CHAPTER 49: Assessment of the Musculoskeletal System

Biopsies

A bone biopsy, the physician extracts a specimen of the bone tissue for microscopic examination. This invasive test may confirm the presence of infection or neoplasm. One of two techniques may be used to retrieve the specimen: needle (closed) biopsy or incisional (open) biopsy. Muscle biopsy is done for the diagnosis of atrophy (as in muscular dystrophy) and inflammation (as in polymyositis). The procedure and care for patients undergoing muscle biopsy are the same as those for patients undergoing bone biopsy.

Joints

A joint is a space in which two or more bones come together. This is also referred to as articulation of the joint. There are three types of joints in the body: • Synarthrodial, or completely immovable, joints (e.g., in the cranium) • Amphiarthrodial, or slightly movable, joints (e.g., in the pelvis) • Diarthrodial (synovial), or freely movable, joints (e.g., the elbow and knee) Diarthrodial, or synovial, joint is the most common type of joint in the body. Synovial joints are the only type lined with synovium, a membrane that secretes synovial fluid for lubrication and shock absorption. Patients with inflammatory types of arthritis often have synovitis (synovial inflammation) and breakdown of the cartilage. Bursae, small sacs lined with synovial membrane, are located at joints and bony prominences to prevent friction between bone and structures adjacent to bone. These structures can also become inflamed, causing bursitis. Ball-and-socket joints (shoulder, hip) permit movement in any direction. Hinge joints (elbow) allow motion in one plane—flexion and extension. The knee is often classified as a hinge joint, but it rotates slightly, as well as flexes and extends. It is best described as a condylar type of synovial joint. The gliding movement of the wrist is characteristic of the biaxial joint. Pivot joints permit rotation only, as in the radioulnar area.

Patient History

Accidents, illnesses, lifestyle, and drugs may contribute to a patient's current problem. Young men are at the greatest risk for trauma related to motor vehicle crashes. Older adults are at the greatest risk for falls that result in fractures and soft-tissue injury. Question the patient about any traumatic injuries and sports activities. Previous or current comorbidities such as diabetes. Inquire about his or her ability to perform ADLs independently or if assistive/adaptive devices are used. Weight-bearing activities such as walking can reduce risk factors for osteoporosis and maintain muscle strength. High-impact sports, such as excessive jogging or running, can cause musculoskeletal injury to soft tissues and bone. Tobacco use slows the healing of musculoskeletal injuries. Excessive alcohol intake can decrease vitamins and nutrients the person needs. Inquire about occupation or work life. Certain occupations, such as computer-related jobs, may predispose a person to carpal tunnel syndrome (entrapment of the median nerve in the wrist) or neck pain. Construction workers and health care workers may experience back injury from prolonged standing and excessive lifting. Amateur and professional athletes often experience acute musculoskeletal injuries (e.g., joint dislocations and fractures) and chronic disorders (e.g., joint cartilage trauma), which can lead to OA. Ask about allergies, particularly allergy to dairy products, and previous and current use of drugs—prescribed, over-the-counter, and illicit. Allergy to dairy products could cause decreased calcium intake. Some drugs, such as steroids, can negatively affect calcium metabolism and promote bone loss. Inquire about herbs, vitamin and mineral supplements, or biologic compounds that may be used for arthritis and other musculoskeletal problems, such as glucosamine and chondroitin.

Action Alert

After a bone biopsy, watch for bleeding from the puncture site and for tenderness, redness, or warmth that could indicate infection. Mild analgesics may be used.

Arthroscopy

An arthroscope is a fiberoptic tube inserted into a joint for direct visualization of the ligaments, menisci, and articular surfaces of the joint. The knee and shoulder are most commonly evaluated. In addition, synovial biopsy and surgery to repair traumatic injury can be done through the arthroscope as an ambulatory care or same-day surgical procedure.

