeled as?
- vertebrae: cartilaginous (symphysis)
- rib: cartilaginous (synchondrosis)
What types of joints are the wrist, radioulnar, elbow, hip, CMC-thumb, and atlantoaxial joints? What else are they labeled as?
- wrist: synovial (condyloid)
- radioulnar: synovial (gliding)
- elbow: synovial (hinge)
- hip: synovial (ball & socket)
- CMC-thumb: synovial (saddle)
- atlantoaxial: synovial (pivot)
Why is taking a thorough history on a patient with a compliant important?
Not only gives you a picture of what may be going on but also how this will impact your patient in the future.
What is the general approach to the musculoskeletal exam?
- make sure are is well exposed, move pt gently or let them move themselves
- understand normal functional anatomy
- pts will "protect" the affected area with an acute injury so its helpful to examine the unaffected side first
- use equipment like medical tape measure and goniometer
What is the systematic order of a musculoskeletal examination?
- 1) inspection
- 2) palpation (bony & soft tissue landmarks)
- 3) active & passive ROM (AROM/PROM) & strength
- 4) neurovascular exam
- 5) special maneuvers
- 6) further studies (xray, MRI, labs, etc)- in trauma consider xrays BEFORE movement
What should you look for when performing the inspection?
- joint symmetry, note any malalignments
- surrounding tissues (skin changes, atrophy)
What does acute injury involvement of only 1 joint suggest?
- septic arthritis
If several joints are involved with pain/injury and it is symmetrically distributed what does it suggest?
What are you checking for with palpation?
- tenderness (local/diffuse)
- nodules (RA), popliteal cysts
- crepitus (audible/palpible crunching during movment, is significant with pain)
- swelling (effusion, bogginess, doughiness)
- warmth (arthritis, tendinitis, busitis, osteomyelitis)
- redness (erythema)
What type of swelling indicates disease or injury?
effusion (excess synovial fluid)
What type of swelling indicates synovitis?
What are you looking for when testing range of motion?
- limitations (goniometer)
- joint instability (excess mobility/joint ligamentous laxity)
What are the ways in which you test range of motion?
- PROM: you move the joint
- AROM: patient moves the joint
How do you test muscle strength? What are the grades (0-5) of muscle strength?
- test by asking pt to move actively against your resistance
- 0/5: no muscular contraction detected
- 1/5: barely detectable flicker of contraction
- 2/5: active movement of body part w/ gravity eliminated
- 3/5: active movement against gravity only
- 4/5: active movement with some resistance
- 5/5: active movement against full resistance without fatigue
What is the most active joint in the body? What is it's anatomical location?
- lies midway between the external acoustic meatus & zygomatic arch
What does the disc in the TMJ cushion against?
action of the mandibular condyle against the synovial membrane & capsule of the articulating surfaces of the temporal bone
What are the principle muscles of the opening and closing action of the mandible?
- opening: external pterygoids
- closing: masseter, temporalis, internal pterygoids
How do you palpate the TMJ during examination, what should happen?
- place tips of fingers just in front of the TRAGUS and have pt open & close the mouth
- fingertips should drop into the joint spaces as mouth opens
- check for smooth ROM
- snapping/clicking can be heard in normal people
What are the signs and symptoms of TMJ syndrome?
- unilateral chronic pain with chewing/jaw clenching
- often associated with STRESS
- swelling, tenderness, decreased ROM
When inspecting the shoulders during examination what may cause one shoulder to be elevated more than the other?
If a pt comes in with an anterior shoulder dislocation what would be seen during the inspection?
rounded lateral aspect of the shoulder appears flat
When performing an inspection of the shoulders on a pt who had a rotator cuff tear about 2-3 weeks ago, you notice increased prominence of the scapular spine. What is the most likely cause for this finding?
atrophy of the supraspinatus and infraspinatus
A significant amount of ________ is needed before swelling appears withing the shoulder joint.
What are the bony and soft tissue landmarks you need to palpate during a shoulder examination?
- sternoclavicular joint & along clavicle
- bony spine of scapulae to the tip of the acromion
- ACJ & coracoid process
- biceps tendon (roll it under fingertips or rotate forearm externally)
- subacromial & subeltoid bursae, SITS muscles (extended humerus)
- capsule & synovial membrane
What are the 6 motions used to test P/AROM of the shoulder?
