Musculoskeletal System Assessment

Musculoskeletal Musculoskeletal System System Musculoskeletal Musculoskeletal System System

BY: Darren Ashley BY: Darren Ashley UmaliUmali

Inroduction• Millions of Americans experience

annually• Multiple MOI

– Falls, crashes, violence, etc.– Multi-system trauma

Anatomy & Physiology Musculoskeletal system provides:

• Musculoskeletal system provides • support for body • protection of internal organs • mobility to engage in physical activities • production of RBCs • storage of minerals •   • For proper functioning, must be integration between

neurologic and musculoskeletal systems • M-S system provides mobility and stability through the

integration of muscles, bones and joints which are assessed together

Functions of the Musculoskeletal System

– it supports the sorrounding tissues.

– It protects vital organs and other soft tissues cof the body.

– It assists in body movements, giving attachment to the muscles, thus providing leverage.

– It manufactures blood cells.This hematopoietic function occurs in the red bone marrow.

– It provides storage for mineral salts, specifically phosphorus and calcium which supply body needs.

The Skull

Anatomy and Physiology of Synovial

Joints1. The synovial fluid is a viscous lubricant found in all synovial

joint cartilages

2. The articular cartilage acts as a cushion, providing a smooth gliding surface.

3. Synovial joint is also present in the synovial membrane. This membrane surrounds the cavities and slips in and out of the openings caused by movement.

4. Ligaments help to maintain the relationships between bones and limit motion.

5. Articular muscles function to maintain the stability of joints by relaxation and contraction to insure firm contact throughout the articular surface.

6. Joint is the functional unit of the MS system

Joints

Regulation Movement

• tendons - join muscle to bone

• ligaments and muscles give joint stability

• cartilage - pads joints during weight bearing

Movements of Synovial Joints

1. Flexion – decreasing angle between 2 bones.2. Extension- increasing angle between 2 bones.3. Abduction- the bones moves away from the midline.4. Adduction - bone moves toward the midline.5. Rotation - the bones moves around the central axis.6. Circumduction - bone describes the surface of a cone.7. Supination- the palm is turned upward.8. Pronation –the palm is turned downward.9. Eversion – the sole of the foot is turned outward.10. Inversion – the sole of the foot is moved inward.

Movements of Synovial Joints

11. Depression- lowering a part of the body.12. Elevation- raising a part of the body.13. Retraction- moving a part of the body

backward on a plane parallel to the ground14. Protration- moving a part of the body

forward on a plane parallel to the ground

Types of Joints1. Ball and Socket Joint- provides the widest of motion, with

movement. Example: hip, joints

2. Hinge Joint- the motion is limited to flexion and extension. Example: elbow joint

3. Pivot Joint- motion is limited to rotation; the joint is formed by a pivotlike process which rotates within a bony fossa around a longitudinal axis. Example: atlas and axis.

4. Condyloid- an oval-shaped condyle that fits into elliptical cavity. Example: The wrist joint between the radius and carpal bones.

5. Saddle Joint- tjis type of joint moves in one direction, concave and convex, a unique joint of the thumb.

6.Gliding Joint- is formed by the opposing plane surfaces or slightly convex and concave. Example: intervertebral joint

Joint Structure

Example Temporomandibular

joint

Objective Data• Temporomandibular joint

– Inspect area anterior to ear while seated– Place tips of 1st two fingers in front of ear &

drop to depressed area over joint– Ask client to perform active ROM

• Open mouth maximally• Partially open mouth• Protrude lower jaw & move it side to side• Normal: smooth motion of mandible,

audible click or snap may occur• Abnormal: swelling, crepitus, pain

Objective Data• Cervical spine

– Inspect head & neck alignment• Spine should be straight, head erect

– Palpate spinous processes, sternomastoid, trapezius, & paravertebral muscles • Should be firm, no spasm or tenderness

Growth & Formation of Bones

• The cartilage skeleton is found in the embryo at the end of three months during the prenal age.

• Vertical growth continues at age 15 for girls and 16 for boys and modeling and shaping continue to about 21 years of age.

• Bone consists of protein matrix (the ground substance in which cells are embedded) and salts, primarily hydroxyapatite(makes up the major portion of salts present in bone). Small amount of calcium carbonate are also present.

• Deposition (salt) of bone is regulated by both stress and injury. Bone develops from spindle-shaped cells called osteoblasts, which are found beneath the fibro-vascular membrane covering the bone (perosteum) and in the endosteum.