Mobility and Functional Assessment

Assess the patient's need for ambulatory devices. Observe his or her ability to perform ADLs. A goniometer is a tool that may be used by rehabilitation therapists or nurses to provide an exact measurement of flexion and extension or joint ROM. Active range of motion (AROM) can be evaluated by asking the patient to move each joint through the ROM. If the patient cannot actively move a joint through range of motion, ask him or her to relax the muscles in the extremity. Hold the part with one hand above and one hand below the joint to be evaluated and allow passive range of motion (PROM) to evaluate joint. Circumduction is a movement that can also be evaluated in the shoulder. Observe the skin for color, elasticity, and lesions that may relate to musculoskeletal dysfunction. For instance, redness or warmth may indicate an inflammatory process and/or pressure injury to skin.

Specific Assessments 2

Assessment of hand function is perhaps the most critical part of the examination. If the hands are affected, inspect and palpate the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. Determine the range of motion (ROM) for each joint by observing active movement. If movement is not possible, evaluate passive motion. For a quick and easy assessment of ROM, ask the patient to make a fist and then appose each finger to the thumb. Evaluation of the hip joint relies primarily on determination of its degree of mobility, because the joint is deep and difficult to inspect or palpate. The patient with hip pain usually experiences it in the groin or has pain that radiates to the knee. The knee is readily accessible for physical assessment, particularly when the patient is sitting and the knee is flexed. Fluid accumulation, or effusion, is easily detected in the knee joint. Limitations in movement with accompanying pain are common findings. The knees may be poorly aligned, as in genu valgum ("knock-knee") or genu varum ("bowlegged") deformities. Observe and palpate each joint of the ankles and feet, and test for ROM if feet are affected by musculoskeletal problems.

Radiography

Bone density, alignment, swelling, and intactness can be seen on x-ray. The conditions of joints can be determined, including the size of the joint space, the smoothness of articular cartilage, and synovial swelling. Soft-tissue involvement may be evident but not clearly differentiated. Inform the patient that the x-ray table is hard and cold, and instruct him or her to remain still. Keep older adults and those at risk for hypothermia as warm as possible (e.g., by using blankets). Myelography involves the injection of contrast medium into the subarachnoid space of the spine, usually by spinal puncture. The vertebral column, intervertebral disks, spinal nerve roots, and blood vessels can be visualized. CT and MRI have often replaced such invasive and potentially painful and risky diagnostic techniques. The post-test care is similar to that for lumbar puncture, except that the patient is usually placed with the head of the bed elevated 30 to 50 degrees to prevent the contrast medium from getting into the brain. An arthrogram is an x-ray study of a joint after contrast medium (air or solution) has been injected. Double-contrast arthrography uses both air and solution. Most joints are now studied by MRI and magnetic resonance (MR) arthrography. CT has gained wide acceptance for detecting musculoskeletal problems, particularly those of the vertebral column and joints.

Laboratory Assessment

Disorders of bone and the parathyroid gland are often reflected in an alteration of the serum calcium or phosphorus level. Alkaline phosphatase (ALP) is an enzyme normally present in blood. The concentration of ALP increases with bone or liver damage. In metabolic bone disease and bone cancer, the enzyme concentration rises. The major muscle enzymes affected in skeletal muscle disease or injuries are: • Creatine kinase (CK-MM) • Aspartate aminotransferase (AST) • Aldolase (ALD) • Lactic dehydrogenase (LDH) As a result of damage, the muscle tissue releases additional amounts of these enzymes, which increases serum levels. The serum CK level begins to rise 2 to 4 hours after muscle injury and is elevated early in muscle disease, such as muscular dystrophy. The CK molecule has two subunits: M (muscle) and B (brain). Three isoenzymes have been identified. Skeletal muscle CK (CK-MM, or CK3) is the only isoenzyme that rises in concentration with damage to skeletal muscle. This test is 90% accurate because it is affected by exercise and certain drugs, such as anticoagulants, furosemide, and statins. AST is moderately elevated (3 to 5 times normal) in certain muscle diseases, such as muscular dystrophy. The levels of the isoenzymes aldolase A (ALD-A) and LDH5 also increase

Electromyography

Electromyography (EMG) may be performed to evaluate diffuse or localized muscle weakness. EMG is usually accompanied by nerve conduction studies for determining the electrical potential generated in an individual muscle. This test helps in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders. EMG may cause temporary discomfort, especially when the patient is subjected to episodes of electrical current. May also prescribe a temporary discontinuation of skeletal muscle relaxants several days before the procedure to prevent drugs from affecting the test.

