Ppt16

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 16
The Musculoskeletal System

Joint Structure and Function:
Anatomical Terminology
• Articular structures: include joint capsule and articular
cartilage, synovium and synovial fluid, intra-articular
ligaments, and juxta-articular bone
• Extra-articular structures: include periarticular ligaments,
tendons, bursae, muscle, fascia, bone, nerve, and overlying
skin
– Ligaments: ropelike bundles of collagen fibrils that connect
bone to bone
– Tendons: collagen fibers connecting muscle to bone
– Cartilage: collagen matrix overlying bony surfaces
– Bursae: pouches of synovial fluid that cushion the
movement of tendons and muscles over bone or other joint
structures

Types of Joint Articulation: Synovial,
Cartilaginous, and Fibrous
Synovial joint
• Joint is freely movable
• Bones are covered by articular
cartilage
• Bones are separated by
synovial cavity
• Synovial membrane secretes
synovial fluid that lubricates
joint movement
– Examples: shoulder, knee

Cartilaginous, and Fibrous (cont.)
Cartilaginous joint
• Joint is slightly movable
• Bones separated by
fibrocartilaginous discs
• Discs contain nucleus
pulposus that cushions
bony movement
– Examples: vertebral
bodies of the spine

Cartilaginous, and Fibrous (cont.)
Fibrous joint
• Joints have no
appreciable movement
• Bones separated by
fibrous tissue or cartilage
– Example: sutures of
the skull

Synovial Joints
Synovial Joints
Type of
Joint
Articular
Shape Movement Example
Spheroidal
(ball and
socket)
Convex
surface in
concave
cavity
Wide-ranging flexion,
extension, abduction,
adduction, rotation,
circumduction
Shoulder, hip
Hinge Flat, planar Motion in one plane;
flexion, extension
Interphalangeal
joints of hand
and foot; elbow
Condylar Convex or
concave
Movement of two
articulating surfaces
not dissociable
Knee; temporo-
mandibular
joint

Musculoskeletal System:
The Health History
Common or Concerning Symptoms
Low back pain
Neck pain
Monoarticular or polyarticular joint pain
Inflammatory or infectious joint pain
Joint pain with systemic features such as fever, chills,
rash, anorexia, weight loss, weakness
Joint pain with symptoms from other organ systems

Musculoskeletal System:
Tips for Assessing Joint Pain
• Ask the patient to “point to the pain”
– This saves considerable time since patient
descriptions of the location of the pain may be vague
• Clarify and record the mechanism of injury, particularly
if the joint pain is caused by trauma
• Determine whether the pain is:
– Localized or diffuse
– Acute or chronic
– Inflammatory or noninflammatory

Techniques of Examination:
Overview for Each of the Major Joints*
• Inspect for joint symmetry, alignment, or any bony
deformities
• Inspect and palpate surrounding tissues for any skin
changes, nodules, muscle atrophy, or crepitus
• Assess any degenerative or inflammatory changes,
especially swelling, warmth, tenderness, or redness
• Perform range of motion; use joint-specific maneuvers
to test:
– Joint function and stability
– Integrity of ligaments, tendons, and bursae
* Includes shoulder, wrist and hands, spine, hips, knees, and ankles. For examination of the temporomandibular,
elbow, and foot joints, refer to Chapter 16 in the textbook.

Important Bones of the Shoulder
• Review bony anatomy

Shoulder: Examination
• Inspect for swelling, deformity, muscle atrophy or
fasciculations, or abnormal positioning
• Palpate over the three bony landmarks and any areas
of tenderness
• Check range of motion: flexion, extension, abduction,
adduction, and internal (hands behind small of back)
and external (hands behind neck) rotation
• Perform maneuvers to assess:
– Acromioclavicular joint
– Subacromial and subdeltoid bursae
– Overall shoulder rotation (Apley scratch test)
– Rotator cuff

Question
A patient presents to you with shoulder pain after
falling during an ice storm. On examination, he
exhibits localized shoulder pain when you perform
the “crossover test” (arm moved across the chest
toward the opposite side while extended at the
elbow). Which of the following is the most likely site
of injury?
a. Rotator cuff
b. Bicipital tendon
c. Glenohumeral joint
d. Acromioclavicular joint

