Musculoskeletal System

Musculoskeletal System

muscles, bones, and joints

- needed for support and to stand erect

- needed to move

- to encase and protect inner vital organs

- produces RBC in bone marrow

- reservoirs for storage of essential minerals

- provides support for the soft tissue and organs of the body

206

How many bones are in the body?

bones and cartilage

specialized forms of connective tissue

joint

A place where two or more bones meet

- needed for ADLs

ligaments

Fibrous connective tissue that connects bone to bone

- strengthen the joint and prevent unwanted movement

bursa

Enclosed cavity filled with fluid that prevents friction on moving parts

- serves as a cushion

tendon

Connects muscle to bone

skeletal muscle

A muscle that is attached to the bones of the skeleton and provides the force that moves the bones.

- voluntary control

nonsynovial joints

bones are united by fibrous tissue or cartilage and are immovable

- aka fibrous joints

- ex: sutures in the skull

also can have cartilaginous joints: slightly movable : vertebrae joints

Synovial Joints

move freely bc bones are seperated and enclosed in a joint cavity

- cavity is filled with lubricant/ synovial fluid that allows a sliding movement

muscles

Account for 40-50% of body weight

- when they contract, they produce movement

- 3 types: skeletal, smooth and cardiac

- skeletal/voluntary under conscious control

- skeletal attached to bone by tendon

flexion

bending a limb at a joint

extension

Straightening of a joint

Abduction

Movement away from the midline of the body

adduction

Movement toward the midline of the body

pronation

turning the palm downward

supination

movement that turns the palm up

circumduction

moving the arm in a circle around the shoulder

inversion

Turning the sole of the foot inward

eversion

moving the sole of the foot outward at the
ankle

rotation

moving the head around a central axis

Protraction

moving a body part forward and parallel to the ground

retraction

moving a body part backward and parallel to the ground

Elevation

raising a body part

Depression

lowering a body part

temporomandibular joint

The articulation of the mandible with the temporal bone

- TMJ permits jaw function and speaking/chewing

3 motions

1. hinge action to open and close jaws

2. gliding action for protrusion and retraction

3. gliding for side to side movement of lower jaw

33

How many vertebrae are there?

spinous process

What can you feel when you run your hand down along someones spine?7

7

How many cervical vertebrae are there?

12

How many thoracic vertebrae are there?

5

How many lumbar vertebrae are there?

5

How many sacral vertebrae are there?

3-4

How many coccygeal vertebrae are there?

flexion, extension, abduction, rotation

What are the motions of the vertebral column?

curves of the vertebral column

• There are four curvatures in the adult spine:

• Cervical (concave post.) : inward

• Thoracic (convex post.) outward

• Lumbar (concave post.) inward

• Sacral (convex post.) outward

this allows for the spine to absorb shock due to the compensatory balance

aging adult

Reabsorption happens more than bone deposition; no bone remodeling

- leads to osteoporosis

- postmenopausal women due to lack of estrogen

Postural changes evident w/ decreased height

- about 3cm-5cm lost due to loss of water content and thinning of intervertebral discs

- osteoporosis disease process

- not noticeable until 60 years and greatest change between 70-80

- kyphosis

Loss of subcutaneous fat makes bony prominences more noticeable

- fat deposits more on abdomen and hips

Loss in muscle mass occurs

- decrease in size; atrophy, weakness

Osteoporosis

- physical activity helps prevent

osteoporosis RF

Access leads to osteoporosis

A- alcohol use

C - corticosteroid use

C - calcium low

E - estrogen low

S - smoking

S- sedentary lifestyle

culture and genetics

Racial/ ethnic differences exist with bone mineral density seen nationally and globally

- high BMD; dense bone

- low BMD: weak, fragile bone; consistent predictor of hip/vertebral fractures

Post menopausal Caucasian women are at highest risk for low BMD

- gender differences women> men

there was an earlier peak for BMD with white men around age 30-33 and that weight bearing activity crucial to slow progress of BMD

lordosis

abnormal anterior curvature of the lumbar spine (sway-back condition)

- pregnancy

subjective data

Joints, knee joint, muscles, bone, functional assessment, ADL, patient centered care

joints (subjective data)

Any problems with your joints? Any pain?

