Musculoskeletal System Chapter 23 PDF

Chapter 23 MUSCULOSKELETAL SYSTEM  Structure and Function  Musculoskeletal system consists of bones, joints, and muscles  Needed for support and to stand erect  Needed for movement  To encase and protect inner vital organs  To produce RBCs in the bone marrow...

Chapter 23 MUSCULOSKELETAL SYSTEM  Structure and Function  Musculoskeletal system consists of bones, joints, and muscles  Needed for support and to stand erect  Needed for movement  To encase and protect inner vital organs  To produce RBCs in the bone marrow  Serve as a reservoir for storage of essential minerals  Musculoskeletal components:  Bones and cartilage—specialized forms of connective tissue  Fibrous, cartilaginous and synovial joints—joints or articulations are places of union of two or more bones  Ligaments—fibrous bands from one bone to another that strengthen the joint and prevent unwanted movement  Bursa—enclosed fluid filled sac that serves as a cushion  Muscle—skeletal, voluntary control connected by tendon (muscle to bone) Fibrous, Cartilaginous and Synovial Joints  Fibrous joints  Bones united by interjacent fibrous tissue or cartilage and do not move (sutures in skull)  Cartilaginous joints  Separated by fibrocartilaginous discs and are slightly moveable (vertebrae)  Synovial joints  Freely moveable joints separated by one another and enclosed in a cavity lined with synovial membrane that secretes fluid  Contains a layer of avascular cartilage which receives nourishment from synovial fluid that circulates during joint movement with slow cell turnover.  Surrounded by ligaments which are fibrous bands from one bone to another bone that strengthens the joint and helps prevent movement in undesirable directions.  Bursae located in areas of potential friction to facilitate movement of muscles and tendons (closed fluid filled sac that functions as a gliding surface to reduce friction between tissues of the body). Terminology p. 586 Articular disease: Extra-Articular Disease: Crepitation: Synovial Joint Muscles Muscles account for 40% to 50% of body weight. When they contract they produce movement. Muscles are of three types: skeletal, smooth, and cardiac. This chapter is concerned with skeletal, or voluntary, muscles—those under conscious control. Each skeletal muscle is composed of bundles of muscle fibers or fasciculi. 6 Skeletal Muscles Produce the Following Movements  Flexion: bending limb at joint  Extension: straightening limb at joint  Abduction: moving limb away from midline of body  Adduction: moving limb toward midline of body  Pronation: turning forearm so that palm is down  Supination: turning forearm so that palm is up  Circumduction: moving arm in circle around shoulder  Inversion: moving sole of foot inward at ankle  Eversion: moving sole of foot outward at ankle  Rotation: moving head around central axis  Protraction: moving body part forward, parallel to ground  Retraction: moving body part backward, parallel to ground  Elevation: raising a body part  Depression: lowering a body part Skeletal Muscle Movements Temporomandibular Joint (TMJ)  Articulation of mandible and temporal bone  Can feel it in depression anterior to tragus of ear  TMJ permits jaw function of speaking and chewing.  Allows three motions:  Hinge action to open and close jaws  Gliding action for protrusion and retraction  Gliding for side-to-side movement of lower jaw 10  Spine and Vertebrae  Vertebrae: 33 connecting bones stacked in vertical column  Intervertebral discs cushion the spine like a shock absorber and help it move.  Each disc center has a nucleus pulposus made of soft, semifluid, mucoid material  As the spine moves, the elasticity of the discs allows compression on one side, with compensatory expansion on the other.  Sometimes compression can be too great.  The disc then can rupture, and the nucleus pulposus can herniate out of the vertebral column, compressing on the spinal nerves and causing pain.  Spine  Lateral view shows vertebral column having four curves, a double-S shape  Cervical and lumbar curves are concave (inward or anterior)  Thoracic and sacrococcygeal curves are convex  Balanced or compensatory nature of curves, together with intervertebral discs, allows spine to absorb shock  Motions of vertebral column:  Flexion  Extension  Abduction (lateral flexion)  Rotation  Surface Landmarks of Spine Vertebrae in humans: 7 cervical 12 thoracic 5 lumbar 5 sacral 3 to 4 (most common) coccygeal  Shoulder  Shoulder girdle:  Humerus, scapula, clavicle, joints and muscle  Ball-and-socket action allows mobility of arm on many axes-more than any other joint  The joint is enclosed by a group of four powerful muscles and tendons that support and stabilize it.  Together these are called the rotator cuff.  