Ch 24 -- Assessing Musculoskeletal System

Bones

provide structure, give protection, serve as levers, store calcium, and produce blood cells

Physical assessment of the musculoskeletal system

provides data regarding the client's posture, gait, bone structure, muscle strength, and joint mobility, as well as the client's ability to perform ADLs. includes inspecting and palpating the joints, muscles, and bones, testing ROM, and assessing muscle strength.

Knees -- bulge test

bulge test -- With the client in a supine position, use the ball of your hand firmly to stroke the medial side of the knee upward, three to four times, to displace any accumulated fluid. Then press on the lateral side of the knee and look for a bulge on the medial side of the knee.

What do some synovial joints contain?

bursae, which are small sacs filled with synovial fluid that serve to cushion the joint

Cartilaginous joints

(e.g., joints between vertebrae) are joined by cartilage.

Synovial joints

(e.g., shoulders, wrists, hips, knees, ankles; Fig. 24-3, p. 510) contain a space between the bones that is filled with synovial fluid, a lubricant that promotes a sliding movement of the ends of the bones.

Fibrous joints

(e.g., sutures between skull bones) are joined by fibrous connective tissue and are immovable.

How many bones in the human body?

206 bones

Lateral bending

40 degrees in each direction

How is muscle strength rated?

5 Active motion against full resistance Normal 4 Active mtn against some res Slight weakness 3 Active motion against gravity Average weakness 2 Passive ROM (grav rem&asst by exmnr) Poor ROM 1 Slight flicker of contraction Severe weakness 0 No muscular contraction Paralysis

rotation of the cervical vertebrae

70 degrees

FLAT FEET

A flat foot (pes planus) has no arch and may cause pain and swelling of the foot surface.

SCOLIOSIS

A lateral curvature of the spine with an increase in convexity on the side that is curved is seen in scoliosis.

KYPHOSIS

A rounded thoracic convexity (kyphosis) is commonly seen in older adults.

LUMBAR LORDOSIS

An exaggerated lumbar curve (lumbar lordosis) is often seen in pregnancy or obesity.

WRIST, FINGERS, THUMB

Articulation between the distal radius, ulnar bone, carpals, and metacarpals. Contains ligaments and is lined with a synovial membrane. Motion: Wrists: Flexion, extension, hyperextension, adduction, radial and ulnar deviation Fingers: Flexion, extension, hyperextension, abduction, and circumduction Thumb: Flexion, extension, and opposition

HIP

Articulation between the head of the femur and the acetabulum. Contains a fibrous capsule. Motion: Flexion with knee flexed and with knee extended Extension and hyperextension Circumduction Rotation (internal and external) Abduction Adduction

ANKLE AND FOOT

Articulation between the talus (large posterior foot tarsal), tibia, and fibula. The talus also articulates with the navicular bones. The heel (calcaneus bone) is connected to the tibia and fibula by ligaments. Motion: Ankle: Plantar flexion and dorsiflexion Foot: Inversion and eversion Toes: Flexion, extension, abduction, adduction

TEMPOROMANDIBULAR

Articulation between the temporal bone and mandible. Motion: Opens and closes mouth. Projects and retracts jaw. Moves jaw from side to side.

ELBOW

Articulation between the ulna and radius of the lower arm and the humerus of the upper arm; contains a synovial membrane and several bursae. Motion: Flexion and extension of the forearm Supination and pronation of the forearm

KNEE

Articulation of the femur, tibia, and patella; contains fibrocartilaginous discs (medial and lateral menisci) and many bursae. Motion: Flexion Extension

SHOULDER

Articulation of the head of the humerus in the glenoid cavity of the scapula. The acromioclavicular joint includes the clavicle and acromion process of the scapula. It contains the subacromial and subscapular bursae. Motion: Flexion and extension Abduction and adduction Circumduction Rotation (internal and external)

THENAR ATROPHY

Atrophy of the thenar prominence due to pressure on the median nerve is seen in carpal tunnel syndrome.

What do you note when inspecting gait?

Base of support Weight-bearing stability Foot position Stride and length and cadence of stride Arm swing Posture

Flexion:

Bending the extremity at the joint and decreasing the angle of the joint

Describe the kinds of marrow that is contained by bones

Bones contain red marrow that produces blood cells and yellow marrow composed mostly of fat

CALLUS

Calluses are nonpainful, thickened skin that occur at pressure points.

CHRONIC RHEUMATOID ARTHRITIS

Chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited range of motion, and finger deviation toward the ulnar side are seen in chronic rheumatoid arthritis.