Arthroscopy: Postprocedure Care

Encourage the patient to perform exercises as taught before the procedure. The surgeon prescribes a mild analgesic, such as acetaminophen. Patient may have short-term activity restrictions. Ice is often used for 24 hours, and the extremity should be elevated for 12 to 24 hours. Monitor and teach the patient to observe for: • Swelling • Increased joint pain attributable to mechanical injury • Thrombophlebitis • Infection Severe joint or limb pain after discharge may indicate a possible complication. Teach the patient to contact the physician immediately.

Neurovascular Assessment/Action Alert

Perform an assessment of peripheral vascular and nerve integrity. Beginning with the injured side, always compare one extremity with the other. Perform a complete neurovascular assessment (also called a "circ check"), which includes palpation of pulses in the extremities below the level of injury and assessment of sensation, movement, color, temperature, and pain in the injured part. If pulses are not palpable, use a Doppler to find pulses in the extremities.

Nutrition History

Most people, especially women, do not get enough calcium in their diet. Determine if the patient has had a significant weight gain or loss. Lactose intolerance is a common problem that can cause inadequate calcium intake. People who cannot afford to buy food are especially at risk for undernutrition. Some older adults and others are not financially able to buy the proper foods. Inadequate protein or insufficient vitamin C or D in the diet slows bone and tissue healing. Obesity places excess stress and strain on bones and joints. People with eating disorders such as anorexia nervosa and bulimia nervosa are also at risk for osteoporosis related to decreased intake of calcium and vitamin D.

Bones: Types and Structure

Long bones, such as the femur, are cylindric with rounded ends and often bear weight. Short bones, such as the phalanges, are small and bear little or no weight. Flat bones, such as the scapula, protect vital organs and 1018often contain blood-forming cells. Bones that have unique shapes are known as irregular bones. The carpal bones in the wrist and the small bones in the inner ear are examples of irregular bones. The sesamoid bone is the least common type and develops within a tendon; the patella is a typical example. The outer layer of bone, or cortex, is composed of dense, compact bone tissue. The inner layer, in the medulla, contains spongy, cancellous tissue. The long bone typically has a shaft, or diaphysis, and two knoblike ends, or epiphyses. The haversian system is a complex canal network containing microscopic blood vessels that supply nutrients and oxygen to bone, as well as lacunae, which are small cavities that house osteocytes (bone cells). The softer cancellous tissue contains large spaces, or trabeculae, which are filled with red and yellow marrow. Hematopoiesis (production of blood cells) occurs in the red marrow. The yellow marrow contains fat cells, which can be dislodged. In the deepest layer of the periosteum are osteogenic cells, which later differentiate into osteoblasts (bone-forming cells) and osteoclasts (bone-destroying cells). atrix consisting chiefly of collagen, mucopolysaccharides, and lipids. Deposits of inorganic calcium salts (carbonate and phosphate) in the matrix provide the hardness of bone. Bone is a very vascular tissue. Its estimated total blood flow is between 200 and 400 mL/min. Each bone has a main nutrient artery that enters mid-shaft.

Magnetic Resonance Imaging

MRI, with or without the use of contrast media, is commonly used to diagnose musculoskeletal disorders. It is more accurate than CT and myelography for many spinal and knee problems. MRI is most appropriate for 1026joints, soft tissue, and bony tumors that involve soft tissue. CT is still the test of choice for injuries or pathology that involves only bone. Image is produced through the interaction of magnetic fields, radio waves, and atomic nuclei showing hydrogen density. Simply put, the radio waves "bounce" off the body tissues being examined. The test is particularly useful in identifying problems with muscles, tendons, and ligaments. Ensure that the patient removes all metal objects and checks for clothing zippers and metal fasteners. Although joint implants made of titanium or stainless steel are usually safe, depending on the age of the MRI equipment, pacemakers, stents, and surgical clips usually are not. MR arthrography combines arthrography and magnetic resonance imaging. It is particularly useful for diagnosing problems of the shoulder. The patient's shoulder is injected with gadolinium contrast medium under fluoroscopy. Then the patient is taken for an MRI where the shoulder is examined. This test is particularly useful for diagnosing the type and degree of rotator cuff tears

Assessment of the Muscular System

Notice the size, shape, tone, and strength of major skeletal muscles. The circumference of each muscle may be measured and compared for symmetry. Apply resistance by holding the extremity and asking the patient to move against resistance.

