Review of Human Skeletal

Anatomy

Mark Anthony R. Rivera, MD RN CST

Lecturer, College of Nursing
Our Lady of Fatima University
 Assessment of the

Musculoskeletal System
The Body Axis
• The body is made up of the skull, vertebral
column, ribs, and coccyx (tailbone)
– Skull is made up of the cranium, which
protects the brain, and the face.
– Vertebral column is the backbone. It has
33 vertebrae
• Vertebrae are small, rigid bones that
stack together
– The ribs protect the heart and lungs. There
are 12 pairs.
Spine

• Starts with the cervical vertebrae (7

vertebrae), then the thoracic (12) and the
lumbar (5). It finishes off with the sacrum and
the coccyx.
• Each of the vertebrae are separated by an
intervertebral disk.
– These prevent the vertebrae from grinding
into each other.
• The thoracic vertebrae connect to the ribs.
Arm
• At the tips of your fingers are the phalanges.
– Long, slender, lightweight.
• Phalanges are connected to metacarpal bones.
– Metacarpals are framework of the palm.
• Metacarpals branch off from the carpal bones.
– 8 of them; pebble-ish
• The carpal bones are below the ulna and the radius.
– If your palm is face-up and your arm extended, your elbow
is your ulna.
• The ulna and the radius are connected to the humerus.
• The humerus in turn connects to the scapula.
– The scapula is held in place by muscles.
• The scapula is then connected to the clavicle, or collarbone.
Legs
• At the tips of your toes are the phalanges.
• These connect to the metatarsals….
• Which in turn connect to the tarsals.
– 7 tarsals, only 1 is heel.
• Connected to the tarsals are the tibia and fibula.
– Tibia is the shin bone.
• At the knee, the tibia and fibula are separated from the femur
by a large section of cartilage.
• On this cartilage rests the patella.
• The femur is then connected to the coxal bone, which is
connected to the sacrum
– Femur is the largest bone in the body.
Skeletal System
• Bone types
• Bone structure
• Bone function
• Bone growth and metabolism
affected by:
1. calcium and phosphorous,
2. calcitonin,
3. vitamin D,
4. parathyroid hormone,
5. growth hormone,
6. glucocorticoids,
7. estrogens and androgens,
8. thyroxine, and
9. insulin
Bones
• Support the body and anchor muscles.
• Ligaments link bones to other bones.
• Tendons link bones to muscle
• Two types of bones
– Compact Bone
– Spongy Bone
• Inside bones is a central shaft. This is the marrow
cavity where fat is stored.
• Bone matrixes contain the bone’s proteins and
minerals. These heal bone and maintain healthiness.
2 Major Types of Bone
Compact Spongy
• Has few and very small • Has many large
spaces inside. spaces. It contains red
marrow where red
• Made of osteons.
blood cells are made.
• Made of trabeculae.
Joints
• Types include
– synarthrodial,
– amphiarthrodial,
– diarthrodial
• Structure and function of the
diarthrodial or synovial joint
• Subtyped by anatomic structure:
– Ball-and-socket
– Hinge
– Condylar
– Biaxial
– Pivot
Joint types
• Ball and socket Arm
• Pivot Neck
• Saddle Thumb
• Ellipsoid Knuckles
• Hinge Knee
• Plane Ankle
MUSCULAR SYSTEM
 Muscular
System

Movements to

know!

• Structure
• Function
• Supporting structures
• Musculoskeletal changes associated with aging
• Cultural considerations
Know aging changes vs.
 List of major muscles

Common Name Scientific Name

Base of neck Trapezius
Upper arm Deltoid
Back of arm Triceps brachii
Inner arm Biceps brachii
Back Latissimus dorsi
Stomach Abdominal muscles
Butt Gluteus maximus
Front part of the upper leg Sartoris and Rectus femoris
Back part of the upper leg Biceps femoris
Muscles
• In humans with hard skeletons, muscles are
in antagonistic pairs
– e.g. shin and calf muscles
• The skeletal muscles are muscles that are
attached to bones. These move the skeleton.
• Made of muscle fibers, multi-nuclei cells.
– The plasma membranes enclose long
bundles called fibrils.
Muscles Cont.
• They work by shortening (contracting) and
lengthening (flexing)
– The energy is supplied my mitochondria in
the fibrils.
– Muscle contraction is called Sliding
Filament Mechanism, where filaments in
cells slide past each other.
• Cardiac muscle is electrically connected.
 Different Types