Circumduction:

Circular motion

Test for thumb weakness

Client cannot raise the thumb up from the plane and stretch the thumb pad to the little finger pad. This indicates thumb weakness in carpal tunnel syndrome.

TMJ

Clients with temporomandibular joint (TMJ) dysfunction may have difficulty chewing and may describe their jaws as "getting locked or stuck." Jaw tenderness, pain, or a clicking sound may also be present with TMJ.

CORN

Corns are painful thickenings of the skin that occur over bony prominences and at pressure points. The circular, central, translucent core resembles a kernel of corn.

What do you do if you find a limitation in RoM?

If you identify a limitation in ROM, measure ROM with a goniometer (a device that measures movement in degrees). To do so, move the arms of the goniometer to match the angle of the joint being assessed. Then describe the limited motion of the joint in degrees: for example, "elbow flexes from 45 degrees to 90 degrees."

GANGLION

Nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) is commonly seen at the dorsum of the wrist.

BOUTONNIÈRE AND SWAN-NECK DEFORMITIES

Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint (boutonnière deformity) and hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint (swan-neck deformity) are also common in chronic rheumatoid arthritis.

Phalen's test.

For carpal tunnel Ask the client to rest elbows on a table and place the backs of both hands against each other while flexing the wrists 90 degrees with fingers pointed downward and wrists dangling (Fig. 24-20A). Have the client hold this position for 60 seconds.

HALLUX VALGUS

Hallux valgus is an abnormality in which the great toe is deviated laterally and may overlap the second toe. An enlarged, painful, inflamed bursa (bunion) may form on the medial side.

HAMMER TOE

Hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint (hammer toe) commonly occurs with the second toe.

Test for back and leg pain.

If the client has low back pain that radiates down the back, perform the straight leg test to check for a herniated nucleus pulposus. Ask the client to lie flat and raise each relaxed leg independently to the point of pain. At the point of pain, dorsiflex the client's foot. Note the degree of elevation when pain occurs, the distribution and character of the pain, and the results from dorsiflexion of the foot.

Flick signal

If the patient responds with a motion that resembles shaking a thermometer (flick signal), carpal tunnel may be suspected.

ACUTE GOUTY ARTHRITIS

In gouty arthritis, the metatarsophalangeal joint of the great toe is tender, painful, reddened, hot, and swollen.

What does smoking do to the musculoskeletal system?

Increased risk of osteoperosis

Assessing Joints

Inspect size, shape, color, and symmetry. Note any masses, deformities, or muscle atrophy. Compare bilateral joint findings. Palpate for edema, heat, tenderness, pain, nodules, or crepitus. Compare bilateral joint findings. Test each joint's range of motion (ROM). Demonstrate how to move each joint through its normal ROM, then ask the client to actively move the joint through the same motions. Compare bilateral joint findings.

Hips -- inspection and palpation

Instability, inability to stand, and/or a deformed hip area are indicative of a fractured hip. Tenderness, edema, decreased ROM, and crepitus are seen in hip inflammation and DJD. The most common injuries of the hip and groin region in athletes are groin pulls and hamstring strains. Strains, a stretch or tear of muscle or tendons, often occur in the lower back and the hamstring muscle Inability to abduct the hip is a common sign of hip disease. Pain and a decrease in internal hip rotation may be a sign of osteoarthritis or femoral neck stress fracture. Pain on palpation of the greater trochanter and pain as the client moves from standing to lying down may indicate bursitis of the hip.

Hyperextension:

Joint bends greater than 180 degrees

STERNOCLAVICULAR

Junction between the manubrium of the sternum and the clavicle; has no obvious movements.

knees -- inspection and palpation

Knees turn in with knock knees (genu valgum) and turn out with bowed legs (genu varum). Swelling above or next to the patella may indicate fluid in the knee joint or thickening of the synovial membrane. Tenderness and warmth with a boggy consistency may be symptoms of synovitis. Asymmetric muscular development in the quadriceps may indicate atrophy.

Abduction

Moving away from midline of the body

Retraction:

Moving backward

Inversion:

Moving inward

Eversion:

Moving outward

Adduction:

Moving toward midline of the body

TMJ Assessment Findings

Normal -- Snapping and clicking may be felt and heard in the normal client. Mouth opens 1-2 inches (distance between upper and lower teeth). The client's mouth opens and closes smoothly. Jaw moves laterally 1-2 cm. Jaw protrudes and retracts easily. Abnormal -- Decreased ROM, swelling, tenderness, or crepitus may be seen in arthritis. Decreased muscle strength with muscle and joint disease. Decreased ROM, and a clicking, popping, or grating sound may be noted with TMJ dysfunction.

