Lecture 7 - Musculoskeletal

Review of Human Skeletal Anatomy Mark Anthony R. Rivera, MD RN CST Lecturer, College of Nursing Our Lady of Fatima University

Assessment of the

Musculoskeletal System

The Body Axis • The body is made up of the skull, vertebral column, ribs, and coccyx (tailbone) – Skull is made up of the cranium, which protects the brain, and the face. – Vertebral column is the backbone. It has 33 vertebrae • Vertebrae are small, rigid bones that stack together – The ribs protect the heart and lungs. There are 12 pairs.

Spine • Starts with the cervical vertebrae (7 vertebrae), then the thoracic (12) and the lumbar (5). It finishes off with the sacrum and the coccyx. • Each of the vertebrae are separated by an intervertebral disk. – These prevent the vertebrae from grinding into each other. • The thoracic vertebrae connect to the ribs.

Arm • At the tips of your fingers are the phalanges. – Long, slender, lightweight. • Phalanges are connected to metacarpal bones. – Metacarpals are framework of the palm. • Metacarpals branch off from the carpal bones. – 8 of them; pebble-ish • The carpal bones are below the ulna and the radius. – If your palm is face-up and your arm extended, your elbow is your ulna. • The ulna and the radius are connected to the humerus. • The humerus in turn connects to the scapula. – The scapula is held in place by muscles. • The scapula is then connected to the clavicle, or collarbone.

Legs • At the tips of your toes are the phalanges. • These connect to the metatarsals…. • Which in turn connect to the tarsals. – 7 tarsals, only 1 is heel. • Connected to the tarsals are the tibia and fibula. – Tibia is the shin bone. • At the knee, the tibia and fibula are separated from the femur by a large section of cartilage. • On this cartilage rests the patella. • The femur is then connected to the coxal bone, which is connected to the sacrum – Femur is the largest bone in the body.

Skeletal System • Bone types • Bone structure • Bone function • Bone growth and metabolism affected by: 1. calcium and phosphorous, 2. calcitonin, 3. vitamin D, 4. parathyroid hormone, 5. growth hormone, 6. glucocorticoids, 7. estrogens and androgens, 8. thyroxine, and 9. insulin

Bones • Support the body and anchor muscles. • Ligaments link bones to other bones. • Tendons link bones to muscle • Two types of bones – Compact Bone – Spongy Bone • Inside bones is a central shaft. This is the marrow cavity where fat is stored. • Bone matrixes contain the bone’s proteins and minerals. These heal bone and maintain healthiness.

2 Major Types of Bone Compact • Has few and very small spaces inside.

Spongy •

Has many large spaces. It contains red marrow where red blood cells are made.

•

Made of trabeculae.

• Made of osteons.

Joints • Types include – synarthrodial, – amphiarthrodial, – diarthrodial • Structure and function of the diarthrodial or synovial joint • Subtyped by anatomic structure: – Ball-and-socket – Hinge – Condylar – Biaxial – Pivot

Joint types • Ball and socket

Arm

• Pivot

Neck

• Saddle

Thumb

• Ellipsoid

Knuckles

• Hinge

Knee

• Plane

Ankle

MUSCULAR SYSTEM

Muscular System

Movements to know!

• Structure • Function • Supporting structures • Musculoskeletal changes associated with aging • Cultural considerations

Know aging changes vs.

List of major muscles

Common Name Base of neck Upper arm Back of arm Inner arm

Scientific Name Trapezius Deltoid Triceps brachii Biceps brachii

Back Stomach Butt Front part of the upper leg Back part of the upper leg

Latissimus dorsi Abdominal muscles Gluteus maximus Sartoris and Rectus femoris Biceps femoris

Muscles • In humans with hard skeletons, muscles are in antagonistic pairs – e.g. shin and calf muscles • The skeletal muscles are muscles that are attached to bones. These move the skeleton. • Made of muscle fibers, multi-nuclei cells. – The plasma membranes enclose long bundles called fibrils.

Muscles Cont. • They work by shortening (contracting) and lengthening (flexing) – The energy is supplied my mitochondria in the fibrils. – Muscle contraction is called Sliding Filament Mechanism, where filaments in cells slide past each other. • Cardiac muscle is electrically connected.

Different Types

Smooth

Skeletal

• Found in hollow • Composed of body organs like long fibers. digestive tract • Controls and blood voluntary vessels. movement. • Have 1 nucleus.

Cardiac • Central nuclei.

