Musculoskeletal Disorders 2 (1)

7/18/2019 Musculoskeletal Disorders 2 (1)

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment of Musculoskeletal

Function


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Objectives

During this session we will:

1.Review the anatomy and physiology of themusculoskeletal system;

2.Discuss the assessment of the musculoskeletal system;

3.Discuss treatment modalities for patients with

musculoskeletal disorders; and.Discuss common conditions!diseases of the

musculoskeletal system.


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Figure 41-1 Bones of the human skeleton.


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Functions of the Musculoskeletal System

"rotection of vital organs

#o$ility and movement %acilitate return of $lood to the heart

"roduction of $lood cells &hematopoiesis'

Reservoir for immature $lood cells

Reservoir for vital minerals


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Structure

2() *ones in the $ody

+ ,ong $ones+ -hort $ones

+ %lat $ones

+ rregular $ones

/oints

#uscles


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Structure contd.

0ial skeleton supports and protects organs of headneck and trunk

0ppendicular skeleton $ones of lim$s and $ones thatanchor them to the aial skeleton

0rticulation where 4oints are formed


7/76Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Structure of a Long Bone; om!osition ofom!act Bone



Bone Marrow

Red $one marrow

+ %ound in flat $ones of sternum ri$s and ileum+ "roduces $lood cells and hemoglo$in

5ellow $one marrow

+ %ound in shaft of long $ones

+ 6ontains fat and connective tissue



"oints #Articulation$% "unction of &'o orMore Bones

-ynartrosis

0mphiartrosis Diarthrosis

+ *all and socket

+ 7inge

+ -addle

+ "ivot

+ 8liding



Joints

mmo!a"le #synarthosis$ "ones suture% together"y connecti!e tissue skull

'lightly mo!a"le #amphiarthosis$ connecte% "y

(i"rocartilage or hyaline cartilage!erte"rae) ri"*sternum +oint) pu"ic

symphysis

,reely mo!a"le #%iarthrosis$



-ypes o( (reely mo!a"le +oints

'a%%le carpal an% metacarpal "ones o( thum"

.all an% socket shoul%er an% hip +oints

/i!ot rotation only proimal en% o( ra%ius an% ulna

Hinge up an% own mo!ement in one plane

knee an% el"ow

li%ing sli%ing an% twisting wrist an% ankle

Con%yloi% mo!ement in %i((erent planes "ut not

rotations "tw metacarpals an% phalanges



-ypes o( mo!ement

(leion mo!e lower leg towar% upper

etension straightening the leg

a"%uction mo!ing leg away (rom "o%y

a%%uction mo!ong leg towar% the "o%y

rotation aroun% its ais

supination rotation o( arm to palmup position

pronation palm %own

circum%uction swinging arms in circles

in!ersion turning (oot so sole is inwar%

e!ersion sole is out



Muscles

0ttached to $ones and other structures $y tendons

6ontraction of muscle causes movement

-keletal &voluntary'

+ 0llows voluntary movement

-mooth &involuntary'

+ #uscle movement controlled $y internal mechanism

+ e.g. muscles in $ladder wall and 8 system

6ardiac&involuntary'

+ %ound in heart



Skeletal Muscle

-keletal muscle contracts with the release ofacetylcholine

9he more fi$ers that contract the stronger the musclecontraction



Bone ells

steo$lasts

+ %unction in $one formation

steocytes

+ #ature $one cells that function in $one maintenance

steoclasts

+ #ultinuclear cells function in destroying resor$ingand remodeling $one



Bone Formation and Maintenance steogenesis: process of $one formation

+ ssification: the process of formation of the $onematri and deposition of minerals

*one is in constant state of turnover

Regulating factors

+ -tress and weight$earing

+ itamin D

+ "arathyroid hormone and calcitonin

+ *lood supply



Bone (ealing

7ematoma and inflammation

0ngiogenesis and cartilage formation

6artilage calcification

6artilage removal

*one formation

Remodeling

*one healing completed within a$out ) weeks; up to )months in the older person



Changes in Older Adult

#usculoskeletal changes can $e due to:

