Download Musculoskeletal System

Chapter 14
Musculoskeletal System
Kevin Dobi, MSN, APRN
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Motion:
◦ Mechanisms that facilitate and impair mobility.
Interrelated concepts include:
◦ Oxygenation of blood to tissues.
◦ Intracranial regulation by brain, spinal cord,
and peripheral nerves.
◦ Pain from motion can limit movement.
◦ Nutrition must be adequate.
 Excessive weight can damage joints
◦ Elimination – risk of constipation due to limited
mobility.
Concept Overview
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Functions of bones include:
◦ Support for soft tissues and organs.
◦ Protection of organs—brain and spinal cord.
◦ Body movement and hematopoiesis.
◦ Continual remodeling and changing collagen
and mineral composition to accommodate
stress placed upon them.
Anatomy and Physiology:
Skeleton Overview
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Function dictates shape and surface features.
 Long bones act as levers and have a flat surface
for attachment of muscles with grooves at end
for tendon or nerve.
◦ Examples of long bones are humerus, femur,
fibula, and phalanges.
◦ Short bones, such as carpal and tarsal bones,
are cube shaped.
◦ Flat bones make up cranium, ribs, and scapula.
◦ Vertebrae are irregular bones.

Anatomy and Physiology:
Skeleton Overview (contd.)
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Human skeleton has two major divisions:
◦ Axial skeleton:
 Facial bones
 Auditory ossicles
 Vertebrae
 Ribs
 Sternum
 Hyoid bone
◦ Appendicular skeleton:
 Scapula
 Clavicle
 Bones of pelvis and legs
Anatomy and Physiology:
Skeleton Divisions
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Composed of muscle fibers that attach to bones
to facilitate movement.
◦ All are under voluntary control.
◦ Some move by reflex.
◦ Muscles attach to bone, ligament, tendon, or
fascia.
◦ Muscle fibers arranged parallel to long axis of
bones to which attached or are obliquely
attached.
Anatomy and Physiology:
Skeletal Muscles
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Articulations where two or more bones come
together; hold bones together while allowing
movement.
 Classified in two ways:
◦ By type of material between bones: Fibrous,
cartilaginous, or synovial.
◦ By degree of movement:
 Synarthrodial—immovable joints (sutures of
skull).
 Amphiarthrodial—slightly movable joint
(symphysis pubis).
 Diarthrodial—freely movable joints (knee joint).

Anatomy and Physiology:
Joints
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Diarthrodial classified by type of movement:
◦ Hinge joints permit extension and flexion; some
allow hyperextension.
◦ Pivot joints permit movement of one bone with a
ring or notch of another bone.
◦ Condyloid or ellipsoidal joints: Condyle of one bone
fits into elliptically shaped articulating bone.
◦ Ball-and-socket joints: Ball-shaped bone fits into
concave area of articulating bone.
◦ Gliding joints permit movement along axes through
flat articulating surfaces such as joints between two
vertebrae.
Anatomy and Physiology:
Joints: Type of Movement
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Diarthrodial joints are synovial joints because
they are lined with synovial fluid lubricating joint
to facilitate movement.
◦ Meniscus is pad of cartilage that cushions joint
of some synovial joints (knee).
◦ Joint capsule, an extension of periosteum, is a
covering surrounding joint; ligaments also
encase capsule to add strength.
Anatomy and Physiology:
Joint: Diarthrodial Joints
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Difference more functional than structural.
◦ Ligaments are strong, dense, flexible bands of
connective tissue that hold bones together.
 Provide support by encircling joint, gripping it
obliquely, or lying parallel to bone ends across joint.
 Allow some movements while restricting others.
◦ Tendons are strong, nonelastic cords of collagen that
attach muscles to bones.
 Tendons support bone movement in response to
skeletal muscle contractions.
 Transmit remarkable force from contracting muscles to
bone without sustaining injury themselves.
Anatomy and Physiology:
Ligaments and Tendons
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Cartilage: Semismooth, gel-like supporting
tissue; strong and able to support weight.
◦ Flexibility of cartilage allows thorax to move
when lungs expand and contract.
◦ Forms cap over ends of long bones for smooth
articulation surface.
◦ Reinforces respiratory passages of nose,
larynx, trachea, and bronchi.
◦ Receives nutrition forced from synovial fluid
that is forced into it during movement and
weight-bearing activities that are essential to
maintaining cartilage health.
Anatomy and Physiology:
Cartilage
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Bursae are small sacs in connective tissues
adjacent to some joints (shoulders and knees).
◦ Bursa lined with synovial membrane containing
synovial fluid acting as lubricant for joint.
◦ Functions to reduce friction when muscles or
tendons rub against other muscles, tendons, or
bones.
Anatomy and Physiology:
Bursae
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Anatomy and Physiology:
Axial Skeleton and Supporting
Structures – Skull and Neck