Smooth Skeletal Cardiac

• Found in hollow • Composed of • Central nuclei.
body organs like long fibers.
digestive tract
• Controls
and blood
vessels. voluntary
movement.
• Have 1 nucleus.
Muscle energy
• The Immediate Energy System is a quick blast of
muscle power. This uses fast-twitch fibers.
• The Glycotic Energy System splits glucose by
glycolysis in the muscles.
• The Oxidative Energy System (Aerobic Energy System)
is for prolonged muscle use, like marathons. This uses
slow-twitch fibers.
– Slow-twitch fibers are packed with mitochondria
and myoglobin.
• Fast oxidative-glycolytic muscle fibers are moderately
powerful and last for a moderate amount of time.
Assessments

• Family history and genetic risk

• Personal history

• Dietary history

• Socioeconomic status and ability to afford food

• Current health problems including obesity

Physical Assessment
• General inspection
• Posture
• Abnormality in gait such as antalgic gait or lurch
• Goniometer, which provides a measure of ROM
• Head and neck: evaluate the temporomandibular joints
• Spine: lordosis, scoliosis
• Upper extremities
• Lower extremities
)
Diagnostic Assessment
• Laboratory tests: serum calcium and
phosphorus, alkaline phosphatase, serum
muscle enzymes
• Radiographic examinations: standard
radiography, tomography and xeroradiography,
myelography, arthrography, and CT
• Other diagnostic tests: bone and muscle biopsy
Electromyography
• EMG aids in the diagnosis of neuromuscular, lower
motor neuron, and peripheral nerve disorders; usually
with nerve conduction studies.
• Low electrical currents are passed through flat
electrodes placed along the nerve.
• If needles are used, inspect needle sites for hematoma
formation.
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.
Other Tests
• Bone scan
• Gallium or thallium scan
• Magnetic resonance imaging
• Ultrasonography
 Interventions for Clients with

Musculoskeletal
Problems
Osteoporosis
• Metabolic disease, in which bone demineralization
results in decreased density and subsequent fractures
• Osteopenia (low bone mass), which occurs when there
is a disruption in the bone remodeling process
Classification of Osteoporosis
• Generalized osteoporosis occurs most
commonly in postmenopausal women and men
in their 60s and 70s.
• Secondary osteoporosis results from an
associated medical condition such as
hyperparathyroidism, long-term drug therapy,
long-term immobility.
• Regional osteoporosis occurs when a limb is
immobilized.
Health Promotion/Illness Prevention
• Ensure adequate calcium intake.
• Avoid sedentary life style.
• Continue program of weight-bearing exercises.
Unchangeable risk factors for osteoporosis include female

gender, older age, small or thin body size, Caucasian and Asian

ethnicity, and family history of fractures.

Modifiable risk factors include a diet low in calcium and vitamin

D, use of certain medications, an inactive lifestyle or extended

bed rest, cigarette smoking, and excessive alcohol

consumption.
Assessment
• Physical assessment
• Psychosocial assessment
• Laboratory assessment
• Radiographic assessment
Drug Therapy
• Hormone replacement therapy
• Parathyroid hormone
• Calcium and vitamin D
• Bisphosphonates
• Selective estrogen receptor modulators
• Calcitonin
• Other agents used with varying results
Diet Therapy
• Protein
• Magnesium
• Vitamin K
• Trace minerals
• Calcium and vitamin D
• Avoid alcohol and caffeine
Fall Prevention
• Hazard-free environment
• High-risk assessment through programs such as
Falling Star protocol
• Hip protectors that prevent hip fracture in case of
a fall
Fall
Contributors Medications