• Osteoblasts are responsible for reabsorbing bone. This is brought about by the secretion of enzymes which digest the protein portion of bone and split the salts.

• Intramembranous ossification( conversation of fibrous tissue or cartillage into bone or bony substances) is the process by which the bones of the face and skull are formed

Physiology of BoneLack of Calcium results in:1. Depolarization of nerve fiber membranes with

transmission of unconrtolled impulses. Under these conditions, tetany,or spasm of the skeletal musculature occurs.

2. Weakening of cardiac muscle with a consequent inadequate supply of blood to the total body circulation.

3. Interference wit the process of blood coagulation.

• 90% of the total calcium of the body exists in the bone, which is present in the blood plasma and in fluid, where the ionized form of calcium participates in vital chemical reactions.

Classification of Bones1. Long Bones- consists of long shafts and two extremities.

The shaft consists of diaphysis, a compact bone and the metaphysis, the flared portion at each end of the diaphysis which is composed of cancellous bone.

2. Short Bones- a thin layer of compact tissues which covers the spongy or cancellous tissues of a typical short bone.

3. Irregular Bones- are bones of peculiar shape, like the bones of vertebrae and ossicles of the ear.

4. Sesamoid Bones- are bones that are smail, rounded and are enclosed in tendon and facial tissues.

5. Flat Bones- for extensive muscle attachment, e.g ribs, scapula

Musculoskeletal System• Bone Structure

– Diaphysis– Epiphysis

• End of a long bone– Metaphysis

• Between epiphysis and diaphysis

• Growth plate– Medullary canal

• Contains bone marrow– Periosteum

• Fibrous covering of diaphysis

– Cartilage• Connective tissue that

provides a smooth articulation surface for other bones

•Joint Injury– Sprain– Subluxation– Dislocation

• Bone Injury– Open fracture– Closed fracture– Hairline fracture– Impacted fracture– Transverse

Healing of Fracture1. Stage of the hematoma- Bleeding occurs

from damaged structures and a blood clot or hematoma form between and around the bone

2. Stage of granulation- the clot is invaded by cells and new capillaries.

3. Callus formation- a large mass of loosely woven bone forms, subsequently remodelling in accordance with Wolff’s Law.

Wolff’s Law reflects that the role of mechanical force acting on a bone and its structure is dependent on its function

• blood vessel & nerve damage

• Fat embolus

• disability or deformity

Complications of fx

Injuries• Sprain• Strain• Dislocation• Closed fracture• Open fracture

Sprains & Strains• Sprain

– Joint injury with tearing of ligaments

• Strain– Stretching or tearing of a muscle

Fractures• Closed fracture

– does not break the skin

• Open fracture– External wound

•Nondisplaced Nondisplaced fracturefracture

-Simple crack -Simple crack

•Displaced Displaced fracturefracture

-deformity-deformity

Closed fracture• Signs & symptoms

– Pain– Edema– Possible deformity– Contusion– Loss of motion– false motion– Crepitus– Guarding

• Treatment - immobilize, ice, elevate if possible.

Open fracture• Signs & symptoms

– Pain– Deformity– Break in skin and/or exposed bone

• Treatment - dressing, immobilize, ice, & elevate if possible

Bleeding (internal)• Bones have a blood supply!

• Fractures bleed internally - – Femur - 1 liter – Pelvis - 1 liter– Tibia - 500 cc

Tips & other stuff

• Depressed skull fracture• Basilar skull fracture• Angulation or angulated extremity• Flail Chest

Musculoskeletal Injury Management

• Care for Specific Joint Injuries– Hip– Knee– Ankle– Foot– Shoulder– Elbow– Wrist/Hand– Finger

Hip Fractures• Common in the elderly.• May be able to support weight.

– Ability to walk does not rule out fracture.

• Leg often externally rotated.• May refer pain to the knee.• Use other leg for splint.• Use vacuum mattress if available.

Hip Dislocation• Orthopedic emergency• Posterior dislocation most common• Hip flexed and leg rotated

internally• Severe pain on attempts to

straighten

Hip Dislocation Management

• Splint in most comfortable position.

• Document sensation and pulse.• Prompt transport.• Be alert for associated knee

injuries or fractures

Knee Fracture or Dislocation

• Orthopedic emergency• Frequently causes vascular injury• Dislocation associated with 50%

rate of amputation of leg

Knee Fracture or Dislocation

Management• Obvious dislocation without distal

pulse:– Apply gentle traction along the long axis of

the joint.

