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Musculoskeletal System

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Title: Musculoskeletal System


1
Musculoskeletal System
2
The Musculoskeletal System
  • What are the functions of
  • Bones (206) structure protection act as
    levers produce blood cells store calcium
  • Muscles (650) allow for movement and position
    produce heat
  • Joints point of articulation of two bones
    provide ROM
  • Tendons connect muscle to bone
  • Ligament connects bone to bone
  • Cartilage supports and shapes acts as a shock
    absorber
  • Bursae sacs filled with synovial fluid cushion
    and reduce friction between joints

3
Common Disorders
  • Osteoarthritis
  • AKA-Degenerative Joint Disease (DJD)
  • Noninflammatory, localized, progressive disorder
    involving deterioration of articular cartilage
    and subchondral bone and formation of new bone
    (osteophytes) at joint surface
  • S/S Asymmetrical joint involvement, stiffness,
    swelling, bony protuberances, pain with motion
    and decreased ROM

4
Common Disorders
  • Rheumatoid Arthritis
  • Chronic, systemic inflammatory disease of joints
    surrounding connective tissue.
  • Inflammation of synovial membrane leads to
    thickening then fibrosis, which decreases ROM,
    and finally bony ankylosis
  • S/S Symmetric joint involvement, heat, redness,
    swelling, painful motion, fatigue, weakness,
    anorexia, weight loss, low grade fever,
    lymphadenopathy

5
Common Disorders
  • Osteoporosis-
  • Decrease in skeletal bone mass when rate of bone
    resorption is greater than bone formation.
  • Increased risk for stress fractures
  • Wrist, hips, vertebrae most common
  • Loss of height frequently first clinical sign of
    osteoporosis
  • Height loss occurs in trunk as result of
    vertebral fracture and collapse

6
Health History
  • Pain
  • Onset
  • Location
  • Duration
  • Character
  • Aggravating Alleviating factors/Associated
    factors
  • Radiation
  • Treatments tried
  • RICE
  • Numbness or Tingling
  • Muscle weakness

Rest, Ice, Compression, Elevation
7
Health History
  • Current Health Information
  • Activities of daily living (personal care,
    household tasks, shopping, etc.)
  • Current/Previous employment
  • Exercise
  • Nutrition
  • Tobacco/Alcohol use
  • Medications

8
Health History
  • Past Medical History
  • Previous accidents/injuries to bones, nerves,
    soft tissue
  • Previous orthopedic surgery
  • Congenital deformities
  • Chronic illnesses (i.e. rheumatoid/osteoarthritis
    arthritis, osteoporosis, cancer, neurological
    problems)
  • Family History
  • Congenital deformities, chronic illness

9
Inspection
  • Gait
  • Stance
  • Initial contact (heel strike), loading response,
    midstance, terminal stance (toe off), preswing
  • Swing
  • Initial swing, midswing, terminal swing

10
Inspection
  • Gait
  • Guarded vs. relaxed
  • Speed
  • Smoothness
  • Fatigue
  • Normal variance
  • Genu varum (bowleg)
  • Genu valgum (knock-knee)
  • Gait smooth and coordinated

11
Inspection
  • Posture
  • Erect, slumped, guarded
  • Kyphosis (hump back)
  • Lordosis (sway back)
  • Scoliosis (crooked back)
  • Posture erect with normal spinal curvature

12
Inspection
  • Symmetry
  • Size/Length (shortened limb, amputation)
  • Contour (deformity, muscle tone)
  • Contractures, dislocations, subluxation)
  • Color (erythema, ecchymosis, cyanotic, other
    discoloration)
  • Edema
  • Masses
  • Joints and muscles symmetric no swelling,
    masses, deformity.

