Download Assessment of Musculoskeletal System

Assessment of Musculoskeletal System
Dr. Belal Hijji, RN, PhD
March 7, 2012
Learning Outcomes
At the end of this lecture, students will be able to:
• Describe the process of performing musculoskeletal
assessment related to posture, gait, joint function, and muscle
strength and size.
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Introduction
• Physical assessment techniques of inspection and palpation are
used to evaluate the patient’s posture, gait, bone integrity, joint
function, muscle strength and size, skin, and neurovascular
status.
• Due to time limitations, this presentation excludes skin and
neurovascular status.
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Posture
• The normal curvature of the spine is convex [‫]محدب‬through the
thoracic portion and concave [‫ ]مقعر‬through the cervical and
lumbar portions (slides 5 & 6).
• Common deformities of the spine include kyphosis (due to
arthritis or osteoporosis); lordosis, frequently seen during
pregnancy; and scoliosis (may be congenital, idiopathic, or the
result of damage to the paraspinal muscles, as in
poliomyelitis).
(Continued on slide 10)
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5
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Kyphosis: an increased forward curvature of the thoracic spine
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Lordosis: an exaggerated curvature of the lumbar spine
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Scoliosis: a lateral curving
deviation of the spine
The forward bend test is used most
often to screen for scoliosis. The
child bends forward with the feet
together and knees straight while
dangling the arms.
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Posture (Continued …)
• During inspection of the spine, the entire back, buttocks, and
legs are exposed. The examiner inspects the spinal curves and
trunk symmetry from posterior and lateral views. Standing
behind the patient, the examiner notes any differences in the
height of the shoulders. Shoulder and hip symmetry, as well as
the line of the vertebral column, are inspected with the patient
erect and with the patient bending forward.
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Gait
• Gait is assessed by having the patient walk away from the
examiner for a short distance. The examiner observes the
patient’s gait for smoothness and rhythm. Any unsteadiness or
irregular movements are considered abnormal.
• Most frequently, limping is caused by painful weight bearing.
If one extremity is shorter than another, a limp may also be
observed as the patient’s pelvis drops downward on the
affected side with each step. Abnormal gait is seen in some
neurologic conditions. In spastic hemiparesis gait the leg on
the affected side is extended and internally rotated. The upper
limb on the same side is also adducted at the shoulder, flexed
at the elbow, and pronated at the wrist with the thumb tucked
into the palm and the fingers curled around it. In steppage gait,
foot drop where the foot hangs with the toes pointing down,
causing the toes to scrape the ground while walking, requiring
someone to lift the leg higher than normal when walking. For
shuffling gait, a video can illustrate it.
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Joint Function
• Assess range of motion both actively (the joint is moved by
the muscles surrounding the joint) and passively (the joint is
moved by the examiner). Skeletal deformity, joint pathology,
contracture (a permanent shortening of muscle or tendon)
producing deformity or distortion, or osteoarthritis may limit
range of motion and may reduce patient’s ability to perform
activities of daily living.
• Joint (next slide) deformity may be caused by contracture,
dislocation (complete separation of joint surfaces), subluxation
(incomplete dislocation that occurs when a bone slips over
another and eliminates the joint space), or disruption of
structures surrounding the joint.
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Typical Joint
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Joint Function (Continued…)
• Examine the knee joint for effusion (excessive fluid within the
capsule), if it is painful or if its motion is compromised,
swelling, and increased temperature that may reflect active
inflammation. An effusion is suspected if the joint is swollen
and the normal bony landmarks are obscured. If a small
amount of fluid is present in the joint spaces beneath the
patella, it may be identified by the following maneuver.
Perform the ballottement test (See below) to detect effusion.
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Joint Function (Continued…)
• Palpation of a passively moved joint provides information
about its integrity. Normally, the joint moves smoothly. A
snap [‫ ]طقطقة‬may indicate that a ligament is slipping over a
bony prominence. Slightly roughened surfaces, as in arthritic
conditions, result in crepitus (crackling sound) due to
movement of irregular joint surfaces across one another.
• Examine the tissues surrounding joints for nodule formation
(As in Rheumatoid arthritis, gout). Rheumatoid arthritis
produces soft nodules that occur within and along tendons
(Slide 13) . In gout, the nodules are hard and lie within and
immediately adjacent to the joint capsule itself.
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Muscle Strength and Size
• Assess muscle strength by having the patient perform certain
maneuvers with and without added resistance. When testing
the biceps muscle, ask the patient to extend the arm fully and
then to flex it against resistance you apply. Handshake may
provide an indication of grasp strength.
Biceps Muscle
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Muscle Strength and size (Continued…)
• To assess muscle size, measure the girth of an extremity to
monitor increased size due to exercise, edema, or bleeding into
the muscle. Girth may decrease due to muscle atrophy. The
unaffected extremity is measured and used as the reference
standard. Measurements are taken at the maximum
circumference of the both extremities, same location and
position, with the muscle at rest.
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