Download - Examination of Muscles and Bones 2009
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Examination of muscles and
bones
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Muscular diseases
Important cause for invalidity, temporary orpermanent
Determined by loss of functionality of:
o Muscular fibers
o Innervations
o Blood supply
o Adjacent connective tissues Motor unit: composed by a neuron and the
totality of muscle fibers innervated by it;mechano-receptors: muscular tonus
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The neuro-muscular unit
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Etiology
Muscular: dystrofias, infections,
inflammatory diseases, trauma
Neurological: central and lower neuronsyndromes, pyramidal syndrome, extra-
pyramidal syndrome, dysfunction of the
neuro-muscular connection
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Symptoms
Subjective:
o Pain = Myalgia
Objective:o Weakness
o Atrophy (hypotrophy)
o Hypertrophy, tumefaction, inflammatory
symptomso Modification in muscular tonus
o Tremor, involuntary movements, myoclonia
o Diminution of muscular straight
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Examination
Inspection
Passive (static time) - distribution
- symmetry
Active (dynamic time) - tonus
- kinetics
Palpation passive/ active
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Lab and procedures
Lab determinations:
o CK, LDH, TGO
o Calcium, other electrolytes
EMG (electromyography)
Muscle biopsy Immunological and genetic testing
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Myalgia
= muscular pain
Diffuse: acute
chronic
Localized
- Febrile syndrome
- Infectious (influenza, bacterial and parasitic)/ Vaccinations
- Electrolyte disturbances: hypokalemia
- Alcoholism/ withdrawal
- Adverse reaction of drugs (statins)- Exercise: over-use or over-stretching
- Autoimmune: multiple sclerosis
- Metabolic myopaties: glycogenosis
- chronic fatigue syndrome
-Trauma
-Intermittent: claudication
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Weakness
= ("lack of strength") is a direct term for the inability to exert
force with one's muscles to the degree that would be
expected given the individual's general physical fitness.
- Perceived/ True
- Proximal: bilateral - myopathies- Distal: bilateralneuropathies
- Proximal, induced by exercise, improved by rest:
myastenia gravis
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Atrophy
= reduction in muscle(s) mass; appreciated by the
disappearance of muscle contour, more easily when is
asymmetrical
- Primary:o Neuromuscular diseases
- Secondary:-Part of cachexia (cancer, AIDS)
- Inactivity/ bed rest
- Organ failure: heart, liver
-Poliomyelitis
- Lateral amyotrophic sclerosis
- Pyramidal syndrome, mononevritis
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Hypertrophy
Increase of muscle mass
- Secondary to chronic overuse:
- occupational
- myotonia (Thomsen/ Beckers
diseases)
- Pseudo-hypertrophy: parasitic
infiltration= cysticercosis
- Localized tumefaction: amyloidosis,
sarcoidosis neo lazia hematomas
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Disturbances of muscle tone
Muscle tone (tonus) = the ability of muscles to respond to
abrupt straight; involuntary; not to be confused with
mass/force; responsible for maintaining body posture.
- Diminishedhypotonia
Congenital: genetic disorders (Down syndrome); congenital hypothyroidism
Acquired: infectious (meningitis, encephalitis, polio); hypothyroidism;
hypervitaminoses
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Disturbances of muscle tone
spasticity: lesion of the upper motor neuron (pyramidal syndr.)- pocket knife
rigidity: extra-pyramidal syndr., cog-wheel
localized: antalgic contacture
trismus (lockjaw): temporo-mandibular arthritis, pericoronitis, peri-tonsillarabscesses
tetanic contractions: alcalosis, hypocalcemia, adverse drug reactions
- Increased= hypertonia
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Involuntary movements
Seizures = paroxysmal events that interest
whole muscles
Myoclonus = brief, involuntary twitching of a
muscle or a group of muscles; contractions are
calledpositive myoclonus, relaxations are callednegative myoclonus.
Epilepsy
Head or spinal cord injury, brain tumors
Essential myoclonus: benign, sometimes inherited
Post-hypoxemia
Epilepsy; tumor/head trauma/ intra-cranian hypertension
Hypoglycemia; cardiac/circulatory arrest; any profound metabolic imbalance
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Involuntary movements Hemiballismus = unilateral wild, large amplitude, movements
of the arm and leg, normally causing falls and preventingpostural maintenance.
