Musculoskeletal System

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Musculoskeletal System
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The Musculoskeletal System

• What are the functions of
• Bones (206) structure protection act as
  levers produce blood cells store calcium
• Muscles (650) allow for movement and position
  produce heat
• Joints point of articulation of two bones
  provide ROM
• Tendons connect muscle to bone
• Ligament connects bone to bone
• Cartilage supports and shapes acts as a shock
  absorber
• Bursae sacs filled with synovial fluid cushion
  and reduce friction between joints

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Common Disorders

• Osteoarthritis
• AKA-Degenerative Joint Disease (DJD)
• Noninflammatory, localized, progressive disorder
  involving deterioration of articular cartilage
  and subchondral bone and formation of new bone
  (osteophytes) at joint surface
• S/S Asymmetrical joint involvement, stiffness,
  swelling, bony protuberances, pain with motion
  and decreased ROM

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Common Disorders

• Rheumatoid Arthritis
• Chronic, systemic inflammatory disease of joints
  surrounding connective tissue.
• Inflammation of synovial membrane leads to
  thickening then fibrosis, which decreases ROM,
  and finally bony ankylosis
• S/S Symmetric joint involvement, heat, redness,
  swelling, painful motion, fatigue, weakness,
  anorexia, weight loss, low grade fever,
  lymphadenopathy

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Common Disorders

• Osteoporosis-
• Decrease in skeletal bone mass when rate of bone
  resorption is greater than bone formation.
• Increased risk for stress fractures
• Wrist, hips, vertebrae most common
• Loss of height frequently first clinical sign of
  osteoporosis
• Height loss occurs in trunk as result of
  vertebral fracture and collapse

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Health History

• Pain
• Onset
• Location
• Duration
• Character
• Aggravating Alleviating factors/Associated
  factors
• Radiation
• Treatments tried
• RICE
• Numbness or Tingling
• Muscle weakness

Rest, Ice, Compression, Elevation
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Health History

• Current Health Information
• Activities of daily living (personal care,
  household tasks, shopping, etc.)
• Current/Previous employment
• Exercise
• Nutrition
• Tobacco/Alcohol use
• Medications

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Health History

• Past Medical History
• Previous accidents/injuries to bones, nerves,
  soft tissue
• Previous orthopedic surgery
• Congenital deformities
• Chronic illnesses (i.e. rheumatoid/osteoarthritis
  arthritis, osteoporosis, cancer, neurological
  problems)
• Family History
• Congenital deformities, chronic illness

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Inspection

• Gait
• Stance
• Initial contact (heel strike), loading response,
  midstance, terminal stance (toe off), preswing
• Swing
• Initial swing, midswing, terminal swing

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Inspection

• Gait
• Guarded vs. relaxed
• Speed
• Smoothness
• Fatigue
• Normal variance
• Genu varum (bowleg)
• Genu valgum (knock-knee)
• Gait smooth and coordinated

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Inspection

• Posture
• Erect, slumped, guarded
• Kyphosis (hump back)
• Lordosis (sway back)
• Scoliosis (crooked back)
• Posture erect with normal spinal curvature

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Inspection

• Symmetry
• Size/Length (shortened limb, amputation)
• Contour (deformity, muscle tone)
• Contractures, dislocations, subluxation)
• Color (erythema, ecchymosis, cyanotic, other
  discoloration)
• Edema
• Masses
• Joints and muscles symmetric no swelling,
  masses, deformity.

