Examination of muscles and

bones

Muscular diseases

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Important cause for invalidity, temporary or

permanent
Determined by loss of functionality of:
Muscular fibers
Innervations
Blood supply
Adjacent connective tissues
Motor unit: composed by a neuron and the totality of
muscle fibers innervated by it; mechano-receptors:
muscular tonus

The neuro-muscular unit

Etiology
Muscular: dystrofias, infections,
inflammatory diseases, trauma
Neurological: central and lower neuron
syndromes, pyramidal syndrome, extrapyramidal syndrome, dysfunction of the
neuro-muscular connection

Symptoms

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Subjective:
Pain = Myalgia
Objective:
Weakness
Atrophy (hypotrophy)
Hypertrophy, tumefaction, inflammatory
symptoms
Modification in muscular tonus
Tremor, involuntary movements, myoclonia
Diminution of muscular straight

Examination

Inspection

Passive (static time) - distribution

- symmetry

Active (dynamic time) - tonus

- kinetics

Palpation

passive/ active

Lab and procedures

Lab determinations:
o CK, LDH, TGO
o Calcium, other electrolytes
EMG (electromyography)
Muscle biopsy
Immunological and genetic testing

Myalgia
= muscular pain

Diffuse: acute

- Febrile syndrome
- Infectious (influenza, bacterial and parasitic)/
Vaccinations
- Electrolyte disturbances: hypokalemia
- Alcoholism/ withdrawal
- Adverse reaction of drugs (statins)
- Exercise: over-use or over-stretching

chronic

Localized

- Autoimmune: multiple sclerosis

- Metabolic myopaties: glycogenosis
- chronic fatigue syndrome

-Trauma
-Intermittent:
claudication

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.
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Perceived/ True

Proximal: bilateral - myopathies

Distal: bilateral neuropathies
Proximal, induced by exercise, improved by rest: myastenia
gravis

Atrophy
= reduction in muscle(s) mass; appreciated by the
disappearance of muscle contour, more easily when is
asymmetrical
-Poliomyelitis
- Lateral amyotrophic sclerosis

Primary:

Neuromuscular diseases
- Pyramidal syndrome, mononevritis

Secondary:
-Part of cachexia (cancer, AIDS)
- Inactivity/ bed rest
- Organ failure: heart, liver

Hypertrophy

Increase of muscle mass

- Secondary to chronic overuse:
- occupational
- myotonia (Thomsen/ Beckers diseases)
- Pseudo-hypertrophy: parasitic infiltration=
cysticercosis
- Localized tumefaction: amyloidosis, sarcoidosis,
neoplazia, hematomas

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.
- Diminished hypotonia
Congenital: genetic disorders (Down syndrome); congenital
hypothyroidism
Acquired: infectious (meningitis, encephalitis, polio); hypothyroidism;
hypervitaminoses

Disturbances of muscle tone

- Increased= hypertonia

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, peritonsillar abscesses
tetanic contractions: alcalosis, hypocalcemia, adverse drug
reactions

Involuntary movements

Seizures = paroxysmal events that interest

whole muscles

Epilepsy; tumor/head trauma/ intra-cranian hypertension

Hypoglycemia; cardiac/circulatory arrest; any profound metabolic
imbalance

Myoclonus = brief, involuntary twitching of a

muscle or a group of muscles; contractions are
called positive myoclonus, relaxations are called
negative myoclonus.

Epilepsy
Head or spinal cord injury, brain tumors
Essential myoclonus: benign, sometimes inherited
Post-hypoxemia

Involuntary movements

Hemiballismus = unilateral wild, large amplitude, movements of the

arm and leg, normally causing falls and preventing postural
maintenance.

lesion, usually an infarct, around the contralateral subthalamic

nucleus

Chorea = nonrhythmic, jerky, rapid, nonsuppressible involuntary

movements, mostly of distal muscles or the face; movements may
merge imperceptibly into purposeful or semipurposeful acts that
mask the involuntary movements.
Athetosis is nonrhythmic, slow, writhing, sinuous movements
predominantly in distal muscles, often alternating with postures of
the proximal limbs to produce a continuous, flowing stream of
movement
Choreoathetosis

Huntingtons disease= common cerebellar, autosomal dominant

disorder
Sydenhams choreea = rheumathic fever

Tremor
= rhythmic, alternating, or oscillatory movements
- Resting tremor = maximal at rest and decreases with
activity - Parkinson's disease.
- Postural tremor = maximal when a limb is maintained in
a fixed position against gravity.
Essential= gradual onset
Abrupt onset = metabolic, drug adverse reactions

- Intention tremor = maximal during movement toward a

target, as in finger-to-nose testing - cerebellar disorder,
multiple sclerosis, Wilson's disease.

Diminution of muscular straight

= difficulty/ impossibility of conducting of a
specific movement

Total = Paralysis // Partial = Paresis

Generalized // Localized

Acute // Chronic

Paralysis/paresis

Hemiplegia

Paraplegia

Quadriplegia

Examination of bones

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 for
modifications

Clinical examination

Percussion

Detects/elicit sensibility (=low-grade pain)

Can appreciate consistency/ structure of
tissue composing deformations

Auscultation

Can detect bones crackles

Symptoms
As a rule:
Uniloculate modification --- orthopedic or trauma
Multiloculate affectation --- another cause

Pain
Tumefactions/ tumors
Bones deformations
Fractures

Pain

Easy to be recognized, confined to the affected

region
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

Tumefaction/ tumors

Callus = bone healing after a fracture

History = the fracture

Vicious callus = can determine functional
disturbances or compress/ include anatomical
structures

Osteomyelitis (infection of the bone or

bone marrow)

Discrete tumefaction, with imprecise margins,

extremely painful

Tumefaction/ tumors

Benign tumors/ cysts

Palpable after they reach certain dimensions

Well delimitated
More easily palpable when superficial, skin above- evident
venous 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

Bone deformation

Does not affect bones integrity

Scimitar tibia- congenital syphilis
Scimitar femur and diaphysis
hypertrophy- Pagets disease of
bone
rickets = twisting of long bones +
genu valgum/ varum, Harrisons
groove, ribs rosary
Acromegaly

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

Symptoms

intense pain in a localized point,

loss of functionality,
deformations of the region, eventually shortening
of a limb,
abnormal mobility (!),
crackles,
echimosis/ hematoma
Vicious position (ex: fracture of the head of
femur)

Osteoporosis
= disease of the skeleton in which the bone
mineral density (BMD) is reduced and bone
architecture is disrupted
Diagnosis = BMD < 2,5 standard deviations
below peak bone mass
Causes post-menopausal
- glucocorticoid treatment/ Cushing syndrome