13
Palpation
  • Bones, joints, and muscles for tenderness
  • Muscle tone
  • Temperature
  • Edema
  • Crepitus
  • Masses
  • Capillary Refill pulses
  • Sensation (If acute injury want to chart CMS
    intact)
  • No tenderness to palpation of joints no heat,
    swelling, or masses

14
Range of Motion
  • ROM
  • Flexion-decreases angle between bones of joint
  • Extension- increases angle between bones of joint
  • Abduction- mvmt of limb away from midline
  • Adduction- mvmt of limb towards midline
  • Rotation- mvmt of bone around long axis
  • Circumduction- mvmt in circle

Goniometer
15
Range of Motion
  • Lateral Flexion- decreasing angle of joints
    laterally.
  • Dorsiflexion (foot towards shin)/Plantar flexion
    (foot towards floor)
  • Inversion (sole medial)/Eversion (sole lateral)
  • Supination (palm up)/Pronation (Palm down)
  • Protraction (nonangular mvmt anterior)/Retraction
    (nonangular mvmt posterior)
  • Elevation (lifting superiorly)/Depression (moving
    inferiorly)
  • Opposition- thumb touches other finger

16
Range of Motion
  • Active vs. Passive ROM
  • Active Patient moves joints through ROM
  • Passive You move relaxed joints through ROM
  • Excess fluid, loose bodies, contractures/stiffness
    , laxity, crepitus, pain.
  • Full ROM movement smooth without crepitance or
    tenderness

17
Strength
  • Test strength by resisting ROM
  • Grip strength (upper body)
  • Plantar flexion (lower body)
  • Grading
  • 5- Full ROM against gravity, full resistance
  • 4- Full ROM against gravity, some resistance
  • 3- Full ROM with gravity
  • 2- Full ROM with gravity eliminated (passive)
  • 1- Slight contraction
  • 0- No contraction
  • Muscle strength 5/5

18
Additional Information
  • Shoulder
  • Elbow
  • Wrist/Hands/Fingers
  • Hip
  • Knee
  • Ankles/Feet
  • Spine

19
Shoulder
  • Palpate
  • Clavicle
  • Acromioclavicular joint
  • Subacromial bursa area
  • Greater tuberacle of humerus
  • Biceps groove
  • Anterior aspect of
  • glenohumeral joint
  • Scapula

20
Shoulder
  • ROM
  • Forward flexion
  • 180
  • Hyperextension
  • 50
  • Internal rotation
  • 90
  • External rotation
  • 90
  • Abduction
  • 180
  • Adduction
  • 50

21
Shoulder
  • Strength-
  • Against resistance have pt
  • Shrug shoulders (also CNXI)
  • Flex shoulders forward
  • Abduct

22
Elbow
  • Palpate
  • Olecranon process
  • Olecranon bursa area
  • Grooves on side of olecranon process
  • With thumb in lateral groove and index and middle
    finger in medial groove palpate either side of
    olecranon process

23
Elbow
  • ROM
  • Flexion
  • 150-160
  • Extension
  • 0
  • Hyperextension 5-10
  • Supination
  • 90
  • Pronation
  • 90

24
Elbow
  • Strength
  • Against resistance ask patient to
  • Flex
  • Extend

25
Wrist/Hands/Fingers
  • Inspect for
  • OA Nodules
  • Bouchards nodes
  • Heberdens nodes
  • RA deformities

26
Wrist/Hands/Fingers
  • Rheumatoid Arthritis

27
Wrist/Hands/Fingers
  • Palpate
  • Wrist
  • Support hand with fingers under it and palpate
    wrist with both thumbs

28
Wrist/Hands/Fingers
  • Fingers
  • Use thumb and index finger in pinching motion to
    palpate sides of interphalangeal joints.

29
Wrist/Hands/Fingers
30
Wrist/Hands/Fingers
  • ROM
  • Wrist Flexion
  • 90
  • Wrist Hyperextension
  • 70
  • Radial deviation
  • 20
  • Ulnar deviation
  • 50-60
  • Finger flexion
  • 90
  • Finger hyperextension
  • 30
  • Finger abduction
  • 20
  • Make a fist
  • Finger opposition

31
Wrist/Hands/Fingers
  • Muscle strength
  • Position patients forearm palm up resting on a
    table. Hold mid-forearm and ask patient to flex
    wrist against your resistance

32
Carpal Tunnel Syndrome
  • Thenar eminence atrophy
  • Phalens Test
  • Have pt hold both hands back to back while
    flexing at wrists at 90 degrees.
  • Normal No symptoms in hands after 60 seconds (-)
  • Abnormal Numbness and burning along median nerve
    distribution within 60 seconds ()
  • Tinels Sign
  • Directly percuss over median nerve at wrist
  • Normal No symptoms with percussion (-)
  • Abnormal Burning and tingling along median nerve
    distribution ()