- flexion: raise arms in front & overhead
- extension: raise arms behind you
- abduction: raise arms out & overhead
- adduction: cross arm in front of body
- internal rotation: place hand behind you and touch scapula
- external rotation: rotate arm outward
- (OR bring arms up behind your head, and then behind your back- internal/external)
What are some special maneuvers used to examine shoulder injuries? What are these maneuvers testing?
- crossover test: ACJ
- neer's/hawkin's: rotator cuff tendonitis/tear
- supraspinatus strength: rotator cuff tendonitis/tear
- infraspinatus strength: rotator cuff/biceps tendonitis
- drop-arm: rotator cuff tear
- forearm supination: biceps tendonitis
How do you inspect the elbow?
- support forearm & flex at about 70 degrees
- inspect contours (extensor surface of ulna & olecranon process)
What are the bony & soft tissue landmarks you need to palpate during elbow examination?
- grooves between epicondyles & olecranon
- synovium between olecranon & epicondyles (normally not palpable)
- ulnar nerve posteriorly between olecranon process &medial epicondyle
What are the 4 motions used to test P/AROM in the elbow? What muscles are being tested?
- flexion: biceps, brachialis, brachioradialis
- extension: triceps
- supination: biceps, supinator
- pronation: pronator teres, pronator quadratus
What is inspected when looking at the wrist & hands?
- position & movement
- fingers should be slightly flexed & aligned (at rest)
- thenar & hypothenar eminences for atrophy
- flexor tendons
Thenar or hypothenar atrophy shows compression of what nerves?
- median nerve (thenar)
- ulnar nerve (hypothenar)
What are the bony and soft tissue landmarks you need to palpate during wrist & hand examination?
- distal radius & ulna
- radial styloid & anatomical snuffbox (for scaphoid fracture)
- carpal & metacarpal bones
- proximal & distal interphalangeal joints & phalanges
- compress MCP joints
What is the anatomical snuff box?
hollowed depression just distal to the radial styloid formed by the abductor & extensor muscles of the thumb
What are the motions for testing P/AROM of the wrist, fingers and thumb?
- wrist: flexion & extension, radial & ulnar deviation
- fingers: flexion & extension of each joint, abduction (spread), adduction (together)
- thumb: flexion (move thumb across palm to 5th MCP), extension (move it back across palm away from fingers), abduction (move anteriorly away from palm), adduction (move toward palm), opposition (touch thumb to each finger)
What are the special maneuvers/tests used on wrist and hands for carpal tunnel?
- sensation of median nerve (pulp of index), ulnar nerve (pulp of 5th finger), radial nerve (dorsal web space of thumb & finger)
- thumb abduction & grip strength
- Tinel's sign (tapping median nerve @ carpal tunnel)
- Phalen's sign (hold wrists in flexion x 60 secs, numbness & tingling is positive)
What is the test used to determine pain caused by de Quevain's tenosynovitis in the hand/wrist?
Finkelstein's test (fist the thumb with wrist ulnar deviation, pain means positive)
What things are looked at when inspecting a pt's hips & gait?
- stance phase (foot bearing weight, most probs are identified during weight bearing phase)
- swing phase (foot moves forward, doesn't bear weight)
- width of base (2-4 inches from heel to heel, wide base suggest cerebellar disease/foot problems)
- normal gait is smooth and continuous, knee flexed throughout stance phase except when heel strikes ground
- check anterior & posterior surfaces of hip for atophy, swelling, & bruising
What bony and soft tissue landmarks should you palpate during the hips examination?
- upper margin of iliac crest at lvl of L4
- anterior-superior iliac spine (ASIS) to iliac tubercle & greater trochanter
- pubic symphysis (same lvl as greater trochanter)
- posterior-superior iliac spine (PSIS) underneath dimples just above buttocks
- greater trochanter posterior at gluteal flod & ischial tuberosity
- sacroiliac (SI) joint not always palpable
What are the inguinal structures palpated during the hips examination?
- inguinal ligament w/ ipsilateral heel on opposite knee
- femoral nerve, artery, vein bisect the inguinal ligament; lymph nodes lie medially (NAVEL)
What are the structures in the bursae that are palpated during the hips examination?
- psoas bursae below the inguinal ligament on a deeper plane
- trochanteric bursa overlying greater trochanter
- ischiogluteal bursa overlying the ischial tuberosity (not normally palpable unless inflamed)
What are the 6 motions used to test P/AROM in the hips? What muscles are involved?
- flexion: iliopsoas
- extension: gluteus maximus
- abduction: gluteus maximus and minimus
- adduction: adductors, pectineus, gracilis
- external rotation (swing leg medially): obeterators, quadratus femoris, gemuli
- internal rotation (swing leg laterally): gluteus medius & minimus
What is looked for when inspecting the knee/gait?
