Musculoskeletal System Randa M. Albusoul Introduction This system - - PowerPoint PPT Presentation

Randa M. Albusoul Musculoskeletal System

Introduction

• This system consist of: bones, joints, muscles.

Joints: articulation where 2 or more bones are joined. Ligaments: Fibrous bands that hold bone to bone. Tendons: Collagen at end of muscles that attaches muscle to bone Bone: hard, rigid and dense connective tissue. Cartilage: Smooth connective tissue.

Synovial joints: example: knee, shoulder, freely movable because they have bones that are separated from each other with synovial fluid present to allow sliding of opposing surfaces. Cartilaginous Joints: Example: between vertebrae and the symphysis pubis, are slightly

• movable. Fibrocartilaginous discs

separate the bony surfaces. Nucleus pulposus serves as a cushion or shock absorber between bony surfaces.

Fibrous Joints: example: sutures of the skull, immovable, intervening layers of fibrous tissue or cartilage hold the bones together. Types of Synovial Joints: The shape of synovial joints differ determining the direction and degree of motion. 1) Spheroidal joints: ball and socket configuration, wide range of rotatory movement, ex. Hip and shoulder.

2) Hinge joints: flat, plantar, or slightly curved, allowing for a small motion in a single plane such as flexion or extension of the digits. 3) Condylar joints: one convex, and

• ne concave

structures, such as knee.

Bursae: disc-shape synovial sacs that allow muscles and tendons to glide over each other during

• movement. Are present between the skin and

convex surface of a bone or joint or in area were tendons and bones rub against bone, ligaments, or

• ther tendons or muscles.

Muscles:

• Account for 40-50% of body’s weight.
• When contract  produce movement
• Types:

Skeletal- voluntary muscles Smooth- involuntary muscles cardiac

Flexion: Bending a limb at a joint. Extension: Straightening a limb at a joint. Pronation:Turning the forearm ̶ palm is down. Supination: Turning the forearm ̶ palm is up. Abduction: moving a limb away from the midline Adduction: moving a limb toward the midline.

Circumdution: Circular movement of the arm around the shoulder. Inversion: moving the sole of the foot inward at the ankle. Eversion: moving the sole of the foot outward at the ankle. Rotation: moving the head around a central axis.

Protraction: moving forward and parallel to the ground. Retraction: moving backward and parallel to the ground. Elevation: raising Depression: lowering

Subjective Data Common symptoms: Joint pain Joint pain with systematic symptoms; rash, chills, fever, weight loss, weakness Low back pain Neck pain bone pain muscle pain, cramps, weakness

Myalgias: pain in the muscle. Arthralgia: pain in the joint. Ostealgia: pain in the bones. Some questions: location of the pain? Only one joint

• r all? Any trauma?

Low back pain: any associated numbness or paresthesias? Any bladder or bowel dysfunction? Neck pain: any radiation to arm? Or arm/leg weakness, paresthesias, bowel or bladder dysfuction?

Objective Data 1- inspect joints size, shape, color, symmetry, note any masses, deformities, or muscle atrophy. Compare bilateral. 2- palpate for skin changes, crepitus, nodules, atrophy, assess for inflammation: redness, swelling, tenderness, warmth 3-Test joints range of motion (ROM) passive, active; to test function, stability, and integrity. 4-assess of muscle strength.

Muscle bulk:

• When looking for atrophy pay attention to the hands,

shoulders, and thighs.

• Be alert for fasciculations in atrophic muscles.

Fasciculation: small, local, involuntary muscle contraction and relaxation, which may be visible under the skin.

• Muscle tone: when normal muscle with intact

nerves is relaxed voluntarily it maintain a slight tension known as muscle tone. It can be assessed best by feeling the muscle’s resistance to passive stretch.

• Muscle strength:
• Note the age, gender, and muscular training.
• A dominated side may be slightly stronger.
• Shorter muscles are stronger.

1- Test muscle strength by asking patient to move each extremity in its full ROM against resistance.

• If can’t move against resistance, ask client to move

against gravity.

• If can’t against gravity, eliminate the gravity.

When documenting muscle strength, indicate the scale used, e.g., muscle strength 3 out of 5 or 3/5.

Temporomandibular Joint

• The muscles that open the mouth are external

pterygoids.

• The muscles that close the mouth are internal

pterygoids, masseter, temporalis and are innervated by cranial nerve V (trigeminal nerve).