33
Hip
  • Inspection begins with observation of the
    patients gait, observe stance and swing
  • Smooth, even gait reflects equal leg lengths
    functional hip motion

34
Hip
  • Palpate
  • Hip joint
  • Normal
  • Joint stable
  • Symmetric
  • No tenderness
  • No crepitus

35
Hip
  • ROM
  • Flexion
  • Knee flexed 120
  • Knee straight
  • Hyperextension
  • 15
  • Internal rotation
  • 40
  • External rotation
  • 45
  • Abduction
  • 40-45
  • Adduction
  • 20-30

36
Knee
  • Inspect
  • Lower leg alignment
  • Should extend in same axis as thigh
  • Genu varum (bowleg)
  • Genu valgum (knock knee)
  • Flexion contracture

37
Knee
  • Palpate
  • Tibiofemoral joint
  • Patella
  • For crepitus

38
Knee
  • ROM
  • Flexion
  • 130-150
  • Extension
  • 0
  • Hyperextension 15

39
Knee
  • Muscle strength
  • Against resistance have patient
  • Flex knee
  • Extend knee
  • Extension can also be demonstrated by success in
    rising from low chair or rising from squat
    without support

40
Foot Inspection Abnormalities
41
Ankles/Feet
  • Palpate
  • Grasp heel with fingers while palpating ankle
    with thumbs

42
Ankles/Feet
  • Palpate
  • Palpate metatarsophalangeal joints between thumb
    and dorsum of fingers on plantar surface
  • Using pinching motion of thumbs and forefingers
    to palpate interphalangeal joints

43
Ankles/Feet
  • ROM
  • Plantar flexion
  • 45
  • Dorsiflexion
  • 20
  • Eversion
  • 20
  • Inversion
  • 30
  • Toe flexion
  • 40
  • Toe extension
  • 40

44
Ankles/Feet
  • Muscle Strength
  • Against resistance ask patient to
  • Dorsiflex
  • Plantarflexion

45
Spine
  • Inspect
  • From the side cervical concavity, thoracic
    convexity, lumbar concavity
  • From behind upright spinal column, alignment of
    the shoulders, the iliac crests, and the skin
    creases below the buttocks are symmetrical
  • Have bend over and touch toes spine without
    lateral deviation, shoulder height symmetrical

46
Spine
  • Palpate
  • Spinous processes
  • Paravertebral muscles
  • Sternomastoid and trapezius muscles

47
Spine
  • ROM

48
Spine
  • ROM
  • Cervical
  • Flexion
  • 45
  • Hyperextension
  • 55
  • Lateral bend
  • 40
  • Rotation
  • 70
  • Lumbar
  • Flexion
  • 90
  • Hyperextension
  • 30
  • Lateral bend
  • 30
  • Rotation
  • 30

49
Spine
  • Muscle Strength
  • Cervical
  • Flexion
  • Extension
  • Rotation (also tests CN XI)
  • Lumbar
  • Assess L5 S1 nerve root
  • Have walk on toes and heels

50
Spine
  • Straight Leg Raise
  • For low back pain that radiates to the leg, check
    straight leg raise on each side.
  • Raise the leg until pain occurs, record the
    degree of elevation, the quality and distribution
    of the pain, and the effects of dorsiflexion.
  • Sharp pain radiating down the leg when leg raised
    30-60 degrees is suggestive of nerve root
    compression, typically due to a herniated lumbar
    disc.
  • Crossed leg raise is very diagnostic
  • for disk injury
  • Positive when radiation of pain
  • in leg that is not raised

51
Nursing Computer Charting
  • Normal Parameters
  • Moves all extremities
  • No evidence of muscle wasting
  • Steady gait, balance intact
  • Ambulates safely and independently (with/without
    devices)

52
Modified Hendrich Fall Risk Assessment
  • Risk Factors
  • Recent history of falls 5
  • Confusion/disorientation 4
  • Depression 2
  • Altered elimination 1
  • Dizziness/vertigo 1

53
Modified Hendrich Fall Risk Assessment
  • Get Up and Go Test Rising from Chair
  • Able to rise in single movement 0
  • Pushes up successfully one attempt 1
  • Multiple attempts but successful 2
  • Unable to rise without assistance 3
  • Add points from risk factors and rising from
    chair.
  • 0-3 points low risk, use basic safety
    surveillance
  • gt3 high risk, use fall prevention interventions
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