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Assessment of the
MusculoskeletalSystem
Merchie Lissa F. Tandog, RNSeptember 11, 2009
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ANATOMY AND
PHYSIOLOGY
OF THE
MUSCULOSKELETALSYSTEM
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The musculoskeletal system consist
the skeletal system -- bones and jo
(union of two or more bones) -- and skeletal muscle system (voluntary
striated muscles). These two systems w
together to provide basic functions that
essential to life, including: Protection: protects the brain and inte
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 o
movement or force. The levers amainly the long bone of the bod
and the axes are the joints wher
the bones meet.
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Typical
Arrangement of
MusculoskeletalTissues
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Skeletal muscles, attached to bone by
tendons, produce movement by bendthe skeleton at movable joints.
The connecting tendon closest to the b
or head is called the proximal
attachment: this is termed the origin of muscle. The other end, the distal
attachment, is called the insert ion. Du
contraction, the origin remains stationa
and the insertion moves.
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The force producing the bending i
always exerted as a pull by
contraction, thus making the
muscle shorter
Muscles cannot actively push.
Reversing the direction in which ajoint 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 - actinand myos in.Where the strands overlap, the fiberappears dark. Where they do notoverlap, the fiber appears light. These
alternating bands of light and dark givskeletal muscle its characteristic striaappearance.
The trigger which starts contraction
comes from the motor nerve attachedeach muscle fiber at the motor endplate.
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Types of Muscle Contraction
1. Isometric- the length of themuscle remains constant but theforce generated by the muscles increased
2. Isotonic- shortening of themuscles with no increase intension 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 u
99% of the bodys calcium and 90% othe bodys phosphorous
Inverse relationship; as calcium increase
phosphorous decrease
Calcitonin- produced by thyroid glandand decreases calcium concentration
is above the normal level; inhibits bon
resorption and increases renal excret
of Ca and Phosphorous as needed tomaintain equilibrium
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Vitamin D- produced and transported in tbody to promote the absorption of calciumand phosphorous from the small intestine
PTH- secretion increases when calcium
levels are low to stimulate bone to producmore calcium into the blood
Growth Hormone- secreted by the anterpituitary gland responsible for increasingbone length and determining the amount
bone matrix formed before puberty Glucocorticoids- regulates protein
metabolism
Estrogen and Androgen- estrogen inhibPTH, androgen increase bone mass
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ROM (Range of Motion)
A goal of ROM is to keepatient in the best physi
shape possible.
Another goal is to increa
joint mobility and toincrease circulation to th
affected part.
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Passive ROM
The patient is unable tomove independently and
someone else
manipulates body parts.
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Active ROM The patient moves
independently through a ROM for each joint.
Active ROM increases
muscle tone, mass, stren
and improves cardiac andpulmonary functioning
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Assessment Techniques
History Demographic Data
Young men at greater risk for trauma r/t V
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 D in the diet; obesity
Socio-economic status
Lifestyle, occupation (manual labor e.g
housekeepers, mechanics), computer-
related jobs, construction workers;
athletes
C t h lth bl
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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 manifestationMeasures that improve clinical
manifestation
MOST COMMON COMPLAINT OF
PEOPLE WITH MUSCULOSKELETPROBLEMS 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
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
Goniometerto measure ROM
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Assessment of head and neck
Inspect and palpate the skull for shapsymmetry, tenderness and masses
Temporomandibular joints (TMJs)
Note for pain, crepitus, swelling
Inspect and palpate each vertebra ofthe spine in the neck
Malalignment, tenderness, inability to fle
extend, rotate the neck as expected
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Assessment of the Spine
Thoracic, lumbar and sacral spine areevaluated in the same manner as the neck
A t f th
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Assessment of the upper
extremities
Assess both extremities at the sametime
Palpate for size, swelling, deformity,
malalignment, tenderness, pain and
mobility
Assessment of the upper
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Assessment of the upper
extremities
Evaluate the hip by its degree ofmobility
Knee- assess for pain and limitation i
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 andcapillary refill distal to an injury or cas
Palpation of pulses below the level of
injury an assessment of sensation,
movement, and pain on the injured p
Assessment of the Muscular
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Assessment of the Muscular
System
Evaluate size, shape, tone andstrength of major skeletal muscles
Lovett s scale for grading muscle
strength
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Diagnostic Evaluation
Bl d T t
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Blood Tests
ESR
Rate at which RBCs settle inunclotted blood in mm/hr
elevated in arthritis,
Serum Uric Acid By product of purine metabolism
elevated in gout
Minerals:
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Minerals:
Calcium- decreased levels in
osteomalacia and osteoporosis; increas
levels in bone tumors, healing fractures
Alkaline Phosphatase- enzyme norma
present in the blood- increases with bon
or liver damage Normal range- 30-150 mU/L; elevated in bo
cancer, osteoporosis
Phosphorous- increased levels in
healing fractures, bone tumors
Muscle Enzymes
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Aldolase (ALD)-
Normal range: 22-59 mU/L
Creatinine kinase (CK-MM)- rise
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
Muscle Enzymes
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IMAGING STUDIES
X-ray 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
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Computed Tomography (CT Scan
Shows in detail a specific plane of
involved bone and can reveal tumors
the soft tissue or injuries to the ligameor tendons
It is used to identify the location and
extent of fractures in areas that aredifficult to evaluate
CT studies may be performed with or
without contrast agents- lasts about 1
hour The patient must remain still during th
CT i f thi h l
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CT scan image of thigh muscles
MRI
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MRI
Used to detect abnormalities (i.e.,
tumors or narrowing of tissue pathways
through bone) of soft tissues such asmuscle, tendon, cartilage, nerve and fat
Because an electromagnet is used,
patients with any metal implants, clips o
pacemakers are not candidates for MRI
To enhance visualization of anatomic
structures, contrast media may be
injected intravenously
During the procedure the patient
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During the procedure, the patient
needs to lie still for 1 to 2 hours
and will hear a rhythmic knockingsound
Patients with claustrophobia may
be unable to tolerate the
confinement of closed MRIequipment without sedation
MRI i f th k
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MRI image of the knee
Arthrography
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Useful in identifying acute or chronic tears
the joint capsule or supporting ligaments o
the knee, shoulder, ankle, hip or wristA radiopaque substance or air is injected
the joint cavity to outline soft tissue structu
and the contour of the joint
The joint is put through its ROM to distributhe contrast agent while a series of x-rays
obtained. If a tear is present, the contrast
agent leaks out of the joint and is evident
the x-ray image
After the arthrography the joint i
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After the arthrography, the joint i
usually rested for 12 hours and
compression elastic bandage is applie
as prescribed Nurse provides comfort measures (mil
analgesia, ice) as appropriate
The nurse should explain to the patien
that it is normal to experience clickin
or crackling in the joint for a day or tw
after the procedure, until the contras
agent is absorbed.
Shoulder arthrography
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Shoulder arthrography
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Bone Scan
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Bone Scan
Measures radioactivity in
bone 2 hours after IVinjection of a radioisotope
Detects bone tumors,
osteomyelitis
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Client Preparation
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p
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 stillduring the procedure
Arthroscopy
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Arthroscopy
Insertion of a fiberoptic
scope into a joint for directvisualization to diagnose
joint disorders
Treatment of tears, defects,and disease process may be
performed through the
arthroscope
PROCEDURE:
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PROCEDURE:
Performed in the OR under sterile
conditions Insertion of a local anesthetic into th
joint or a general anesthesia is used
A large bore needle is inserted andthe joint is distended with saline
The arthroscope is introduced and
joint structures, synovium and
articular surfaces are visualized
POST PROCEDURE:
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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
Arthroscopy of the knee
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Arthroscopy of the knee
Arthrocentesis
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Joint aspiration; carried out to obta
synovial fluid for purposes of
examination or to relieve pain dueeffussion
Helpful in the diagnosis of septic
arthritis and other inflammatoryarthropathies and reveals the
presence of hemarthrosis
Normally, the synovial fluid is cleapale, straw-colored, and scanty in
PROCEDURE
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PROCEDURE:
Using aseptic technique, thephysician inserts a needle into a
joint and aspirates fluid
Anti-inflammatory agents may beinserted into a joint
A sterile dressing is applied after
aspiration
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Arthrocentesis and lavage
of the temporomandibular
joint
Knee joint aspiration
Biopsy
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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. is applied as prescribed to control
bleeding and edema.
In addition, analgesics are prescribed
administered for comfort
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Bone marrow biopsy
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Bone marrow biopsy
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Thank you!