Chapter 23 Musculoskeletal System PDF

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Beerbower, M....

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Structure and Function - Musculoskeletal system consists of bones, joints, and muscles, functions are: - Support - Movement - Protection - Production of RBCs, WBCs, and platelets - Reservoir of essential minerals - 206 bones in the adult body - Joint: place of union of 2 or more bones, functional units of bones because they permit mobility - Fibrous Joints: bones are united by fibrous tissue or cartilage and are immovable - Cartilaginous Joints: separated by fibrocartilaginous discs and are only slightly moveable - Synovial Joints: freely movable because the bones are separated and in a cavity lined with synovial membrane that acts as a lubricant and a layer of cartilage covers surface of opposing bones - Ligaments: fibrous bands running directly from one bone to another that strengthen joint and help prevent movement in undesirable directions - Bursa: enclosed sac filled with viscous synovial fluid, are located in areas of potential friction to help muscles and tendons glide - Tendon: skeletal muscle attached to bone by this cord - Muscles account for 40-50% of body weight - Skeletal Muscles: under voluntary control made up of muscles fibers (fasciculi) - Flexion, extension, abduction, adduction, pronation, supination, circumduction, inversion, eversion, rotation, protraction, retraction, elevation, depression - Smooth Muscles: - Cardiac Muscles: - Temporomandibular Joint: articulation of mandible and temporal bone, allows for speaking and chewing and has 3 motions: hinge to open and close, gliding for protrusion and retraction, and gliding side to side - Spine: 33 vertebrae; C1-C7, T1-T12, L1-L5, S1-S5, and coccyx (3 or 4) - C7 + T1 are prominent at base of neck - Inferior angle of scapula is normally between T7-T8 - L4 is at the highest angle of the iliac crest - And then a bit lower where the “dimples” of the superior spines are is where the sacrum is - Cervical and lumbar spines curve inward - Thoracic and sacrococcygeal curve opposite - This allows for the spine to absorb a great deal of shock - Intervertebral Discs: elastic fibrocartilaginous plates that constitute ¼ of length of column, each has a nucleus pulposus in the center that feels like toothpaste to cushion them, if it ruptures then it can press against spinal nerves causing pain

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Shoulder Girdle: belt of 3 large bones (humerus, scapula, and clavicle), joints, and muscles Glenohumeral Joint: articulation of humerus with glenoid fossa of scapula, allows more mobility than any joint - Rotator Cuff: SITS- supraspinatus, infraspinatus, teres minor, subscapularis - Subacromial Bursa: helps abduction of arm so the greater tubercle of humerus moves easily Over ½ of bones are on the hands and feet Radiocarpal Joint: articulation of distal radius and row of 8 carpal bones, permits flexion and extension, and side to side deviation Midcarpal Joint: articulation between the 2 parallel rows of carpal bones, does flexion, extension, and some rotation Metacarpophalangeal and Interphalangeal Joints: permit finger flexion and extension Elbow: contains 3 bony articulation of the humerus, radius, and ulna, moves in a hinge action so it has flexion and extension - Bracioradialis + biceps = flexion - Triceps + brachialis = extension - Olecranon bursa lies between olecranon process - Ulnar nerve runs between olecranon process and medial epicondyle - Radius and ulna provide pronation and supination of hand and forearm Hip Joint: articulation between C-shaped acetabulum and head of femur, has a bit less of ROM than shoulder but it is more stable and has 3 bursae

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During palpation you can feel the entire ilica crest, ischial tuberosity while hip is flexed, and greater trochanter below iliac crest Knee Joint: articulation between 3 bones, femur, tibia, and patella, there is no overlying fat or muscle - Synovial membrane is the largest in the body - Has the suprapatellar pouch (behind quadriceps), medial and lateral menisci, (cushion tibia and femur), cruciate ligaments (stability + rotation control), prepatellar bursa (between patella and skin) and infrapatellar fat pad (below patella behind patellar ligament) - Landmarks of knee joint start with large quadriceps muscle - Tibial tuberosity can be felt as a bony prominence in midline Tibiotalar Joint: articulation of tibia, fibula, and talus, is limited to dorsiflexion and plantar flexion - Landmarks include 2 bony prominences on either side: medial and lateral malleolus - Calcaneus: aka heel is under talus - Foot has a longitudinal arch with weight bearing distributed between the parts that touch the ground