Skull and neck:
◦ Six cranial bones are fused together: One frontal,
two parietal, two temporal, and one occipital.
◦ Face consists of 14 bones: 2 nasal, 1 frontal, 2
lacrimal, 1 sphenoid, 2 zygomatic, 2 maxillary, and
mandible (movable).
◦ Neck supported by cervical vertebrae, ligaments, and
sternocleidomastoid and trapezius muscles.
 Greatest mobility at level of C4 to 5 or C5 to 6.
 Movements permitted include flexion, extension,
and hyperflexion, and lateral flexion and rotation.
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Anatomy and Physiology:
Axial Skeleton and Supporting
Structures – Skull and Neck (contd.)
Sternocleidomastoid muscle supports neck from
upper sternum and anterior clavicle to mastoid
process.
 Trapezius links scapula, lateral third of clavicle,
and vertebrae, extending to occipital prominence.

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Anatomy and Physiology:
Axial Skeleton and Supporting
Structures – Trunk, Pelvis, Spine
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Trunk formed by vertebrae, ribs, and sternum of
axial skeleton, and scapula and clavicle of
appendicular skeleton.
Pelvis is part of appendicular skeleton.
Spine composed of 7 cervical, 12 thoracic, 5
lumbar, and 5 sacral vertebrae.
◦ Cervical, thoracic, and lumbar are separated
from each other by fibrocartilaginous disks;
sacral vertebrae are fused.
 Vertebrae with disks move slightly over one
another permitting flexion, hyperextension, lateral
bending, and rotation; cervical joints are most
active.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Shoulder
and Upper Arm

Upper extremities: Shoulder:
◦ Shoulder joint, also called glenohumeral joint, is
point where humerus and glenoid fossa of scapula
articulate.
 Acromial and coracoid processes and surrounding
ligaments protect ball-and-socket joint and permit
flexion, extension and hyperextension, abduction
and adduction, and internal and external rotation.
◦ Two other joints contribute to shoulder movement:
 Acromioclavicular joint, between acromial process
and clavicle.
 Sternoclavicular joint, between sternal manubrium
and clavicle.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Elbow,
Forearm, and Wrist
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Upper extremities: Elbow and wrist:
◦ Elbow joint consists of humerus, radius, and ulna in
a single synovial cavity protected by ligaments and
bursa between olecranon and skin.
 Elbow is hinge joint permitting extension, flexion,
and sometimes hyperextension; pronation and
supination of forearm provided also.
◦ Wrist joins radius and carpal bones with disks of
wrist, ligaments, and fibrous capsule forming a
condyloid joint.
 Permits flexion, extension, and hyperextension, as
well as radial and ulnar flexion, also called radial
deviation and ulnar deviation.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Hand
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Upper extremities: Hand:
◦ Small, subtle movements or articulations within
hand between carpals and metacarpals,
between metacarpals and proximal phalanges,
and between middle and distal phalanges.
 Ligaments protect diarthrotic joints, which
allow flexion, extension, and hyperextension.
 Fingers are able to flex and extend, abduct
and adduct.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Hand
(contd.)
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Upper extremities: Hand:
◦ Names of joints in hand describe location:
 Distal interphalangeal (DIP) joint is distal joint
of fingers.
 Proximal interphalangeal (PIP) joint is middle
joint of each finger.
 Metacarpophalangeal (MCP) joint attaches
metacarpal to carpal joint.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Hip and
Thigh

