Musculoskeletal Disorders 2

Assessment of Musculoskeletal
Function
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Objectives
During this session we will:
1.Review the anatomy and physiology of the
musculoskeletal system;
2.Discuss the assessment of the musculoskeletal system;
3.Discuss treatment modalities for patients with
musculoskeletal disorders; and
4.Discuss common conditions/diseases of the
musculoskeletal system.
Figure 41-1 Bones of the human skeleton.
Functions of the Musculoskeletal System

Protection of vital organs
Mobility and movement
Facilitate return of blood to the heart
Production of blood cells (hematopoiesis)
Reservoir for immature blood cells
Reservoir for vital minerals
Structure
206 Bones in the body
Long bones
Short bones
Flat bones
Irregular bones
Joints
Muscles
Structure contd.
Axial skeleton supports and protects organs of head,
neck and trunk
Appendicular skeleton- bones of limbs and bones that

anchor them to the axial skeleton
Articulation- where joints are formed
Structure of a Long Bone; Composition of

Compact Bone
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 (Articulation): Junction of Two or

More Bones
Synartrosis
Amphiartrosis
Diarthrosis
Ball and socket
Hinge
Saddle
Pivot
Gliding
Joints
Immovable (synarthosis) bones sutured together
by connective tissue: skull
Slightly movable (amphiarthosis) connected by
fibrocartilage or hyaline cartilage:
vertebrae, rib/sternum joint, pubic
symphysis
Freely movable (diarthrosis)
Types of freely movable joints

Saddle: carpal and metacarpal bones of thumb
Ball and socket: shoulder and hip joints
Pivot- rotation only: proximal end of radius and ulna
Hinge- up and own movement in one plane:
knee and elbow
Gliding- sliding and twisting: wrist and ankle
Condyloid- movement in different planes but not
rotations: btw metacarpals and phalanges
Types of movement
flexion- move lower leg toward upper
extension- straightening the leg
abduction- moving leg away from body
adduction- movong leg toward the body
rotation- around its axis
supination- rotation of arm to palm-up position
pronation- palm down
circumduction- swinging arms in circles
inversion- turning foot so sole is inward
eversion- sole is out
Muscles
Attached to bones and other structures by tendons
Contraction of muscle causes movement
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
Skeletal muscle contracts with the release of
acetylcholine
The more fibers that contract, the stronger the muscle
contraction
Bone Cells
Osteoblasts
Function in bone formation
Osteocytes
Mature bone cells that function in bone maintenance
Osteoclasts
Multinuclear cells function in destroying, resorbing,
and remodeling bone
Bone Formation and Maintenance

Osteogenesis: process of bone formation
Ossification: the process of formation of the bone
matrix and deposition of minerals
Bone is in constant state of turnover
Regulating factors
Stress and weight-bearing
Vitamin D
Parathyroid hormone and calcitonin
Blood supply
Bone Healing
Hematoma and inflammation
Angiogenesis and cartilage formation
Cartilage calcification
Cartilage removal
Bone formation
Remodeling
Bone healing completed within about 6 weeks; up to 6
months in the older person
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
Assessment
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
Joint function
Muscle strength and size
Skin
neurovascular status
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
Normal Spine and 3 Abnormalities
Diagnostic Evaluation
X-rays
Computed tomography
MRI
Arthrography: use of radiopaque dye to detect tears
of joint capsule
Bone densitometry estimates bone mineral density
Bone scan
Diagnostics contd.
Arthroscopy visualizes joint to assess for disorders
Arthrocentesis: aspiration of synovial fluid
Electromyography: assesses electrical potential of
muscles
Biopsy
Laboratory studies
Diagnostic Test
Laboratory
Urine Tests
24 hour creatine-creatinine ratio (muscle
diseases)
Urine Uric acid 24 hr specimen (gout)
Urine deoxypyridino-line (assess bone
resorption)
Diagnostic Test
Laboratory
Blood Tests
Serum muscle enzymes (muscle damage)
Rheumatoid Factor
LE Prep/Antinuclear Antibodies(ANA) -(SLE)
Erythrocyte Sedimentation Rate (bone tumors,
infections)
Calcium, Phosphorous, Alkaline phosphatase
Musculoskeletal Care
Modalities
Cast
A rigid, external immobilizing device
Uses
Immobilize a reduced fracture
Correct a deformity
Apply uniform pressure to soft tissues
Support to stabilize a joint
Materialsnonplaster (fiberglass), plaster
Long-Arm and Short-Leg Cast and