Poor Lighting
Uneven surfaces
Clutter
No Handrails
Outdoors Extension Cords Health
Bad lighting Unstable Handrails
Slick Surfaces Conditions
Scatter rugs
Pets
Indoors

Chronic Health Conditions

-HTN
Cardiac Arrhythmias
peripheral neuropathies

Flexibility and Strength

Others
• Exercise
• Pain management
• Orthotic devices
Exercises

• Lateral Raises with Therabands; tension is

increased by shortening the band to comfort level.
 Osteomyelitis
• Osteomyelitis is an acute or chronic inflammatory process
of the bone and its structures secondary to infection with
pyogenic organisms.
• Infection of bone with rich vascular supply from
bacteremia, UTI, long term IV caths, Salmonella from GI,
poor dental hygiene, MRSA
• Trauma admits bacteria such as Pseudomonas directly.
• Acute -> high temp, swelling, bone pain
• Chronic -> skin ulceration, sinus tract, local pain, drainage
• AB Tx IV, Infection control, > 3 months, surg debridement
or bone grafts, amputation.
Padget’s Disease
• Metabolic disorder of bone remodeling in which
bone deposits are weak, enlarged and
disorganized.
• 2nd most common bone disease in elderly.
• Cause unknown but may be latent viral
appearing > 80 yrs.
• 80% asymptomatic; affects bone in skull,
vertebrae, long bones, hip joint etc.
• Tx- symptomatic for pain- NSAIDS, calcitonin,
Fosamax.
Interventions for Clients with

Musculoskeletal
Trauma
Classification of Fractures
• A fracture is a break or disruption in the continuity
of a bone.
• Types of fractures include:
– Complete
– Incomplete
– Open or compound
– Closed or simple
– Pathologic (spontaneous)
– Fatigue or stress
– Compression
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
 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
• 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
• Myoglobinuric renal failure, known as
rhabdomyolysis
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 Assessment
• Change in bone alignment
• Alteration in length of extremity
• Change in shape of bone
• Pain upon movement
• Decreased ROM
• Crepitation
• Ecchymotic 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.
Risk for Peripheral Neurovascular
Dysfunction
• Interventions include:
– Emergency care: assess for respiratory
distress, bleeding and head injury
– Nonsurgical management: closed reduction
and immobilization with a bandage, splint,
cast, or traction
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
• Cast care and client education
• Cast complications: infection, circulation impairment,
peripheral nerve damage, complications of immobility
 Traction

• Application of a pulling force to the body to provide reduction,

alignment, and rest at that site
• Types of traction: skin, skeletal, plaster, brace,
circumferential
• Traction care:
– Maintain correct balance between traction pull and
countertraction force
– Care of weights
– Skin inspection
– Pin care
– Assessment of neurovascular status
 Operative Procedures

• Open reduction with internal

fixation (ORIF)

• External fixation

• Postoperative care: similar to that

for any surgery; certain
complications specific to fractures
and musculoskeletal surgery
include fat embolism and venous
thromboembolism
Procedures for Nonunion
• Electrical bone stimulation
• Bone grafting
• Bone banking
 Acute Pain
• Interventions include:
– Reduction and immobilization of fracture
– Assessment of pain
– Drug therapy: opioid and nonopioid drugs
– Complementary and alternative therapies: ice,
heat, elevation of body part, massage, baths,
back rub, therapeutic touch, distraction, imagery,
music therapy, relaxation techniques
 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.
Impaired Physical Mobility
• Interventions include:
– Use of crutches to promote mobility
– Use of walkers and canes to promote mobility
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
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
Normal
N ---------------------------------Fracture-------------------------- ORIF
Lower Extremity Fractures
• Fractures include those of the:
– Femur
– Patella
– Tibia and fibula
– Ankle and foot
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, flexion contracture
 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
– Wrap residual limb in a
figure eight pattern, not
a circular one. Wrapping
in a circular pattern will
cut off the blood flow
and cause harm.

