Assessment of the Assessment of the Musculoskeletal SystemMusculoskeletal System

Skeletal SystemSkeletal System Bone typesBone types

– Long bones, Long bones, such as the femur, are cylindric such as the femur, are cylindric with rounded ends; they often bear weight. with rounded ends; they often bear weight.

– Short bones, Short bones, such as the phalanges, are such as the phalanges, are small and bear little or no weight. small and bear little or no weight.

– Flat bones, Flat bones, such as the scapula, protect such as the scapula, protect vital organs and often contain blood-vital organs and often contain blood-forming cells. forming cells.

– Bones that have unique shapes are known Bones that have unique shapes are known as as irregular bones irregular bones (e.g., the carpal bones in (e.g., the carpal bones in the wrist). the wrist).

– The The sesamoid bone sesamoid bone is the least common is the least common type and develops within a tendon; the type and develops within a tendon; the patella is a typical example.patella is a typical example.

Skeletal SystemSkeletal System

Bone Bone structurestructure

Skeletal SystemSkeletal System

Bone functionBone function– Provides a framework for the bodyProvides a framework for the body– Supports the surrounding tissues (e.g., Supports the surrounding tissues (e.g.,

muscle and tendons)muscle and tendons)– Assists in movement through muscle Assists in movement through muscle

attachment and joint formationattachment and joint formation– Protects vital organs, such as the heart Protects vital organs, such as the heart

and lungsand lungs– Manufactures blood cells in red bone Manufactures blood cells in red bone

marrowmarrowProvides storage for mineral salts (e.g., Provides storage for mineral salts (e.g., calcium and phosphorus)calcium and phosphorus)

Skeletal SystemSkeletal System After puberty, bone reaches its maturity After puberty, bone reaches its maturity

and maximal growth. Bone is a dynamic and maximal growth. Bone is a dynamic tissue, however, that undergoes a tissue, however, that undergoes a continuous process of formation and continuous process of formation and resorption, or destruction, at equal rates resorption, or destruction, at equal rates until the age of 35 years. In later years, until the age of 35 years. In later years, bone resorption accelerates, decreasing bone resorption accelerates, decreasing bone mass and predisposing clients to bone mass and predisposing clients to injury.injury.

Bone growth and metabolism affected by Bone growth and metabolism affected by calcium and phosphorous, calcitonin, calcium and phosphorous, calcitonin, vitamin D, parathyroid hormone, growth vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulinandrogens, thyroxine, and insulin

Classification Based on Movement Classification Based on Movement Joints PermitJoints Permit

Synarthrosis: Immovable (e.g., Synarthrosis: Immovable (e.g., sutures of skull).sutures of skull).

Amphiarthrosis: Limited Amphiarthrosis: Limited movement (e.g., symphysis movement (e.g., symphysis pubis).pubis).

Diarthrosis: Freely movable Diarthrosis: Freely movable (e.g., hip).(e.g., hip).

Classification Based on Connecting Classification Based on Connecting Tissues That Hold Bones TogetherTissues That Hold Bones Together

Fibrous joints: No joint cavity; fibrous Fibrous joints: No joint cavity; fibrous connective tissue joins bones; usually connective tissue joins bones; usually allow nomovement. Types include: allow nomovement. Types include: – Sutures: Bones fused together (e.g., skull).Sutures: Bones fused together (e.g., skull).– Syndesmoses: Bones very close together; Syndesmoses: Bones very close together;

held together by ligament that held together by ligament that givesstrength and support to joint and also givesstrength and support to joint and also limits movement (e.g., tibiofibular joint).limits movement (e.g., tibiofibular joint).

– Gomphoses: Peg and socket (e.g., root of Gomphoses: Peg and socket (e.g., root of tooth).tooth).