Lower extremities: Hip and thigh:
◦ Acetabulum and femur form hip joint.
◦ Protected by fibrous capsule and three bursae.
◦ Three ligaments stabilize head of femur in joint
capsule.
◦ Ball-and-socket joint—flexion, extension, and
hyperextension, abduction and adduction,
internal and external rotation, and
circumduction.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Knee and
Lower Leg

Lower extremities: Knee and lower leg:
◦ Hinge joint is point of articulation between femur,
tibia, patella.
◦ Medial and lateral menisci (fibrous cartilage)
cushion tibia and femur and connect to articulated
capsule.
 Ligaments provide stability.
 Bursae reduce friction between femur and tibia.
◦ Movements include flexion, extension, and
sometimes hyperextension.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Ankle

Lower extremities: Ankle:
◦ Ankle joint (tibiotalar) is hinge joint; flexion
(dorsiflexion) and extension in one plane (plantar
flexion).
◦ Protective medial and lateral ligaments join tibia,
fibula, and talus to form ankle joint.
 Smaller joints, subtalar (talocalcaneal) and
talonavicular (transverse tarsal) within ankle permit
pivot or rotation movement, producing inversion
and eversion, and adduction and abduction.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Foot
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Lower extremities: Foot:
◦ Five metatarsal bones form sole of foot.
◦ Names of joints in feet describe their location.
◦ Interphalangeal joint is between distal phalanx
and proximal phalanx.
◦ Metatarsophalangeal joint is between proximal
phalanx and first metatarsal.
◦ Tarsometatarsal joint attaches first metatarsal
to tarsal.
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Anatomy and Physiology:
Appendicular Skeleton and
Supporting Structures – Foot
(contd.)

Lower extremities: Foot:
◦ Foot has gliding joint allowing inversion and
eversion of foot.
◦ Toes are condyloid joints allowing flexion and
extension, as well as abduction and adduction.
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Assessment
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Any chronic diseases?
◦ Loss of bone density or osteoporosis?
Take medications?
◦ What, and how often?
◦ Take as prescribed?
Changes in ability to move/participate in usual
activities?
◦ Changes in muscle strength?
◦ How did you adapt to changes?
General Health History:
Present Health Status
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Have you ever had accidents or trauma?
◦ Any continuing problems?
Have you had surgery on bones or joints?
◦ What was the outcome?
General Health History:
Past Health History
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Is there a history of curvature of spine or back
problems in your family?
Is there history of:
◦ Arthritis?
 Rheumatoid arthritis?
 Osteoarthritis?
 Gout?
General Health History:
Family History
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Do you exercise?
◦ How often?
Sports?
◦ Which, and how often?
◦ Protect yourself from injury while exercising or
playing sports?
Do you lift, push, pull, bend, or stoop frequently
as part of daily routine at home or work?
◦ How do you protect yourself from muscle strain
or injury?
General Health History:
Personal and Psychosocial History
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Where was pain felt?
◦ When was it first noticed?
◦ Related to movement?
Did pain occur suddenly or gradually?
◦ When during day, when do you feel pain?
Does pain move from one joint to another?
◦ Any injury, overuse, or strain of muscles or
joints?
What makes pain worse?
◦ Does pain shoot to another part of your body?
What was done to relieve the pain?
◦ How effective was that?
Problem-Based History:
Pain
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How long have you had movement problem?
◦ Are joints swollen, red, or hot to touch?
 Have you had a recent sore throat?
 Muscle weakness?
◦ Which ones?
◦ Does it get worse throughout day?
 Do knees or ankles give way with pressure?
◦ What do you think makes it happen?
 Joints felt as if locked and will not move?
◦ When?
◦ What relieves it?
◦ What makes it worse?
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Problem-Based History:
Problems with Movement
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Are activities limited by musculoskeletal
disorder?
◦ To what extent are activities limited?
◦ How do you compensate?
Note that any impaired mobility or function may
cause a self-care deficit.
For patients who have chronic disability or
crippling disease:
◦ How has illness affected interactions with
family?
◦ Has it affected relationships with friends?
Problem-Based History:
Problems with Daily Activities
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Physical Examination
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To examine musculoskeletal system, use a
cephalocaudal organization with side-to-side
comparisons for examining bones, muscles, and
joints.
Because there are often no “normals” for
musculoskeletal system, normality is established
best by comparing with other side.
Examination: Overview
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Cephalocaudal organization with side-to-side
comparison (no normals).
 Techniques used depend on reason for exam,
setting, condition and age of the patient, skill of
the nurse.
 Findings during exam may warrant use of
additional techniques.
 Nurse determines which techniques should be
indicated for each exam.