• If gentle traction does not restore the pulse:– Splint in place.

• Prompt transport.

Foot or Hand Injury• Common industrial injury.• Often disabling.• Rarely life threatening.• Splint foot with pillow.• Splint hand in position of function.

Shoulder Injury• AC Separation

– Sling and swathe.

• Shoulder Dislocation– Use pillow with sling and swathe.

• Fracture– Use sling and swathe.

Elbow Injury• Fracture or dislocation may cause

neurovascular injury.• Splint in position found.• Transport promptly.

Forearm/Wrist Injury• Rigid Splint

– Keep hand in “position of function.”

• Air Splint– May be hard to reassess circulation.

• Pillow

Assessment of injured extremities

• PMSC– Pulse– Movement– Sensation– Capillary refill

Cold, blue, pulseless extremity has circulation problem

ALWAYS CHECK DISTAL FUNCTION BEFORE & AFTER SPLINTING !!!!!

• AND DOCUMENT WHAT YOU FOUND !!

Splinting•Why we splint...

–relieve pain–reduce tissue/vessel damage during movement

Types of splints• Self splinting• Pillows, blankets, & items of clothing• Sling & swath• Rigid

– Cardboard– plastic– ladder

• Air or vacuum • Traction

Traction splints• Closed, mid-shaft femur fracture

without hip, knee, or ankle injury.

General Principles of Splinting

• Remove clothing area• PMSC• Dress all wounds• Do not move the patient before

splinting

General Principles of Splinting

• Immobilize the joints • Pad rigid splints• Maintain manual immobilization.• Realign angulations PRN• When in doubt, splint• Reassess PMSC• Immobilize all suspected spinal injuries

in a neutral in-line position**pain, resistance, crepitus

Realignment issues

• NEVER REALIGN A JOINT

• NEVER REALIGN A INJURY WITH GOOD DISTAL FUNCTION

• Only pulseless, longbone fractures

Basic Realignment Steps

• Have all equipment ready & in place• Explain procedure to patient• In 1 move, with gentle traction, align

extremity (goal is anatomical position)• Use the least amount of force necessary.• If resistance is met or pain increases, splint

in deformed position.

• Reassess distal function

Hazards of Improper Splinting

• Further damage• Delay in transport• Reduction of distal circulation• Aggravation of the injury• Injury to tissue, nerves, blood

vessels, or muscle

Remember

•No matter how bad the fracture our priorities are the ABC’s

Muscles

Types of Muscle

•Skeletal (voluntary) muscle Skeletal (voluntary) muscle Attached to the bones of the Attached to the bones of the bodybody

•Smooth (involuntary) muscleSmooth (involuntary) muscle-Carry out the automatic -Carry out the automatic muscular functions of the bodymuscular functions of the body

•Cardiac muscleCardiac muscle-Involuntary muscle-Involuntary muscle-Has own blood supply and electrical -Has own blood supply and electrical systemsystem-Can tolerate interruptions of blood -Can tolerate interruptions of blood supply for only very short periodssupply for only very short periods

Sign & Symptoms1. Paralysis2. Weakness3. Pain4. Atrophy5. Spasm6. Cramps

Developmental Considerations

• Infants & children– Skeleton is cartilage 3 mos. gestation– Congenital hip dislocation – Bone growth

• Rapid during infancy• Steady during childhood• Rapid growth spurt in adolescence• Occurs in 2 directions

– Width or diameter– Lengthening at epiphyses or growth plates

– Screen for scoliosis starting at age 10-12

Developmental Considerations

• Pregnancy– ↑ levels of circulating hormones → ↑ joint

mobility• Estrogen• Relaxin • Corticosteroids

– Progressive lordosis• Anterior flexion of neck• Slumping of shoulder girdle

Developmental Considerations

• Aging adult– Bone loss (resorption) > new bone growth

(deposition) → loss of bone density (osteoporosis)– Osteoporosis

• Females > males• Whites > blacks

– ↓ height due to shortening vertebral column

– Kyphosis, backward head tilt, slight flexion of knees & hips

Developmental Considerations

• Aging adult– Lose fat in face & forearms → abdomen & hips– Loss in muscle mass & some atrophy →

weakness– Sedentary lifestyle hastens musculoskeletal

changes of aging– Exercise ↑ skeletal mass & delays

osteoporosis• Esp. postmenopausal & older women

Subjective Data• Joints

– Problems, pain• Stiffness, edema, heat, redness, limited ROM, ADL

– Location, unilateral vs. bilateral– Quality, severity, onset, time of day– Aggravating factors

• Movement, rest, position, weather– Relieving factors

• Rest, medication, heat or ice– Associated sx

• Chills, fever, recent sore throat, trauma, repetitive activity

Subjective Data

• Muscles– Problems, pain, cramping, weakness

location• Muscle atrophy

– Any calf pain?• Associated with walking?• Relief with rest?