Classification Based on Connecting Classification Based on Connecting Tissues That Hold Bones TogetherTissues That Hold Bones Together

Cartilaginous joints: Bones joined by Cartilaginous joints: Bones joined by hyaline cartilage or fibrocartilaginous hyaline cartilage or fibrocartilaginous disc; allows slight movement. Types disc; allows slight movement. Types include:include:– Synchondrosis (primary cartilaginous joint): Synchondrosis (primary cartilaginous joint):

Allows for growth, but not movement (e.g., Allows for growth, but not movement (e.g., epiphyseal plate joins diaphysis and epiphysis epiphyseal plate joins diaphysis and epiphysis of long bones and allows growth). Once of long bones and allows growth). Once growth is complete, joint becomes synostosic growth is complete, joint becomes synostosic (sealed).(sealed).

– Symphyses (secondary cartilaginous joint): Symphyses (secondary cartilaginous joint): Articulating bones covered with hylaine Articulating bones covered with hylaine cartilage; fibrocartilaginous discs that act as cartilage; fibrocartilaginous discs that act as shock absorbers; allows for some movement shock absorbers; allows for some movement (e.g., symphysis pubis moves during (e.g., symphysis pubis moves during pregnancy to allow for fetal growth).pregnancy to allow for fetal growth).

Synovial: Most movable and complex. Has Synovial: Most movable and complex. Has cavity filled with lubricating (synovial)cavity filled with lubricating (synovial) fluid fluid to help ends of bones slide. Enclosed by to help ends of bones slide. Enclosed by fibrous capsule of connective tissuefibrous capsule of connective tissue and and connected to periosteum of bone. Contain connected to periosteum of bone. Contain free-floating synovial cells andfree-floating synovial cells and various various leukocytes that phagocytose joint debris and leukocytes that phagocytose joint debris and microorganisms. Some containmicroorganisms. Some contain bursae. bursae. Synovial joints may be: Synovial joints may be: – Uniaxial: Movement limited to one axis (e.g., Uniaxial: Movement limited to one axis (e.g.,

elbow).elbow).– Biaxial: Movement on two axes (e.g., hand).Biaxial: Movement on two axes (e.g., hand).– Multiaxial or triaxial: Movement on three axes Multiaxial or triaxial: Movement on three axes

(e.g., shoulder).(e.g., shoulder).

Classification Based on Connecting Classification Based on Connecting Tissues That Hold Bones TogetherTissues That Hold Bones Together

Ligaments and TendonsLigaments and Tendons Ligaments – strong, dense, flexible Ligaments – strong, dense, flexible

bands of connective tissue that hold bands of connective tissue that hold bones to bonesbones to bones– Provide support by encircling joint, Provide support by encircling joint,

gripping it obliquely or by lying gripping it obliquely or by lying parallel to bone ends across jointparallel to bone ends across joint

Tendons – strong, nonelastic cords of Tendons – strong, nonelastic cords of collagen located at ends of muscles to collagen located at ends of muscles to attach them to bonesattach them to bones– Support bone movement in Support bone movement in

response to skeletal muscle response to skeletal muscle contractionscontractions

Present Health StatusPresent Health Status Chronic diseasesChronic diseases Loss of bone density or Loss of bone density or

osteoporosis osteoporosis MedicationsMedications Changes in ability to move, Changes in ability to move,

muscle strength or perform muscle strength or perform ADL’sADL’s

Type and frequency of Type and frequency of exerciseSmoke or consume exerciseSmoke or consume alcoholalcohol

Sports activity – type and Sports activity – type and frequency, use of protective frequency, use of protective devicesdevices

Usual routine at home or work Usual routine at home or work to lift, push or pull items, bend to lift, push or pull items, bend or stoopor stoop

Protect self from muscle strain Protect self from muscle strain or injuryor injury

Past Medical HistoryPast Medical History

Accidents or trauma to bones or Accidents or trauma to bones or joints resulting in fractures, strains, joints resulting in fractures, strains, sprains or dislocations. Any sprains or dislocations. Any continuing problems or difficulties continuing problems or difficulties from these problemsfrom these problems

Congenital bone or joint problems. Congenital bone or joint problems. Altered activities and adaptation to Altered activities and adaptation to this alterationthis alteration

Surgery on bones, joints or muscles Surgery on bones, joints or muscles and outcomeand outcome

Family HistoryFamily History

Curvature of spine or back problemsCurvature of spine or back problems Arthritis, rheumatoid arthritis, Arthritis, rheumatoid arthritis,

osteoarthritis or goutosteoarthritis or gout

Problem-Based History: Problem-Based History: Presenting ProblemsPresenting Problems

