musculoskeletal system

1. ASSESSMENT ON
MUSCULOSKETAL
SYSTEM
SUBMITTED BY
PANKAJ SINGH RANA
NURSE PRACTITIONER IN
CRITICAL CARE
SRHU

2. SKELETAL SYSTEM
▪ Bone types
▪ Bone structure
▪ Bone function
▪ Bone growth and metabolism affected by calcium and phosphorous,
calcitonin, vitamin D, parathyroid, growth hormone, glucocorticoids,
estrogens and androgens, thyroxine, and insulin.

3. Bones
▪ Human skeleton has 206 bones
▪ Provide structure and support for soft tissue
▪ Protect vital organs

4. Figure 41-1 Bones of the human skeleton.

5. BONES
▪ Compact bone
–Smooth and dense
–Forms shaft of long bones and outside layer of
other bones
▪ Spongy bone
–Contains spaces
–Spongy sections contain bone marrow

6. BONE MARROW
▪ Red bone marrow
– Found in flat bones of sternum, ribs, and
ileum
– Produces blood cells and hemoglobin
▪ Yellow bone marrow
– Found in shaft of long bones
– Contains fat and connective tissue

7. JOINTS (ARTICULATIONS)
▪ Area where two or more bones meet
▪ Holds skeleton together while allowing body to
move

8. Synovial Joints
▪ Found at all limb articulations
▪ Surface covered with cartilage
▪ Joint cavity covered with tough fibrous capsule
▪ Cavity lined with synovial membrane and filled
with synovial fluid

9. LIGAMENTS
▪ Bands of connective tissue that connect bone to
bone
▪ Either limit or enhance movement
▪ Provide joint stability
▪ Enhance joint strength

10. TENDONS
▪ Fibrous connective tissue bands that connect bone
to muscles
▪ Enable bones to move when muscles contract

11. MUSCLES
▪ Skeletal (voluntary)
–Allows voluntary movement
▪ Smooth (involuntary)
–Muscle movement controlled by internal
mechanism
–e.g., muscles in bladder wall and GI system
▪ Cardiac (involuntary)
–Found in heart

12. SKELETAL MUSCLE
▪ 600 skeletal muscles
▪ Made up of thick bundles of parallel fibers
▪ Each muscle fiber made up of smaller structure
myofibrils
▪ Myofibrils are strands of repeating units called
sarcomeres

13. Skeletal Muscle
▪ Skeletal muscle contracts with the release of
acetylcholine
▪ The more fibers that contract, the stronger the
muscle contraction

14. Changes in Older Adult
▪ Musculoskeletal changes can be due to:
– Aging process
– Decreased activity
– Lifestyle factors

15. Changes in Older Adult
▪ Loss of bone mass in older women
▪ Joint and disk cartilage dehydrates causing loss of
flexibility contributes to degenerative joint disease
(osteoarthritis); joints stiffen, lose range of motion

16. Changes in Older Adult
▪ Cause stooped posture, changing center of gravity
▪ Elderly at greater risk for falls
▪ Endocrine changes cause skeletal muscle atrophy
▪ Muscle tone decreases

18. Diagnostic Tests
▪ Blood tests
▪ Arthrocentesis
▪ X-rays
▪ Bone density scan
▪ CT scan
▪ MRI
▪ Ultrasound
▪ Bone scan

19. DIAGNOSTIC EVALUATION
▪ Imaging Procedures – CT, Bone Scan, MRI
▪ Nuclear Studies - radioisotope bone density,
▪ Endoscopic Studies –arthrocentesis, arthroscopy
▪ Other Studies –biopsy, synovial fluid, Arthrogram,
venogram,
▪ Electromyography
▪ Myelography*
▪ Laboratory Studies

20. ▪ Laboratory
– Urine Tests
▪ 24 hour creatine-
creatinine ratio
▪ Urine Uric acid –24 hr
specimen
▪ Urine deoxypyridino-
line
▪ Laboratory
– Blood Tests
▪ Serum muscle enzymes
▪ Rheumatoid Factor
▪ LE Prep/Antinuclear
Antibodies(ANA)
▪ Erythrocyte
Sedimentation Rate
▪ Calcium, Phosphorous,
Alkaline phosphatase

21. ▪ Blood Tests
– CBC – Hgb, Hct
– Acid phosphatase
– Metabolic/Endocrine
– Enzymes
Increase creatine kinase, serum increase
glutamin-oxaloacetic due to muscle
damage, aldolase, SGOT

22. RADIOGRAPHIC
▪ Standard radiography,
tomography and xeroradiography,
myelography, arthrography and CT
▪ Other diagnostic tests: bone and
muscle biopsy

23. Arthroscopy
▪ Fiberoptic tube is inserted into a joint for direct
visualization.
▪ Client must be able to flex the knee; exercises are
prescribed for ROM.
▪ Evaluate the neurovascular status of the affected
limb frequently.
▪ Analgesics are prescribed.
▪ Monitor for complications.

