NR509 Final Chapter 23 Muscloskelatal.pdf

o Seps or examining joins ▪ Inspecon Evaluae visually or signs o deormiy, asymmery, swelling, scars, inammaon, or muscle arophy. ▪ Palpaon Feel surace anaomy landmarks used or localizaon o poins...

o Seps or examining joins ▪ Inspecon Evaluae visually or signs o deormiy, asymmery, swelling, scars, inammaon, or muscle arophy. ▪ Palpaon Feel surace anaomy landmarks used or localizaon o poins o enderness, crepius. ▪ Range o moon involved joins are moved acvely by he paen, hen passively by he examiner. ▪ Special maneuvers I indicaed, sress maneuvers are perormed o evaluae sabiliy and inegriy o ligamens, endons, and Bursae. o Signs o inammaon ▪ Swelling palpable swelling may involve: o The synovial membrane, which can eel boggy or doughy; eusion rom excess synovial uid wihin he join space; or so ssue srucures, such as Bursae, endons, and endon sheahs. ▪ palpable bogginess or doughiness indicaes synovis, enderness over he endon sheah is ound in endonis. ▪ Warmh use he backs o your ngers o compare he involved join wih is unaeced conralaeral join, or wih nearby ssues i boh joins are involved. o Increased warmh can be seen in arhris, endonis, Bursis, oseomyelis ▪ Redness redness o he overlying skin is he leas common sign o inecon near he joins and is usually seen in more supercial joins like ngers, oes, and knees o diuse enderness and warmh sugges arhris or inecon; Focal enderness suggess injury or rauma ▪ pain or enderness ry o ideny he specic anaomic srucure ha is ender. o redness over a ender join suggess acue inammaon seen in sepc, crysalline, or RA o Temporal mandibular join ▪ key componens o TMJ examinaon inspec he ace and TMJ palpae he TMJ and muscles o mascaon (masers, emporal muscles, perygoid muscles). Assess range o moon: opening, closing; Prorusion, reracon; Laeral, or side o side, moons o Shoulders ▪ key componens o he shoulder exam  inspec shoulder and shoulder girdle aneriorly and scapulae and relaed muscles poseriorly. palpae sernal clavicular join, clavicle, acromioclavicular join, coracoid process, greaer ubercle, biceps endon, subacromial and subdeloid Bursa, and underlying palpable SITS muscles. Assess range o moon: exion, exension, abducon, adducon, and inernal and exernal roaons. Perorm special maneuvers i indicaed: painul arc es, neer es, Hawkins es, drop arm es, empy can es ▪ Inspec he conour o shoulders and shoulder girdles rom ron and back. When he shoulder muscles appear arophic, inspec or scapular winging. Muscle arophy; Anerior or poserior dislocaon o humoral head; scoliosis i shoulder heighs asymmeric painul shoulders ▪ Palpae clavicle rom he sernoclavicular join o he acromioclavicular join. o Sep os i racure rom rauma bicipial endon o By palpang along he bicipial groove in he righ shoulder subacromial and subdeloid Bursa aer liing arm poseriorly o exending he righ humerus poseriorly o palpae he SITS muscle inserons and Bursae. ▪ Assess range o moon shoulder arhris o Perorm special maneuvers o assess he SITS muscles o he roaor cu and bicipal endon i indicaed.  ▪ Subacromial or subdeloid Bursis; enderness over he SITS (supraspinaus, inraspinaus, eres minor, subscapularis) muscle inserons and diculy abducng he arm above shoulder level occurs in sprains, ears, endon rupure o roaor cu. ▪ Pain or inabiliy o perorm hese maneuvers in roaor cu sprains, endonis, rupure o Pain provocaon es ▪ painul arc es Fully adduc he paens arm rom zero o 180 degrees. ▪ Hawkins impingemen sign Flex he paen shoulder and elbow o 90 degrees wih he palm acing down. Then, wih one hand on he orearm and one on he arm roae he arm inernally. This compresses he greaer uberosiy agains he supraspinaus endon and coracoacromial ligamen. ▪ Neer impingemen sign press on he scapula o preven scapular moon wih one hand and raise he paens arm wih he oher. This compresses he greaer uberosiy o he humerus agains he acromion.  ▪ Srengh es drop arm es o ask he paen o ully abduc he arm o shoulder level, up o 90 degrees, and lower i slowly. Noe ha abducon above shoulder level, rom 90 o 120 degrees reecs acon o he deloid muscle. ▪ Composie es empy can es o elevae he arms o 90 degrees and inernally roae he arms wih he humbs poinng down as i empying a can ask he paen o resis as you place downward pressure on he arms o Elbows ▪ key componens o he elbow join examinaon Inspec and palpae conours o elbow, exensor suraces o ulna, olecranon processes. o Olecranon process: olecranon bursis; poserior dislocaon rom direc rauma or supracondylar racure. o Medial and laeral epicondyles: enderness disal o epicondyle in epicondylis (medial = ennis elbow, laeral = pichers’ elbow) o Exensor surace o he ulna: rheumaoid nodules. Assess range o moon: exion, exension, pronaon, and supinaon o Perorm special maneuvers i indicaed: cozens es (laeral epicondylis) o Cozens es ▪ sabilize he paen's elbow and palpae he laeral epicondyle. Then ask he paen o pronae and exend he wris agains resisance. Pain should be reproduced along he laeral aspec o he elbow. o Wris and hands ▪ key componens o wris join and hand examinaon inspec wris, hand, and nger bone; henar and hypohenar eminences; And exor endons. o Guarded movemen in injury o Asymmeric DIP, PIP deormies in OA; Symmeric deormies in PIP, MCP, wris joins in our a; Swelling and arhris, ganglia; Impaired alignmen o ngers in exor endon damage; Flexion conracures in dupuyrens conracure. o Thenar arophy and median nerve compression (carpal unnel syndrome); hypohenar arophy in older nerve compression. Palpae radius, ulna, radial syloid bone, and anaomic snufox (is he hollow space disal o he radial syloid bone; Thumb exensor and abducor endons); carpal bone; Meacarpals and proximal, meal, and disal anges, wris join, MCP’s and PIP's. o swelling and enderness and rheumaoid arhris, gonococcal inecon o join or exensor endon sheahs. o Tenderness over he ulnar syloid in Colles racure o Tenderness over he anaomic snufox sugges scaphoid racure. Tenderness over exensor and abducor endons in de Quervain enosynovis. o swelling in he meacarpophalangeal joins sugges rheumaoid arhris  o Proximal nodules are ound in OA; Bouchard (PIP) and Heberden (DIP) nodes in OA Assess range o moon. o Wris; exion, exension, abducon, and adducon o Finger; exion, exension, abducon, and adducon o Thumb: exion, exension, abducon, adducon, and opposion Perorm special maneuvers; hand grip srengh, ess or humb enosynovis (Finkelsein es), and nerve enrapmen neuropahy (sensaon, humb abducon and opposion, Tinel sign (aching, ngling, and numbness in second, hird, and 4h ngers is a posive Tinel sign), Phalen sign (aching, ngling, and numbness and second, hird, and 4h volar ngers is a posive Phalen sign.)) o Spine ▪ Key componens o he verebral spine examinaon inspec posure; Inspec cervical, horacic, and lumbar curves laerally; alignmen o shoulders, iliac Cres, and glueal olds poseriorly. o Kyphosis, scoliosis, lordosis, gibbus, lis curvaures. o scoliosis, pelvic l, unequal leg lengh palpae verebral spinous processes, paraverebral muscles, ace joins, lumbosacral verebra, sacroiliac join, iliac Cres, and poserior superior iliac spines. o Tender i rauma, inecon; sep os in spondylolishesis, racure o sacroiliis, ankylosing spondylis o Paraverebral muscle spasm in abnormal posure, degenerave and inammaory muscle disorders, overuse Assess range o moon o Cervical spine; exion, exension, roaon, and laeral bending. o Thoracolumbosacral spine: exion, ex, roaon, and laeral bending o perorm special maneuver; cervical radiculopahy (spurling es). ▪ Decreased mobiliy in arhris o Hips ▪ key componens o he hip join examinaon inspec gai and inspec he lumbar spine, legs, and anerior and poserior hip  o Mos problems arise during he weighbearing sance phase o The widh o base is usually wo o our inches rom heel o heel, shi o pelvis, exion o knee ▪ Cerebellar disease or oo problems i wide base; Impaired shi o pelvis in