Chapter 52

Assessment of the Musculoskeletal System

Skeletal System

 Bone types
 Bone structure
 Bone function
 Bone growth and metabolism
affected by calcium and
phosphorous, calcitonin,
vitamin D, parathyroid
hormone, growth hormone,
glucocorticoids, estrogens
and androgens, thyroxine,
and insulin

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High Ca++ Mj

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Figure 36-1.   Bone cells. A, Osteoblasts are responsible for the production of collagenous

and noncollagenous proteins that compose osteoid. Active osteoblasts are lined up on the

osteoid. Note the eccentrically located nuclei. B, Scanning electron micrograph showing an

osteocyte within a lacuna. The cell is surrounded by collagen fibers and mineralized bone. C,

Osteoclasts actively resorb mineralized tissue. The scalloped surface in which the

multinucleated osteoclasts rest is termed Howship lacuna.

A and C from Damjanov I, Linder J, editors: Anderson's pathology, ed 10, St Louis, 1996, 4
Figure 36-2.   Cross section of bone.

Longitudinal section of long bone (tibia)

showing spongy (cancellous) and

compact bone.

From Thibodeau GA, Patton KT: Anatomy

& physiology, ed 5, St Louis, 2003,

Mosby.

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 Figure 36-3C.   Structure of compact and cancellous

bone. C, Section of a flat bone. Outer layers of

compact bone surround cancellous bone. Fine

structure of compact and cancellous bone is shown to

the right.

From Thibodeau GA, Patton KT: Anatomy &

physiology, ed 5, St Louis, 2003, Mosby.

Figure 36-3A, B.   Structure of compact and cancellous

bone. A, Longitudinal section of a long bone showing both

cancellous and compact bone. B, A magnified view of

compact bone.

From Thibodeau GA, Patton KT: Anatomy & physiology, ed 5,

St Louis, 2003, Mosby.

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Figure 36-5.   Bone remodeling. In the remodeling

sequence, bone sections are removed by bone-resorbing

cells (osteoclasts) and replaced with a new section laid

down by bone-forming cells (osteoblasts). The cells work

in response to signals generated in that environment. The

first phase of remodeling is mediated only by the

multinucleated osteoclastic cells. They are activated,

scoop out bone, A, and resorb it; then the work of the

osteoblasts begins, B. They form new bone that replaces

bone removed by the resorption process, C. The

sequence takes 4 to 5 months. D, Micrograph of active

bone remodeling seen in the settings of primary or

secondary hyperparathyroidism. Note the active

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Joints
 Types include synarthrodial, amphiarthrodial,
diarthrodial
 Structure and function of the diarthrodial or
synovial joint

Synarthrosis =

Immovable

Amphiarthrosis =

Slightly movable

Diathrosis = freely

moveable

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Bone Types

 Subtyped by anatomic structure:

• Ball-and-socket
• Hinge
• Condylar
• Biaxial
• Pivot

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Figure 36-14.   Myofibrils. Myofibrils of a skeletal muscle fiber

(cells) and overall organization of skeletal muscle.

From Thibodeau GA, Patton KT: Anatomy & physiology, ed 5, St

Louis, 2003, Mosby.

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 Muscular System

 Structure
 Function
 Supporting structures
 Musculoskeletal changes
associated with aging
 Cultural considerations

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Properties of the three different muscle types
  Skeletal Cardiac Smooth
Histologic Cross-striated, Cross-striated, single Nonstriated, spindle cells with a
appearance multinucleated nucleated muscle fibers single nucleus
muscle fibers containing intercalated
disc
Site skeletal coverings muscular component of found in wall of blood vessel,
the heart airways glands, and walls of
hollow organs

self-regulated by
pacemaker cells; heart Involuntary control or
voluntary/reflex: rate can be altered by regulation by inhrent
contolled by somatic autonomic nervous contraction initiation (visceral
control nervous system system smooth muscle)

nature of the rapid contraction and spontaneous and thythmic

contraction relaxation contraction slow and sustained contraction

voluntary movement related to the structure (e.g.

of skeletal and contraction pump blood regulation of blood wessel
Function posture maintenance around the body diameter, hair erection)
Source:Walji, A. (2006). Crash Course: Musculoskeletal system. Mosby

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 Types of Muscle tissue

The nuclei are centrally located, there are no

striations, and the muscle fibers do not branch.