Common Pressure Areas
Teaching Needs of the Patient with a Cast

Prior to cast application
Explanation of condition necessitating the cast
Purpose and goals of the cast
Expectations during the casting process- for example
heat from hardening plaster
Cast care: keep dry, do not cover with plastic
Positioning: elevation of extremity, use of slings
Hygiene
Activity and mobility
Teaching Needs of the Patient with a Cast

Do not scratch or stick anything under cast
Cushion rough edges
Signs and symptoms to report:
persistent pain or swelling, changes in sensation,
movement, skin color or temperature, signs of
infection or pressure areas
Required follow-up care
Cast removal
Splint and Braces

Contoured splints of plaster or pliable thermoplastic
materials may be used for conditions that do not require
rigid immobilization, for those in which swelling may be
anticipated, and for those that require special skin care.
Braces are used to provide support, control movement,
and prevent additional injury. They are custom fitted to
various parts of the body.
External Fixation Devices

Used to manage open fractures with soft tissue damage
Provide support for complicated or comminuted fractures
Patient requires reassurance due to appearance of device
Discomfort is usually minimal and early mobility may be
anticipated with these devices.
Elevate to reduce edema
Monitor for signs and symptoms of complications
including infection
Pin care
Patient teaching
Traction
The application of pulling force to a part of the body
Purposes:
Reduce muscle spasms
Reduce, align, and immobilize fractures
Reduce deformity
Increase space between opposing forces
Used as a short-term intervention until other modalities
are possible
All traction needs to be applied in two

directions. The lines of pull are vectors of
force. The result of the pulling force is
between the two lines of the vectors of
force.
Principles of Effective Traction

Whenever traction of applied a counterforce must be applied.
Frequently the patients body weight and positioning in bed
supply the counterforce.
Traction must be continuous to reduce and immobilize
fractures.
Skeletal traction is never interrupted.
Weights are not removed unless intermittent traction is
prescribed.
Any factor that reduces pull must be eliminated.
Ropes must be unobstructed and weights must hang freely.
Knots or the footplate must not touch the foot of the bed.
Types of Traction
Skin traction
Bucks extension traction
Cervical head halter
Pelvic traction
Skeletal traction
Preventive Nursing Care Needs of the

Patient in Traction
Proper application and maintenance of traction
Monitor for complications of skin breakdown, nerve
pressure, and circulatory impairment
Inspect skin at least three times a day
Palpate traction tapes to assess for tenderness
Assess sensation and movement
Assess pulses color capillary refill, and temperature of
fingers or toes
Assess for indicators of DVT
Assess for indicators of infection
Preventative Interventions
Promptly report any alteration in sensation or circulation
Frequent back care and skin care
Regular shifting of position
Special mattresses or other pressure reduction devices
Perform active foot exercises and leg exercises every hour
Elastic hose, pneumatic compression hose, or
anticoagulant therapy may be prescribed
Trapeze to help with movement for patients in skeletal
traction
Pin care
Exercises to maintain muscle tone and strength
Care of the Patient in Traction

