Assessment of musculoskeletAl

function

HAnnAH mAe B. PlAteRos, Rn

 Anatomic & Physiologic Overview

The Musculoskeletal
System is composed
of the :
• bones
• joints
• muscles
• tendons
• ligaments
• bursae
• Major functions of
this system are to
support and protect
the body and foster
movement of the
extremities
 Structure and Function of the Skeletal
System
• There are 206 bones
in the human body.
• 4 categories:
1. Long bones (femur)
2. Short bones
(metacarpals)
3. Flat bones (sternum)
4. Irregular bones
(vertebrae)
• Long bones are designed for weight bearing and
movement.
• Short bones consist of cancelous bone covered by a
layer of compact bone.
• Flat bones are important sites of hematopoiesis and
frequently provide vital organ function. They are made
of cancellous bones layered between compact bone.
• Irregular bones have unique shapes related to their
function and their structure is same as flat bones.
• Bones are constructed of
cancellous
(trabecular/spongy) or
cortical (compact) bone tissue.
• The shaft is know as diaphysis
is primarily cortical bones.
• The ends of long bones are
known as epiphysis are
primarily cancellous bone.
• The epiphyseal plate
separates the two.
• The ends of long bones are
covered at the joints with
articular cartilage which is
tough, elastic and avascular
tissue.
• 3 types of bone cells:
1. Osteoblasts – they secrete
bone matrix (collagen & ground
substances like glycoprotiens
and proteoglycans) that
provides a framework in which
inorganic minerals (calcium and
phosphorous) are deposited.
2. Osteocytes – they are involved
in bone maintenance.
3. Osteoclasts – they are
involved in dissolving and
resorbing bone.
• The functional unit of cortical bone is the osteon
(Haversian system).
• The center of the osteon is the Haversian canal which
contains a capillary.
• Around the capillary are circles of mineralized bone
matrix called lamellae.
• Within the lamellae are lacunae that contain the
osteocytes which are nourished through tiny structures
called canaliculi.
• Lacunae in cancellous bone are layered in an irregular
lattice network called trabeculae.
• Red bone marrow fills the lattice network.
• Covering the bone is a dense, fibrous
membrane known as the periosteum.
• The endosteum is a thin, vascular
membrane that covers the marrow cavity
of long bones and the spaces in
cancellous bones. Osteoclasts are located
near the endosteum in Howship’s
lacunae.
• Bone Marrow is a vascular tissue located
in the medullary (shaft) cavity of long
bones and flat bones. In adults, it is mainly
located in the sternum, ilium, vertebrae
and ribs. They are responsible for
producing RBCs, WBCs, and platelets.
The long bone marrow is filled with fatty,
yellow marrow.
• In cases of severe hemorrhage, the body
can convert yellow to red bone marrow.
 Bone foRmAtion
• Osteogenesis (bone formation)
begins long before birth.
• Ossification is the process by
which the bone matrix is formed
and hard mineral crystals are bound
to collagen fibers.
• 2 basic processes:
1. Endochondral – a cartilage-like
tissue(osteoid) is formed, resorbed,
and replaced by bone.
2. Intramembraneous – It occurs when
bone develops within a
membrane,as in bones in the face
and skull.
 Bone mAintenAnce
• During childhood, bones grow and form by
a process called modeling.
• By early 20s, remodeling is the primary
process that occurs.
• Remodeling is the simultaneous resorption
and osteogenesis, and as a result,
complete skeletal turnover occurs every 10
years.
fActoRs tHAt influence Bone Remodelling

1. Physical activity
– Particularly weight-bearing activity stimulates
bone formation and remodeling.
– Bones subjected to this tend to be thick and
strong while people who are immobile have
bones which are osteopenic and weak.
Factors that influence bone remodelling

2. Good dietary
habits
– Absorption of
approximately
1000-1200 mg of
calcium daily is
essential to
maintaining adult
bone mass.
Factors that influence bone remodelling

3. Vitamins
– Biologically active Vitamin D (Calcitriol)
functions to increase the amount of calcium
in the blood by promoting calcium absorption
from the GIT.
– It also facilitates mineralization of osteoid
tissue.
Factors that influence bone remodelling

4. Hormones
– Parathyroid hormone and calcitonin are the
major hormonal regulators of calcium
homeostasis.
– Parathyroid hormone regulates the
concentration of calcium in the blood by
promoting calcium movement from the bone.
– Calcitonin (thyroid) inhibits bone resorption
and increases the deposition of calcium into
the bone.
Factors that influence bone remodelling

