Musculoskeletal system

Grade and Lovett scale for muscle strength

tool used to grade muscle strength

no evidence of contractibility

0/zero

Evidence of slight contractibility

1/Trace

Complete ROM with gravity eliminated

2/poor

complete ROM with gravity

3/fair (50% normal)

Complete ROM against gravity with some resistance

4/good

Complete ROM against gravity with full resistance

5/normal (100% of normal)

during an examination how should you do it?

Cephalo-caudal approach (head to toe), move side to side (bilateral comparison muscle size and strength should be equal bilaterally). use Goniometer to measure joint range of motion and use tape measure for muscle circumference.

during inspection of muscles what does the nurse look at?

skeletal and extremities. Alignment and symmetry and the muscles symmetry and size.

during palpation of muscles what does the nurse look at?

bones for pain, joints for pain, temp, and edema. Muscles for pain, temp, edema and tone.

what do nurses observe on a patient during a musculoskeletal assessment?

The range of motion of each joint and adjacent muscles. Look at their gait (the patient’s pattern of walking; their conformity, rhythm, and symmetry)

Normal findings

expect muscle strength to be 5/5 bilaterally symmetrical with full resistance to opposition

Abnormal findings

paralysis (exaggerated muscle tone) is the involuntary contraction of muscles that occurs after a spinal cord injury or cerebrovascular accident (stroke).

Flaccid paralysis

is a lack of muscle tone or deep tendon reflexes after damage to lower motor neurons

How can nurse check the patients Biceps muscle strength?

patient flexes the arm while the nurse pulls to extend arm

How can nurse check the patient’s triceps muscle strength?

Patient extends the arm while nurse pushes to flex the arm

How can nurses check the patient’s ankle/foot muscles?

Patient performs dorsiflexion while the nurse pushes the foot to plantar. Patient performs plantar flexion while the nurse pushes the foot to do dorsiflexion.

Active Range of motion

movement done by client and should be smooth and painless through its complete range

Passive Range of motion

examiner moves the relaxed joint through the limits of movement. Stop if encounter pain or resistance

Flexion

bending, decrease angle

Extension

straightening limb to increase angle

Hyperextension

bend as far as possible

Abduction

away from midline

adduction

toward the midline

internal rotation

turning the part toward midline

external rotation

turning away from the midline

circumduction

circular movement

supination

turning palm up

pronation

turning palm down

opposition

touching thumb to each finger on same hand

Inversion

turn inward

eversion

turn outward

Dorsiflexion

move foot so that toes are pointed upward

plantarflexion

move foot so that toes are pointed downwards

Structural scoliosis

lateral curvature of thoracic/lumbar vertebrae. Most often in adolescents and in females. Treatment includes a brace to prevent further progression of the curvature.

Functional scoliosis

Temporary change due to unequal leg length, muscle spasms, poor posture. Correct underlying problem to eliminate spinal curvature. Assess by forward flexion at the wrist and rise slowly. Shoulders and iliac crests are unequal/

Kyphosis

excessive convexity of the thoracic spine caused by ageing, poor posture, Scheuermann’s disease (developmental disorders of spine), arthritis, osteoporosis, disk degeneration, fractures, cancer treatments. HUMP BACK

Lordosis

inward curvature of lower back caused by obesity, pregnancy, osteoporosis.

ROM of elbow

flexion, extension, supination and pronation

How do you do hip flexion

bringing knee up to stomach/chest

how do you do hip extension

by moving the leg backward behind the body

How do you do hip abduction?

move the leg out to the side away from the middle of the body

How do you do hip adduction

move leg towards the middle of the body

how do you do external rotation of hip?

turn your thigh outward, away from the body’s midline

how do you do internal rotation of hip?

turn the thigh inward, toward the body’s midline

How do you do knee flexion?

bend your knee, bring your heel to your butt

how do you extend the knee?

straighten the knee, sit in a chair and straighten your lower leg

How do you do ankle dorsiflexion?

pull your toes up toward your shin

How do you do ankle plantarflexion?

Point your toes downward like pressing a gas peddle

How do you do inversion of foot/ankle?

turn the sole of your foot inward

How do you do eversion of foot/ankle?

turn the sole of your foot outward

carpal tunnel syndrome

caused by pressure on median nerve as it travels through the carpal tunnel.

Tinel’s sign

done to test for carpal tunnel syndrome, tap on median nerve where it passes through carpel tunnel, no pain or tingling is a negative test

Phalens test

done to test for carpal tunnel syndrome, flex both wrists and press dorsal aspects against each other for 1 minute. If pain, numbness or tingling that means its a positive for carpal tunnel

Rheumatoid arthritis

• chronic inflammatory autoimmune disease that causes destruction of connective tissue. Synovial joints become inflamed causing swelling which leads to deterioration of cartilage and erosion of bone surface.

