Assessment of the Musculoskeletal System

Skeletal System Bone types Bone types –Long bones, such as the femur, are cylindric with rounded ends; they often bear weight. –Short bones, such as the phalanges, are small and bear little or no weight. –Flat bones, such as the scapula, protect vital organs and often contain blood-forming cells. –Bones that have unique shapes are known as irregular bones (e.g., the carpal bones in the wrist). –The sesamoid bone is the least common type and develops within a tendon; the patella is a typical example.

Skeletal System Bone structure Bone structure

Skeletal System Bone function Bone function –Provides a framework for the body –Supports the surrounding tissues (e.g., muscle and tendons) –Assists in movement through muscle attachment and joint formation –Protects vital organs, such as the heart and lungs –Manufactures blood cells in red bone marrow Provides storage for mineral salts (e.g., calcium and phosphorus)

Skeletal System After puberty, bone reaches its maturity and maximal growth. Bone is a dynamic tissue, however, that undergoes a continuous process of formation and resorption, or destruction, at equal rates until the age of 35 years. In later years, bone resorption accelerates, decreasing bone mass and predisposing clients to injury. After puberty, bone reaches its maturity and maximal growth. Bone is a dynamic tissue, however, that undergoes a continuous process of formation and resorption, or destruction, at equal rates until the age of 35 years. In later years, bone resorption accelerates, decreasing bone mass and predisposing clients to injury. Bone growth and metabolism affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin Bone growth and metabolism affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin

Classification Based on Movement Joints Permit Synarthrosis: Immovable (e.g., sutures of skull). Synarthrosis: Immovable (e.g., sutures of skull). Amphiarthrosis: Limited movement (e.g., symphysis pubis). Amphiarthrosis: Limited movement (e.g., symphysis pubis). Diarthrosis: Freely movable (e.g., hip). Diarthrosis: Freely movable (e.g., hip).

Classification Based on Connecting Tissues That Hold Bones Together Fibrous joints: No joint cavity; fibrous connective tissue joins bones; usually allow nomovement. Types include: Fibrous joints: No joint cavity; fibrous connective tissue joins bones; usually allow nomovement. Types include: –Sutures: Bones fused together (e.g., skull). –Syndesmoses: Bones very close together; held together by ligament that givesstrength and support to joint and also limits movement (e.g., tibiofibular joint). –Gomphoses: Peg and socket (e.g., root of tooth).

Classification Based on Connecting Tissues That Hold Bones Together Cartilaginous joints: Bones joined by hyaline cartilage or fibrocartilaginous disc; allows slight movement. Types include: Cartilaginous joints: Bones joined by hyaline cartilage or fibrocartilaginous disc; allows slight movement. Types include: –Synchondrosis (primary cartilaginous joint): Allows for growth, but not movement (e.g., epiphyseal plate joins diaphysis and epiphysis of long bones and allows growth). Once growth is complete, joint becomes synostosic (sealed). –Symphyses (secondary cartilaginous joint): Articulating bones covered with hylaine cartilage; fibrocartilaginous discs that act as shock absorbers; allows for some movement (e.g., symphysis pubis moves during pregnancy to allow for fetal growth).

Synovial: Most movable and complex. Has cavity filled with lubricating (synovial) fluid to help ends of bones slide. Enclosed by fibrous capsule of connective tissue and connected to periosteum of bone. Contain free-floating synovial cells and various leukocytes that phagocytose joint debris and microorganisms. Some contain bursae. Synovial joints may be: Synovial: Most movable and complex. Has cavity filled with lubricating (synovial) fluid to help ends of bones slide. Enclosed by fibrous capsule of connective tissue and connected to periosteum of bone. Contain free-floating synovial cells and various leukocytes that phagocytose joint debris and microorganisms. Some contain bursae. Synovial joints may be: –Uniaxial: Movement limited to one axis (e.g., elbow). –Biaxial: Movement on two axes (e.g., hand). –Multiaxial or triaxial: Movement on three axes (e.g., shoulder). Classification Based on Connecting Tissues That Hold Bones Together

