The Musculoskelatal System

Review of the Anatomy and Physiology

I. MUSCULAR SYSTEM make up 40% to 50% of body weight produces movement and heat by contraction 2 Purposes of Movement 5. Necessary to perform muscle activities of daily living

3 types of muscles: 1. Skeletal Muscle- attaches to bones of the skeleton 2. Cardiac Muscle- myocardium - involuntarily and exists only in the heart -controlled by signals from the autonomic nervous system, hormones and amount of venous return 3. Smooth Muscle- involuntarily and is present in the walls of hollow organs and in other areas -controlled by the autonomic nervous

FUNCTIONS OF MUSCULAR SYSTEM 1. Movement-

contraction occurs when a stimulus excites an individual muscle fiber 2 purpose of movement: c. To perform muscle ADLs d. Source of pleasure

Stimulus / nerve impulse Release Ach at the end of motor neuron Ach crosses te neuromuscular junction and elicits potential by binding to a receptor Contraction due to release of calcium inside the cell Continuos flow of stimuli

Calcium returns to storage in muscles

Rapid impulse causing continuos contractions

2. Propulsion- contraction of smooth muscles applies pressure that may mix, break-up or move substances forward 3. Heat production- contraction produces heat which used to maintain body temperature

II. SKELETAL SYSTEM Axial Skeleton 80 bones found in the upper and lower extremities consist of the skull, vertebral column and thorax Appendicular Skeleton 126 bones consists of bones of extremities, shoulder and pelvis

Types of Bones According to Shape 1. Long bones longer than their width found in the upper and lower extremities   2. Short bones do not have a long axis they are cubical in shape   3. Flat bones protect soft body parts and provide large surface for muscle attachment 4. Irregular bones have various shape

Collagen- fibrous composition of bone which provide bone with great tensile strength so that it can withstand stretching   Hydroxyapatite- inorganic salts which allow bone to withstand compression

Microscopic Anatomy  Compact Bones  Spongy Bones

Gross Anatomy of the Bones  Diaphysis - Shaft  Epiphysis - ends

- Epiphyseal plate/ line  Medullary Cavity marrow

  *Periosteum *Endosteum

3 Types of Bone Cells 1. Osteoblasts bone-forming cells lay down new bone by calatalyzing reactions that take calcium and phosphate from the blood and form it into bone matrix in a collagen meshwork   2. Osteocytes- Osteoblasts that are found in the bone matrix   3. Osteoclasts- cells that resorb (remove) damaged, old bone cells during periods of growth repair *Joints- also known as articulations

Kinds of Joints 1. Synovial joints- freely movable, permitting position and motion changes - synovial membrane produces synovial fluid which fills the cavity fro lubrication and cartilage nourishment 2. Fibrous joints- articulations in which bones are held together by fibrous connective tissues; minimal movement is possible 3. Cartilaginous joints- bones which are held together by cartilage; slight movement is possible in these joints   SUPPORTIVE STRUCTURES Bursae – are small sacs lined with synovial membrane and filled with synovial fluid that act as cushion between structure. Tendon sheaths - found where tendons cross joints and may be subject to constant friction Ligaments - bonds of fibrous tissues that connect

FUNCTIONS OF SKELETAL SYSTEM  Bones give form to the body- support various tissues and organs and permit movement by providing attachment for tendons and ligaments  Bones protect internal organs- e.g. skull, rib, cage  Hematopoietic function- bone houses hematopoietic tissues which manufacture blood cells

2 types of Bone Marrow 1. Yellow Bone Marrow connective tissue composed of fat cells found in the shafts a long bones and extends into the haversian system does not produce blood cells except during times of increased blood cell needs 2. Red bone Marrow has a hemapoietic function located in the cancellous bone spaces found in flat bones *Osteoporosis- a condition of decreased calcium in bone which

ASSESSMENT

Health history- provides direction for further assessment  Childhood Diseases  DM  Blood dyscrasias  Psoriasis  Cartilage damage due to trauma

>Ask the client about history of TB, sickle cell dse, poliomyelitis, inflammatory or degenerative arthritis, scurvy, rickets, osteomyelitis, soft tissue infection, fungus, infection of bones or joints, and streptococcal and neuromuscular disorder

 Major Illnesses and Hospitalization  Ask the client about hospitalization r/t musculoskeletal d/o or trauma  If they cannot remember details then ask permission to obtain medical records  Ask past or present minor injury including 1) circumstances of the injury 2) dx of the injury 3) tx received 4) duration of tx 5) current problem from the injury or residual impairment

