Transcript Chapter 7 Body Systems

Chapter 21
Musculoskeletal System
Musculoskeletal System
 The musculoskeletal system provides the stability and mobility
necessary for physical activity.
 Physical performance requires bones, muscles, and joints that
function smoothly and effortlessly.
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General
 Inspect the skeleton and extremities and compare sides for the
following:




Alignment
Contour and symmetry of body parts
Size
Gross deformity
 Inspect the skin and subcutaneous tissues over muscles and joints for
the following:




Color
Number of skinfolds
Swelling
Masses
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General (Cont.)
 Inspect muscles and compare contralateral sides for the
following:
 Size
 Symmetry
 Fasciculations or spasms
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General (Cont.)
 Palpate all bones, joints, and surrounding muscles for the following:





Muscle tone
Heat
Tenderness
Swelling
Crepitus
 Test each major joint for active and passive range of motion and
compare contralateral sides.
 Test major muscle groups for strength and compare contralateral
sides.
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Joints
 Joints that deserve particular attention include the following:
 Hands and wrists
 Elbows
 Shoulders
 Temporomandibular joint
 Cervical, thoracic, and lumbar spine
 Hips
 Legs and knees
 Feet and ankles
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Musculoskeletal System
 Bony structure with its joints held together by ligaments, attached to
muscles by tendons, and cushioned by cartilage
 Bones
 Joints
 Muscles
 Tendons
 Connect muscle to bone
 Cartilage
 Ligaments
 Connect bone to bone
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Musculoskeletal System Functions
 Give structure to soft tissues
 Allows movement of body
 Protects vital organs
 Storage space for minerals
 Produces blood cells (hematopoiesis)
 Resorption
 Reformation
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Joint Types
 Synarthrosis: no movement permitted
 Suture
 Cranial sutures
 Synchondrosis
 Joint between epiphysis and diaphysis of long bones
 Amphiarthrosis: slightly movable
 Symphysis
 Symphysis pubis
 Syndesmosis
 Radius–ulna articulation
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Joint Types (Cont.)
 Diarthrosis (synovial): freely movable
 Ball and socket
 Hip, shoulder
 Hinge
 Elbow
 Pivot
 Atlantoaxial
 Condyloid
 Wrist between radius and carpals
 Saddle
 Thumb at carpal-metacarpal joint
 Gliding
 Intervertebral
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Diarthrodial Joints
 Fibrous capsule, cartilage, and ligaments
 Covers ends of opposing bones
 Synovial membrane
 Lines the articular cavity
 Synovial fluid
 Provides lubrication
 Bursae
 Promote ease of motion at points where friction would otherwise
occur
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Muscles
 Size and strength affected by the following:
 Genetics
 Exercise
 Nutrition
 Muscles move joints through range of motion (ROM).
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Upper Extremities
 Shoulder
 Elbow
 Forearm
 Wrist
 Hand
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Head and Spine
 TMJ
 Spine
 Cervical vertebrae
 Thoracic vertebrae
 Lumbar vertebrae
 Sacral vertebrae
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Lower Extremities
 Hip
 Knee
 Ankle
 Foot
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Infants and Children
 Long bones increase in length and thickness throughout
childhood.
 Cartilage in smaller bones ossifies.
 Ligaments are stronger than bones until adolescence.
 Fractures common
 Muscle fibers lengthen.
 Skeletal system grows.
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Adolescents
 Rapid growth in puberty results in:
 Decreased strength in epiphyses
 Increased risk for injury
 Bone growth completed about age 20
 Peak bone mass achieved at age 35
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Pregnant Women
 Increased mobility of pelvic joints
 Hormones
 Progressive lordosis of spine
 Compensate for enlarging uterus
 Lower back pain
 Muscle cramps
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Older Adults
 Loss of bone density
 At risk for fractures
 Deterioration of joint cartilage
 Decreased mobility
 Muscle mass decreases.
 Muscle tone and strength decrease.
 Reaction time and speed decrease.
 Endurance decreases.
 Sedentary lifestyle promotes degeneration of musculoskeletal system.
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History of Present Illness
 Joint symptoms
 Character
 Associated events
 Temporal factors
 Efforts to treat
 Medications: NSAIDs, acetaminophen, biologic modifiers and
other immunosuppressants, corticosteroids, topical analgesics,
glucosamine, chondroitin, hyaluronic acid
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History of Present Illness (Cont.)
 Muscular symptoms
 Character
 Precipitating factors
 Efforts to treat
 Medications: muscle relaxants, salicylates, NSAIDs
 Skeletal symptoms
 Character
 Associated event
 Efforts to treat
 Medications: hormone therapy, calcium, calcitonin, bisphosphonates
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History of Present Illness (Cont.)
 Injury
 Sensation at time of injury
 Mechanism of injury
 Pain
 Swelling
 Efforts to treat
 Medications: analgesics, antiinflammatory drugs
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History of Present Illness (Cont.)
 Back pain
 Abrupt or gradual onset
 Character of pain and sensation
 Associated event
 Efforts to treat
 Medications: muscle relaxants, analgesics, antiinflammatory drugs
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Past Medical History
 Trauma: nerves, soft tissue, bones, joints; residual problems; bone
infection
 Surgery on joint or bone; amputation, arthroscopy
 Chronic illness
 Skeletal deformities and congenital anomalies
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Family History
 Congenital abnormalities of hip and foot
 Scoliosis and back problems
 Arthritis
 Genetic disorders: osteogenesis imperfecta, skeletal dysplasia,
rickets, hypophosphatemia, hypercalciuria
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Personal and Social History
 Employment
 Exercise
 Functional abilities
 Weight and height changes
 Nutrition
 Tobacco and alcohol use
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Infants and Children
 Birth history
 Presentation, large for gestational age, birth injuries (may result in
fractures or nerve damage), type of delivery (vaginal vs. cesarean
section), use of forceps
 Low birth weight, premature, resuscitation efforts, required
ventilator support (may result in anoxia leading to muscle tone
disorders)
 Fine and gross motor developmental milestones, appropriate
for chronologic age
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Infants and Children (Cont.)
 Overweight or obese
 Quality of movement: spasticity, flaccidity, cog wheel rigidity
 Arm or leg pain
 Character
 Onset
 Participation in organized or competitive sports, weightlifting
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Pregnant Women
 Muscle cramps
 Back pain
 Weeks of gestation, associated with multiple pregnancy, efforts to
treat
 Associated symptoms: uterine tightening, nausea, vomiting, fever,
malaise (could signify musculoskeletal discomfort if not from
another condition)
 Type of shoes (heels may increase lordosis)
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Older Adults
 Weakness
 Onset
 Associated symptoms
 Increases in minor injuries
 Change in ease of movement
 Nocturnal muscle spasm
 History of injuries or excessive use of a joint or group of joints,
claudication, known joint abnormalities
 Previous fractures
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Equipment
 Marking pencil
 Goniometer
 Tape measure
 Reflex hammer
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Inspection
 Posture
 Erectness
 Symmetry
 Alignment
 Skin and subcutaneous tissues
 Swelling
 Redness
 Masses
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Inspection (Cont.)
 Extremities
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
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

Size
Deformities
Enlargement
Alignment
Contour
Symmetry
 Muscles





Bilateral symmetry
Hypertrophy
Atrophy
Fasciculations
Spasms
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Palpation
 Palpate bones, joints, and surrounding muscles for the
following:
 Heat
 Tenderness
 Swelling
 Fluctuation
 Crepitus
 Resistance to pressure
 Muscle tone
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Range of Motion
 Active ROM and passive ROM for each joint and related
muscle group
 Note
 Pain
 Limited or spastic movement
 Joint instability
 Deformity
 Contracture
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Range of Motion (Cont.)
 Passive ROM may exceed active ROM by 5 degrees.
 Active ROM and passive ROM should be equal in contralateral
joints.
 Discrepancies may indicate muscle weakness or disorder.
 Use goniometer where there is increased or limited ROM.
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Muscle Strength
 Compare bilateral muscles

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

Strength
Symmetry
Equality
Resistance
 Muscle strength
 Graded 0 (no voluntary contraction) to 5 (full muscle strength)
 Weakness may result from:
 Disuse atrophy
 Pain
 Fatigue
 Overstretching
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Hands and Wrists (Inspection)
 Inspect
 Contour
 Position
 Shape
 Number and completeness of digits
 Finger deviation
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Hands and Wrists (Palpation)
 Palpate joints.
 Texture
 Swelling
 Tenderness
 Bogginess
 Nodules
 Bony overgrowths
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Hands and Wrists (ROM)
 Assess ROM.
 Flexion of fingers: expect 90 degrees
 Hyperextension of fingers: expect 30 degrees
 Flexion of wrist: expect 90 degrees
 Hyperextension of wrist: expect 70 degrees
 Rotation of hand: expect radial motion of 20 degrees, ulnar motion
of 55 degrees
 Assess muscle strength and grip
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Elbows (Inspection/ palpation)
 Inspect
 Contour
 Carrying angle
 Subcutaneous nodules
 Palpate
 Tenderness
 Swelling
 Thickening
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Elbows (ROM/ strength)
 Assess ROM.
 Flexion: expect 160 degrees
 Extension: expect 180 degrees
 Pronation: expect 90 degrees
 Supination: expect 90 degrees
 Assess muscle strength.
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Shoulders (Inspection/ palpation)
 Inspect
 Size
 Symmetry
 Contour
 Dislocation or winging of scapula
 Palpate
 Joints
 Muscles
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Shoulders (ROM)
 Assess ROM.
 Forward flexion: expect 180 degrees
 Hyperextension: expect 50 degrees
 Abduction: expect 180 degrees
 Adduction: expect 50 degrees
 Internal and external rotation: expect 90 degrees
 Shrug: evaluate shoulder girdle muscles and cranial nerve XI
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Shoulders (Strength)
 Strength of rotator cuff muscles
 Supraspinatus: abduct arms 90 degrees and flex shoulders
forward 30 degrees; apply downward pressure on distal humerus
when arms are rotated so that thumbs point down or up
 Subscapularis: arm at side, elbow flexed 90 degrees; rotate
forearm medially against resistance
 Infraspinatus and teres minor: arm at side, elbow flexed 90
degrees, and rotate arm laterally against resistance
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Temporomandibular Joint (TMJ)
 Palpate
 Pain
 Crepitus, locking, and popping
 Assess ROM
 Open and close
 Lateral movement
 Protrusion and contraction
 Assess muscle strength
 Temporalis
 Masseter
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Cervical Spine (Inspection/palpation)
 Inspect
 Head alignment
 Symmetry of muscles and skinfolds
 Palpate
 Tone
 Symmetry
 Tenderness
 Spasm
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Cervical Spine (ROM/ strength)
 Assess ROM.
 Flexion: expect 45 degrees
 Extension: expect 45 degrees
 Rotation: expect 70 degrees
 Assess muscle strength.
 Sternocleidomastoid
 Trapezius
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Thoracic and Lumbar Spine
(Inspection/palpation)
 Inspect
 Alignment
 Straightness
 Curves
 Lordosis, kyphosis, and gibbus
 Scoliosis
 Palpate
 Tenderness
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Thoracic and Lumbar Spine (ROM)
 Assess ROM.
 Flexion: expect 70 to 90 degrees
 Hyperextension: expect 30 degrees
 Lateral bending: expect 35 degrees
 Rotation of upper trunk: expect 30 degrees
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Hips (Inspect/ palpate)
 Inspect
 Symmetry
 Size
 Gluteal folds
 Palpate
 Stability
 Tenderness
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Hips (ROM/ strength)
 Assess ROM.
 Flexion: expect 90 degrees
 Hyperextension: expect 30 degrees
 Abduction and adduction
 Internal rotation: expect 40 degrees
 External rotation: expect 45 degrees
 Assess muscle strength
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Legs and Knees (Inspect/ palpate)
 Inspect
 Landmarks
 Concavities
 Alignment
 Palpate
 Swelling
 Tenderness
 Bogginess
 Crepitus
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Legs and Knees (ROM/ strength)
 Assess ROM.
 Flexion: expect 130 degrees
 Extension: expect 30 degrees of full extension
 Hyperextension: expect 15 degrees
 Assess muscle strength.
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Feet and Ankles (Inspect/ palpate)
 Inspect



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
Contour and position
Size and number of toes
Alignment
Weight bearing
Arch
 Palpate
 Heat
 Swelling
 Tenderness
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Feet and Ankles (ROM/ strength)
 Assess ROM.
 Dorsiflexion and plantarflexion
 Inversion and eversion
 Abduction and adduction
 Assess muscle strength.
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Hand and Wrist Assessment
 Several procedures are used to evaluate the integrity of the
median nerve.
 Certain patterns of pain, numbness, and tingling are
associated with carpal tunnel syndrome.
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Hand and Wrist Assessment (Cont.)
 Thumb abduction test
 Isolates the strength of the abductor pollicis brevis muscle,
innervated only by the median nerve
 Tinel sign
 Tested by striking the patient’s wrist with your index or middle
finger where the median nerve passes under the flexor
retinaculum and volar carpal ligament
 Tingling sensation radiating from the wrist to the hand in the
distribution of the median nerve is a positive Tinel sign
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Hand and Wrist Assessment (Cont.)
 Phalen test
 Patient holds both wrists in a fully palmarflexed position with the
dorsal surfaces pressed together for 1 minute.
 Numbness and paresthesia in the distribution of the median nerve
are suggestive of carpal tunnel syndrome.
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Shoulder Assessment
 Several procedures are used to evaluate rotator cuff for
impingement or tear―increased pain associated with
inflammation or tear
 Hawkins test
 Forward flexing shoulder to 90 degrees, flexing elbow to 90
degrees, and then internally rotating arm to its limit
 Neer test
 Internally rotate and forward flex arm at the shoulder: presses
supraspinatus muscle against anteroinferior acromion
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Lower Spine Assessment
 Straight leg raising (SLR) test
 SLR used to test for nerve root irritation or lumbar disk herniation
at the L4, L5, and S1 levels.
 Have the patient lie supine with the neck slightly flexed.
 Ask the patient to raise the leg, keeping the knee extended.
 No pain should be felt below the knee with leg raising.
 Radicular pain below the knee in a dermatome pattern may be
associated with disk herniation.
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Lower Spine Assessment (Cont.)
 Femoral stretch test
 Used to detect inflammation of the nerve root at the L1, L2, L3,
and sometimes L4 level.
 Have the patient lie prone and extend the hip.
 No pain is expected.
 The presence of pain on extension is a positive sign of nerve root
irritation.
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Hip Assessment
 Thomas test
 Detect flexion contractures of hip masked by excessive lumbar
lordosis.
 Have the patient lie supine.
 Fully extend one leg flat on the examining table and flex the other
leg with the knee to the chest.
 Observe the patient’s ability to keep the extended leg flat on the
examining table.
 Lifting the extended leg off the examining table indicates a hip
flexion contracture in the extended leg.
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Hip Assessment (Cont.)
 Ballottement: excess fluid or effusion
 Bulge sign: excess fluid
 Trendelenburg test
 Detect weak hip abductor muscle.
 Patient stands and balances first on one foot and then the other.
 Observing from behind, note any asymmetry or change in the level
of the iliac crests.
 When the iliac crest drops on the side of the lifted leg, the hip
abductor muscles on the weight-bearing side are weak.
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Knee Assessment
 Lachman test: anterior cruciate ligament integrity
 Varus and valgus stress test: instability of lateral and medial
collateral ligaments
 McMurray test: torn medial or lateral meniscus
 Patient lies supine and flexes one knee.
 Palpable or audible click, pain, grinding, or lack of extension
during outward (valgus) and inward (varus) stress during flexion of
knee is a positive sign.
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Knee Assessment (Cont.)
 Anterior and posterior drawer test: instability of cruciate
ligaments
 Patient lies supine and flexes the knee 45 to 90 degrees, placing
the foot flat on the table.
 Draw the tibia forward and backward, forcing the tibia to slide
forward of the femur.
 Anterior or posterior movement of the knee greater than 5 mm in
either direction is an unexpected finding.
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Limb Measurement
 Performed when difference is suspected
 Measure bilateral
 Circumference
 Length
 Should be no more than 1-cm difference in length and
circumference between matching extremities
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Infants
 Inspect general
 Posture
 Spontaneous generalized movements
 Inspect back




Hair tufts and dimples
Discolorations
Cysts or masses near spine
Curvature of spine
 Inspect extremities.




Symmetry
Movement
Equality
Deformity
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Infants (Cont.)
 Palpate bones.




Fractures or dislocations
Crepitus
Masses
Tenderness
 Palpate spine.
 Shape
 Formation
 Splitting
 Palpate muscles and joints.
 Tone
 Mobility
 Subluxation or dislocation
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Infants (Cont.)
 Assess motor development.
 Fine
 Gross
 Assess ROM.
 Assess muscle strength.
 Assess tibial torsion.
 Barlow-Ortolani maneuver to detect hip dislocation or subluxation
should be performed each time you examine the infant during the
first year of life.
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Infants (Cont.)
 Barlow maneuver
 Position yourself at the supine infant’s feet, and flex the hip
and knee to 90 degrees.
 Grasp the leg with your thumb on the inside of the thigh, the
base of the thumb on the knee, and your fingers gripping the
outer thigh with fingertips resting on the greater trochanter.
 Adduct the thigh and gently apply downward pressure on the
femur in an attempt to disengage the femoral head from the
acetabulum.
 A positive sign is when a clunk or sensation is felt as the
femoral head exits the acetabulum posteriorly.
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Infants (Cont.)
 Ortolani maneuver
 Slowly abduct the thigh while maintaining axial pressure.
 Fingertips on the greater trochanter, exert a lever movement in the
opposite direction so that your fingertips press the head of the
femur back toward the acetabulum center.
 If the head of the femur slips back into the acetabulum with a
palpable clunk when pressure is exerted, suspect hip subluxation
or dislocation.
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Children
 Assess motor development.
 Fine
 Gross
 Assess ROM.
 Inspect:




