Musculoskeletal

Musculoskeletal
System
System

BY: Darren Ashley

Umali
 Inroduction
• Millions of Americans experience
annually
• Multiple MOI
– Falls, crashes, violence, etc.
– Multi-system trauma
 Anatomy & Physiology
Musculoskeletal system provides:
• Musculoskeletal system provides
• support for body
• protection of internal organs
• mobility to engage in physical activities
• production of RBCs
• storage of minerals
•  
• For proper functioning, must be integration between neurologic
and musculoskeletal systems
• M-S system provides mobility and stability through the
integration of muscles, bones and joints which are assessed
together
Functions of the Musculoskeletal
System
– it supports the sorrounding tissues.
– It protects vital organs and other soft tissues
cof the body.
– It assists in body movements, giving
attachment to the muscles, thus providing
leverage.
– It manufactures blood cells.This
hematopoietic function occurs in the red bone
marrow.
– It provides storage for mineral salts,
specifically phosphorus and calcium which
supply body needs.
The Skull
 Anatomy and Physiology
of Synovial Joints
1. The synovial fluid is a viscous lubricant found in all synovial joint
cartilages
2. The articular cartilage acts as a cushion, providing a smooth gliding
surface.
3. Synovial joint is also present in the synovial membrane. This membrane
surrounds the cavities and slips in and out of the openings caused by
movement.
4. Ligaments help to maintain the relationships between bones and limit
motion.
5. Articular muscles function to maintain the stability of joints by
relaxation and contraction to insure firm contact throughout the
articular surface.
6. Joint is the functional unit of the MS system
Joints
 Regulation Movement
• tendons - join muscle
to bone
• ligaments and muscles
give joint stability
• cartilage - pads joints
during weight bearing
 Movements of Synovial
Joints
1. Flexion – decreasing angle between 2 bones.
2. Extension- increasing angle between 2 bones.
3. Abduction- the bones moves away from the midline.
4. Adduction - bone moves toward the midline.
5. Rotation - the bones moves around the central axis.
6. Circumduction - bone describes the surface of a cone.
7. Supination- the palm is turned upward.
8. Pronation –the palm is turned downward.
9. Eversion – the sole of the foot is turned outward.
10. Inversion – the sole of the foot is moved inward.
 Movements of Synovial
Joints

11. Depression- lowering a part of the body.

12. Elevation- raising a part of the body.
13. Retraction- moving a part of the body backward
on a plane parallel to the ground
14. Protration- moving a part of the body forward on
a plane parallel to the ground
 Types of Joints
1. Ball and Socket Joint- provides the widest of motion, with
movement. Example: hip, joints

2. Hinge Joint- the motion is limited to flexion and extension.

Example: elbow joint

3. Pivot Joint- motion is limited to rotation; the joint is formed by

a pivotlike process which rotates within a bony fossa around a
longitudinal axis. Example: atlas and axis.

4. Condyloid- an oval-shaped condyle that fits into elliptical cavity.

Example: The wrist joint between the radius and carpal bones.

5. Saddle Joint- tjis type of joint moves in one direction, concave

and convex, a unique joint of the thumb.

6.Gliding Joint- is formed by the opposing plane surfaces or slightly

convex and concave. Example: intervertebral joint
Joint Structure
 Example
Temporomandibular joint
Objective Data
• Temporomandibular joint
– Inspect area anterior to ear while seated
– Place tips of 1st two fingers in front of ear &
drop to depressed area over joint
– Ask client to perform active ROM
• Open mouth maximally
• Partially open mouth
• Protrude lower jaw & move it side to side
• Normal: smooth motion of mandible, audible
click or snap may occur
• Abnormal: swelling, crepitus, pain
Objective Data
• Cervical spine
– Inspect head & neck alignment
• Spine should be straight, head erect
– Palpate spinous processes,
sternomastoid, trapezius, &
paravertebral muscles
• Should be firm, no spasm or tenderness
 Growth & Formation of Bones
• The cartilage skeleton is found in the embryo at the end of
three months during the prenal age.
• Vertical growth continues at age 15 for girls and 16 for boys and
modeling and shaping continue to about 21 years of age.
• Bone consists of protein matrix (the ground substance in which
cells are embedded) and salts, primarily hydroxyapatite(makes
up the major portion of salts present in bone). Small amount of
calcium carbonate are also present.
• Deposition (salt) of bone is regulated by both stress and injury.
Bone develops from spindle-shaped cells called osteoblasts,
which are found beneath the fibro-vascular membrane covering
the bone (perosteum) and in the endosteum.
• Osteoblasts are responsible for reabsorbing bone. This is
brought about by the secretion of enzymes which digest the
protein portion of bone and split the salts.
• Intramembranous ossification( conversation of fibrous tissue or
cartillage into bone or bony substances) is the process by which
the bones of the face and skull are formed
 Physiology of Bone
Lack of Calcium results in:
1. Depolarization of nerve fiber membranes with
transmission of unconrtolled impulses. Under these
conditions, tetany,or spasm of the skeletal musculature
occurs.
2. Weakening of cardiac muscle with a consequent
inadequate supply of blood to the total body circulation.
3. Interference wit the process of blood coagulation.

