Week 1 MSK Lectures (Combined) PDF

NUR1114 – Week 1 NUR1114 – Week 1 Musculoskeletal Assessment and Musculoskeletal Assessment and Management of Musculoskeletal Injuries Management of Musculoskeletal Injuries Prepared by Animesh Ghimire Prepared by Cliff Connell Updated by Animesh Ghimire  Learning Objectives for Week...

NUR1114 – Week 1 NUR1114 – Week 1 Musculoskeletal Assessment and Musculoskeletal Assessment and Management of Musculoskeletal Injuries Management of Musculoskeletal Injuries Prepared by Animesh Ghimire Prepared by Cliff Connell Updated by Animesh Ghimire  Learning Objectives for Week 1 List the common musculoskeletal structure and functions Discuss the systematic assessment of the musculoskeletal system List the common musculoskeletal system conditions Identify the diagnostic studies associated with the musculoskeletal system Describe the principles and methods of fracture immobilisation Identify conditions that can impact neurovascular function List the indications for the undertaking a neurovascular assessment Identify and explain each component of a neurovascular examination Discuss the definition and incidence of falls Review common injuries Discuss risk factors related to falls 2 Learning Objective 1. List the common musculoskeletal structure and functions 3 Structure and Function Components of musculoskeletal system Bone Cartilage Ligaments and tendons Muscles 4 Structure and Function Movement of joints – Flexion – Inversion – Extension – Eversion – Abduction – Rotation – Adduction – Protraction – Pronation – Retraction – Supination – Elevation – Circumduction – Depression 5 Skeletal Muscle Movements © Pat Thomas, 2006 6 Learning Objective 2. Discuss the systematic assessment of the musculoskeletal system 7 Developmental Considerations Infants and children – Spinal curve changes – Developmental dysplasia of the hip The pregnant woman – Increased joint mobility (relaxation of joints due to oestrogen and relaxin) – Progressive lordosis Late adulthood – Osteoporosis – Postural changes – Musculoskeletal changes 8 Subjective Data — General Principles Presenting complaint Gait, arms, legs and spine (GALS) screening assessment Joints Muscles Bones Functional assessment (ADLs) Health and lifestyle management 9 Subjective Data — General Principles Additional history for infants and children – Labour trauma, resuscitation – Motor milestones – Wellness – Broken bones/bruising/dislocations – Bone deformity 10 Subjective Data — General Principles Additional history for adolescents – Sport participation – Special equipment/training – Warm-ups – Bone/spine deformity 11 Subjective Data — General Principles Additional history for the older adult – Change/increasing in weakness – Increase in falls/stumbling (falls assessment) – Walking aids 12 Objective Data—The Physical Examination Systematic approach – Head to toe – Proximal to distal – Compare corresponding paired joints – Neurovascular assessment of upper and lower limbs Order of the examination – Look (inspect) – Feel (palpate) – Then move 13 Objective Data—The Physical Examination GALS screening assessment ▪ Validated quick and efficient MSK assessment system – Gait – Arms – Legs – Spine 14 Objective Data—The Physical Examination Inspection – Size and contour of joint – Colour, swelling and masses/deformity Palpation – Temperature, muscles, bony articulations, area of joint capsule – Tenderness, crepitus, swelling or masses – Boggy synovial membrane (not normally palpable) 15 Objective Data—The Physical Examination Range of motion -Ask for active movement -Passive motion -Goniometer (Physio and OT) -Crepitation (Crunching or grating sound on movement) 16 Objective Data—The Physical Examination Muscle testing – Equal bilateral strength and should resist opposing force Movement and ROM – without resistance – with resistance 17 Objective Data—The Physical Examination Temporomandibular joint Inspect joint area Palpate as person opens mouth Motion and expected range – Open mouth maximally – Protrude lower jaw and move side to side – Stick out lower jaw Palpate muscles of mastication 18 Objective Data—The Physical Examination Cervical spine ▪ Inspect alignment of head and neck ▪ Palpate