- knee should be extended at heel strike & flexed during other phases of swing & stance
- alignment and contours; atrophy of quadriceps muscles (bow leg/knock knees)
- loss of normal hollows around the patella (swelling in joint & supra-patellar pouch)
What does the term genu varum refer to? What does genu valgum refer to?
What does swelling over the patella indicate?
What does swelling over the tibial tubercle suggest?
What does swelling medial to the tibial tubercle suggest?
What are the bony and soft tissue landmarks palpated during a knee examination?
- patellar tendon and patella (should lie just above medial & lateral joint lines)
- tibial plateau
- articulating surface of femur & patella
- medial meniscus (easier to palpate if tibia is slightly internally rotated) and MCL
- lateral meniscus & LCL
- suprapatellar pouch (10 cm above superior border of patella)
- popliteal fossa (for cysts-'Bakers cyst')
- gastrocnemious & soleus muscles
What are the signs of minor and major effusions of the knee?
- bulge sign (minor)
- ballottment sign (major)
What are the 4 motions used to test P/AROM in the knee?
- internal rotation
- external rotation
What are the special maneuvers used to assess knee injuries? What do they suggest?
- McMurray test: click or pop along medial joint w/ valgus stress, ext rotation, & leg extension suggests tear of posterior medial meniscus
- Valgus Stress test: pain/gap in medial joint line suggest injury to MCL
- Varus Stress test: pain or a gap in lateral joint line suggests injury to LCL
- A/P drawer: compare on both knees, in unequal it may indicate ACL/PCL injury
- Lachman test: significant forward excursion of the tibia suggests ACL injury (most sensitive test for ACL injury)
What are you looking for when inspecting the ankle and foot?
What are the bony and soft tissue landmarks palpated during an ankle & foot examination?
- ankle joint
- achilles tendon
- heel & inferior calcaneus & plantar fascia
- medial & lateral malleolus
- tarsal and metatarsal bones
- MTP joints w/ medial squeeze
- toes and interphalangeal joints
What are the motions used to test P/AROM of the ankle & foot? What muscles are involved?
- plantar flexion: gastrocsoleus, plantaris, tibialis posterior
- dorsiflexion: tibialis anterior, ext dig longus, ext hallicus longus
- inversion: tibialis posterior & anterior
- eversion: peroneus longus & brevis
What motions are used to isolate specific joints in the ankle and foot?
- tibiotalar joint: dorsiflexion/plantar flexion
- subtalar joint: inversion/eversion of foot
- transverse tarsal joint: inversion/eversion of forefoot
- MTP joints: flexion of toes
What are you looking for when inspecting the spine?
- movement & ease of gait
- alignment of joints while pt is standing
- landmarks (prominent C7 & T1, paravertebral muscles, iliac crests, PSIS marked by skin dimples)
- spinal curves
What are the bony and soft tissue landmarks palpated during a spine examination?
- spinous processes
- facet joints in neck (deep to trapezius)
- step-offs (spondylolisthesis/foward slipping of one vertebra)
- SI joint
- paravertebral muscles for tenderness & spasm
- sciatic nerve midway between greater trochanter & ischial tuberosity (best palpated w/ pt on side & hip flexed)
What are motions used to test P/AROM of the neck and spine?
- flexion & extension
- lateral bending
- **stabilize pt's pelvis when checking spine, except in flexion**
What are the special maneuvers used to check for spine injuries?
- straight leg raise: raise pt's relaxed straight leg, flexing @ the hip, then dorsiflex the ankle; assess degree of elevation at which pain occurs and the quality and distribution of pain and the effects of dorsiflexion
- tightness/discomfort in the buttocks/hamstrings is common (not positive)
- pain radiating to ipsilateral leg is positive for lumbar radiculopathy
What is lower back pain that radiates down the leg commonly called?
What is the Patrick's (FABER) test, and what does it test for?
- FABER=Flexion ABduction External Rotation
- tests for sacroiliac (SI) joint problems such as sacroiliitis
What is the Patrick's (FABER) test method?
- 1) ask pt to lie supine on exam table
- 2) place foot of affected side on the opposite knee
- 3) pain in groin area indicates problem with the hip, not the spine
- 4) press down gently but firmly on flexed knee & the opposite anterior superior iliac crest
- 5) pain in sacroiliac area indicates a problem with SI joints