- which joints? one or both sides? (rheuma vs osteo)

- what does pain feel like? how severe? when it did start?

- what time of day? how long does it last? how often does it occur? (RA pain worse in morning, osteo at night)

- aggravated by movement, rest, position, weather

- relieved by rest, meds, application of heat/ice?

- associated with chills, fever, recent sore throat?

- stiffness in joints?

- any swelling, heat, redness, in joints,

- recent tick bites (lyme disease risk)

- any limited movement? ADL problems?



seeks care
Joint pain and loss of function are the most common musculoskeletal concerns that a person.........?

rheumatoid arthritis

What disease has pain right when you wake up?

osteoarthritis

What disease has pain worse later in the day?

RA

Which arthritis does movement decrease pain?

OA

Which arthritis does movement increase pain?

rheumatic fever

Joint pain 10-14 days after untreated strep throat suggests?

decreased ROM

_________________ ______________- may be caused by joint injury to cartilage or capsule or muscle contracture

knee joint (if reported) (subjective data)

How did you injure your knee?

- inside or outside hit?

- twisting? pivoting? overuse?

- did you hear a pop? (may be torn ligament or fracture) (obtain xray if pt cannot flex knee 90 degrees or unable to bear weight)

- can you stand? flex?

muscles (subjective data)

Any problems in the muscles such as pain or cramping?

- which muscles? (myalgia)

- calf muscles: intermittent claudication

- muscle aches with fever, chills, flu (viral illness)

- any weakness in muscles? where? how long? (can be musculoskeletal/neurological changes)

- do muscles look smaller than before (atrophy)

myalgia

pain in the muscle

- felt as cramping or aching

bones (subjective data)

Any bone pain?

- pain from movement? (

Any deformity of the bone/joint?

- trauma origin? affect ROM?

Any accidents or trauma to bones/joints?

- fractures (sharp pain with movement) , joint strain/sprain, dislocation?

- when? tx given? any current problems since?

- any back pain? shooting down the leg ?

- numb or tingles?
- worried or anxious (chronic pain can trigger)

sharp pain

Fracture causes ________ _________ that increases with movement

dull, deep

Other bone pain usually feels _______ and ________ and is unrelated to movement

functional assessment (ADLS) (subjective data)

Do your joints/muscle/bone problems limit your ADLS?

- bathing

- toileting

- dressing

- grooming

- eating

- mobility

- communication

patient centered care (subjective data)

Any occupational hazards that affect the muscles and joints?

- heavy lifting

- repetitive motions/ chronic stress to joints (back pain or carpal tunnel risk)

- exercise

- recent weight gain/loss

- meds: NSAIDS, aspirin, muscle relaxants, pain, HRT,

- supplements: calcium, vit D

- ADL impact

- smoking

bisphosphonates

first line drug for osteoporosis

additional history for aging adult (subjective data)

Use the functional assessment history questions to elicit loss of function, self care deficit, or safety risk

1. Any changes in weakness over past month or years? falls?

2. Do you use mobility aids: walker, cane?

3. DXA screening for osteoporosis females 65 and older

- recommended every 2 years to see BMD changes

-- if normal: 15 years between is fine

5 years if its moderate

screening musculoskeletal exam

good enough for most people; inspect and palpate joints, observe ROM, age-specific screening

complete musculoskeletal exam

for people with articular disease, history of musculoskeletal symptoms, problems with ADLs

prep

- drape and provide privacy

- take an orderly approach; head to toe, proximal to distal

- support each joint

- compare bilaterally

- know normal/abnormal findings

- observe before exam starts: how they enter, take off jacket etc

equipment

tape measure

pen

goniometer

inspection

Note size and contour of joint

- inspect for color, swelling, masses, deformities,

- compare bilaterally

swelling (joint inspection abnormal finding)

from excess joint fluid (effusion)