General Inspection

Observe the patient's posture, gait, and general mobility for gross deformities and impairment.

Musculoskeletal Changes Associated with Aging

Osteopenia, or decreased bone density (bone loss), occurs as one ages. Many older adults, especially white, thin women, have severe osteopenia, a disease called osteoporosis. Synovial joint cartilage can become less elastic and compressible as a person ages. As a result of these cartilage changes and continued use of joints, the joint cartilage becomes damaged, leading to osteoarthritis (OA). Most common joints affected are the weight-bearing joints of the hip, knee, and cervical and lumbar spine, but joints in the shoulder and upper extremity, feet, and hands also can be affected. As one ages, muscle tissue atrophies. Increased activity and exercise can slow the progression of atrophy and restore muscle strength.

Family History and Genetic Risk

Osteoporosis (age-related bone loss) and gout, for instance, often occur in several generations of a family. Osteogenic sarcoma, a type of bone cancer, may be genetically influenced by Tp53 gene mutation

TABLE 49-1 Musculoskeletal Differences in Selected Racial/Ethnic Groups

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Chart 49-1 Nursing Focus on the Older Adult Changes in the Musculoskeletal System Related to Aging

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TABLE 49-2 Common Scale for Grading Muscle Strength

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Chart 49-2 Laboratory Profile Musculoskeletal Assessment

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Specific Assessments 1

Pain or weakness in the face or neck, inspect and palpate this area for tenderness and masses. Ask the patient to open his or her mouth while palpating the temporomandibular joints (TMJs). Common abnormal findings are tenderness or pain, crepitus (a grating sound), and a spongy swelling caused by excess synovium and fluid. Inspect and palpate each vertebra of the spine in the neck. Proceed cautiously and gently if pain. Findings may include malalignment; tenderness; or inability to flex, extend, and rotate the neck as expected. Muscle and nerve pain often accompany neck pain if spinal nerves. The thoracic spine, lumbar spine, and sacral spine are evaluated in the same manner as the neck. Place both hands over the posterior iliac crests with the thumbs over the lumbosacral area. Apply pressure with the thumbs along the lumbosacral spine to elicit tenderness. Many patients do not have discomfort until the area is palpated. Lordosis is common in adults who have abdominal obesity. Screening for scoliosis, ask the patient to flex forward from the hips and inspect for lateral curve. Assess arms or legs at the same time for side-to-side comparisons. For example, inspect and palpate both shoulders for size, swelling, deformity, poor alignment, tenderness or pain, and mobility. Assess the elbows and wrists in a similar way.

What might you NOTICE in a patient with adequate mobility and sensory perception related to the musculoskeletal system?

Physical assessment: • No gross deformities or impairments in posture or gait • Adequate size, strength, and symmetry of muscle for age • Can perform ADLs independently • Can perform other routine daily activities independently • Can ambulate with or without assistive devices • No pain or tenderness on palpation or passive range-of-motion (ROM) of joints • Active ROM of joints within normal limits for age • No crepitus when moving joints • No swelling of joints or extremities • Equal size and alignment of extremities • Equal sensation in extremities Diagnostic assessment: • Muscle enzymes (e.g., CK-MM, ALD) within normal limits for age • Bone density adequate for age and gender • Joint changes within normal limits for age

Posture and Gait

Posture includes the person's body build and alignment when standing and walking. Assess the curvature of the spine and the length, shape, and symmetry of extremities. Fig. 49-3 illustrates several common spinal deformities. Inspect muscle mass for size and symmetry. The nurse or therapist evaluates the patient's balance, steadiness, and ease and length of stride. Any limp or other asymmetric leg movement or deformity is noted. An abnormality in the stance phase of gait is called an antalgic gait. When part of one leg is painful, the patient shortens the stance phase on the affected side. An abnormality in the swing phase is called a lurch. This abnormal gait occurs when the muscles in the buttocks and/or legs are too weak to allow the person to change weight from one foot to the other. In this case, the shoulders are moved either side-to-side or front-to-back for help in shifting the weight from one leg to the other.