 Medication   Question about past and present

        

prescriptions, OTC, and herbal meds and find out 1) reason for taking it 2) dose and freq. 3) how long the client has taken it 4) S/E Corticosteroids High doses of anticoagulants Anticonvulsants Phenothiazines K wasting diuretics Amphetamines and caffeine HRT w/ estrogen NSAIDs x 4wks Herbal: Glucosamine, Chondroitin, Cayenne, White willow

 Personal history- biographical and

demographic data

 enables individualized care planning  client’s address and means of transportation helps to understand the energy required for the client to keep and appointment  AGE and GENDER     

 

osteoarthritis Osteoporosis Reiter’s syndrome Osteogenic sarcoma Carpal tunnel syndrome

Chief complaint  Ask the reason for seeking health care  Common musculoskeletal clinical manifestations are pain, tenderness, muscle tightness or weakness, joint stiffness, cramps, muscle spasms, swelling, redness, deformity, reduced movement or joint range of motion, sensory changes, and other abnormal sensations, inability to perform ADLs  Ask about client’s perception of the condition, fears and concerns

 Symptom analysis

 Pain Ask about the exact location Ask the client to describe pain Determine pain intensity Aggravating factors Movement? Temperature changes? Lifting heavy things? Worse at particular time of the day? Does it wake the client or prevent sleep and rest?

 Relieving factors:  Which medications help reduce the

pain? Pain from inflammation?  Pain from traumatic injury – Opioids

Associated conditions: Recent injuries? Fall? Pain associated with chills, fever, rash or sore throat?

Joint stiffness > Ask the client to point to joints that are stiff. Are they always stiff? How long does the stiffness last? > At what time is the stiffness worst? > What relieves the stiffness? Temperature changes? Exercise? > Does the joint lock so it cannot move? Does the client hear or feel bones rubbing together? > Does the client have pain or weakness in muscle with certain movement? Does it interfere w/ ADLs?

Swelling Ask how long the client has had swelling? Is there pain? Does swelling limit the client’s movement? Does rest or elevating the part give relief? Recent cast? Has the area been hot or red? RICE

Deformity and immobility Has the deformity developed suddenly or gradually? Is the movement limited? Is this limitation always present? It is worse after activity? Does any body position make it worse or better? Ask how the deformity affects the client’s ADLs. Does the client use any supportive equipment such as crutches, a walker, or bandages?

 Sensory changes Does the client have history of back pain or injury? If so, where is the pain located? Does the pain travel? Does the client have trouble walking? Is there a loss of feeling anywhere? If so, is the loss of feeling associated with any pain? Does the client have any tingling or burning sensation?

 Family health history – arthritis,

osteoporosis, ankylosing spondylitis, gout, heberden’s nodes in osteoarthritis, muscular dystrophy, and scoliosis  30% of Psoriatic Arthritis have family

history of psoriasis

Psychological history  Occupation – muscle strain, degenerative

vertebral disk problems, and other trauma heavy lifting or strenuous activities; low back pain from extensive driving; uneven pressure on spinal column due to habitual carrying of heavy objects; Orthopedic injuries from repetitive strain common in prolonged use of computers and keyboards

 Activities of daily living

>Difficulty in performing the following:

 Opening containers, pouring liquids, and cutting up foods  Dressing, using zippers, fastening and unfastening buttons, snaps or hooks  Grooming, combing hair, and applying make up  Running a bath and testing water temperature, washing hair, and shaving  Writing  Getting out of the house, climbing stairs, or getting in and out of chairs and cars >Ask about safety practices

Exercise >lack of exercise produces poor muscle tone, which leads to muscle strain >sporadic exercise of poorly toned muscles is more likely to cause muscle injury and spasm >lack of warm up exercises increase likelihood of injury >fractures and other trauma – contact sports, >Achilles tendon damage - improper landing on heels with jogging >Pain in arm joints – racket sports >high heeled shoes – shorten the achilles tendon and pitch the center of gravity forward leading to lordosis Nutrition >Well balanced diet helps maintain structure of bones and muscle including Vit. A, D and calcium >Obesity stresses weight bearing joints and predisposes to ligament instability, particularly of the lower back >Poor calcium intake can lead to bone decalcification and fractures

 

Habits and safety >Positive lifestyle >Screening programs for early detection of osteoporosis REVIEW OF SYSTEMS: Pain or burning when urinating, which is associated with Reiter’s syndrome Tachycardia and HTN, which may accompany gout Chronic diarrhea, which may occur when arthritis is associated with colitis or other GI problems Conjuctivitis, which may indicate Reiter’s syndrome Skin changes, which may indicate musculoskeletal problems (dry skin over the thumb and the first two fingers suggests carpal tunnel syndrome) Cramping leg pain (intermittent claudication) Generalized muscle cramping which may result from electrolyte imbalance Joint pain with recent chills, fever, or sore throat which may result from rheumatic fever