- thickening of the synovial lining

- inflamed soft tissue surrounding (bursae and tendons )

- bony enlargement

fracture

broken bone

dislocation

displacement of a bone from its joint

subluxation

partial dislocation of a joint

contracture

shortening of a muscle leading to limited ROM of joint

ankylosis

abnormal condition of stiffness

palpation

Palpate each joint

- temperature, muscles, bony articulations, area of joint capsules

- notice any heat, tenderness, swelling, masses = inflammation

- if present: use landmarks to specify where

abnormal

(not palpable; if it is; may feel doughy/baggy)

Palpable fluid is?

range of motion

Ask for active (voluntary) ROM

- if you see a limitation; use passive motion

Normal: no pain, tenderness, crepitation

crepitation

audible and palpable crunching or grating that accompanies movement

- occurs when articular surfaces in a joint are roughened like in RA

active ROM

Performed by client without assistance
Maintains mobility of joints

passive ROM

Range of Motion in which the resident is unable to assist with movement

- hcw helps

- stabilize the joint and move it

limited ROM (more limited, worse the disease is)

What is the most sensitive sign to joint
disease?

articular disease

inside the joint capsule; produces swelling and tenderness around the whole joint and limits all planes of ROM in both active and passive motion

extraarticular disease

Injury to specific tendon, ligament, nerve

swelling or tenderness in one spot

affects certain roms; esp during active ROM

muscle testing

Test strength of prime mover muscle groups for each joint; repeat motions for active ROM

Ask person to flex and hold as you apply opposing force

Muscle strength should be equal bilaterally and should fully resist opposing force

- can use a standardized grading system 0-5

5

Full ROM; against gravity; full resistance

- 100% normal

normal finding

4

Full ROM; against gravity; some resistance

- 75% normal

- good

3

Full ROM with gravity

-50% and fair

2

Full ROM with gravity eliminated (passive motion)

- 25% and poor

1

Slight contracture

-25% trace

0

No contraction

0% ; none

TMJ (assessment)

With person sitting; inspect area before ear

- place 2 fingers in front of each ear and ask person to open and close their mouth

- a pop may be heard and that is normal

Instruct

- open mouth maximally : should be able to open 3-6cm or three fingers sideways

- partially open mouth and protrude the jaw and move side to side; should be able to move laterally 1-2 cm

- stick out lower jaw : protrude w/o deviation

Also; palpate while they clench teeth and move jaw against resistance (CN V)

TMJ abnormalities

Swelling around the joint

- moderate/visible

Crepitus and pain

- occurs with TMJ dysfunction during movement or chewing

Malocclusion of teeth also causes palpable crepitus or clicks

- Decreased ROM and tenderness = TMJ inflammation and arthritis

- lateral motion may be lost before vertical

cervical spine (assessment)

Inspect the alignment of the head and neck (straight and erect)

Palpate the spinous processes, sternomastoid, trapezius and paravertebral muscles

- firm w/ no tenderness or spasms

Instruct to perform these motions:

Flexion (head forward) 45 degrees

Hyperextension (head back) 55 degrees

R/L head movement to shoulder (lateral bending ) 40 degrees

Turning head side to side 70 degrees

Perform motions again while applying resistance; should be able to maintain flexion against (CN XI)

cervical spine abnormalities

Head tilted

Asymmetric muscles

Tenderness and hard muscles w/ spasm

Tenderness w/ arthritis or postural disorder

Limited ROM w/ arthritis

Pain with movement ; arthritis, overuse

Pt cannot hold flexion

Shoulder (assessment) (inspection)