spinous processes and muscles ▪ Motion and expected range – Chin to chest – Lift chin Head Motions and Expected Ranges – Each ear to shoulder – Turn chin to each shoulder 3 19 Objective Data—The Physical Examination Cervical spine – NEXUS CRITERIA Doctors use NEXUS to rule out cervical spine fracture clinically, without need for x-ray. Nurses can and should use NEXUS as an assessment technique that will help decision about immobilisation. In the setting of patient who has experienced a trauma AND there is NO: ▪ Focal neurologic deficit present (e.g. altered sensation along C5 dermatome) Cliff’s C-Spine following ▪ Midline spinal tenderness present trauma! ▪ Altered level of consciousness present ▪ Intoxication (e.g. alcohol, drugs) ▪ Distracting injury present (e.g. # femur) 20 Cervical Spine Immobilisation Positive NEXUS criteria? Requires at least 2 health care workers: 1. Immobilise (prevent flexion, extension, rotation) 2. Nurse/doctor/physio/paramedic competent in applying c-spine collar 21 Objective Data—The Physical Examination Shoulders ▪ Inspect joint (posterior and anterior) ▪ Palpate shoulders and axilla ▪ Motion and expected range – Arms forwards and up – Arms behind back and hands up – Arms to sides and up over head – Touch hands behind head 22 Objective Data—The Physical Examination Elbow ▪ Inspect joint in flexed and extended positions ▪ Palpate joint and bony prominences ▪ Motion and expected range – Bend and straighten elbow – Pronate and supinate hand ▪ Muscle strength- - Person flexes elbow and nurse applies resistance at wrist 41 23 Objective Data—The Physical Examination Wrist and Hand ▪ Inspect joints on dorsal and palmar sides ▪ Palpate each joint 24 Objective Data—The Physical Examination Wrist and Hand ▪ Motion and expected range – Bend hand up, down – Bend fingers up, down – Turn hands out, in – Spread fingers, make fist – Touch thumb to each finger – Muscle strength – flex the wrist against resistance at the palm 25 Objective Data—The Physical Examination Carpal Tunnel Wrist and Syndrome? Hand Numbness and burning? ▪ Phalen’s test- numbness and burning in carpel tunnel syndrome Phalen’s Test Burning and tingling? ▪ Tinel’s sign- a positive sign is when percussion of the median nerve produces burning and tingling Tinel’s sign 26 Objective Data—The Physical Examination Hip ▪ Inspect as person stands ▪ Palpate with person supine ▪ Motion and expected range – Raise leg – Knee to chest – Flex knee and hip; swing foot out, in – Swing leg laterally, medially – Stand and swing leg back 45 27 Objective Data—The Physical Examination Knee ▪ Inspect joint and muscle - can have leg extended or dangling - shape and contour - atrophy of quadriceps muscle ▪ Palpate - note consistency of tissues - note any warmth, tenderness or thickening 28 Objective Data—The Physical Examination Knee ▪ Bulge sign -for swelling in suprapatellar notch. -confirms the presence of fluid as you move fluid from one side of joint to the other. 29 Objective Data—The Physical Examination Knee ▪ Ballottement of patella -reliable when large amounts of fluid present in knee -check for crepitus by holding hand on the patella while flexing and extending knee 30 Objective Data—The Physical Examination Knee ▪ Motion and expected range – Bend knee – Extend knee – Check knee during ambulation ▪ Muscle strength -Ask person to flex the knee while you try and pull leg forward 31 Objective Data—The Physical Examination Ankle and foot ▪ Inspect with person sitting, standing and walking ▪ Palpate joints ▪ Motion and expected range – Point toes down, up – Turn soles out, in – Flex and straighten toes – dorsiflexion and plantar Muscle strength: 50 flexion against resistance 32 Objective Data—The Physical Examination Spine ▪ Inspection form behind and side 33 Objective Data—The Physical Examination Spine ▪ Inspection from behind and side ▪ ROM – Flexion – Extension – Rotation 34 Objective Data—The Physical Examination Spine ▪ Straight Leg Raising (or Sciatic Pain? Lasegue’s Test) ▪ Positive if it produces sciatic pain ▪ Confirms the presence of a herniated nucleus pulposis 35 Learning Objective 3.List the common musculoskeletal system conditions 36 Common MSK condition