HIPPP PDF - Musculoskeletal System

Musculoskeletal system (206 BONE IN BODY) Basic terminology ○ Joint– articulation of bone ○ Ligament – connect bone to bone ○ Tendon– connect muscle to bone ○ Bursae – fluid filled sac to reduce friction ○ Cartilage – connective tissue, articular vs fibrous ○ Strain – injury to muscle/ tendon ○ Spra...

Musculoskeletal system (206 BONE IN BODY) Basic terminology ○ Joint– articulation of bone ○ Ligament – connect bone to bone ○ Tendon– connect muscle to bone ○ Bursae – fluid filled sac to reduce friction ○ Cartilage – connective tissue, articular vs fibrous ○ Strain – injury to muscle/ tendon ○ Sprain – injury to ligament contusion-bruise ○ Fracture- break in the continuity of the bone ○ Dislocation – ends of joints of 2 bones forcibly separated ○ Subluxation – partial dislocation of a joint ○ -itis– inflammation of tendinitis, bursitis, arthritis Describing location Musculoskeletal elimination ○ History of present illness Traumatic vs non-traumatic? Mechanism of injury? Determine whether pain is: Localized or diffuse Acute or chronic Inflammatory or noninflammatory Review of systems ○ Does anything suggest that this problem is organic Weight gain/loss Urinary or bowel complaints Nausea or vomiting Dizziness Abdominal and back pain Chest pain and back pain Significant weakness Polyarticular Fever redness/warmth over multiple joints ??? History ○ Onset- acute or chronic ○ Palliative – rest or activity ○ Provocative– standing, sitting, movement ○ Quality – deep, boring pain ○ Radiation – is primary area of complaint cause of pain ○ severity – 1-10 (good for grading response to treatment) ○ Timing- night pain without injury Tips for assessing MS pain ○ Ask the patient to “point to the pain” Sometimes you have to coach the patient a bit ○ Claridy the mechanism of injury (MOI) Describe how it happened. Did anyone else see or hear it? ○ Determine whether the pain is Localized or diffuse Acute or chronic Inflammatory or noninflammatory ○ Think about causes, primary MS, referred, organic Organic (systemic) pathology can present with MS symptoms Be aware of age related changes Examination ○ Observation ○ Inspect ○ Palpate Assess (AROM/PROM) ○ Perform (special tests) Observe posture and habitus ○ Is the patient antalgic? (painful gait, limping) ○ Guarding? ○ How is the patient moving ? ○ Examine posture form back, side and front Arch of feet ( pes planus, pes cavus) Knee (valgus, varus) Hips (pelvis) SI joints Thoraco-lumbar spine (scoliosis/curvature) Head carriage Inspect and palpate ○ Inspect patient’s movement ○ Observe patient’s comfort level ○ Symmetry ○ Alignment ○ Deformity ○ Skin changes ○ Nodules ○ Atrophy ○ Crepitus Asses ○ Inflammation ○ Level of pain ○ Swelling ○ Warmth ○ Tenderness ○ Redness Perform ○ Range of motion ○ Special tests Range of motion: ○ There are 2 phases of range of motion: Active (by the patient) AROM Passive (by the examiner) PROM If patient have painful joints, move them gently or let patients demonstrate the movements themselves, showing you how they manage For injured joints with concern for fracture, consider an x-ray before attempting movement Test active and passive ROM to assess for: Limitations in ROM which may be present for arthritis, joints with effusion, joints with tissue inflammation or surrounding fibrosis or bony fixation (ankylosis) Joint instability from excess mobility of joint ligaments, called ligamentous laxity Examination techniques by area ○ Spine ○ Pelvis and hips ○ Shoulder ○ Upper extremity ○ Lower extremity ○ Remember: multiple areas may be injured (MOI?) C/spine and shoulder Double crush knee/hip/low back The vertebral spine ○ The vertebral column or spine is the central supporting structure of the trunk and back. ○ The concave curves of the cervical and lumbar spine and convex curves of the thoracic and sacrococcygeal spine helps distribute upper body weight to the pelvis and lower extremities and cushion the concussive impact of walking or running ○ The complex mechanics of the back reflect the coordinated action of: Vertebrae and intervertebral discs An interconnecting system of ligaments between anterior vertebrae and posterior vertebrae. Ligament between the spinous processes, and ligaments between the lamina of 2 adjacent vertebra Large superficial muscles, deeper intrinsic muscles, and muscles of the abominable wall Spine exam Keys to examination of vertebral spine Spine: inspection ○ With patient in gown, or shirt off inspect: From the side From behind The spine ○ Inspection, palpation, ROM Inspection Alignment in sagittal and coronal plane (e.g., kyphotic spine) Prior surgical scars Skin defects ( e.g., cafe au lait spots associated with neurofibromatosis) Muscle atrophy Palpation Palpate local tenderness on the spinal axis, facets, paravertebral muscles ROM Document range of motion in flexion, extension, rotations and bend Normal range of motion of spine Cervical spine ○ BATES ROM of thoracolumbosacral spine ○ Movement Flexion ○ Primary muscle affecting movement Psoas major, psoas minor, and quadratus lumborum; abdominal muscles attaching to the anterior vertebrae, such as internal and external obliques and rectus abdominis ○ Movement Extension ○ Primary muscles affecting movement Deep intrinsic muscles of the back, such as the erector spinae, transversospinalis groups, iliocostalis, longissimus, and spinalis ○ Movement Rotation ○ Primary muscles affecting movement Abdominal muscles and intrinsic muscles of the back ○ Movement Lateral bending ○ Primary muscles affecting movement Abdominal muscles and intrinsic muscles of the back The spine Cervical radiculopathy ○ Deep tendon reflexes Biceps (C5, part of C6) Brachioradialis (C6) Tricep (C7) Spurling’s Test-cervical radiculopathy ○ Spurling’s test Compression test Axial load Pain