arhris, hip dislocaon, abducor weakness, disruped gae i poor knee exion palpae o anerior landmarks ▪ iliac Cres, iliac ubercle, Anerior superior iliac spine, greaer rochaners o emur, and he pubic ubercle. o Poserior landmarks ▪ poserior superior iliac spine, greaer rochaners laerally, ischial uberosiy, and he sacroiliac join. Palpang inguinal ligamen (ideny he nerve- arery-vein-empy space-lymph node, NAVEL) o Bulges are ound in inguinal hernia, aneurysm Psoas Bursae Trochaneric Bursa o on he greaer rochaner o he emur ▪ ocal enderness in rochaneric Bursis, oen described by paens as low back pain. Ischioglueal Bursa o Supercial o he ischial uberosiy ▪ ender and Bursis (weaver's boom) rom prolonged sing o Assess range o moon; exion, ex, abducon, adducon, inernal and exernal roaons ▪ Flexion o opposie leg sugges deormiy o ha hip  ▪ Exension is painul in iliopsoas Abscess ▪ Abducon and adducon are resriced in hip arhris ▪ Exernal and inernal roaon are resriced in hip arhris. o Perorm special maneuvers: groin srain (FABER or Parick es) ▪ Flexion, abducon, exernal roaon or Parick es or groin srain. Wih he paen supine, posion he lake ino 90 degrees o exion and inernally roae and abduc i so ha he ipsilaeral ankle res disal o he knee o he conralaeral leg, o Knees ▪ key componens o he knee join examinaon Inspec gai, knee hollows around Paella and quadricep muscles o Sumbling or giving away during heel srike in quadriceps weakness or abnormal paellar racking o bowlegs, knock knees; Flexion conracures and limb paralysis or hamsring ghness o quadriceps aer ee wih paelloemoral disorder; Swelling over he Paella in prepaellar Bursis (housemaid's knee), over he bial ubercle in inra paellar or i more medial anserine bursis. palpae bioemoral join ▪ Irregular, Bony ridges in oseoarhris ▪ There is enderness over he medial and laeral meniscus i here is a meniscus ear ▪ here is enderness in he medial and laeral conralaeral ligamens wih an MCL ear. o Medial comparmen  ▪ medial emoral condyle, adducor ubercle, medial bial plaeau, and MCL. o laeral comparmen ▪ laeral emoral condyle, laeral bial plaeau, and LCL o paelloemoral comparmen ▪ Paella, paellar endon, bial uberosiy, prepaellar Bursa, anserine Bursa, and poplieal ossa. Swelling over he Paella in prepaellar Bursis or housemaid's knee enderness or inabiliy o exend he leg in paral or complee ear o he paellar endon pain, crepius, and a hisory o knee pain in paelloemoral disorder pain during conracon o quadriceps in chondromalacia here's swelling in he suprapaellar pouch wih synovis and arhris here is swelling in he inrapaellar spaces and arhris here is swelling in he medial bial condyle wih pes anserine bursis. assess range o moon: ex and exion perorm special maneuvers: o McMurray es (meniscus) ▪ Wih he paen supine, grasp he heel and ex he knee. Cup your oher hand over he knee join wih ngers and humb along he medial join line period rom he heel, exernally roae he lower leg hen push on he laeral side o apply a valgus sress on he medial side o he join. Slowly exend he lower leg in exernal roaon. The same maneuver wih inernal roaon sresses he laeral meniscus a click or pop along he medial join wih valgus sress, exernal roaon, and leg exension and ear o poserior medial meniscus o abducon or valgus es (MCL)  ▪ Wih he knee slighly exed, push immediaely agains laeral surace o knee wih one hand and pull laerally a he ankle wih he oher hand pain or gap in he medial join line poins o a paral or complee MCL ear o adducon or varus es (LCL) ▪ wih knee slighly exed, push laerally along medial surace o mea wih one hand and pull medially a he ankle wih he oher hand pain or gap in he laeral join line poins o a paral or complee LCL ear o anerior drawer sign or lachmann es (ACL) ▪ Drawer: wih he knee exed, place humbs on medial and laeral join line and place ngers on hamsring inserons. Pull bia orward, observe i bia slides orward like a drawer. Compared o opposie knee orward slide o proximal