Chorea = nonrhythmic, jerky, rapid, nonsuppressibleinvoluntary movements, mostly of distal muscles or the face;movements may merge imperceptibly into purposeful orsemipurposeful acts that mask the involuntary movements.
Athetosis is nonrhythmic, slow, writhing, sinuous movementspredominantly in distal muscles, often alternating withpostures of the proximal limbs to produce a continuous,flowing stream of movement
Choreoathetosis
Huntingtons disease= common cerebellar, autosomal dominant disorder
Sydenhams choreea = rheumathic fever
lesion, usually an infarct, around the contralateral subthalamic nucleus
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Tremor
= rhythmic, alternating, or oscillatory movements
- Resting tremor = maximal at rest and decreaseswith activity - Parkinson's disease.
- Postural tremor = maximal when a limb ismaintained in a fixed position against gravity.
- Intention tremor = maximal during movementtoward a target, as in finger-to-nose testing -cerebellar disorder, multiple sclerosis, Wilson's
disease.
Essential= gradual onset
Abrupt onset = metabolic, drug adverse reactions
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Diminution of muscular straight
= difficulty/ impossibility of conducting of aspecific movement
Total = Paralysis // Partial = Paresis
Generalized // Localized
Acute // Chronic
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Paralysis/paresis
Hemiplegia
Paraplegia
Quadriplegia
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Examination of bones
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Clinical examination
Inspection General/ on each segment
Steps - static: appreciates integrity and
symmetry
- dynamic: finds abnormal movements
Palpation
Follows inspections steps, confirms observations,determines relationship with neighboring tissues formodifications
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Clinical examination
Percussion
Detects/elicit sensibility (=low-grade pain)
Can appreciate consistency/ structure oftissue composing deformations
Auscultation
Can detect bones crackles
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Symptoms
As a rule:
Uniloculate modification --- orthopedic or trauma
Multiloculate affectation --- another cause
Pain
Tumefactions/ tumors
Bones deformations
Fractures
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Pain
Easy to be recognized, confined to the affectedregion
Permanent, exacerbated with movement and
percussion Associates systemic symptoms:
Pain + fever = acute osteomyelitis
Pain + low grade fever, asthenia, loss of appetite =
chronic osteomyelitis
Neuralgic type + deformation of plain bones = syphilis
Localized to cranium, tibia, clavicle, sternum ribs(spares the pelvis) = multiple myeloma
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Tumefaction/ tumors
Callus = bone healing after a fracture History = the fracture
Vicious callus = can determine functionaldisturbances or compress/ include anatomicalstructures
Osteomyelitis (infection of the bone or
bone marrow) Discrete tumefaction, with imprecise margins,
extremely painful
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Tumefaction/ tumors
Benign tumors/ cysts Palpable after they reach certain dimensions
Well delimitated
More easily palpable when superficial, skin above- evidentvenous circulation
Not adherent to superficial structures
Malignant tumors If palpable= they surpassed bones cortex
Painful spontaneous, exacerbated with palpation Adherent
Imprecise delimited
Thick external layer, fluctuent content = multiple myeloma
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Bone deformation
Does not affect bones integrity
Scimitar tibia- congenital syphilis
Scimitar femur and diaphysishypertrophy- Pagets disease of
bone
rickets = twisting of long bones +
genu valgum/ varum, Harrisons
groove, ribs rosary
Acromegaly
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Fractures
= a break in the continuity of the bone
On normal bone // on pathological bone,primarily by history
Favored by:
Osteoporosis
Protein depletion (cirrhosis, nephrotic syndr)
Lack of physical exercise
Hypogonadism, menopause,hyperparathyroidism, hypercorthicism
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Symptoms
intense pain in a localized point,
loss of functionality,
deformations of the region, eventuallyshortening of a limb,
abnormal mobility (!),
crackles, echimosis/ hematoma
Vicious position (ex: fracture of the head of
femur)
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Osteoporosis
= disease of the skeleton in which the bone
mineral density (BMD) is reduced and
bone architecture is disruptedDiagnosis = BMD < 2,5 standard deviations
below peak bone mass
Causes post-menopausal- glucocorticoid treatment/
Cushing syndrome