Movements of the Shoulder:  Flexion and Extension  Hyperextension  Abduction and Adduction  Circumduction  Internal and External rotation  Elevation Shoulder Joint Tendon torn (or frayed) away from bone Elbow and Wrists and Carpals  Elbow  Elbow joint contains three bony articulations: humerus, radius, and ulna of forearm  Palpable landmarks are medial and lateral epicondyles of humerus and large olecranon process of proximal ulna  Radius and ulna articulate with each other at two radioulnar joints, one at elbow and one at wrist  Movements of the Elbow: Flexion and Extension  Wrist, or radiocarpal joint  Articulation of radius on thumb side and row of carpal bones  Condyloid action permits movement in two planes at right angles: flexion and extension, and side-to-side deviation  Midcarpal joint: articulation allows: Flexion, Extension, Rotation, Side to Side (radial and ulnar deviation) Trivia: Of the 206 bones in the body, over ½ are in the hands and feet 19  Hip  Hip: articulation between acetabulum and head of the femur  Ball-and-socket action permits wide range of motion on many axes.  More stability for weight-bearing function  Muscles enhance stability and bursae facilitate movement.  Palpation of bony landmarks will guide examination  Iliac crest—anterior superior spine to posterior  Ischial tuberosity  Greater trochanter of the femur  Knee  Knee joint: articulation of three bones—femur, tibia, and patella —in common articular cavity  Largest joint in body; hinge joint, permitting flexion and extension of lower leg on single plane  Synovial membrane is largest in body  Two wedge-shaped cartilages, called medial and lateral menisci, cushion tibia and femur  Knee stabilized by two sets of ligaments:  Cruciate give anterior and posterior stability and help control rotation  Collateral ligaments give medial and lateral stability and prevent dislocation 22  Ankle and Foot  Ankle or tibiotalar joint: articulation of tibia, fibula, and talus  Hinge joint: limited to flexion (dorsiflexion) and extension (plantar flexion) in one plane  Landmarks are two bony prominences on either side  Medial malleolus and the lateral malleolus  Help stability of ankle  May be torn in eversion or inversion sprains of ankle  Joints distal to ankle give additional mobility to foot  Subtalar joint permits inversion and eversion of foot ◦ Movements of the ankle: plantar flexion, dorsi flexion, rotation, inversion and eversion Ankle and Foot 25 Subjective Data Joints: pain, stiffness, swelling, heat, redness, limitation of movement Knee joint (if injured) Muscles: pain (cramps) or weakness Bones: pain, deformity, trauma (fractures, sprains, or dislocation) Functional Assessment (ADLs) Patient-centered care Health History Questions: Joints  Ask about  Pain: Do you have any pain in or problems with your joints?  Location: Unilateral or bilateral  Characteristics: Quality: and severity  Onset, duration and frequency  Aggravating or precipitating factors  Associated clinical presentations  Limitation of motion, stiffness, swelling or erythema  Impact on ADLs  Health History Questions: Muscles  Ask about  Location of pain or cramping  Pain while walking versus pain relief at rest. Consider claudication (pain due to poor circulation especially with movement) if pain is in calf perhaps associated with peripheral arterial disease (PAD).  Associated clinical presentations  Muscle characteristics: weakness and size  Onset and duration of symptoms  Health History Questions: Bones  Ask about  Pain: at rest and/or affected by movement  Presence of deformity due to injury or trauma and effect on ROM  History of accidents or trauma with impact on bones  Medical and/or surgical treatment—any residual deficits  Presence of back pain—provide pain characteristic description  Presence of neurological or physical deficits  Numbness, tingling, limping  Functional Assessment of ADLs  Ask about  Do joint (muscle, bone) problems create any limits on your usual ADLs? Which ones?  Screens safety of independent living , need for home services and quality of life  Ask specific questions about all these topic areas: Bathing Toileting Dressing Grooming Eating Mobility Communicating  Patient-Centered Care  Ask about  Occupational hazards  Exercise program pattern  Dietary review: recent weight gain or weight loss  Medications: Rx and OTC r/t muscle/bone health  Supplemental vitamins and minerals: vitamin D and calcium  Smoking history  Impact on ADLs: acute versus chronic disability  Self-esteem disturbance.  Loss of independence.  Body image disturbance.  Role performance disturbance.  Social isolation.  