Assessment of the Musculoskeletal System

Merchie Lissa F. Tandog, RN

September 11, 2009

ANATOMY AND PHYSIOLOGY OF THE MUSCULOSKELETAL SYSTEM

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 The musculoskeletal system consists of the skeletal system -- bones and joints (union of two or more bones) -- and the skeletal muscle system (voluntary or striated muscles). These two systems work together to provide basic functions that are essential to life, including:
Protection: protects the brain and internal organs Support: maintains upright posture

Blood cell formation: hematopoiesis

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 Mineral homeostasis
Storage: stores fat and minerals. Leverage: A lever is a simple machine that magnifies speed of movement or force. The levers are mainly the long bone of the body and the axes are the joints where the bones meet.
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Typical Arrangement of Musculoskeletal Tissues

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 Skeletal muscles, attached to bone by tendons, produce movement by bending the skeleton at movable joints. The connecting tendon closest to the body or head is called the proximal attachment: this is termed the origin of the muscle. The other end, the distal attachment, is called the insertion. During contraction, the origin remains stationary and the insertion moves.
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 The force producing the bending is always exerted as a pull by contraction, thus making the muscle shorter Muscles cannot actively push. Reversing the direction in which a joint bends is produced by contracting a different set of muscles.
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Muscle fiber- the contracting unit. Muscle fibers consist of two main protein strands - actin and myosin. Where the strands overlap, the fiber appears dark. Where they do not overlap, the fiber appears light. These alternating bands of light and dark give skeletal muscle its characteristic striated appearance. The trigger which starts contraction comes from the motor nerve attached to each muscle fiber at the motor end plate. MLT PC SY '09-'10

Types of Muscle Contraction

1. Isometric- the length of the muscle remains constant but the force generated by the muscles is increased 2. Isotonic- shortening of the muscles with no increase in tension within the muscles

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Body Movements produced by muscle contraction

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Flexion & Extension

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Growth and Metabolism

Calcium and Phosphorous- make up 99% of the bodys calcium and 90% of the bodys phosphorous
Inverse relationship; as calcium increase, phosphorous decrease

Calcitonin- produced by thyroid gland and decreases calcium concentration if it is above the normal level; inhibits bone resorption and increases renal excretion of Ca and Phosphorous as needed to maintain equilibrium
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 Vitamin D- produced and transported in the body to promote the absorption of calcium and phosphorous from the small intestine PTH- secretion increases when calcium levels are low to stimulate bone to produce more calcium into the blood Growth Hormone- secreted by the anterior pituitary gland responsible for increasing bone length and determining the amount of bone matrix formed before puberty Glucocorticoids- regulates protein metabolism Estrogen and Androgen- estrogen inhibit PTH, androgen increase bone mass

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ROM (Range of Motion)

A goal of ROM is to keep patient in the best physical shape possible. Another goal is to increase joint mobility and to increase circulation to the affected part.

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Passive ROM
The patient is unable to move independently and someone else manipulates body parts.

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Active ROM

The patient moves independently through a full ROM for each joint. Active ROM increases muscle tone, mass, strength and improves cardiac and pulmonary functioning

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Assessment Techniques
History
Demographic Data Young men at greater risk for trauma r/t VA; elderly for falls that result in fracture and soft-tissue injury Family history and genetic risk Osteoporosis, bone cancer, osteoarthritis Personal History Accidents, illnesses, lifestyle, medications, previous or concurrent diseases, sports, level of activity
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 Diet History Women who do not consume adequate amounts of calcium, lactose intolerance, inadequate protein or insufficient Vit C or D in the diet; obesity Socio-economic status Lifestyle, occupation (manual labor e.g. housekeepers, mechanics), computerrelated jobs, construction workers; athletes

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 Current health problems Collect data as follows: Date and tome of onset Factors that cause pr exacerbate the problem Course of the problem Clinical manifestation Measures that improve clinical manifestation MOST COMMON COMPLAINT OF PEOPLE WITH MUSCULOSKELETAL PROBLEMS IS PAIN!
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PQRST Model to assess pain

P- provoking incident? Q- quality of pain? R- region, radiation, and relief? S- severity of the pain? T- time?
It is best for the client describes the pain in his or her own words and points to its location if possible
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Physical Assessment
IPPA and ROM Posture- persons body build and alignment when standing or walking Gait Stance and swing phase Antalgic or lurch

Mobility
Ask client to perform ADLs Goniometer to measure ROM
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Assessment of head and neck

Inspect and palpate the skull for shape, symmetry, tenderness and masses Temporomandibular joints (TMJs)
Note for pain, crepitus, swelling

Inspect and palpate each vertebra of the spine in the neck

Malalignment, tenderness, inability to flex, extend, rotate the neck as expected

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Assessment of the Spine

Thoracic, lumbar and sacral spine are evaluated in the same manner as the neck

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Assessment of the upper extremities

Assess both extremities at the same time Palpate for size, swelling, deformity, malalignment, tenderness, pain and mobility

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Assessment of the upper extremities

Evaluate the hip by its degree of mobility Knee- assess for pain and limitation in mobiliy
Knock knee (genu valgum) Gena varum (bow-legged)

