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215 Cards in this Set
- Front
- Back
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rank of low back pain among reasons for clinical visits and rank for most common symptom of patients seeking care
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5th highest reason
2nd most common symptom |
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articular disease
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involves swelling and tenderness of entire joint and limits both active and passive ROM
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extra-articular disease
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involves selected regions of the joint and types of movement
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ligaments connect
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bone to bone
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list articular structures
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joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, juxta-articular bone
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list extra-articular structures
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periarticular ligaments, tendons, bursae, muscles, fascia, bone, nerve, overlying skin
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tendons connect
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muscle to bone
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bursae
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pouches of synovial fluid that cushion movement of tendons and muscles over bone or other joints
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synovial joints
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bones do not touch each other- joint articulations are freely moveable
- covered with articular cartilage and separated by a synovial cavity filled with synovial fluid |
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cartilaginous joints
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vertebral bodies
- slightly moveable - fibrocartilaginous discs separate the bony surfaces - center of each disc- nucleus pulposus |
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fibrous joints
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- skull sutures
- intervening layers of fibrous tissue or cartilage hold the bones together - allows no appreciable movement |
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spheroidal (bone and socket)
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- convex surface in concave cavity
- shoulder, hip - wide ranging flexion, ex, ab, ad, rot, circum |
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hinge
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- flat, planar
- motion in one plane; flexion, extenion - interphalangeal joints of hand and foot; elbow |
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condylar
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- convex or concave
- knee; TMJ - movement of two articulating surfaces not dissociable |
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fraction of adults with low back pain
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2/3
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what percentage of patients have idiopathic back pain
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85%
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think what for midline back pain
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musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metastases, epidural abscess
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think what for off the midline pain
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sacroiliitis, trochanteric bursitis, sciatica, hip arthritis
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presentation of sciatica
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radicular gluteal and posterior leg pain in S1 distribution that increases with cough or fever
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presentation of spinal stenosis
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leg pain that resolves with rest and/or lumbar forward flexion
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presentation of cauda equina syndrome
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bowel or bladder dysfunction (esp urinary retention and overflow incontinence)
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"red flags" for serious underlying systemic disease
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- age >50
- hx of CA - unexplained wt loss - pain > 1 month or that doesnt respond to treatment - pain at night or increased by rest - hx of IVD use - presence of infection |
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probability of serious systemic disease in cases of LBP (low back pain) plus a red flat
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10%
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most common radicular pain in the neck region
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spinal cord compression C7 followed by C6
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usual cause of radicular pain in the neck
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foraminal impingement from degenerative joint changes (not herniation)
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pain in one joint suggests
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trauma, monoarticular arthritis, tendinitis, bursitis
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lateral hip pain near greater trochanter suggests
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trochanteric bursitis
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migratory pattern of spread seen when
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rheumatic fever or gonococcal arthritis
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progressive additive pattern with symmetric involvement
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RA
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presentation of acute septic arthritis or gout
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severe pain of rapid onset in a red, swollen joint; maybe osteomyelitis in kids
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fever, chills, warmth, redness seen in?
