Musculoskeletal System Chapter 22

Structure and Function Subjective Data—Health History Questions Objective Data—The Physical Exam Abnormal Findings

Structure and Function Joints Nonsynovial or synovial joints Cartilage Ligament Bursa Muscles Fasciculi Tendon Skeletal muscle movements

Synovial Joint

Skeletal Muscle Movements

Skeletal Muscle Movements (cont.)

Structure and Function (cont.) Temporomandibular joint Spine Vertebrae Landmarks of the spine Intervertebral disks Shoulder Glenohumeral joint Rotator cuff Subacromial bursa Acromion process Greater tubercle of the humerus Coracoid process

Landmarks of the Spine

Shoulder

Structure and Function (cont.) Elbow Medial and lateral epicondyles Olecranon process of ulna Wrist and carpals Radiocarpal joint Midcarpal joint Metacarpophalangeal joints Interphalangeal joints

Right Elbow

Bones of the Hand

Structure and Function (cont.) Hip Acetabulum and head of femur Anterior superior iliac spine Ischial tuberosity Greater trochanter of femur Knee Femur, tibia, and patella Suprapatellar pouch Medial and lateral menisci Cruciate ligaments Prepatellar bursa Quadriceps muscle Ankle and foot Tibiotalar joint Medial and lateral malleolus Metatarsals

Hip Joint

Landmarks of the Knee

Ankle and Foot

Subjective Data— Health History Questions Joints Pain Stiffness Swelling, heat, and redness Joints: • Any problems with your joints? Any pain? • Location: Which joints? On one side or both sides? • Quality: What does the pain feel like: aching, stiff, sharp or dull, shooting? Severity: How strong is the pain? • Onset: When did this pain start? • Timing: What time of day does the pain occur? How long does it last? How often does it occur? • Is the pain aggravated by movement, rest, position, weather? Is the pain relieved by rest, medications, application of heat or ice? • Is the pain associated with chills, fever, recent sore throat, trauma, repetitive activity? • Any stiffness in your joints? • Any swelling, heat, redness in the joints? • Any limitation of movement in any joint? Which joint? • Which activities give you problems?

Subjective Data— Health History Questions (cont.) Muscles Pain (cramps) Weakness Muscles: • Any problems in the muscles, such as any pain or cramping? Which muscles? • If in calf muscles: Is the pain with walking? Does it go away with rest? • Are your muscle aches associated with fever, chills, the "flu"? • Any weakness in muscles? • Location: Where is the weakness? How long have you noticed weakness? • Do the muscles look smaller there?

Subjective Data— Health History Questions (cont.) Bones Pain Deformity Trauma (fractures, sprains, dislocations) Bones: • Any bone pain? Is the pain affected by movement? • Any deformity of any bone or joint? Is the deformity due to injury or trauma? Does the deformity affect ROM? • Any accidents or trauma ever affected the bones or joints: fractures, joint strain, sprain, dislocation? Which ones? • When did this occur? What treatment was given? Any problems or limitations now as a result? • Any back pain? In which part of your back? Is pain felt anywhere else, like shooting down leg? • Any numbness and tingling? Any limping?

Subjective Data— Health History Questions (cont.) Functional assessment (activities of daily living) Self-care behaviors Functional assessment (activities of daily living): Do your joint (muscle, bone) problems create any limits on your usual activities of daily living (ADLs)? Which ones? (Note: Ask about each category; if the person answers "yes," ask specifically about each activity in category.) • Bathing—getting in and out of the tub, turning faucets? • Toileting—urinating, moving bowels, able to get self on/off toilet, wipe self? • Dressing—doing buttons, zipper, fasten opening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, getting shoes that fit? • Grooming—shaving, brushing teeth, brushing or fixing hair, applying makeup? • Eating—preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking? • Mobility—walking, walking up or down stairs, getting in/out of bed, getting out of house? • Communicating—talking, using phone, writing? Self-care behaviors: Any occupational hazards that could affect the muscles and joints? Does your work involve heavy lifting? Or any repetitive motion or chronic stress to joints? Any efforts to alleviate these? • Tell me about your exercise program. Describe the type of exercise, frequency, the warm-up program. • Any pain during exercise? How do you treat it? • Have you had any recent weight gain? Please describe your usual daily diet. (Note the person's usual caloric intake, all four food groups, daily amount of protein, calcium.) • Are you taking any medications for musculoskeletal system: aspirin, antiinflammatory, muscle relaxant, pain reliever? • If person has chronic disability or crippling illness: How has your illness affected your interaction with family? Your interaction with friends? The way you view yourself?

Objective Data—The Physical Exam Preparation Screening musculoskeletal examination Complete musculoskeletal examination Equipment needed Tape measure Goniometer, to measure joint angles Skin marking pen Order of the examination Inspection Size and contour of joint Skin and tissues over joint Palpation Skin temperature Muscles, bony articulations, area of joint capsule Range of motion Muscle testing Apply opposing force Grading muscle strength

Objective Data—The Physical Exam (cont.) Temporomandibular joint Inspect joint area Palpate as person opens mouth Motion and expected range Open mouth maximally Protrude lower jaw and move side to side Stick out lower jaw Palpate muscles of mastication

Objective Data—The Physical Exam (cont.) Cervical spine Inspect alignment of head and neck Palpate spinous processes and muscles Motion and expected range Chin to chest Lift chin Each ear to shoulder Turn chin to each shoulder Shoulders Inspect joint Palpate shoulders and axilla Motion and expected range Arms forward and up Arms behind back and hands up Arms to sides and up over head Touch hands behind head

Objective Data—The Physical Exam (cont.) Elbow Inspect joint in flexed and extended positions Palpate joint and bony prominences Motion and expected range Bend and straighten elbow Pronate and supinate hand Wrist and Hand Inspect joints on dorsal and palmar sides Palpate each joint Motion and expected range Bend hand up, down Bend fingers up, down Turn hands out, in Spread fingers, make fist Touch thumb to each finger Phalen’s test Tinel’s sign

Objective Data—The Physical Exam (cont.) Hip Inspect as person stands Palpate with person supine Motion and expected range Raise leg Knee to chest Flex knee and hip; swing foot out, in Swing leg laterally, medially Stand and swing leg back Knee Inspect joint and muscle Palpate Bulge sign Ballottement of patella Motion and expected range Bend knee Extend knee Check knee during ambulation McMurray’s test

Objective Data—The Physical Exam (cont.) Ankle and foot Inspect with person sitting, standing, and walking Palpate joints Motion and expected range Point toes down, up Turn soles out, in Flex and straighten toes Spine Inspect while person stands Palpate spinous processes Motion and expected range Bend sideways, backward Twist shoulders to each side Straight leg raising Measure leg length discrepancy

Sample Charting

Abnormal Findings Abnormalities Affecting Multiple Joints Inflammatory conditions Rheumatoid arthritis Ankylosing spondylitis Degenerative conditions Osteoarthritis (degenerative joint disease) Osteoporosis

Abnormal Findings Abnormalities of the Shoulder Atrophy Dislocated shoulder Joint effusion Tear of the rotator cuff Frozen shoulder—adhesive capsulitis Subacromial bursitis

Abnormal Findings Abnormalities of the Elbow Olecranon bursitis Gouty arthritis Subcutaneous nodules Epicondylitis—tennis elbow

Abnormal Findings Abnormalities of the Wrist and Hand Ganglion cyst Colles’ fracture Carpal tunnel syndrome Ankylosis Dupuytren’s contracture Swan-neck and boutonniere deformities Ulnar deviation or drift Degenerative joint disease or osteoarthritis Acute rheumatoid arthritis Syndactyly Polydactyly

Abnormal Findings Abnormalities of the Knee Abnormalities of the Ankle and Foot Mild synovitis Prepatellar bursitis Swelling of menisci Osgood-Schlatter disease Chondromalacia patellae Achilles tenosynovitis Chronic/acute gout Hallux vagus with bunion and hammer toes Callus Plantar wart Ingrown toenail

Abnormal Findings (cont.) Abnormalities of the Spine Common Congenital or Pediatric Abnormalities Scoliosis Herniated nucleus pulposus Congenital dislocated hip Talipes equinovarus (clubfoot) Spina bifida Coxa plana (Legg-Calvé-Perthes syndrome) Edition change: note that routine screening for scoliosis is no longer recommended.

Ankylosis is… one or more bones in a joint being out of position partial dislocation of a joint shortening of a muscle leading to limited range of motion of joint stiffness or fixation of a joint Correct Answer: D. A is dislocation. B is subluxation. C is contracture.

Why would the examiner ask a high school athlete “what do you do when you get hurt?” Because so many young athletes are injured that it is important to plan ahead. Because many athletes are reticent to report injuries because they think it will limit their playing time. Because it is important for young athletes to understand the risks involved in playing sports. Because it is important for the athlete to report an injury to a clinician, rather than a coach, who may not take the injury seriously. Correct Answer: B. It is important for athletes to understand that their health is more important than playing time and that their long-term ability is dependent upon prompt, thorough treatment of any injuries that do occur. A is incorrect because the planning should be focused on reducing the number of injuries. C is true but not the reason for this question. D implies a lack of professionalism on the part of the coaches, which is neither fair nor accurate.