• 90% of the total calcium of the body exists in the bone,

which is present in the blood plasma and in fluid, where
the ionized form of calcium participates in vital
chemical reactions.
 Classification of Bones
1. Long Bones- consists of long shafts and two extremities. The
shaft consists of diaphysis, a compact bone and the
metaphysis, the flared portion at each end of the diaphysis
which is composed of cancellous bone.

2. Short Bones- a thin layer of compact tissues which covers the

spongy or cancellous tissues of a typical short bone.

3. Irregular Bones- are bones of peculiar shape, like the bones

of vertebrae and ossicles of the ear.

4. Sesamoid Bones- are bones that are smail, rounded and are
enclosed in tendon and facial tissues.

5. Flat Bones- for extensive muscle attachment, e.g ribs, scapula

 Musculoskeletal System
• Bone Structure
– Diaphysis
– Epiphysis
• End of a long bone
– Metaphysis
• Between epiphysis and
diaphysis
• Growth plate
– Medullary canal
• Contains bone marrow
– Periosteum
• Fibrous covering of diaphysis
– Cartilage
• Connective tissue that
provides a smooth
articulation surface for other
bones
• Joint Injury
– Sprain
– Subluxation
– Dislocation
• Bone Injury
– Open fracture
– Closed fracture
– Hairline fracture
– Impacted fracture
– Transverse
 Healing of Fracture
1. Stage of the hematoma- Bleeding occurs
from damaged structures and a blood clot or
hematoma form between and around the
bone
2. Stage of granulation- the clot is invaded by
cells and new capillaries.
3. Callus formation- a large mass of loosely
woven bone forms, subsequently remodelling
in accordance with Wolff’s Law.

Wolff’s Law reflects that the role of mechanical

force acting on a bone and its structure is
dependent on its function
 Complications of fx
• blood vessel & nerve damage

• Fat embolus

• disability or deformity
 Injuries
• Sprain
• Strain
• Dislocation
• Closed fracture
• Open fracture
 Sprains & Strains
• Sprain
– Joint injury with tearing of ligaments
• Strain
– Stretching or tearing of a muscle
 Fractures
• Closed fracture •Nondisplaced
– does not break fracture
the skin -Simple crack

•Displaced
• Open fracture
fracture
– External wound -deformity
 Closed fracture
• Signs & symptoms
–Pain
–Edema
–Possible deformity
–Contusion
–Loss of motion
–false motion
–Crepitus
–Guarding
• Treatment - immobilize, ice, elevate if possible.
 Open fracture
• Signs & symptoms
– Pain
– Deformity
– Break in skin and/or exposed bone

• Treatment - dressing, immobilize, ice, &

elevate if possible
 Bleeding (internal)
• Bones have a blood supply!

• Fractures bleed internally -

– Femur - 1 liter
– Pelvis - 1 liter
– Tibia - 500 cc
 Tips & other stuff
• Depressed skull fracture
• Basilar skull fracture
• Angulation or angulated extremity
• Flail Chest
 Musculoskeletal Injury
Management
• Care for Specific Joint Injuries
– Hip
– Knee
– Ankle
– Foot
– Shoulder
– Elbow
– Wrist/Hand
– Finger
 Hip Fractures
• Common in the elderly.
• May be able to support weight.
– Ability to walk does not rule out fracture.
• Leg often externally rotated.
• May refer pain to the knee.
• Use other leg for splint.
• Use vacuum mattress if available.
 Hip Dislocation
• Orthopedic emergency
• Posterior dislocation most common
• Hip flexed and leg rotated internally
• Severe pain on attempts to
straighten
 Hip Dislocation
Management
• Splint in most comfortable position.
• Document sensation and pulse.
• Prompt transport.
• Be alert for associated knee injuries
or fractures
 Knee Fracture or
Dislocation
• Orthopedic emergency
• Frequently causes vascular injury
• Dislocation associated with 50% rate
of amputation of leg
 Knee Fracture or
Dislocation
Management
• Obvious dislocation without distal pulse:
– Apply gentle traction along the long axis of the
joint.
• If gentle traction does not restore the
pulse:
– Splint in place.
• Prompt transport.
 Foot or Hand Injury
• Common industrial injury.
• Often disabling.
• Rarely life threatening.
• Splint foot with pillow.
• Splint hand in position of function.
 Shoulder Injury
• AC Separation
– Sling and swathe.
• Shoulder Dislocation
– Use pillow with sling and swathe.
• Fracture
– Use sling and swathe.
 Elbow Injury
• Fracture or dislocation may cause
neurovascular injury.
• Splint in position found.
• Transport promptly.
 Forearm/Wrist Injury
• Rigid Splint
– Keep hand in “position of function.”
• Air Splint
– May be hard to reassess circulation.
• Pillow
 Assessment of injured
extremities
• PMSC
– Pulse
– Movement
– Sensation
– Capillary refill