Arthroscopy: Procedure

The patient is usually given local, light general, or epidural anesthesia, depending on the purpose of the procedure. The arthroscope is inserted through a small incision less than a fourth of an inch (0.6 cm) long. Multiple incisions may be required. After the procedure, a dressing may be applied, depending.

Ultrasonography

Sound waves produce an image of the tissue in ultrasonography. An ultrasound procedure may be used to view: • Soft-tissue disorders, such as masses and fluid accumulation • Traumatic joint injuries • Surgical hardware placement A jelly-like substance applied to the skin over the site to be examined promotes the movement of a metal probe. No special preparation or post-test care is necessary. A quantitative ultrasound (QUS) may be done for determining fractures or bone density.

Key Points: Health Promotion and Maintenance

• Be aware that older adults have physiologic changes that affect their musculoskeletal system, such as decreased bone 1028density and joint cartilage degeneration (see Chart 49-1).

Nuclear Scans

The bone scan is a radionuclide test in which radioactive material is injected for viewing the entire skeleton. It may be used primarily to detect tumors, arthritis, osteomyelitis, osteoporosis, vertebral compression fractures, and unexplained bone pain. Bone scans are used less commonly today bc of MRI. It may be very useful for detecting hairline fractures in patients with unexplained bone pain and diffuse metastatic bone disease. The gallium and thallium scans are similar to the bone scan but are more specific and sensitive in detecting bone problems. Gallium citrate (67Ga) is the radioisotope most commonly used. This substance also migrates to brain, liver, and breast tissue and therefore is used in examination of these structures. Because bone takes up gallium slowly, the nuclear medicine physician or technician administers the isotope 4 to 6 hours before scanning. Patients with osteosarcoma, thallium (201Tl) is better than gallium or technetium for diagnosing the extent. Thallium has traditionally been used for the diagnosis of myocardial infarctions but can be used for additional evaluation of cancers of the bone. Instruct the patient that the radioactive material poses no threat because it readily deteriorates in the body/excreted in feces. The patient must lie still for accurate test results to be achieved. The scan may be repeated at 24, 48, and/or 72 hours. Mild sedation may be necessary. The radioisotope is excreted in stool and urine, but no precautions are taken in handling the excreta.

Current Health Problems

The most common reports of persons with a musculoskeletal problem are pain and weakness, either of which can impair mobility. • Date and time of onset • Factors that cause or exacerbate (worsen) the problem • Course of the problem (e.g., intermittent or continuous) • Clinical manifestations (as expressed by the patient) and the pattern of their occurrence • Measures that improve clinical manifestations (e.g., heat, ice) Pain assessment: P = Provocation/Palliation Q = Quality/Quantity R = Region/Radiation S = Severity Scale T = Timing Determine if weakness occurs in proximal or distal muscles or muscle groups. Proximal weakness (near trunk of body) may indicate myopathy (a problem in muscle tissue), whereas distal weakness (in extremities) may indicate neuropathy (a problem in nerve tissue). Muscle weakness in the lower extremities may increase the risk for falls and injury. Weakness in the upper extremities may interfere with ADLs.

Key Points: Safe and Effective Care Environment

• Collaborate with the physical and/or occupational therapist to perform a complete musculoskeletal assessment, including gait, muscle strength, and ADL ability.

Arthroscopy: Patient Preparation

The patient must have mobility in the joint being examined. Those who cannot move the joint or who have an infected joint are not candidates. Done for surgical repair, the patient may have a physical therapy consultation before arthroscopy to learn the exercises that are necessary after the test. ROM exercises are also taught but may not be allowed immediately after. The nurse also reinforces the explanation of the procedure and post-test care and ensures that the patient has signed an informed consent.

Action Alert

The priority for postprocedure care after arthroscopy is to assess the neurovascular status of the patient's affected limb every hour or according to agency or surgeon protocol. Monitor and document distal pulses, warmth, color, capillary refill, pain, movement, and sensation of the affected extremity.