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septic arthritis, gout, rhematic fever
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gelling
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stiffness and limited motion after inactivity in degenerative joint disease but usually lasts only a few minutes
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stiffness lasting 30 minutes or more
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RA
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systemic findings common in these arthritides
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RA, SLE, PMR
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papules, pustules, vesicles on reddened bases, on distal extremities
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conococcal arthritis
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expanding erythematous patch early in illness
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Lyme
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hives
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serum sickness, drug rxn
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erosions or scale on the penis and crusted, scaling papules on soles and palms
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Reiter's syndrome- arthritis, uveiitis, urethritis
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red, burning, itchy eyes
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Reiter's; Behcet's syndrome
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diarrhea, abdominal pain, cramping
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arthritis with UC, regional enteritis, scleroderma
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urethritis
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reiter's; gonococcal
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percentage of americans who are lazy as shit and live sedentary lifestyles
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20- 30%
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vulnerable area of the lower back involved with lifting
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L5-S1
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what percentage of the population experiences low back pain in life
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60-80%
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leading cause of non-fatal injuries and account for rise in death rates after age 65
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falls
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general population vs. 65-74 y.o. population vs. 85+ population for death rates related to falls
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5/100,000
10/100,000 147/100,000 |
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fraction of patients who regain prior level of function and of those who require nursing home placement
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1/3 each
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how many americans have osteoporosis and how many are at increased risk
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10 million
34 million |
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what percentage of patients with osteoporotic hip fractures die within 1 year
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20%
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osteopenia on the bone density scale
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1.0-2.5 standard deviations below the mean for young adult white women
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osteoporosis on bone density scale
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2.5 or more standard deviations below the mean for young adult white women
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who uses Z scores as a better measure
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young people, because it allows comparison with those of similar, age, ht, wt
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where is bone density measured
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hip, femoral neck, Ward's triangle, greater trochanter, total hip
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what drop in bone density is assd with what increase in risk for fracture
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10% drop in bone density is assd with a 20% increase in risk for fracture
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statistics for those with osteoporosis vs osteopenic groups and fracture risk
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relative risk is higher in those with osteoporosis but almost half of all fragility fractures occur in osteopenic group
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risk factors for osteoporosis
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- postmenopausal white women
- age >50 - wt less than 70 kg - family hx 1st degree relative (fract) - hx of fracture - alcohol intake - delayed menarche or early menopause - current smokers - low levels of 25-hydroxyvitamin D - use of corticosteroids for >2mo - other AI stuff |
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treatment for osteoporosis
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- calcium
- vitamin D (up to 2/3 with fractures are deficient) - antiresorptive agents- inhibit osteoclast activity and slow bone remodeling-- bisphosphonates, SERMs, calcitonin, postmenopausal estrogen - anabolic agents- PTH- stimulate bone formation by acting primarily on osteoblasts |
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subcutaneous nodules seen in
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RA or rheumatic fever
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effusions seen in
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trauama
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crepitus over inflamed joints
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osteoarthritis
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conditions where there is decreased ROM
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arthritis, inflammation, fibrosis around joint, bony fixation (ankylosis)
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palpable bogginess or doughiness of synovial membrane
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synovitis; accompanied by effusion
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osteomyelitis
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arthritis, tendinitis, bursitis
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DDx for nonarticular condition
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- trauma/fracture
- fibromyalgia - polymyalgia rheumatica - bursitis - tendonitis |
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possibilities if chronic noninflammatory arthritis that does not involve DIP, CMC1, hip, or knee joints
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- osteonecrosis
- Charcot joints |
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possibilities if chronic inflammatory arthritis involving 1-3 joints
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- indolent infection
- psoriatic arthritis - Reiter's - pauciarticular JA |
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most active joint in the body
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TMJ
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what makes up the TMJ
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fossa and articular tubercle of temporal bone and condyle of mandible
- midway between external acoustic meatus and zygomatic arch |
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principle muscles that open the mouth
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external pterygoids
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muscles that close the mouth and their innervation
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cranial nerve V
- masseter, temporalis, internal pterygoids |
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DDx for pain with chewing
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TMJ
trigeminal neuralgia temporal arteritis |
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dynamic stablers of the shoulder
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SITS
- Supraspinatus - Infraspinatus - teres minor - Subscapularis |
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function of SItS muscles
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move the humerus and depress and stabilize humeral head in glenoid fossa
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statis stabilizers of shoulder
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bone, labrum, articular capsule, glenohumeral ligaments
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labrum
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fibrocartilaginous ring that surrounds the glenoid and deepends its socker
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articular capsule
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formed by tendons of rotator cuff- adds to stability
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Supraspinatus
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- runs above glenohumeral joint; inserts on greater tubercle
- abduction |
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infraspinatus and teres minor
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-cross glenohumeral joint posteriorly; insert on greater tubercle
- external rotation |