Muscle energy • The Immediate Energy System is a quick blast of muscle power. This uses fast-twitch fibers. • The Glycotic Energy System splits glucose by glycolysis in the muscles. • The Oxidative Energy System (Aerobic Energy System) is for prolonged muscle use, like marathons. This uses slow-twitch fibers.

– Slow-twitch fibers are packed with mitochondria and myoglobin. • Fast oxidative-glycolytic muscle fibers are moderately powerful and last for a moderate amount of time.

Assessments • Family history and genetic risk • Personal history • Dietary history • Socioeconomic status and ability to afford food • Current health problems including obesity

Physical Assessment • General inspection • Posture • Abnormality in gait such as antalgic gait or lurch • Goniometer, which provides a measure of ROM • Head and neck: evaluate the temporomandibular joints • Spine: lordosis, scoliosis • Upper extremities • Lower extremities )

Diagnostic Assessment • Laboratory tests: serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes • Radiographic examinations: standard radiography, tomography and xeroradiography, myelography, arthrography, and CT • Other diagnostic tests: bone and muscle biopsy

Electromyography • EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies. • Low electrical currents are passed through flat electrodes placed along the nerve. • If needles are used, inspect needle sites for hematoma formation.

Arthroscopy • Fiberoptic tube is inserted into a joint for direct visualization. • Client must be able to flex the knee; exercises are prescribed for ROM. • Evaluate the neurovascular status of the affected limb frequently. • Analgesics are prescribed. • Monitor for complications.

Other Tests • Bone scan • Gallium or thallium scan • Magnetic resonance imaging • Ultrasonography

Interventions for Clients with

Musculoskeletal Problems

Osteoporosis • Metabolic disease, in which bone demineralization results in decreased density and subsequent fractures • Osteopenia (low bone mass), which occurs when there is a disruption in the bone remodeling process

Classification of Osteoporosis • Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. • Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility. • Regional osteoporosis occurs when a limb is immobilized.

Health Promotion/Illness Prevention • Ensure adequate calcium intake. • Avoid sedentary life style. • Continue program of weight-bearing exercises. Unchangeable risk factors for osteoporosis include female

gender, older age, small or thin body size, Caucasian and Asian ethnicity, and family history of fractures. Modifiable risk factors include a diet low in calcium and vitamin D, use of certain medications, an inactive lifestyle or extended bed rest, cigarette smoking, and excessive alcohol consumption.

Assessment • Physical assessment • Psychosocial assessment • Laboratory assessment • Radiographic assessment

Drug Therapy • Hormone replacement therapy • Parathyroid hormone • Calcium and vitamin D • Bisphosphonates • Selective estrogen receptor modulators • Calcitonin • Other agents used with varying results

Diet Therapy • Protein • Magnesium • Vitamin K • Trace minerals • Calcium and vitamin D • Avoid alcohol and caffeine

Fall Prevention • Hazard-free environment • High-risk assessment through programs such as Falling Star protocol • Hip protectors that prevent hip fracture in case of a fall

Fall Contributors

Outdoors

Indoors

Medications

Uneven surfaces No Handrails Bad lighting Slick Surfaces

Poor Lighting Clutter Extension Cords Unstable Handrails Scatter rugs Pets

Chronic Health Conditions -HTN Cardiac Arrhythmias peripheral neuropathies

Flexibility and Strength

Health Conditions

Others • Exercise • Pain management • Orthotic devices

Exercises

• Lateral Raises with Therabands; tension is increased by shortening the band to comfort level.

Osteomyelitis • Osteomyelitis is an acute or chronic inflammatory process of the bone and its structures secondary to infection with pyogenic organisms. • Infection of bone with rich vascular supply from bacteremia, UTI, long term IV caths, Salmonella from GI, poor dental hygiene, MRSA • Trauma admits bacteria such as Pseudomonas directly. • Acute -> high temp, swelling, bone pain • Chronic -> skin ulceration, sinus tract, local pain, drainage • AB Tx IV, Infection control, > 3 months, surg debridement or bone grafts, amputation.

Padget’s Disease • Metabolic disorder of bone remodeling in which bone deposits are weak, enlarged and disorganized. • 2nd most common bone disease in elderly. • Cause unknown but may be latent viral appearing > 80 yrs. • 80% asymptomatic; affects bone in skull, vertebrae, long bones, hip joint etc. • Tx- symptomatic for pain- NSAIDS, calcitonin, Fosamax.

