Wollo University

College of Medicine and Health Sciences

School of Nursing and Midwifery
Department of Adult Health Nursing

Assessment of the Musculoskeletal System

By: Yosef Aregawi

Dec/5/22
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 Anatomy and physiology review of MSS

Structure and Function of Bone

Outlines
❖Bone
❖Classification of bone
❖Macroscopic structure of bone
❖Microscopic structure of bone
❖Ossification
❖Factors regulating bone growth
❖Blood supply to a long bone
❖Nerve supply to the bone
❖Function of the bone 2
 objectives
At the end of this session we will be able to
❖Identify basic structures of bone.
❖Explain factors regulating bone growth.
❖Mention blood and nerve supply of bone.
❖State functions of bone.
<Asses Muscloskeletal system.

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 Bone

A highly vascular living connective tissue in which

the matrix is calcified by the deposition of calcium
phosphate.
Structural support of the body
Connective tissue that has the potential to repair
and regenerate.

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 Bone …
Comprised of a rigid matrix of calcium salts
deposited around protein fibers.
Minerals provide rigidity.
Proteins provide elasticity and strength

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 Classification of bone

1) According to their position

 Axial :- bones forming the axis of the body.
 Appendicular :- bones of the limbs.
2) According to their shape
A) Long bones:-
 They have three parts: upper end, lower end and a
middle shaft.
 The ends of these bones take part in forming the
joint.
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 Classification of bone …

B) Short bones
 Small and generally cuboidal in shape, e.g. carpal
and tarsal bones.
C) Flat bones
 These bones are expanded and are flat, e.g.,
sternum, scapula, ribs and parietal bone.
D) Irregular bones
 The shape is irregular without any proper outline,
e.g., vertebrae, sphenoid, temporal bones etc...

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 Classification of bone …

3) According to their gross structure

A) Compact ( lamellar)
 Structurally it is made up of bony plates, which are
arranged compactly, e.g., outer cortical part of the
long bone.
B) Spongy bone (cancellous)
 Structurally it is made up of boney plates, which are
arranged irregularly leaving spaces in between
them.
 It gives a spongy appearance, e.g., flat bones,
irregular bones, ends of long bone. 8
 Classification of bone …

C) Diploic bones
• It consists of inner and outer tables of compact bone with
an interval, which is occupied by bone marrow and diploic
veins, e.g., most of the cranial bones (parietal, frontal,
occipital).
4) According to their development
• Membranous bones
• Cartilaginous bones
# Special types of bones
• Pneumonic bones(any bone,such as the mastoid process.)
• Sesamoid bones(small,rounded that embedded in the flexor
tendon of hand.) 9
 Macroscopic structure of long bone

The long bone consists of two ends (epiphysis)

and a shaft (diaphysis.)
The shaft consists of a cylindrical cavity inside
called ‘medullary cavity’, which is filled with
bone marrow. The outer (cortical) part of the shaft
is made up of compact bone.
The two ends of the long bones are filled with tiny
plates of bone containing numerous spaces. This is
referred as ‘ spongy bone’ to which the medullary
cavity does not extend.
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 Macroscopic structure …

The outer surface of the bone is covered by a

highly vascular connective tissue membrane
called ‘periosteum’ except at the articulr surfaces.
The medullary cavity is lined by another
connective tissue membrane called ‘endosteum.’

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 Bone marrow

• It is a vascular connective tissue present in the cavity

(medullary cavity) of the bone.
• Occurs in two forms, yellow and red marrow.
• The red marrow is actively engaged in the production
of blood cells.
• The yellow marrow derives its color from the large
quantity of fat cells it contains.
• At birth the red marrow is present throughout the
skeleton.
• After about fifth year of potential life, the red marrow
is gradually replaced in the long bones by yellow
marrow. 12
 Microscopic structure of bone

Adult long bone consists of the following

components:
• Bone cells
• Matrix (ground substance)

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 Matrix (ground substance)

• The matrix of the bone consists of both organic and

inorganic constituents:
A) Organic constituents (25% of the matrix)
• It is mainly made up of collagen fibers
• These collagen fibers are embedded in proteins,
carbohydrates and water.
• The collagen fibers are responsible for toughness
and resilience of bone. These fibers are synthesized
by oestioblasts.
• Chondroitin sulphate is another important organic
constituent of the bone. 14
 Matrix (ground substance) …

B) Inorganic constituent (75% of the matrix)

• Calcium phosphate (85%).
• Calcium carbonate (10%).
• Small amount of calcium fluoride and
magnesium phosphate.