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subscapularis
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- originates on anterior surface of scapula and crosses joint anteriorly; inserts on lesser tubercle
- internal rotation |
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axioscapular group
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- attaches the trunk to the scapula
- trapezius, rhomboids, serratus anterior, levator scapulae - rotate the scapula |
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axiohumeral group
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- attaches trunk to humerus
- pectoralis major and minor and latissimus dorsi |
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principal bursa of the shoulder
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subacromial bursa- between acromion and head of humerus and overlying supraspinatus
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when will subacromial bursa be painful if inflamed
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abduction and rotation
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shoulder muscles of flexion
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anterior deltoid, pectoralis major, coracobrachialis, biceps brachii
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shoulder muscles- extension
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lat, teres major, posterior deltoid, triceps brachii
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shoulder muscles- abduction
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supraspinatus, middle deltoid, serratus anterior
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how do you test pure glenohumeral motion
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raise arms to 90 degrees with palms facing down
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shoulder muscles adduction
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pec major, coracobrachialis, lat dorsi, teres major, subscapularis
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shoulder muscles- internal rotation
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subscapularis, anterior deltoid, pec major, teres major, lat
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shoulder muscles- external rotation
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infraspinatus, teres minor, posterior deltoid
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apley scratch test
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patient touches opposite scapula behind them; difficulty- rotator cuff
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neer's impingement sign
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press on scapula with one hand and raise pts arm with the other; compresses greater tuberosity of humerus against acromion
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hawkin's impingement sign
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flex patient's shoulder and elbow to 90 degrees with palm down; rotate arm internally; compress greater tuberosity against coracoacromial ligament
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empty can test- tests supraspinatus
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elevate arms to 90 degrees and internally rotate
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test infraspinatus how
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patient place arms at side and flex elbows to 90 degrees with thumbs up; resist as patient presses forearms out
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articulations of the radius, ulna, humerus
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humeroulnar joint, radiohumeral joint, radioulnar joint
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elbow flexion
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biceps brachii, brachialis, brachioradialis
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elbow extension
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triceps brachii, anconeus
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elbow supination
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biceps brachii, supinator
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elbow pronation
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pronator teres, pronator quadratus
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where does the ulnar nerve run by the elbow
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posteriorly in the ulnar groove between the medial epicondyle and the olecranon process
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location of the medial nerve at the elbow
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medial to the brachial artery
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tenderness distal to the epicondyle
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lateral epicondylitis
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when is the olecranon displaced posteriorly
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posterior disolcation of elbow and supracondylar fracture
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the carpal tunnel contains
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the sheath and flexor tendons of the forearm muscles and the median nerve
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median nerve sensory distribution (distal)
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palm and palmar surface of most of the thumb, second and third digits, and half of the fourth digit; innervates muscles of flexion, abduction, and opposition in thumb
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poor finger alignment seen in what kind of damage
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flexor tendon damage
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nodes in osteoarthritis
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Heberden's at DIPs
Bouchard's at PIPs |
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ulnar deviation seen when
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RA
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thenar atrophy
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carpal tunnel syndrome
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flexion contractures in the ring, 5th, and 3rd fingers are what and arise from what
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Dupuytren's contractures; from thickening of palmar fascia
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colles' fracture produces pain where on exam
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distal radius
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de Wuervain's tenosynovitis and gonococcal tenosynovitis present how
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tenderness over the extensor and abductor tendons of the thumb at the radial styloid
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tenderness over the "snuffbox"
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scaphoid fracture- most common injury of carpal bones
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wrist flexion
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flexor carpi radialis, flexor carpi ulnaris
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wrist extension
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extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis
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adduction (tested palm down)
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flexor carpi ulnaris
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abduction (tested palm down)
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flexor carpi radialis
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hand grip stregth tests
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wrist joints, finger flexors, intrinsic muscles of hand
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wrist pain and grip weakness
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deQuervain's tenosynovitis
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decreased grip strength
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arthritis, CTS, epicondylitis, cervical radiculopathy
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Finkelstein's test
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pain IDs de Quervain's tenosynovitis from inflammation of abductor pollicis longus and extensor pollicis brevis tendons and tendon sheaths
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why is there increased risk for disc herniation and subluxation, or slippage, of L5 on S1
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vertebral column angles sharply posterior at lumbosacral junction and becomes immovable
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neck stiffness think of
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arthritis, muscle strain, underlying pathology
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lateral deviation and rotation of the head suggest
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torticollis from contraction of SCM
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level of iliac crests
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L4
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tenderness in arthritis especially at the facet joints between which vertebrae
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C5 and C6
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"step-offs" felt on palpation of lower lumbar area in?