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Palpation

• Bones, joints, and muscles for tenderness
• Muscle tone
• Temperature
• Edema
• Crepitus
• Masses
• Capillary Refill pulses
• Sensation (If acute injury want to chart CMS
  intact)
• No tenderness to palpation of joints no heat,
  swelling, or masses

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Range of Motion

• ROM
• Flexion-decreases angle between bones of joint
• Extension- increases angle between bones of joint
• Abduction- mvmt of limb away from midline
• Adduction- mvmt of limb towards midline
• Rotation- mvmt of bone around long axis
• Circumduction- mvmt in circle

Goniometer
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Range of Motion

• Lateral Flexion- decreasing angle of joints
  laterally.
• Dorsiflexion (foot towards shin)/Plantar flexion
  (foot towards floor)
• Inversion (sole medial)/Eversion (sole lateral)
• Supination (palm up)/Pronation (Palm down)
• Protraction (nonangular mvmt anterior)/Retraction
  (nonangular mvmt posterior)
• Elevation (lifting superiorly)/Depression (moving
  inferiorly)
• Opposition- thumb touches other finger

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Range of Motion

• Active vs. Passive ROM
• Active Patient moves joints through ROM
• Passive You move relaxed joints through ROM
• Excess fluid, loose bodies, contractures/stiffness
  , laxity, crepitus, pain.
• Full ROM movement smooth without crepitance or
  tenderness

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Strength

• Test strength by resisting ROM
• Grip strength (upper body)
• Plantar flexion (lower body)
• Grading
• 5- Full ROM against gravity, full resistance
• 4- Full ROM against gravity, some resistance
• 3- Full ROM with gravity
• 2- Full ROM with gravity eliminated (passive)
• 1- Slight contraction
• 0- No contraction
• Muscle strength 5/5

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Additional Information

• Shoulder
• Elbow
• Wrist/Hands/Fingers
• Hip
• Knee
• Ankles/Feet
• Spine

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Shoulder

• Palpate
• Clavicle
• Acromioclavicular joint
• Subacromial bursa area
• Greater tuberacle of humerus
• Biceps groove
• Anterior aspect of
• glenohumeral joint
• Scapula

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Shoulder

• ROM
• Forward flexion
• 180
• Hyperextension
• 50
• Internal rotation
• 90
• External rotation
• 90
• Abduction
• 180
• Adduction
• 50

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Shoulder

• Strength-
• Against resistance have pt
• Shrug shoulders (also CNXI)
• Flex shoulders forward
• Abduct

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Elbow

• Palpate
• Olecranon process
• Olecranon bursa area
• Grooves on side of olecranon process
• With thumb in lateral groove and index and middle
  finger in medial groove palpate either side of
  olecranon process

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Elbow

• ROM
• Flexion
• 150-160
• Extension
• 0
• Hyperextension 5-10
• Supination
• 90
• Pronation
• 90

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Elbow

• Strength
• Against resistance ask patient to
• Flex
• Extend

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Wrist/Hands/Fingers

• Inspect for
• OA Nodules
• Bouchards nodes
• Heberdens nodes
• RA deformities

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Wrist/Hands/Fingers

• Rheumatoid Arthritis

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Wrist/Hands/Fingers

• Palpate
• Wrist
• Support hand with fingers under it and palpate
  wrist with both thumbs

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Wrist/Hands/Fingers

• Fingers
• Use thumb and index finger in pinching motion to
  palpate sides of interphalangeal joints.

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Wrist/Hands/Fingers
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Wrist/Hands/Fingers

• ROM
• Wrist Flexion
• 90
• Wrist Hyperextension
• 70
• Radial deviation
• 20
• Ulnar deviation
• 50-60

• Finger flexion
• 90
• Finger hyperextension
• 30
• Finger abduction
• 20
• Make a fist
• Finger opposition

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Wrist/Hands/Fingers

• Muscle strength
• Position patients forearm palm up resting on a
  table. Hold mid-forearm and ask patient to flex
  wrist against your resistance

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Carpal Tunnel Syndrome

• Thenar eminence atrophy
• Phalens Test
• Have pt hold both hands back to back while
  flexing at wrists at 90 degrees.
• Normal No symptoms in hands after 60 seconds (-)
• Abnormal Numbness and burning along median nerve
  distribution within 60 seconds ()
• Tinels Sign
• Directly percuss over median nerve at wrist
• Normal No symptoms with percussion (-)
• Abnormal Burning and tingling along median nerve
  distribution ()