+ 0ging process

+ Decreased activity

+ ,ifestyle factors




,oss of $one mass in older women

/oint and disk cartilage dehydrates causing loss offlei$ility contri$utes to degenerative 4oint disease&osteoarthritis'; 4oints stiffen lose range of motion




6ause stooped posture changing center of gravity


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Assessment

7ealth history

6hief complaint

nset of pro$lem


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Assessment


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Phsical !"amination

"osture

8ait

0$ility to walk with or without assistive devices

0$ility to feed toilet and dress self

#uscle mass and symmetry

/oint function

#uscle strength and si>e -kin

neurovascular status


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Phsical !"amination

nspect and palpate $one 4oints for visi$le deformitiestenderness or pain swelling warmth and R#

0ssess and compare corresponding 4oints

"alpate 4oints knees and shoulder for crepitus


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Phsical !"amination

?ever attempt to move a 4oint past normal R# or pastpoint where patient eperiences pain

*ulge sign and $allottement sign used to assess for fluidin the knee 4oint

9homas test performed when hip fleion contracturesuspected


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)ormal S!ine and * Abnormalities


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+iagnostic ,valuation

@rays

6omputed tomography

#R 0rthrography: use of radiopa=ue dye to detect tears

of 4oint capsule

*one densitometry+ estimates $one mineral density

*one scan


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+iagnostics contd.

0rthroscopy + visuali>es 4oint to assess for disorders

0rthrocentesis: aspiration of synovial fluid


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+iagnostic &est

,a$oratory

+ Arine 9ests 2 hour creatinecreatinine ratio &muscle

diseases'

Arine Aric acid +2 hr specimen &gout'

Arine deoypyridinoline &assess $oneresorption'


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+iagnostic &est

,a$oratory

+ *lood 9ests -erum muscle en>ymes &muscle damage'

Rheumatoid %actor

,< "rep!0ntinuclear 0nti$odies&0?0' &-,


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Musculoskeletal are

Modalities


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ast

0 rigid eternal immo$ili>ing device

Ases

+ mmo$ili>e a reduced fracture

+ 6orrect a deformity

+ 0pply uniform pressure to soft tissues

+ -upport to sta$ili>e a 4oint

#aterialsBnonplaster &fi$erglass' plaster


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Long-Arm and Short-Leg ast andommon ressure Areas


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&eaching )eeds of the atient 'ith a ast "rior to cast application

+


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&eaching )eeds of the atient 'ith a ast

Do not scratch or stick anything under cast

6ushion rough edges

-igns and symptoms to report:+ persistent pain or swelling changes in sensation

movement skin color or temperature signs ofinfection or pressure areas

Re=uired followup care 6ast removal


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S!lint and Braces 6ontoured splints of plaster or plia$le thermoplastic

materials may $e used for conditions that do not re=uirerigid immo$ili>ation for those in which swelling may $e

anticipated and for those that re=uire special skin care. *races are used to provide support control movement

and prevent additional in4ury. 9hey are custom fitted tovarious parts of the $ody.


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,/ternal Fi/ation +evices Ased to manage open fractures with soft tissue damage

"rovide support for complicated or comminuted fractures

"atient re=uires reassurance due to appearance of device

Discomfort is usually minimal and early mo$ility may $eanticipated with these devices.


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&raction

9he application of pulling force to a part of the $ody

"urposes:

+ Reduce muscle spasms

+ Reduce align and immo$ili>e fractures

+ Reduce deformity

+ ncrease space $etween opposing forces

Ased as a shortterm intervention until other modalitiesare possi$le


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All traction needs to be a!!lied in t'o

directions. &he lines of !ull are 0vectors offorce.1 &he result of the !ulling force isbet'een the t'o lines of the vectors offorce.