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 Bone cells

A) Oesteoblasts
• These are bone forming cells.
• More numerous in periosteum.
• Responsible for laying down the organic matrix
of bone including the collagen fibers.
• Responsible for calcification of the matrix.
B) Osteocytes
• Are mature bone cells.
• Derived from osteoblasts after they have laid
down the matrix. 16
 Bone cells …

C) Osteoclasts
• Are bone removing cells and found in relation to
the surface of the bone.
• Are multinucleated large cells (diameter varies
from 20 to 100μm.
• The lysosomes present in their cytoplasm contain
“acid phosphate.”
• Involved in demineralization and removal of
bone matrix.
• Stimulated by parathyroid hormone.
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 Ossification

• The process of bone formation is called

ossification.
• All bones are developed from the mesenchymal
tissue of the embryo.

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 Types of ossification
1) Membranous ossification
• The embryonic mesenchymal tissue will directly
form the bone. E.g., bones of the cranial vault,
mandible and clavicle.
2) Cartilaginous ossification
• The mesenchymal tissue is first transformed into a
‘cartilage’. Later this cartilage is ossified to form
a bone.

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 Factors regulating bone growth

• Normal bone growth requires constant dietary

source of calcium and phosphate salts.
• Vitamin A and C are essential for normal bone
growth and remodeling.
• Vitamin D plays an important role in normal
calcium metabolism by stimulating the absorption
and transport of calcium and phosphate ions in to
the blood.

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 Factors regulating …

• The thyroid gland secrets the hormone calcitonin,

which stimulates osteoblasts to produce new
matrix.
• The secretion of parathyroid stimulates osteoclast
activity.
• Growth hormone produced by the pituitary and
thyroxin from the thyroid gland stimulate the
bone growth.

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 Blood supply to a long bone

A) Nutrient artery
• It enters the shaft through a nutrient foramen with
one or two veins. On reaching the bone marrow
cavity they divided in to ascending and
descending branches.
B) Epiphseal arteries
• Several in number and enter the bone near the
ends.

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 Blood supply …
C) Metaphyseal arteries
• Enter the bone along the line of attachment of
capsular ligament (near the articular end.)
D) Periosteal arteries
• Numerous and enter the bone along the muscular
attachment.

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 Nerve supply to the bone

• Bones are innervated by sensory nerves and

injuries to the bone can be very painful.

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 Functions of the bone

• Provides supporting framework and shape for the body.

• Protects vital organs of the body.

• Helps in transmission of the body weight.

• Provides attachment to the muscles and act as levers of

the joints helping in locomotion.
• A store house of calcium salts.

• Involved in erythropoiesis.
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Assessment of the Musculo-Skeletal System

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Components of Routine Nursing Assessment

1) Subjective Assessment
Collect subjective data from the patient and pay
particular attention to what the patient is reporting
about current symptoms, as well as past history of
musculoskeletal injuries and disease. Information
during the subjective assessment should be
compared to expectations for the patient’s age
group or that patient’s baseline.

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 Con.....
2) Objective Assessment
The purpose of a routine physical exam of the
musculoskeletal system by a registered nurse is
to assess function and to screen for
abnormalities. Most information about function
and mobility is gathered during the patient
interview, but the nurse also observes the
patient’s posture, walking, and movement of
their extremities during the physical exam.
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During Routine Assessment Nurses Complete
the following Mss Asse..
1) Assess gait
2) Inspect the spine
3) Observe range of motion of joints
4) Inspect muscles and extremities for size and
symmetry
5) Assess muscle strength
6) Palpate extremities for tenderness

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 Outlines

1. History
2. Physical Exam
3. Inspection
4. Palpation
5. ROM (Range of motion)
6. Diagnostic studies

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 Objectives
• At the end of this session we will be able to
 Identify components of musculoskeletal history
 State areas of physical examination in pts with
MSS disorders
 Explain the diagnostic modalities of MSS
disorders

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 History Taking
❖ Accurate history.
❖ Should be in chronologic order and
❖ Details of the current problem.
❖ The age and sex of the patient can be
significant in uderstanding the nature of the
disorder and planning.
❖ its specific location.
❖ the character of the pain.