4. Hormones
– Thyroid hormones and
cortisol/corticosteroids
– excess thyroid hormone in adults (eg.
Grave’s Disease) causes increased bone
resorption and decreased bone formation.
– Growth hormone stimulates the liver and
the bone to produce insulin-like growth factor
(IGF-1), which accelerates growth in children
and adolescents.
Factors that influence bone remodelling

4. Hormones
– Estrogen stimulates osteoblasts and inhibit
osteoclasts.
– Testosterone directly causes skeletal
growth in adolescence and has continued
effects on skeletal growth throughout the
lifespan. It is also converted into estrogen in
adipose tissue for aging men.
Bone HeAling
• Fracture healing occurs in 4 major
areas:
1. Bone marrow – where endothelial cells
rapidly undergo transformation and
become osteoblastic bone-forming cells.
2. Bone cortex – where new osteons are
formed.
3. Periosteum – where a hard callus/bone is formed
through intramembraneous ossification peripheral to
the fracture, and where a cartilage model is formed
through endochondral ossification adjacent to the
fracture site.
4. External soft tissue – where a bridging callus
(fibrous tissue) stabilizes the fracture.
 Fracture Healing

https://www.youtube.com/watch?v=od8oU5OLMGU
stRuctuRes & function of tHe
ARticulAR system
• A joint (articulation)
is the junction of two
or more bones.
• 3 basic kinds:
1. Synarthrosis
(immovable joints –
skull sutures)
2. Amphiarthrosis
(limited motion only –
vertebral joints)
3. Diarthrosis (freely
movable joints)
Types of diarthrosis joints:
1. Ball-and-socket joints
• Hip and the shoulder
• Permit full freedom of
movement
2. Hinge joints
• Permit bending in one
direction only
• Elbow and knee
3. Saddle joints
• Allows movement in two
planes at right angles at each
other.
• Joint at the base of the thumb
4. Pivot joints
• Characterized by the
articulation between the
radius and ulna.
• They permit rotation for
such activities as turning a
doorknob.
5. Gliding joints
• Allow for limited
movement in all directions
and are represented by
the joints of the carpal
bones in the wrist.
• The ends of the articulating
bones of a typical movable joint
are covered with smooth hyaline
cartilage called the articulating
cartilage.
• A tough fibrous sheath called the
joint capsule surrounds the
articulating joints.
• The capsule is lined with a
membrane called the synovium
which secretes the lubricating
and shock-absorbing synovial
fluid into the joint capsule.
• Ligaments (fibrous connective
bands) bind the articulating
bones together. These, together
with muscle tendons, provide
joint stability.
• A bursa is a sac-filled with
synovial fluid that cushions the
movement of tendons, ligaments,
and bones at a point of friction.
stRuctuRe And function of tHe
skeletAl muscle system
• Muscles are
attached by
tendons to bones
or aponeurosis to
connective tissue,
other muscles, soft
tissue, or skin.
• The muscles of the
body are encased
in fibrous tissue
called fascia or
epimysium.
• Sarcomeres are the actual contractile units
of skeletal muscle and contains myosin and
actin filaments which slides across one
another causing movement.
• The contraction of muscle fibers can result in
either isotonic or isometric contraction of the
muscle.
• Isometric contraction, the length of the
muscles remains constant but the force
generated by the muscles is increased.
• Isotonic contraction, is characterized by
shortening of the muscle with no increase in
tension within the muscle.
Muscle Tone
• Muscle tone (tonus) is
produced by the
maintenance of some of the
muscle fibers in a
contracted state to readily
respond to contraction
stimuli.
• Muscle spindles are the
sense organ of muscles
which monitors for muscle
tone.
• Flaccid is a muscle that is
limp and without tone while
a muscle with greater than
the normal tone is described
as spastic.
• Atonic muscles (soft and
flabby) results from motor
neuron destruction.
 Muscle Actions
• The prime mover is the muscle
that causes a particular motion.
• The muscles assisting the prime
mover are known as synergists.
• The muscle causing movement
opposite to that of the prime
mover is known as the
antagonist.
• An antagonist must relax to
allow the prime mover to
contract causing movement.
• Example is flexion of the elbow
with the use of biceps and
triceps.
Body movements
Assessment
Health History