Developmental Competence - Infants and Children - By 3 mos gestation the fetus has a scale model of skeleton made of cartilage, bone growth continues rapidly in infant and steady during childhood until adolescence - Epiphyses: growth in length at growth plates - Any trauma or infection here puts them at risk for bone deformity, lasts until about age of 20 (closes) - At birth infant only has a “C shape” spine, at 3-4 mos they develop the anterior curve in cervical, at 12-18 mos standing helps them develop the lumbar - Aging Adult - Peak bone mass is reached at 20s for caucausians with females peaking earlier - Bone Remodeling: cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repair or replacement - Osteoporosis: bone resorption occurs more rapidly so there is a loss in bone density - Decreased levels of estrogen - Resistance and weight bearing exercise may increase bone density at hip and umbar - Long bones DO NOT shorten with age - Decreased height of 3-5 cm occurs with shortening spine - Not significant until 60 yrs and then at 70-80 it decreases even more because of osteoporotic collapse of vertebrae - INCREASE in thoracic curve (kyphosis) and slight flexion of knees and hips - Men and women gain weight in 40-50s and lose it in the face and place it into abdomen and hips, 80-90s it decreases even more in periphery

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especially forearms - Sedentary lifestyle hastens musculoskeletal aging Pregnant Women - Increased levels of hormones (estrogen, relaxin from corpus luteum, and corticosteroids) cause increased mobility in joints - Contributes to noticeable changes in maternal posture - Lordosis: compensates for enlarging fetus by shifting weight further back on lower extremities, which causes a strain on lower back muscles (lower back pain) - Anterior flexion of neck and slumping of shoulder girdle are other postural changes that compensate which can put pressure on ulnar and median nerves during the 3rd trimester

Culture and Genetics - Higher BMD = denser bone - Afro-Caribbean women had higher BMD hp measurements, then Aftrican-American women which means they have lower fracture risk among them - All races of women gained BMD up to 30/33 years old, white women peaked earlier 55 yrs (Ottawa knee rules) have them obtain an x-ray 3. Muscles a. Pain (cramps) i. Myalgia: felt as cramping or aching (often associated with viral illness

ii. In calf muscles suggests intermittent claudication b. Weakness i. May involve neurological or musculoskeletal systems ii. Atrophy if muscles look smaller 4. Bones (PQRST) a. Pain i. Fractures cause sharp pain that increases with movement, dull and deep pain is unrelated to movement ii. Lower back pain occurs with degenerative discs, osteoporosis, lumbar stenosis, or nonspecific iii. Chronic pain can increase anxiety symptoms iv. Any deformity of bone or joint? Caused by injury or trauma? Affect ROM? v. Any accidents ever affect bones or joints? When? What tx? Any problems or limitations now? vi. Any numbness or tingling? Limping? b. Deformity c. Trauma (fx, sprains, dislocations) 5. Functional Assessment (ADLs) a. Screens safety of independent living, need for home health services, and quality of life b. Assess self care deficits c. Assess impaired mobility and verbal communication 6. Patient-Centered Care a. Assess for occupational risks such as back pain or carpal tunnel syndrome b. Exercise? c. Recent weight gain? d. Assess medications taken i. Daily aspirin and NSAID schedule ii. Screen for adverse effects such as GI pain, bleeding iii. Biophosphates are first-line therapy for osteoporosis, hormone therapy is not recommended e. Assess supplements taken i. Dietary calcium is better absorbed than supplements f. Asses smoking and drug use i. Smoking increase bone loss and risk of fx in older women ii. Moderate-heavy drinking increases fall risk Additional History for Infants and Children 1. Any trauma during labor and delivery? Headfirst? Forceps needed? Resuscitation? a. Traumatic deliver increases risk of fx b. Period anoxia may result in hypotonia of muscles 2. Motor milestones achieved around same time as siblings/friends? 3. Broken bones or dislocations? Tx?

4. Noticed any bone deformity? Spinal curvature? Unusual shape of feet? What age? Tx? Additional History for Adolescents 1. Sports? How many times per week? How does it fit in with other activities? a. Assess safety of sport for child, note adequate weight and height for sport 2. Special equipment used? Training program? a. Decreases sports injuries 3. What do you do if you get hurt? a. Students may not say anything because they don’t want to be limited from participation Additional History for Aging Adults 1. Any change in weakness over time? Increased falls? a. Encourage exercise, history of falls = increased risk for future falls 2. Mobility aids to help walk around? 3. Screening for osteoporosis of women age 65 yrs or older with DXA? results? a. Screening interval of 2 years is suggested to measure changes in BMD, if normal than interval of 15 years is enough, if moderate than 5 year intervals Objective Data - Purpose of musculoskeletal exam are to assess function for ADLs and screen for abnormalities - Screening musculoskeletal exam suffices for most - Complete musculoskeletal exam is appropriate for those with articular disease, history of musculoskeletal symptoms or any problems with ADLs - Do head to toe and proximal to distal - Support each joint at rest because the muscles need to be soft and relaxed to assess joints properly - Equipment Needed: - Tape measure - Skin marking pen - Goniometer (occasionally) -

