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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 themusculoskeletal system;
2.Discuss the assessment of the musculoskeletal system;
3.Discuss treatment modalities for patients with
musculoskeletal disorders; and.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
"rotection of vital organs
#o$ility and movement %acilitate return of $lood to the heart
"roduction of $lood cells &hematopoiesis'
Reservoir for immature $lood cells
Reservoir for vital minerals
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Structure
2() *ones in the $ody
+ ,ong $ones+ -hort $ones
+ %lat $ones
+ rregular $ones
/oints
#uscles
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Structure contd.
0ial skeleton supports and protects organs of headneck and trunk
0ppendicular skeleton $ones of lim$s and $ones thatanchor them to the aial skeleton
0rticulation where 4oints are formed
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Structure of a Long Bone; om!osition ofom!act Bone
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Bone Marrow
Red $one marrow
+ %ound in flat $ones of sternum ri$s and ileum+ "roduces $lood cells and hemoglo$in
5ellow $one marrow
+ %ound in shaft of long $ones
+ 6ontains fat and connective tissue
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"oints #Articulation$% "unction of &'o orMore Bones
-ynartrosis
0mphiartrosis Diarthrosis
+ *all and socket
+ 7inge
+ -addle
+ "ivot
+ 8liding
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Joints
mmo!a"le #synarthosis$ "ones suture% together"y connecti!e tissue skull
'lightly mo!a"le #amphiarthosis$ connecte% "y
(i"rocartilage or hyaline cartilage!erte"rae) ri"*sternum +oint) pu"ic
symphysis
,reely mo!a"le #%iarthrosis$
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-ypes o( (reely mo!a"le +oints
'a%%le carpal an% metacarpal "ones o( thum"
.all an% socket shoul%er an% hip +oints
/i!ot rotation only proimal en% o( ra%ius an% ulna
Hinge up an% own mo!ement in one plane
knee an% el"ow
li%ing sli%ing an% twisting wrist an% ankle
Con%yloi% mo!ement in %i((erent planes "ut not
rotations "tw metacarpals an% phalanges
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-ypes o( mo!ement
(leion mo!e lower leg towar% upper
etension straightening the leg
a"%uction mo!ing leg away (rom "o%y
a%%uction mo!ong leg towar% the "o%y
rotation aroun% its ais
supination rotation o( arm to palmup position
pronation palm %own
circum%uction swinging arms in circles
in!ersion turning (oot so sole is inwar%
e!ersion sole is out
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Muscles
0ttached to $ones and other structures $y tendons
6ontraction of muscle causes movement
-keletal &voluntary'
+ 0llows voluntary movement
-mooth &involuntary'
+ #uscle movement controlled $y internal mechanism
+ e.g. muscles in $ladder wall and 8 system
6ardiac&involuntary'
+ %ound in heart
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Skeletal Muscle
-keletal muscle contracts with the release ofacetylcholine
9he more fi$ers that contract the stronger the musclecontraction
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Bone ells
steo$lasts
+ %unction in $one formation
steocytes
+ #ature $one cells that function in $one maintenance
steoclasts
+ #ultinuclear cells function in destroying resor$ingand remodeling $one
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Bone Formation and Maintenance steogenesis: process of $one formation
+ ssification: the process of formation of the $onematri and deposition of minerals
*one is in constant state of turnover
Regulating factors
+ -tress and weight$earing
+ itamin D
+ "arathyroid hormone and calcitonin
+ *lood supply
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Bone (ealing
7ematoma and inflammation
0ngiogenesis and cartilage formation
6artilage calcification
6artilage removal
*one formation
Remodeling
*one healing completed within a$out ) weeks; up to )months in the older person
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Changes in Older Adult
#usculoskeletal changes can $e due to:
+ 0ging process
+ Decreased activity
+ ,ifestyle factors
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Changes in Older Adult
,oss of $one mass in older women
/oint and disk cartilage dehydrates causing loss offlei$ility contri$utes to degenerative 4oint disease&osteoarthritis'; 4oints stiffen lose range of motion
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Changes in Older Adult
6ause stooped posture changing center of gravity
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Assessment
7ealth history
6hief complaint
nset of pro$lem
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Assessment
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Phsical !"amination
"osture
8ait
0$ility to walk with or without assistive devices
0$ility to feed toilet and dress self
#uscle mass and symmetry
/oint function
#uscle strength and si>e -kin
neurovascular status
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Phsical !"amination
nspect and palpate $one 4oints for visi$le deformitiestenderness or pain swelling warmth and R#
0ssess and compare corresponding 4oints
"alpate 4oints knees and shoulder for crepitus
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Phsical !"amination
?ever attempt to move a 4oint past normal R# or pastpoint where patient eperiences pain
*ulge sign and $allottement sign used to assess for fluidin the knee 4oint
9homas test performed when hip fleion contracturesuspected
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)ormal S!ine and * Abnormalities
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+iagnostic ,valuation
@rays
6omputed tomography
#R 0rthrography: use of radiopa=ue dye to detect tears
of 4oint capsule
*one densitometry+ estimates $one mineral density
*one scan
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+iagnostics contd.