Assessment
Assessment of neurovascular status and for complications
Assessment for mobility-related complications of
pneumonia, atelectasis, constipation, nutritional
problems, urinary stasis, or UTI
Pain and discomfort
Emotional and behavioral responses
Coping
Knowledge
Collaborative Problems/Potential
Complications
Pressure ulcer
Atelectasis
Pneumonia
Constipation
Anorexia
Urinary stasis and infection
DVT
Joint Replacements
Used to treat severe joint
pain and disability and for
repair and management of
joint fractures or joint
necrosis.
Frequently replaced joints
include the hip, knee, and
fingers.
Joints including the shoulder,
elbow, wrist, and ankle may
also be replaced.
Carpal Tunnel Syndrome

Common condition; the median nerve in the wrist
becomes compressed, causing pain and numbness
Common repetitive strain injury via occupational or
sports motions
Nonsurgical management: drug therapy and
immobilization
Possible surgical management
Osteoporosis
Affects approximately 40 million people over the age of
50 in the United States.
Normal homeostatic bone turnover is altered and the rate
of bone resorption is greater than the rate of bone
formation, resulting in loss of total bone mass.
Bone becomes porous, brittle, and fragile, and break
easily under stress
Frequently result in compression fractures of the spine,
fractures of the neck or intertrochanteric region of the
femur, and Colles fractures of the wrist
Risk factors.
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, longterm drug therapy, long-term immobility.
Regional osteoporosis occurs when a limb is
immobilized.
Typical Loss of Height Associated with

Osteoporosis and Aging
Prevention
Balanced diet high calcium and vitamin D throughout life
Use of calcium supplements to ensure adequate calcium
intaketake in divided doses with vitamin C
Regular weight-bearing exerciseswalking
Weight training stimulates bone mineral density (BMD)
Care of the Patient with Osteoporosis

Assessment
Occurrence of osteopenia and osteoporosis
Family history
Previous fractures
Dietary consumption of calcium
Exercise patterns
Onset of menopause
Use of corticosteroids as well as alcohol, smoking, and
caffeine intake
Interventions
Promoting understanding of osteoporosis and the
treatment regimen
Relieving pain
Improving bowel elimination
Preventing injury
Drug Therapy: Osteoporosis

Hormone replacement therapy
Parathyroid hormone
Calcium and vitamin D
Bisphosphonates
Selective estrogen receptor modulators
Calcitonin
Other agents used with varying results
Diet Therapy - Osteoporosis

Protein
Magnesium
Vitamin K
Trace minerals
Calcium and vitamin D
Avoid alcohol and caffeine
Fall Prevention - Osteoporosis

Hazard-free environment
High-risk assessment through programs such as Falling
Star protocol
Hip protectors that prevent hip fracture in case of a fall
Osteomalacia
A metabolic bone disease characterized by inadequate
bone mineralization
Softening and weakening of the long bones causes pain,
tenderness, and deformities caused by the bowing of
bones and pathologic fractures
Deficiency of activated vitamin D causes lack of bone
mineralization and low extracellular calcium and
phosphate
Causes include gastrointestinal disorders, severe renal
insufficiency, hyperparathyroidism, and dietary deficiency
Treatment of Osteomalacia
Correct underlying cause
Increased doses of vitamin D and calcium are usually
recommended
Handle patient gently; patient is at high risk for fractures
Address pain and discomfort
Osteomyelitis
Infection of the bone
Etiology:
Extension of soft tissue infection
Direct bone contamination
Blood-borne spread from another site of infection
This typically occur in an area of bone that has been
traumatized or has lowered resistance
Causative organisms
Staphylococcus aureus (7080%)
Other: Proteus and Pseudomonas species, E. coli, strep
Prevention of osteomyelitis is the goal.