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spondylolisthesis
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spondylolisthesis
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forward slippage of one vertebra- may compress spinal cord
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tenderness over sacroiliac joint
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ankylosing spondylitis
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pain on percussion
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osteoporosis, infection, malignancy
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unequal shoulder heights seen in
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scoliosis, Sprengel's deformity of scapula; winged scapula; contralateral weakness of trap
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unequal heights of iliac crests of pelvic tilt
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leg length difference; scoliosis and hip abduction/adduction; listing in herniated lumbar disk
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what may overlie spina bifida
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birthmarks, port wine stains, hairy patches, lipomas
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cafe au lait spots in
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with skin tags and fibrous tumors in NF
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sciatic nerve roots and where it lies
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L4-S3; midway between the greater trochanter and ischial tuberosity as it leaves pelvis through sciatic notch
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most common herniated IV discs and tenderness they produce
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L5-S1; L4-L5; tenderness of spinous processes, IV joints, paravertebral muscles, sacrosciatic notch, sciatic nerve
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neck muscles of flexion
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SCM, scalene, prevertebral muscles
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neck muscles of extension
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splenius capitus and cervicis, small intrinsic neck muscles
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neck muscles of rotation
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SCM, small intrinsic neck muscles
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neck muscles of lateral bending
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scalenes and small intrinsic neck muscles
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muscles involved in flexion
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psoas major, psoas minor, quadratus lumborum; int/ext obliques and rectus abdominis
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muscles involved in extension
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erector spinae, transversospinalis
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bones of the pelvis, inferior and posterior connections
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- acetabulum, ilium, ischium
- inferiorly with symphysis pubis - posteriorly with sacroiliac bone |
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level of PSIS
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S2
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percentage of walking cycle when foot is on ground and bearing weight
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60%
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wide based gait suggests
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cerebellar problems
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hip dislocation, arthritis, abductor weakness can produce what type of gait
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cause pelvis to drop on opposite side- waddling gait
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width of the base from heel to heel
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2-4 inches
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leg shortening and external rotation suggests
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hip fracture
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inguinal ligament
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from ASIS to pubic tubercle
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relation of femoral contents to inguinal ligament
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structures bisect; NAVEL; lymph nodes are medial
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focal tenderness over the trochanter
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trochanteric bursitis
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"weaver's bottom"
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ischiogluteal bursitis; may mimic sciatica
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hip flexion
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iliopsoas
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hip extension
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gluteus maximus
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hip abduction
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gluteus medius and minimus
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hip adduction
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adductor brevis, adductor longus, adductor magnus, pectineus, gracilis
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hip external rotation
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internal and external obturators, quadratus femoris, superior and inferior gemelli
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internal rotation
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gluteus medius and minimus
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flexion deformity of the hip- when opposite hip is flexed
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affected hip does not allow full leg extension and affected thigh looks flexed
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quadriceps femoris muscles
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rectus femoris, vastus lateralis, vastus medialis
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hamstring muscles
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semimembranosus, gracilis, sartorius, semitendinosus
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describe medial and lateral menisci
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cushion action of femur on tibia; crescent-shaped; fibrocartilaginous
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describe MCL
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broad, flat ligament; connects medial femoral epicondyle to medial condyle of tibia
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describe LCL
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connects lateral femoral epicondyle to head of fibula
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describe ACL
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crosses obliquely from anterior medial tibia to lateral femoral condyle; prevents tibia from moving forward
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describe PCL
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crosses from posterior tibia and lateral meniscus to medial femoral condyle; prevents tibia from moving backwards
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prepatellar bursa lies where
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between patella and overlying skin
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anserine bursa lies where
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1-2 inches below the knee joint on the medial surface, proximal and medial to the attachments of the medial hamstring muscles on the proximal tibia
