Musculoskeletal System

Musculoskeletal System Review

Introduction

• The musculoskeletal system is responsible for movement and stabilization of joints.
• A video on anatomy and physiology (A&P) may not be the most crucial for understanding the conditions discussed.

Bone Remodeling

• Bones are constantly remodeling: breaking down and rebuilding.
• Remodeling Process & Resources: If resources like calcium and phosphorus are insufficient, bone structure weakens over time.
• Age and Bone Strength: As we age, insufficient resources lead to weaker bones, increasing fracture risk.
• Bones as Living Tissue: Bones are living tissue requiring blood flow and nutrients for the breakdown/rebuild process.

Gerontological Considerations

• Muscles: Decrease in size, strength, and mass.
• Weight-bearing exercises help maintain muscle and bone density.
• Joints::
  • Decreased agility and loss of rigidity.
  • Increased cartilage erosion.
  • Stiffened joints.
  • Decreased range of motion and mobility.
  • Increased pain.
• Discs: Loss of water leads to decreased height.
• Posture: Weakened posture due to decreased muscle mass can further reduce height.
• Bones: Bone density decreases.
• Osteopenia: Bone loss that is not as severe.
• Osteoporosis: Diagnostic condition of significant bone density decrease.
• Bone density is determined via diagnostic tests.

Assessment: Subjective Data

• Past Health History:
  • Neuromuscular disorders impact bone density and muscle mass (e.g., multiple sclerosis, ALS, muscular dystrophy).
  • Tuberculosis (disseminated).
  • Poliomyelitis.
  • Soft tissue infections.
  • Diabetes also have an impact.
  • Trauma.
    • Falls.
    • Motor vehicle accidents.
  • Joint issues: arthritis, gout, osteomyelitis.
• Medications:
  • Over-the-counter pain medications.
  • Anti-seizure medications can cause bone softening due to vitamin D and calcium deficiency resulting in osteomalacia.
  • Corticosteroids can lead to avascular necrosis (reduced blood flow to the bone), especially in long bones like the femur; can also decrease muscle mass.
  • Diuretics can lead to potassium depletion, muscle cramping, and weakness.
• Surgery: Joint replacements and fracture repairs.
• Functional Health Pattern:
  • Health perception and management: Assess daily activities and repetitive motions causing joint stress.
  • Evaluate use of medications like NSAIDs or aspirin for pain management.
• Nutritional Metabolic:
  • Assess usual food intake over 24 hours.
  • Evaluate supplement use, especially calcium.
  • Note any recent weight changes.
  • Determine who prepares their food.
• Elimination Pattern:
  • Assess if musculoskeletal issues affect voiding.
  • Inquire about incontinence due to immobility.
  • Assess use of assistive devices for bathroom access.
  • Evaluate constipation, which may be linked to decreased activity.
• Sleep-Rest Pattern:
  • Check for difficulty sleeping due to musculoskeletal issues or pain.
  • Determine if pain causes nighttime awakenings, potentially mistaken for voiding issues.
• Cognitive-Perceptual:
  • Assess musculoskeletal pain and management strategies.
  • Use the mnemonic OPQRST for a complete pain assessment.
• Self-Perception, Self-Concept:
  • Determine if musculoskeletal issues affect self-esteem.
• Role-Relationship:
  • Assess the need for assistance and dependency on others due to musculoskeletal problems.
  • Evaluate risk for potential abuse or neglect if dependent on a spouse for personal care.
• Sexuality-Reproductive:
  • Address any sexual concerns related to physical limitations.
• Coping-Stress Tolerance Patterns:
  • Examine how the patient has dealt with their musculoskeletal limitations.
• Value-Belief Pattern:
  • Consider cultural or religious practices affected by limitations or management of musculoskeletal problems.

Objective Data

• Inspections:
  • Head-to-toe inspection.
  • Skin assessment.
  • Posture evaluation.
  • Muscle size comparison bilaterally.
  • Contour of joints.
  • Assess for swelling or deformity.
  • Assess limb length to check for abnormalities.
• Palpation:
  • Head-to-toe, superficial and deep palpation.
  • Assess for discomfort, edema.
  • Assess for crepitation (trepidation), indicative of a fracture.
• Motion:
  • Active range of motion (if possible); otherwise, passive range of motion.
  • Identify limitations without forcing joints.
• Muscle Strength:
  • Use a scale of 0 to 5 (5 being no limitations).
• Measurements:
  • Limb length and muscle mass measurements, comparing bilaterally.
  • Measure muscle mass at the largest circumferential area.
  • Limb length: From anterior superior iliac crest to medial malleolus.

Assistive Devices

• Evaluate the use and fit of assistive devices (e.g., braces).
• Check for pressure points and skin breakdown.
• Assess posture and gait with assistive devices.

Normal Physical Assessment Findings

• Normal spinal curvatures.
• No atrophy or asymmetry.
• No joint swelling, deformity, or trepidation.
• No tenderness on palpation of the spine, joints, or muscles.
• Full range of motion without pain or laxity.
• Muscle strength 5/5.

Diagnostics

• X-Ray:
  • Common initial diagnostic with limitations.
  • May require follow-up with a CT scan if inconclusive.
  • Useful for obvious fractures and post-repair alignment checks.
• CT Scan:
  • Higher radiation but better visualization of fractures.
  • May use contrast media (positive absorbs energy, negative highlights areas around absorption).
• MRI:
  • Helpful for back issues, disc evaluation, bone infections, and joint imaging.
  • Provides better soft tissue visualization; more expensive and less accessible than CT scans.
• Arthrography:
  • Uses X-ray, MRI, or CT with contrast media injected into a vein or joint.
  • Helps assess joint movement limitations and blood flow.
  • Better visualization of soft tissues than CT scans and X-rays.
• DEXA (Bone Densitometry):
  • Evaluates bone structure and density for osteoporosis or osteopenia.
  • Uses a small amount of radiation.
  • Also evaluates treatment effectiveness.

T-Score and Z-Score

• T-score:
  • Compares bone mass to peak bone mass of the same gender.
  • Negative score indicates bone mass is less than peak.
  • $\ge -1.0$: Normal.
  • $-1.1 \text{ to } -2.4$: Osteopenia.
  • $\le -2.5$: Osteoporosis.
• Z-score:
  • Compares bone mass to people of the same age; less useful for treatment evaluation.

Bone Scan

• Uses radioactive material and a gamma camera to image bone activity.
• Increased activity in areas with infection or cancer.
• Ensure patient hydration and use precautions when handling urine after the procedure.

Equations

• The T-score is evaluated using following formulas.

• Normal T-score: $T \ge -1.0$

• Score indicating Osteopenia: $-1.1 \le T \le -2.4$

• Score indicating Osteoporosis: $T \le -2.5$