Feet- observe and palpate each joint and test for ROM
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Neurovascular Assessment
Inspect skin color, temperature and capillary refill distal to an injury or cast Palpation of pulses below the level of injury an assessment of sensation, movement, and pain on the injured part

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Assessment of the Muscular System

Evaluate size, shape, tone and strength of major skeletal muscles Lovett s scale for grading muscle strength

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Diagnostic Evaluation

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Blood Tests
ESR
Rate at which RBCs settle in unclotted blood in mm/hr elevated in arthritis,

Serum Uric Acid

By product of purine metabolism elevated in gout

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Minerals:
Calcium- decreased levels in osteomalacia and osteoporosis; increased levels in bone tumors, healing fractures Alkaline Phosphatase- enzyme normally present in the blood- increases with bone or liver damage
Normal range- 30-150 mU/L; elevated in bone cancer, osteoporosis

Phosphorous- increased levels in healing fractures, bone tumors

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Muscle Enzymes
Aldolase (ALD) Normal range: 22-59 mU/L

Creatinine kinase (CK-MM)- rises 2-4 hrs after muscle injury

Elevated in skeletal muscle injuries

Lactic Dehydrogenase (LDH)

Normal range- 100-225 mU/mL Elevated in skeletal muscle necrosis, extensive cancer
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IMAGING STUDIES

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X-ray Studies
Determine bone density, texture, erosion, and changes in bone relationship Multiple x-rays are needed for full assessment of the structure being examined Joint x-ray reveals fluid, irregularity, spur formation, narrowing and changes in joint structure

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Computed Tomography (CT Scan)

Shows in detail a specific plane of involved bone and can reveal tumors of the soft tissue or injuries to the ligaments or tendons It is used to identify the location and extent of fractures in areas that are difficult to evaluate CT studies may be performed with or without contrast agents- lasts about 1 hour The patient must MLT PC SY '09-'10 remain still during the

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CT scan image of thigh muscles

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MRI
Used to detect abnormalities (i.e., tumors or narrowing of tissue pathways through bone) of soft tissues such as muscle, tendon, cartilage, nerve and fat Because an electromagnet is used, patients with any metal implants, clips or pacemakers are not candidates for MRI To enhance visualization of anatomic structures, contrast media may be injected intravenously
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 During the procedure, the patient needs to lie still for 1 to 2 hours and will hear a rhythmic knocking sound Patients with claustrophobia may be unable to tolerate the confinement of closed MRI equipment without sedation

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MRI image of the knee

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Arthrography
Useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip or wrist A radiopaque substance or air is injected into the joint cavity to outline soft tissue structures and the contour of the joint The joint is put through its ROM to distribute the contrast agent while a series of x-rays is obtained. If a tear is present, the contrast agent leaks out of the joint and is evident on the x-ray image
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 After the arthrography, the joint is usually rested for 12 hours and a compression elastic bandage is applied as prescribed Nurse provides comfort measures (mild analgesia, ice) as appropriate The nurse should explain to the patient that it is normal to experience clicking or crackling in the joint for a day or two after the procedure, until the contrast agent is absorbed.
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Shoulder arthrography

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Bone Scan
Measures radioactivity in bone 2 hours after IV injection of a radioisotope Detects bone tumors, osteomyelitis

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Client Preparation
Inquire about possible allergy to the radioisotope Instruct client to void immediately before the procedure- to ensure the pelvis bone is scanned Instruct to increase OFI to distribute the isotope Instruct client to remain still MLT PC SY '09-'10 during the procedure

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Arthroscopy
Insertion of a fiberoptic scope into a joint for direct visualization to diagnose joint disorders Treatment of tears, defects, and disease process may be performed through the arthroscope
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PROCEDURE:
Performed in the OR under sterile conditions Insertion of a local anesthetic into the joint or a general anesthesia is used A large bore needle is inserted and the joint is distended with saline The arthroscope is introduced and joint structures, synovium and articular surfaces are visualized
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POST PROCEDURE: Puncture wound is closed with adhesives strips or sutures and covered with sterile dressing Ice may be applied to control edema and discomfort Joint is left extended and elevated to reduce swelling

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Arthroscopy of the knee

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Arthrocentesis
Joint aspiration; carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effussion Helpful in the diagnosis of septic arthritis and other inflammatory arthropathies and reveals the presence of hemarthrosis Normally, the synovial fluid is clear, MLT PC SY '09-'10 pale, straw-colored, and scanty in

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PROCEDURE:

Using aseptic technique, the physician inserts a needle into a joint and aspirates fluid Anti-inflammatory agents may be inserted into a joint A sterile dressing is applied after aspiration
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Arthrocentesis and lavage of the temporomandibular joint

Knee joint aspiration

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Biopsy
May be performed to determine the structure and composition of bone marrow, bone muscle, or synovium to help diagnose specific diseases. The nurse monitors the biopsy site for edema, bleeding, pain, and infection. Ice is applied as prescribed to control bleeding and edema. In addition, analgesics are prescribed or administered for comfort
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Bone marrow biopsy

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Thank you!

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