Interventions for Clients with

Musculoskeletal Trauma

Classification of Fractures • A fracture is a break or disruption in the continuity of a bone. • Types of fractures include: – Complete – Incomplete – Open or compound – Closed or simple – Pathologic (spontaneous) – Fatigue or stress – Compression

Stages of Bone Healing • Hematoma formation within 48 to 72 hr after injury • Hematoma to granulation tissue • Callus formation • Osteoblastic proliferation • Bone remodeling • Bone healing completed within about 6 weeks; up to 6 months in the older person

Acute Compartment Syndrome • Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area • Prevention of pressure buildup of blood or fluid accumulation • Pathophysiologic changes sometimes referred to as ischemia-edema cycle

Emergency Care • Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr. • Monitor compartment pressures. • Fasciotomy may be performed to relieve pressure. • Pack and dress the wound after fasciotomy.

Possible Results of Acute Compartment Syndrome • Infection • Motor weakness • Volkmann’s contractures • Myoglobinuric renal failure, known as rhabdomyolysis

Other Complications of Fractures • Shock • Fat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream • Venous thromboembolism • Infection • Ischemic necrosis • Fracture blisters, delayed union, nonunion, and malunion

Musculoskeletal Assessment • Change in bone alignment • Alteration in length of extremity • Change in shape of bone • Pain upon movement • Decreased ROM • Crepitation • Ecchymotic skin • Subcutaneous emphysema with bubbles under the skin • Swelling at the fracture site

Special Assessment Considerations • For fractures of the shoulder and upper arm, assess client in sitting or standing position. • Support the affected arm to promote comfort. • For distal areas of the arm, assess client in a supine position. • For fracture of lower extremities and pelvis, client is in supine position.

Risk for Peripheral Neurovascular Dysfunction • Interventions include: – Emergency care: assess for respiratory distress, bleeding and head injury – Nonsurgical management: closed reduction and immobilization with a bandage, splint, cast, or traction

Casts

• Rigid device that immobilizes the affected body part while allowing other body parts to move • Cast materials: plaster, fiberglass, polyester-cotton • Types of casts for various parts of the body: arm, leg, brace, body • Cast care and client education • Cast complications: infection, circulation impairment, peripheral nerve damage, complications of immobility

Traction

• Application of a pulling force to the body to provide reduction, alignment, and rest at that site • Types of traction: skin, skeletal, plaster, brace, circumferential • Traction care: – Maintain correct balance between traction pull and countertraction force – Care of weights – Skin inspection – Pin care – Assessment of neurovascular status

Operative Procedures • Open reduction with internal fixation (ORIF) • External fixation • Postoperative care: similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism

Procedures for Nonunion • Electrical bone stimulation • Bone grafting • Bone banking

Acute Pain • Interventions include: – Reduction and immobilization of fracture – Assessment of pain – Drug therapy: opioid and nonopioid drugs – Complementary and alternative therapies: ice, heat, elevation of body part, massage, baths, back rub, therapeutic touch, distraction, imagery, music therapy, relaxation techniques

Risk for Infection • Interventions include: – Apply strict aseptic technique for dressing changes and wound irrigations. – Assess for local inflammation – Report purulent drainage immediately to health care provider. – Assess for pneumonia and urinary tract infection. – Administer broad-spectrum antibiotics prophylactically.

Impaired Physical Mobility • Interventions include: – Use of crutches to promote mobility – Use of walkers and canes to promote mobility

Imbalanced Nutrition: Less Than Body Requirements • Interventions include: – Diet high in protein, calories, and calcium, supplemental vitamins B and C – Frequent small feedings and supplements of high-protein liquids – Intake of foods high in iron

Upper Extremity Fractures • Fractures include those of the: – Clavicle – Scapula – Humerus – Olecranon – Radius and ulna – Wrist and hand

Fractures of the Hip • Intracapsular or extracapsular • Treatment of choice: surgical repair, when possible, to allow the older client to get out of bed • Open reduction with internal fixation • Intramedullary rod, pins, a prosthesis, or a fixed sliding plate • Prosthetic device Normal N ---------------------------------Fracture-------------------------- ORIF

Lower Extremity Fractures • Fractures include those of the: – Femur – Patella – Tibia and fibula – Ankle and foot

Fractures of the Pelvis • Associated internal damage the chief concern in fracture management of pelvic fractures • Non–weight-bearing fracture of the pelvis • Weight-bearing fracture of the pelvis

Compression Fractures of the Spine • Most are associated with osteoporosis rather than acute spinal injury. • Multiple hairline fractures result when bone mass diminishes. • Nonsurgical management includes bedrest, analgesics, and physical therapy. • Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected.

