MSK

NUR 307: Musculoskeletal (MSK)

Instructor Information

  • Professor: Galbally MSN, CRNP, FNP-BC

Learning Outcomes

  1. Demonstrate proper history taking and interviewing techniques for a patient with a musculoskeletal complaint.

  2. Describe the structure and function of various joints in the body.

  3. Identify the normal range of motion for each joint.

  4. Demonstrate proper patient positioning to ensure comfort during a musculoskeletal examination.

  5. Explain the rationale and methods for examining the musculoskeletal system.

  6. Assess a patient's functional ability through appropriate examination techniques.

  7. Accurately document findings from the musculoskeletal assessment.

  8. Perform a complete musculoskeletal system assessment.

Important Terms

  • Abduction: Movement away from the midline of the body.

  • Adduction: Movement toward the midline of the body.

  • Ankylosis: Stiffness or immobility of a joint due to fusion of the bones.

  • Ataxia: Lack of muscle coordination during voluntary movement.

  • Bone: Rigid organ that constitutes part of the vertebrate skeleton.

  • Bursa: Small fluid-filled sac that reduces friction between tissues.

  • Cartilage: A flexible connective tissue found in joints, ribcage, ear, nose, throat, and intervertebral discs.

  • Cartilaginous joint: A type of joint where the bones are connected by cartilage.

  • Circumduction: The circular movement of a limb.

  • Crepitation: A grating sound produced by movement of bone fragments.

  • Dorsal: Related to the back side of the body.

  • Eversion: Movement of the sole of the foot outward.

  • Extension: Straightening a joint to increase the angle between the bones.

  • Fibrous joint: Joints connected by dense connective tissue with no joint cavity.

  • Flexion: Bending movement that decreases the angle between body parts.

  • Inversion: Movement of the sole of the foot inward.

  • Joint: The point at which two or more bones meet.

  • Kyphosis: An excessive outward curvature of the spine.

  • Ligament: Connective tissue that connects bones to other bones.

  • Lordosis: An excessive inward curvature of the spine.

  • Muscle: Soft tissue that produces force and motion.

  • Nucleus pulposus: The inner core of the intervertebral disc.

  • Olecranon process: Bony prominence of the ulna at the elbow.

  • Patella: The kneecap, a protective bone in front of the knee joint.

  • Plantar: Relating to the sole of the foot.

  • Pronation: Rotational movement of the forearm that results in palm facing downward.

  • Protraction: Movement of a body part forward.

  • Range of Motion (ROM): The full movement potential of a joint.

  • Retraction: Movement of a body part backward.

  • Skeletal muscle: A type of muscle tissue that is under voluntary control.

  • Supination: Rotational movement of the forearm that results in palm facing upward.

  • Synovial joint: A joint that is surrounded by a fluid-filled capsule, allowing for movement.

  • Tendon: A flexible but inelastic cord of tissue attaching a muscle to a bone.

Musculoskeletal Anatomy Tips

  • Connect Muscles to Bones using Tendons.

  • Connect Bones to Bones using Ligaments.

Bones and Muscles Overview

  • Cranium: Protects the brain, composed of various bones.

  • Facial Muscles: Responsible for facial expressions.

  • Vertebra: Individual bones that make up the spine.   - Cervical: Neck region vertebrae.   - Thoracic: Upper back region vertebrae.   - Lumbar: Lower back region vertebrae.

  • Humerus: Upper arm bone.

  • Radius & Ulna: Forearm bones.

  • Femur: Thigh bone, longest bone in the body.

  • Tibia & Fibula: Leg bones.

  • Patella: Knee cap.

  • Tarsals, Metatarsals, Phalanges: Bones of the foot.

Joints Classification

  • Fused Joints: Found in the skull, immovable.

  • Synovial Joint: Includes various types based on movement:   - Hinge Joint: Allows flexion and extension (e.g., elbow).   - Ball-and-Socket Joint: Allows movements in multiple directions (e.g., shoulder).   - Pivot Joint: Allows rotational movement (e.g., neck).   - Condyloid Joint: Allows movement but no rotation (e.g., wrist).

Subjective Patient Assessment

General Musculoskeletal Issues

  • Onset (O): When did it start? Gradual or sudden?

  • Location (L): Unilateral or bilateral? Which joint?

  • Duration (D): How long have the symptoms lasted? Intermittent or constant?

  • Characteristics (C): Describe the pain (sharp, dull, etc.).

  • Aggravating Factors (A): Anything that makes it worse? Active during a specific time?

  • Relieving Factors (R): What alleviates the pain?