Inspection and palpation of the sternomandibular joint

Normal -- There is no visible bony overgrowth, swelling, or redness; joint is nontender. Abnormal -- Swollen, red, or enlarged joint or tender, painful joint is seen with inflammation of the joint.

Ankle and feet assessment

Normal -- Toes usually point forward and lie flat; however, they may point in (pes varus) or point out (pes valgus). Toes and feet are in alignment with the lower leg. Smooth, rounded medial malleolar prominences with prominent heels and metatarsophalangeal joints. Skin is smooth and free of corns and calluses. Longitudinal arch; most of the weight bearing is on the foot midline. No pain, heat, swelling, or nodules are noted. Abnormal -- A laterally deviated great toe with possible overlapping of the second toe and possible formation of an enlarged, painful, inflamed bursa (bunion) on the medial side is seen with hallux valgus. Common abnormalities include feet with no arches (pes planus or "flat feet"), feet with high arches (pes cavus); painful thickening of the skin over bony prominences and at pressure points (corns); nonpainful thickened skin that occurs at pressure points (calluses); and painful warts (verruca vulgaris) that often occur under a callus (plantar warts; Ankles are the most common site of sprains, which occur with stretched or torn ligaments (tough bands of fibrous tissue connecting bones in a joint; Mayo Clinic Staff, 2011). Tender, painful, reddened, hot, and swollen metatarsophalangeal joint of the great toe is seen in gouty arthritis. Nodules of the posterior ankle may be palpated with rheumatoid arthritis.

OSTEOARTHRITIS

Osteoarthritis (degenerative joint disease) nodules on the dorsolateral aspects of the distal interphalangeal joints (Heberden's nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they may affect middle-aged or older adults and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Similar nodules on the proximal interphalangeal joints (Bouchard's nodes) are less common. The metacarpophalangeal joints are spared.

Inspection and palpation of the hands and fingers:

Pain, tenderness, swelling, shortened finger, depressed knuckle and/or inability to move the finger is seen with finger fractures. Swollen, stiff, tender finger joints are seen in acute rheumatoid arthritis. Boutonnière deformity and swan-neck deformity are seen in long-term rheumatoid arthritis. Atrophy of the thenar prominence may be evident in carpal tunnel syndrome. In osteoarthritis, hard, painless nodules may be seen over the distal interphalangeal joints (Heberden's nodes) and over the proximal interphalangeal joints (Bouchard's nodes) Inability to extend the ring and little fingers is seen in Dupuytren's contracture. Painful extension of a finger may be seen in tenosynovitis (infection of the flexor tendon sheathes; Decreased muscle strength against resistance is associated with muscle and joint disease.

TENOSYNOVITIS

Painful extension of a finger may be seen in acute tenosynovitis (infection of the flexor tendon sheaths).

PLANTAR WART

Plantar warts are painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots.

What do skeletal muscles do?

Skeletal muscles assist with posture, produce body heat, and allow the body to move.

Extension:

Straightening the extremity at the joint and increasing the angle of the joint

Swelling and tenderness in the wrists

Swelling is seen with rheumatoid arthritis. Tenderness and nodules may be seen with rheumatoid arthritis. A nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) may be noted on the wrists Signs of a wrist fracture include pain, tenderness, swelling, and inability to hold a grip; as well as pain that goes away and then returns as a deep, dull ache. Extreme tenderness occurs when pressure is applied on the side of the hand between the two tendons leading to the thumb Snuffbox tenderness may indicate a scaphoid fracture, which is often the result of falling on an outstretched hand.

ACUTE RHEUMATOID ARTHRITIS

Tender, painful, swollen, stiff joints are seen in acute rheumatoid arthritis.

TMJ ROM test

Test -- Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V (trigeminal nerve). Normal -- Jaw has full ROM against resistance. Contraction palpated with no pain or spasms. Abnormal -- Lack of full contraction with cranial nerve V lesion. Pain or spasms occur with myofascial pain syndrome.

Test ROM of the cervical spine.

Test -- ask the client to touch the chin to the chest (flexion) and to look up at the ceiling (hyperextension). Normal -- Flexion of the cervical spine is 45 degrees. Extension of the cervical spine is 45 degrees. Abnormal -- Cervical strain is the most common cause of neck pain. It is characterized by impaired ROM and neck pain from abnormalities of the soft tissue (muscles, ligaments, and nerves) due to straining or injuring the neck. Causes of strains can include sleeping in the wrong position, carrying a heavy suitcase, or being in an automobile crash. Cervical disc degenerative disease and spinal cord tumors are associated with impaired ROM and pain that radiates to the back, shoulder, or arms. Neck pain with a loss of sensation in the legs may occur with cervical spinal cord compression.