Early detection and prompt treatment
of osteomyelitis is required to reduce
potential for chronic infection and
disability.
Osteomyelitis
Typical signs and symptoms : Acute osteomyelitis
include:
Fever that may be abrupt
Irritability or lethargy in young children
Pain in the area of the infection
Swelling, warmth and redness over the area of the
infection
Osteomylitis
Chronic osteomyelitis include:
Warmth, swelling and redness over the area of the
infection
Pain or tenderness in the affected area
Chronic fatigue
Drainage from an open wound near the area of the
infection
Fever, sometimes
Care of the Patient with Osteomyelitis

Planning
Major goals may include relief of pain, improved physical
mobility, within therapeutic limitations, control and
eradication of infection, and knowledge of therapeutic
regimen.
Interventions
Reliving pain
Immobilization
Elevation
Handle with great care and gentleness
Administer prescribed analgesics
Improving physical mobility
Activity is restricted
Gentle ROM to joints above and below the affected
part
Participation in ADLs within limitations
Interventions
Promote good nutrition: vitamin C and protein
Encourage adequate hydration
Administer and monitor antibiotic therapy
Patient and family teaching
Long-term antibiotic therapy and management of
home IV administration
Mobility limitations
Safety and prevention of injury
Follow-up care
Referral for home health care
Surgical Management
Osteomyelitis
Sequestrectomy (Surgical removal of a sequestrum),
a detached piece of necrotic bone that often

migrates to a wound, abscess, etc.
Bone grafts
Bone segment transfers
Amputation
Bone Tumors
Primary tumors
Benign tumors are more common and generally are
slow growing and present few symptoms
Malignant
Prognosis depends upon type and whether the
tumor has metastasized
Osteogenic sarcoma is the most common, and
most often fatal, primary malignant bone tumor
Metastatic bone tumors
More common than primary tumors
Malignant Bone Tumors

Primary tumors, those tumors that originate in the bone
Osteosarcoma
Ewings sarcoma
Chondrosarcoma
Fibrosarcoma
Metastatic bone disease
Treatment Cancer of Bone

Interventions include:
Treatment aimed at reducing the size or
removing the tumor
Drug therapy; chemotherapy
Radiation therapy
Surgical management
Promotion of physical mobility with ROM
exercises
Collaborative Problems/Potential
Complications
Delayed wound healing
Nutritional deficiency
Infection
Hypercalcemia
Care of the Patient with a Bone Tumor

Planning
Major goals include knowledge of disease process and
treatment regimen, control of pain, absence of pathologic
fractures, effective coping patterns, improved selfesteem, and absence of complications.
Interventions
Care is similar to that of other patients who have
undergone orthopedic surgery.
Patient and family teaching regarding diagnosis, disease
process, and treatment.
Prevention of pathologic fractures
Support affected extremities at all times and handle
gently
External supports or fixation devices may be required
Restrict weight-bearing and activity as prescribed
Use of assistive devices
Interventions
Promoting proper nutrition
Administer antiemetics as prescribed
Relaxation techniques
Oral care
Nutritional supplements
Provide adequate hydration
Use strict aseptic technique
Cancer of Bone
Anticipatory Grieving
Interventions include:
Active listening
Encouraging client and family to verbalize feelings
Making appropriate referrals
Helping client and others to cope with the loss and
grieving
Promoting the physician-client relationship
References
Bashayreh, I. Musculoskeletal System Assessment
& Disorders.

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Assessment of Musculoskeletal

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Figure 41-1 Bones of the human skeleton.

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Functions of the Musculoskeletal System

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Appendicular skeleton- bones of limbs and bones that

Articulation- where joints are formed

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Structure of a Long Bone; Composition of

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Joints (Articulation): Junction of Two or

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of freely movable joints

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bone Formation and Maintenance

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Changes in Older Adult

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Changes in Older Adult

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Changes in Older Adult

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Normal Spine and 3 Abnormalities

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Long-Arm and Short-Leg Cast and

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Teaching Needs of the Patient with a Cast

Teaching Needs of the Patient with a Cast

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Splint and Braces

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External Fixation Devices

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

All traction needs to be applied in two

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Principles of Effective Traction

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preventive Nursing Care Needs of the

Care of the Patient in Traction

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Carpal Tunnel Syndrome

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins