Ch.

52 Assessment of the Musculoskeletal System

I. Intro
A. Includes
1. bones
2. joints
3. skeletal muscles
4. supporting structures (needed for movement)

B. Mobility (movement)
1. basic human need
2. needed to perform ADLs
3. immobility
 decreased self esteem
 decreased self worth
a. results from
 trauma
 disease
 surgery
b. for extended period of time
 other body systems can be affected
(1) skin breakdown
(2) constipation
(3) thrombus formation
(4) sensation problems
 if nerves are damaged by trauma or disease
II. ANATOMY & PHYSIOLOGY REVIEW
A. Skeletal System
 206 bones and multiple joints
 growth and development during childhood and adolescence
1. Bones
a. Types & Structure
(1) classification/types
(a) shape
 i) long bones
 cylindric with rounded ends
 i.e. femur
 often bear weight
ii) short bones
 small
 i.e. phalanges
 bear little or no weight
iii) flat bones
 protect vital organs and usually contain blood forming cells
 i.e. scapula
iv) irregular bones
 unique shapes
 i.e. carpal bones in wrist, small bones in the inner ear
v) sesamoid bones
 least common type
 develops within a tendon
 i.e. patella
(b) structure/composition
i) tissue types
 almost every bone has both tissue types but in varying quatities
 i.e. long bone has a shaft (diaphysis) and two knoblike ends
(epiphyses)
(1) cortex
 outer layer of bone
 dense, compact bone tissue
 structural unit is the haversian system
(a) haversian system
 complex canal network containing microscopic blood vessels
 these blood vessels supply nutrients and oxygen to bone &
lacunae (small cavities that house osteocytes, or bone cells)
 canals run vertically in hard, cortical bone tissue
(2) medulla
  inner layer
 spongy, cancellous tissue
(a) contains trabeculae (large spaces)
 filled with red and yellow marrow
i) red marrow
 hematopoesis (blood cell production) site
ii) yellow marrow
 contains fat cells
 these can be dislodged and enter the blood stream to cause fat
embolism syndrome (FES) - life threatening complication
ii) volkmann's canals
 connect bone marrow vessels with the haversian system and
periosteum (outermost covering of the bone)
(1) osteogenic cells
 in deepest layer of periosteum
 differentiate into
(a) osteoblasts (bone forming cells)
(b) osteoclasts (bone destroying cells)
iii) matrix (osteoid)
 consists of collagen, mucopolysaccharide, and lipids
 deposits of inorganic calcium salts (carbonate and phosphate) in the
matrix - provide the hardness of bone
iv) bone is a very vascular tissue
 total blood flow between 200 and 400 mL/min
 each bone has a main nutrient artery - enters near the middle of the
shaft and branches into ascending and descending vessels
 very few nerve fibers are connected to bone
 sympathetic nerve fibers control dilation of blood vessls
 sensory nerve fibers transmit pain signals experienced by patients
who have primary lesions of the bone (bone tumors)
(1) these vessels supply:
(a) cortex
(b) marrow
 (c) haversian system
b. Function
(1) The Skeletal System:
 after puberty, bone reaches its maturity and maximal growth
 bone is a dynamic tissue
 it undergoes a continuous process of formation and resorption (destruction)
at equal rates until the age of 35
 late years - bone resrption increases, leads to decreased bone mass,
predisposing patients to injury (esp older women)
(a) functions:
i) provides a framework for the body
 allows the body to weight bearing or upright
ii) supports the surrounding tissues
 i.e. muscle and tendons
iii) assists in the movement through muscle attachment and joint
formation
iv) protects vital organs
 such as the heart and lungs
v) manufactures blood cells in bone marrow
vi) provides storage for mineral salts (calcium and phosphorus)
(b) numerous minerals and hormones affect bone growth and metabolism
i) calcium & phosphorus
 bone accounts for 99% of calcium in body & bone accounts for
90% of phosphorus
 calcium & phosphorus have inverse relationship (i.e. as calcium
rises, phosphorus decreases)
 if calcium is decreased, the bone (which stores calcium) releases
calcium into the bloodstream in response to PTH stimulation
 no calcium = no bone growth
 Crohn’s/Ulcerative Colitis – don’t absorb calcium, prone
osteoporosis
 High Ca++ Mj

