musculoskeletal assessment.ppt

7/27/2019 musculoskeletal assessment.ppt

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Assessment of the

MusculoskeletalSystem

Merchie Lissa F. Tandog, RNSeptember 11, 2009


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ANATOMY AND

PHYSIOLOGY

OF THE

MUSCULOSKELETALSYSTEM


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The musculoskeletal system consist

the skeletal system -- bones and jo

(union of two or more bones) -- and skeletal muscle system (voluntary

striated muscles). These two systems w

together to provide basic functions that

essential to life, including: Protection: protects the brain and inte

organs

Support: maintains upright posture

Blood cell formation: hematopoiesis


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Mineral homeostasis

Storage: stores fat and minerals Leverage: A lever is a simple

machine that magnifies speed o

movement or force. The levers amainly the long bone of the bod

and the axes are the joints wher

the bones meet.


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Typical

Arrangement of

MusculoskeletalTissues


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Skeletal muscles, attached to bone by

tendons, produce movement by bendthe skeleton at movable joints.

The connecting tendon closest to the b

or head is called the proximal

attachment: this is termed the origin of muscle. The other end, the distal

attachment, is called the insert ion. Du

contraction, the origin remains stationa

and the insertion moves.


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The force producing the bending i

always exerted as a pull by

contraction, thus making the

muscle shorter

Muscles cannot actively push.

Reversing the direction in which ajoint bends is produced by

contracting a different set of

muscles.


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Muscle fiber- the contracting unit.Muscle fibers consist of two main

protein strands - actinand myos in.Where the strands overlap, the fiberappears dark. Where they do notoverlap, the fiber appears light. These

alternating bands of light and dark givskeletal muscle its characteristic striaappearance.

The trigger which starts contraction

comes from the motor nerve attachedeach muscle fiber at the motor endplate.


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Types of Muscle Contraction

1. Isometric- the length of themuscle remains constant but theforce generated by the muscles increased

2. Isotonic- shortening of themuscles with no increase intension within the muscles


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Body Movements produced by muscle

contraction


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Flexion & Extension


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Growth and Metabolism

Calcium and Phosphorous- make u

99% of the bodys calcium and 90% othe bodys phosphorous

Inverse relationship; as calcium increase

phosphorous decrease

Calcitonin- produced by thyroid glandand decreases calcium concentration

is above the normal level; inhibits bon

resorption and increases renal excret

of Ca and Phosphorous as needed tomaintain equilibrium


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Vitamin D- produced and transported in tbody to promote the absorption of calciumand phosphorous from the small intestine

PTH- secretion increases when calcium

levels are low to stimulate bone to producmore calcium into the blood

Growth Hormone- secreted by the anterpituitary gland responsible for increasingbone length and determining the amount

bone matrix formed before puberty Glucocorticoids- regulates protein

metabolism

Estrogen and Androgen- estrogen inhibPTH, androgen increase bone mass


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ROM (Range of Motion)

A goal of ROM is to keepatient in the best physi

shape possible.

Another goal is to increa

joint mobility and toincrease circulation to th

affected part.


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Passive ROM

The patient is unable tomove independently and

someone else

manipulates body parts.


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Active ROM The patient moves

independently through a ROM for each joint.

Active ROM increases

muscle tone, mass, stren

and improves cardiac andpulmonary functioning


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Assessment Techniques

History Demographic Data

Young men at greater risk for trauma r/t V

elderly for falls that result in fracture and

soft-tissue injury

Family history and genetic risk Osteoporosis, bone cancer, osteoarthritis

Personal History

Accidents, illnesses, lifestyle, medications

previous or concurrent diseases, sports,level of activity


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Diet History

Women who do not consume adequate

amounts of calcium, lactose intolerance

inadequate protein or insufficient Vit C D in the diet; obesity

Socio-economic status

Lifestyle, occupation (manual labor e.g

housekeepers, mechanics), computer-

related jobs, construction workers;

athletes

C t h lth bl


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Current health problems

Collect data as follows:

Date and tome of onset

Factors that cause pr exacerbate the

problem

Course of the problem

Clinical manifestationMeasures that improve clinical

manifestation

MOST COMMON COMPLAINT OF

PEOPLE WITH MUSCULOSKELETPROBLEMS IS PAIN!