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signs of quadriceps weakness
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stumbling of pushing the knee into extension with the hand during heel strike
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genu varum vs genu valgum- lay terms
|
- bowlegs
- knock-knees |
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swelling over the patella
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prepatellar bursitis
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swelling over tibial tubercle
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infra-patellar or anserine bursitis
|
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think of what if presentation of bony ridges along joint margins, genu varum deformity, stiffness 30 minutes or less
|
osteoarthritis
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which meniscus is more likely to tear
|
medial (with trauma)
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pain and crepitus in patellofemoral grind test
|
roughening of patellar undersurface where it articulates with femur; also when climbing or getting up from a chair
|
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pain with compression during grind
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chondromalacia or degenerative patella (patellofemoral syndrome)
|
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housemaid's knee
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prepatellar bursitis from excessive kneeling
|
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anserine bursitis commonly from
|
running, valgus knee deformity, fibromyalgias, osteoarthritis
|
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popliteal or "baker's" cyst
|
from distention of gastrocnemius semimembranous bursa
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bulge sign
|
- for minor effusions
- have knee extended, left hand above knee, put pressure on suprapatellar puch and "milk" fluid downward - stroke downward on medial aspect of knee - tap lateral margin |
|
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positive bulge sign
|
fluid wave on medial side between patella and femur- consistent w effusion (minor)
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balloon sign
|
place thumb and index finger on either side of patella; with L hand compress suprapatellar puch against femur; feel for fluid entering in spaces next to patella under R thumb and index finger
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positive balloon sign
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with a large effusion suprapatellar compression ejects fluid into spaces adjacent to patella
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ballotting the patella
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push patella sharply against femur and watch for fluid to return to pouch
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Achilles tendon is common to which two muscles
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gastrocnemius and soleus
|
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ruptured Achilles tendon
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defect in muscles with tenderness and swelling
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Achilles tendonitis
|
thickening of tendon above calcaneus, with protuberant posterolateral bony process of calcaneus
|
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absence of plantar flexion
|
positive to indicate rupture of Achilles tendon
- sudden, severe pain, ecchymosis from calf to heel, and flat foot gait with absence of "toe-off" may be present |
|
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muscles of IR at knee
|
sartorius, gracilis, semitendinosus, semimembranosus
|
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muscles of ER at knee
|
biceps femoris
|
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McMurray test
|
pt supine; grasp heel and flex knee; cup hand over knee joint with fingers and thumb along medial and lateral joint line; from heel- rotate lower leg internally and externally; push on lateral side to apply a valgus stress on medial side of the joint
|
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to test MCL
|
apply valgus stress (abduction)
- (+) with pain or gap in medial joint line (ligamentous laxity and partial tear) |
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to test LCL
|
apply varus stress (adduction)
|
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positive anterior drawer sign makes ACL tear how many times more likley
|
11.5
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lachman test
|
knee in 15 degrees of flexion and external rotation
- grasp distal femur and upper tibia with other hand - with thumb of tibial hand on joint line, move the tibia forward and femur back |
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positive Lachman test makes ACL tear how many times more likely
|
17
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principle joints of the ankle
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tibiotalar, subtalar (talocalcaneal)
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plantar flexion of ankle powered by what muscles
|
gastrocnemius, posterior tibial muscle, toe flexors
- tendons run behind malleoli |
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dorsiflexion powered by what muscles
|
anterior tibial muscle, toe extensors
- lie on the anterior surface of the ankle, anterior to the malleoli |
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deltoid ligament
|
medially; fans out from inferior surface of medial malleolus to the talus and proximal tarsal bones- protects from eversion
|
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lateral ligaments
|
- anterior talofibular ligament
- calcaneofibular ligament - posterior talofibular ligament |
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which ligaments of ankle are most likely to be injured
|
lateral ligaments; most at risk from inversion= anterior talofibular ligament
|
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inserts on medial tubercle of calcaneus
|
plantar fascia
|
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plantar fasciitis presentation
|
focal heel pain on palpation of plantar fascia
|
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plantar fasciitis associated with
|
prolonged standing or heel-strike exercise; RA, gout
|
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post-trauma; can't bear weight after 4 steps and tenderness over posterior aspect of either malleolus- especially medial- think what
|
ankle fracture- Ottowa ankle rule
|
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metatarsalgia seen with what
|
trauma, arthritis, vascular compromise
|
|
|
Morton's neuroma
|
tenderness over 3rd and 4th metatarsal heads on plantar surface
|
|
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muscles of ankle flexion (plantar flexion)
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gastrocnemius, soleus, plantaris, tibialis posterior
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muscles of ankle extension (dorsiflexion)
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tibialis anterior, extensor digitorum longus, extensor hallucis longus
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muscles of ankle inversion
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tibialis posterior and anterior
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muscles of ankle eversion
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peroneus longus and brevis
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difference between pain elicited in arthritic joint vs ligamentous sprain
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arthritic joint- pain when moved in any direction
ligamentous strain- pain when ligament is stretched |