25. Bone Scan
▪ Nuclear medicine procedure in which amount of
radioactive isotope taken up by bones is evaluated
▪ Abnormal bone scans show hot spots due to
malignancies or infection
▪ Cold spot uptakes show areas of bone that are
ischemic

26. Arthroscopy
▪ Flexible fiberoptic endoscope used to view joint
structures and tissues
▪ Used to identify:
– Torn tendon and ligaments
– Injured meniscus
– Inflammatory joint changes
– Damaged cartilage

29. PAIN
▪ Pain is the most common symptom with problems
of the musculoskeletal system. Check its character,
nature of onset, site, radiation, severity,
periodicity, exacerbating and relieving factors
(particularly how it is influenced by rest and
activity.
▪ Pain in a joint is called arthralgia .
▪ Pain in a muscle is called myalgia .

30. CHARACTER
▪ Bone pain is typically experienced as boring and penetrating
and is often worse at night. Causes include tumor, chronic
infection, avascular necrosis.
▪ Pain associated with a fracture is usually sharp and stabbing
and is often exacerbated by movement.

31. ONSET
▪ Acute onset of pain is often a manifestation of
infection, such as septic arthritis or (e.g., gout).
▪ Osteoarthritis and rheumatoid arthritis (RA) can cause
chronic pain.
SITE
▪ Determine the exact site of maximal pain.

34. STIFFNESS
▪ Stiffness is the inability to move the joints. It may be
due to mechanical dysfunction, local inflammation of
a joint, or a combination of both
▪ Early-morning stiffness is seen in inflammatory
conditions (e.g., rheumatoid arthritis), whereas
mechanical joint disease will become worse as the
day progresses.

35. LOCKING
▪ This is the sudden inability to complete a
certain movement and suggests a
mechanical block or obstruction, usually
caused by a loose body or torn cartilage
within the joint (often secondary to
trauma).

36. SWELLING
▪ Joint swelling can be due to a variety of
factors, including inflammation of the
synovial lining, an increase in volume of
synovial fluid, hypertrophy of bone, or
swelling of structures surrounding the joint.

37. WEAKNESS
▪ Always inquire about the presence of localized or
generalized weakness, which suggests a peripheral
nerve lesion or systemic cause, respectively.
▪ Consider that the weakness may be neurogenic or
myopathic in origin.

38. LOSS OF FUNCTION
▪ Loss of function can be caused by a combination of
muscle weakness, pain, mechanical factors, and
damage to the nerve supply.

39. EXTRA-ARTICULAR FEATURES
▪ Several musculoskeletal disorders (e.g., rheumatoid arthritis)
cause extraarticular or multisystem features, some of which
are outlined below:
▪ Systemic symptoms: fever, weight loss, fatigue, lethargy
▪ Skin rash
▪ Eye symptoms
▪ Cardiorespiratory: breathlessness (pulmonary fibrosis?),
pericardial and pleuritic chest pain, aortic regurgitation.
▪ Neurological: migraine, depression, stroke.

40. HISTORY
PAST MEDICAL HISTORY
▪ All previous medical and surgical disorders and
inquire about any previous history of trauma or
musculoskeletal disease.

41. FAMILY HISTORY
It is important to note any Family History of illness,
especially those musculoskeletal conditions:
▪ Osteoarthritis
▪ Rheumatoid arthritis
▪ Osteoporosis

42. DIETARY HISTORY
▪ Low calcium intake leads to osteoporosis.
▪ Increase protein intake can lead to increase uric acid
production.

