Musculoskeletal System Notes - Chapter 23 (PDF)

musculoskeletal system: structure and function -musculoskeletal system consists of bones, joints and muscles what are 5 major functions of the musculoskeletal system? ◦bones ◦joints ‣ fibrous ‣ cartilaginous ‣ synovial joints ◦ligame...

musculoskeletal system: structure and function -musculoskeletal system consists of bones, joints and muscles what are 5 major functions of the musculoskeletal system? ◦bones ◦joints ‣ fibrous ‣ cartilaginous ‣ synovial joints ◦ligaments ‣ fibrous bands between bones ◦bursa ‣ enclosed fluid filled sac ◦muscle ‣ skeletal, voluntary control connected by tendon to bone -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 -spine Spinous processes of C7 and T1 prominent at base of neck Inferior angle of scapula normally at level of interspace between T7 and T8 Imaginary line connecting highest point on each iliac crest crosses L4 Imaginary line joining two symmetric dimples that overlie posterior superior iliac spines crosses sacrum -shoulder -elbow medial and lateral epicondyles olecranon process of ulna -wrist and carpals radoiocarpal joint mid-carpal joint metacarpophalangeal joints interphalangeal joints -hips -knee Femur, tibia, and patella Supra patellar pouch ◦above patella up to 6 cm Medial and lateral menisci ◦cushion tibia and femur Cruciate ligaments ◦anterior and posterior stability Collateral ligaments ◦medial and lateral stability Prepatellar bursa ◦between patella and skin Quadriceps muscle -ankle and foot musculoskeletal system: defining the 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 musculoskeletal system: subjective health history joints ◦pain, stiffness, swelling, heat, and redness muscles ◦pain (cramps, weakness bones ◦pain, deformity, trauma (fractures, sprains, dislocations)  functional assessment (activities of daily living) self care behaviors musculoskeletal system: children, adolescents and aging adult Infants and children ◦labor and delivery information ◦achievement of developmental milestones ◦history of broken bones/trauma with treatment and/or residual deficits ◦presence of bone/spinal deformity Adolescent ◦history or sports activities ◦pattern of warm up and exercise ◦interventions if injury occurs Aging adult ◦functional assessment questions can 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 DEXA screening for females ages 65 and older musculoskeletal system: physical exam preparation ◦orderly approach (head to toe) ◦bilateral comparison  ◦awareness of abnormal vs normal screening exam ◦suffices for most patients ◦inspection and palpation of each joint ◦evaluate range of motion (ROM) ◦age-specific screening measures: ‣ ortolani sign ‣ scoliosis complete exam ◦Appropriate for persons with articular disease ◦Hx of MSK symptoms ◦Identified problems with ADLs musculoskeletal system: physical exam - inspection joints ◦size and contour overlying skin ◦color, swelling, masses, deformity always compare sides musculoskeletal system: physical exam - palpation and range of motion palpation ◦skin temperature, muscles, bony articulation, joint capsule range of motion (ROM)  ◦important to know hx and functional assessment first ◦ask for active voluntary ROM while stabilizing the body area proximal to the being moved ◦if you see a limitation gently use passive ROM active ROM - patient moves their joint independently passive ROM - nurse moves the patient's joint musculoskeletal system: physical exam - muscle testing apply opposing force, while patient performs ROM ◦Test strength of prime mover muscle groups for each joint; repeat motions for active ROM ◦Ask person to flex/extend and hold as you apply opposing force ◦Muscle strength should be equal bilaterally and should fully resist opposing force grade strength 0-5 (5 = normal) ◦Normal, 5= Full ROM against gravity, full resistance ◦Good, 4= Full ROM against gravity, some resistance ◦Fair, 3= Full ROM with gravity ◦Poor, 2= Passive ROM ◦Trace, 1= slight contraction ◦Zero, 0= No contraction musculoskeletal system: physical exam - 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 musculoskeletal system: physical exam - cervical spine inspect alignment of head and neck palpate spinous processes and muscles ◦should feel firm with no spasm or tenderness motion and expected range - with and without force ◦chin to