` Musculoskeletal System

Assessment

dr. Lauhil Mahfudz, SpB

Skeletal System
• Bone types
• Bone structure
• Bone function
• Bone growth and metabolism affected by calcium and
phosphorous, calcitonin, vitamin D, parathyroid, growth
hormone, glucocorticoids, estrogens and androgens,
thyroxin, and insulin.
Bones
• Human skeleton has 206 bones
• Provide structure and support for soft tissue
• Protect vital organs
• Compact bone
• Smooth and dense
• Forms shaft of long bones and outside layer of other
bones
• Spongy bone
• Contains spaces
• Spongy sections contain bone marrow
Bone Marrow
• Red bone marrow
• Found in flat bones of sternum, ribs, and ileum
• Produces blood cells and hemoglobin
• Yellow bone marrow
• Found in shaft of long bones
• Contains fat and connective tissue
Joints (Articulations)
• Area where two or more bones meet
• Holds skeleton together while allowing body to move
• Synarthrosis
• Immovable (e.g., skull)
• Amphiarthrosis
• Slightly movable (e.g., vertebral joints)
• Diarthrosis or synovial
• Freely movable (e.g., shoulders, hips)
Synovial Joints
• Found at all limb articulations
• Surface covered with cartilage
• Joint cavity covered with tough fibrous capsule
• Cavity lined with synovial membrane and filled with synovial
fluid
Ligaments
• Bands of connective tissue that connect bone to bone
• Either limit or enhance movement
• Provide joint stability
• Enhance joint strength
Tendons
• Fibrous connective tissue bands that connect bone to
muscles
• Enable bones to move when muscles contract
Muscles
• Skeletal (voluntary)
• Allows voluntary movement
• Smooth (involuntary)
• Muscle movement controlled by internal mechanism
• e.g., muscles in bladder wall and GI system
• Cardiac (involuntary)
• Found in heart
Skeletal Muscle
• 600 skeletal muscles
• Made up of thick bundles of parallel fibers
• Each muscle fiber made up of smaller structure myofibrils
• Myofibrils are strands of repeating units called sarcomeres
• Skeletal muscle contracts with the release of acetylcholine
• The more fibers that contract, the stronger the muscle
contraction
Changes in Older Adult
• Musculoskeletal changes can be due to:
• Aging process
• Decreased activity
• Lifestyle factors
• Loss of bone mass in older women
• Joint and disk cartilage dehydrates causing loss of flexibility
contributes to degenerative joint disease (osteoarthritis);
joints stiffen, lose range of motion
• Cause stooped posture, changing center of gravity
• Elderly at greater risk for falls
• Endocrine changes cause skeletal muscle atrophy
• Muscle tone decreases
Assessment
• Health history
• Chief complaint
• Onset of problem
• Effect on ADLs
• Precipitating events, e.g., trauma
• Examine complaints of pain for location, duration, radiation
character (sharp dull), aggravating, or alleviating factors
• Inquire about fever, fatigue, weight changes, rash, or swelling
Physical Examination
• Posture
• Gait
• Ability to walk with or without assistive devices
• Ability to feed, toilet, and dress self
• Muscle mass and symmetry
Physical Examination
• Inspect and palpate bone, joints for visible deformities, tenderness or
pain, swelling, warmth, and ROM
• Assess and compare corresponding joints
• Palpate joints knees and shoulder for crepitus
• Never attempt to move a joint past normal ROM or past point where
patient experiences pain
• Bulge sign and ballottement sign used to assess for fluid in the knee
joint
• Thomas test performed when hip flexion contracture suspected
Diagnostic Tests
• Blood tests
• Arthrocentesis
• X-rays
• Bone density scan
• CT scan
• MRI
• Ultrasound
• Bone scan
Diagnostic Evaluation
• Imaging Procedures – CT, Bone Scan, MRI
• Nuclear Studies - radioisotope bone density,
• Endoscopic Studies –arthrocentesis, arthroscopy
• Other Studies –biopsy, synovial fluid, Arthrogram, venogram,
• Electromyography
• Myelography*
• Laboratory Studies
• Other diagnostic tests: bone and muscle biopsy
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.
• Flexible fiberoptic endoscope used to view joint structures and tissues
• Used to identify:
• Torn tendon and ligaments
• Injured meniscus
• Inflammatory joint changes
• Damaged cartilage
Bone Scan
• Nuclear medicine procedure in which amount of radioactive
isotope taken up by bones is evaluated
• Abnormal bone scans show hot spots due to malignancies or
infection
• Cold spot uptakes show areas of bone that are ischemic
Musculoskeletal Trauma
• Tissue is subjected to more force than it can absorb
• Severity depends on:
• Amount of force
• Location of impact