Cold, blue, pulseless extremity has circulation

problem
 ALWAYS CHECK
DISTAL FUNCTION
BEFORE & AFTER
SPLINTING !!!!!
• AND DOCUMENT WHAT YOU
FOUND !!
 Splinting
• Why we splint...

– relieve pain
– reduce tissue/vessel damage
during movement
 Types of splints
• Self splinting
• Pillows, blankets, & items of clothing
• Sling & swath
• Rigid
– Cardboard
– plastic
– ladder
• Air or vacuum
• Traction
 Traction splints
• Closed, mid-shaft femur fracture
without hip, knee, or ankle injury.
 General Principles of
Splinting
• Remove clothing area
• PMSC
• Dress all wounds
• Do not move the patient before
splinting
 General Principles of
Splinting
• Immobilize the joints
• Pad rigid splints
• Maintain manual immobilization.
• Realign angulations PRN
• When in doubt, splint
• Reassess PMSC
• Immobilize all suspected spinal injuries in a
neutral in-line position*
*pain, resistance, crepitus
 Realignment issues

• NEVER REALIGN A JOINT

• NEVER REALIGN A INJURY WITH

GOOD DISTAL FUNCTION

• Only pulseless, longbone fractures

Basic Realignment Steps
• Have all equipment ready & in place
• Explain procedure to patient
• In 1 move, with gentle traction, align
extremity (goal is anatomical position)
• Use the least amount of force necessary.
• If resistance is met or pain increases, splint in
deformed position.
• Reassess distal function
 Hazards of Improper
Splinting
• Further damage
• Delay in transport
• Reduction of distal circulation
• Aggravation of the injury
• Injury to tissue, nerves, blood
vessels, or muscle
 Remember