• Obtain a general impression of the patient’s

health status, gathering subjective data from the
patient concerning the onset of the problem and
how it has been managed, as well as the
perceptions and expectations related to health.
• Concurrent health conditions (ex diabetes) and
related problems also need to be considered.
• A history of medication use and response to
analgesics aids in designing medication
management regimens.
• Note allergies also.
• Assess for use of tobacco, alcohol, and
prescription and over-the-counter
medications and herbal substances to
evaluate how these agents may affect patient
care.
• Information concerning the patient’s learning
ability, economic status, and current
occupation is needed for rehabilitation and
discharge planning.
PAin

• Bone pain is characterized as a dull, deep

ache that is “boring” in nature, while
muscular pain is described as soreness or
aching and is referred to as muscle
cramps.
• Fracture pain is sharp and piercing and is
relieved by immobilization.
• Bone infection pain is sharp with muscle
spasm or pressure on a sensory nerve.
• Rest relieves most musculoskeletal pain.
• Pain that increases with activity may indicate joint
sprain or strain.
• Steadily increasing pain points to the progression
of an infectious process, a malignant tumor, or
neurovascular complications.
• Radiating pain occurs in conditions in which
pressure is exerted on a nerve root.
AlteRed sensAtion

• Paresthesias are burning, tingling

sensations or numbness. These may be
caused by pressure on the nerves or by
circulatory impairment.
FRACTURE RISK ASSESSMENT
TOOL (FRAX)
• Predicts a patient’s 10-year risk of
fracturing a hip or other major bone
(includes spine, forearm or shoulder)
• The output is a percentage, and higher
values indicate a greater risk of fracture.
• the tool can accessed online
FRAX
PHysicAl Assessment
Posture

• The normal curvature

of the spine is convex
through the thoracic
portion and concave
through the cervical
and lumbar portion.
• Kyphosis is an
increased forward
curvature of the
thoracic spine.
• It is frequently seen in
elderly patient with
osteoporosis.
• Lordosis (swayback) is an
exaggerated curvature of the
lumbar spine.
• It is frequently seen during
pregnancy as the woman
adjusts her posture in response
to changes in her center of
gravity.
• Scoliosis is a lateral
carving deviation of the
spine.
• It may be congenital,
idiopathic (without any
identifiable cause), or the
result of damage to the
paraspinal muscles (polio)
Gait

• Gait is the manner of walking.

• It is assessed by having the patient walk
away from the examiner for a short
distance.
• The examiner observes the patient’s gait
for smoothness and rhythm.
• Abnormal gaits include:
1. Spastic hemiparesis gait – stroke patients
2. Scissors gait – patients with cerebral palsy
3. Propulsive gait – patients with parkinson’s
disease
4. Steppage gait – patients with polio, GBS, MS,
and other lower motor neuron disease.
5. Waddling (myopathic) gait –patients who are
pregnant, congenital hip dysplasia, muscular
dystrophy, and spinal muscle atrophy.
Bone Integrity

• The bony skeleton is assessed for

deformities and alignment.
• Symmetric part of the body, such as
extremities, are compared.
Joint function
• Range of motion is
evaluated both
actively and
passively.
• Precise
measurement of
ROM can be made
by a goniometer.
• Contracture is the
shortening of
surrounding joint
structures.
Goniometer
• Joint is also examined for effusion
(excessive fluid within the capsule)
through balloon and ballottement sign.
 Balloon sign
• The medial and lateral aspects of the
extended knee are milked firmly in a
downward motion, which displaces the fluid
downward. The examiner feels for any fluid
entering the space directly inferior to the
patella.
 Ballottement sign
• The medial and lateral aspects of the extended
knee are milked firmly in a downward motion. The
examiner pushes the patella toward the femur
and observes for fluid return to the region
superior to the patella.
• When larger amounts of fluid are present, the
patella elevates, there is visible return of fluid to
the region directly superior to the patella.
Muscle Strength & Size

• The muscular
system is assessed
by noting muscular
strength and
coordination, the
size of individual
muscles, and the
patient’s ability to
change position.
• Muscle tone (tonus) is produced by the
maintenance of some of the muscle fibers
in a contracted state.
• Muscle spindles, which are sense organs
in the muscles, monitor muscle tone.
• Muscle tone is minimal during sleep and is
increased when the person is anxious.
• A muscle that is limp and without tone is
described as flaccid;
• a muscle with greater-than-normal tone is
described as spastic.
• Muscle clonus is the
rhythmic contraction of a
muscle in the ankle or
wrist by sudden, forceful,
sustained dorsiflexion of
the foot or extension of
the wrist.
• Fasciculation is the
involuntary twitching of
muscle fiber groups.
Skin