Answer
d. Acromioclavicular joint
• Localized tenderness or pain with adduction
suggests inflammation of the acromioclavicular
joint

Wrist and Hand: Review the Anatomy

Wrist and Hand: Examination
• Inspect for smoothness of motion, surface contour,
alignment of wrist and fingers, and any bony deformities
– At rest, the fingers should be slightly flexed and
aligned almost in parallel
• Palpate
– Distal radius and ulna at the wrist, the eight carpal
bones, and the MCP, PIP, and DIP joints for swelling
or tenderness
– “Anatomic snuffbox” just distal to the radial styloid
process with lateral extension of thumb away from
hand

Wrist and Hand: Examination (cont.)
• Check range of motion
– Wrist: flexion, extension, ulnar (abduction) and
radial (adduction) deviation
– Fingers: flexion, extension, abduction (fingers
spread apart), adduction (fingers back together)
– Thumb: flexion, extension, abduction (thumb
moves away from palm), adduction (thumb
moves toward palm), opposition (thumb
touches each finger)
• Test hand grip strength
• Test sensation on the palmar and dorsal surfaces
innervated by the median, ulnar, and radial nerves

Wrist and Hand: Carpal Tunnel Syndrome
• Clinical features
– Pain or numbness of the first three fingers of the hand,
but not in the palm, especially at night
– Loss of sensation in distribution of the medial nerve:
palmar surface of thumb, index, middle, and medial
4th fingers
• Assess
– Weak abduction of the thumb: most sensitive test
– Tinel’s sign: tingling with tapping over the median
nerve as it enters the carpal tunnel
– Phalen’s sign: numbness or tingling with pressing
backs of hands together in acute flexion for 60 seconds

Question
A patient who presents to clinic complaining of hand pain
says she was told by a friend that it is most likely carpal
tunnel syndrome. Upon assessing the patient, you note
the following findings. Which would be suggestive of
carpal tunnel syndrome?
a. Hand pain when holding both hands in acute
extension
b. Numbness and tingling when tapping over the
course of the radial nerve
c. Symptoms related to compression are evident in all
of the fingers
d. None of the above

Answer
d. None of the above
• The symptoms of carpal tunnel syndrome are:
– Numbness or tingling with pressing backs of
hands together in acute flexion for 60 seconds
– Tingling with tapping over the median
nerve as it enters the carpal tunnel
– Pain or numbness of the first three fingers of
the hand, but not in the palm

Spine: Anatomy of Representative
Cervical and Lumbar Vertebrae
• 7 cervical, 12 thoracic, and 5 lumbar vertebrae are stacked on
the sacrum and coccyx
• Review the anatomy below:

Spine: Muscle Groups

Spine: Examination — Inspection
• With patient in gown,
directly inspect:
– From the side
o Cervical, thoracic,
and lumbar curves
– From behind
o Upright spinal column
o Alignment of the
shoulders, iliac crests,
and the gluteal folds
o Skin markings, tags,
or masses

Spine: Examination — Palpation
• Palpate
– With patient standing or
sitting
o Spinous processes of
each vertebrae
o Facet joints in the
neck
o Lower lumbar area
for vertebral “step-
offs” or tenderness
– Paravertebral muscles for
tenderness or spasm
– Sacroiliac joint

Spine: Examination — Range of Motion
• Neck
– Flexion and extension: chin to chest, look up at
ceiling
– Rotation and lateral bending: look over one
shoulder and then the other; bring ear to shoulder
• Spine (support the patient during exam if necessary)
– Flexion and extension: bend forward and try to
touch toes; bend backward
– Rotation and lateral bending: rotate trunk (pull
shoulder and then the opposite hip posteriorly);
bend to side from waist

Hip: Review Bony Anatomy and Bursae

Hip: Examination — Inspection
• Inspect two phases of gait
– Swing (foot moves forward, non-weight bearing)
and stance (foot on ground, weight bearing)
o Assess width of base (2-4 in. heel to heel),
shift of the pelvis (smooth and continuous),
and flexion of the knee (flexed throughout
stance phase)
• Inspect anterior and posterior surfaces of the hip
for muscle atrophy or bruising

