Musculoskeletal System

BY: Darren Ashley Umali

‡ Millions of Americans experience annually ‡ Multiple MOI
² Falls, crashes, violence, etc. ² Multi-system trauma

Introduction to Musculoskeletal Injuries
‡ Millions of Americans experience annually ‡ Multiple MOI
² Falls, crashes, violence, etc. ² 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
² it supports the sorrounding tissues.
² It protects vital organs and other soft tissues cof the body. ² It assists in body movements, giving attachment to the muscles, thus providing leverage. ² It manufactures blood cells.This hematopoietic function occurs in the red bone marrow. ² It provides storage for mineral salts, specifically phosphorus and calcium which supply body needs.

The Skull

Anatomy and Physiology of Synovial Joints
1. 2. 3. The synovial fluid is a viscous lubricant found in all synovial joint cartilages The articular cartilage acts as a cushion, providing a smooth gliding surface. 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. Ligaments help to maintain the relationships between bones and limit motion. Articular muscles function to maintain the stability of joints by relaxation and contraction to insure firm contact throughout the articular surface. Joint is the functional unit of the MS system

4. 5.



Regulation Movement
‡ tendons - join muscle to bone ‡ ligaments and muscles give joint stability ‡ cartilage - pads joints during weight bearing

Movements of Synovial Joints
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Flexion ² decreasing angle between 2 bones. Extension- increasing angle between 2 bones. Abduction- the bones moves away from the midline. Adduction - bone moves toward the midline. Rotation - the bones moves around the central axis. Circumduction - bone describes the surface of a cone. Supination- the palm is turned upward. Pronation ²the palm is turned downward. Eversion ² the sole of the foot is turned outward. Inversion ² 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. 2. 3. Ball and Socket Joint- provides the widest of motion, with movement. Example: hip, joints Hinge Joint- the motion is limited to flexion and extension. Example: elbow joint 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. Condyloid- an oval-shaped condyle that fits into elliptical cavity. Example: The wrist joint between the radius and carpal bones. 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 ² Inspect area anterior to ear while seated ² Place tips of 1st two fingers in front of ear & drop to depressed area over joint ² 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
² Inspect head & neck alignment
‡ Spine should be straight, head erect

² 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. Short Bones- a thin layer of compact tissues which covers the spongy or cancellous tissues of a typical short bone. Irregular Bones- are bones of peculiar shape, like the bones of vertebrae and ossicles of the ear. Sesamoid Bones- are bones that are smail, rounded and are enclosed in tendon and facial tissues. Flat Bones- for extensive muscle attachment, e.g ribs, scapula

2. 3. 4. 5.

‡ Bone Structure
² Diaphysis ² Epiphysis ² Metaphysis

‡ End of a long bone ‡ Between epiphysis and diaphysis ‡ Growth plate ‡ Contains bone marrow


² Medullary canal ² Periosteum ² Cartilage

‡ Fibrous covering of diaphysis ‡ Connective tissue that provides a smooth articulation surface for other bones

‡ Joint Injury
² Sprain ² Subluxation ² Dislocation

‡ Bone Injury
² ² ² ² ² 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

‡ ‡ ‡ ‡ ‡ Sprain Strain Dislocation Closed fracture Open fracture

Sprains & Strains
‡ Sprain
² Joint injury with tearing of ligaments

‡ Strain
² Stretching or tearing of a muscle

‡ Closed fracture
² does not break the skin

‡Nondisplaced fracture -Simple crack ‡Displaced fracture -deformity

‡ Open fracture
² External wound

Closed fracture
‡ Signs & symptoms
² ² ² ² ² ² ² ² Pain Edema Possible deformity Contusion Loss of motion false motion Crepitus Guarding

‡ Treatment - immobilize, ice, elevate if possible.

Open fracture
‡ Signs & symptoms
² Pain ² Deformity ² Break in skin and/or exposed bone ‡ Treatment - dressing, immobilize, ice, & elevate if possible

Bleeding (internal)
‡ Bones have a blood supply! ‡ Fractures bleed internally ² Femur - 1 liter ² Pelvis - 1 liter ² 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 ² Hip ² Knee ² Ankle ² Foot ² Shoulder ² Elbow ² Wrist/Hand ² Finger

Hip Fractures
‡ Common in the elderly. ‡ May be able to support weight.
² 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:
² Apply gentle traction along the long axis of the joint.

‡ If gentle traction does not restore the pulse:
² 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
² Sling and swathe.

‡ Shoulder Dislocation
² Use pillow with sling and swathe.

‡ Fracture
² Use sling and swathe.

Elbow Injury
‡ Fracture or dislocation may cause neurovascular injury. ‡ Splint in position found. ‡ Transport promptly.

Forearm/Wrist Injury
‡ Rigid Splint
² Keep hand in ´position of function.µ

‡ Air Splint
² May be hard to reassess circulation.