43. DRUG HISTORY
▪ Take a full drug history, including all prescribed and over-the-counter
medications.
▪ Gastric upset associated with nonsteroidal anti-inflammatory drugs
(NSAIDs)
▪ Long-term side effects of steroid therapy, such as osteoporosis,
myopathy, infections, and avascular necrosis
▪ Ask also about medication with known adverse musculoskeletal
effects:
▪ Statins: myalgia, myosistis, and myopathy
▪ ACE inhibitors: myalgia

44. SOCIAL HISTORY
▪ Certain occupations predispose to specific
musculoskeletal problems—e.g., repetitive strain
injury, hand-vibration syndrome, and fatigue fractures
seen sometimes in dancers and athletes.
▪ Ethnicity is relevant, as there is an overrepresentation
of lupus and TB in Asian populations. Both of these
disorders are linked to a variety of musculoskeletal
complaints.

45. THE OUTLINE EXAMINATION
▪ A full examination of the entire musculoskeletal system can be long
and complicated. Examination is done separately as following
▪ joints and regions
▪ elbow
▪ shoulder
▪ spine
▪ hip
▪ knee
▪ ankle
▪ foot

46. GALS screen
▪ The GALS screen was originally devised as a quick
screen for abnormality without symptoms.
The GALS screen consists of four components:
▪ G = gait
▪ A = arms
▪ L = legs
▪ S = spine

47. GAIT
▪ Watch the patient walk.
▪ There should be symmetry and smoothness of
movement.The patient should be able to start, stop,
and turn quickly.

49. ▪ Arms (sitting on couch)
▪ Inspection: Look for muscle wasting and joint deformity at the
shoulders, elbows, wrists, and fingers. Squeeze across the
second to fifth metacarpals.
▪ Shoulder abduction: Ask the patient to raise their arms out
sideways, above their head. Normal range is 170–180°.
▪ Shoulder external rotation: Ask the patient to touch their back
between their shoulder blades.

53. ▪ Shoulder internal rotation: Ask the patient to touch the small
of their back.They should touch aboveT10.
▪ Elbow extension: Ask patient to straighten out arms. Normal is
0*.
▪ Wrist and finger extension: the prayer sign.
▪ Power grip: Ask patient to make a tight fist, hiding fingernails.
▪ Precision grip: Ask patient to put their fingertips on their
thumb.

55. SPINE (STANDING)
▪ Inspection from behind: Look for scoliosis, muscle
bulk at the paraspinals, shoulders, and gluteals.
▪ Inspection from the side: Look for normal thoracic
kyphosis and lumbar and cervical lordosis.
▪ Lumbar flexion: Ask patient to touch their toes.
Normal is finger floor distance <15 cm. Lumbar
expansion (Schober’s test)
▪ Cervical lateral flexion: Ask the patient to put their
ear on their shoulder.

61. Elbow
INSPECTION
▪ Inspect the elbow joint from the front, side, and behind, noting:
▪ Misalignments of the bones
▪ Scars
▪ Skin change (e.g., psoriatic plaques)
▪ Skin or subcutaneous nodules
▪ Deformities
▪ Swelling

62. MOVE
▪ Check that there is good shoulder function before attempting
to assess
▪ elbow movements.
▪ movements
▪ Remember to test passive (you do the moving) and active
▪ movements (the patient does the moving) at each stage.
▪ Ask the patient to place their arms on the back of their head.
▪ Next assess elbow flexion and extension with the upper arm
fixed.

63. PALPATION
▪ Palpate the joint posteriorly and feel for the following:
▪ Temperature
▪ Subcutaneous nodules
▪ Swelling
▪ Hard swelling suggests a bony deformity.
▪ Boggy swelling suggests synovial thickening (e.g., secondary
to RA).

64. SHOULDER
INSPECTION
▪ Look especially for the following:
▪ Contours
▪ Make note of any obvious asymmetry or deformity
▪ Joint swelling
▪ This is more obvious from the front and may be a clue to acute bleeds, rheumatoid
effusions, sepsis.
▪ Scars
▪ Bruising or other skin or subcutaneous tissue changes

65. MOVE
▪ Remember to test passive movements and active movements.
▪ Flexion: Ask the patient to raise their arms forward above their
head.
▪ Extension: Straighten the arms backward as far as possible.
▪ Abduction: Move the arm away from the side of the body until the
fingertips are pointing to the ceiling.
▪ Adduction: Ask the patient to move the arm inward toward the
opposite side, across the trunk.