0rthroscopy + visuali>es 4oint to assess for disorders
0rthrocentesis: aspiration of synovial fluid
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+iagnostic &est
,a$oratory
+ Arine 9ests 2 hour creatinecreatinine ratio &muscle
diseases'
Arine Aric acid +2 hr specimen &gout'
Arine deoypyridinoline &assess $oneresorption'
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+iagnostic &est
,a$oratory
+ *lood 9ests -erum muscle en>ymes &muscle damage'
Rheumatoid %actor
,< "rep!0ntinuclear 0nti$odies&0?0' &-,
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Musculoskeletal are
Modalities
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ast
0 rigid eternal immo$ili>ing device
Ases
+ mmo$ili>e a reduced fracture
+ 6orrect a deformity
+ 0pply uniform pressure to soft tissues
+ -upport to sta$ili>e a 4oint
#aterialsBnonplaster &fi$erglass' plaster
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Long-Arm and Short-Leg ast andommon ressure Areas
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&eaching )eeds of the atient 'ith a ast "rior to cast application
+
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&eaching )eeds of the atient 'ith a ast
Do not scratch or stick anything under cast
6ushion rough edges
-igns and symptoms to report:+ persistent pain or swelling changes in sensation
movement skin color or temperature signs ofinfection or pressure areas
Re=uired followup care 6ast removal
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S!lint and Braces 6ontoured splints of plaster or plia$le thermoplastic
materials may $e used for conditions that do not re=uirerigid immo$ili>ation for those in which swelling may $e
anticipated and for those that re=uire special skin care. *races are used to provide support control movement
and prevent additional in4ury. 9hey are custom fitted tovarious parts of the $ody.
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,/ternal Fi/ation +evices Ased to manage open fractures with soft tissue damage
"rovide support for complicated or comminuted fractures
"atient re=uires reassurance due to appearance of device
Discomfort is usually minimal and early mo$ility may $eanticipated with these devices.
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&raction
9he application of pulling force to a part of the $ody
"urposes:
+ Reduce muscle spasms
+ Reduce align and immo$ili>e fractures
+ Reduce deformity
+ ncrease space $etween opposing forces
Ased as a shortterm intervention until other modalitiesare possi$le
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All traction needs to be a!!lied in t'o
directions. &he lines of !ull are 0vectors offorce.1 &he result of the !ulling force isbet'een the t'o lines of the vectors offorce.
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rinci!les of ,ffective &raction
Chenever traction of applied a counterforce must $e applied.%re=uently the patients $ody weight and positioning in $edsupply the counterforce.
9raction must $e continuous to reduce and immo$ili>e
fractures. -keletal traction is never interrupted.
Ceights are not removed unless intermittent traction isprescri$ed.
0ny factor that reduces pull must $e eliminated.
Ropes must $e uno$structed and weights must hang freely.
Enots or the footplate must not touch the foot of the $ed.
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&y!es of &raction
-kin traction
+ *ucks etension traction
+ 6ervical head halter
+ "elvic traction
-keletal traction
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reventive )ursing are )eeds of theatient in &raction
"roper application and maintenance of traction
#onitor for complications of skin $reakdown nerve
pressure and circulatory impairment
+ nspect skin at least three times a day
+ "alpate traction tapes to assess for tenderness
+ 0ssess sensation and movement
+ 0ssess pulses color capillary refill and temperature offingers or toes
+ 0ssess for indicators of D9
+ 0ssess for indicators of infection
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reventative 2nterventions
"romptly report any alteration in sensation or circulation
%re=uent $ack care and skin care
Regular shifting of position
-pecial mattresses or other pressure reduction devices
"erform active foot eercises and leg eercises every hour
e to help with movement for patients in skeletaltraction
"in care
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are of the atient in &raction3Assessment
0ssessment of neurovascular status and for complications
0ssessment for mo$ilityrelated complications of
pneumonia atelectasis constipation nutritionalpro$lems urinary stasis or A9
"ain and discomfort
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ollaborative roblems4otentialom!lications
"ressure ulcer
0telectasis
"neumonia
6onstipation
0noreia
Arinary stasis and infection
D9
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"oint 5e!lacements
Ased to treat severe 4ointpain and disa$ility and forrepair and management of4oint fractures or 4ointnecrosis.
%re=uently replaced 4ointsinclude the hip knee andfingers.
/oints including the shoulderel$ow wrist and ankle mayalso $e replaced.
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ar!al &unnel Syndrome 6ommon condition; the median nerve in the wrist
$ecomes compressed causing pain and num$ness
6ommon repetitive strain in4ury via occupational orsports motions
?onsurgical management: drug therapy andimmo$ili>ation
"ossi$le surgical management
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Osteo!orosis
0ffects approimately ( million people over the age ofF( in the Anited -tates.
?ormal homeostatic $one turnover is altered and the rateof $one resorption is greater than the rate of $one
formation resulting in loss of total $one mass.
*one $ecomes porous $rittle and fragile and $reakeasily under stress
%re=uently result in compression fractures of the spine
fractures of the neck or intertrochanteric region of thefemur and 6olles fractures of the wrist
Risk factors.