‡ Pillow

Assessment of injured extremities
² ² ² ² Pulse Movement Sensation Capillary refill Cold, blue, pulseless extremity has circulation problem


‡ Why we splint...
² relieve pain ² reduce tissue/vessel damage during movement

Types of splints
‡ ‡ ‡ ‡ Self splinting Pillows, blankets, & items of clothing Sling & swath Rigid
² Cardboard ² plastic ² 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

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

‡ No matter how bad the fracture our priorities are the ABC·s


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. 2. 3. 4. 5. 6. Paralysis Weakness Pain Atrophy Spasm Cramps

Developmental Considerations
‡ Infants & children
² Skeleton is cartilage 3 mos. gestation ² Congenital hip dislocation ² Bone growth
‡ ‡ ‡ ‡ Rapid during infancy Steady during childhood Rapid growth spurt in adolescence Occurs in 2 directions
² Width or diameter ² Lengthening at epiphyses or growth plates

² Screen for scoliosis starting at age 10-12

Developmental Considerations
‡ Pregnancy
² levels of circulating hormones mobility
‡ Estrogen ‡ Relaxin ‡ Corticosteroids


² Progressive lordosis
‡ Anterior flexion of neck ‡ Slumping of shoulder girdle

Developmental Considerations
‡ Aging adult
² Bone loss (resorption) > new bone growth (deposition) loss of bone density (osteoporosis) ² Osteoporosis ‡ Females > males ‡ Whites > blacks ² height due to shortening vertebral column ² Kyphosis, backward head tilt, slight flexion of knees & hips

Developmental Considerations
‡ Aging adult
² Lose fat in face & forearms abdomen & hips ² Loss in muscle mass & some atrophy weakness ² Sedentary lifestyle hastens musculoskeletal changes of aging ² Exercise skeletal mass & delays osteoporosis
‡ Esp. postmenopausal & older women

Subjective Data
‡ Joints
² Problems, pain
‡ Stiffness, edema, heat, redness, limited ROM, ADL

² Location, unilateral vs. bilateral ² Quality, severity, onset, time of day ² Aggravating factors
‡ Movement, rest, position, weather

² Relieving factors
‡ Rest, medication, heat or ice

² Associated sx
‡ Chills, fever, recent sore throat, trauma, repetitive activity

Subjective Data
‡ Muscles
² Problems, pain, cramping, weakness location
‡ Muscle atrophy

² Any calf pain?
‡ Associated with walking? ‡ Relief with rest?

² Associated symptoms
‡ Fever, chills, flu-like symptoms

Subjective Data
‡ Bones
² Bone or back pain
‡ Is pain affected by movement? ‡ Location, radiating pain, numbness & tingling, limping

² Bone or joint deformity
‡ Injury, trauma, ROM

² Hx accidents or trauma
‡ Fractures, joint strain, sprain, dislocation ‡ Date, tx, sequelae (problems or limitations)

Subjective Data
‡ Functional assessment (ADL)
² Do joint (muscle, bone) problems limit ADLs?
‡ Bathing
² Getting in & out of tub, turning on faucets

‡ Toileting
² Urinating, moving bowels, getting on/off toilet, wiping self

‡ Dressing
² Buttons, zippers, fastening openings behind neck, pulling sweater over head, pulling up pants, tying shoes, getting shoes that fit

Subjective Data
‡ Functional assessment (ADL)
² Grooming
‡ Shaving, brushing teeth, brushing or grooming hair, applying make-up

² Eating
‡ Preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking

² Mobility
‡ Walking, going up or down stairs, getting in/out of bed, getting out of house

² Communicating
‡ Talking, using phone, writing

Subjective Data
‡ Self-care behaviors
² Occupational hazards related to muscles & joints
‡ Heavy lifting, repetitive motion, chronic joint stress ‡ Efforts to alleviate above

² Exercise program
‡ Type, frequency, warm-up ‡ Pain during exercise & tx

² Recent wt gain, usual diet ² Medications
‡ ASA, NSAIDs, muscle relaxants, analgesics

² If chronic disability, effect on interaction with family, friends, & view of self

Subjective Data
‡ Infants & children
² Infant trauma during L & D
‡ Breech or forceps delivery ‡ Resuscitation

² Achievement of developmental milestones
‡ Siblings, peers

² Hx broken bones, dislocations & tx ² Hx bone deformity, spinal curvature, unusual shape of toes or feet & tx

Subjective Data
‡ Adolescents
² Involvement in sports during or after school ² Use of safety equipment, sports training program ² Type of daily warm-up ² Reporting of injuries ² Relation of sport to school demands & other activities

Subjective Data
‡ Aging adult
² Do in-depth functional assessment if needed ² Change or weakness in past months or years ² in falls or stumbling in past months or years ² Use of mobility aids
‡ Cane, walker

‡ Screening
² Sufficient for most people ² Inspection & palpation of joints integrated with each body region ² Observation of ROM ² Age-specific screening measures
‡ Ortolani·s maneuver ² infants ‡ Scoliosis screening - adolescents

‡ Complete musculoskeletal exam
² Persons with joint disease ² Hx musculoskeletal symptoms ² Problems with ADL

‡ Make person comfortable ‡ Drape for full visualization of body part without exposing client ‡ Orderly approach ² Head-to-toe ² Proximal to distal ‡ Joint to be examined should be supported at rest ‡ Avoid rough manipulation ² Use firm support, gentle movement, gentle return to relaxed state ‡ Compare corresponding paired joints ² ¥ symmetry structure & function ² ¥ normal parameters for the joint

Objective Data
‡ Inspection
² Note joint size & contour ² Inspect skin over joints for color, swelling, masses, or deformity

‡ Palpation
² Palpate each joint ‡ Skin temperature, muscles, bony articulations, joint capsule ‡ Note heat, tenderness, edema, or masses ‡ Normal: joints nontender, no swelling ² Synovial membrane normally nonpalpable, if thickened ´doughyµ or ´boggyµ

Objective Data
‡ Range of motion (ROM) ² Ask for active ROM while stabilizing body area proximal to area moved ‡ Know joint type & normal ROM ‡ Normal: no tenderness, pain, or crepitation ² Discrete crack during motion normal ² 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 ² Goniometer: used to measure joint angles precisely


Objective Data
‡ Muscle testing
² Test strength of prime mover muscle groups for each joint ² 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