chest ◦lift chin ◦each ear to shoulder ◦turn chin to each shoulder musculoskeletal system: physical exam - shoulders inspect/compare joints bilaterally palpate shoulders and axilla ◦if pain, ask to point to spot ◦may be local or referred/serious pain ‣ local is reproducible with palpation or motion motion and expected range ◦arms forward and up ◦arms behind back and hands up ◦arms to side and up over head  ◦touch hands behind head musculoskeletal system: physical exam - elbow inspect joint in flexed and extended positions ◦look for deformities, redness, and swelling palpate joint and bony prominences at 70 degrees and relaxed ◦use stabilizing technique to support extremity ROM and muscle strength ◦bend and straighten elbow ◦pronate and supinate hand musculoskeletal system: physical exam - wrist and hand inspect joints on dorsal and palmar sides palpate each joint motion and expected range ◦bend hand up, down ◦bend fingers up, down ◦turns hands out, in ◦spread fingers, make fist ◦touch thumb to each finger phalen's test ◦90 degree ◦60 second hold ◦assess for numbness or burning with acute flexion of wrist (+ sign)  tinel's test ◦direct percussion on median nerve ◦assess for numbness or tingling (+ sign) musculoskeletal system: physical exam - hip inspect as person stands ◦symmetry of illiac crests, gluteal folds, and equally sized buttocks ◦smooth, even gait palpate with person supine ◦stable, symmetric, no crepitation assess ROM ◦raise leg ◦knee to chest ◦flex knee and hip; swing foot out/ in ◦swing leg laterally, medially ◦stand and swing leg back musculoskeletal system: physical exam - knee inspect joint and muscle palpate bulge sign ballottement of patella check quad muscles for any atrophy motion and expected range  ◦bend knee ◦extend knee ◦check knee during ambulation McMurray's test ◦if meniscal tear is supected ◦audile click on exam = + tear musculoskeletal system: physical exam - ankle and foot inspect with person sitting, standing, and walking ◦compare bilaterally ◦assess arch palpate joints assess ROM for limitation or pain ◦point toes down, up - resist ◦turn soles out, in ◦flex and straighten toes musculoskeletal system: physical exam - spine inspect while person stands ◦inspect if spine is straight from the back ◦from side, note thoracic curve (convex) + lumbar curve (concave) palpate spinous processes ◦straight, non tender (normal) motion and expected range  ◦bend sideways, backward ◦twist shoulders to each side ◦touch toes ◦flexion 775-90 degrees ◦smoothness/ symmetry ◦confirm suspected curvature musculoskeletal system: physical exam - straight leg lift herniated nucles pulposus (sciatica) is a condition in which part or all of the soft, gelatinous central portion of an interverbal disk is forced through a weakened part of the disk, resulting in back pain and nerve root irritation ◦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 musculoskeletal system: developmental competence - infants Examine infant fully undressed and lying on back; maintain temperature. Feet and legs ◦Note any positional deformities, a residual of fetal positioning ◦Note relationship of forefoot to hind-foot ◦Check for tibial torsion, a twisting of the tibia Hips  ◦Check hips for congenital dislocation; most reliable is Ortolan’s maneuver, which should be done at every visit until infant is 1 year old ◦Allis test is also used to check for hip dislocation Hands and arms ◦Inspect hands, noting shape, number, and position of fingers and palmar creases ◦Palpate length of clavicles; the bone most frequently is fractured during birth Back ◦Lift infant and examine back; note normal single C-curve of newborn’s spine ◦Inspect length of spine for any tuft of hair, dimple in midline, cyst, or mass; normally none is present Observe ROM through spontaneous movement ◦Test muscle strength by lifting up the infant with your hands under the axillae; baby with normal muscle strength wedges securely between your hands musculoskeletal system: developmental competence - preschool/ school aged Back: note posture; you should note a “plumb line” from back of head, along spine, to middle of sacrum Shoulders: level within 1 cm; scapulae symmetric; lordosis common throughout childhood Observe legs and feet for various deformities ◦bowleg, knock knees, flatfoot, pigeon toes Particularly, check arm for full ROM