Amputations • Surgical amputation • Traumatic amputation • Levels of amputation • Complications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma, flexion contracture

Phantom Limb Pain • Phantom limb pain is a frequent complication of amputation. • Client complains of pain at the site of the removed body part, most often shortly after surgery. • Pain is intense burning feeling, crushing sensation or cramping. • Some clients feel that the removed body part is in a distorted position.

Management of Phantom Pain • Phantom limb pain must be distinguished from stump pain because they are managed differently. • Recognize that this pain is real and interferes with the amputee’s activities of daily living. • Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain. • Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics

Exercise After Amputation • ROM to prevent flexion contractures, particularly of the hip and knee • Trapeze and overhead frame • Firm mattress • Prone position every 3 to 4 hours • Elevation of lower-leg residual limb controversial

Prostheses •

Devices to help shape and shrink the residual limb and help client readapt

•

Wrapping of elastic bandages – Wrap residual limb in a figure eight pattern, not a circular one. Wrapping in a circular pattern will cut off the blood flow and cause harm. – The goal of wrapping is to form a cone-shaped residual limb. To do this, apply more pressure to the bottom end of the residual limb, and less pressure to the top portion.

•

Individual fitting of the prosthesis; special care

Crush Syndrome • Can occur when leg or arm injury includes multiple compartments • Characterized by acute compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosis • Treatment: adequate intravenous fluids, lowdose dopamine, sodium bicarbonate, kayexalate, and hemodialysis

Complex Regional Pain Syndrome • A poorly understood complex disorder that includes debilitating pain, atrophy, autonomic dysfunction, and motor impairment • Collaborative management: pain relief, maintaining ROM, endoscopic thoracic sympathectomy, and psychotherapy.

Knee Injuries, Meniscus • McMurray test • Meniscectomy • Postoperative care • Leg exercises begun immediately • Knee immobilizer • Elevation of the leg on one or two pillows; ice.

Knee Injuries, Ligaments • When the anterior cruciate ligament is torn, a snap is felt, the knee gives way, swelling occurs, stiffness and pain follow. • Treatment can be nonsurgical or surgical. • Complete healing of knee ligaments after surgery can take 6 to 9 months.

Tendon Ruptures • Rupture of the Achilles tendon is common in adults who participate in strenuous sports. • For severe damage, surgical repair is followed by leg immobilized in a cast for 6 to 8 weeks. • Tendon transplant may be needed.

Dislocations and Subluxations • Pain, immobility, alteration in contour of joint, deviation in length of the extremity, rotation of the extremity • Closed manipulation of the joint performed to force it back into its original position • Joint immobilized until healing occurs

Strains • Excessive stretching of a muscle or tendon when it is weak or unstable • Classified according to severity: first-, second-, and third-degree strain • Management: cold and heat applications, exercise and activity limitations, antiinflammatory drugs, muscle relaxants, and possible surgery

Sprains • Excessive stretching of a ligament • Treatment of sprains: – first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation – second-degree: immobilization, partial weight bearing as tear heals – third-degree: immobilization for 4 to 6 weeks, possible surgery

Rotator Cuff Injuries • Shoulder pain; cannot initiate or maintain abduction of the arm at the shoulder • Drop arm test • Conservative treatment: nonsteroidal antiinflammatory drugs, physical therapy, sling support, ice or heat applications during healing • Surgical repair for a complete tear

Interventions for Clients with Connective Tissue Disease and Other Types of Arthritis

Rheumatology • Connective tissue disease (CTD) is a major focus of rheumatology. • Rheumatic disease is any disease or condition involving the musculoskeletal system. • Arthritis means inflammation of one or more joints. (Continued)

Rheumatology (Continued) • Non-inflammatory arthritis is not systemic. • Inflammatory arthritis – Rheumatoid arthritis – Systemic lupus erythematosus

Osteoarthritis • Most common type of arthritis • Joint pain and loss of function characterized by progressive deterioration and loss of cartilage in the joints • Osteophytes • Synovitis • Subluxation

Collaborative Management of OA • History • Physical assessment and clinical manifestations – Joint involvement – Heberden's nodes – Bouchard’s nodes – Joint effusions – Atrophy of skeletal muscle