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rinci!les of ,ffective &raction

Chenever traction of applied a counterforce must $e applied.%re=uently the patients $ody weight and positioning in $edsupply the counterforce.

9raction must $e continuous to reduce and immo$ili>e

fractures. -keletal traction is never interrupted.

Ceights are not removed unless intermittent traction isprescri$ed.

0ny factor that reduces pull must $e eliminated.

Ropes must $e uno$structed and weights must hang freely.

Enots or the footplate must not touch the foot of the $ed.


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&y!es of &raction

-kin traction

+ *ucks etension traction

+ 6ervical head halter

+ "elvic traction

-keletal traction


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reventive )ursing are )eeds of theatient in &raction

"roper application and maintenance of traction

#onitor for complications of skin $reakdown nerve

pressure and circulatory impairment

+ nspect skin at least three times a day

+ "alpate traction tapes to assess for tenderness

+ 0ssess sensation and movement

+ 0ssess pulses color capillary refill and temperature offingers or toes

+ 0ssess for indicators of D9

+ 0ssess for indicators of infection


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reventative 2nterventions

"romptly report any alteration in sensation or circulation

%re=uent $ack care and skin care

Regular shifting of position

-pecial mattresses or other pressure reduction devices

"erform active foot eercises and leg eercises every hour

e to help with movement for patients in skeletaltraction

"in care


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are of the atient in &raction3Assessment

0ssessment of neurovascular status and for complications

0ssessment for mo$ilityrelated complications of

pneumonia atelectasis constipation nutritionalpro$lems urinary stasis or A9

"ain and discomfort


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ollaborative roblems4otentialom!lications

"ressure ulcer

0telectasis

"neumonia

6onstipation

0noreia

Arinary stasis and infection

D9


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"oint 5e!lacements

Ased to treat severe 4ointpain and disa$ility and forrepair and management of4oint fractures or 4ointnecrosis.

%re=uently replaced 4ointsinclude the hip knee andfingers.

/oints including the shoulderel$ow wrist and ankle mayalso $e replaced.


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ar!al &unnel Syndrome 6ommon condition; the median nerve in the wrist

$ecomes compressed causing pain and num$ness

6ommon repetitive strain in4ury via occupational orsports motions

?onsurgical management: drug therapy andimmo$ili>ation

"ossi$le surgical management


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Osteo!orosis

0ffects approimately ( million people over the age ofF( in the Anited -tates.

?ormal homeostatic $one turnover is altered and the rateof $one resorption is greater than the rate of $one

formation resulting in loss of total $one mass.

*one $ecomes porous $rittle and fragile and $reakeasily under stress

%re=uently result in compression fractures of the spine

fractures of the neck or intertrochanteric region of thefemur and 6olles fractures of the wrist

Risk factors.


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lassification of Osteo!orosis 8enerali>ed osteoporosis occurs most commonly in

postmenopausal women and men in their )(s andG(s.

-econdary osteoporosis results from an associatedmedical condition such as hyperparathyroidism longterm drug therapy longterm immo$ility.

Regional osteoporosis occurs when a lim$ isimmo$ili>ed.


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&y!ical Loss of (eight Associated 'ithOsteo!orosis and Aging


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revention *alanced diet high calcium and vitamin D throughout life

Ase of calcium supplements to ensure ade=uate calciumintakeBtake in divided doses with vitamin 6

Regular weight$earing eercisesBwalking

Ceight training stimulates $one mineral density &*#D'


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are of the atient 'ith Osteo!orosis3Assessment

ccurrence of osteopenia and osteoporosis

%amily history

"revious fractures

Dietary consumption of calcium


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2nterventions

"romoting understanding of osteoporosis and thetreatment regimen

Relieving pain

mproving $owel elimination

"reventing in4ury


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Drug 9herapy: steoporosis 7ormone replacement therapy

"arathyroid hormone

6alcium and vitamin D

*isphosphonates

-elective estrogen receptor modulators

6alcitonin ther agents used with varying results


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Diet 9herapy steoporosis "rotein

