Musculoskeletal System

Learning objectives
• A brief description of the structure and function of
the musculoskeletal system
• An overview of musculoskeletal evaluation,
including physical examination and diagnostic tests
• A description of fractures, including etiology,
medical-surgical management, clinical findings, and
physical therapy intervention
• A description of joint arthroplasty and common
surgeries of the spine, including surgical
management and physical therapy intervention
 Learning objectives
• An overview of common soft tissue injuries,
including surgical management and physical
therapy intervention
• A brief overview of equipment commonly
used in the acute care setting, including
casts, braces, external fixators, and traction
devices
 Structure and Function of the
Musculoskeletal System
• The musculoskeletal system is made up of the
following
• Boney skeleton
• Contractile and non-contractile soft tissues,
including muscles, tendons, ligaments, joint
capsules, articular cartilage, and non-articular
cartilage.
 Structure and Function of the
Musculoskeletal System
1. It provides dynamic ability of movement,
giving individuals the agility to move through
space, absorb shock, convert reactive forces,
generate kinetic energy, and perform fine
motor tasks.
2. The musculoskeletal system also provides
housing and protection for vital organs and
the central nervous system.
 Musculoskeletal Examination
• Patient History
• Pain
• Observation
• Posture
• Limb Position
• Skin Integrity
• Palpation
 Musculoskeletal Examination
• Upper- and Lower-Quarter Screens
• Functional Mobility and Safety
• Diagnostic Tests
• Management
 Patient History

• Cause and mechanism of injury at present

• Previous musculoskeletal, rheumatologic, or
neurologic disease, injury, or surgery
• Functional level before admission
• Previous use of assistive device(s)
• Recreation or exercise level and frequency
• Need for adaptive equipment or foorwear on
a regular basis (e.g., a shoe lift)
 Patient History
• History of falls
• History of chronic pain
• Physician-dictated precautions or
contraindications to treatment, such as
weight-bearing Status or activity level, or for
the positioning of extremities
• The need for a splint, brace, or other
equipmenr at rest or with activity
 Patient History
• Most recent lab values (e.g., hematocrit)
• Type and last dose of pain medication
• Whether the patient has been out of bed since
admission to the hospital
 Observation

1. General appearance
2. Level of alertness, anxiety, or stress
3. Willingness to move or muscle guarding
4. Presence of external orthopedic devices
5. Muscle substitutions on active movement
 Posture

• Observe the patient's resting posture in

supine, sitting, and standing positions. This
includes inspection of the head, trunk, and
extremities for alignment, symmetry,
deformity, or atrophy.
 Limb Position

• Observe the resting limb position of the

involved extremiry. Compare to both normal
anatomic position and to the contralateral
side. Note if the limb is in position naturally or
if it is supported with a pillow, roll, or wedge
 Skin Integrity
• The patient‘s skin integrity should be inspected in general for the
1. Edema
2. Discoloration
3. Bruising,
4. Scars.
• If there is traumatic injury, carefully inspect the skin at the level
of and distal to the injury.
• Note any lacerations or abrasions. If the patient has recently
had surgery, observe the location, direction, and quality of
incisions.
• Note any pressure sores or potential for such..
 Palpation

• Palpate skin temperature to touch, capillary

refill, and peripheral pulses at the level of or
distal to injury or the surgical site.
 Upper- and Lower-Quarter Screens

• Dermatome
• Myotome
• Reflexes
 Functional Mobility and Safety
• Functional mobility including
1. Bed mobility
2. Transfers
3. Ambulation on level surfaces and stairs, should be evaluated
according to activity level
4. Medical-surgical stability, and prior functional level.
• Safety is a key component of function.
• Observe for the patients ability to maintain weight bearing
or comply with equipment use.
• Monitor the patient‘s self-awareness of risk for falls, speed of
movement, onset of fatigue, and body mechanics.
 Diagnostic Tests
• Radiography
• Computed Tomography
• Magnetic Resonance Imaging
• Bone Scan
• Arthrography
• Myelography
 Bone scan
• Used to detect skeletal
metastases, especially
in the base of the skull,
sternum, scapula, and
anterior ribs.
 Bone scan
• Other uses of bone scan include the diagnosis
of stress fractures and other nondisplaced
fractures, early osteomyelitis, inflammatory or
degenerative arthritis, avascular necrosis
(AVN), and myositis ossificans.
Bone scan
 Arthrography