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 History tak....
❖ the frequency in which the pain occur.
❖ the duration variation of the pain.
❖ Aggravating or relieving factors.
❖ Distribution or radiation of the pain.
❖ All past history including illness,all
immunizations,allergies and injuries.
❖ All medical,surgical and obstetric
treatment.

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 History tak...
There are three main areas: pain, dysfunction and
deformity.
-Pain: when, where, how bad? Does anything make
it worse/better?
-Dysfunction: what can you no longer do? Are there
any ways round this?
-Deformity: how much does it bother you? Why or
when is this a problem?

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 Screening questions for musculoskeletal
disorders
-Do you have any pain or stiffness in your arms,
legs or back?
-Can you walk up and down stairs without
difficulty?
-Can you dress yourself in everyday clothes
without any difficulty?

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 Physical Exam

1. Inspection
❖Observe any lack of symmetry and any
evidence of trauma or disease.
❖ Look for muscle wasting;
❖ Inspect the joint contour (shape) and observe
any evidence of swelling, deformity or
inflammation.

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Assessment of Gait
❖Ask the patient to walk back and forth across the
room.
❖Observe for equality of arm swing , balance and
rapidity and ease of turning.
❖Next, ask the patient to walk on his tiptoes, then on
heels. heels
❖Ask the patient to tandem walk.

• Test patient's ability to stand with feet together

with eyes open and then closed. (Romberg's test).
Reassure patient that you will support him, in case
he becomes unsteady. tiptoes
• Normal: Person can walk in balance with the
arms swinging at sides and can turn smoothly.
Person should be able to stand with feet together
without falling with eyes open or closed.

tandem
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 Upper Extremity Muscles
❖ Inspect the muscles of the
shoulder, arm, forearm and hand.
• Note muscle size (bulk).
• Look for asymmetry, atrophy and
fasciculation.
• Look for tremor and other
abnormal movement at rest and
with arms out stretched.

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 Determine muscle power
❖ By Gently trying to
overpower contraction of each
group of muscles. Abduction
– Shoulder: Abduction
(Deltoid)
– Adduction
– Shrug (Trapezius)

Adduction

Trapezius)

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❖ Elbow: flexion (Biceps)

❖ Elbow extension (Triceps)

❖Wrist: Flexion and extension().

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❖ Hand: Grip
Grip

❖opposition of
thumb and index finger

❖ opposition of
thumb and little finger and

❖finger abduction and 41

• Determine limb tone
(resistance to passive stretch).
• With the patient relaxed

❖Gently move the limb at the

shoulder, elbow and wrist joints
and note whether tone is
normal, increased or decreased

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 Normal findings

• Muscles are symmetrical in size with no

involuntary movements.
• In some, muscles may be slightly larger on the
dominant side.
• Muscle power obviously varies. You should not be
able to overpower with reasonable resistance.
• We have to learn to appreciate the normal tone
from practice.

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 Muscle strength scale
0 – No muscle contraction

1 – Trace muscle contraction, such as a twitch

2 – Active movement only when gravity eliminated

3 – Active movement against gravity but not against resistance

4 – Active movement against gravity and some resistance

5 – Active movement against gravity and examiner’s full resistance

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 Neck - Range of Motion
❖ Fix the head with one hand while you
examine neck
✔ Inspection
– Note the normal concavity of cervical
spine
– Identify Transverse process of C7
– Observe Trapezius and Sternomastoid
muscles
✔Palpation
– Feel each spinous process looking for focal
areas of tenderness
– Joint  Touch chin
• Feel for crepitus during passive motion
– Para spinal muscles
✔Range of motion
– Active
• Touch chin for flexion& headback.
• Throw head back for extension Throw head back 45
 • Touch each shoulder with ears for lateral
flexion
• Touch each shoulder with chin for lateral
rotation
– Passive
• Feel for crepitus during passive motion
• Normal
– 30 degree rotation, able to touch chest
with chin, 55 degree extension and 40
degree lateral bend.
– No resistance during the range of
motion.