 osteoblasts - produce collagenous and noncollagenous proteins that

compose osteoid.
 osteoclasts – actively resorb mineralized tissue
 these are antagonists, important for balance
Bone remodeling –
 in the remodeling sequence, bone sections are removed by bone-resorbing cells (osteoclasts) and
replaced with a new section laid down by bone-forming cells (osteoblasts)
 cells work in response to signals generated in that environment
 1st phase of remodeling is mediated only by the multinucleated osteoclastic cells
 they are activated, scoop out bone and resorb it
 then the work of the osteoblasts begins
 they form new bone that replaces bone removed by the resorption process
 the sequence takes 4 to 5 months
1st 24 hours – start healing
4-6 weeks – most are healed enough to weight bear
3 months – as hard as it was when you fractured it
 ii)
calcitonin
 work to maintain equilibrium when serum levels are altered
 produced by thyroid gland and decreases serum calcium
concentration if above normal
 inhibits bone resorption
 increases renal excretion of calcium and phosphorus
iii) vitamin D
 produced in body and transported in blood
 promotes absorption of calcium and phosphorus from the small
intestine
 enhance PTH activity to release calcium from the bone
 decreased level - osteomalacia (softening of the bone) in the adult
iv) parathyroid hormone (PTH)
 work to maintain equilibrium when serum calcium levels are altered
 secreted when calcium levels drop
 stimulates osteoclastic activity and release calcium into the blood
 reduces renal excretion of calcium and eases its absorption from the
intestine
 if levels increase, PTH diminishes - preserves the bone calcium
supply (feedback loop system)
 calcium police = regulate absorption and reabsorption of calcium
v) growth hormone
 secreted by the anterior lobe of the pituitary gland
 responsible for increasing bone length and determining the amount
 of bone matrix formed before puberty
 in childhood, increased secretion = gigantism; decreased secretion =
dwarfism
 in an adult, an increase = acromegaly (characterized by bone and
soft tissue deformities)
vi) adrenal glucocorticoids
 regulate protein metabolism
 increase or decrease catabolism to reduce or intensify the organic
matrix of the bone
 also aid in regulating intestinal calcium and phosphorus absorption
vii) estrogens and androgens
 estrogens - stimulates osteoblastic (bone-building) activity, inhibits
PTH
 in menopause estrogen decreases, women vulnerable to low calcium
levels with increased bone loss (osteoporosis)
 androgens - (testosterone) promote anabolism (body tissue building)
and increase bone mass
viii) thyroxine
 principal hormone secreted by thyroid gland
 primary function - increase the rate of protein synthesis in all types
of tissue (including bone)
ix) insulin
 works with growth hormone to build and maintain healthy bone
tissue
2. Joints
 space in which two or more bones come together
 aka "articulation" of the joint
 major function - provide movement and flexibility in the body
a. 3 types
(1) Synarthrodial
 synarthrosis = completely immovable (i.e. cranium)
(2) Amphiarthrodial
 amphiarthrosis = slightly movable (i.e. pelvis)
(3) Diarthrodial (synovial)
  diarthrosis = freely movable (i.e. elbow and knee)
 most conmonly involved in disease or injury
(a) only type lined with synovium
 a membrane that secretes synovial fluid for lubrication and shock
absorption
 lines inner portion of joint capsule (does not extend to spongy bone ends)
(b) articular cartilage
 collagen fiber matrix with a complex ground substance within
(c) synovitis (synovial inflammation)
 common in patients with inflammatory arthritis
 accompanied by breakdown of carilage
(d) bursae (small sacs lined with synovial membrane)
 located at joints and bony prominences
 prevent friction between bone and adjacent structures
i) bursitis - inflammation of bursae
(e) joints described by their anatomic structure
i) ball and socket (shoulder, hip)
 permit movement in any direction
ii) hinge (elbow)
 allow flexion and extension (in one plane)
iii) condylar (knee)
 rotates (slightly), extends and flexes
iv) biaxial (wrist)
 gliding
v) pivot (radioulnar)
 permit only rotation
B. Muscular System
1. 3 types of muscle in the body
a. Smooth
 non stirated, involuntary muscle
 responsible for contractions of organs and blood vessels
 controlled by autonomic nervous system
b. Cardiac
 striated, involuntary muscle
 controlled by autonomic nervous system
c. Skeletal
 striated, voluntary muscle
 controlled by the central and peripheral nervous systems
 motor end plate - junction of a peripheral motor nerve and the muscle cells that
it supplies
 fasciculi - connective tissue bundles that hold muscle fibers together
 entire muscle surrounded by dense, fibrous tissue or fascia which contains the
muscle's blood, lymph and nerve supply
 main function - movement of the body and its parts
 adjacent muscle tissue to injury or disease in bones, joints and supporting
structures are often involved (limiting mobility)
 during aging process - muscle fibers decrease in size and number
 atrophy - results when muscles are not regularly exercised and they deteriorate
from disuse
 PROPERTIES OF THE THREE DIFFERENT MUSCLE TYPES
**KNOW HOW MUSCLES CONTRACT**
Skeletal Cardiac Smooth
Histologic Cross-striated, multinucleated Cross-striated, single nucleated Non-striated, spindle cells with a
appearance muscle fibers muscle fibers containing single nucleus
intercalated disc
Site skeletal coverings muscular component of the found in wall of blood vessel,
heart airways glands, and walls of
hollow organs
Control self-regulated by pacemaker Involuntary control or regulation
voluntary/reflex: contolled by cells; heart rate can be altered by inhrent contraction initiation
somatic nervous system by autonomic nervous system (visceral smooth muscle)
nature of the rapid contraction and spontaneous and thythmic
contraction relaxation contraction slow and sustained contraction
related to the structure (e.g.
voluntary movement of skeletal contraction pump blood around regulation of blood wessel
Function and posture maintenance the body diameter, hair erection)