bia is a posive anerior drawer sign in ACL laxiy or ear ▪ Lachman: grasp he disal emur wih one hand in he proximal bia wih he oher, place he humb on he join line. Move he heme are orward and he bia back. Signican orward exrusion o bia and ACL ear o poserior drawer sign (PCL) ▪ posion paen and hands as in he ACL es period push he bia poseriorly and observe or poserior movemen, like a drawer sliding poseriorly isolaed PCL ears are rare o Eusions: bulge sign, balloon sign, and ballong o he Paella ▪ compress he suprapaellar pouch, sroke downward on medial surace, apply pressure o orce uid o laeral surace, and hen ap he knee behind laeral margin o Paella poplieal or bakers cys a uid wave reurning o he medial surace aer a laeral ap conrms in diusion-a posive bulge sign ▪ balloon sign: compress suprapaellar pouch wih one hand; Wih humb and nger o he oher hand ll or uid enering he space is nex o he Paella a palpable uid wave is a posive sign ▪ ballue o Paella: push he Paella sharply agains he emur; Wach or uid reurning o he Super paellar o Ankles and space. ee  ▪ key componens o ankle join and oo examinaon inspec he ankle and oo o Hallux or vagus, corns, calluses palpae ankle join, Achilles endon, Calcaneus, planer ascia, medial and laeral ankle ligamens, medial and laeral malleolus meaarsophalangeal or MTP joins, meaarsals, gasrocnemius, and soleus. o Tender in arhris. o Tenderness and sprain; Laeral ligamens weaker, making inversion injuries (ankle bows ouward, heel bows inward) more common o rheumaoid nodules, enderness and endonis o enderness and arhris, Moron neuroma 3rd and 4h MTP join; Inammaon o rs MTP join in gou Assess range o moon: exion (planar exion), exension (dorsiexion), inversion and eversion o Ankle exion and ankle exension is oen painul wih an arhric join when moved in any direcon, sprain, when injured ligamen is sreched. o Inversion is painul wih an ankle sprain o eversion is painul wih rauma or arhris. perorm special maneuvers. Tes or join inegriy: bioalar, subalar or alocalcaneal, alocrural, ransverse arsal, meaarsophalangeal. Tes or Achilles endon inegriy. Anaomy o Imporan erms ▪ auricular srucures Include he join capsule and arcular carlage, he synovium and synovial uid, inra arcular ligamens, and juxa arcular bone. Arcular carlage is composed o a collagen marix conaining charged ions and waer, allowing he carlage o change shape in response o pressure or load, acng as a cushion or underlying bone. Synovial uid provides nurion o he adjacen relavely a vascular arcular carlage. ▪ Exraarcular srucures include periarcular ligamens, endons, bursae, muscle, ascia, bone, nerve, and overlying skin. ▪ Ligamens are rope like bundles o collagen brils ha connec bone o bone ▪ endons are collagen bers connecng muscle o bone ▪ Bursae  are paches o synovial uid ha cushion he movemen o endons and muscles over bone or oher join srucures.  Back pain (including lumbar spinal senosis) o Low back pain ▪ I he pain radiaes ino he legs, ask abou any associaed numbness, ngling, or weakness. Ask abou hisory o rauma. Check or bladder or bowel dysuncon. Middle back pain is seen in verebral collapse, disc herniaon, epidural Abscess, spinal cord compression, or spinal cord measases. Pain o he midline in muscle srain sacroiliis, rochaneric Bursis, sciaca, hip arhris, renal condions such as pyelonephris or renal sones. Sciaca i radicular glueal and poserior leg pain in he S1 disribuon ha increases wih cough or valsalva maneuver.  