Assessing Muscles

Test muscle strength by asking the client to move each extremity through its full ROM against resistance. Do this by applying some resistance against the part being moved. Document muscle strength by using a standard scale (see the following Rating Scale for Muscle Strength). If the client cannot move the part against your resistance, ask the client to move the part against gravity. If this is not possible, then attempt to move the part passively through its full ROM. If this is not possible, then inspect and feel for a palpable contraction of the muscle while the client attempts to move it. Compare bilateral joint findings. Rate muscle strength

What can a family history of rheumatoid arthritis, gout, or osteoporosis indicate?

These conditions tend to be familial and can increase the client's risk for development of these diseases.

VERTEBRAE (LATERAL VIEW)

Thirty-three bones: 7 concave-shaped cervical (C); 12 convex-shaped thoracic (T); 5 concave-shaped lumbar (L); 5 sacral (S); and 3-4 coccygeal, connected in a vertical column. Bones are cushioned by elastic fibrocartilaginous plates (intervertebral discs) that provide flexibility and posture to the spine. Paravertebral muscles are positioned on both sides of vertebrae. Motion: Flexion Hyperextension Lateral bending Rotation

knees -- ballottement test.

This test helps to detect large amounts of fluid in the knee. With the client in a supine position, firmly press your nondominant thumb and index finger on each side of the patella. This displaces fluid in the suprapatellar bursa, located between the femur and patella. Then with your dominant fingers, push the patella down on the femur (Fig. 24-27). Feel for a fluid wave or a click. Abnormal -- Fluid wave or click palpated, with large amounts of joint effusion. A positive ballottement test may be present with meniscal tears. Palpate the tibiofemoral space. As you compress the patella, slide it distally against the underlying femur. Note crepitus or pain. Abnormal -- A patellofemoral disorder may be suspected if both crepitus and pain are present on examination

Dorsiflexion:

Toes draw upward to ankle

Plantar flexion:

Toes point away from ankle

External rotation:

Turning of a bone away from the center of the body

Rotation:

Turning of a bone on its own long axis

Internal rotation:

Turning of a bone toward the center of the body

Abnormal Gait findings

Uneven weight bearing is evident. Client cannot stand on heels or toes. Toes point in or out. Client limps, shuffles, propels forward, or has wide-based gait. (See Chapter 25, Assessing Neurologic System, for specific abnormal gait findings.)

test for Tinel's sign:

Use your finger to percuss lightly over the median nerve (located on the inner aspect of the wrist; No tingling or shocking sensation.

What effect can weight gain have on the musculoskeletal system?

Weight gain can increase physical stress and strain on the musculoskeletal system.

Pronation:

`Turning or facing downward

Pain or clicking is indicative of what?

a torn meniscus of the knee

osteoblasts

active cells that form bone tissue

another word for joint

articulation

osteoclasts

cells that break down bones

What is falling backwards easily seen with?

cervical spondylosis and Parkinson's disease

two types of bone:

compact bone, hard and dense and makes up the shaft and outer layers spongy bone, contains numerous spaces and makes up the ends and centers of the bones

periosteum

covers the bones; it contains osteoblasts and blood vessels that promote nourishment and formation of new bone tissues

Osteoporosis

disease in which bones demineralize and become porous and fragile, making them susceptible to fractures.

appendicular skeleton

extremities, shoulders, and hips

what are long muscle fibers called?

fasciculi

ROM of the thoracic and lumbar spine

flexion of 75-90 degrees

musculoskeletal system's overall purpose

provide structure and movement for body parts

axial skeleton

head and trunk

What can excessive alcohol or caffiene intake do?

increase risk of osteoperosis

What are bones in synovial joints joined by?

ligaments, which are strong, dense bands of fibrous connective tissue

Firm, nontender, subcutaneous nodules in elbow

may be palpated in rheumatoid arthritis or rheumatic fever. Tenderness or pain over the epicondyles may be palpated in epicondylitis (tennis elbow) due to repetitive movements of the forearm or wrists.

Redness, heat, and swelling in elbows

may be seen with bursitis of the olecranon process due to trauma or arthritis.

how many muscles make up skeletal muscles

musculoskeletal system is made up of 650 skeletal (voluntary) muscles

Inability to shrug shoulders against resistance is

seen with a lesion of cranial nerve XI (spinal accessory). Decreased muscle strength is seen with muscle or joint disease.

three types of muscles:

skeletal, smooth, and cardiac

What is responsible for coordinating the functions of the skeleton and muscles?

the neurologic system