2. supporting structures
 very susceptible to injury
a. tendons
 bands of tough fibrous tissue that attach to bones
b. ligaments
 attach bones to other bones at joints
3. physiology of skeletal muscle contraction
 fatigue – lose muscle contraction
 spasm – group exhausts reserves of energy and no longer wants to work together (twitching,
cramps)
 excitation - change in action potential, changes permeability of the cell to allow
movement of Na and K
 coupling – migration of Ca, coupling with Ca and muscle proteins, depolarization
 contraction – binding of muscle proteins (actin + myosin) causing the muscle to
lengthen
  relaxation – Ca is absorbed by the sarcoplasmic teticulum (muscle protein) causing
the muscle to lengthen
 muscle metabolism – Na/K ATPase (protein that results in energy production)
pump, balance between intra and extracellular electrolytes (Na, K, Cl)

III. MUSCULOSKELETAL CHANGES ASSOCIATED WITH AGING

A. osteopenia - decreased bone density (bone loss)
 occurs as you age
 esp seen in white, thin women
B. osteoporosis = severe osteopenia
 causes posture and gait changes
 predisposition to fractures
C. synovial joint cartilage becomes less elastic and compressible
 as a result, joint cartilage becomes damaged, leading to OA
 genetic defects may contribute
 most commonly affects weight bearing joints (hips, knee, cervical and lumbar spine) but
joints in the shoulder and UE can also be affected
D. muscle tissue atrophy
 increased activity and excercise can slow progression and restore strength
 decreased coordination, loss of strength, gait changes, r/f falls with injury

 aging bones
o loss of bone tissue
 less stiff
 less strong
 more brittle
o bone remodeling takes longer
o stem cells in bone marrow are less efficient
o postural changes
o increased risk of fractures (osteoporosis)
 aging joints:
o cartilage becomes more rigid, fragile, and susceptible to fibrillation, water
decreases in cartilage
 synovial joint cartilage:
o less elastic and compressible
o osteoarthritis
 aging muscle:
o muscle fiber composition change
o changes in the muscle proteins
 changes result:
 o decreased coordination
o muscle strength loss
o gait changes
o predisposition to falls with injury