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PQRST Model to assess pain

P- provoking incident? Q- quality of pain?

R- region, radiation, and relief?

S- severity of the pain?

T- time?

It is best for the client describes the pain

his or her own words and points to its

location if possible


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Physical Assessment

IPPA and ROM Posture- persons body build and

alignment when standing or walking

Gait-

Stance and swing phase

Antalgic or lurch

Mobility

Ask client to perform ADLs

Goniometerto measure ROM


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Assessment of head and neck

Inspect and palpate the skull for shapsymmetry, tenderness and masses

Temporomandibular joints (TMJs)

Note for pain, crepitus, swelling

Inspect and palpate each vertebra ofthe spine in the neck

Malalignment, tenderness, inability to fle

extend, rotate the neck as expected


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Assessment of the Spine

Thoracic, lumbar and sacral spine areevaluated in the same manner as the neck

A t f th


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Assessment of the upper

extremities

Assess both extremities at the sametime

Palpate for size, swelling, deformity,

malalignment, tenderness, pain and

mobility



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extremities

Evaluate the hip by its degree ofmobility

Knee- assess for pain and limitation i

mobiliy

Knock knee (genu valgum)

Gena varum (bow-legged)

Feet- observe and palpate each joint

and test for ROM


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Neurovascular Assessment

Inspect skin color, temperature andcapillary refill distal to an injury or cas

Palpation of pulses below the level of

injury an assessment of sensation,

movement, and pain on the injured p

Assessment of the Muscular


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Assessment of the Muscular

System

Evaluate size, shape, tone andstrength of major skeletal muscles

Lovett s scale for grading muscle

strength


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Diagnostic Evaluation

Bl d T t


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Blood Tests

ESR

Rate at which RBCs settle inunclotted blood in mm/hr

elevated in arthritis,

Serum Uric Acid By product of purine metabolism

elevated in gout

Minerals:


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Minerals:

Calcium- decreased levels in

osteomalacia and osteoporosis; increas

levels in bone tumors, healing fractures

Alkaline Phosphatase- enzyme norma

present in the blood- increases with bon

or liver damage Normal range- 30-150 mU/L; elevated in bo

cancer, osteoporosis

Phosphorous- increased levels in

healing fractures, bone tumors

Muscle Enzymes


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Aldolase (ALD)-

Normal range: 22-59 mU/L

Creatinine kinase (CK-MM)- rise

2-4 hrs after muscle injury

Elevated in skeletal muscle injuries Lactic Dehydrogenase (LDH)

Normal range- 100-225 mU/mL

Elevated in skeletal muscle necrosis

extensive cancer

Muscle Enzymes


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IMAGING STUDIES

X-ray Studies


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X-ray Studies

Determine bone density, texture,

erosion, and changes in bone

relationship

Multiple x-rays are needed for full

assessment of the structure being

examined

Joint x-ray reveals fluid, irregularity,

spur formation, narrowing and

changes in joint structure


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Computed Tomography (CT Scan


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Computed Tomography (CT Scan

Shows in detail a specific plane of

involved bone and can reveal tumors

the soft tissue or injuries to the ligameor tendons

It is used to identify the location and

extent of fractures in areas that aredifficult to evaluate

CT studies may be performed with or

without contrast agents- lasts about 1

hour The patient must remain still during th

CT i f thi h l


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CT scan image of thigh muscles

MRI
http://www.ispub.com/ispub/ijos/volume_10_number_2_4/primary_intramuscular_hydatids_in_vastus_lateralis_and_adductor_magnus_muscles/vastus-fig1.jpg


