H&PA Exam 2 - Musculoskeletal and Tissue Integrity Assessment

Muscles

• Over 600 in the human body

• Coordinate movement

Bones

• 206 in the adult

• Structure, support & protection

Tendons

• Connects muscle to bone

• Aiding in movement of bones

Ligaments

• Connects bone to bone

• Supports joints, preventing undesirable movement

Cartilage

• Flexible structure that cushions joints

• Protects bones from rubbing against each other

Functions:

• Support

• Movement

• Protection

• Hematopoiesis

  • Production of RBCs, WBCs, and platelets within the bone marrow

• Storage

  • Essential minerals such as calcium

Review of Anatomy: The Spine

• Spinal Column

  • 33 stacked vertebrae and Intervertebral discs

    • Cervical – 7

    • Thoracic – 12

    • Lumbar – 5

    • Sacral – 5

    • Coccygeal – 3/4

  • Movement

    • Flexion (bending forward)

    • Extension (bending back)

    • Rotation (twisting)

Review of Anatomy: The Shoulder

• Ball-and-socket joint with a high degree of flexibility

• Structures:

  • Bones

    • Clavicle

    • Acromion Process

    • Scapula

    • Humerus

  • Muscles

    • Deltoid

    • Biceps

• Movement:

  • Rotation

    • Internal/External

  • Flexion/Extension

  • Abduction/Adduction

  • Circumduction

Review of Anatomy: The Elbow

• Hinge joint, located between arm and forearm

• Structures:

  • Bones

    • Humerus

    • Radius

    • Ulna

  • Muscles

    • Biceps

    • Triceps

    • Flexors

    • Extensors

• Movement:

  • Flexion/extension

  • Pronation/supination

Review of Anatomy: The Wrist & Hand

• Joint that is subdivided into three regions:

• Structure:

  • Wrist

    • Radius/ulna form proximal portion and carpal bones form distal portion

  • Metacarpals (Palm)

    • Combination of 5 bones

  • Phalanges (Fingers)

    • 14 bones

• Movement:

  • Flexion/Extension

  • Radial deviation

  • Ulnar deviation

Review of Anatomy: The Hip

• Ball-and-socket joint

• Structure:

  • Bones

    • Femur

    • Acetabulum

    • Iliac Crest

  • Cartilage

    • Articular Cartilage

      • Labrum

  • Muscles

    • Gluteus maximus

    • Quadriceps

      • Vastus Lateralis

• Movement:

  • Flexion/Extension

  • External/Internal Rotation

  • Abduction/Adduction

Review of Anatomy: The Knee

• Hinge joint within the lower extremity

• Structures:

  • Bones

    • Femur

    • Tibia

      • Tibial Tuberosity

    • Patella

  • Cartilage

    • Articular Cartilage

      • Meniscus

  • Muscles

    • Quadriceps

    • Hamstring

    • Gastrocnemius

  • Tendons

    • Patella Tendon

  • Ligament

    • ACL/PCL

    • MCL/LCL

• Movement:

  • Flexion/Extension

Review of Anatomy: The Ankle & Foot

• Hinge joint, at the distal portion of the lower extremity

• Structures:

  • Bones

  • Tibia

  • Fibula

  • Talus

  • Metatarsals

  • Phalanges

• Movement:

  • Plantarflexion/Dorsiflexion

  • Inversion/Eversion

Development Competence: The Aging Adult

• ↑ Risk of Osteoporosis & Fracture d/t loss of bone mineral density

  • Bone mass density declines starting in late 20’s (peak)

  • Bone remodeling slows after 40

    • Resorption occurs more rapidly than repair/replacement

• Postural changes

  • Height Loss

  • Kyphosis

• Increase in bony prominences

  • Decreased and redistributed subcutaneous tissue

• Loss of muscle mass

  • Sedentary lifestyle leads to atrophy and generalized weakness

Bones - Subjective Questions

• Do you have any chronic disease of the bone?

  • If so, does it impact your mobility or ADLs?

• Does the patient have any bone pain?

  • Where is the pain?

  • If back pain, identify the level of pain and if pain radiates down legs or arms.

• Are there any structural deformities of the bone/joint?

• Incidence of trauma or accidents such as fractures, sprains, strains, dislocations?

  • If so, when? How was it repaired? Continuing problems or difficulties as a result of injury?

  • Does it limit movement? If so, how?

Joints - Subjective Questions 

• Do you have any joint pain, stiffness, or tenderness?

  • Is there any swelling, redness or warmth at any of you joints?

  • Does it limit movement? Impact your ADL’s?

• PQRST Questions

  • When does the stiffness occur (i.e. time of day, with activity or after rest)?

  • Bilaterally?

Muscles - Subjective Questions

• Are you experiencing any cramping of your muscles?

  • Is it associated with any muscle weakness or increase in size of the muscle?

  • Does it occur while walking or at rest?