IV. ASSESSMENT METHODS

A. Patient History (Personal)
 detailed, accurate history
o reveals info that can direct physical assessment
o accidents, illnesses, lifestyle and drugs can contribute
o young men - greatest r/f trauma r/t motor vehible crashes
o older adults - greatest risk for falls tat result in fractures and soft-tissue injury
 ask about traumatic injuries and sports activities (no matter when they occurred) - can
cause OA years after
o injuries to spine 30 years ago could be causing lower back pain
o previous or current dz - diabetes (r/f osteomyelitis, slowed healing)
  ask about previous hospitalizations/illnesses/complications
 ask about ability to perform ADLs independently (use of assistive/adaptive devices are
used)
 ask about current lifestyle
o weight bearing activities - reduce risks for osteoporosis &maintain muscle
strength
o high impact sports - injury to soft tissues and bone
o tobacco use - slows healing of musculoskeletal injuries
o excess alcohol - can decrease vitamins and nutrients needed for bone and muscle
tissue growth
 ask about occupation/work life - can cause/contribute to injury
o manual labor = fractures
o computer = carpal tunnel [an entrapment of the median nerve in the wrist] or neck
pain
o construction & health care workers = back injury r/t prolonged standing or excess
lifting
o amateur & prof athletes = acute injuries [joint dislocations, fractures] and chronic
disorders [joint cartilage trauma] could lead to OA)
 ask about allergies - part allergies to dairy products (could cause decreased calcium
intake)
 ask about drug use previous and current use of drugs (prescribed, OTC, illicit) - some
drugs like steroids can negatively affect calcium metabolism and promote bone loss
 some drugs used may be taken to relieve pain - ask about herbs, vitamins/minerals,
biologic compounds (used for arthritis & other problems- glucosamine, chondroitin)
 complementary and alternative therapies - commonly used for various types of arthritis
and arthralgias (joint aching)
1. Nutrition/Dietary History
 determine any risks of inadequate nutrient intake
 most people (esp women) do not get enough calcium in their diet
 determine if the patient has had a significant weight gain or loss
 food recall - ID deficiencies and excess in diet (lactose intolerance is common
problem that can cause inadequate calcium intake)
 undernutrition – (seen in low socioeconomic classes) can't afford foods with adequate
nutrition (esp older adults)
  inadequate protein or insufficient vitamin C & D - slows bone and tissue healing
 obesity - excess stress and strain on bones & joints leading to fractures and trauma to
joint cartilage (good in a sense because it provides stress to keep bones healthy)
 obesity also inhibits mobility (predisposes to respiratory and circulatory probs)
 eating disorders (anorexia, bulimea) - r/f osteoporosis r/t decreased calcium and vit d
intake
 insufficient vit D = rickets
2. Family History & Genetic Risk
 ID disorders with familial or genetic tendency
 osteoporosis, gout - occur in several generations of family
 osteogenic sarcoma - bone cancer, influenced TP53 gene mutation
 + family history increases risk
3. Current Health Problems
 most common reports - pain, weakness (impair mobility)
 ask:
o data & time of onset
o factors that cause or make problem worse
o course of the problem (intermittent/continuous)
o clinical manifestations (subjective) and pattern of their occurence
o measures that improve manifestations (heat, ice)
 pain assessment - can present many challenges, can be r/t bone, muscle, joint
problems
o ask pt to use pain scale to rate pain level
o pain - acute or chronic (depends on onset, duration)
o pain with movement - fracture
o quality of pain - dull, burning, aching or stabbing
o location of pain, areas to which it radiates
o have pt describe in own words and points to location
 weakness - may be r/t individual muscles or muscle groups, proximal or distal
muscles or muscle groups
o proximal weakness may indicate myopathy (a problem in muscle tissue)
o distal muscle weakness may indicate neuropathy (a problem in nerve tissue)
o weakness in LE may increase r/f falls and injury