Inspect and palpate the joint:

• Ask patient to open mouth as widely as possible.
• Move jaw from side to side; lateral.
• Protrude (push out), retract (pull in).

Normally; jaw move laterally 1-2 cm. snapping and clicking is normal. mouth open 1-2 inches (3 fingers) Jaw protrude and retract easily; bottom teeth can be placed in front of the upper.

• To locate and palpate the joint place the tip of your

index finger in front of the tragus of each ear and ask the pt to open her mouth.

• Check for smooth ROM .
• Note any swelling or tenderness.
• Palpate the masseters and temporal muscle.

Muscle strength:

• Perform ROM maneuvers

(projection, lateral, openning) against your resistance.

The Shoulder Shoulder girdle: is the complex interconnection structure of joints, bones, and muscles that moves the shoulder. The bones are: humerus, clavicle, and scapula. The joints are: sternoclavicular, acromioclavicular, and glenohumeral.

Inspection:

• Note any swelling, deformity, muscle atrophy,

fasciculations, abnormal positioning, symmetry.

• Color change, skin alterations, bony contours.

Palpate:

• Heat, tenderness, muscular spasm or atrophy.
• ROM: the motions of shoulder girdle are flexion,

extension, abduction, adduction, internal and external rotation.

Flexion: Raise your arms in front of you and over head. Extension: raise your hands behind you.

Abduction: raise your arms out to the side and

• verhead.

Adduction: cross your arm in front of your body.

Internal rotation: place one hand behind your back and touch your shoulder blade.

Raise your arm to shoulder level, bend your elbow and rotate your forearm toward the ceiling.

The Elbow

• Note the bones,

muscles, and joints

• f the elbow.
• Biceps and

brachioradilis (flexion), triceps (extension), pronator teres (pronation), supinator (supination).

The bursa is normally palpable but swells and becomes tender when inflamed.

• Inspect: the size & contour in both flexed & extended

elbows; redness, deformity, swelling.

• Palpate elbow note any displacement and tenderness.

ROM and muscle strength:

• Stabilize the arm with one hand.
• Ask the pt. to flex elbow against

resistance applied to the wrist.

• Ask the pt. to extend elbow while

adding resistance.

The Wrist and Hands Note the bones and joints in the arm.

• Ulna does not

articulate directly with the carpal bones.

• Radiocarpal joint

provides most of the flexion and extension

• f the wrist.

• inspect the dorsal & palmer sides; position; shape,

and deformities.

• Inspect skin; color, smoothness, muscle mass.
• Palpate each joint in the wrist & hands.
• Palpate thumbs side to side to identify the normal

depressed area “anatomic snuffbox”.

• Palpate the interphalangeal joints by thumb & index.
• Normal joints surface feel smooth no swelling,

nodules or tenderness.

Wrist ROM: Flexion, extension, adduction (radial deviation), abduction (ulnar deviation). Muscle strength: Extension at the wrist (C6, C7, C8, Radial nerve), ask the pt to make a fist and resist your pulling it down

Test the grip (C7, C8, T1), ask pt to squeeze two of your fingers as hard as possible and not let them go.

For complaints of dropping objects, inability to twist lids off jars, aching at the wrist or even the forearm, and numbness of the first three digits, use the tests

• n the next page for assessing carpal tunnel

syndrome.

For carpal tunnel syndrome test:

• The index finger- median nerve.
• The 5th finger (small finger)- ulnar nerve.
• Dorsal web space of the thumb and index finger-

radial nerve. Thumb abduction (ask the pt to raise the thumb straight up as you apply downward resistance)

Tinel’s sign for median nerve compression by tapping lightly over the course of the median nerve in the carpal tunnel. Phalen’s sign for median nerve compression, hold wrists in flexion for 60 sec.

Fingers and thumb ROM: Flexion: make a tight fist with each hand, thumb across the knuckles. Extension: extend and spread the fingers. Abduction and adduction: ask the pt to spread the fingers and back together.

ROM of Thumb: Assess flexion, extension, abduction, adduction, and

• pposition.

Finger muscle strength test: Finger abduction (C8, T1, ulnar nerve) hand with palm down and fingers spread, instruct the pt not to let you move the fingers, try to force them together. Test opposition of the thumb (C8, T1, median nerve) the pt should try to touch the tip of the little finger with the thumb, against your resistance.

The Spine

• Vertebra-33 connecting bones stacked in a vertebral

column.

• Humans have 7 cervical, 12 thoracic, 5 lumbar, 5

sacral, & 3-4 coccygeal vertebra.