 Inspection and Palpation  muscle mass for symmetry  joints for symmetry, crepitus, tenders or pain and range of

motion  bones for deformity and leg length discrepancy  deep tendon reflex  Range of Motion  Deltoid- push down client’s arm while it is held up and client     

resist Biceps- hold client’s arm in extension while it is fully extended and client flexes arm Triceps- keep client’s arm in flexion while it is flexed and client extends arm Wrists and finger muscles- push client’s fingers together while client spreads them and resist Grip strength- pull your own crossed index and middle fingers out from the client’s grasp Hamstrings- straighten client’s knee while the client is supine with knees flexed and resist

 General Examination

-gait, body mobility, pasture, general joint motion, balance

 General Examination  As the client enters the examination room, assess the gait

body mobility , posture, general joint motion, and balance  While observing the movement and gait watch for:  Gait patterns associated with specific disorders  Objective evidence of discomfort  Indication of joint stiffness or muscle weakness, lack of

coordination and deformities,  Have the client sit on the edge of the examination table

and observe general appearance and body build. Examine the head, neck, shoulders, and upper extremities  Have the client stand, and examine the chest, back and

ilium. Observe posture, body build, body contours, body alignment, and the cervical, thoracic, and lumbar spine  Observe for the client’s stance and note spinal deformities

or other abnormalities

Common Spinal Deformities Kyphosis Scoliosis   Lordosis   Genu Varum   Genu Valgum

*Common Spinal Deformities Kyphosis

 thoracic curve or hump-back Scoliosis Lordosis Genu Varum Genu Valgum

F. Last, with the client supine, examine the hips, knees, ankles, and feet for alignment, symmetry, and deformities.

MUSCLES Compare each muscle group with its contralateral side  Fasciculations – fine mucles twitches Palpate from proximal to distal for muscle tone (state of tension in a muscle at rest which is felt as firmness) and size  Hypertrophy, or slight increases in mass on dominant side is normal  Atrophy or decrease muscle mass on either side is abnormal Use tape measure to assess limb circumference (difference if 1cm or less between 2 sides is normal) Assess muscle strength while putting joints on active ROM

JOINTS AND BONES Inspect for bilaterally for symmetry, redness, swelling, enlargement, deformity. Palpate for edema, tenderness and crepitus ROM is the maximum range of movement attainable by a healthy joint. It is measured by a goniometer (flexible protractor type instrument place on a joint to measure the angles created by joint movement   Neurovascular assessment Pain Pallor Pulses Poikilothermia Paresthesia Capillary refill Loss of sensation and motor function

DIAGNOSTICS TESTS NON-INVASIVE  Radiography  Tomography  MRI  Fluoroscopy

Non-invasive    Radiography – most widely used  Tomography – body section radiographs that show tissue at various planes through the body as though slices had been made  Dual-energy x-ray absorptiometry – method used to measure bone density to diagnose osteoporosis because condition is not evident in x-ray until 30 to 50% of bone mass is lost.

Dual-Energy X-ray Absorptiometry (DEXA Scan)

INVASIVE Arthrography used to diagnose trauma to joint capsules or supporting ligaments, especially those of the shoulder, wrist, hip, ankle and knee a contrast agent or air is injected into the joint cavity and a series of x-ray films

 NR:  Explain the procedure  Informed consent  Procedure may take up to an hour  Client must remain still during the

procedure  Determine allergies to local anesthetic, iodine or contrast dye  Suggest client to void before the procedure  Tell client that joint may be uncomfortable for 1 to 2 days and should avoid strenuous activities

Sinography - Radiologic use of a contrast medium to opacify a sinus tract or fistula Myelography - X-ray exam of the spinal cord and spinal column - A special X-ray dye (contrast) will be injected through the needle into the area around the spinal column, so as to highlight the

Bone Scans  image of the skeleton are taken after a

radioisotope is injected intravenously and allowed to migrate to bone

 NR:  Explain the procedure  Informed consent  Procedure may take up to an hour  Client must remain still during the

procedure  Suggest client to void before the procedure  Instruct client to drink large amounts of water for 1 to days to help eliminate radioisotope

Arthrocentesis joint aspiration a method of aspirating synovial fluid, blood or plus via a needle inserted into the joint cavity used to diagnose rheumatoid arthritis and other inflammatory conditions or to remove fluid to relieve pain should be strawcolored and present in minute amounts apply compression

 Electromyography – used to

measure and document electrical currents produced by skeletal muscles. Small needle electrodes are inserted into muscles. The electrical potentials of muscles are amplified and displayed on the skin.

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