 o in UE may interfere with ADLs
B. Assessment of the Skeletal System
 bones, joints, and muscles are usually assessed at same time, head to toe
 ea described separately for emphasis, understanding
 inspection, palpation, ROM used
1. General Inspection
 observe posture, gait, general mobility for gross deformities and impairment
 note unusual findings, coordinate with PT/OT for in depth assessment
a. Posture & Gait
 posture - person's body build and alignment when standing and walking
 assess:
o curvature of the spine
o length, shape, symmetry of extremities
 most w/musculoskeletal problems eventually have probs with gait
o 2 phases of normal, automatic gait: (1) stance (2) swing phase
o evaluate balance, steadiness, ease and length of stride
o limp or other asymmetric leg movement or deformity noted
o antalgic gait - abnormality in the stance phase of gait (when part of one
leg is painful, patient shortens the stance phase on affected side)
o lurch - abnormality in swing phase (muscles in buttocks and/or legs are
too weak to allow the person to change weight from one foot to the other,
shoulders are moved wither side to side or front to back for help in
shifting the weight from one leg to the other)
o some have a combo - chronic hip pain and muscle atrophy from arthritic
disorders
b. Mobility and Functional Assessment/Movement
 assess need for ambulatory aids (canes and walkers) during transfer or while
walking and climbing stairs
 observe ability to perform ADLs
 pain and deformity may limit these
 coordinate with PT & OT to assess the patient's functional status
 assess major bones, joints, muscles by inspection, palpation, ROM
 pay attention to areas that are affected or may be affected according to pt hx or
 current prob
 goniometer - tool used to provide an exact measurement of flexion and extension
or joint ROM
 active ROM (AROM) evaluation - ask pt to move each joint through ROM by
themselves
 if they can't do it themselves, ask to relax muscles in extremity, hold joint with
one hand on top and one below, and allow passive ROM (PROM) to evaluate
joint mobility
 circumduction - evaluated in shoulder by having the patient move the arm in
circles from shoulder joint
 limit in ROM may not be significant if there is no limit in function to meet
personal needs
 for ea. anatomic location - observe skin for color, elasticity, and lesions (r/t
musculoskeletal dysfunction)
 i.e. redness or warmth - indicate an inflammatory process and/or pressure injury
to the skin
c. Specific Assessments
 pain or weakness in face or neck - inspect and palpate this area for tenderness
and masses
o open mouth while palpating temporomandibular joints (TMJ)
o common abnormal findings: tenderness or pain, crepitus (grating sound),
and a spongy swelling caused by excess synovium and fluid
 inspect and palpate ea vertebrae of the spine in the neck - be cautious and gentle
if pain if present
o clinical findings: malalignment, tenderness, inability to flex, extend, and
rotate neck
o muscle and nerve pain often accompany neck pain if spinal nerves are
involved
o thoracic spine, lumbar spine, sacral spine - evaluated in the same manner
as the neck
o spinal alignment problems are common
o place both hands over the posterior iliac crest with the thumbs over the
lumbosacral area
o apply pressure with the thumbs along the lumbosacral spine to elicit
 tenderness
o usually no discomfort until the area is palpated
o lordosis - common finding with abdominal obesity
o scoliosis - flex forward from the hips and inspect for a lateral curve in the
spine
 if extremities affected - assess arms or legs at the same time (compare)
o inspect, palpate both shoulders for size, swelling, deformity, poor
alignment, tenderness or pain, and mobility
 assessment of hand - most critical part of the exam
o inspect and palpate metacarpophalangeal (MCP), proximal
interphalangeal (PIP), distal interphalangeal (DIP)
o same digits compared on R and L hand
o determine ROM by observing active movement, if not possible, evaluate
passive
o quick ROM assessment - ask pt to make a fist then place ea finger next to
the thumb (if able, ROM is not seriously restricted)