Additional History Questions Aging adult ◦ Use functional assessment history questions to elicit any loss of function, self-care deficit, or safety risk ◦ New onset weakness ◦ Increase in falls or stumbling ◦ Use of mobility device ◦ Recommendation for DXA screening for females ages 65 and older & postmenopausal women younger than 65 years of age who are at increased risk Physical Examination Preparation  Purpose of musculoskeletal examination is to assess function for ADLs and to screen for abnormalities  Note additional ADL data as person goes through motions necessary for examination  Age-specific screening measures, such as scoliosis screening for adolescents  Take an orderly approach: head to toe, proximal to distal, and from midline outward  Perform bilateral comparison  Be aware of normal and abnormal findings  Order of Examination  Inspection  Note size and contour of joint; inspect skin and tissues over joints for color, swelling, and any masses or deformity  Palpation  Palpate each joint, including skin for temperature, muscles, bony articulations, and area of joint capsule; notice any heat, tenderness, swelling, or masses which signal inflammation  Swelling may be excess joint fluid or thickening of the synovial lining, inflammation of surrounding soft tissue or bony enlargement p. 585  Range of motion (ROM)  Ask for active voluntary ROM while stabilizing the body area proximal to that being moved  If you see a limitation, gently use passive ROM  Do not confuse crepitation with the normal discrete “crack” heard as a tendon or ligament slips over bone during motion, such as when you do a knee bend.  Muscle Testing  Test strength of prime mover muscle groups for each joint; repeat motions for active ROM  Ask person to flex and hold as you apply opposing force  Muscle strength should be equal bilaterally and should fully resist opposing force  Use standardized grading scale to report results (0 to 5 range) Gra Description de 5/5 Full ROM against gravity, full resistance 4/5 Full ROM against gravity, some resistance 3/5 Full ROM w/ gravity against gravity but not against resistance by examiner 2/5 Full ROM w/gravity eliminated (passive motion) 1/5 Slight contraction 0/5 No contraction  Temporomandibular Joint (TMJ)  Inspection and palpation  Audible and palpable snap or click occurs in many healthy people as mouth opens  Palpate contracted muscles as person clenches teeth  Compare right and left sides for size, firmness, and strength  Ask person to move jaw forward and laterally against your resistance, and to open mouth against your resistance ◦ This tests integrity of cranial nerve V (trigeminal nerve)  Observe for swelling, limitation of motion and/or reported pain. Cervical Spine  Inspect alignment of head and neck  Spine should be straight, and head erect  Palpate spinous processes and sternomastoid, trapezius, and paravertebral muscles  They should feel firm, with no muscle spasm or tenderness  Repeat motions while applying opposing force  Person normally can maintain flexion against full resistance  This tests integrity of cranial nerve XI (spinal nerve)  Observe for limitation of motion and/or reported pain Shoulder Inspect and compare both shoulders posteriorly and anteriorly ◦ Do not attempt if you suspect neck trauma If person reports shoulder pain, ask him or her to point to spot with hand of unaffected side ◦ Shoulder pain may be from local causes or may be referred pain which could be potentially serious ◦ Pain from a local cause is reproducible during the examination by palpation or motion While standing in front of person, palpate both shoulders, noting any muscular spasm or atrophy, swelling, heat, or tenderness ◦ Use a methodical method to assess muscle strength and ROM ◦ Shoulder shrug also tests integrity of cranial nerve XI, spinal accessory nerve  Elbow Inspect size and contour of elbow in both flexed and extended positions ◦ Look for deformity, redness, or swelling ◦ Check olecranon bursa and the normally present hollows on either side of the olecranon process for abnormal swelling Palpate elbow flexed about 70 degrees and relaxed ◦ Use stabilizing technique to support extremity during assessment ◦ Test ROM and assess muscle strength  Wrist and Hand  Inspect hands and wrists on dorsal and palmar sides  Note position, contour, and shape; normally no swelling or redness, deformity, or nodules are present  Palpate each joint in wrist and hands  Perform ROM and assess muscle strength  Use stabilizing technique to support extremity during muscle testing  Perform testing to determine presence of Carpal Tunnel Syndrome.  Testing for Carpal Tunnel Syndrome Phalen Test Tinel Sign 23.28 AND 23.29 41  Hip  Inspect hip joint together with spine later in examination as person stands  Note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks  Smooth, even gait reflects equal leg lengths and functional hip motion  Help person into supine position and palpate hip joints; joints should feel stable and symmetric, with no tenderness or crepitation  Assess ROM.  