Approach to Locomotor System

8/16/2019 Approach to Locomotor System

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Approach to LocomotorSystem

Dr. Ravi Kant

Assistant Professor

Department of General Medicine


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• Musculoskeletal complaints account for >!" millionoutpatient visits per year and nearly #$% of all

outpatient visits in the &nited States.

• 'he (enters for Disease (ontrol and Prevention estimate

that ##% )*+ million, of the &.S. population hasphysician-dianosed arthritis and !/ million have

sini0cant functional limitation.

• 'here are several urent conditions that must 1edianosed promptly to avoid sini0cant mor1id or mortal

se2uelae. 'hese 3red 4a3 dianoses include septicarthritis5 acute crystal-induced arthritis )e..5 out,5 and

fracture. 6ach may 1e suspected 1y its acute onset andmonarticular or focal musculoskeletal pain


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• Goals

• Accurate dianosis

• 'imely provision of therapy

• Avoidance of unnecessary dianostic testin Approach

Anatomic locali8ation of complaint )articular vs. nonarticular,• Determination of the nature of the patholoic

process)in4ammatory vs. nonin4ammatory,

• Determination of the e9tent of involvement)monarticular5polyarticular5 focal5 :idespread,

• Determination of chronoloy )acute vs. chronic, (onsiderthe most common disorders 0rst

• ;ormulation of a di


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Articular versus =onarticular

•

'he musculoskeletal evaluation must discriminatethe anatomic oriin)s, of the patients complaint.;or e9ample5 ankle pain can result from a varietyof patholoic conditions involvin disparateanatomic structures5 includin onococcal

arthritis5 calcaneal fracture5 Achilles tendinitis5plantar fasciitis5 cellulitis5 and peripheral orentrapment neuropathy.

• Distinuishin 1et:een articular and nonarticular

conditions re2uires a careful and detailede9amination. Articular structures include thesynovium5 synovial 4uid5 articular cartilae5intraarticular liaments5 ?oint capsule5 and

?u9taarticular 1one. =onarticular )or periarticular,structures5 such as supportive e9traarticular


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@n4ammatory versus

=onin4ammatory Disorders

• @n the course of a musculoskeletal evaluation5 the e9aminer shoulddetermine the nature of the underlyin patholoic process and:hether in4ammatory or nonin4ammatory 0ndins e9ist.

• @n4ammatory disorders may 1e infectious )infection :ith Neisseriagonorrhoea or Mycobacterium tuberculosis,5 crystal-induced )out5

pseudoout,5 immune-related rheumatoid arthritis )RA,5 systemiclupus erythematosus )SL6,B5 reactive )rheumatic fever5 reactivearthritis,5 or idiopathic.

• @n4ammatory disorders may 1e identi0ed 1y any of the fourcardinal sins of in4ammation )erythema5 :armth5 pain5 or

s:ellin,5• systemic symptoms )fatiue5 fever5 rash5 :eiht loss,5 or

• la1oratory evidence of in4ammation elevated erythrocytesedimentation rate )6SR, or (-reactive protein )(RP,5throm1ocytosis5 anemia of chronic disease5 or hypoal1uminemiaB.


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• Drug-induced lupus ydrala8ine5procainamide5 2uinidine5 phenytoin5car1ama8epine5 methyldopa5 isonia8id5

chlorproma8ine5 lithium5 penicillamine5tetracyclines5 '=; inhi1itors5 A(6 inhi1itors5ticlopidine Osteonecrosis Glucocorticoids5alcohol5 radiation5 1isphosphonates Osteopenia

Glucocorticoids5 chronic heparin5 phenytoin5methotre9ate

• Scleroderma Einyl chloride5 1leomycin5penta8ocine5 oranic solvents5 car1idopa5

tryptophan5 rapeseed oil• Vasculitis Allopurinol5 amphetamines5 cocaine5thia8ides5 penicillamine5 propylthiouracil5montelukast5 '=; inhi1itors5 hepatitis vaccine5

trimethoprimHsulfametho9a8ole


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Rheumatoloic 6valuation of the 6lderly

• 'he incidence of rheumatic diseases rises :ith ae5 such that "I% ofthose >+" years :ill have ?oint complaints.

• Musculoskeletal disorders in elderly patients are often not dianosed1ecause the sins and symptoms may 1e insidious5 overlooked5 orovershado:ed 1y comor1idities.

•

'hese diJculties are compounded 1y the diminished relia1ility ofla1oratory testin in the elderly5 :ho often manifest nonpatholoica1normal results.

• 'he elderly should 1e approached in the same manner as other patients:ith musculoskeletal complaints5 1ut :ith an emphasis on identifyin thepotential rheumatic conse2uences of medical comor1idities and

therapies. A5 osteoporosis5 out5 pseudoout5 polymyalia rheumatica5vasculitis5 and dru-induced disorders are all more common in the elderlythan in other individuals. 'he physical e9amination should identify thenature of the musculoskeletal complaint as :ell as coe9istin diseasesthat may in4uence dianosis and choice of treatment


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Rheumatoloic 6valuation of the

ospitali8ed Patient

• @npatient and outpatient evaluations and dianosticconsiderations may di


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• Acute monarticular in4ammatory arthritis may 1e a 3red 4acondition3 )e..5 septic arthritis5 out5 pseudoout, that :illre2uire arthrocentesis. o:ever5 ne:-onset polyarticularin4ammatory arthritis :ill have a :ider di


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Glossary of Musculoskeletal

'erms


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• Crepitus A palpa1le )less commonly audi1le,vi1ratory or cracklin sensation elicited :ith

?oint motion 0ne ?oint crepitus is common and

often insini0cant in lare ?oints coarse ?ointcrepitus indicates advanced cartilainous anddeenerative chanes )as in osteoarthritis,Subluxation Alteration of ?oint alinment

such that articulatin surfaces incompletelyappro9imate each other

• Dislocation A1normal displacement ofarticulatin surfaces such that the surfaces arenot in contact

• ange o! motion ;or diarthrodial ?oints5 thearc of measura1le movement throuh :hich the

?oint moves in a sinle plane


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• Contracture Loss of full movement resultin from a09ed resistance caused either 1y tonic spasm of muscle)reversi1le, or 1y 01rosis of periarticular structures)permanent,

•

De!ormity A1normal shape or si8e of a structuremay result from 1ony hypertrophy5 malalinment ofarticulatin structures5 or damae to periarticularsupportive structures

• "nthesitis @n4ammation of the entheses )tendinous

or liamentous insertions on 1one,• "picondylitis @nfection or in4ammation involvin an

epicondyle


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Approach to Reional Rheumatic

(omplaints

• Althouh all patients should 1e evaluated in aloical and thorouh manner5 many cases :ithfocal musculoskeletal complaints are caused 1ycommonly encountered disorders that e9hi1it a

predicta1le pattern of onset5 evolution5 andlocali8ation they can often 1e dianosedimmediately on the 1asis of limited historicinformation and selected maneuvers or tests.

Althouh nearly every ?oint could 1e approached inthis manner5 the evaluation of four commoninvolved anatomic reionsNthe hand5 shoulder5

hip5 and kneeNare revie:ed here


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and Pain


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Shoulder Pain


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Antinuclear Anti1ody )Ana,Patterns and (linical

Associations


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A=A Pattern Antien @denti0ed (linical (orrelate

Di


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Documents

Approach to Locomotor System