and presence of pain Look for subluxation of elbow (head of radius) ◦“Nursemaids” - inability to supinate Palpate bones, joints, and muscles of extremities as in adult examination musculoskeletal system: developmental competence - adolescents (Proceed with same musculoskeletal examination as for adult) Pay special note to spinal posture Kyphosis is common during adolescence because of growth spurts Screen for scoliosis with forward bend test ◦From behind standing child, ask child to stand with feet shoulder width apart and bend forward slowly to touch the toes Expect straight vertical spine while standing and also while bending forward; posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests musculoskeletal system: developmental competence - pregnancy (Proceed through same examination as for adult) Expected postural changes in pregnancy include: ◦Progressive lordosis ◦Toward third trimester, anterior cervical flexion ◦Kyphosis and slumped shoulders ◦When pregnancy at term, protuberant abdomen and relaxed mobility in joints create characteristic “waddling” gait musculoskeletal system: developmental competence - aging adult Postural changes include decrease in height, more apparent in eighth and ninth decades Kyphosis common, with backward head tilt to compensate Contour changes include a decrease of fat in body periphery; fat deposition over abdomen and hips Bony prominences become more marked ROM testing Perform functional assessment for ADLs Up and Go Test musculoskeletal system: abnormals affecting multiple joints Inflammatory conditions ◦Rheumatoid arthritis: chronic inflammatory condition of joints believed to be autoimmune ‣ Symmetric and bilateral with pain, swelling, redness ◦Ankylosing spondylitis: chronically inflamed vertebrae causing bony fusion of vertebral joints ‣ Affects the spine, pelvis and thoracic cage - inflammatory pain deep in pelvis and back Degenerative conditions ◦Osteoarthritis (degenerative joint disease): ‣ Noninflammatory, localized, progressive disorder of the articular cartilage ◦Osteoporosis: ‣ Decrease in skeletal bone mass leading to impaired bone density musculoskeletal system: abnormalities of shoulder Atrophy ◦Lack of muscle mass exhibited by loss of fullness Dislocated shoulder ◦Anterior (95% of cases), hunching shoulder with pain Joint effusion ◦Swelling from excess fluid in joint - fluctuance on palpation Tear of the rotator cuff ◦Hunched appearance, positive arm drop test (unable to hold arm up when passively abducted) Frozen shoulder (adhesive capsulitis) ◦Fibrous tissues form in joint capsule leading to limitations in ROM, nocturnal pain. Sling* musculoskeletal system: abnormalities of elbow Arthritis ◦Joint effusion and synovial thickening with redness, heat and pain Rheumatoid Nodules ◦Granulomatous lesions that grow along small blood vessels in RA patients Epicondylitis (tennis elbow) ◦Lateral epicondyle swelling and disabling pain. Extension of hand worsens pain. Caused by chronic supination/pronation (tennis, using screwdriver) Olecranon bursitis ◦Swelling of olecranon bursa causing a “goose-egg” at olecranon. Localized pain and swelling musculoskeletal system: abnormalities of wrist and hand Ganglion Cyst ◦Round, cystic, non tender overlying tendon sheath or joint capsule Carpal Tunnel with Atrophy of Thenar Eminence ◦Carpal tunnel causes pain, inflammation and compression of the median nerve causing impaired motor function Swan-Neck Deformity ◦Extension of PIP and flexion of DIP joint resembling a swan’s neck from chronic RA Boutonniere Deformity ◦Flexion of PIP and extension of DIP joint - knuckle looks like it is coming through a button hole  Bouchard Nodes (PIP joints) and Heberden Nodes (DIP joints) ◦Bony overgrowths from OA Ulnar Deviation ◦Fingers drift to ulnar side as a result of articular capsule and muscle imbalance musculoskeletal system: abnormalities of elbow Knee Osgood-Schlatter Disease ◦Painful swelling at tibial tubercle (just below knee) from overuse and microtrauma Prepatellar Bursitis ◦Local swelling between patella and skin - limited to prepatellar bursa Ankle Acute Gout ◦Painful inflammation from excessive uric acid causing deposition of urate crystals in joint Plantar Fasciitis ◦Repetitive microtrauma to the band of connective tissue from phalanges to calcaneus resulting in pain with dorsiflexion