66. PALPATION
▪ Always ask about pain before getting started. Make note of
any temperature changes, tenderness, or crepitus. Standing
in front of the patient:
▪ Palpate the soft tissues and bony points in the following
order:
▪ sternoclavicular joint, clavicle, acromioclavicular joint,
acromial process, head of humerus, spine of scapula, greater,
tuberosity of humerus.
▪ Check the interscapular area for pain.

67. SPINE
INSPECTION
Scan around the room for any clues, such as a wheelchair or walking aids.
Look especially for the following:
▪ Scars
▪ Pigmentation
▪ Abnormal hair growth
▪ Unusual skin creases
▪ Asymmetry, including abnormal spinal curvature
▪ Kyphosis: convex curvature—normal in the thoracic (T) spine
▪ Lordosis: concave curvature—normal in the lumbar (L) and cervical (C) spines
▪ Scoliosis: side-to-side curvature away from the midline

68. INSPECTION
C spine
▪ Flexion: Ask the patient to put their chin on their chest.
▪ Extension: Ask the patient to look up to the ceiling.
▪ Lateral flexion: Ask the patient to lean their head sideways,
placing an ear on their shoulder.
▪ Rotation: Ask the patient to look over each shoulder.

69. T- and L-spine
▪ Movements at the thoracic and lumbar spine include flexion,
extension,
▪ lateral flexion, and rotation.
▪ Flexion: Ask the patient to touch their toes.
▪ Extension: Ask the patient to lean backward.

70. PALPATION
▪ Palpate each spinous process, noting any prominence or step,
and feel the paraspinal muscles for tenderness, palpating the
sacroiliac joints.

71. SPECIFICTEST
SCHOBER’STEST
▪ This is a useful measurement of lumbar flexion of the posterior superior
iliac spines on the vertebral column.
▪ These are located at 7 L5.
▪ Make a small pen mark at the midline 5 cm below and 10 cm above this
point.
▪ Now instruct the patient to bend at the waist to full forward flexion.
▪ Measure the distance between the two marks, using a tape measure.
▪ The distance should have increased to >20 cm (an increase of >5 cm).
▪ If not, there is a limitation in lumbar flexion (e.g., found in ankylosing
spondylitis).

72. HIP
INSPECTION
▪ Look for the following:
▪ Scars
▪ Sinuses
▪ Asymmetry of skin creases
▪ Swelling
▪ Muscle wasting
▪ Deformities

73. INSPECTION
▪ Flexion: Ask the patient to flex the hip until the knee meets
the abdomen. Normal is around.
▪ Abduction: With the patient’s leg held straight, ask them to
move it away from the midline. Normal is 30–40.
▪ Adduction: With the patient’s leg held straight, ask them to
move it across the midline.

74. PALPATION
▪ Feel for bony prominences, such as the anterior
superior iliac spines and greater trochanters.

75. SPECIALTESTS
Trendelenberg test
▪ This is useful as an overall assessment of the function of the hip and will
expose dislocations or subluxations, weakness of the abductors,
shortening of the femoral neck, or any painful disorder of the hip.
▪ Ask the patient to stand up straight without any support.
▪ Ask them to raise their left leg by bending the knee.
▪ Watch the pelvis (normally it should rise on the side of the lifted leg).
▪ Repeat the test with the patient standing on the left leg.
▪ A positive test is when the pelvis falls on the side of the lifted leg,
indicating hip instability on the supporting side (i.e., the pelvis falls to the
left = right hip weakness).

76. KNEE
INSPECTION
▪ Scan the room for any walking aids or other clues and inspect the patient standing.
The lower limbs should be completely exposed except for underwear so that
comparisons can be made.
▪ Compare one side to the other and look for the following:
▪ Deformity (valgus, varus, or flexion)
▪ Scars or wounds to suggest infection past or present
▪ Muscle wasting (quadriceps)
▪ Swelling (including posteriorly)
▪ Erythema

77. ▪ Remember to test passive movements (you do the
moving) and active movements (the patient does the
moving). Quantify any movement in degrees
(measure) .
Begin by moving the joint passively and feel over the
knee with one hand for any crepitus.
▪ Flexion: Ask the patient to maximally fl ex the knee.
▪ Extension: Ask the patient to straighten the leg at
the knee.