Skeletal System

The skeletal system consists of 206 bones and multiple joints.

Bones: Function

The skeletal system: • Provides a framework for the body and allows the body to be weight bearing, or upright • Supports the surrounding tissues (e.g., muscle and tendons) • Assists in movement through muscle attachment and joint formation • Protects vital organs, such as the heart and lungs • Manufactures blood cells in red bone marrow • Provides storage for mineral salts (e.g., calcium and phosphorus) Numerous minerals and hormones affect bone growth and metabolism, including: • Calcium • Phosphorus • Calcitonin • Vitamin D • Parathyroid hormone (PTH) • Growth hormone • Glucocorticoids • Estrogens and androgens • Thyroxine • Insulin Bone accounts for about 99% of the calcium in the body and 90% of the phosphorus. A decrease in the body's vitamin D level can result in osteomalacia (softening of bone) in the adult. When estrogen levels decline at menopause, women are susceptible to low serum calcium levels with increased bone loss (osteoporosis). Androgens, such as testosterone in men, promote anabolism (body tissue building) and increase bone mass. Thyroxine is one of the principal hormones secreted by the thyroid gland. Its primary function is to increase the rate of protein synthesis in all types of tissue, including bone. Insulin works together with growth hormone to build and maintain healthy bone tissue..

Imaging Assessment

The skeleton is very visible on standard x-rays. Anteroposterior and lateral projections are the initial screening views used most often. Other approaches, such as oblique or stress views, depend.

Muscular System

Three types of muscle in the body: smooth muscle, cardiac muscle, and skeletal muscle. Smooth, or non-striated, involuntary muscle is responsible for contractions of organs and blood vessels and is controlled by the autonomic nervous system. Cardiac or striated involuntary muscle is also controlled by the autonomic nervous system. Skeletal muscle is striated voluntary muscle controlled by the central and peripheral nervous systems. The junction of a peripheral motor nerve and the muscle cells that it supplies is sometimes referred to as a motor end plate. Muscle fibers are held in place by connective tissue in bundles, or fasciculi. The entire muscle is surrounded by dense fibrous tissue, or fascia, which contains the muscle's blood, lymph, and nerve supply. Atrophy results when muscles are not regularly exercised, and they deteriorate from disuse. Supporting structures for the muscular system are very susceptible to injury. They include tendons (bands of tough, fibrous tissue that attach muscles to bones) and ligaments, which attach bones to other bones at joints.

Key Points: Physiological Integrity

• Assess the patient's pain intensity, quality, duration, and location. • Assess the patient's mobility, including gait, posture, and muscle strength. • Interpret the patient's laboratory values that are related to musculoskeletal disease (see Chart 49-2). • Teach the patient that mild discomfort can be expected during electromyography, a test to assess the electrical potential of muscles and their innervation. • Instruct the patient to report swelling, infection, and increased pain after an arthroscopy. • Ask the patient questions to ensure safety before an MRI (see Chart 49-3). • Ask the patient about allergy to contrast media before diagnostic testing such as CT scans. • Evaluate the neurovascular status of the patient's affected extremity after an arthroscopic procedure as the priority for care.

Key Points: Psychosocial Integrity

• Assess the patient's support systems and coping mechanisms when musculoskeletal trauma or disease affects his or her body image. • Ask about the patient's occupation, because heavy manual labor may cause back injury and other musculoskeletal trauma.

Chart 49-3 Preparing the Patient for Magnetic Resonance Imaging

• Is the patient pregnant? • Does the patient have ferromagnetic fragments or implants, such as an older-style aneurysm clip? • Does the patient have a pacemaker, stent, or electronic implant? • Does the patient have chronic kidney disease? (Gadolinium contrast agents may cause severe systemic complications if the kidneys do not function.) • Can the patient lie still in the supine position for 45 to 60 minutes? (May require sedation.) • Does the patient need life-support equipment available? • Can the patient communicate clearly and understand verbal communication? • Did the patient get any tattoo more than 35 years ago? (If so, metal particles may be in the ink.) • Is the patient claustrophobic? (Ask this question for closed MRI scanners; open MRIs do not cause claustrophobia.)