• No matter how bad the

fracture our priorities are
the ABC’s
Muscles
 Types of Muscle

•Skeletal (voluntary) muscle

Attached to the bones of the
body

•Smooth (involuntary) muscle

-Carry out the automatic
muscular functions of the body
•Cardiac muscle
-Involuntary muscle
-Has own blood supply and electrical
system
-Can tolerate interruptions of blood
supply for only very short periods
 Sign & Symptoms
1. Paralysis
2. Weakness
3. Pain
4. Atrophy
5. Spasm
6. Cramps
 Developmental
Considerations
• Infants & children
– Skeleton is cartilage 3 mos. gestation
– Congenital hip dislocation
– Bone growth
• Rapid during infancy
• Steady during childhood
• Rapid growth spurt in adolescence
• Occurs in 2 directions
– Width or diameter
– Lengthening at epiphyses or growth plates
– Screen for scoliosis starting at age 10-12
 Developmental
Considerations
• Pregnancy
– ↑ levels of circulating hormones → ↑ joint
mobility
• Estrogen
• Relaxin
• Corticosteroids
– Progressive lordosis
• Anterior flexion of neck
• Slumping of shoulder girdle
 Developmental
Considerations
• Aging adult
– Bone loss (resorption) > new bone growth (deposition) →
loss of bone density (osteoporosis)
– Osteoporosis
• Females > males
• Whites > blacks
– ↓ height due to shortening
vertebral column
– Kyphosis, backward head tilt,
slight flexion of knees & hips
 Developmental
Considerations
• Aging adult
– Lose fat in face & forearms → abdomen & hips
– Loss in muscle mass & some atrophy →
weakness
– Sedentary lifestyle hastens musculoskeletal
changes of aging
– Exercise ↑ skeletal mass & delays osteoporosis
• Esp. postmenopausal & older women
 Subjective Data
• Joints
– Problems, pain
• Stiffness, edema, heat, redness, limited ROM, ADL
– Location, unilateral vs. bilateral
– Quality, severity, onset, time of day
– Aggravating factors
• Movement, rest, position, weather
– Relieving factors
• Rest, medication, heat or ice
– Associated sx
• Chills, fever, recent sore throat, trauma, repetitive activity
 Subjective Data
• Muscles
– Problems, pain, cramping, weakness location
• Muscle atrophy
– Any calf pain?
• Associated with walking?
• Relief with rest?
– Associated symptoms
• Fever, chills, flu-like symptoms
 Subjective Data
• Bones
– Bone or back pain
• Is pain affected by movement?
• Location, radiating pain, numbness & tingling, limping
– Bone or joint deformity
• Injury, trauma, ROM
– Hx accidents or trauma
• Fractures, joint strain, sprain, dislocation
• Date, tx, sequelae (problems or limitations)
 Subjective Data
• Functional assessment (ADL)
– Do joint (muscle, bone) problems limit ADLs?
• Bathing
– Getting in & out of tub, turning on faucets
• Toileting
– Urinating, moving bowels, getting on/off toilet, wiping
self
• Dressing
– Buttons, zippers, fastening openings behind neck,
pulling sweater over head, pulling up pants, tying shoes,
getting shoes that fit
 Subjective Data
• Functional assessment (ADL)
– Grooming
• Shaving, brushing teeth, brushing or grooming
hair, applying make-up
– Eating
• Preparing meals, pouring liquids, cutting up foods,
bringing food to mouth, drinking
– Mobility
• Walking, going up or down stairs, getting in/out
of bed, getting out of house
– Communicating
• Talking, using phone, writing
 Subjective Data
• Self-care behaviors
– Occupational hazards related to muscles & joints
• Heavy lifting, repetitive motion, chronic joint stress
• Efforts to alleviate above
– Exercise program
• Type, frequency, warm-up
• Pain during exercise & tx
– Recent wt gain, usual diet
– Medications
• ASA, NSAIDs, muscle relaxants, analgesics
– If chronic disability, effect on interaction with family, friends,
& view of self
 Subjective Data
• Infants & children
– Infant trauma during L & D
• Breech or forceps delivery
• Resuscitation
– Achievement of developmental milestones
• Siblings, peers
– Hx broken bones, dislocations & tx
– Hx bone deformity, spinal curvature, unusual
shape of toes or feet & tx
 Subjective Data
• Adolescents
– Involvement in sports during or after school
– Use of safety equipment, sports training
program
– Type of daily warm-up
– Reporting of injuries
– Relation of sport to school demands & other
activities
 Subjective Data
• Aging adult
– Do in-depth functional assessment if needed
– Change or weakness in past months or years
– ↑ in falls or stumbling in past months or years
– Use of mobility aids
• Cane, walker
 Preparation
• Screening
– Sufficient for most people
– Inspection & palpation of joints
integrated with each body region
– Observation of ROM
– Age-specific screening measures
• Ortolani’s maneuver – infants
• Scoliosis screening - adolescents
 Preparation
• Complete musculoskeletal exam
– Persons with joint disease
– Hx musculoskeletal symptoms
– Problems with ADL
 Preparation
• Make person comfortable
• Drape for full visualization of body part without exposing
client
• Orderly approach
– Head-to-toe
– Proximal to distal
• Joint to be examined should be supported at rest
• Avoid rough manipulation
– Use firm support, gentle movement, gentle return to
relaxed state
• Compare corresponding paired joints
– √ symmetry structure & function
– √ normal parameters for the joint
 Objective Data
• Inspection
– Note joint size & contour
– Inspect skin over joints for color, swelling, masses, or
deformity
• Palpation
– Palpate each joint
• Skin temperature, muscles, bony articulations, joint
capsule
• Note heat, tenderness, edema, or masses
• Normal: joints nontender, no swelling
– Synovial membrane normally nonpalpable, if
thickened → “doughy” or “boggy”
 Objective Data
• Range of motion (ROM)
– Ask for active ROM while stabilizing body area proximal
to area moved
• Know joint type & normal ROM
• Normal: no tenderness, pain, or crepitation
– Discrete crack during motion normal
– If limitation, gently attempt passive ROM
• Anchor joint with 1 hand while other hand slowly
moves it to its limit
• Normal ranges for active & passive ROM should be
same
– Goniometer: used to measure joint angles precisely
Goniometer
 Objective Data
• Muscle testing
– Test strength of prime mover muscle groups
for each joint
– Repeat motions elicited for active ROM
• Ask person to flex & hold as you apply opposing force
• Normal: strength = bilaterally fully resist your
opposing force
• May use grading system from 0 to 5
 THE END…

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