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lassification of Osteo!orosis 8enerali>ed osteoporosis occurs most commonly in
postmenopausal women and men in their )(s andG(s.
-econdary osteoporosis results from an associatedmedical condition such as hyperparathyroidism longterm drug therapy longterm immo$ility.
Regional osteoporosis occurs when a lim$ isimmo$ili>ed.
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&y!ical Loss of (eight Associated 'ithOsteo!orosis and Aging
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revention *alanced diet high calcium and vitamin D throughout life
Ase of calcium supplements to ensure ade=uate calciumintakeBtake in divided doses with vitamin 6
Regular weight$earing eercisesBwalking
Ceight training stimulates $one mineral density &*#D'
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are of the atient 'ith Osteo!orosis3Assessment
ccurrence of osteopenia and osteoporosis
%amily history
"revious fractures
Dietary consumption of calcium
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2nterventions
"romoting understanding of osteoporosis and thetreatment regimen
Relieving pain
mproving $owel elimination
"reventing in4ury
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Drug 9herapy: steoporosis 7ormone replacement therapy
"arathyroid hormone
6alcium and vitamin D
*isphosphonates
-elective estrogen receptor modulators
6alcitonin ther agents used with varying results
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Diet 9herapy steoporosis "rotein
#agnesium
itamin E
9race minerals
6alcium and vitamin D
0void alcohol and caffeine
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%all "revention steoporosis 7a>ardfree environment
7ighrisk assessment through programs such as %alling-tar protocol
7ip protectors that prevent hip fracture in case of a fall
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Osteomalacia
0 meta$olic $one disease characteri>ed $y inade=uate$one minerali>ation
-oftening and weakening of the long $ones causes paintenderness and deformities caused $y the $owing of$ones and pathologic fractures
Deficiency of activated vitamin D causes lack of $one
minerali>ation and low etracellular calcium andphosphate
6auses include gastrointestinal disorders severe renalinsufficiency hyperparathyroidism and dietary deficiency
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&reatment of Osteomalacia
6orrect underlying cause
ncreased doses of vitamin D and calcium are usuallyrecommended
7andle patient gently; patient is at high risk for fractures
0ddress pain and discomfort
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Osteomyelitis
nfection of the $one
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"revention of osteomyelitis is the goal.
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steomyelitis 9ypical signs and symptoms : 0cute osteomyelitis
include:
%ever that may $e a$rupt
rrita$ility or lethargy in young children
"ain in the area of the infection
-welling warmth and redness over the area of the
infection
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Osteomylitis hronic osteomyelitis include%
Carmth swelling and redness over the area of theinfection
"ain or tenderness in the affected area
6hronic fatigue
Drainage from an open wound near the area of theinfection
%ever sometimes
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are of the atient 'ith Osteomyelitis3
lanning
#a4or goals may include relief of pain improved physicalmo$ility within therapeutic limitations control anderadication of infection and knowledge of therapeuticregimen.
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2nterventions Reliving pain
+ mmo$ili>ation
+
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2nterventions
"romote good nutrition: vitamin 6 and protein
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-urgical #anagementsteomyelitis
-e=uestrectomy &-urgical removal of a se=uestrum'a detached piece of necrotic $one that often
migrates to a wound a$scess etc. *one grafts
*one segment transfers
0mputation
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Bone &umors
"rimary tumors
+ *enign tumors are more common and generally areslow growing and present few symptoms
+ #alignant
"rognosis depends upon type and whether thetumor has metastasi>ed
steogenic sarcoma is the most common and
most often fatal primary malignant $one tumor #etastatic $one tumors
+ #ore common than primary tumors
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#alignant *one 9umors
"rimary tumors those tumors that originate in the $one
+ steosarcoma
+
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9reatment 6ancer of *one
nterventions include:
+ 9reatment aimed at reducing the si>e orremoving the tumor
+ Drug therapy; chemotherapy
+ Radiation therapy
+ -urgical management
+ "romotion of physical mo$ility with R#eercises
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ollaborative roblems4otential
om!lications
Delayed wound healing
?utritional deficiency
nfection
7ypercalcemia
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are of the atient 'ith a Bone &umor3
lanning
#a4or goals include knowledge of disease process andtreatment regimen control of pain a$sence of pathologicfractures effective coping patterns improved selfesteem and a$sence of complications.
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2nterventions
6are is similar to that of other patients who haveundergone orthopedic surgery.
"atient and family teaching regarding diagnosis diseaseprocess and treatment.
"revention of pathologic fractures
+ -upport affected etremities at all times and handlegently
+
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2nterventions
"romoting proper nutrition
+ 0dminister antiemetics as prescri$ed
+ Relaation techni=ues
+ ral care
+ ?utritional supplements
"rovide ade=uate hydration
Ase strict aseptic techni=ue
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6ancer of *one0nticipatory 8rieving
nterventions include:
+ 0ctive listening
+ e feelings
+ #aking appropriate referrals
+ 7elping client and others to cope with the loss and
grieving
+ "romoting the physicianclient relationship
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5eferences
Bashayreh6 2. Musculoskeletal System Assessment7 +isorders.