• An arthrogram is a radiograph of a joint with air or

dye contrast
• Performed primarily on the knee, shoulder, and
hip, arthrography allows examination for internal
joint derangements or soft tissue disruption.
• Arrhrograms may diagnose meniscal and cruciate
ligament tears or articular cartilage abnormalities of
the knee, adhesive capsulitis or rotator cuff tears of
the shoulder, and arthritis or intra-articular
neoplasm of the hip.
Arthrography
 Myelography

• A myelogram is a radiograph or CT of the

spinal cord, nerve root, and dura mater with
dye contrast.
• A myelogram can demonstrate spinal stenosis,
cord compression, intervertebral disc rupture,
or nerve root injury.
Myelography
 Types of Fracture
• The maintenance of skin integrity:
1. A closed fracture
2. An open fracture
 Types of Fracture
The site of the fracture:
1. At the proximal third, distal third, or at the shaft
of long bones.
2. An intra-articular fracture involves the articular
surface. Intra-articular fractures are further
described as linear, comminuted, impacted, or
with bone loss. An extra-articular fracture does
not involve the articular surface.
3. An epiphyseal fracture involves the growth plate.
Clinical Goals of Fracture Management
• The goal of fracture management is bony union of
the fracture without further bone or soft tissue
damage that enables early restoration of maximal
function.
• Early restoration of function minimizes
cardiopulmonary compromise, muscle atrophy,
and the loss of functional ROM.
• It also minimizes impairments associated with
limited skeletal weight bearing (e.g., osteoporosis).
 Complications of Fracture
1. Loss of fixation or reduction
2. Deep vein thrombosis, pulmonary or fat emboli
3. Nerve damage, such as paresthesia or paralysis
4. Arterial damage, such as blood vessel laceration
5. Compartment syndrome
6. Incision infection
7. Shock
 Complications of Fracture
• Delayed and late complications includes
1. Loss of fixation or reduction
2. Delayed union (fracture fails ro unite in a normal time frame in
the presence of unfavorable healing factors)
3. Non-union(failure of fracture to unite)
4. Mal-union (fracture healed with an angular or rotary deformity)
5. Pseudarthrosis (formation of a false joint at the fracture site)
6. Post-traumatic arthritis
7. Osteomyelitis
8. Myositis ossificans (heterotropic bone in muscle)
9. AVN
 Fracture Management
• Fracture Management According to Body
Region
• Upper Extremity
• Pelvis and Lower Extremity
• Spine
 Joint Arthroplasty
• Hip Arthroplasty
• Physical Therapy Intervention after Hip
Arthroplasty
• Knee Arthroplasty
• Physical Therapy Intervention after Knee
Arthroplasty
• Total Ankle Arthroplasty
• Shoulder Arthroplasty
• Total Elbow Arthroplasty
 Total joint Arthroplasty resection and
Resection
• With in the early postoperative period, an infection in
soft tissue with well-fixed implants can be treated with
an irrigation and debridement procedure, exchange of
polyethylene components, and antibiotic treatment.
• With an infection penetrating the joint space to the
cement-bone interface, it is necessary to perform a
total joint arthroplasty resection, consisting of the
removal of prosthetic components, cement, and foreign
material with debridement of surrounding tissue.
Physical Therapy Intervention after
Resection Arthroplasty
 Surgeries of the Spine
• Discectomy or microdiscectomy
• Laminectomy
• Foraminotomy
• Corpectomy
• Spinal fusion
Physical Therapy intervention after Spinal
Surgery
 Soft Tissue Surgeries
• Common soft tissue surgeries include
1. Tendon transfers
2. Muscle repairs
3. Fasciotomies
 Arthroscopy
• Shoulder arthroscopy
• Experimental soft tissue surgeries
• Knee arthroscopy
 Equipment for fracture and soft tissue
injury management
• Casts
• Braces and splints
• External fixators
• Traction