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Do inspection, palpapation, ROM, muscle testing, temporomandibular joint, cervical spine, UE: shoulder, elbow, wrist + hand, LE: hip, knee, ankle + foot, spine, legs Inspection: note size and contour of every joint, inspect skin + tissues over it. Any swelling? - Effusion: swelling may be excess joint fluid, thickening of synovial lining, inflammation of surrounding tissue or bony enlargement - Subluxation: 2 bones in joint stay in contact but alignment is wrong - Contracture: shortening of muscle leading to limited ROM - Ankylosis: stiffness or fixation of joint Palpation: each joint, include skin temp, muscles, bony articulations, area of joint capsule. Any heat, tenderness, swelling or masses. If tenderness is present try to localize it to specific anatomic structures - Synovial membrane is not usually palpable, when thickened it feels doughy, small amount

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of fluid is normal but not palpable - If you push on one side of sac the fluid will shift and cause a visible bulge which is abnormal Range of Motion (ROM): ask for voluntary ROM while modeling the movements yourself, if you see limitation gently attempt passive motion where you help move the joint, these should be the same as normal ROM - Limitation is most sensitive sign of disease - Articular Disease: inside the capsule produces swelling and tenderness around the entire joint and limits all planes of ROM in either active or passive. - Extra-Articular Disease: injury specific to tendon, ligament, nerve produces swelling and tenderness to one spot in the joint and affects certain planes of RON during active motion - Do not confuse crepitation with normal discrete “crack” heard as tendons or ligaments slip over bone during motion - Crepitation: audible and palpable crunching or grating that accompanies movement, occurs when articular surfaces are roughened like with RA Muscle Testing: test strength of prime-mover muscle groups for each joint and repeat the motions for ROM, then ask patient to flex and hold you as an opposing force. It should be bilaterally and fully resisting you

Temporomandibular Joint - Inspection: inspect area anterior to ear - Palpation: place tips of 2 fingers in front of each ear and have patient open and close mouth then drop your fingers into depressed area over joint and note smooth motion of mandible (audible snap or click occurs in many healthy people) - Palpate contracted temporalis when person clenches teeth and compare sides - Swelling looks like a round bulge over joint, although it must be moderate or marked to be visible - Crepitus and pain occur with TMJ dysfunction during movement or chewing (malocclusion of teeth too) - ROM: have them open mouth, measure 3-6 cm or three finger inserted sideways is

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normal, lateral motion is an extent of 1-2 cm, stick out lower jaw without deviation (tests cranial nerve V) - Decreased ROM occurs with TMJ inflammation + arthritis and causes tenderness with palpation - Lateral motion may be lost earlier and more significantly Cervical Spine - Inspection: alignment of head and neck, spine should be straight, and head erect - Palpation: spinous processes and sternomastoid, trapezius, and paravertebral muscles, should feel firm with no spasm or tenderness - Tenderness and hard muscles with muscle spasm - ROM: ask patient to bring chin to chest, lift chin to ceiling, touch each ear toward shoulder, turn chin toward each shoulder. THEN repeat these motions while applying opposing force, they should be able to maintain flexion against you (tests cranial nerve XI) - Limited ROM occurs with arthritis, pain with movement occurs with arthritis or muscle overuse, or if person cannot hold flexion it is abnormal Shoulder - Inspection: compare shoulders posteriorly and anteriorly, check size and contour of joint and equality of bony landmarks. Check anterior aspect of joint capsule and subacromial bursa for abnormal swelling - Redness - Inequality of bony landmarks = scoliosis - Atrophy shows lack of fullness and that could mean RC problem or disuse - Dislocated shoulder loses shape - Swelling from excess fluid is best seen anteriorly, might be visible distension because capsule is normally loose - Palpation: stand in front of person and palpate both shoulders, noting muscular spasm or atrophy, swelling, erythema. Start at the clavicle and go back towards the scapula and then palpate the pyramid shaped axilla - ROM: have arms extended at sides and have them move them forward and up and then stretched back, rotate the arms internally behind their back by having them cross their arms behind their back, have patient extend arms at side and then have them bring it up and put palms together above head, then have them place hands behind head. (while doing this place hand on shoulders to see if there is any crepitus) - Muscle Strength: Test strength of shoulder muscles by having patient shrug, flex forward and out, and abduct against resistance (tests cranial nerve XI) Elbow - Inspection: size and contour of elbow in flexed and extended positions - Subluxation shows forearm dislocated posteriorly - Swelling and redness of olecranon bursa are localized - Effusion or synovial thickening shows as bulge or fullness on either side of olecranon (those with gouty arthritis and bursitis)

