Assessment of the Musculoskeletal System

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Assessment of the Musculoskeletal System
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Skeletal System

• 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.

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Skeletal System

• Bone structure

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Skeletal System

• 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
  marrowProvides storage for mineral salts (e.g.,
  calcium and phosphorus)

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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.
• Bone growth and metabolism affected by calcium
  and phosphorous, calcitonin, vitamin D,
  parathyroid hormone, growth hormone,
  glucocorticoids, estrogens and androgens,
  thyroxine, and insulin

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Classi?cation Based on Movement Joints Permit

• Synarthrosis Immovable (e.g., sutures of skull).
• Amphiarthrosis Limited movement (e.g.,
  symphysis pubis).
• Diarthrosis Freely movable (e.g., hip).

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Classi?cation Based on Connecting Tissues That
Hold Bones Together

• Fibrous joints No joint cavity ?brous
  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.,
  tibio?bular joint).
• Gomphoses Peg and socket (e.g., root of tooth).

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Classi?cation Based on Connecting Tissues That
Hold Bones Together

• Cartilaginous joints Bones joined by hyaline
  cartilage or ?brocartilaginous 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 ?brocartilaginous discs that act as
  shock absorbers allows for some movement (e.g.,
  symphysis pubis moves during pregnancy to allow
  for fetal growth).

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Classi?cation Based on Connecting Tissues That
Hold Bones Together

• Synovial Most movable and complex. Has cavity
  ?lled with lubricating (synovial) ?uid to help
  ends of bones slide. Enclosed by ?brous capsule
  of connective tissue and connected to periosteum
  of bone. Contain free-?oating 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).

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Ligaments and Tendons

• 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
• Support bone movement in response to skeletal
  muscle contractions

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Present Health Status

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

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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
• Congenital bone or joint problems. Altered
  activities and adaptation to this alteration
• Surgery on bones, joints or muscles and outcome

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Family History

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

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Problem-Based History Presenting Problems

• Pain
• Complete symptom analysis or OLD CARTS
• 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
• Limitations of what activities
• Adaptation to limitation
• Affect of chronic illness or crippling disease
  with family interaction and friends

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Examination Equipment

• Tape measure
• Goniometer

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Inspection

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

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Inspection (cont)

• Joints of wrists and hands for position, contour
  and number of digits
• Hips for symmetry
• Knees for symmetry and alignment
• Ankles and feet for contour, alignment and number
  of toes

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Observation

• 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

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Palpation

• Bones for tenderness
• Joints for tenderness, heat and edema
• Muscles for tenderness, heat, edema and tone
• 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
• Neck for pain
• Knees for contour, tenderness and edema

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Palpation (cont)

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

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Percussion

• Spinal processes for tenderness

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Testing Muscle Strength

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

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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
• 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.

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Gerontological Considerations

• Decrease in bone mass
• 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
• 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
• Decrease in elasticity and tone of tendons and
  muscles
• Muscles loose mass and strength
• Loss of agility

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Gerontological Considerations

• Assess activities of daily living and degree of
  independence. Assistance required for ADLs
• Use of assistive devices for eating, dressing,
  mobility or toilet
• Fall Risk Assessment
• Measures to prevent falls

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Diagnostic Assessement

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

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Electromyography

• 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.
• If needles are used, inspect needle sites for
  hematoma formation.

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Arthroscopy

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

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Other Tests

• Bone scan
• Gallium or thallium scan
• Magnetic resonance imaging
• Ultrasonography