Examination: Overview (contd.)
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Inspect axial skeleton and extremities for
alignment, contour, symmetry, size, and gross
deformities:
◦ Body symmetric, straight spine (normal
curves), knees straight line (hips and ankles),
feet flat, forward.
Inspect muscles for size and symmetry:
◦ Bilateral symmetry, muscle circumference.
Examination:
Procedures and Techniques
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Examination:
Procedures and Techniques
(contd.)
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Palpate bones for tenderness; joints and muscles
for tenderness, heat, edema, tone.
◦ Bones nontender, joints or muscles same temp
as tissue, no tenderness or edema on
palpation; firm muscles
Observe range of motion and palpate major
joints and adjacent muscles for tenderness on
movement, joint stability, and deformity.
Test muscle strength, and compare sides.
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Observe gait for conformity, symmetry, and
rhythm.
◦ Conformity, regular smooth rhythm, leg swing,
length symmetry, smooth swaying or
symmetric arm swing.
Inspect face and neck musculature for symmetry.
Palpate temporomandibular joint for movement,
sounds, and tenderness.
Examination of Specific
Musculoskeletal Regions
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Observe jaw for range of motion.
◦ Motion smooth, without pain.
◦ Protrude and retract chin without difficulty or
pain.
 Palpate neck for pain.
◦ Soft and firm without masses, pain, or spasms.
 Observe neck for range of motion.
 Test neck muscles for strength.

Examination of Specific
Musculoskeletal Regions (contd.)
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Inspect shoulders and cervical, thoracic, and
lumbar spine for alignment and symmetry:
◦ Vertebrae aligned in straight line, shoulders
level.
 Observe range of motion of thoracic and lumbar
spine:
◦ 75 degrees of flexion while touching toes, 30
degrees back from neutral with hyperextension,
and 35 degrees lateral flexion.

Examination of Specific
Musculoskeletal Regions (contd.)
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Palpate posterior neck, spinal processes,
paravertebral muscles for alignment and
tenderness.
◦ Spine straight and nontender.
Percuss spinal processes for tenderness.
◦ No muscle spasm or tenderness.
Examination of Specific
Musculoskeletal Regions (contd.)
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Inspect shoulders and shoulder girdle for equality
of height and contour.
◦ Structures smooth, regular, bilaterally
symmetrical; shoulders level, rounded, firm,
smooth contour, no bony prominences.
◦ Each shoulder equidistant from vertebral
columns.
Palpate the shoulders for firmness, fullness,
tenderness, and masses.
◦ Nontender, smooth, firm, full without masses,
bilaterally symmetrical; larger on dominant
side.
Examination of Specific
Musculoskeletal Regions (contd.)
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Test trapezius muscles for strength.
Observe shoulders for range of motion:
◦ 180 degrees straight extension, 50 degrees
back hyperextension, 180 degrees shoulder
abduction, 50 degrees adduction, 90 degrees
external or internal rotation.
Test arms for muscle strength.
Palpate elbows for tenderness, edema, and
nodules.
Observe the elbows for range of motion.
Examination of Specific
Musculoskeletal Regions (contd.)
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Inspect joints of wrists and hands for position,
contour, and number of digits.
 Palpate each joint of hand and wrist for surface
characteristics and tenderness.
 Test for muscle strength and observe for range of
motion of wrists and fingers.
◦ Symmetrical flexion or extension, able to overcome
resistance; bilaterally equal grip strength
◦ 70 degrees hyperextension; 90 degrees palmar
flexion, 90 degrees metacarpophalangeal joint
flexion, 30 degrees extension; 50 to 60 degrees
ulnar, 20 degrees radial deviation