#agnesium

itamin E

9race minerals

6alcium and vitamin D

0void alcohol and caffeine


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%all "revention steoporosis 7a>ardfree environment

7ighrisk assessment through programs such as %alling-tar protocol

7ip protectors that prevent hip fracture in case of a fall


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Osteomalacia

0 meta$olic $one disease characteri>ed $y inade=uate$one minerali>ation

-oftening and weakening of the long $ones causes paintenderness and deformities caused $y the $owing of$ones and pathologic fractures

Deficiency of activated vitamin D causes lack of $one

minerali>ation and low etracellular calcium andphosphate

6auses include gastrointestinal disorders severe renalinsufficiency hyperparathyroidism and dietary deficiency


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&reatment of Osteomalacia

6orrect underlying cause

ncreased doses of vitamin D and calcium are usuallyrecommended

7andle patient gently; patient is at high risk for fractures

0ddress pain and discomfort


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Osteomyelitis

nfection of the $one


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"revention of osteomyelitis is the goal.


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steomyelitis 9ypical signs and symptoms : 0cute osteomyelitis

include:

%ever that may $e a$rupt

rrita$ility or lethargy in young children

"ain in the area of the infection

-welling warmth and redness over the area of the

infection


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Osteomylitis hronic osteomyelitis include%

Carmth swelling and redness over the area of theinfection

"ain or tenderness in the affected area

6hronic fatigue

Drainage from an open wound near the area of theinfection

%ever sometimes


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are of the atient 'ith Osteomyelitis3

lanning

#a4or goals may include relief of pain improved physicalmo$ility within therapeutic limitations control anderadication of infection and knowledge of therapeuticregimen.


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2nterventions Reliving pain

+ mmo$ili>ation

+


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2nterventions

"romote good nutrition: vitamin 6 and protein


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-urgical #anagementsteomyelitis

-e=uestrectomy &-urgical removal of a se=uestrum'a detached piece of necrotic $one that often

migrates to a wound a$scess etc. *one grafts

*one segment transfers

0mputation


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Bone &umors

"rimary tumors

+ *enign tumors are more common and generally areslow growing and present few symptoms

+ #alignant

"rognosis depends upon type and whether thetumor has metastasi>ed

steogenic sarcoma is the most common and

most often fatal primary malignant $one tumor #etastatic $one tumors

+ #ore common than primary tumors


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#alignant *one 9umors

"rimary tumors those tumors that originate in the $one

+ steosarcoma

+


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9reatment 6ancer of *one

nterventions include:

+ 9reatment aimed at reducing the si>e orremoving the tumor

+ Drug therapy; chemotherapy

+ Radiation therapy

+ -urgical management

+ "romotion of physical mo$ility with R#eercises


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ollaborative roblems4otential

om!lications

Delayed wound healing

?utritional deficiency

nfection

7ypercalcemia


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are of the atient 'ith a Bone &umor3

lanning

#a4or goals include knowledge of disease process andtreatment regimen control of pain a$sence of pathologicfractures effective coping patterns improved selfesteem and a$sence of complications.


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2nterventions

6are is similar to that of other patients who haveundergone orthopedic surgery.

"atient and family teaching regarding diagnosis diseaseprocess and treatment.

"revention of pathologic fractures

+ -upport affected etremities at all times and handlegently

+


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2nterventions

"romoting proper nutrition

+ 0dminister antiemetics as prescri$ed

+ Relaation techni=ues

+ ral care

+ ?utritional supplements

"rovide ade=uate hydration

Ase strict aseptic techni=ue


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6ancer of *one0nticipatory 8rieving

nterventions include:

+ 0ctive listening

+ e feelings

+ #aking appropriate referrals

+ 7elping client and others to cope with the loss and

grieving

+ "romoting the physicianclient relationship


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5eferences

Bashayreh6 2. Musculoskeletal System Assessment7 +isorders.

Documents

Musculoskeletal Disorders 2 (1)