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Assessment of Musculoskeletal

Function

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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.

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Figure 41-1 Bones of the human skeleton.

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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

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Structure
206 Bones in the body
Long bones
Short bones
Flat bones
Irregular bones
Joints
Muscles

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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

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Structure of a Long Bone; Composition of


Compact Bone

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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

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Joints (Articulation): Junction of Two or


More Bones
Synartrosis
Amphiartrosis
Diarthrosis
Ball and socket
Hinge
Saddle
Pivot
Gliding
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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)

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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
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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
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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
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Skeletal Muscle
Skeletal muscle contracts with the release of
acetylcholine
The more fibers that contract, the stronger the muscle
contraction

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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

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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
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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

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Changes in Older Adult


Musculoskeletal changes can be due to:
Aging process
Decreased activity
Lifestyle factors

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Changes in Older Adult


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

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Changes in Older Adult


Cause stooped posture, changing center of gravity
Elderly at greater risk for falls
Endocrine changes cause skeletal muscle atrophy
Muscle tone decreases

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Assessment
Health history
Chief complaint
Onset of problem
Effect on ADLs
Precipitating events, e.g., trauma

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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

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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

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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

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Physical Examination
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

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Normal Spine and 3 Abnormalities

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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

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Diagnostics contd.
Arthroscopy visualizes joint to assess for disorders
Arthrocentesis: aspiration of synovial fluid
Electromyography: assesses electrical potential of
muscles
Biopsy
Laboratory studies

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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)

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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

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Musculoskeletal Care
Modalities

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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

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Long-Arm and Short-Leg Cast and


Common Pressure Areas

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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
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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

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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.

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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
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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

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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.

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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.

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Types of Traction
Skin traction
Bucks extension traction
Cervical head halter
Pelvic traction
Skeletal traction

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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
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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
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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

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Collaborative Problems/Potential
Complications
Pressure ulcer
Atelectasis
Pneumonia
Constipation
Anorexia
Urinary stasis and infection
DVT

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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.

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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

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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.

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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.

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Typical Loss of Height Associated with


Osteoporosis and Aging

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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)

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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
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Interventions
Promoting understanding of osteoporosis and the
treatment regimen
Relieving pain
Improving bowel elimination
Preventing injury

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Drug Therapy: Osteoporosis


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

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Diet Therapy - Osteoporosis


Protein
Magnesium
Vitamin K
Trace minerals
Calcium and vitamin D
Avoid alcohol and caffeine

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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

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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
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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

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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
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Prevention of osteomyelitis is the goal.


Early detection and prompt treatment
of osteomyelitis is required to reduce
potential for chronic infection and
disability.

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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

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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

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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.

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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
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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
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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

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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
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Malignant Bone Tumors


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

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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

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Collaborative Problems/Potential
Complications
Delayed wound healing
Nutritional deficiency
Infection
Hypercalcemia

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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.

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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
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Interventions
Promoting proper nutrition
Administer antiemetics as prescribed
Relaxation techniques
Oral care
Nutritional supplements
Provide adequate hydration
Use strict aseptic technique

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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

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References
Bashayreh, I. Musculoskeletal System Assessment
& Disorders.

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