Spine curvature
Sitting posture
Foot arch
Alignment of feet and legs
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Children (Cont.)
 Evaluate for the following:
 Bowlegs (genu varum)
 Knock-knees (genu valgum)
 Palpate bones, muscles, and joints.
 Evaluate rising from seated position.
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Adolescents
 Do same examination procedures as for adult.
 Note presence of scoliosis.
 Note slight kyphosis or rounded shoulders.
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Pregnant Women
 Postural changes
 Lordosis
 Forward cervical flexion
 Waddling gait
 Assess for:
 Lumbosacral hyperextension
 Causes lower back pain
 Carpal tunnel syndrome
 Secondary increased fluid retention
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Older Adults
 Assessment of activities of daily living for fine and gross motor
skills
 Osteoporosis risk assessment instrument to screen for
osteoporosis
 Inspect:
 Dorsal kyphosis
 Base of support broader (feet more widely spaced)
 Reduction in total muscle mass
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Older Adults (Cont.)
 Palpate muscle for the following:
 Tone
 Atrophy
 Assess muscle strength and ROM.
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Abnormalities (Cont.)
 Ankylosing spondylitis
 Hereditary, chronic inflammatory disease
 Initially affects the lumbar spine and sacroiliac joints
 Lumbosacral radiculopathy
 Herniated lumbar disk that irritates the corresponding nerve root
 Lumbar stenosis
 Hypertrophy of the ligamentum flavum and facet joints that results
in narrowing of the spinal canal
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Abnormalities (Cont.)
 Gout
 Disorder of purine metabolism that results from an elevated serum
uric acid level
 Form of arthritis
 Carpal tunnel syndrome
 Compression on the median nerve
 Lyme disease
 Tickborne disease that can lead to multisystemic infection
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Abnormalities (Cont.)
 TMJ syndrome
 Painful jaw movement
 Osteomyelitis
 Infection in the bone
 Bursitis
 Inflammation of the bursa
 Paget disease (osteitis deformans)
 Focal metabolic disorder of the bone
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Abnormalities (Cont.)
 Fibromyalgia
 Painful, nonarticular condition that leads to diffuse musculoskeletal
discomfort
 Osteoarthritis
 Deterioration of the articular cartilage covering the ends of bone in
synovial joints
 Rheumatoid arthritis
 Chronic systemic inflammatory disorder of the synovial tissue
surrounding the joints
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Sports Injuries
 Muscle strain
 Can be due to excessive stretching or forceful contraction beyond
the muscles functional capacity
 Dislocation
 Complete separation of the contact between two bones in a joint
 Fracture
 Partial or complete break in the continuity of a bone
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Sports Injuries (Cont.)
 Tenosynovitis (tendonitis)
 Inflammation of the synovium-lined sheath around a tendon
 Rotator cuff tear
 Microtrauma and tearing of the rotator cuff muscles; most often the
supraspinatus
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Infants and Children
 Osgood-Schlatter disease
 Traction apophysitis (inflammation of a bony outgrowth) of the anterior
aspect of the tibial tubercle
 Clubfoot (talipes equinovarus)
 Fixed congenital defect of the ankle and foot
 Metatarsus adductus
 Most common congenital foot deformity
 Metatarsus adductus can be either fixed or flexible
 Legg-Calvé-Perthes disease
 Avascular necrosis of the femoral head
85
Infants and Children (Cont.)
 Slipped capital femoral epiphysis
 Disorder in which the capital femoral epiphysis slips over the neck of the
femur
 Muscular dystrophy
 Group of genetic disorders involving gradual degeneration of the muscle
fibers
 Scoliosis
 Concave curvature of the anterior vertebral bodies, convex posterior
curves, and lateral rotation of the thoracic spine
 Radial head subluxation
 Known as nursemaid’s elbow, this is a dislocation injury.
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Older Adults
 Osteoporosis
 Disease in which a decrease in bone mass occurs because bone
resorption is more rapid than bone deposition
 Dupuytren contracture
 Contractures involving the flexor hand tendons
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