• Surface Landmarks-

Spinous process C-7 & T-1 Inferior angle of scapula- T-7 & T-8 Imaginary line connecting highest point on each iliac crest crosses L-4

• Lateral view of spine- double S shape.
• These curves together with the intervertebral disks

allow the spine to absorb a great deal of shock.

• Intervertebral Disks- elastic fibro cartilaginous

plates that constitute ¼ of the length of the column.

• Each disk has a nucleus pulposus
• The disks cushion the spine & help it move.
• As spine moves - elasticity of the disks allow

compression on one side, with compensatory expansion on the other. Sometimes compression is too great—disk can rupture and the nucleus pulposus can herniated out the vertebral column—compressing on spinal nerve & causing pain.

Inspection:

• Observe the pt posture and position of neck and

trunk.

• Assess the pt for erect position of the head,

coordinated neck movement, and ease of gait.

• Assess the landmarks and spinal curvatures.

Palpation:

• Palpate the spinous process of each vertebra.
• Palpate for tenderness.

ROM of neck: Flexion and extension (C1), rotation (C1-C2), lateral bending (C2-C7). Muscle strength: Can be tested when the examiner place his hand to resist the motion of the pt.

ROM for spinal column: Flexion: bend forward and try to touch your toes. Extension: bend back as far as possible. Rotation: rotate from side to side. Lateral bending: bend to the side from the waist.

Muscle strength test: Assessment of muscle strength of the spinal column may also be performed during the range-of-motion assessment by having the patient flex, extend, and flex laterally against resistance.

The Hip

Inspection: Inspect the gait of the pt when entering the room.

Palpate: Palpate the hip joints and landmarks; feel stable and symmetric, not tender or crepitance. ROM: Include flexion, extension, abduction, adduction, external rotation, internal rotation.

For further examination see this maneuver:

• Flexion: With the patient supine, place your hand

under the patient’s lumbar spine. Ask the patient to bend each knee in turn up to the chest and pull it firmly against the abdomen. When the back touches your hand, indicating normal flattening of the lumbar

• lordosis. As the thigh is held against the abdomen,
• bserve the degree of flexion at the hip and knee.

Normally the anterior portion of the thigh can almost touch the chest wall. Note whether the opposite thigh remains fully extended, resting on the table.

Muscle strength test:

• Flexion: place your hand of the pt thigh and ask

him to raise the leg against your hand. Extension: by having the supine pt push the posterior thigh against your hand.

• Abduction: place your hands firmly on the bed
• utside the pt knees and ask the pt to spread both legs

against your hands.

• Adduction: place your hands firmly on the bed

between the pt knees. Ask the pt to bring both legs together.

• External and internal rotation:

Flex the leg to 90° at hip and knee, stabilize the thigh with one hand, grasp the ankle with the other, and swing the lower leg medially for external rotation at the hip and laterally for internal rotation.

The Knee

Inspect:

• Observe the gait when entering the room.
• The skin; smooth, even color no lesion.
• Lower leg alignment; extend in the same

axis.

• The shape and contour of knee; distinct,

concave or hollows on both side of patella.

• Prepatellar bursa & suprapatellar pouch;

no swelling.

• Quadriceps muscle in the anterior thigh;

no atrophy.

Palpate:

• The anterior thigh, above patella; consistence, soft

smooth, non tender, not hot. no lesions.

• Bulge sign; for swelling in the suprapatellar pouch:

no fluids.

• Ballottement test; large amount of fluid in the

suprapatellar pouch smooth margins, non tender.

ROM for knee:

Note; muscles affecting movement for self reading

Muscle strength test: Flexion: Support the knee in flexion and ask the pt to straighten the leg against your hand. Extension: Place the patient’s leg so that the knee is flexed with the foot resting on the bed. Tell the patient to keep the foot down as you try to straighten the leg.

The Ankle and Foot

Inspection:

• Observe all surfaces of the feet and ankles noting

any deformity, nodules, swelling. Palpate:

• Palpate the joints, note any swelling, or tenderness.

ROM:

Muscle strength test: Test muscle strength during dorsiflexion and planter flexion by asking the pt to pull up and push down against your hand.

The subtalar (talocalcaneal) joint: stabilize the ankle with one hand, grasp the heel with other and invert and evert the foot.

Transverse tarsal joint: stabilize the heel and invert and evert the forefoot. Metatarsophalangeal joints: flex the toes in relation to the feet.