Assessments of OA • Psychosocial • Laboratory assessment of erythrocyte sedimentation rate and C-reactive protein (may be slightly elevated) • Radiographic assessment • Other diagnostic assessments – MR imaging – CT studies

Chronic Pain in OA Interventions: • Pain control may be accomplished at home with drug and nonpharmacologic measures. • Surgery may be performed to reduce pain. • Comprehensive pain assessment should be performed before and after implementing interventions. • Rest, positioning, thermal modalities, weight control, TENS, complementary and alternative therapies, stem cell therapy • Surgical management

Total Hip Arthroplasty • Preoperative care • Operative procedures • Postoperative care – Prevention of dislocation, infection, and thromboembolic complications – Assessment of bleeding – Management of anemia

Care of Total Hip Arthroplasty • Assessment for neurovascular compromise • Management of pain • Progression of activity • Promotion of self-care

Impaired Physical Mobility Interventions: • Goal: to achieve independent function • Therapeutic exercise • Promotion of activities of daily living and ambulation • Teaching about health and how to use assistive devices

Connective Tissue or Rheumatic Diseases Inflammation of synovial joints due to an immune response with degeneration as a secondary process. Blood vessels, heart, skin and kidneys may also be affected. • Rheumatoid Arthritis (RA) – joint deformity • Lupus Erythematosis (SLE) - skin, heart, kidneys • Scleroderma - skin • Sjogren’s Syndrome - dry mouth, dry eye -> systemic • Raynaud’s Disease- blood vessels

Lab Studies • Creatinine  • ESR – inflammation RBC - RA and SLE  WBC – SLE Antinuclear Antibody (ANA) – all • Rheumatoid Factor - > 80%

Rheumatoid Arthritis • A most common connective tissue disease and the most destructive to the joints • Chronic, progressive, systemic inflammatory autoimmune disease primarily affecting the synovial joints • Autoantibodies (rheumatoid factors) formed that attack healthy tissue • Affects synovial tissue of any organ or body system

Rheumatoid Arthritis Education Rest Exercise Support Progressive meds Surgical reconstruction Depression Sleep deprivation Nutrition Pacing

Collaborative Management for RA • Assessment • Physical assessment and clinical manifestations – Early disease manifestations – Late disease manifestations – Joint involvement – Systemic complications – Associated syndromes

Assessments for RA • Psychosocial assessment • Laboratory assessment: rheumatoid factor, antinuclear antibody titer, erythrocyte sedimentation rate, serum complement, serum protein electrophoresis, serum immunoglobulins • Other diagnostic assessments

Drug Therapy for RA Mild disease • Nonsteroidal anti-inflammatory drugs (NSAIDs), for instance, celecoxib, rofecoxib, valdecoxib with cox-2 inhibiting properties • Disease modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine, sulfasalazine, and minocycline Moderate to severe disease • Methotrexate • Leflunomide • Biological response modifiers such as etanercept, infiximab, adalimumab, anakinra

• Immunosuppressive

RA Medications

– Methotrexate –gold standard for RA, used also in SLE

• ASA

– Imuran

• NSAIDS

– Cytoxan

• Antimalarials - visual changes

– Cyclosporin

– Plaquenil – Aralen • Gold – administer with

NSAIDS. Stomatitis, diarrhea, proteinuria… may be a problem

• Sulfasalazine • Penicillamine

– Arava – Enbrel – Remicade • Corticosteroids – Prednisone – Prednisolone – Hydrocortisone • Topical – Capsaicin

Nonpharmacologic Modalities in the Treatment of RA • Plasmapheresis • Complementary and alternative therapies • Promotion of self-care • Management of fatigue • Enhancement of body image • Health teaching

Lupus Erythematosus • Chronic, progressive, inflammatory connective tissue disorder can cause major body organs and systems to fail. • Many clients with SLE have some degree of kidney involvement.

Lupus Erythematosis • Shows up in childbearing years • Medication related • Any body system • Rash, lesions • Exacerbations • Pericarditis • Renal > HTN • CNS • Fever, fatigue, weight loss, arthritis, hematuria

Assessments for Lupus • Psychosocial results can be devastating. • Laboratory – Skin biopsy (only significant test to confirm diagnosis) – Anti-Ro (SSA) test – Complete blood count – Body system functions

Collaborative Management of SLE • Physical assessment and clinical manifestations – Skin involvement – Musculoskeletal changes – Systemic manifestations including pleural effusions or pneumonia and Raynaud’s phenomenon