Limitation of abduction of hip while supine is most common motion dysfunction found in hip disease 23.30  Knee  Person should remain supine or sitting  Inspect lower leg alignment, knee shape, and contour  Check quadriceps muscle in anterior thigh for any atrophy  Perform ROM to assess for any limitation or presence of pain  Exams of the knee:  Ballottement of the Patella  Bulge Sign  McMurray Test  Tears of the Meniscus Lateral Medial Normal Anatomy Ankle and Foot Inspection  Inspect while person is sitting and when standing and walking  Compare both feet, noting contour of joints; foot should align with long axis of lower leg  Weight-bearing should fall on middle of foot; most feet have a longitudinal arch, but this can vary normally from “flat feet” to high instep  Toes point straight forward and lie flat; note locations of calluses or bursal reactions as they reveal areas of abnormal friction  Examining well-worn shoes helps assess areas of wear and accommodation Ankle and Foot Palpation  Palpate metatarsophalangeal joints between your thumb on dorsum and fingers on plantar surface  Perform ROM to assess for any limitation or presence of pain  Assess muscle strength by asking person to maintain dorsiflexion and plantar flexion against your resistance  Spine  Person should be standing, draped in gown open at back  Place yourself far enough back so that you can see entire back  Inspect and note if spine is straight  From side, note normal convex thoracic curve and concave lumbar curve  Kyphosis: Enhanced thoracic curve typically seen in aging people  Lordosis: Pronounced lumbar curve seen in obese people  Palpate spinous processes; normally straight and not tender.  Palpate paravertebral muscles; should feel firm with no tenderness or spasm.  Spinal Abnormalities 48  Spine Check ROM of spine by asking person to touch toes; look for flexion of 75 to 90 degrees, and smoothness and symmetry of movement ◦ Concave lumbar curve should disappear with this motion; back should have single convex C-shaped curve ◦ If you suspect spinal curvature during inspection, this may be more clearly seen when person touches toes Spine  Stabilize pelvis with your hands; check ROM  Bend sideways: lateral bending of 35 degrees  Bend backward: hyperextension of 30 degrees  Twist shoulders to one side, then the other: rotation of 30 degrees, bilaterally ◦ These maneuvers reveal gross restrictions only; movement is still possible even if some spinal fusion has occurred  Test gait/balance by asking the person to walk on his or her toes for a few steps, then return walking on heels Straight Leg Raising or Lasègue’s Test  These maneuvers reproduce back and leg pain and may confirm presence of herniated nucleus pulposus  Straight leg raising while keeping the knee extended normally produces no pain  Raise affected leg just short of point where it produces pain; then dorsiflex foot  Test positive if it reproduces sciatic pain; if lifting affected leg reproduces sciatic pain, it confirms presence of herniated nucleus pulposus  Raise unaffected leg leaving other leg flat; inquire about involved side Straight Leg Raising Test  Genetics and Environment an Bone mineral density (BMD) ◦ Higher BMD = denser bone ◦ Low BMD consistent predictor of hip and vertebral fractures/osteoporosis Racial/ethnic differences in BMD seen nationally and globally: Pg. 581 ◦ Non-Hispanic Black adults tend to have the greatest BMD. ◦ However, Black women and men have a higher mortality rate after hip fracture/longer hospital stays. ◦ White women in the U.S. are more likely to develop osteoporosis. ◦ Asian and White women have similar BMD, however Asian women have a lower rate of developing osteoporosis. Gender Differences: ◦ Earlier peak and rapid decline of BMD: Women > Men ◦ Associated with increased fracture risk in Caucasian women (estrogen) Copyright © 2020 by Elsevier Inc. All rights reserved. Developmental Competence: Infants and Adolescents  Proceed with same musculoskeletal examination as for adult; pay special note to spinal posture  Kyphosis is common during adolescence because of chronic poor posture  Screen for scoliosis with forward bend test (functional vs. structural)  Expect straight vertical spine while standing and while bending forward; posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests  Developmental Competence: Pregnancy  Proceed through same examination as for adult  Increased levels of circulating hormones cause increased mobility in joints.  Increased mobility in sacroiliac, sacrococcygeal, and symphysis pubis joints in pelvis contributes to noticeable changes in maternal posture.  