• Mild to severe
• Soft tissue
• Fractures
• Affect function of muscle, tendons, and ligaments
• Complete amputation
Preventing Trauma
• Teach importance of using safety equipment
• Seat belts
• Bicycle helmets
• Football pads
• Proper footwear
• Protective eyewear
• Hard hats
Soft Tissue Trauma
• Contusion
• Bleeding into soft tissue
• Significant bleeding can cause a hematoma
• Swelling and discoloration (bruise)
Soft Tissue Trauma - Sprain
Ligament injury (Excessive stretching of a ligament)
Twisting motion
Overstretching or tear
◦ Grade I—mild bleeding and inflammation
◦ Grade II—severe stretching and some tearing and inflammation and
hematoma
◦ Grade III—complete tearing of ligament
◦ Grade IV—bony attachment of ligament broken away
• Treatment of sprains:
• first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation
• second-degree: immobilization, partial weight bearing as tear heals
• third-degree: immobilization for 4 to 6 weeks, possible surgery
Soft Tissue Trauma - Strain
• Microscopic tear in the muscle
• May cause bleeding
• “Pulled muscle”
• Inappropriate lifting or sudden acceleration-deceleration

• To decrease swelling and pain, and encourage rest

• Ice for first 48 hours
• Splint to support extremities and limit movement
• Compression dressing
• Elevation to increase venous return and decrease swelling
• NSAIDs
Soft Tissue Trauma
• Diagnosis
• X-ray to rule out fracture
• MRI
Fractures
• Break in the continuity of bone
• Direct blow
• Crushing force (compression)
• Sudden twisting motions (torsion)
• Severe muscle contraction
• Disease (pathologic fracture)
 Fractures
Classification of Fractures

• Closed or simple
• Open or compound
• Complete or incomplete
• Stable or unstable
• Direction of the fracture line
• Oblique
• Spiral
• Lengthwise plane (greenstick)
 Stages of Bone Healing

Hematoma formation within 48 to 72 hr after

injury
Hematoma to granulation tissue
Callus formation
Osteoblastic proliferation
Bone remodeling
Bone healing completed within about 6 weeks;
up to 6 months in the older person
Fractures – Emergency Care
• Immobilize before moving client
• Joint above and below
• Check pulse, color, movement, sensation before splinting
• Sterile dressing for open wounds
Fractures – Emergency Care
• Fracture reduction
• Closed—external manipulation
• Open—surgery
 Acute Compartment Syndrome

Serious condition in which increased pressure within one

or more compartments causes massive compromise of
circulation to the area
Prevention of pressure buildup of blood or fluid
accumulation
Pathophysiologic changes sometimes referred to as
ischemia-edema cycle
 Emergency Care - Acute
Compartment Syndrome
• Within 4 to 6 hr after the onset of acute compartment
syndrome, neuromuscular damage is irreversible; the limb
can become useless within 24 to 48 hr.
• Monitor compartment pressures
• Fasciotomy may be performed to relieve pressure.
• Pack and dress the wound after fasciotomy.
 Possible Results of Acute
Compartment Syndrome

• Infection
• Motor weakness
• Volkmann’s contractures: (a deformity of the hand, fingers,
and wrist caused by a lack of blood flow (ischemia) to the
muscles of the forearm)
 Other Complications of Fractures

Shock
Fat embolism syndrome: serious complication resulting
from a fracture; fat globules are released from yellow bone
marrow into bloodstream
Venous thromboembolism
Infection
Ischemic necrosis
Fracture blisters, delayed union, nonunion, and malunion
 Musculoskeletal
Complications

• Muscle Atrophy, loss of muscle strength range of motion,

pressure ulcers, and other problems associated with
immobility
• Embolism/Pneumonia/ARDS
• TREATMENT – hydration, albumin, corticosteroids
• Constipation/Anorexia
• UTI
• DVT
 Musculoskeletal Assessment - Fracture
• Change in bone alignment
• Alteration in length of extremity
• Change in shape of bone
• Pain upon movement
• Decreased ROM
• Crepitation
• Echymotic skin
• Subcutaneous emphysema with bubbles under the skin
• Swelling at the fracture site
Special Assessment Considerations

For fractures of the shoulder and upper

arm, assess client in sitting or standing
position.
Support the affected arm to promote
comfort.
For distal areas of the arm, assess client
in a supine position.
For fracture of lower extremities and
pelvis, client is in supine position.
 Casts
• Rigid device that immobilizes the affected
body part while allowing other body parts to
move
• Cast materials: plaster, fiberglass, polyester-
cotton
• Types of casts for various parts of the body:
arm, leg, brace, body
 Casts