  • Treatments (T): Home remedies tried?

  • Severity (S): Evaluate the pain on a scale.

  • Review of Systems (ROS): Any recent trauma, illness, or travel?

Specific Musculoskeletal Complaints

  • Knee Injury: Ask about history, location, characteristics, and any audible sounds.

  • Myalgia/Muscle Weakness: Assess severity and associated symptoms.

  • Bone Pain/Deformity: Document changes in appearance and sensation.

Five P's of Musculoskeletal Assessment

  • Pain: Evaluate severity and location.

  • Pallor: Check for color changes in skin.

  • Pulse: Assess circulation around the joint.

  • Paresthesia: Evaluate any numbness or tingling sensations.

  • Paralysis: Assess functional loss in the area.

Order of Musculoskeletal Assessment

  1. Inspect: Visual assessment of the joint.

  2. Palpate: Touch for abnormalities and tenderness.

  3. Assess Range of Motion (ROM): Both active and passive.

  4. Muscle Strength: Evaluate against resistance.

Assessment Techniques

Inspection

  • Evaluate joint size, contour, and skin color.

  • Observe gait patterns such as spastic, scissor, propulsive, or steppage.

  • Check for conditions like Ataxia and Foot Drop.

Palpation

  • Palpate joint for temperature changes, tenderness, swelling, or masses.

  • Always check distal pulse while examining a joint.

Range of Motion (ROM)

  • Active ROM is preferred; use passive ROM if the patient cannot perform.

  • Specific movements to assess include flexion, extension, abduction, adduction, and rotation.

Muscle Strength Evaluation

  • Use a grading system (0-5) to assess strength:   - 5: Full ROM against gravity and resistance (Normal).   - 4: Full ROM against gravity with some resistance (Good).   - 3: Full ROM with gravity (Fair).   - 2: Full ROM without gravity (Poor).   - 1: Slight contraction (Trace).   - 0: No contraction (Zero).

Specific Joint Assessments

Temporomandibular Joint (TMJ)

  • Inspect: Look at the area anterior to the outer ear.

  • Palpate: Use your fingers to palpate movements; check for crepitus or swelling.

  • ROM: Assess jaw movements—open and close mouth, lateral movements.

Cervical Spine Assessment

  • Inspect: Neck alignment and head positioning.

  • Palpate: Check for tenderness in the spinous processes and surrounding muscles.

  • ROM: Include chin to chest (flexion), head back (hyperextension), and side-to-side movement (rotation).

Shoulder Assessment

  • Inspect: Check for symmetry and anatomical landmarks.

  • Palpate: Feel for spasms, atrophy, and tenderness.

  • ROM: Evaluate flexion, extension, and rotational movements.

Elbow Assessment

  • Inspect: Look for deformities and swelling.

  • Palpate: Check for tenderness or warmth at the olecranon bursa.

  • ROM: Assess flexion and extension capabilities.

Wrist & Hand Assessment

  • Inspect: Examine dorsal and plantar sides for contour and swelling.

  • Palpate: Evaluate joints for tenderness and smoothness.

  • ROM: Include wrist flexion/extension and finger movements.

Hip Assessment

  • Inspect: Symmetry of hip joints and leg lengths.

  • Palpate: Check for joint stability.

  • ROM: Assess leg raising, bending, and rotation.

Knee Assessment

  • Inspect: Look for smooth skin and equal coloring.

  • Palpate: Ensure quadriceps are relaxed during assessment.

  • ROM: Assess the ability to flex and extend the knee.

Ankle & Foot Assessment

  • Inspect: Review foot positioning and contour.

  • Palpate: Check joint spaces for smoothness.

  • ROM: Include dorsiflexion and plantarflexion.

Red Flags with Back Pain

  • Symptoms: Chills, fever, bladder/bowel incontinence, progressive weakness, new paresthesia, or unexplained weight loss.

  • History: Prior cancer or IV drug use increases concerns.

Aging and Musculoskeletal Changes

  • Postural Changes: Decrease in height from 3-5 cm noted in older adults (70s/80s).

  • Common Issues: Kyphosis and osteoporosis with age, leading to increased fall risk.

  • Regular Exercise: Vital for maintaining bone density and overall functional capacity.

  • Fall Risk Assessment: "Get Up and Go Test" should be performed, with 12 seconds as the cutoff for increased risk.

  • Bone Density Scan: Recommended for females at age 65 and for males if risk factors exist.

Conclusion

  • Understanding musculoskeletal anatomy and assessments is vital for nursing practice, especially for effective patient evaluations and interventions.