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 Muscles of Lower Extremity
Inspect the muscles of the hip, knee and
ankle.
✔ Note muscle size (bulk)
✔ Look for asymmetry, atrophy and
fasciculation.
✔ Look for abnormal movement.
✔ Determine muscle power by gently trying Hip flexion
to overpower contraction of each group of
muscles.
❖ Hip: Flexion (Iliopsoas), Extension (Gluteus
maximus), Abduction, Adduction.

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 The Knee Exam
Inspection
❖ Make sure that both knees are fully
exposed. The patient should be in
either a gown or shorts. Rolled up pant
legs do not provide good exposure!
✔ Watch the patient walk.
✔ Do they limp or appear to be in
pain?
✔ When standing, is there evidence
of bowing (varus) or knock-kneed varus Knee deformity,
(valgus) deformity? ❖There is a more marked on the left
leg
predilection for degenerative joint
disease to affect the medial aspect of
the knee, a common cause of bowing.

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❖ Is there evidence of atrophy of the
quadriceps, hamstring, or calf muscle
groups?

❖ Knee problems/pain can limit the use

of the affected leg, leading to wasting of
the muscles.

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 ✔ Knee : Flexion (Hamstrings), Extension
(Quadriceps)
Knee extension
✔Ankle : Dorsiflexion (Tibialis anterior),
Plantar flexion (Gastronemius).
❖ Determine limb tone resistance to passive
stretch. With the patient relaxed, gently move the
limb at the hip, knee and ankle and note whether Knee flexion

tone is normal, increased or dicreased.

Flex the hip and knee.
Dorsiflexion
❖Support the knee, dorsiflex the ankle sharply
and hold the foot in this position checking for
clonus. 50
 Spine (Bone)
✔ The examiner should stand behind the patient
and observe the alignment of the spine in the
flexed position to determine scoliosis.
✔ View the spine from the side to determine
kyphosis.

✔ Ask the patient if he is aware of sore spots.

Palpate the spinous process and be gentle with the
sore spots. Percuss one vertebra at a time, starting
from head.

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❖ Assess range of motion of spine by
having patient bend down to pick up an
object without bending his legs while you
hold his hips.
• Normal

• Gentle concavities in cervical and

lumbar regions and a convexity in the
thorax.
• Vertebral line and gluteal cleft align
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 Diagnostic studies
1) Complete Blood Count
Hemoglobin and erythrocyte count
-Reduction of hemoglobin level is seen in chronic
rheumatoid disease.
-This anemia may be due to impairment of
utilization of iron, hemolytic, or toxic effects of
anti-rheumatoid drugs.
-Systemic lups erythmatous may be associated with
hemolytic anemia.

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 2) Leukocyte count
-Total leukocyte count (TLC) is elevated in the acute
phase of inflammatory artheritis

-Considerable elevation of TLC with marked

preponderance of neutrophils suggests pyogenic
arthritis, acute rheumatoid disease or acute gout.

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 Leukocyte count …
-In chronic forms of these diseases and in
tuberculosis arthritis, lymphocyte may show
relative preponderance.
-TLC and differential count are absolutely essential
to diagnose leukemia which may masquerade as
polyarthritis on initial presentation.

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 3) Platelet count
-Generally platelet count is not diagnostic of the
primary condition.
-Thrombocytopenia may occur in systemic lupus
erythmatous as part of the disease
-More often thrombocytopenia is an early sign of
drug induced bone marrow aplasia. -Several drugs
such as NSAIDs, gold salts, penicilliamine and
immunosuppressant drugs are known to produce
bone marrow aplasia.

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 Test for rheumatoid factor

 RF which consists of different types of

immunoglobulins is present in 70-80% of cases of
rheumatoid arthritis.
 Since the usual test detect only IgM antibodies,
negative results are obtained in about 25% of cases.
> Presence of RF is not specific for rheumatoid
arthritis.
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 Test for rheumatoid factor...

 Other conditions in which RF is present in a

smaller proportion of case include SLE,
progressive systemic sclerosis, mixed connective
tissue disease and others.
 False positive RF may be seen in several other
conditions such as infective hepatitis, leprosy,
tuberculosis and typhoid.
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 Referance
❖ Miller,S.B(1990) an over view of
muscloskeletal system.
❖ Medscap.com

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 Acknowledgment
❖ For Dr. Kumer
❖For Adult Health Nursing

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