Hip: Examination — Palpation
• Palpate bony landmarks
– Anterior aspect: iliac crest, iliac tubercle,
anterior superior iliac spine, greater trochanter,
pubic symphysis
– Posterior aspect: posterior superior iliac spine,
greater trochanter, ischial tuberosity, sacroiliac
joint
• Inguinal ligament

Hip: Examination – Range of Motion
• Assess
– Flexion – bend knee to chest and pull against
abdomen; check for flexion deformity (opposite knee
goes into flexion)
– Extension – leg extends posteriorly with patient
carefully positioned near edge of table
– Abduction and adduction – reach across and
grasp opposite hip; grasp ankle and move leg
laterally, then medially, toward opposite hip
– External and internal rotation – flex hip and knee
to 90°, grasp ankle, rotate flexed lower leg medially
then laterally

Knee: Review the Anatomy
• Identify bony structures
on the medial, anterior,
and lateral surfaces
• Joints
– Two condylar
tibiofemoral joints
– Patellofemoral joint
– Trochlear groove
• Ligaments
– MCL, LCL, ACL, PCL
• Medial and lateral menisci

Knee: Examination — Inspection and
Palpation
• Inspect
– Contours and alignment of knees for swelling
– Atrophy of quadriceps muscle
– Knee action during swing and stance phases of gait
• Palpate (patient sitting)
– Infrapatellar spaces adjacent to patella
– Medial and lateral femoral epicondyles and
condyles
– Medial and lateral margins of tibial plateau
– Insertion of patellar tendon at the tibial tubercle

Knee: Examination — Palpation
• Palpate, with the knee flexed, and note any tenderness:
– Along the joint line, including menisci and bursae
– Along the medial and lateral collateral ligaments
(MCL and LCL)
– Over the patellar tendon. If tender, compress the patella
against the femur and check knee extension
• Palpate:
– Over the suprapatellar bursa above the knee
– Prepatellar bursa over the patella
– Pes anserine bursa on posteromedial knee
• If swelling, palpate for bulge sign or balloon sign, or
“balotte” the patella

Knee: Examination —
Range of Motion and Maneuvers
• Assess range of motion, with patient sitting:
– Flexion and extension
– Internal and external rotation – patient rotates foot
medially and laterally
• If pain or swelling, use maneuvers to test stability of
ligaments and integrity of menisci
o MCL – abduction or valgus stress test
o LCL – adduction or varus stress test
o Anterior cruciate ligament (ACL) – anterior drawer
sign, Lachman test
o Posterior cruciate ligament (PCL) – posterior
drawer sign
o Medial and lateral menisci – McMurray test

Ankle and Foot: Review the Anatomy
Note: Pay particular attention to the bony medial and lateral malleoli, the triangular deltoid
ligament medially, and the three less stable ligaments laterally.

Ankle and Foot: Examination —
Inspection and Palpation
• Inspect the surfaces of the ankles and feet for any
deformities, nodules, swellings, calluses, or corns
• Palpate
– Anterior aspect of each ankle joint for bogginess,
swelling, tenderness
– Achilles tendon for nodules or tenderness
– Heel for tenderness
– Medial and lateral malleolus for tenderness
– Metatarsophalangeal joints for tenderness
– Heads of the 5 metatarsals by compressing
between your thumb and index finger

Ankle and Foot: Examination —
Range of Motion
• Ankle flexion (plantar flexion)
– Point foot toward the floor
• Ankle extension (dorsiflexion)
– Point foot toward the ceiling
• Inversion
– Bend heel inward
• Eversion
– Bend heel outward

Ankle and Foot: Examination — Maneuvers
• Assess range of motion
– Tibiotalar joint (ankle)
o Dorsiflex- and plantar-flex the foot at the ankle
– Subtalar (talocalcaneal) joint
o Stabilize the ankle and grasp the heel; invert
and evert the heel
– Transverse tarsal joint
o Stabilize the heel; invert and evert the forefoot
– Metatarsophalangeal joints
o Flex toes in relation to the feet

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