Ligaments and Tendons Ligaments – strong, dense, flexible bands of connective tissue that hold bones to bones Ligaments – strong, dense, flexible bands of connective tissue that hold bones to bones –Provide support by encircling joint, gripping it obliquely or by lying parallel to bone ends across joint Tendons – strong, nonelastic cords of collagen located at ends of muscles to attach them to bones Tendons – strong, nonelastic cords of collagen located at ends of muscles to attach them to bones –Support bone movement in response to skeletal muscle contractions

Present Health Status Chronic diseases Chronic diseases Loss of bone density or osteoporosis Loss of bone density or osteoporosis Medications Medications Changes in ability to move, muscle strength or perform ADL’s Changes in ability to move, muscle strength or perform ADL’s Type and frequency of exerciseSmoke or consume alcohol Type and frequency of exerciseSmoke or consume alcohol Sports activity – type and frequency, use of protective devices Sports activity – type and frequency, use of protective devices Usual routine at home or work to lift, push or pull items, bend or stoop Usual routine at home or work to lift, push or pull items, bend or stoop Protect self from muscle strain or injury Protect self from muscle strain or injury

Past Medical History Accidents or trauma to bones or joints resulting in fractures, strains, sprains or dislocations. Any continuing problems or difficulties from these problems Accidents or trauma to bones or joints resulting in fractures, strains, sprains or dislocations. Any continuing problems or difficulties from these problems Congenital bone or joint problems. Altered activities and adaptation to this alteration Congenital bone or joint problems. Altered activities and adaptation to this alteration Surgery on bones, joints or muscles and outcome Surgery on bones, joints or muscles and outcome

Family History Curvature of spine or back problems Curvature of spine or back problems Arthritis, rheumatoid arthritis, osteoarthritis or gout Arthritis, rheumatoid arthritis, osteoarthritis or gout

Problem-Based History: Presenting Problems Pain Pain –Complete symptom analysis or “OLD CARTS” Problems with Movement Problems with Movement –How long had problem –Joints swollen, red or hot to touch –Recent sore throat –Weakness in muscles, progressively worse –Knees or ankles giving way with pressure –Joints lock or not move – frequency, alleviates or aggravates it Problems with Daily Activities Problems with Daily Activities –Limitations of what activities –Adaptation to limitation –Affect of chronic illness or crippling disease with family interaction and friends

Examination: Equipment Tape measure Tape measure Goniometer Goniometer

Inspection Axial skeleton and extremities for alignment, contour, symmetry, size and gross deformities Axial skeleton and extremities for alignment, contour, symmetry, size and gross deformities Muscles for size and symmetry Muscles for size and symmetry Muscles of face and neck for symmetry Muscles of face and neck for symmetry Shoulders and cervical, thoracic, and lumbar spine for alignment and symmetry Shoulders and cervical, thoracic, and lumbar spine for alignment and symmetry Shoulders and shoulder girdle for equality of height and contour Shoulders and shoulder girdle for equality of height and contour

Inspection (cont) Joints of wrists and hands for position, contour and number of digits Joints of wrists and hands for position, contour and number of digits Hips for symmetry Hips for symmetry Knees for symmetry and alignment Knees for symmetry and alignment Ankles and feet for contour, alignment and number of toes Ankles and feet for contour, alignment and number of toes

Observation Each major joint and adjacent muscles for Each major joint and adjacent muscles for –Range of motion  Jaw, neck, thoracic and lumbar spine, shoulders, elbows, wrist, fingers, knees, ankles, feet and hips –Tenderness on movement –Joint stability –Deformity Gait for conformity, symmetry and rhythm Gait for conformity, symmetry and rhythm

Palpation Bones for tenderness Bones for tenderness Joints for tenderness, heat and edema Joints for tenderness, heat and edema Muscles for tenderness, heat, edema and tone Muscles for tenderness, heat, edema and tone Each major joint and adjacent muscles for tenderness on movement, joint stability and deformity Each major joint and adjacent muscles for tenderness on movement, joint stability and deformity Each temporomandibular joint (TMJ) in front of the tragus of each ear for movement, sounds and tenderness Each temporomandibular joint (TMJ) in front of the tragus of each ear for movement, sounds and tenderness Neck for pain Neck for pain Knees for contour, tenderness and edema Knees for contour, tenderness and edema