Osteoporosis ▪ Bone remodelling ▪ Osteoporosis = disease characterised by low bone mass and micro- architectural deterioration of bone tissue/fragility ▪ Bone loss occurs silently 37 Osteoporosis ▪ Risk factors: – Family history, increasing age, low dietary calcium intake, vitamin D deficiency and/or lack of sunlight, medical history, corticosteroid therapy, early menopause, late menarche, low testosterone (men), malabsorption syndromes, certain chronic diseases, some medications, lifestyle factors 38 Abnormal Findings - Affecting Multiple Joints ▪ Inflammatory conditions – Rheumatoid arthritis – Ankylosing spondylitis Rheumatoid arthritis Osteoporosis ▪ Degenerative conditions – Osteoarthritis (degenerative joint disease) – Osteoporosis Ankylosing Spondylitis 39 Abnormal Findings of the Shoulder Atrophy Fracture Dislocated shoulder Subluxation Joint effusion Tear of the rotator cuff Frozen shoulder— adhesive capsulitis Sub-acromial bursitis 40 Abnormal Findings of the Elbow Fracture Olecranon bursitis Gouty arthritis Subcutaneous nodules Epicondylitis—tennis elbow Olecranon bursitis 41 Abnormal Findings of the Wrist and Hand ▪ Ganglion cyst ▪ Ulnar deviation or drift ▪ Colles fracture ▪ Degenerative joint ▪ Carpal tunnel syndrome disease or osteoarthritis ▪ Ankylosis ▪ Acute ▪ Dupuytren’s rheumatoid contracture arthritis ▪ Swan-neck and boutonnière ▪ Syndactyly deformities ▪ Polydactyly 42 Abnormal Findings of the Knee Patella dislocation Septic arthritis Mild synovitis Pre-patellar bursitis Swelling of menisci Osgood-Schlatter disease Chondromalacia patellae 43  Abnormal findings- Ankle and foot Sprain Achilles tenosynovitis Chronic/acute gout Hallux valgus with bunion and hammertoes Callus Tophi with chronic gout Plantar fasciitis Ingrown toenail 44 Abnormal Findings of the spine Scoliosis Herniated nucleus pulposus Kyphosis Lordosis Degenerative changes Chronic pain 45 Abnormal Findings for Advanced Practice Common Congenital or Paediatric Abnormalities Congenital or developmental hip Hip Dysplasia dysplasia Talipes (clubfoot) Spina bifida Coxa plana (Legg-Calvé- Perthes syndrome) Talipe Legg-Calvé-Perthes s 46 Revision Question What does ‘GALS’ stand for? Option 1: Goals, Assessment & Location Option 2: Gait, Arms, Legs & Spine Option 3: Gait, Assessment, Location & Spine Check the lecture notes for the correct answer 47 Learning Objective 4.Identify the diagnostic studies associated with the musculoskeletal system 48 Diagnostic studies They perform the diagnosis and prognosis of musculoskeletal disorders Provides information on bone density, calcification in soft tissues and fractures Also used in inflammatory and metabolic disorders 49 Diagnostic studies ▪ X-ray ▪ MRI ▪ CT +/- contrast ▪ Arthrography ▪ Bone mineral density ▪ Bone scan ▪ Arthroscopy Another one of Cliff’s trauma X-rays ▪ Arthrocentesis and synovial fluid analysis ▪ Electromyography ▪ Serological studies 50 Learning Objective 5. Describe the principles and methods of fracture immobilisation 51 Immobilisation Fractures, dislocations and Soft Tissue Injuries ▪ RICE(R) – Rest – Ice (cold therapy) – Compression – Elevation – Referral 52 Immobilisation Fractures, dislocations and Soft Tissue Injuries ▪ Fractures – Sling - triangular bandages – Collar & cuff – Plaster-of Paris (POP) – Traction (more in 2nd year) ▪ Soft tissue injuries – Compression bandaging 53 Immobilisation ▪ Treatment (surgical & non-surgical) – Open reduction & internal fixation (ORIF) – Local anaesthetic, manipulation and plaster (LAMP) – General anaesthetic, manipulation and plaster (GAMP) 54 Neurological Supply ▪ The arm has an extensive neurological supply – why? 73 Questions 56 References ▪ Hall, H., Glew, P., & Rhodes, J. (2022). Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care (4th ed.). New South Wales: Wolters Kluwer. ▪ Forbes, H., & Watt, E. (2020). Jarvis's Physical Examination & Health Assessment (3rd ed.). New South Wales: Elsevier. ▪ Farrell, M. (2017). Smeltzer and Bare's Textbook of Medical- Surgical Nursing (4th ed.). Lippincott, Williams and Wilkins. ▪ Tollefson, J., & Hillman, E. (2022). Clinical psychomotor skills : assessment tools for nurses (five point assessment tool) (8th ed). South Melbourne, Vic: Cengage Learning 57 Neurovascular Assessment Chris Scott Learning objectives 1. Identify conditions that can impact neurovascular function 2. List the indications for the undertaking a neurovascular assessment 3. Identify and explain each component of a neurovascular examination Neurovascular assessment Involves the evaluation of the neurological and vascular integrity of a limb Evaluates sensory and motor function Detects signs and symptoms of potential complications such as: acute limb ischaemia compartment syndrome. Do not confuse a neurological assessment with a neurovascular assessment Neurological assessment determines level of consciousness/alertness and ability to obey instructions Neurovascular assesses neurological/vascular integrity of a limb Acute limb ischaemia Causes include: Emboli (cardiac and non-cardiac) Iatrogenic & non-iatrogenic injury to vessels and Aetiology: joints Sudden decrease in limb perfusion Occlusion of a bypass graft conduit Causes time-critical threat to limb viability Hypercoagulable state Usually related to arterial occlusion Outflow venous occlusion Chronic peripheral arterial occlusive disease Treatment varies: Thrombolysis (catheter directed) Embolectomy Bypass Amputation Compartment syndrome Increased pressure within a muscle compartment Caused by bleeding and/or swelling Pressure increases due to plaster cast or bandages Rigid compartment allows only limited swelling Nerves and blood vessels become compressed Leads to compromised tissue perfusion and ischaemia Requires emergency management Results in muscle, nerve and tissue death Damage can become irreparable within ~4 hours Treatment of compartment syndrome Treatment requires removal of pressure Removal of cast/bandage Surgical fasciotomy Early detection is key Best method for early detection of compartment syndrome? NEUROVASCULAR ASSESSMENT! Indications Musculoskeletal injury to limbs Application of a plaster cast Fracture, crush injury Patients with circumferential burns to limbs Post operatively Signs of infection to limb Internal or external fixation of fracture Application of traction (skin or skeletal) Plastic surgery on extremities Envenomation Orthopaedic surgery, spinal surgery Cardiac catheterisation AND MANY MORE! The 7 P’s of neurovascular assessment Pain Paraesthesia (sensation) Pallor (colour) Polar (warmth) – sometimes called poikilothermia Paralysis (movement) Pulses (distal to injury) Pressure Pain Earliest and most reliable indicator of tissue ischaemia or compartment syndrome Undertake a detailed pain assessment (not just a rating) Use PQRST or COLDSPA Compare pain at rest and on movement Passively move fingers/toes and assess Pain on stretch is an important indicator Reviewing for intense pain disproportionate to the injury Unrelieved with positioning, elevation or opioid analgesia Paraesthesia ‘Sensation’ Assess sensation in the distal limb Have them close their eyes and identify sensations Sharp (end of pen), soft (cotton bud) Ask about changes in sensation Such as numbness, tingling, pins & needles (or any other sensation) These can be symptoms of nerve compression Source: RCH Neurovascular observations Pallor ‘Colour’ Colour should be the same in both limbs Healthy well perfused, pink in Caucasians In darker skinned people, the palms, soles and nailbeds should be pink Compartment syndrome affects pallor based on injury. Usually: Pale in arterial insufficiency Red or cyanotic on venous insufficiency Polar / Poikilothermia Temperature/warmth Limb should be warm to the touch Or at least similar to unaffected limb Assess temperature with dorsum (back) of hand In compartment syndrome limb likely cold or cooler than other limbs Paralysis Movement Assess motor function Ask patient to move limb through full range of motion Consider any surgical restrictions Do not perform on anyone who has had: Microsurgery Repairs to tendons, arteries or nerves Pulses Should be same rate/strength as same pulse point on unaffected limb Dorsalis pedis (pedal) pulses can be hard to find Mark with permanent marker (for repeat assessments) May need Doppler if pulse is faint Assess capillary refill time (in several digits) Should be