Inspect and compare shoulders bilaterally, anterior and posterior

- check size, contour, and symmetry of landmarks

- normally no redness, atrophy, deformity or swelling

- if you suspect neck trauma; do NOT continue

If patient reports pain; have them point to the spot

- can be from local cause, hiatal hernia, cardiac/pleural condition

- local pain will flare during exam

shoulder abnormalities

Redness

unequal landmarks - scoliosis

atrophy - signal rotator cuff problem

dislocated shoulder; loses normal round shape and looks flat

swelling from excess fluid: best seen on front

- would have to be a large amount of fluid to see

swelling of subacromial bursa; localized under deltoid muscle and protrudes when pt raises arm

hard muscles w/ muscle spasm

Crepitus with motion

Rotator cuff may cause limited ROM, pain and muscle spasms during abduction

shoulder (assessment) (palpation)

While standing in front, palpate both shoulders

- note muscle spasms, atrophy, heat, tenderness, swelling

- start at clavicle and explore all landmarks

shoulder (assessment) (ROM)

Ask person to perform 4 motions

1. With arms at sides and elbows extended, move both arms forward and up in wide vertical arc and move them back

- forward flexion 180 degrees

- hyperextension 50 degrees

2. rotate arms internally behind back, place back of hands as high as possible towards scapula

- internal rotation 90 degrees

3. With arms at sides and elbows extended, raise both arms in wide arcs in the coronal plane; touch palms together above head

-abduction 180 degrees

- adduction 50 degrees

4. Touch both hands behind the head with elbows flexed and rotated posteriorly

- external rotation 90 degrees

shoulder strength

Test by asking person to shrug shoulders flex forward and up against resistance

- CN XI

elbow (assessment)

Inspect joint in flexed and extended positions

- look for deformity, redness, swelling

- check olecranon bursa and the normally present hollows on either side for abnormal swelling (occurs with gout and bursitis)

Palpate with the elbow flexed about 70 degrees as relaxed as possible

- use L hand to support and palpate

- normally feel solid; check for swelling, nodules, tenderness

Test ROM

Bend and straighten elbow

- flexion 150-160; extension 0

Pronation and supination

- 90 degrees

Muscle strength: stabilize the arm and have them flex their elbow and you apply resistance in both directions

subcutaneous nodules

raised, firm, nontender, overlying skin moves freely [occur with RA]

- common in elbow and ulnar surface of hand

wrist and hand (assessment)

Inspect the hands and wrists on dorsal and palmar sides

- note position, color, shape, contour

- normally no nodules, redness, swelling, deformity

- skin normal around knuckles

Palpate each joint in the wrists and hands

Test ROM

Extend wrist : 70 degrees

Flex wrist 90 deg

hyperextend fingers 30 deg

flex fingers 90 deg

radial deviation 20 deg

ulnar deviation 55 deg

open fingers 20 deg, make a fist, thumb adducts

Muscle testing: position hand on table supported and flex the fingers against resistance

Phalen test, Tinel sign for carpal tunnel

wrist and hand abnormalities (assessment)

Subluxation = partial dislocation of wrist

Ulnar deviation- fingers lay to ulnar side

Ankylosis- wrist in extreme flexion

Dupuytren contracture; flexion contracture of the fingers

Swan neck fingers

Phalen test

Ask the person to hold both hands back to back while flexing the wrists 90 degrees.

- Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand

- produces numbness and burning with carpal tunnel

Tinel sign

direct percussion of the median nerve at the wrist produces no symptoms in the normal hand.

- If positive test, percussion produces tingling and burning along distribution.

Sign of carpal tunnel syndrome

hip (assessment)

Inspect: wait to do together with spine when person stands

- iliac crests, gluteal folds, buttocks should be symmetric

- a smooth even gait reflects equal leg lengths and functional hip motion

Palpate: have pt in supine position and palpate the joints

- should feel stable and symmetric with no tenderness or crepitation

Assess ROM

Raise each leg with knee extended- 90 degree hip flexion

Bend knee to chest with other leg straight- hip flex 120 deg

Flex knee and hip to 90; stabilize thigh and ankle and swing foot outward and inward

- internal rotation 40 degrees

- external rotation 45 degrees

Swing leg laterally and then medially

- abduction 40-45 degrees

- adduction 20-30 degrees

Swing leg backs

- hyperextension 15 degrees