Most characteristic change is progressive lordosis leading to increased back strain  Developmental Competence: Aging Adult  Bone remodeling is cyclic process of resorption and deposition  Risk for osteoporosis (when resorption > deposition)  Postural changes and decreased height are most noticeable  Kyphosis with slight flexion of hips and knees to compensate  Distribution of subcutaneous fat changes leading to different contour  Loss of subcutaneous fat leaves bony prominences more marked.  Absolute loss in muscle mass  Decrease in size and atrophy producing weakness  Impact of sedentary lifestyle  Hastens musculoskeletal changes of aging  Health Promotion and Patient Teaching Focus on the following areas: ◦ Diet to protect and maintain healthy bones  calcium & vitamin D ◦ Smoking cessation ◦ Alcohol intake pattern ◦ Exercise promotion ◦ Osteoporosis Screening ◦ Fall prevention Common Abnormalities Rheumatoid Arthritis - chronic, systemic inflammatory disease of joints and surrounding connective tissue; characterized by heat, redness, swelling, and painful motion of the affected joints. Symmetric involvement with stiffness primarily in the morning which improves with movement. P. 615 Osteoarthritis – non-inflammatory (degenerative), localized, asymmetric, progressive disorder involving deterioration of articular cartilages and subchondral bone, and formation of new bone at joint surfaces; affected joints have stiffness, swelling with hard bony protuberances (Heberden and Bouchard nodes), pain with motion, and limitation of motion. Contributors: genetics, weight, injury and overuse, bone and joint disorders. P. 616 Osteoporosis – Disease involving the loss of mineralized bone mass: decrease in skeletal bone mass occurring when rate of bone resorption (loss of bone) is greater than that of bone formation. Occurs primarily in post menopausal white women (estrogen). Risk increased with smaller height/weight, younger age at menopause, lack of physical (weight bearing) activity. P. 616 Atrophy - loss of muscle mass 58 59 Acute Rheumatoid Arthritis 60 Common Abnormalities Joint effusion - swelling from excess fluid (effusion) Swelling: caused by effusion in the joint capsule, thickening of the synovial lining, and inflammation of surrounding soft tissue Torn Rotator Cuff - characteristic “hunched” position and limited abduction of arm Gouty Arthritis - joint effusion or synovial thickening; characterized by redness, heat, soft, boggy or fluctuant fullness to palpation and limited ROM Carpal Tunnel Syndrome - atrophy occurs from interference with motor function due to compression of the median nerve inside the carpal tunnel, caused by chronic repetitive motion Scoliosis - curvature of the spine Spina Bifida - incomplete closure of the posterior part of vertebrae results in a neural tube defect, usually occurs 4th week of gestation Osteoporosis Risks  Gender-woman (lower estrogen post menopause, elevated thyroid hormone)  Older adult  Race- white or Asian  Family Hx- parent or sibling or hx fractured hip  Body frame- small with less bone mass  Diet-low calcium  Eating Disorders  GI surgery to reduce stomach or remove part of intestine  Steroids-long term use  Medical problems-Rheumatoid arthritis  Sedentary or bed ridden  Smokers (affects the ability to absorb Ca++)  ETOH excessive consumption (affects Ca++ absorption, affects pancreas and Vit D metabolism) Prevention  Calcium dairy, dark green leafy veggies, Salmon with bones, soy, calcium fortified cereal and OJ  Vitamin D supplementation (helps absorb calcium)  Exercise- Weight bearing exercise (walking, jogging) and strength and balance training  Screening: DEXA scan for bone density Abnormalities  Shoulder  Wrist and hand  Atrophy  Ganglion Cyst  Dislocated Shoulder  Colles’ Fracture (fx in radius close  Joint Effusion to wrist)  Carpal Tunnel Syndrome  Tear of Rotator Cuff  Ankylosis (fused bones)   Knee Frozen Shoulder - Adhesive Capsulitis Dupuytren Contracture  Post-Polio Muscle  Elbow Atrophy  Olecranon Bursitis  Mild Synovitis  Arthritis  Prepatellar Bursitis  Swelling of Menisci  Rheumatoid Nodules  Ankle and foot  Epicondylitis—Tennis Elbow  Achilles Tenosynovitis  Spine  Chronic Gout/Acute Gout  Scoliosis  Bunion and Hammer toes  Herniated Intervertebral Disc  Plantar Fasciitis or wart  Back & Radicular Leg Pain  Ingrown Toenail Post Polio Muscle Atrophy 64 Acute Gout (uric acid crystals) 65  Fibromyalgia Syndrome Widespread musculoskeletal pain greater than 3 months ◦ Additional body symptoms  fatigue, sleep disturbance, psychological stress & functional symptoms ◦ More prevalent in women than men ◦ Issue with sensory processing  allodynia and/or hyperalgesia ◦ Revision of diagnostic criteria proposed 67