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Health Assessment of the Musculoskeletal System:

Health Assessment of the Musculoskeletal System Wegdan Bani-Issa , RN, PhD

Musculoskeletal System:

Musculoskeletal System Today ’ s Objectives Review structure and function of joints Conduct Heath history Conduct techniques of examination for specific joints, follow a head–to-toe sequence

Function of MS:

Function of MS Human need this system: Support and stand For movement To encase and protect the inner vital organs ( brain, ,spinal cord, heart) To produce RBCs in the bone marrow ( hempatopoiesis ) Reservoir for storage of essential minerals ( Ca , phosphorus in the bone).

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The skeleton is the bony framework of the body 206 bones support the body. Bone and cartilage are specialized form of connective tissues. Bone is hard, rigid, very dense (bones turnover for remodeling). Joint: (articulation) is the place of union of two or more bones. Joints are the functional unit of the MS system for activities.

Types of joints :

Types of joints 1 Synovial: freely movable because they have bones

Structure and Function of Joints :

Structure and Function of Joints Review some anatomical terminology Cartilage : in synovial joints, cartilage covers opposing surfaces of the joints Ligaments : ropelike bundles of collagen fibers that connect bone to bone. Tendons: collagen fibers connecting muscle to bone. Another type of collagen matrix forms the cartilage that overlies bony surfaces Bursae : an enclosed sac filled with viscous fluid. A cushion the movement of tendons and muscle over bone or other bone structures: easing joint movement (subracromial bursa of the shoulder, and prepattelar of the knee).

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Muscle: 40 to 50% of the body ’ s wt. When they contract they produce movement Three types: skeletal, smooth, and cardiac. Today will deal with skeletal muscle-voluntary compased of bundles of muscle fibers- (fasciculi) Skeletal muscle: attach to the bone by tendon. Produce Flexion, extension, abduction, adduction, pronation, supination, circumduction, inversion, eversion, rotation, protraction, retraction, elevation, and depression

Joints :

Joints Temporomandibular joint: Articulation of the mandible to the temporal bone

Shoulder :

Shoulder Shoulder joint: glenohumeral joint: articulation of the humerus with the glenoid fossa of the scapula A: acromion process: the very top of the shoulder B: greater tubercle of the of the humorous C: coracoid process of the scapula A B C Genoid fossa Connect clavicle with acromion process

Elbow :

Elbow Elbow joint: contains the three bony articulations of the humerus, radius, and ulna of the forearm Lateral epicondyle, medial epidondyle and the olectranon Process of the ulna between them The sensitive ulnar nerve runs between olectranon Process & medial epidcondyle)

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Wrist and hands: > ½ of the 206 bones located in hands and feet. Two parallel rows of carpal bones (carbal bones)

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Lower extremities: Hip Knee Foot

The hip joint :

The hip joint The hip joint: articulation between acetabulum and the head of the femur Ball and socket

Knee joint :

Knee joint Knee joint: articulation of three bones: femur, tibia, patella (kneecap) Suprapatellor pouch : knee's synovial membrane: 6 cm below the quadriceps muscles Menisci: a cushion For tibia & femur Medial condyle Tibial tuporicity Lateral condyle cartilage The joint is stabilize by cruciate ligaments and collateral ligaments Landmarks: quadriceps muscle & tibial tuberosity

Ankle and foot :

Ankle and foot Ankle and foot : articulation of the tibia, fibula, talus Tarsal Metatarsal Metatarsaphalengeal joints

Spine :

Spine Vertebra: are 33 connecting bones and disk to prevent friction. Function: unique structure enables both upright posture and flexibility for motion: flexion (bending forward, extension bending back),, abduction (to either sides), and rotation. Important: all joints were structured to facilitate the movement in certain direction and angles

Subjective DATA :

Subjective DATA 1- Joint: any problem with your joint? Location, which joint? Severity, onset… Stiffness: swelling, heat, limitation of movement. 2- Muscle: pain or cramping. Myalgia: cramping muscular pain. 3- bones 4-functional assessment 5-self-care behaviors

Health history :

Health history

Techniques for examination :

Techniques for examination

Techniques for Examination :

Techniques for Examination Inspection: Size, contour of the joint, skin changes around the joint, swelling, masses or deformity. Swelling may indicate joint irritation. Palpation : skin temp, bony articulation, and areas of joint capsule. Heat, tenderness, ,swelling, ,masses) Synovial membrane: usually not palpable. When thickened, or boggy (bulging)- abnormal. Notice : do not touch painful joint before doing x-ray.

Range of Motion :

Range of Motion Active ROM: while stabilizing the body area proximal to that being moved. If you see limitation: gently attempt passive ROM. Move slowly the joint to its limit Passive and active ROM should be the same.