78. PALPATION
▪ Always ask about pain before getting started. Always
compare sides.
▪ With the patient lying supine:
▪ Palpate for temperature using the back of the hand.
▪ Ask if the knee is tender on palpation.
▪ Feel around the joint line while asking the patient to bend the
knee slightly.
▪ Palpate the collateral ligaments (either side of the joint).

79. Special tests
MCMURRAYTEST
▪ This is a test for detecting meniscal tears.
▪ With the patient lying supine, bend the hip and knee to 90*.
▪ Grip the heel with your right hand and press on the medial and lateral
cartilage with your left hand.
▪ Internally rotate the tibia on the femur and slowly extend the knee.
▪ Repeat, but externally rotate the distal leg while extending the knee.
▪ Repeat with varying degrees of knee flexion.
▪ If there is a torn meniscus, a tag of cartilage may become trapped between
the articular surfaces, causing pain and an audible click.You may also be
able to feel the click with your left hand.

80. ANKLE AND FOOT
INSPECTION
▪ Look for the following:
▪ Skin or soft tissue lesions, including calluses, swellings,
ulcers, and scars
▪ Muscle wasting at the calf and lower leg
▪ Deformities, especially those involving the arch
▪ Pes planus (flat foot)
▪ Pes cavus (high-arched foot)

81. INSPECTION
▪ The ankle and foot constitute a series of joints that function as
a unit.
▪ Remember to test passive movements (you do the moving) and
active movements (the patient does the moving) at each stage.
▪ Active movements should be performed with the patient’s legs
hanging over the edge of the bed.
▪ • Ankle dorsiflexion: Ask the patient to point their toes at their
head.
▪ • Ankle plantarflexion: Ask the patient to push their toes down
toward the floor, like pushing on a pedal.

82. PALPATION
▪ Always ask about pain before getting started.
▪ Assess the skin temperature and compare over both the feet.
▪ Look for areas of tenderness, particularly over bony
prominences
▪ Squeeze across the joints and assess pain and movement.
▪ Remember to palpate any swelling, edema, or lumps.

83. Special tests
Thompson or Simmond test
▪ This test is used to assess for a ruptured Achilles
tendon.
▪ Ask the patient to kneel on a chair with their feet
hanging over the edge. Squeezes both calves
▪ Normally the feet should plantarflex. If the Achilles
tendon is ruptured, there will be no movement on
the affected side.

84. Important presenting patterns
▪ Rheumatoid arthritis (RA)
▪ RA is a chronic inflammatory, multisystem, autoimmune
disease mediated by proinflammatory cytokines, such as
tumor necrosis factor alpha (TNF-A), and in some cases is
characterized by the presence of rheumatoid factor (RF).
▪ The clinical features of RA can be divided into articular and
extra-articular features.

85. Articular features
▪ RA usually presents as a symmetrical poly arthritis affecting
the wrists and small joints of the hands and feet.
▪ Common presenting symptoms are joint pain, stiffness, and
swelling that are typically worse in the mornings and improve
as the day progresses.

86. Extra-articular features of RA
▪ Rheumatoid nodules: common at sites of pressure (elbows
and wrists).
▪ They are associated with more severe disease and always RF
positive.
▪ Carpal tunnel syndrome
▪ Amyloidosis (proteinuria, hepato splenomegaly)
▪ Systemic features (fever, malaise, weight loss, and
lymphadenopathy)

87. OSTEOARTHRITIS
▪ Osteoarthritis is a chronic disorder of synovial joints that is
characterized by focal cartilage loss and an accompanying
reparative bone response. It represents the single-most
important cause of musculoskeletal disability with a
prevalence that increases with age and has a female
preponderance.
▪ The joints commonly affected include the hips, knees, spine,
and first carpometacarpal, first metatarsal.

88. Clinical features
▪ Common symptoms include swelling, deformity, stiffness,
weakness, and
▪ pain that is normally worse after activity and relieved by rest.
▪ Common signs include the following:
▪ Valgus and varus deformities
▪ Crepitus
▪ Wasting and weakness (especially of the quadriceps and
glutei)
▪ Tilting of the pelvis

89. CRYSTAL ARTHROPATHIES
GOUT
▪ Gout is a disorder of purine metabolism. It is characterized by
hyperuricemia due to either overproduction or underexcretion of
uric acid.
▪ Clinical features of acute gout
▪ Severe pain and swelling classically in the great toe MTP
joint(Metatarsophalanger, worse at night and associated with
redness
▪ Occasionally multiple joints are involved.