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Hip

• Inspection begins with observation of the
  patients gait, observe stance and swing
• Smooth, even gait reflects equal leg lengths
  functional hip motion

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Hip

• Palpate
• Hip joint
• Normal
• Joint stable
• Symmetric
• No tenderness
• No crepitus

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Hip

• ROM
• Flexion
• Knee flexed 120
• Knee straight
• Hyperextension
• 15
• Internal rotation
• 40
• External rotation
• 45
• Abduction
• 40-45
• Adduction
• 20-30

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Knee

• Inspect
• Lower leg alignment
• Should extend in same axis as thigh
• Genu varum (bowleg)
• Genu valgum (knock knee)
• Flexion contracture

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Knee

• Palpate
• Tibiofemoral joint
• Patella
• For crepitus

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Knee

• ROM
• Flexion
• 130-150
• Extension
• 0
• Hyperextension 15

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Knee

• Muscle strength
• Against resistance have patient
• Flex knee
• Extend knee
• Extension can also be demonstrated by success in
  rising from low chair or rising from squat
  without support

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Foot Inspection Abnormalities
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Ankles/Feet

• Palpate
• Grasp heel with fingers while palpating ankle
  with thumbs

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Ankles/Feet

• Palpate
• Palpate metatarsophalangeal joints between thumb
  and dorsum of fingers on plantar surface
• Using pinching motion of thumbs and forefingers
  to palpate interphalangeal joints

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Ankles/Feet

• ROM
• Plantar flexion
• 45
• Dorsiflexion
• 20
• Eversion
• 20
• Inversion
• 30
• Toe flexion
• 40
• Toe extension
• 40

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Ankles/Feet

• Muscle Strength
• Against resistance ask patient to
• Dorsiflex
• Plantarflexion

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Spine

• Inspect
• From the side cervical concavity, thoracic
  convexity, lumbar concavity
• From behind upright spinal column, alignment of
  the shoulders, the iliac crests, and the skin
  creases below the buttocks are symmetrical
• Have bend over and touch toes spine without
  lateral deviation, shoulder height symmetrical

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Spine

• Palpate
• Spinous processes
• Paravertebral muscles
• Sternomastoid and trapezius muscles

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Spine

• ROM

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Spine

• ROM
• Cervical
• Flexion
• 45
• Hyperextension
• 55
• Lateral bend
• 40
• Rotation
• 70

• Lumbar
• Flexion
• 90
• Hyperextension
• 30
• Lateral bend
• 30
• Rotation
• 30

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Spine

• Muscle Strength
• Cervical
• Flexion
• Extension
• Rotation (also tests CN XI)
• Lumbar
• Assess L5 S1 nerve root
• Have walk on toes and heels

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Spine

• Straight Leg Raise
• For low back pain that radiates to the leg, check
  straight leg raise on each side.
• Raise the leg until pain occurs, record the
  degree of elevation, the quality and distribution
  of the pain, and the effects of dorsiflexion.
• Sharp pain radiating down the leg when leg raised
  30-60 degrees is suggestive of nerve root
  compression, typically due to a herniated lumbar
  disc.
• Crossed leg raise is very diagnostic
• for disk injury
• Positive when radiation of pain
• in leg that is not raised

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Nursing Computer Charting

• Normal Parameters
• Moves all extremities
• No evidence of muscle wasting
• Steady gait, balance intact
• Ambulates safely and independently (with/without
  devices)

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Modified Hendrich Fall Risk Assessment

• Risk Factors
• Recent history of falls 5
• Confusion/disorientation 4
• Depression 2
• Altered elimination 1
• Dizziness/vertigo 1

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Modified Hendrich Fall Risk Assessment

• Get Up and Go Test Rising from Chair
• Able to rise in single movement 0
• Pushes up successfully one attempt 1
• Multiple attempts but successful 2
• Unable to rise without assistance 3
• Add points from risk factors and rising from
  chair.
• 0-3 points low risk, use basic safety
  surveillance
• gt3 high risk, use fall prevention interventions