Psychosocial - Subjective Questions 

• Exercise Regimen

  • What do you do for exercise? How often do you exercise and for what duration?

  • Do you play sports? If so, which ones and how often? How do you protect yourself?

  • Any injuries?

  • Does exercising make you feel better? Less stress, anxiety, restlessness?

Functional Assessment

Do your joint (muscle or bone) problems cause any limitations with your usual activities of daily living?

The MSK Assessment - Inspection

• Bilateral upper and lower extremities

• Observe for: symmetry, swelling, muscle tone and deformities

The MSK Assessment - Palpation

• Directly over each joint

• Note any warmth, tenderness, swelling, masses

The MSK Assessment - Range of Motion

• Preference is active ROM however; passive ROM may be needed if the patient has limitations

• Note any decreased range of motion and crepitus

Crepitus

Audible or palpable crunching / grating

The MSK Assessment - Muscle Testing

Use the grading system to determine the patient's strength

Muscle Testing

• Assesses strength of prime mover muscle groups

• Repeat ROM exercises with opposing force (resistance)

• Evaluate the strength:

  • Normal: Equal bilaterally and fully resist opposing force

• Document using 5-point scale

Inspection (examples)

• Size and Contour

• Obvious swelling, bulges, masses or deformities

• Symmetry

• Compare joint bilaterally

• Color

• Observe for redness

Palpation (examples)

• Temperature

• Warmth

• Tenderness

• Swelling

• Masses

Assessing The Shoulders - Range of Motion

• Abduction

  • With arms beginning at sides, bring arms up in an outward arc, bringing the palms together above the head

• Adduction

  • Bring arms down, continue past resting location and towards midline

Assessing The Shoulders - Strength

• Flexion against resistance (Pizza box)

  • Holding arms straight out with palms up

  • Ask pt to perform flexion (bring arms upward without bending elbows)

  • Apply downward resistance

Assessing The Wrist/Hand - Range of Motion

• Palmar flexion/extension

  • Bend hand down at wrist, return to resting

• Ulnar/radial deviation

  • With palm facing down, turn wrist outward (ulnar) and then inward (radial)

Assessing The Wrist/Hand - Strength

• Wrist flexion against resistance

  • With person’s arm resting on table, palm up, stabilize the persons mid-forearm

  • Ask the person to flex their wrist against resistance applied to the palm

Assessing The Elbow - Range of Motion

• Pronation/Supination

  • Turn the palms down then up

  • Using ulnar edge of the hand resting on the table

  • Touch front and back sides of the hand to table

Assessing The Elbow - Strength

• Flexion against resistance

  • Stabilize the persons arm by holding their elbow in one hand

  • Ask person to flex by bending at elbow while applying resistance downward

• Extension against resistance

  • From the flexion position, ask patient to extend the arm while applying resistance, trying to keep the arm in the flexed position

Assessing The Cervical Spine - Range of Motion

• Flexion – touch the chin to the chest

• Hyperextension – lift the chin to the ceiling

• Lateral bending – touch the ear towards the corresponding shoulder without lifting the shoulder

• Rotation – turn the chin towards each shoulder

Assessing The Cervical Spine - Strength

Rotation against resistance

Assessing The Spine

• Range of Motion

  • Flexion/Hyperextension

    • Bend forward at hip and touch the toes then have the patient bend backwards going past midline.

  • Lateral Bending

    • Bend sideways at the hip, sliding hand down the leg, return to midline then repeat on opposite side.

  • Rotation

    • Twist shoulders to one side then the other

Assessing The Hips - Range of Motion

• Abduction

  • Place gently pressure downward on opposite iliac crest and ask the patient to swing the leg laterally (out)

• Adduction

  • Ask the patient to bring the leg back towards midline and cross over midline if possible

Assessing The Hips - Strength

• Abduction/adduction against resistance

  • Apply inward resistance (pushing toward midline) when performing abduction and outward resistance(pushing laterally) when performing adduction at the level of the thigh.

Assessing The Knee - Range of Motion

• Flexion/extension

  • Bend each knee by bringing the heel towards the buttocks, then extend each knee

Assessing The Knee - Strength

• Maintain flexion

  • Attempt to pull the leg forward while the patient maintains flexion

Tissue Integrity: Special Considerations

• The environment of the injury

  • Dirt, debris, water

• Foreign body risk

  • Ex: Motorcycle crash

• Bite injuries

  • High risk for infection

• Compression injuries

  • High risk for necrosis

Tissue Integrity: Mechanism of Injury

• Penetrating: Motion of a foreign body entering the body, causing direct damage

• Indirect Injury:

  • GSW: High velocity

  • Stab: Low velocity

  • Impalement: Collision of object into patient

  • Avulsion/Degloving: Stretching/tearing away of soft tissue

Dehiscence

• The partial or complete separation of a surgical incision that has been previously closed.

• A closed anatomical structure that splits open, releasing its contents.

Evisceration

The protrusion of organs (usually abdominal) through a surgical wound that has opened.