Examination of Specific
Musculoskeletal Regions (contd.)
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Inspect hips for symmetry and palpate hips for
stability and tenderness.
 Observe hips for range of motion:
◦ 120 degrees flexion from straight extended position
◦ 90 degrees hip flexion from straight extended
position
◦ 45 degrees external hip rotation from straight
midline position
◦ 40 degrees internal hip rotation from straight
midline position
◦ 45 degrees abduction, 30o adduction
◦ 30 degrees hyperextension

Examination of Specific
Musculoskeletal Regions (contd.)
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
Test hips for muscle strength:
◦ Raise leg from supine position; should be able
to overcome resistance.
◦ Extend leg from sitting position; should be able
to maintain extension.
◦ Bend knee; should be able to maintain flexion.
Examination of Specific
Musculoskeletal Regions (contd.)
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Inspect knees for symmetry and alignment.
◦ Knees lined with tibia; ankle without medial or
lateral deviation.
Palpate knees for contour, tenderness, and
edema.
◦ Suprapatellar pouch should be smooth,
nontender, nonedematous.
◦ Medial and lateral aspects of tibiofemoral joint
space should be nonedematous, nontender.
◦ Popliteal space should be smooth, nontender.
Examination of Specific
Musculoskeletal Regions (contd.)
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Observe knees for range of motion:
◦ 130 degrees flexion from straight extended
position.
◦ 15 degrees if able to hyperextend from midline.
Test leg muscles for strength.
◦ Should maintain flexion and extension against
resistance.
Examination of Specific
Musculoskeletal Regions (contd.)
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Inspect ankles and feet for contour, alignment,
number of toes.
Palpate ankles and feet for contour, edema, and
tenderness.
◦ Ankles should be smooth without deformity.
◦ Feet should be straight, aligned with long axis
of lower leg.
◦ Five toes.
◦ Structures should be smooth, nonedematous,
and nontender.
Examination of Specific
Musculoskeletal Regions (contd.)
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Observe ankles and feet for range of motion:
◦ 20 degrees dorsiflexion, 45 degrees plantar
flexion from midline.
◦ 20 degrees eversion, 30 degrees inversion from
midline.
◦ 10 degrees abduction, 20 degrees adduction.
◦ Equal bilateral flexion and extension of toes
Test ankles and feet muscles for strength.
◦ Should be able to walk on toes, heels, and
inside and outside of foot.
Examination of Specific
Musculoskeletal Regions (contd.)
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Several differences in assessment for infants and
young children.
Infants’ movement is assessed during voluntary
movement, and hip joints and feet are assessed
for abnormalities.
Children’s motor development compared with
standardized tables for age and sequences.
Musculoskeletal assessment of older child and
adolescent follows same procedures as that for
adults and reveals similar expected findings.
Age-Related Variations:
Infants, Children, and Adolescents
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Assessing musculoskeletal system of older adults
usually follows same procedures as that for
younger adults.
Older adults may be slower at performing rangeof-motion, and muscle strength may be less than
a younger adult.
Age-Related Variations:
Older Adults
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Fracture is partial or complete break in continuity
of a bone.
◦ Skin intact in closed fracture; skin broken in
open fracture.
◦ Pathologic fracture results from weakness in
bone, (osteoporosis or neoplasm).
Clinical findings:
◦ Pain caused by muscle spasm is common.
◦ Deformity or loss of function caused by tissue
shortening around bone and localized edema.
Common Problems and Conditions:
Bones – Fracture
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Osteoporosis is loss of bone density and
decreased bone strength results in osteoporosis.
◦ Causes include factors associated with aging:
Decline of estrogen and relationship to calcium
deficit, and lack of exercise.
 Clinical findings:
◦ Osteoporosis occurs without signs or
symptoms; patients may not know until they
realize loss of height, have spontaneous
fracture from brittle bones, or develop kyphosis
(convex curvature of thoracic spine).