Palpation (cont) Posterior neck, spinal processes and paravertebral muscles for alignment and tenderness Posterior neck, spinal processes and paravertebral muscles for alignment and tenderness Shoulders for firmness, fullness, tenderness and masses Shoulders for firmness, fullness, tenderness and masses Elbows for tenderness, edema and nodules Elbows for tenderness, edema and nodules Each joint of the hand and wrist for surface characteristics and tenderness Each joint of the hand and wrist for surface characteristics and tenderness Hips for stability and tenderness Hips for stability and tenderness Ankles and feet for contour, edema and tenderness Ankles and feet for contour, edema and tenderness

Percussion Spinal processes for tenderness Spinal processes for tenderness

Testing Muscle Strength Ask client to flex muscle and then resist when you apply opposing force against the muscles Ask client to flex muscle and then resist when you apply opposing force against the muscles Compare contralateral sides Compare contralateral sides Neck, Trapezius, arms (Biceps, Triceps), wrists, fingers, hips, legs, ankles and feet Neck, Trapezius, arms (Biceps, Triceps), wrists, fingers, hips, legs, ankles and feet

Ethnic and Cultural Variations The long bones of African Americans (especially males) are longer, narrower and denser. Less problems with osteoporosis or other long bone diseases The long bones of African Americans (especially males) are longer, narrower and denser. Less problems with osteoporosis or other long bone diseases Caucasians and Asians are at greater risk of osteoporosis; especially females. Caucasians and Asians are at greater risk of osteoporosis; especially females. Higher incidence of hip dislocation in infants of the Navajo Indians and Canadian Eskimos because infants tightly wrapped in blankets or strapped to cradle boards. Higher incidence of hip dislocation in infants of the Navajo Indians and Canadian Eskimos because infants tightly wrapped in blankets or strapped to cradle boards.

Gerontological Considerations Decrease in bone mass Decrease in bone mass Narrowing of intervertebral disks with loss of 1.5 – 3 inches in height Narrowing of intervertebral disks with loss of 1.5 – 3 inches in height Lordotic or convex curve of back flattens with both flexion and extension of back decreasing Lordotic or convex curve of back flattens with both flexion and extension of back decreasing Change in center of gravity – Men walk with smaller steps and wider base. Women become bowlegged with a narrow standing base Change in center of gravity – Men walk with smaller steps and wider base. Women become bowlegged with a narrow standing base Cartilage and ligaments calcify Cartilage and ligaments calcify Decrease in elasticity and tone of tendons and muscles Decrease in elasticity and tone of tendons and muscles Muscles loose mass and strength Muscles loose mass and strength Loss of agility Loss of agility

Gerontological Considerations Assess activities of daily living and degree of independence. Assistance required for ADL’s Assess activities of daily living and degree of independence. Assistance required for ADL’s Use of assistive devices for eating, dressing, mobility or toilet Use of assistive devices for eating, dressing, mobility or toilet Fall Risk Assessment Fall Risk Assessment –Measures to prevent falls

Diagnostic Assessement Laboratory tests: serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes Laboratory tests: serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes Radiographic examinations: standard radiography, tomography and xeroradiography, myelography, arthrography, and CT Radiographic examinations: standard radiography, tomography and xeroradiography, myelography, arthrography, and CT Other diagnostic tests: bone and muscle biopsy Other diagnostic tests: bone and muscle biopsy

Electromyography EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies. EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies. Low electrical currents are passed through flat electrodes placed along the nerve. Low electrical currents are passed through flat electrodes placed along the nerve. If needles are used, inspect needle sites for hematoma formation. If needles are used, inspect needle sites for hematoma formation.

Arthroscopy Fiberoptic tube is inserted into a joint for direct visualization. Fiberoptic tube is inserted into a joint for direct visualization. Client must be able to flex the knee; exercises are prescribed for ROM. Client must be able to flex the knee; exercises are prescribed for ROM. Evaluate the neurovascular status of the affected limb frequently. Evaluate the neurovascular status of the affected limb frequently. Analgesics are prescribed. Analgesics are prescribed. Monitor for complications. Monitor for complications.

Other Tests Bone scan Bone scan Gallium or thallium scan Gallium or thallium scan Magnetic resonance imaging Magnetic resonance imaging Ultrasonography Ultrasonography