– The goal of wrapping is

to form a cone-shaped
residual limb. To do this,
apply more pressure to
the bottom end of the
residual limb, and less
pressure to the top
portion.
• 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,
kayexalate, and hemodialysis
Complex Regional Pain Syndrome
• A poorly understood complex disorder that
includes debilitating pain, atrophy, autonomic
dysfunction, and motor impairment
• Collaborative management: pain relief,
maintaining ROM, endoscopic thoracic
sympathectomy, and psychotherapy.
Knee Injuries, Meniscus
• McMurray test
• Meniscectomy
• Postoperative care
• Leg exercises begun
immediately
• Knee immobilizer
• Elevation of the leg on
one or two pillows; ice.
Knee Injuries, Ligaments
• When the anterior cruciate ligament is torn, a
snap is felt, the knee gives way, swelling occurs,
stiffness and pain follow.
• Treatment can be nonsurgical or surgical.
• Complete healing of knee ligaments after
surgery can take 6 to 9 months.
Tendon Ruptures
• Rupture of the Achilles tendon is common in
adults who participate in strenuous sports.
• For severe damage, surgical repair is followed
by leg immobilized in a cast for 6 to 8 weeks.
• Tendon transplant may be needed.
Dislocations and Subluxations
• Pain, immobility, alteration in contour of joint,
deviation in length of the extremity, rotation of
the extremity
• Closed manipulation of the joint performed to
force it back into its original position
• Joint immobilized until healing occurs
Strains
• Excessive stretching of a muscle or tendon
when it is weak or unstable
• Classified according to severity: first-, second-,
and third-degree strain
• Management: cold and heat applications,
exercise and activity limitations, anti-
inflammatory drugs, muscle relaxants, and
possible surgery
Sprains
• Excessive stretching of a ligament
• 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
Rotator Cuff Injuries
• Shoulder pain; cannot initiate or maintain
abduction of the arm at the shoulder
• Drop arm test
• Conservative treatment: nonsteroidal anti-
inflammatory drugs, physical therapy, sling
support, ice or heat applications during healing
• Surgical repair for a complete tear
 Interventions for Clients with
Connective Tissue Disease and
Other Types of Arthritis
Rheumatology
• Connective tissue disease (CTD) is a major
focus of rheumatology.
• Rheumatic disease is any disease or condition
involving the musculoskeletal system.
• Arthritis means inflammation of one or more
joints.

(Continued)
Rheumatology (Continued)
• Non-inflammatory arthritis is not systemic.
• Inflammatory arthritis
– Rheumatoid arthritis
– Systemic lupus erythematosus
Osteoarthritis
• Most common type of
arthritis
• Joint pain and loss of
function characterized by
progressive deterioration
and loss of cartilage in
the joints
• Osteophytes
• Synovitis
• Subluxation
Collaborative Management of OA
• History
• Physical assessment and clinical manifestations
– Joint involvement
– Heberden's nodes
– Bouchard’s nodes
– Joint effusions
– Atrophy of skeletal muscle
Assessments of OA
• Psychosocial
• Laboratory assessment of erythrocyte
sedimentation rate and C-reactive protein (may
be slightly elevated)
• Radiographic assessment
• Other diagnostic assessments
– MR imaging
– CT studies
Chronic Pain in OA
Interventions:
• Pain control may be accomplished at home with
drug and nonpharmacologic measures.
• Surgery may be performed to reduce pain.
• Comprehensive pain assessment should be
performed before and after implementing
interventions.
• Rest, positioning, thermal modalities, weight
control, TENS, complementary and alternative
therapies, stem cell therapy
• Surgical management
Total Hip Arthroplasty
• Preoperative care
• Operative procedures
• Postoperative care
– Prevention of
dislocation, infection,
and thromboembolic
complications
– Assessment of
bleeding
– Management of
anemia
Care of Total Hip Arthroplasty
• Assessment for
neurovascular
compromise
• Management of pain
• Progression of activity
• Promotion of self-care
Impaired Physical Mobility
Interventions:
• Goal: to achieve independent function
• Therapeutic exercise
• Promotion of activities of daily living and
ambulation
• Teaching about health and how to use assistive
devices
 Connective Tissue
or Rheumatic Diseases
Inflammation of synovial joints due to an immune response with
degeneration as a secondary process. Blood vessels, heart, skin
and kidneys may also be affected.
• Rheumatoid Arthritis (RA) – joint deformity