• Cast care and client education

• Cast complications: infection, circulation impairment,
peripheral nerve damage, complications of immobility
 Managing Care of the Patient in a Cast

• Casting Materials
• Relieving Pain
• Improving Mobility
• Promoting Healing
• Neurovascular Function
• Potential Complications
 Cast, Splint, Braces, and Traction
Management Considerations

• Arm Casts
• Leg Casts
• Body or Spica Casts
• Splints and Braces
• External Fixator
• Traction
POLYESTER/FIBERGLASS
LOWER EXTREMITY CAST
 Musculoskeletal
Casts Care

• Neurovascular
• Check color/capillary refill
• Temperature
• Pulse
• Movement
• Sensation
 Cast Care

• Elevate Extremity
• Exercises – to unaffected side; isometric exercises to affected
extremity
• Keep heel off mattress
• Handle with palms of hands if cast wet
• Turn every two hours till dry
• Notify MD at once of wound drainage
• Do not place items under cast.
Managing the Patient Undergoing Orthopedic
Surgery

• Joint Replacement
• Total Hip Replacement
• Total Knee Replacement
 Risk for Infection

• Interventions include:
• Apply strict aseptic technique for dressing changes and
wound irrigations.
• Assess for local inflammation
• Report purulent drainage immediately to health care
provider.
• Assess for pneumonia and urinary tract infection.
• Administer broad-spectrum antibiotics prophylactically.
 Imbalanced Nutrition: Less Than
Body Requirements

• Interventions include:
• Diet high in protein, calories, and calcium, supplemental
vitamins B and C
• Frequent small feedings and supplements of high-
protein liquids
• Intake of foods high in iron
 Upper Extremity Fractures

• Fractures include those of the:

• Clavicle
• Scapula
• Humerus
• Olecranon
• Radius and ulna
• Wrist and hand
 Lower Extremity Fractures

• Fractures include those of the:

• Femur
• Patella
• Tibia and fibula
• Ankle and foot
 Fractures of the Hip

• Intracapsular or extracapsular
• Treatment of choice: surgical repair, when possible, to
allow the older client to get out of bed
• Open reduction with internal fixation
• Intramedullary rod, pins, a prosthesis, or a fixed sliding
plate
• Prosthetic device
 Fractures of the Pelvis

• Associated internal damage the chief concern in fracture

management of pelvic fractures
• Non–weight-bearing fracture of the pelvis
• Weight-bearing fracture of the pelvis
Compression Fractures of the Spine

• Most are associated with osteoporosis rather than acute

spinal injury.
• Multiple hairline fractures result when bone mass
diminishes.
• Nonsurgical management includes bedrest, analgesics, and
physical therapy.
• Minimally invasive surgeries are vertebroplasty and
kyphoplasty, in which bone cement is injected.
 Amputations

• Surgical amputation
• Traumatic amputation
• Levels of amputation
• Complications of amputations: hemorrhage, infection,
phantom limb pain, problems associated with immobility,
neuroma (a growth or tumour of nerve tissue), flexion
contracture
 Amputation

Management
• relieving pain
• minimizing altered sensory perception
• promoting wound healing
• enhancing body image
• self-care
 Phantom Limb Pain

• Phantom limb pain is a frequent complication of

amputation.
• Client complains of pain at the site of the removed body
part, most often shortly after surgery.
• Pain is intense burning feeling, crushing sensation or
cramping.
• Some clients feel that the removed body part is in a
distorted position.
 Management of Phantom Pain

Phantom limb pain must be distinguished from stump pain

because they are managed differently.
Recognize that this pain is real and interferes with the
amputee’s activities of daily living.
• Some studies have shown that opioids are not as effective
for phantom limb pain as they are for residual limb pain.
• Other drugs include intravenous infusion calcitonin, beta
blockers, anticonvulsants, and antispasmodics.
 Exercise After Amputation

• ROM to prevent flexion contractures, particularly of the hip

and knee
• Trapeze and overhead frame
• Firm mattress
• Prone position every 3 to 4 hours
• Elevation of lower-leg residual limb controversial
 Prostheses

• Devices to help shape and shrink the residual limb and help
client readapt
• Wrapping of elastic bandages
• Individual fitting of the prosthesis; special care
 Crush Syndrome
Can occur when leg or arm injury includes multiple
compartments
Characterized by acute compartment syndrome,
hypovolemia, hyperkalemia, rhabdomyolysis, and acute
tubular necrosis
Treatment: adequate intravenous fluids, low-dose
dopamine, sodium bicarbonate, and hemodialysis

End of lecture….