loss o bowel or bladder uncon is presen in cauda equina syndrome rom S2 o S4 umor or disc herniaon, especially i saddle aneshesia rom perianal numbness. ▪ Elici any red ags or serious underlying sysemic disease. Red ags or a low back pain rom underlying sysemic disease o age less han 20 years or older han 50 years. o hisory o cancer o unexplained weigh loss, ever, or decline in general healh o pain lasng more han one monh or no responding o reamen o pain a nigh or persisen a res o hisory o Iv drug use, addicon, or immunosuppression o presence o acve inecon or human immunodeciency virus inecon o long erm seroid herapy o saddle aneshesia o bladder or bowel inconnence o neurologic sympoms or progressive neurological deci o lower exremiy weakness o Mechanical low back pain ▪ aching pain in lumbosacral area; May radiae ino lower leg, along L5 or S1 dermaomes. Usually acue, work relaed, in age group 30 o 50 years; No underlying pahology ▪ Physical signs perispinal muscle or ace enderness, muscle spasm or pain wih back movemen, loss o normal lumbar lordosis bu no moor or sensory loss or reex abnormalies. In oseoporosis check or horacic kyphosis, percussion enderness over a spinous process, or racures in he horacic spine or hip o Sciaca (radicular low back pain) ▪ usually rom disc herniaon: more rarely rom nerve roo compression, primary or measac umor ▪ physical signs disc herniaon mos likely i cal wasng, weak ankle dorsiexion, absen ankle jerk, posive crossed sraigh leg raise (pain and aeced leg when healhy leg esed), negave sraigh leg raise makes diagnosis highly unlikely. o Lumbar spinal senosis ▪ pseudo claudicaon pain in he back or legs ha improves wih res, orward lumbar exion. Pain is vague bu usually bilaeral wih pareshesia in one or boh legs; Usually rom arhric narrowing o spinal canal. ▪ Physical signs posure may be exed orward wih lower exremiy weakness and hyporeexia: sraigh leg raise usually negave o chronic back sness  ▪ consider ankylosing spondylis in inammaory polyarhris, mos common in men under 40 years o age. Diuse idiopahic skeleal hyperososis (DISH) aecs men more han women, usually age older han 50. ▪ Physical signs loss o he normal lumbar lordosis, muscle spasm, limied inerior and laeral exion; i improves wih exercise. Laeral immobiliy o he spine, especially horacic segmen. o Nocurnal back pain, unrelieved by res ▪ consider measasis o spine rom cancer o he prosae, breas, lung, hyroid, and kidney, and mulple myeloma. ▪ Physical signs ndings vary wih he source. Local verebral enderness may be presen. o Pain reerred rom he abdomen or pelvis ▪ usually a deep aching pain he level o which varies wih he source ▪ physical signs spinal movemens are no painul and range o moon is no aeced. Look or signs o he primary disorder, such as pepc ulcer, pancreas, dissecng aorc aneurysm. Elbow pain (including epicondylis) o Laeral Epicondylis (ennis elbow) ▪ pain and enderness develop 1 cm disal o he laeral epicondyle and possibly in he exensor muscle close i. When paen ried o exend he wris agains resisance, pain increases. Rheumaoid arhris (RA) o Chronic inammaon o synovial membranes wih secondary erosion o adjacen carlage and bone, damage o ligamens and endons o common locaons ▪ hands (proximal inerphalangeal and meacarpophalangeal joins), ee (meaarsophalangeal joins), wris, knees, elbows, ankles o paern o spread ▪ symmerically addive: progresses o oher joins; Persis in inial ones o onse ▪ usually insidious o progression and duraon ▪ oen chronic wih remissions and exacerbaons o associaed sympoms ▪ requen swelling o synovial ssue in joins or endon shees; Also subcuaneous nodules. Tender, oen warm bu seldom red. Prominen sness oen greaer han one hour in he mornings Oseoarhris (OA) o The generaon and progressive loss o carlage wihin joins, damage o underlying bone, ormaon o new bone a margins o carlage o common locaons ▪ knees, hips, hands(disal, somemes proximal inerphalangeal joins), cervical and lumbar spine, and wris (rs carpomeacarpal join); also joins previously injured or diseased  o paern o spread ▪ addive; However, somemes only one join is aeced o onse ▪ usually insidious o progression and duraon ▪ slowly progressive, wih exacerbaon aer overuse o associaed sympoms ▪ small join eusions may be presen, especially in knees, also Boney and largemen. Tender, seldom warm or red. Frequen bu brie sness in he morning. Cervical/neck pain o Ask abou locaon, radiaon ino he shoulders