Muscular Movements:

Muscular Movements Flexion: decrease angle of a joint/bending limb at a joint Extension: increase angle of a joint/straitening limb at a joint Abduction: away from the midline Adduction: adding to the midline Pronation : palms down Supination : palms up Circumduction : circular motion Inversion: soles of feet inward Eversion : soles of feet outward

Muscle testing :

Muscle testing 5 = full ROM against gravity, full resistance (100 = normal) 4 = full ROM against gravity, some resistance (75 = good) 3 = full ROM against gravity, 50=fair 2 = full ROM with gravity eliminated (passive motion), 25= poor 1 = slight contraction (10 = trace) 0 = no contraction (0=zero)

Techniques For examination :

Techniques For examination Temporomandibular (TMJ) joint: TMJ: the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet. for speaking and chewing Hinge action (open & close); gliding action (side-to-side & protrusion/retraction)

TMJ:

TMJ Mouth movements Palpate TMJ for audible and palpable snap or clicking (normal) Abnormalities: tenderness, swelling, lost of movement (lateral motion may be lost earlier and more significant than upper vertical) Place your index finger in front of the tragus of each ear and ask the patient to open his or her mouth, the fingertips must drop into the joint space as the mouth open.

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Compare Rt. & Lt. side for strength and firmness. Indicates the integrity of the Cranial nerve V (trigeminal). ROM: ask the patient to open and close the mouth gliding movement, protrusion and retraction (jutting the jaw forward), lateral or side to side.

Cervical Spine: neck :

Cervical Spine: neck Inspect: alignment of head and neck. Palpate: the spinous process, sternomastoid, trapezius, paravertebral muscle Any tenderness, impaired movement warrants careful neurological testing of the neck and upper extremities

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ROM: Flexion Extension Lateral flexion/bending Rotation Extension Flexion

Upper extremities: Shoulder:

Upper extremities: Shoulder Review anatomy on your own Ball and socket action allows for great mobility Three land marks for inspection and palpation Acromioclavicular joint Greater tubercle Coracoid process Check for inequality landmarks. Atrophy, lack of fullness. Dislocated shoulder loses the normal round shape and looks flattened laterally.

The shoulder :

The shoulder

Shoulders:

Shoulders Posterior and lateral views Inspect size, contour, muscle atrophy, deformity, swelling (best seen interiorly), or dislocation or abnormal positioning. Ask about history of shoulder pain. Ask the patient to point at the pain. Palpate for any tenderness (as a result of local or referred pain), spasm, atrophy, swelling, or heat. Palpate around the acromion process, Acromiocalvicular joint and down to the coracoid process (posterior shoulder, lateral and anterior)

ROM:

ROM 50 hyperextension Forward flexion Internal rotation Abduction adduction External rotation

The Elbow :

The Elbow Elbow: inspect Medial & lateral Epicondyles, Olecranon process.

Elbow:

Elbow Inspection and palpation : flex the elbow to about 70 degree and identify medial and lateral epicondyle and olcranon process. Note any nodules and swelling tenderness, displacement Normal: fairly solid joint Abnormalities: Soft, boggy, or fluctuating swelling (in synovial thickening or effusion) Subluxation of the elbow: forearm dislocated posteriorly Swelling and redness of the olecranon bursa ROM: Flexion/extension Pronation/supination Muscle strength

Wrist and Hand:

Wrist and Hand Inspection : Observe the position of the hand. Movement is smooth and natural. Swelling over the joint The skin smooth with knuckle wrinkles Note any deformities of the wrist, hand, finger bones, angulation from radial and ulnar deviation. Thickness of the flexor tendons or flexion contractures in the fingers.

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Palpation: wrist (carpal, metacarpal, phalanges, metacarpophalangeal (connect the palm with the fingers), & interphalangeal joints (proximal, middle and distal, the radial styloid bone). Squeeze the metacararpophalangeal joint between your thumb and fingers. Normally: smooth with no bogginess, nodules, tenderness. Loss of ROM is the most common and significant functional loss of the wrist

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Palpate the anatomic snuffbox: Snuffbox Palpate each joint individually

Wrist and Hand:

Wrist and Hand Muscle strength Wrist ROM: Flexion/extension -radial and ulnar deviation

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Fingers ROM for the hand: Flexion and extension : Ask patient to make a tight fist and then extend and spread the fingers. Flexion and extension: abduction/adduction : ask patient to spread the fingers apart and then bring them together Grip strength: ask the person to flex the wrist against your resistance

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Touch the thumb to each finger and to the base of little finger

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Test sensation of fingers:

Special Test:

