Download Assessment of the Musculoskeletal System

Assessment of the
Musculoskeletal System
Skeletal System
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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
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Bone structure
Skeletal System
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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
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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.
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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).
 Amphiarthrosis: Limited movement
(e.g., symphysis pubis).
 Diarthrosis: Freely movable (e.g.,
hip).
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Classification Based on Connecting Tissues
That Hold Bones Together
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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
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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).
Classification Based on Connecting Tissues
That Hold Bones Together
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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).
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
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Chronic diseases
Loss of bone density or osteoporosis
Medications
Changes in ability to move, muscle
strength or perform ADL’s
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
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
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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
Examination: Equipment
Tape measure
 Goniometer
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Inspection
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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
Inspection (cont)
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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
Observation
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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
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– Tenderness on movement
– Joint stability
– Deformity
Gait for conformity, symmetry and rhythm
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
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Spinal processes for tenderness
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 ADL’s
 Use of assistive devices for eating, dressing,
mobility or toilet
 Fall Risk Assessment
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– Measures to prevent falls
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
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