PainPain– Complete symptom analysis or “OLD CARTS”Complete symptom analysis or “OLD CARTS”

Problems with MovementProblems with Movement– How long had problemHow long had problem– Joints swollen, red or hot to touchJoints swollen, red or hot to touch– Recent sore throatRecent sore throat– Weakness in muscles, progressively worseWeakness in muscles, progressively worse– Knees or ankles giving way with pressureKnees or ankles giving way with pressure– Joints lock or not move – frequency, alleviates or Joints lock or not move – frequency, alleviates or

aggravates itaggravates it Problems with Daily Activities Problems with Daily Activities

– Limitations of what activitiesLimitations of what activities– Adaptation to limitationAdaptation to limitation– Affect of chronic illness or crippling disease with Affect of chronic illness or crippling disease with

family interaction and friendsfamily interaction and friends

Examination: EquipmentExamination: Equipment

Tape measureTape measure GoniometerGoniometer

InspectionInspection

Axial skeleton and extremities for Axial skeleton and extremities for alignment, contour, symmetry, size and alignment, contour, symmetry, size and gross deformitiesgross deformities

Muscles for size and symmetryMuscles for size and symmetry Muscles of face and neck for symmetryMuscles of face and neck for symmetry Shoulders and cervical, thoracic, and Shoulders and cervical, thoracic, and

lumbar spine for alignment and symmetrylumbar spine for alignment and symmetry Shoulders and shoulder girdle for equality Shoulders and shoulder girdle for equality

of height and contourof height and contour

Inspection (cont)Inspection (cont)

Joints of wrists and hands for position, Joints of wrists and hands for position, contour and number of digitscontour and number of digits

Hips for symmetryHips for symmetry Knees for symmetry and alignmentKnees for symmetry and alignment Ankles and feet for contour, alignment and Ankles and feet for contour, alignment and

number of toesnumber of toes

Observation Observation

Each major joint and adjacent Each major joint and adjacent muscles formuscles for – Range of motionRange of motion

Jaw, neck, thoracic and lumbar spine, Jaw, neck, thoracic and lumbar spine, shoulders, elbows, wrist, fingers, knees, shoulders, elbows, wrist, fingers, knees, ankles, feet and hipsankles, feet and hips

– Tenderness on movementTenderness on movement– Joint stabilityJoint stability– DeformityDeformity

Gait for conformity, symmetry and Gait for conformity, symmetry and rhythmrhythm

PalpationPalpation Bones for tendernessBones for tenderness Joints for tenderness, heat and edemaJoints for tenderness, heat and edema Muscles for tenderness, heat, edema and Muscles for tenderness, heat, edema and

tonetone Each major joint and adjacent muscles for Each major joint and adjacent muscles for

tenderness on movement, joint stability tenderness on movement, joint stability and deformity and deformity

Each temporomandibular joint (TMJ) in Each temporomandibular joint (TMJ) in front of the tragus of each ear for front of the tragus of each ear for movement, sounds and tendernessmovement, sounds and tenderness

Neck for painNeck for pain Knees for contour, tenderness and edemaKnees for contour, tenderness and edema

Palpation (cont)Palpation (cont) Posterior neck, spinal processes and Posterior neck, spinal processes and

paravertebral muscles for alignment paravertebral muscles for alignment and tendernessand tenderness

Shoulders for firmness, fullness, Shoulders for firmness, fullness, tenderness and massestenderness and masses

Elbows for tenderness, edema and Elbows for tenderness, edema and nodulesnodules

Each joint of the hand and wrist for Each joint of the hand and wrist for surface characteristics and tendernesssurface characteristics and tenderness

Hips for stability and tendernessHips for stability and tenderness Ankles and feet for contour, edema and Ankles and feet for contour, edema and

tendernesstenderness

PercussionPercussion

Spinal processes for tendernessSpinal processes for tenderness

Testing Muscle StrengthTesting Muscle Strength

Ask client to flex muscle Ask client to flex muscle and then resist when and then resist when you apply opposing force you apply opposing force against the musclesagainst the muscles