– Associated symptoms• Fever, chills, flu-like symptoms

Subjective Data• Bones

– Bone or back pain• Is pain affected by movement?• Location, radiating pain, numbness & tingling,

limping

– Bone or joint deformity• Injury, trauma, ROM

– Hx accidents or trauma• Fractures, joint strain, sprain, dislocation• Date, tx, sequelae (problems or limitations)

Subjective Data• Functional assessment (ADL)

– Do joint (muscle, bone) problems limit ADLs?• Bathing

– Getting in & out of tub, turning on faucets• Toileting

– Urinating, moving bowels, getting on/off toilet, wiping self

• Dressing– Buttons, zippers, fastening openings behind neck,

pulling sweater over head, pulling up pants, tying shoes, getting shoes that fit

Subjective Data• Functional assessment (ADL)

– Grooming• Shaving, brushing teeth, brushing or

grooming hair, applying make-up– Eating

• Preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking

– Mobility• Walking, going up or down stairs, getting

in/out of bed, getting out of house– Communicating

• Talking, using phone, writing

Subjective Data• Self-care behaviors

– Occupational hazards related to muscles & joints• Heavy lifting, repetitive motion, chronic joint stress• Efforts to alleviate above

– Exercise program • Type, frequency, warm-up• Pain during exercise & tx

– Recent wt gain, usual diet– Medications

• ASA, NSAIDs, muscle relaxants, analgesics– If chronic disability, effect on interaction with family,

friends, & view of self

Subjective Data• Infants & children

– Infant trauma during L & D• Breech or forceps delivery• Resuscitation

– Achievement of developmental milestones• Siblings, peers

– Hx broken bones, dislocations & tx– Hx bone deformity, spinal curvature,

unusual shape of toes or feet & tx

Subjective Data

• Adolescents– Involvement in sports during or after school– Use of safety equipment, sports training

program– Type of daily warm-up– Reporting of injuries– Relation of sport to school demands & other

activities

Subjective Data

• Aging adult– Do in-depth functional assessment if

needed – Change or weakness in past months or

years– ↑ in falls or stumbling in past months or

years– Use of mobility aids

• Cane, walker

Preparation• Screening

– Sufficient for most people– Inspection & palpation of joints

integrated with each body region– Observation of ROM– Age-specific screening measures

• Ortolani’s maneuver – infants• Scoliosis screening - adolescents

Preparation• Complete musculoskeletal exam

– Persons with joint disease– Hx musculoskeletal symptoms– Problems with ADL

Preparation• Make person comfortable• Drape for full visualization of body part without

exposing client• Orderly approach

– Head-to-toe– Proximal to distal

• Joint to be examined should be supported at rest• Avoid rough manipulation

– Use firm support, gentle movement, gentle return to relaxed state

• Compare corresponding paired joints– √ symmetry structure & function– √ normal parameters for the joint

Objective Data• Inspection

– Note joint size & contour– Inspect skin over joints for color, swelling, masses, or

deformity• Palpation

– Palpate each joint• Skin temperature, muscles, bony articulations,

joint capsule• Note heat, tenderness, edema, or masses• Normal: joints nontender, no swelling

– Synovial membrane normally nonpalpable, if thickened → “doughy” or “boggy”

Objective Data• Range of motion (ROM)

– Ask for active ROM while stabilizing body area proximal to area moved• Know joint type & normal ROM• Normal: no tenderness, pain, or crepitation

– Discrete crack during motion normal– If limitation, gently attempt passive ROM

• Anchor joint with 1 hand while other hand slowly moves it to its limit

• Normal ranges for active & passive ROM should be same

– Goniometer: used to measure joint angles precisely

Goniometer

Objective Data• Muscle testing

– Test strength of prime mover muscle groups for each joint

– Repeat motions elicited for active ROM• Ask person to flex & hold as you apply opposing

force• Normal: strength = bilaterally fully resist your

opposing force• May use grading system from 0 to 5

THE END…

THANK YOU FOR LISTENING CALASSMATE!