Common Problems and Conditions:
Bones – Osteoporosis
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
Rheumatoid arthritis (RA) is chronic,
autoimmune inflammatory disease of connective
tissue.
◦ Onset is usually gradual with fatigue, morning
stiffness, diffuse muscle ache, and weakness.
◦ Synovial lining inflamed with deterioration of
cartilage and erosion of surfaces (spurs).
◦ Ligaments and tendons around joints become
fibrotic and shortened (contractures and joint
subluxation).
Common Problems and Conditions:
Joints – Rheumatoid Arthritis
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Common Problems and Conditions:
Joints – Rheumatoid Arthritis
(contd.)

Clinical findings:
◦ Joint involvement is bilateral.
◦ Symptoms are pain, edema, and stiffness of
fingers, wrists, ankles, feet, and knees.
◦ Systemic symptoms caused by autoimmune
response include low-grade fever and fatigue.
◦ As disease continues, ulnar deviation, swan-neck
deformity, and boutonnière deformity may be
observed.
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
Osteoarthritis is degenerative change in articular
cartilage.
◦ Affects weight-bearing joints (vertebrae, hips,
knees, and ankles); also hands and fingers.
◦ Affects joints with repetitive movement, those
used playing sports on a regular basis.
◦ As cartilage wears away, bones move against
each other (joint inflammation).
◦ Joint involvement may be unilateral or
bilateral.
Common Problems and Conditions:
Joints – Osteoarthritis
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
Clinical findings:
◦ Symptoms include joint edema and aching
pain.
◦ Joint deformities of fingers develop:
 Heberden’s nodes in distal interphalangeal
joints.
 Bouchard’s nodes in peripheral
interphalangeal joints.
 Know these differences!!!
Common Problems and Conditions:
Joints – Osteoarthritis (contd.)
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
Bursitis is an inflammation of the bursa.
◦ May be precipitated by arthritis, infection, injury

Common sites:
◦
◦
◦
◦

Shoulder
Elbow
Hip
Knee
Clinical findings:
◦
◦
◦
◦
◦
Pain
Limited motion
Edema
Point tenderness
Erythema of affected joint
Common Problems and Conditions:
Joints – Bursitis
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


Gout is hereditary disorder with increase in
serum uric acid due to increased production, or
decreased excretion of uric acid and urate salts.
Thought to be caused by lack of an enzyme
needed to completely metabolize purines for
renal excretion.
Uric acids not only accumulate commonly in
great toe but also in other joints such as wrists,
hands, ankles, and knees.
Common Problems and Conditions:
Joints – Gout
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
Clinical findings:
◦ Manifestations include erythema and edema of
joints that are very painful to move and limit
range of motion.
◦ Tophi, a sign of gout, are round, pea-like
deposits of uric acid in ear cartilage, or large,
irregularly shaped deposits in subcutaneous
tissue or other joints.
◦ Kidney stones from uric acid crystals can cause
manifestations of flank pain, and costovertebral
angle tenderness.
Common Problems and Conditions:
Joints – Gout (contd.)
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