 evaluation of hip - relies primarily on degree of mobility bc joint is deep and
difficult to inspect or palpate
o hip pain is usually in the groin or has pain that radiates to the knee
o assessment - have pt sit and have knee flexed
o effusion (fluid accumulation) is easily seen in knee
o limitations in movement with pain are common
o poor alignment - genu valgum (knock-knee) or genu varum
(bowlegged) deformities
 ankles and feet exams often neglected - contain multiple bones and joints that
disease and injury can affect
o observe and palpate each joint and test for ROM if feet are affected
d. Neurovascular Assessment
 assessment of peripheral vascular and nerve integrity
 begin with injured site, compare extremities
 neurovascular assessment - palpate pulses below level of injury, assessment of
sensation, movement, color, temperature, pain in the injured part
 if pulses are not palpated a Doppler should be used to find pulses in the
extremities
C. Assessment of the Muscular System
 notice size, shape, tone and strength of major skeletal muscles
 circumference of ea muscle may be measured and compared - gives an estimation of
muscle mass (only if abnormalities seen)
 ask pt to demonstrate muscle strength - apply resistance to extremity and ask pt to move
against resistance (not easily quantified) - Lovett's Scale (0-5)
D. Psychosocial Assessment
 clues for anticipating psychosocial problems - long work absence or permanent disability
could mean career loss
 further stress if chronic pain continues and pt can not cope with stressors
 anxiety & depression common with chronic pain
 deformities resulting from musculoskeletal dz/injury (amputation) can effect body image
and self concept
 help pt ID support systems and coping mechanisms that may be useful
 encourage verbalization of feelings related to loss and body image changes
 refer for psychological or spiritual counseling if needed
E. Diagnostic Assessment
1. Laboratory Assessment – Chart 52-3 test for “skeletal muscle health”
1. Laboratory Assessment
 no special patient prep or follow up for any of tests in chart 52-3
 teach purpose of test and the procedure they should expect
 additional tests for CTDs like RA
a. Serum Calcium and Phosphorus
 disorders of bone and parathyroid gland - alteration of serum calcium or
phosphorus level
 monitor these electrolytes
b. alkaline phosphatase (ALP)
 enzyme normally present in blood
 ALP increases with bone or liver damage
 in metabolic bone disease and bone cancer the enzyme concentration rises in
proportion to osteoblastic activity (bone formation)
 normally slightly increased in older adults
c. muscle enzymes
 major enzymes affected in skeletal muscle injury or disease
 as a result of damage, muscle tissue releases additional amounts of these
enzymes, increases serum levels
 enzymes increase in heart attack, trauma
(1) creatine kinase (CK-MM)
 begins to rise 2-4 hours after muscle injury
 elevated early in muscle disease (MD)
 CK molecule has 2 subunits: (1) M - muscle & (2) B - brain
 3 isoenzymes have been IDed
 CK (CK-MM, or CK3) is the only isoenzyme that rises in concentration with
damage to skeletal muscle
(2) aspartate aminotransferase (AST)
 moderately elevated (3-5x normal) in certain muscle dz (MD)
(3) aldolase (ALD)
 levels of isoenzyme aldolase A (ALD-A) increases in certain muscle dz
(MD)
(4) lactic dehydrogenase (LDH)
 LDH5 increases in certain muscle dz
2. Imaging Assessment
 skeleton very visible on standard X-rays
 anteroposterior and lateral projections are most common initial views
 bone density, alignment, swelling and intactness can be seen
 can determine conditions of joints - size of joint space, smoothness of articular
cartilage and synovial selling
 soft tissue involvement may be seen but not clearly differentiated
 "x-ray table is hard and cold", "remain still during filming"
 try to keep older adults/those at risk for hypothermia as warm as possible - use
blankets
 standard xrays - superimpose one structure on another
 tomography - planes produced or slices for focus and blurs the images of other
structures
o helpful to view detailed musculoskeletal system (bc many close structures