reproduced Cervical distraction Pain relieved ○ The spurling test is positive when the patient feels pain going down the arm on the same side the head is turned and indicates cervical nerve root involvement. Its sensitivity varies from moderate to high (38% and 97%), but it has a high specificity (89% to 100%) Pelvis and hips ○ The hip joint lies below the middle third of the inguinal ligament but in a deeper plane. ○ It is a ball and socket joint ○ Note how the rounded head of the femur articulates with the cup-like activity of the acetabulum ○ Because of its overlying muscles and depth, the hip joint is not readily palpable. ○ Review the bones of the pelvis – the ilium, the ischium, and the pubis – and the connection inferiorly at the symphysis pubis and posteriorly with the sacrum. ○ Recognize that the acetabulum is a confluence of all 3 bones of the pelvis ○ Inspection: Inspection of the hips begins with careful observation of the patient’s gait when entering the room Observe the two phases of gait: Stance– when the foot is on the ground and bears weight (normal 60% of the normal gait cycle) Swing– when the foot moves forward and does not bear weight (40% of the normal gait cycle) Most hip problems appear during the weight-bearing stance phase Pelvis and hips ○ On the anterior surface of the hip, locate the following bony structure Iliac crest at level l4 Iliac tubercle Anterior superior iliac spine Greater tubercle Pubic tubercle Pubic symphysis ○ On the posterior surface of the hip, locate the following Posterior superior iliac spine at the level of S2 Greater trochanter Ischial tuberosity Sacroiliac joint ○ The flexor group lies anteriorly and flexes the hip. The primary hip flexor is the iliopsoas, a confluence of the iliacus and psoas muscle that originate at the iliac crest and on the lumbar spine, respectively, and extend to the lesser trochanter ○ The adductor group is medial and pulls the thigh toward the body. The muscles in this group aris from the rami of the pubis and ischium and insert on the posteromedial aspect of the femur ○ The ABDUCTOR group is lateral and extends from the iliac crest to the greater trochanter, pulling the thigh away from the body. This group includes the gluteus medius and minimus. These muscles help stabilize the pelvis during the stance phases of gait ○ With the patient supine, ask the patient to place the heel of the leg being examined on the opposite knee. Then palpate all the inguinal ligament which extends from the anterior- superior iliac spine to the pubic tubercle ○ Bulges along the ligament suggest an inguinal hernia or at times, an aneurysm, although these may be difficult to palpation unless they are significant ○ Enlarged lymph nodes point to infection in the pelvis or lower extremity ○ Causes of groin tenderness may include tendonitis/tendinopathy of the adductor or iliopsoas tendons, pubic symphysitis, femoral or inguinal hernias, synovitis of the hip joint, arthritis, bursitis or possible psoas abscess ○ Focal tenderness over the trochanter indicates greater trochanteric pain syndrome, which is rarely caused by bursitis and may indicate tendinopathy of the gluteus medius. Tenderness over the posterolateral surface of the greater trochanter occurs in localized tendinitis, muscle spasms from referred hip pain, and iliotibial band tendonitis ○ If the hip is painful, palpate the psoas bursa underneath the inguinal ligament. With the patient resting on one side and the hip flexed and internally rotated, palpate the trochanteric bursa lying over the greater trochanter ○ Flexion With the patient supine, place your hand under the patients lumbar spine Ask the patient to bend each knee in turn up to the chest and pull it firmly against the abdomen Note that the hip can flex further when the knee is flexed because the hamstrings are relaxed. When the back touches your hand, indicating normal flattening of the lumbar lordosis, further flexion must arise from the hip joint itself. As the thigh is held against the abdomen, inspect the degree of flexion at the hip and knee ○ External and internal rotation Flex the leg 90* at hip and knee, stabilize the high with one hand, graph the ankle with the other, and swing the lower leg– medially for external rotation at the hip and laterally for internal rotation Although confusing at first, it is the motion of the head of the femur in the acetabulum that identifies these movements ○ Adduction: With the patient supine, stabilize the pelvis, hold one ankle and move the body and over the opposite extremity Toward body ○ Abduction: Stabilize the pelvis by pressing down on the opposite anterior– superior iliac spine with one hand. With the other hand, grasp the ankle and abduct the extended leg until you feel the iliac spine move. This movement marks the limit of hip abduction Away from body ○ Test for groin strain (labral tear) When groin strain is suspected due to sudden forced abduction of the hip from sports injury that requires lateral movement or pivoting, you may test for reproducible pain with FABER (Flexion, Abduction, external rotation) or Patrick test With the patient supine, position the leg into 90* of flexion and externally rotate and abduct it so that the ipsilateral ankle rests distal to the knee of the contralateral leg ○ Test for hip flexion deformity This can be tested using the kendall test. Start with the patient in the sitting position with the patient's thighs half off the examining table. Then ask the patient to lie down and flex the uninvolved leg towards the chest and hold just enough to flatten the lower back on the table The other knee should be at the edge of the table with the knee free to flex Normally, with the low back and sacrum flat on the table, the posterior thigh should touch the table and the knee passively flexes