Health Assessment Exam #2 - Musculoskeletal System

(Lumbar) Lordosis

Anatomical Site/Feature: Exaggerated inward lumbar curve (“swayback”)

Target Population: Toddlers (due to abdominal muscle dominance) & pregnant women (center of gravity shift)

Expected/Unexpected: Expected in toddlers & pregnancy; Unexpected in adolescents & general adults

Interventions/Pathophysiology: Reassure pregnant/toddler patients; evaluate posture habits & back pain; suggest posture exercises for non-pregnant adults

(Thoracic) Kyphosis

Anatomical Site/Feature: Exaggerated outward thoracic curvature (“humpback”)

Target Population: Aging adults

Expected/Unexpected: Expected mild progression in aging adults due to disc thinning and osteoporotic vertebral compression fractures

Interventions/Pathophysiology: Encourage weight-bearing exercise, calcium, & Vitamin D; assess for altered pulmonary mechanics

(Lateral) Scoliosis

Anatomical Site/Feature: Lateral “S-Shaped” spinal curvature accompanied by vertebral rotation

Target Population: Adolescents (most noticeable during rapid growth spurts)

Expected/Unexpected: Unexpected; requires clinical evaluation

Interventions/Pathophysiology: Perform Forward Bent Test (inspect shoulder, scapular, and iliac crest asymmetry); refer to orthopedics if curvature is noted

Active ROM

Patient executes joint movements independently

Passive ROM

Nurse gently guides join through movement while patient is completely relaxed; stop immediately if pain or resistance is encountered

Crepitus

Dry, crackling, grating sound or sensation caused by bone ends rubbing together due to cartilage erosion

Effusion

Excess fluid accumulation within a joint cavity (indicated inflammation or injury)

Boggy Synovial Thickening

Soft, spongy swelling felt along join margins indicated active synovial membrane inflammation

Contracture

Permanent shortening of soft tissue, muscles, or tendons, locking joint in fixed position

Ankylosis

Stiffness or complete bony fixation/fusion of a joint

Subluxation

Partial dislocation of a joint where joint surfaces remain partially in contact

Dislocation

Complete separation of two bones forming a joint

DDH Screening - Barlow Maneuver

Adduct infant’s thighs (brining knees toward midline) while applying mild backward pressure

• Positive sign: sensation or sound of femoral head popping out of acetabulum

DDH Screening - Ortolani Maneuver

Abduct infant’s thighs outward while applying forward pressure on greater trochanter

• Positive sign: a distinct “clunk” as dislocated femoral head moves back into acetabulum

Infant Primitive Reflexes - Rooting Reflex

Infant turns head toward brushed cheek (fades at 3 - 4 months)

Infant Primitive Reflexes - Moro Reflex

Sudden startle leads to arm extension, abduction, and fan-shaped finger opening, followed by arm flexion (fade at 1 - 4 months)

Infant Primitive Reflexes - Palmar Grasp

Tight grasp of finger placed in palm (fades at 3 - 4 months)

Infant Primitive Reflexes - Tonic Neck Reflex

“Fencer position” - head turned to one side causes same-side arm/leg extension and opposite-side flexion (fades at 4 - 6 months)

Infant Primitive Reflexes - Babinski Reflex

Stroke lateral plantar surface of foot from heel to toe

• Infants up to Age 2: Expected normal response is dorsiflexion of the great toe and fanning of remaining toes

• Adults / Children > 2 Years: Abnormal; Fanning indicates upper motor neuron lesion (CVA, spinal trauma); Normal adult response is plantar flexion (curling) of toes

Leg Alignment - Genu Varum (“Bowlegs”)

Lateral bowing of lower extremities

• Expected in infants and early toddlers

• Abnormal if persistent beyond age 2 - 3

Leg Alignment - Genu Valgum (“Knock-Knees”)

Stance where knees touch while angles are separated

• Expected in preschoolers (ages 2 - 5)

• Abnormal if persistent beyond age 6 -7 or asymmetrical

MSA 0/5

Description: No muscular contraction detected

Intervention: Complete paralysis (Zero strength)

MSA 1/5

Description: Slight contraction felt; no joint movement

Intervention: Trace muscle activation

MSA 2/5

Description: Complete ROM with gravity eliminated (passive motion)

Intervention: Poor muscle strength

MSA 3/5

Description: Complete ROM against gravity, but cannot overcome applied resistance

Intervention: Fair muscle strength

MSA 4/5

Description: Complete ROM against gravity, but cannot overcome applied resistance

Intervention: Good strength; mild weakness

MSA 5/5

Description: Complete ROM against gravity with fill applied resistance

Intervention: Normal strength

Rheumatoid Arthritis

Pathophysiology: Systemic, chronic autoimmune inflammatory disorder of synovial membranes

Onset/Age: Rapid onset (weeks to months); can begin at any age (typically 20 - 50)

Joint Involvement: Symmetrical, bilateral involvement, affects small joints (MCP/PIP) & large joints

Manifestations: Pain, boggy swelling, warmth, redness, stiffness; metacarpophalangeal (MCP) swelling

Morning Stiffness: Prominent morning stiffness lasting > 1 hour

Deformities/Signs: Ulnar drift, Swan-Neck deformities, Boutonniere deformities

Systemic Symptoms: Present - Fatique, low-grade fever, malaise, lymphadenopathy

Osteoarthritis

Pathophysiology: Localized, non-inflammatory progressive degenerative breakdown of articular cartilage

Onset/Age: Gradual, slow onset over years; begins later in life (> 50)

Joint Involvement: Asymmetrical, unilateral involvement initially; weight-bearing joints (knees, hips, spine, DIPs)

Manifestations: Bony, enlarged joint w/o acute heat/redness; pain worse with joint usage

Morning Stiffness: Brief morning stiffness lasting < 30 minutes; stiffness worsens at end of day

Deformities/Signs: Heberden nodes (DIP joints) and Bouchard nodes (PIP joints)

Systemic Symptoms: Absent - localized mechanical issue w/o systemic inflammatory signs

Osteoporosis

Pathophysiology: Bone resorption by osteoclasts exceeds bone matrix deposition by osteoblasts, causing micro-architectural deterioration and low Bone Mineral Density

Risk Factors: Caucasian/Asian female, postmenopasual, advanced age, low body weight, sedentary lifestyle, low Calcium/Vitamin D intake, smoking, long-term systemic corticosteroid therapy

Diagnostic Screening: DXA scan

Timed Up and Go (TUG)

Technique: Ask patient to sit in an armless chair, stand up, walk 3 meters (10 feet), turn around, return to chair, and sit back down

Normal Finding: Completion in 10 - 12 seconds

High Fall Risk Finding: Taking > 12 seconds to complete test indicated impaired mobility and high fall risk

Priority Action: Initiate fall precaution immediately (non-skid socks, bed alarm, call bell within reach, gait belt during transfer, environmental decluttering)

CTA - Phalen Test

Ask patient to hold both hands back-to-back while flexing wrists at 90 degrees for 60 seconds

• Positive Finding: Numbness and burning/tingling sensation along median nerve distribution (thumb, index, middle finger)

CTA - Tinel Sign

Percuss/tap lightly directly over media nerve at flexor retinaculum of wrist

• Positive Finding: Tingling or electric shock sensation radiating into median nerve distribution