make visualization difficult)
 xeroradiography - highlights contrast between structures, clearly see margins and
edges *edge enhancement*
o higher radiation dose to the patient
o inability of test to determine tissue densities
 myelography - injection of contrast medium into the subarachnoid space of the spine
(usually by spinal puncture
o vertebral column, intravertebral disks, spinal nerve roots, and blood vessels
can be visualized
o less popular than it used to be, CT and MRI have replaced this invasive,
potentially painful and risky diagnostic techniques
o similar post-test care as lumbar puncture
 except HOB elevated 30-50 degrees to prevent the contrast medium
from getting into the brain
 arthogram - xray study of a joint after contrast medium (air or solution) injected to
enhance visualization
o double contrast arthrography - uses both air and contrast, may be
performed when a traumatic injury is suspected
o can often determine bone chips, torn ligaments or other loose bodies within
 joint
o not commonly used bc of newer advances, most joints now studied with MRI
 computed tomography (CT) scan - detects musculoskeletal problems, particularly
vertebral column and joints
o scanned images used to create additional images from other angles or to
create 3-D images and view complex structures from any view
o ask ab iodine-based contrast allergies
3. Nuclear Scans
 bone scan - radionuclide test in which radioactive material is injected for viewing
the entire skeleton
o primary use - detect bone tumors, arthritis, osteomyelitis, osteoporosis,
vertebral compression fractures, and unexplained bone pain
o less common today - MRI is becoming more available
o may be useful for detecting hairline fractures in patients w/unexplained
bone pain and diffuse metastic bone dz
 gallium and thallium scans - similar to bone scans
o more specific and sensitive in detecting bone problems
o gallium citrate (67Ga) is most commonly used, also migrates to brain,
liver, and breast tissues & used in examination of these when dz is
suspected
o thallium (201Tl) is better for pt with osteosarcoma and diagnosing extent
of dz, traditionally used for MI diagnosis but can be used for additional
evaluations of cancers of the bone
o bones take up gallium slowly - isotope administered 4-6 hours before scan
(cannot do other tests that require contrast media or isotopes during this
time)
o teach that radioactive material poses no threat - readily deteriorates in the
body
o gallium is excreted in intestinal tract - accumulates in feces after scan
o depending on tissue, pt is taken to nuclear medicine dept 4-6 hours after
injection
o procedure takes 30-60 minutes
o patient must lies still for accurate test results
o may be repeated at 24, 48 and 72 hours
 o mild sedation may be needed - relaxation and cooperation (confused older
adults, those in severe pain)
o no special care required after test
o excreted in stool and urine, but no precautions while handling
o push fluids to facilitate urinary excretion
4. Magnetic Resonance Imaging (MRI)
 w/ or w/o use of contrast media
 used to diagnose musculoskeletal disorders
 more accurate than CT and myelography for spinal and knee problems
 most appropriate for joints, soft tissue, and bony tumors that involve soft tissue
(CT is best for injuries or pathologies that involve only the bone)
 image produced through the interaction of magnetic fields, radio waves and
atomic nuclei showing hydrogen density
o radio waves bounce off body tissues, since ea has its own density,
computer can distinguish between normal and abnormal
 for some tissues, cross sectional image is better than that produced by radiography
or CT
 lack of hydrogen ions in cortical bones - easily distinguishable from soft tissue
 particularly useful in IDing problems with muscles, tendons, ligaments
 ensure pt removes all metal objects and checks for clothing zippers and zippers
and metal fasteners
 joint implants made of titanium or stainless steel are safe
 pacemakers, stents, surgical clips usually are not
 open MRIs prevent claustrophobia with older, encased machines
The Patient Preparing for Magnetic Resonance Imaging