Another good clue that this is smooth muscle is

that when smooth muscle contracts, the nuclei

take on a corkscrew appearance.

This slide contains a section of cardiac muscle, which is striated like

skeletal muscle but well adapted for involuntary, rhythmic contractions

like smooth muscle. Although the myofibrils are transversely striated,

each cell has only one centrally located nucleus.  Note the faintly stained

transverse bands called intercalated disks (indicated by the blue arrows)

that mark the boundaries between the ends of the cells.  These specialized
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Excitement

Coupling

Depoloraization

Contraction

Repolorization

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 Physiology of skeletal muscle
contraction
 Excitation
• Change in action potential
• Changes the permeability of the cell to allow movement of Na++ and K+
 Coupling
• Migration of Ca
• Coupling with Ca and muscle proteins
 Contraction
• Binding of muscle proteins (actin + myosin) causing a shortening of the
muscle fibers = contraction
 Relaxation
• Ca is absorbed by sarcoplasimc teticulum (muscle protein) causing the
muscle to lengthen.
 Muscle metabolism
• Na++ / K+ ATPase pump
• Balance between intracellular and extracellular electrolytes (Na++, K+,
Cl-)
• ATPase (protein that results in energy production)

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 Assessments

 Family history and genetic risk

 Personal history
 Dietary history
 Socioeconomic status and ability to afford
food
 Current health problems including obesity

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Physical Assessment

 General inspection
 Posture
 Abnormality in gait such as antalgic
gait or lurch
 Goniometer, which provides a measure
of ROM
 Head and neck: evaluate the
temporomandibular joints
(Continued)

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Physical Assessment (Continued)

 Spine: lordosis, scoliosis

 Upper extremities
 Lower extremities
SPON SCOLIOSIS

LORDOSIS SCOLIOSIS KYPHOSIS

LORDOSIS

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 Diagnostic Assessment

 Laboratory tests: serum Normal Levels (Chart 52-3, p. 1148)

calcium and phosphorus, Ca2 : 9.0-10.5 mg/dL
alkaline phosphatase, serum Phosphorus: 3.0 -4.5 mg/dL
muscle enzymes
Alkaline phosphatase
•30-120 Units/L
 Radiographic examinations: 
Serum Muscle Enzymes
standard radiography,
•Creatine Kinase: (CK)
tomography and
• Men = 55 -170 units/L
xeroradiography,
• Women = 30-135 untis/L
myelography, arthrography,
•Aspartate aminotrnasferase (AST)
and CT
• 0-35 IU/L
 Other diagnostic tests: bone •Aldolase (ALD)
and muscle biopsy • 3.0-8.2 units/Dl
•Lactic dehyrogenase (LDH)
• 100-190 units/L

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Electromyography

 EMG aids in the diagnosis of neuromuscular,

lower motor neuron, and peripheral nerve
disorders; usually with nerve conduction
studies.
 Low electrical currents are passed through
flat electrodes placed along the nerve.
 If needles are used, inspect needle sites for
hematoma formation.

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21
Arthroscopy

 Fiberoptic tube is inserted into a joint for

direct visualization.
 Client must be able to flex the knee; exercises
are prescribed for ROM.
 Evaluate the neurovascular status of the
affected limb frequently.
 Analgesics are prescribed.
 Monitor for complications.

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Other Tests

 Bone scan
 Gallium or thallium scan
 Magnetic resonance imaging
 Ultrasonography

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 Musculoskeletal Changes Associated with Aging

 Aging Bones
• Loss of bone tissue: bones less stiff, less strong, and more brittle
• Bone remodeling takes longer
• Stem cells in bone marrow perform less efficiently
• Postural changes
• Increase risk of fractures (Osteoporosis
 Aging Joints
• Cartilage becomes more rigid, fragile, and susceptible to fibrillation, water
decreases in cartilage
 Synovial Joint cartilage becomes less elastic and compressible
• Osteorarthritis
 Aging Muscle
• Muscle fiber composition change
• Changes in the muscle proteins:
 Changes results in decreased coordination, muscle strength loss, gait
changes, predisposition to falls with injury (see chart 53-1)

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