Compare contralateral Compare contralateral sidessides

Neck, Trapezius, arms Neck, Trapezius, arms (Biceps, Triceps), wrists, (Biceps, Triceps), wrists, fingers, hips, legs, fingers, hips, legs, ankles and feetankles and feet

Ethnic and Cultural Ethnic and Cultural VariationsVariations

The long bones of African Americans The long bones of African Americans (especially males) are longer, narrower (especially males) are longer, narrower and denser. Less problems with and denser. Less problems with osteoporosis or other long bone diseasesosteoporosis or other long bone diseases

Caucasians and Asians are at greater risk Caucasians and Asians are at greater risk of osteoporosis; especially females.of osteoporosis; especially females.

Higher incidence of hip dislocation in Higher incidence of hip dislocation in infants of the Navajo Indians and Canadian infants of the Navajo Indians and Canadian Eskimos because infants tightly wrapped Eskimos because infants tightly wrapped in blankets or strapped to cradle boards.in blankets or strapped to cradle boards.

Gerontological Gerontological ConsiderationsConsiderations

Decrease in bone massDecrease in bone mass Narrowing of intervertebral disks Narrowing of intervertebral disks

with loss of 1.5 – 3 inches in heightwith loss of 1.5 – 3 inches in height Lordotic or convex curve of back Lordotic or convex curve of back

flattens with both flexion and flattens with both flexion and extension of back decreasingextension of back decreasing

Change in center of gravity – Men Change in center of gravity – Men walk with smaller steps and wider walk with smaller steps and wider base. Women become bowlegged base. Women become bowlegged with a narrow standing basewith a narrow standing base

Cartilage and ligaments calcifyCartilage and ligaments calcify Decrease in elasticity and tone of Decrease in elasticity and tone of

tendons and musclestendons and muscles Muscles loose mass and strengthMuscles loose mass and strength Loss of agility Loss of agility

Gerontological Gerontological ConsiderationsConsiderations

Assess activities of daily living and degree Assess activities of daily living and degree of independence. Assistance required for of independence. Assistance required for ADL’sADL’s

Use of assistive devices for eating, Use of assistive devices for eating, dressing, mobility or toiletdressing, mobility or toilet

Fall Risk AssessmentFall Risk Assessment– Measures to prevent fallsMeasures to prevent falls

Diagnostic AssessementDiagnostic Assessement

Laboratory tests: serum calcium and Laboratory tests: serum calcium and phosphorus, alkaline phosphatase, phosphorus, alkaline phosphatase, serum muscle enzymesserum muscle enzymes

Radiographic examinations: standard Radiographic examinations: standard radiography, tomography and radiography, tomography and xeroradiography, myelography, xeroradiography, myelography, arthrography, and CTarthrography, and CT

Other diagnostic tests: bone and Other diagnostic tests: bone and muscle biopsymuscle biopsy

ElectromyographyElectromyography

EMG aids in the diagnosis of EMG aids in the diagnosis of neuromuscular, lower motor neuron, neuromuscular, lower motor neuron, and peripheral nerve disorders; and peripheral nerve disorders; usually with nerve conduction usually with nerve conduction studies.studies.

Low electrical currents are passed Low electrical currents are passed through flat electrodes placed along through flat electrodes placed along the nerve.the nerve.

If needles are used, inspect needle If needles are used, inspect needle sites for hematoma formation.sites for hematoma formation.

Arthroscopy Arthroscopy

Fiberoptic tube is inserted into a Fiberoptic tube is inserted into a joint for direct visualization.joint for direct visualization.

Client must be able to flex the Client must be able to flex the knee; exercises are prescribed for knee; exercises are prescribed for ROM.ROM.

Evaluate the neurovascular status Evaluate the neurovascular status of the affected limb frequently.of the affected limb frequently.

Analgesics are prescribed.Analgesics are prescribed. Monitor for complications. Monitor for complications.

Other Tests Other Tests

Bone scanBone scan Gallium or thallium scanGallium or thallium scan Magnetic resonance imagingMagnetic resonance imaging UltrasonographyUltrasonography