Herniated nucleus pulposus (HNP) (also called
herniated disk and slipped disk) occurs when
fibrocartilage surrounding an intervertebral disk
ruptures and nucleus pulposus is displaced and
compresses adjacent spinal nerves.
Rupture frequently occurs in lumbar spine with
increased strain on vertebrae, such as lifting a
heavy object improperly.
Common Problems and Conditions:
Spine – HNP
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
Clinical findings:
◦ Depends on location of affected disk.
◦ Patient may complain of numbness and radiating
pain in extremity from herniated lumbar disk.
◦ Straight leg raises cause pain in involved leg by
putting pressure on spinal nerve.
◦ Cervical herniated nucleus pulposus causes arm
pain and paresthesia.
◦ Deep tendon reflexes may be depressed or absent,
depending on spinal nerve root involved.
Common Problems and Conditions:
Spine – HNP (contd.)
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
Scoliosis is S-shaped deformity of vertebrae.
◦ Skeletal deformity in three planes, usually
lateral curvature, spinal rotation (causing rib
asymmetry), and thoracic kyphosis.
◦ Evidence suggests that idiopathic scoliosis may
be genetic.
◦ Causes include congenital malformations of
spine, neuromuscular diseases, traumatic
injury, and unequal leg length.
◦ Structural scoliosis affects girls more than
boys.
Common Problems and Conditions:
Spine – Scoliosis
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
Clinical findings:
◦ Produces uneven shoulders and hip levels.
◦ Curvature less than 10% considered normal
variation; between 10% and 20% mild.
◦ Rotation deformity may also cause rib hump
and flank asymmetry on forward flexion.
◦ Depending on severity of curve, physiologic
function of lungs, spine, and pelvis may be
compromised.
Common Problems and Conditions:
Spine – Scoliosis (contd.)
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Common Problems and Conditions:
Ligaments and Muscles –
Carpal Tunnel Syndrome

Carpal tunnel syndrome occurs when median
nerve compressed between flexor retinaculum
(carpal ligament) and other structures within
carpal tunnel.
◦ May be caused by repetitive movements of
hands and arms, injury to wrist, and systemic
disorders such as rheumatoid arthritis, gout,
and hypothyroidism.
◦ It may also occur with fluid retention that
occurs with pregnancy and menopause.
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Common Problems and Conditions:
Ligaments and Muscles – Carpal
Tunnel Syndrome (contd.)

Clinical findings:
◦ Manifestations include burning, numbness, and
tingling in hands, often at night.
◦ Patients report numbness, pain, and
paresthesia during Phalen’s sign or Tinel’s sign
used to assess for this disorder.
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As the nurse assesses the patient, the following is
noted. What would be the most accurate
assessment of this?
A.
B.
C.
D.
Osteoarthritis
Ulnar deviation
Congenital anomaly
Osteomalacia
Question 1
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The musculoskeletal assessment requires a patient
to perform multiple exercises for identifying health
status of this system. To test trapezius muscle
strength, the nurse should ask the patient to:
A. Shrug his shoulders against resistance.
B. Lift his knee against resistance.
C. Hyperextend his leg without resistance.
D. Touch his toes from the standing position.
Question 2
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Silas is a 60-year-old male who is a postal worker.
He is married and has four grown kids. He admits
to being a “workaholic.” He has no surgical history.
He admits to eating all the seafood platters and
beef platters he can get when he travels with the
family on weekends. Patient has hypertension and
chronic obstructive pulmonary disease (COPD).
Case Study
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

Subjective data:
◦ Complains of 8/10 R great toe pain.
◦ Gait unsteady with pain.
◦ This is the second “attack” he has had this
year.
◦ Pain from R great toe seems to be radiating to
R ankle.
Objective data:
◦ Vital signs: T 96.2; P 82; R 16. BP 142/62.
◦ R great to swollen and red.
◦ R ankle slightly swollen with +1 pitting edema.
Case Study (contd.)
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
Questions:
1. What risk factors does Silas have for gout?
2. What measures might have helped prevent
gout?
3. What should the nurse do in this clinical
situation? Prioritize actions.
Case Study (contd.)
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The End
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