or arms, arm or leg weakness, bowel, or bladder dysuncon. ▪ C7 or C6 spinal nerve compression rom oraminal impingemen is more common han disc herniaon o I he paen repors neck rauma, common in moor vehicle accidens, ask abou neck enderness and consider clinical decision rules ha ideny risk o cervical cord injury. o Mechanical neck pain ▪ aching pain in he cervical paraspinal muscles and ligamens wih associaed muscle spasm, sness, and ghness in he upper back and shoulder, lasng up o six weeks. No associaed radiaon, pareshesia, or weakness. Headache may be presen ▪ physical signs local muscle enderness, pain on movemen. No neurologic decis. Possible rigger poins and bromyalgia. Torcollis i prolonged abnormal neck posure and muscle spasm. o mechanical neck pain-whiplash ▪ also mechanical neck pain wih aching paracervical pain and sness, oen beginning he day aer injury. Occipial headache, dizziness, malaise, and ague may be presen period chronic whiplash syndrome his sympoms las more han six monhs, presen and 20 o 40% o injuries. ▪ Physical signs localized para cervical enderness, decreased neck range o moon, perceived weakness o he upper exremies. Causes o cervical cord compression such as racure, herniaon, head injury, or alered consciousness are excluded. o Cervical radiculopahy-rom nerve roo compression ▪ sharp burning or ngling pain in he neck and one arm, associaed wih pareshesia and weakness. Sensory sympoms oen in myoomal paern, deep in muscle, raher han dermaomal paern. ▪ Physical signs C7 nerve roo aeced mos oen in 45 o 60% o he me wih weakness and riceps and nger exors and exensors. C6 nerve roo involvemen also common, wih weakness and biceps, brachioradialis, wris exensors. o Cervical myelopahy-rom cervical cord compression  ▪ neck pain wih bilaeral weakness and pareshesia in boh upper and lower exremies, oen wih urinary requency. Hand clumsiness, palmer pareshesia, and gai changes maybe suble. Neck exion oen exacerbaes sympoms. ▪ Physical signs hyperreexia; Clonus a he wris, knee, or ankle; Exensor planar reexes (posive Babinski signs); and gai disurbances. May also see Lhermie sign: neck exion wih resulng sensaon o elecrical shock radiang down he spine. Conrmaon o cervical myelopahy warrans neck immobilizaon and neurosurgical evaluaon. Chapter 24 Nervous System Techniques o examinaon o When neurologic disease is suspeced, wo complemenary quesons should be addressed hroughou your assessmen. These quesons are no answered separaely, bu ineracvely as you learn abou he paen during he inerview and esablish your neurologic ndings ▪ wha is he locaon o he responsible lesions in he nervous sysem? ▪ wha is he underlying pahophysiology causing he disease? o he nervous sysem can be divided ino he cenral nervous sysem (CNS) and he peripheral nervous sysem (PNS). o Special echniques ▪ meningeal signs make sure here is no injury or racure o he cervical verebrae or cervical cord. This oen requires radiologic evaluaon. Brudzinski’s sign Anaomy o Brain- CNS ▪ he brain has our regions: he cerebrum, he diencephalon, he brainsem, and he cerebellum. Each cerebral hemisphere is subdivided ino ronal, parieal, emporal, and occipial lobes. ▪ The brain consiss o Gray maer and Myelinaed neuronal axons, or whie maer. ▪ Imporan srucures include he basal ganglia, he halamus, he hypohalamus, he brainsem (midbrain, pawns, and medulla), which connecs he corex wih he spinal cord, he recular acvang (arousal) sysem linked o consciousness, and he cerebellum o spinal cord- CNS ▪ he spinal cord exends rom he medulla o he rs or second lumbar verebrae ▪ he spinal cord is divided ino 5 segmens: cervical (C1 o C8), horacic (T1 o T12), lumbar (L1 o L5), sacral (S1 o S5), and Coccygeal. is roos an ou like a horses ail a L1 o L2, he cauda equina. ▪ conains imporan moor and sensory nerve pahways ha exi and ener he cour via anerior and poserior nerve roos and spinal and peripheral nerves. ▪ Mediaes he monosynapc muscle srech reexes.