• Lupus Erythematosis (SLE) - skin, heart, kidneys

• Scleroderma - skin

• Sjogren’s Syndrome - dry mouth, dry eye -> systemic

• Raynaud’s Disease- blood vessels

Lab Studies
• Creatinine 
• ESR – inflammation
RBC - RA and SLE
 WBC – SLE
Antinuclear Antibody (ANA) – all
• Rheumatoid Factor - > 80%
Rheumatoid Arthritis
• A most common connective tissue disease and
the most destructive to the joints
• Chronic, progressive, systemic inflammatory
autoimmune disease primarily affecting the
synovial joints
• Autoantibodies (rheumatoid factors) formed that
attack healthy tissue
• Affects synovial tissue of any organ or body
system
 Rheumatoid Arthritis
Education
Rest Exercise
Support
Progressive meds
Surgical
reconstruction
Depression
Sleep deprivation
Nutrition
Pacing
Collaborative Management for RA
• Assessment
• Physical assessment and clinical manifestations
– Early disease manifestations
– Late disease manifestations
– Joint involvement
– Systemic complications
– Associated syndromes
Assessments for RA
• Psychosocial assessment
• Laboratory assessment: rheumatoid factor,
antinuclear antibody titer, erythrocyte
sedimentation rate, serum complement, serum
protein electrophoresis, serum immunoglobulins
• Other diagnostic assessments
Drug Therapy for RA
Mild disease
• Nonsteroidal anti-inflammatory drugs (NSAIDs), for
instance, celecoxib, rofecoxib, valdecoxib with cox-2
inhibiting properties
• Disease modifying antirheumatic drugs (DMARDs), such
as hydroxychloroquine, sulfasalazine, and minocycline
Moderate to severe disease
• Methotrexate
• Leflunomide
• Biological response modifiers such as etanercept,
infiximab, adalimumab, anakinra
 • Immunosuppressive
– Methotrexate –gold
RA Medications standard for RA, used
also in SLE
• ASA – Imuran
• NSAIDS – Cytoxan
• Antimalarials - visual – Cyclosporin
changes – Arava
– Plaquenil – Enbrel
– Aralen – Remicade
• Gold – administer with • Corticosteroids
NSAIDS. Stomatitis, – Prednisone
diarrhea, proteinuria… may
be a problem – Prednisolone
• Sulfasalazine – Hydrocortisone
• Penicillamine • Topical
– Capsaicin
Nonpharmacologic Modalities in the
Treatment of RA
• Plasmapheresis
• Complementary and alternative therapies
• Promotion of self-care
• Management of fatigue
• Enhancement of body image
• Health teaching
Lupus Erythematosus
• Chronic, progressive, inflammatory connective
tissue disorder can cause major body organs
and systems to fail.
• Many clients with SLE have some degree of
kidney involvement.
 Lupus Erythematosis
• Shows up in childbearing
years
• Medication related
• Any body system
• Rash, lesions
• Exacerbations
• Pericarditis
• Renal > HTN
• CNS
• Fever, fatigue, weight
loss, arthritis, hematuria
Assessments for Lupus
• Psychosocial results can be devastating.
• Laboratory
– Skin biopsy (only significant test to confirm
diagnosis)
– Anti-Ro (SSA) test
– Complete blood count
– Body system functions
Collaborative Management of SLE
• Physical assessment and clinical manifestations
– Skin involvement
– Musculoskeletal changes
– Systemic manifestations including pleural
effusions or pneumonia and Raynaud’s
phenomenon