HA Q3

Musculoskeletal

Overall Structure and Function

• Composed of bones, muscles, and joints

Bones: Structure and Function

• 206 bones

  • Axial: head, trunk

  • Appendicular: extremities, shoulders, hips

    • 2 Types: compact, spongy

  • Osteoblasts = active cells that form bone tissue

  • Osteoclasts = cells that degrade

• Contains red and yellow marrow

  • Red marrow = produces blood

  • Yellow marrow = composed mostly of fat

• Periosteum = covers the bones

• Shapes: short, long, flat, irregular

Muscles: Structure and Function

• Types: voluntary (skeletal), smooth, cardiac

  • 650 voluntary (skeletal) muscles

• Tendons: attach muscles to bones

• Assist with posture, produce body heat, and allow the body to move

• Skeletal or voluntary muscles are under conscious control

Movement

Joints: Structure and Function

• Joint = where two or more bones meet

• Provide Range of Motion (ROM)

• Classifications:

  • Fibrous (sutures between skull bones): joined by fibrous connective tissue, immovable

  • Cartilaginous (joints between vertebrae): joined by cartilage

  • Synovial (Knees, wrists, hips) : space between bones filled with synovial fluid, provides lubrication for movement

    • Joined by ligaments, encased by a capsule

    • Bursae, provides cushion

Biological and Cultural Behaviors

• Frontal bone thicker in Blacks; parietal bones thicker in Whites

• Ethnic differences in lengths of radius and ulna

• Difference in the number of vertebrae

• Difference in incidence of arthritis: non-Hispanic Whites (41.3 million), non-Hispanic Blacks (6.1 million), Hispanics (4.4 million), non-Hispanic Asians (1.5 million); 26% women, 19.1% men

• Osteoporosis-related fractures: 51% Europeans and Americans, followed by Western Pacific and Southeast Asia Lactose intolerance: 80% to 95% of Asians and Native Americans; 18% to 26% of northern Europeans

• Some African Americans have large gluteal prominence that tends to look like lumbar lordosis.

• Unequal lengths of ulna and radius have been found in some ethnic groups (Swedes, Chinese).

Older Adult Considerations

• Osteoporosis: affects 200 million women worldwide: approximately 1/10 aged 60, 1/5 aged 70, 2/5 aged 80, 2/3 aged 90; one in three women and one in five men will have fractured bone

• Bone lose density with age, risk for bone fracture, especially wrists, hips, vertebrae.

• Joint-stiffening conditions may be misdiagnosed as arthritis, especially in older adult.

• Osteoporosis is more common as person ages because bone resorption increases, calcium absorption decreases, and production of osteoblasts decreases.

• Some positions during physical examination will be uncomfortable due to decreased flexibility.

• Slower movements, reduced flexibility, decreased muscle strength due to age-related muscle fiber and joint degeneration, reduced elasticity of tendons, joint capsule calcification

• May have impaired sense of position in space, contributing to risk of falling

• Kyphosis is common.

• Do not insist client touches toes when bending forward unless client comfortable with the movement.

• May have bow-legged appearance due to decreased muscle control

Functional Assessment of ADLs

• Do joint (muscle, bone) problems create any limits on your usual ADLs? Which ones?

• Bathing: Do you have trouble getting in and out of tub or using faucets?

• Toileting: Do you have trouble urinating or moving bowels? Are you able to get on and off toilet and to wipe yourself?

• Dressing: Can you do buttons, zippers, fastening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, and can you get shoes that fit?

• Grooming: Can you shave, brush teeth, brush or fix hair, and apply makeup?

• Eating: Can you prepare meals, pour liquids, cut up foods, bring food to mouth, and drink?

• Mobility: Can you walk, walk up or down stairs, get in and out of bed, get out of house?

• Communicating: Can you talk, use the telephone, and write?

General Routine vs. Focused Assessment

Physical Examination: Sequence

1. Observe gait and posture.

2. Inspect joints, muscles, extremities for size, symmetry, and color.

3. Palpate joints, muscles, extremities for tenderness, edema, heat, nodules, and crepitus.

4. Test muscle strength and ROM of joints.

5. Compare bilateral findings of joints and muscles.

6. Perform special tests for CTS.

7. Perform the “bulge,” “ballottement,” and McMurray knee tests.

Range of Motion (ROM)

• Ask for active voluntary ROM

• Familiarize yourself with the type of each joint and its normal ROM so that you can recognize limitations

• For limitations, gently attempt passive motion; anchor joint with one hand while other hand slowly moves it to its limit; normal ranges of active and passive motion should be the same

• Joint motion normally causes no tenderness, pain, or crepitation

Muscle Strength Rating

• 5: Normal (Active motion against full resistance)

• 4: Slight weakness (Active motion against some resistance)

• 3: Average weakness (Active motion against gravity)

• 2: Poor ROM (Passive ROM (gravity removed and assisted by examiner))

• 1: Severe weakness (Slight flicker of contraction)

• 0: Paralysis (No muscular contraction)

Ottawa Ankle Rules for X-ray Referral

• Ankle x-ray indicators

  • Malleolar area pain, bone tenderness at tips of 6-cm edges of lateral malleolus or medial malleolus

  • Inability to bear weight immediately or during examination

• Foot x-ray indicators

  • Pain in midfoot area and bone tenderness at bone of fifth metatarsal or navicular bone area

  • Inability to bear weight immediately or during examination

Osteoporosis General Information

• Bones demineralize and become porous and fragile, susceptible to fractures; occurs silently and progressively; often no symptoms until first fracture

• Most common fractures: spine, wrist, hip

• Affects 200 million women worldwide

• Screening: in women aged 65 years and older, postmenopausal women younger than 65 whose fracture risk is same or more than that of a 65-year-old White woman who has no additional risk factors

Osteoporosis Risk Factors

• Fixed risk factors

  • Age, female gender, ethnicity, family history of osteoporosis, previous fracture, menopause/hysterectomy, long-term glucocorticoid therapy, rheumatoid arthritis, primary/secondary hypogonadism in men

• Modifiable risk factors

  • Alcohol intake, smoking, low BMI, poor nutrition, vitamin D deficiency, eating disorders, low dietary calcium intake, insufficient exercise, frequent falls

• Risk Reduction

  • Nutrition with calcium intake, protein, vitamin D, physical activity, second-hand smoke

Spinal Abnormalities

Wrists, Hands, and Fingers Abnormality

Feet and Toes Abnormality