examination of muscles and bones 2009

8/10/2019 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

examination of muscles and bones 2009

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