• Risk factors: females in their 30-40s, viral infection trigger. Small framed and genetic predisposition.

• Person may develop abnormal antibodies, the body doesn’t recognize these antibodies, so it forms an antibody known as Rheumatoid factor to fight against the antibodies. These cause synovial lining inflammation which damages cartilage and destroys joints bilaterally. Eventually results in bone spurs, ligaments and tendons become fibrotic and shortened, visually being able to see partial dislocation of joints. Will see swan neck/ulnar deviation on DIP (distal finger joints) and Boutonniere deformities on PIP (proximal finger joints). Morning stiffness lasts more than 30 minutes

Osteoporosis

• Bones become porous due to a loss in bone mass and density (osteopenia) and decrease in bone formation. (bone density loss)

• Silent disease: don’t know until you start breaking bones, no signs or symptoms before it happens. Often lose height. Happens to older women who are old, frail, thin, because they start to lose estrogen. Also, can happen to those that exercise.

• Avoid by lifting weights, taking calcium and vitamin D.

• kyphosis

Osteoarthritis

• Degenerative Joint Disease (DID)

• caused by using a joint too much, usually happens to one side (Unilateral)

• caused by wear or tear trauma, obesity, frequent pregnancy

• affects vertebrae, hips, knees, ankles, and fingers

• Symptoms: morning stiffness last less than 30 minutes and decreases with movement. Joints edema, aching, diffuse pain with movement.

• Can develop Heberden nodes on DIP joints and Bouchard nodes on PIP Joint painful.

Gout

• Form of arthritis that develops from an increase in uric acid causing crystals of uric acid to deposit in one or more joints.

• mainly on appears on big, great toe, wrists, knees, ankles

• Reported sudden and progressively severe onset of redness, pain, inflamed and edema on affected joint

• More common in men

• alcohol, red meat, and bad diet causes increase in uric acid

Infants

• palpate clavicle for fractures (common birth injury)

• Inspect back/spine for alignment, tufts of hair, bulges, or obvious malformations

• Assess hips: Barlow maneuver (up to 3 months). Ortolani maneuver, Allis sign

• Hip dysplasia: hip socket that doesn’t fully cover the ball portion of the upper thighbone. Allows the hip joint to become partially/completely dislocated.

• Most people with hip dysplasia are born with the condition

Child

• compare data tables of normal age and sequence of motor development

• Observe gait of steadiness

• Examine back—→ shoulders, scapula, iliac crest for symmetry

• Outward rotation of the lower extremities can be normal in children ages 2-3.5 years

• Inward rotation requires further evaluation

• Balance problems or increases in falls should be evaluated

• Lordosis- most common in African American children can be present up to age 6

Adolescents

• screen for scoliosis, kyphosis, and lordosis

• Injuries due to sports or car accidents

Older adults

• decreased bone and muscle mass

• Intervertebral disk narrows (height decreases/loss of height)

• Increased risk of falls and fractures (move head slowly to prevent falls)

• decreased agility and endurance for exercise

• Gait is slower

Allis sign

a difference in the height of the knees when the hips and knees are bent, may indicate a hip problem

Barlow’s maneuver

a test used on infants to check for hip instability or dislocating by gently moving the thigh to see if the hip can be displaced

Dysplasia

abnormal development of a body part, like abnormal development of the hip joint

Heberden nodes

hard bony bumps at the end of finger joints (DIP), commonly associated with osteoarthritis

Ortolani maneuver

a test on infants to check hip dislocation or instability by gently moving the hip to see if it can be placed back into the socket (should be no clicking)

flexion of head

bending your head forward, bringing the chin to the chest

extension of head

tilting the head backward, looking up toward the ceiling

Lateral flexion of head

tilting your head toward one shoulder, then the other

rotation of head

turning your head to look over your left shoulder and then your right shoulder

Flexion of shoulder

raise your arm forward and upward, toward your ear

Extension of shoulder

move your arm backward behind your body

Abduction of shoulder

raise your arm out to the side and overhead, away from your bodies midline

Adduction of shoulder

Bring your arm back toward your body or across your chest

Internal rotation of shoulder

rotate your arm inward, such as moving your hand behind your back. (put hand behind lower back)

External rotation of shoulder

rotate arm outward, such as moving your forearm away from your abdomen with your elbow bent. (put hand behind your head)

Flexion of elbows

bend your elbow, bringing your hand toward your shoulder

Extension of elbow

straighten your elbow

Pronation and supination of elbow

Rotate your forearm so your palm faces down (pronation) or up (supination)

Why should we be very careful and slowly when assessing the ROM of the neck and head of an older adult?

they’re at risk for falls; moving them to fast and them getting up could cause them to fall which can be very deadly for them.