• Inspect the skin for

edema,
temperature and
color.
• Inspect also for
bruises, cuts, skin
color and evidence
of decreased
circulation or
inflammation.
neuRovAsculAR stAtus
• Indicators of peripheral neurovascular dysfunction
include:
1. Circulation
• Color: Pale, cyanotic
• Temp: Cool
• CRT: more than 3 secs
2. Motion
• Weakness
• Paralysis
3. Sensation
• Paresthesia, Unrelenting Pain,
• Pain on passive stretch
• Absence of feeling
diAgnostic evAluAtion
X-ray Studies
• Bone X-rays determine
bone density, texture,
erosion, and changes
in bone relationships.
• Serial X-rays may be
indicated to determine
if healing of a fractured
bone is progressing
normally or to
determine if a bone
affected by a
degenerative disease
(osteoarthritis) is
responding to
prescribed therapy.
Computed Tomography
• It shows in detail a
specific plane of
involved bone and can
reveal tumors of the
soft tissue or injuries
to the ligaments or
tendons.
• It lasts for about 1
hour and patient must
remain still throughout
the procedure.
Magnetic Resonance Imaging

• It is a non-invasive imaging technique

that uses magnetic fields, radiowaves,
and computers to demonstrate
abnormalities.
• Patients with metal implants, chips or
pacemakers are not candidate for MRI.
 Arthrography
• It is useful in identifying acute or chronic tears of the joint
capsule or supporting ligaments of the knee, shoulder,
ankle hip or wrist.
• A radiopaque contrast agent or air is injected into the joint
cavity to outline soft tissue structures and the contour of the
joint.
• The joint is put through a series of ROM to distribute the
contrast agent while a series of X-rays are obtained.
• If a tear is present, the contrast agent leaks out of the joint.
• After the procedure, a compression elastic
bandage is applied as prescribed and the
joint is usually rested for 12 hours.
• Explain to the patient that it is normal to
experience clicking or cracking in the joint for
a day or two after the procedure, until the
contrast medium or air is absorbed.
Bone Densitometry

• It is used to estimate bone mineral density.

• This can be performed through the use of x-
rays or ultrasound.
• Dual-energy x-ray absorptiometry (DEXA)
determines bone mineral density at the wrist,
hip or spine to estimate the extent of
osteoporosis.
 Bone Scan
• It is performed to detect metastatic
and primary bone tumors,
osteomyelitis, certain fractures, and
aseptic necrosis.
• A bone-seeking radioisotope is
injected IV. The scan is performed 2-3
hours after the injection.
• The degree of nuclide uptake is
related to the metabolism of the bone.
• An increased uptake is seen in
primary skeletal disease
(osteosarcoma), metastatic bone
disease, osteomyelitis, and certain
types of fractures.
• Assess for possible allergy to the radioisotope and
assess for any condition that would contraindicate
performing the procedure (pregnancy).
• Encourage the patient to drink plenty of fluids to help
distribute and eliminate the isotope.
• Before the scan, ask the patient to empty his/her bladder
to minimize discomfort.
Arthroscopy
• It is a procedure that allows
direct visualization of a joint
to diagnose joint disorders.
• The procedure is performed
in the OR under sterile
conditions and with local
anesthetics.
• Post-operatively, the joint is
wrapped with a
compression dressing, is
kept extended and elevated
to minimize swelling.
• Administer prescribed
analgesics to control
discomforts.
• Explain also when the
patient can resume activity
and what weight-bearing
limits to follow as prescribed
by the orthopedic surgeon.
Arthrocentesis

• Arthrocentesis (joint aspiration) is carried out to

obtain synovial fluid for purposes of examination
or to relieve pain due to effusion.
• Examination of synovial fluid is helpful in the
diagnosis of septic arthropathies and reveals the
presence of hemarthrosis (bleeding into the
joint cavity), which suggests trauma or bleeding
disorders.
Electromyography
• Electromyography (EMG) provides information about
the electrical potential of the muscles and the
nerves leading to them.
• It is performed to evaluate muscle weakness, pain, and
disability.
• The purpose of the procedure is to determine any
abnormality of function and to differentiate muscle and
nerve problems.
Electromyography
Biopsy
• It may be performed to
determine the structure and
composition of bone
marrow, bone, muscle, or
synovium to help diagnose
specific disease.
• Monitor the biopsy site for
edema, bleeding, pain and
infection.
• Ice is prescribed to control
bleeding and edema.
• Analgesics are
administered to promote
comfort.