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MRI

Used to detect abnormalities (i.e.,

tumors or narrowing of tissue pathways

through bone) of soft tissues such asmuscle, tendon, cartilage, nerve and fat

Because an electromagnet is used,

patients with any metal implants, clips o

pacemakers are not candidates for MRI

To enhance visualization of anatomic

structures, contrast media may be

injected intravenously

During the procedure the patient


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During the procedure, the patient

needs to lie still for 1 to 2 hours

and will hear a rhythmic knockingsound

Patients with claustrophobia may

be unable to tolerate the

confinement of closed MRIequipment without sedation

MRI i f th k


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MRI image of the knee

Arthrography


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Useful in identifying acute or chronic tears

the joint capsule or supporting ligaments o

the knee, shoulder, ankle, hip or wristA radiopaque substance or air is injected

the joint cavity to outline soft tissue structu

and the contour of the joint

The joint is put through its ROM to distributhe contrast agent while a series of x-rays

obtained. If a tear is present, the contrast

agent leaks out of the joint and is evident

the x-ray image

After the arthrography the joint i


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After the arthrography, the joint i

usually rested for 12 hours and

compression elastic bandage is applie

as prescribed Nurse provides comfort measures (mil

analgesia, ice) as appropriate

The nurse should explain to the patien

that it is normal to experience clickin

or crackling in the joint for a day or tw

after the procedure, until the contras

agent is absorbed.

Shoulder arthrography


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Shoulder arthrography
http://www.radiology.wisc.edu/divisions/msk/interventional/Shoulder%20arthrogram/image1.jpghttp://www.radiology.wisc.edu/divisions/msk/interventional/Shoulder%20arthrogram/image1.jpg


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Bone Scan


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Bone Scan

Measures radioactivity in

bone 2 hours after IVinjection of a radioisotope

Detects bone tumors,

osteomyelitis


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Client Preparation


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p

Inquire about possible allergy to

the radioisotope Instruct client to void

immediately before the

procedure- to ensure the pelvis

bone is scanned

Instruct to increase OFI to

distribute the isotope

Instruct client to remain stillduring the procedure

Arthroscopy


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Arthroscopy

Insertion of a fiberoptic

scope into a joint for directvisualization to diagnose

joint disorders

Treatment of tears, defects,and disease process may be

performed through the

arthroscope

PROCEDURE:


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PROCEDURE:

Performed in the OR under sterile

conditions Insertion of a local anesthetic into th

joint or a general anesthesia is used

A large bore needle is inserted andthe joint is distended with saline

The arthroscope is introduced and

joint structures, synovium and

articular surfaces are visualized

POST PROCEDURE:


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Puncture wound is closed with

adhesives strips or sutures and

covered with sterile dressing

Ice may be applied to control

edema and discomfort

Joint is left extended and

elevated to reduce swelling

Arthroscopy of the knee


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Arthroscopy of the knee

Arthrocentesis


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Joint aspiration; carried out to obta

synovial fluid for purposes of

examination or to relieve pain dueeffussion

Helpful in the diagnosis of septic

arthritis and other inflammatoryarthropathies and reveals the

presence of hemarthrosis

Normally, the synovial fluid is cleapale, straw-colored, and scanty in

PROCEDURE


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PROCEDURE:

Using aseptic technique, thephysician inserts a needle into a

joint and aspirates fluid

Anti-inflammatory agents may beinserted into a joint

A sterile dressing is applied after

aspiration


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Arthrocentesis and lavage

of the temporomandibular

joint

Knee joint aspiration

Biopsy


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May be performed to determine the

structure and composition of bone

marrow, bone muscle, or synovium to

help diagnose specific diseases.

The nurse monitors the biopsy site for

edema, bleeding, pain, and infection. is applied as prescribed to control

bleeding and edema.

In addition, analgesics are prescribed

administered for comfort


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Bone marrow biopsy


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Bone marrow biopsy
http://upload.wikimedia.org/wikipedia/commons/c/cb/Bone_marrow_biopsy.jpg


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Thank you!

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musculoskeletal assessment.ppt