Is the patient pregnant?

Does the patient have ferromagnetic fragments or implants, such as an older-style aneurysm clip?

Does the patient have a pacemaker, stent, or electronic implant?

Can the patient lie still in the supine position for 45 to 60 minutes (may require sedation)?

Does the patient need life support equipment available?

Can the patient communicate clearly and understand verbal communication?

Did the patient get any tattoo more than 20 years ago? (If so, metal particles may be in the ink.)
 Is the patient claustrophobic? (Ask this question for closed MRI scanners)

5. Ultrasonography
 sound waves produce and image of the tissue in ultrasonography
 ultrasound procedure used to view:
o soft tissue disorders (masses, fluid accumulation)
o traumatic joint injuries
o osteomyelitis
o surgical hardware placement
 jelly-like substance applied to the skin over the site to be examined promotes the
movement of a metal probe
 no special pre or post test care necessary
 quantatative ultrasound (QUS) - may be done for determining fractures or bone
density
F. Other Diagnostic Assessment
1. Biopsies
 bone biopsy - the physician extracts a specimen of the bone tissue for microscopic
examination
o invasive test may confirm the presence of infection or neoplasm
o not commonly done today
o 1 of 2 techniques used to get specimen:
 (1) needle (closed) biopsy
 (2) incisional (open) biopsy
o important to watch for bleeding at the puncture site, tenderness, redness, or
warmth (infection indicators)
o mild analgesics may be used
 muscle biopsy - done for diagnosis of atrophy (as in MD) and inflammation (as in
polymyositis)
o procedure and care are the same as bone biopsy
o diagnoses for chronic muscle dz
2. Electromyography (EMG)
 evaluates diffuse or localized muscle weakness “quality of contration”
 time it takes from nerve stimulation to the time the muscle contracts
  usually accompanied by nerve conduction studies for determining the electrical
potential an individual muscle generates
 helps in diagnosis of neuromuscular, lower motor neuron and peripheral nerve
disorders
 contraindicated in pts undergoing anticoagulant therapy
 may cause temporary discomfort, esp when subjected to electrical current
 selected pts - mild sedation prescribed
 may prescribe temporary discontinuation of muscle relaxants several days before to
prevent inaccurate test results
 at bedside or in EMG lab
 when EMG and nerve conduction are being done - nerve conduction is usually test
1st
 flat electrodes placed along nerve, low electrical currents are passed thru electrodes to
nerve and muscle innervated
o if nerve conduction occurs - muscle contracts
 testing muscle potential - small needle electrodes inserted, pt asked to perform
activities (minimal and maximal contraction tested), degree of nerve and muscle
activity recorded for later interpretation
 complications: nurse provides comfort measures and inspects the needle sites for
hematoma formation (application of ice as prevention), pt may report increased pain
and anxiety after test
3. Arthroscopy
 arthroscopy - may be used as a diagnostic test or a surgical procedure
 arthroscope - fiberoptic tube inserted into a joint for direct visualization of the
ligaments, menisci, & articular surfaces of the joint (knee and shoulder most
common)
 synovial biopsy and surgery to repair traumatic injury can be done through the
arthroscope as an ambulatory care procedure
a. Patient Preparation
 knee is most commonly "scoped" so care r/t that joint
 ambulatory basis or same day surgery
 pt must be able to flex the knee atleast 40 degrees (so arthroscope can be
inserted)
 knee can't be infected (may get worse from mechanical trauma of insertion)
  procedure done for surgical repair - pt may have PT consult before arthroscopy to
learn exercises for after
o SLRs, and quad-sets are practiced in sets of 10 each
o ROM exercises also taught but may not be allowed immediately
 nurse role: teach/reinforce exercises, reinforces procedure explanation and post-
test care, ensures pt signs informed consent
b. Procedure
 usually given local, light general or epidural anesthesia, depending on the
purpose of the procedure
 large pneumatic tourniquet - used around the thigh to minimize bleeding during
the procedure
 drugs that promote vasoconstriction for control of bleeding may be used with
tourniquet
 knee is flexed atleast 40 degrees and irrigated
 arthroscope is inserted through a small incision is less than 1/4 inch long
 multiple incisions may be needed - allow inspection at a variety of angles
 after procedure a dressing may be applied depending on amt of manipulation
during test or surgery
c. Follow-Up Care
 priority - evaluate neurovascular status of the patient's affected limb q hour or
according to agency/surgeon protocol
o monitor and doc distal pulses, warmth, color, capillary refill, pain,
movement and sensation of the affected extremity
 encourage exercises that were taught prior to procedure
 mild discomfort - mild analgesic (acetaminophen/Tylenol)
 if post-op - may have short-term mobility restrictions
 ice for 24 hours, elevated 12-24 hours
 arthroscopic surgery - opioid-analgesic combo like oxycodone and
acetaminophen (Percocet, Tylox)
o complications not common
 observe pt for swelling, increased joint pain r/t mechanical injury,
thrombophlebitis, infection
 severe joint or limb pain - possible complcation - teach pt to
contact doctor immediately
 surgeon sees pt 1 week after to check for complications