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Palpation: with elbow flexed at 70 degrees and as relaxed as possible, use your hand to support their elbow (by holding hand up) and palpate olecranon process and medial and lateral epicondyles of humerus with other hand - Epicondyles, head of radius, and tendons are common sites of inflammation aka tennis elbow - Subcutaneous Nodules: raised, firm, and nontender and overlying skin moves freely, common sites are olecranon bursa and along extensor surface of ulna, occur with RA - ROM: have the patient flex and extend elbow and then have them do pronation and supination of wrist - After trauma, full extension of elbow can usually rule out fx - Muscle Strength: stabilize person’s arm and then have them try to flex while you are holding their wrist Wrist and Hand - Inspection: inspect dorsal and palmar sides, note position, contour, and shape, fingers can flex efficiently and are straight. Skin should be smooth with knuckle wrinkles present and thenar eminence (palm showing rounded mound proximal to thumb) and smaller rounded mound proximal to little finger - Ulnar deviation, fingers list to ulnar side - Ankylosis, wrist in extreme flexion - Dupuytren Contracture: flexion contracture of fingers - Swan-neck or boutonniere deformity in fingers - Atrophy of thenar eminence with carpal tunnel - Palpation: each joint in wrist and hands, face person and support hand with your fingers under it and palpate both wrists firmly with both your thumbs on its dorsum. Palpate MCPJ with thumbs just distal to and on either side of knuckle. “Pinch” the sides of the interphalangeal joints. - Ganglion cyst is localized swelling on wrist - Synovial swelling is on dorsum - Generalized swelling = arthritis and infection - RA shows bilateral swelling + tenderness, shows boggy or tender MCPs - Osteoarthritis (OA) does not have boggy or tender MCPs - Heberden and Bouchard nodules are hard and nontender on IPJs and can occur with OA - ROM: extension, flexion, hyperextension, ulnar deviation, abduct fingers, and touch thumb to base of little finger - Phalen Test: reproduces numbness and burning in a person with carpal tunnel, have them hold it for 60 sec

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Muscle Strength: position person’s forearm supinated and resting on table then ask the person to flex their wrist with you pulling back on it

Hip -

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Tinel Sign: in carpal tunnel, percussion of the median nerve produces burning and tingling along it

Knee -

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Inspection: wait to inspect later in the exam when the patient is standing, note the symmetric levels of iliac crests, gluteal folds, and equally sized buttocks. Smooth, even gait reflects equal leg length and functional hip motion Palpation: person should be supine when palpating - Crepitation is abnormal ROM: raise each leg with extended knee, raise bent knee for each leg, have bent knee rotate internally and externally for each leg, have each leg extended and flat on surface and then have them make each leg move outwards laterally Inspection: person should remain supine with legs extended, can be flexed and dangling. Inspect lower leg alignment, inspect shape and contour, check for swelling or fullness. Check the quadriceps muscle in anterior thigh for any atrophy - Shiny and atrophic skin is abnormal - Genu Varum: bowlegs - Genu Valgum: knock-knees - Flexion contracture - If the hollows disappear it is because they may be bulging with synovial thickening or effusion - Atrophy of muscle usually occurs in the medial part first but it is difficult to note because the vastus medialis is relatively small Palpation: have a patient completely supine position with complete relaxation of quadriceps muscle, start high on anterior thigh (10 cm above patella) and then palpate with thumb and fingers downward. Make sure to check the infrapatellar fat bad and the patella,

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check for crepitus - If swelling is present you need to determine if it is caused by soft tissue swelling or increased fluid in the joint, compared with the other knee. - Bulge Sign: swelling in suprapatellar pouch confirms small amounts of fluid so you firmly stroke on the medial aspect of the knee 2-3 times to displace fluid. Then tap on the lateral side and watch the medial side to see if there is a wave - Occurs with 4-8mL of effusion - Ballottement of the Patella: reliable when larger amounts of fluid are present, use left hand to compress the suprapatellar pouch to mov...