Special Test Phalen ’ s test Hold both hands back-to-back while flexing the wrist in 90 degrees for 60 seconds Normal finding: no pain If numbness & burning produced, is a positive sign for tunnel syndrome. Tinel sign: Directly percuss over the median nerve at the wrist Normally, no pain If pain, burning & tingling produced along the nerve, the patient have Positive Tinel ’ s sign and indicate Carpal Tunnel Syndrome

The Hip:

The Hip

The Hip :

The Hip Palpation While standing: Note symmetrical levels of iliac gluteal folds, length of the legs, and equally sized buttocks. while supine position: palpate the joint, feel stable, symmetrical with no tenderness or stiffness, crepitous

ROM :

ROM Flexion Extension Hip and knee flexion External & internal rotation s abduction Adduction

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Adduction: toward the body abduction): away from the body

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Notice any limited ROM Pain on internal rotation or limited abduction may indicate hip disease.

Knee examination:

Knee examination Start with tibial tubricity

The knee: stop here :

The knee: stop here Inspection : while leg extended or knee flexed. observe the gait for smooth, rythmatic movement. Check alignment and contours of the knee. Atrophy of the quadriceps muscle. Loss of normal hallow around the patella, a sign of swelling in the knee joint and suprapatellar pouch (inflammation)

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Enhance palpation: when pt supine, start high on the anterior thigh, about 10 cm above the patella. Palpate with your thumb and fingers in a grasping fashion. Proceed down toward the know. Feel fluctuant or boggy with synovitis of suprpateller pouch. (Fig. 22-32. p. 642) Effusion of the knee

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Bulge sign stroke up on the median aspect of the knee two or three times to display fluid. Tap the lateral aspect, watch the medial side in the hallow for a district budge from fluid wave. Normally none is present Bulge sign: very small amount of fluid 4-8 ml, from flowing a cross the joint.

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Ballottment of the patella: for large amount of fluid Compress the suprapattelar pouch to move any fluid into the knee joint. With right hand,, push the patella sharply against the femor. If no fluid, ,the patella snug against the femor. Continue palpate the tibiofemoral joint

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Check ROM Bend the knee Extend the knee Muscle strength: ask the person to keep knee flexed while you opposes by pull the leg forward. When pt try to raise from standing or setting position shows the muscle strength

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McMurray test: for a person with trauma history Hold the heel and flex the knee and hip. Place your hand over the knee with fingers to the median side Rotate the leg in and out to loosen the joint. Normally, the leg extend smoothly without pain http://www.youtube.com/watch?v=IwBW-X4n1fU

Spine:

Spine Consist of 33 vertebrae (7C, 12T, 5L, 5S, & 3-4 coccyx) C7 & T1 prominent at the base of the neck T7 & T8 at the level of the inferior angle of the scapula L4 at the level of the highest point on iliac crest S2 at the level of dimple of the posterior superior iliac spines crossing. The vertebral column has 4 curves (double S shape) Intervertebral discs: elastic fibrocartilaginous Each disc has a Nucleus Pulposus: soft, semi-fluid material

Techniques for physical examination :

Techniques for physical examination Inspection Observe the patient posture, position of the neck and trunk when entering the room. Smoothness of neck movement and ease of gait. Drape or gown the patient to expose the back completely. While patient in a standing position, the head should be midline in the same plane as the sacrum and the shoulder and pelvic should be level. Inspect the patient from the side and observe the curvature of the spine

Ankle and foot :

Ankle and foot Inspection Palpate the anterior portion of the foot and ankle with your thumb, tendon of achilles and feel for any swelling or bogging, tenderness Palpate the heel and the metatarsophalangeal joints: compress the foot between the thumb and fingers. Exert pressure on the foot. Palpate the heads of the five metatarsals and the grooves between them with the thumb and index fingers.

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Palpation each joint individually

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Range of Motion (dorsiflexion & planter flexion, inversion & eversion )

The spine :

The spine Palpation Palpate the spinous process of each vertebra with your thumb. In the neck: palpate for the facet joint that lies between the cervical vertebra about 1 inch lateral to the spinous process of C2-C7. Notice of the spinous process unusually prominent in relation to the one above it, tenderness. Palpate the posterior-superior iliac spine. Palpate the paravertebral muscle for tenderness and spasm,

Assess range of motion in the spinal process :

Assess range of motion in the spinal process Flexion : bend forward to touch the toes. Note smoothness and symmetry of movement, the ROM, Curve in the lumber area. Normally increase up to 4 cm. Extension : put your hand on the posterior-superior iliac spine and fingers pointing toward the midline and ask patient to bend backward as far as possible Rotation: stabilize the pelvic by placing one hand on the patient ’ s hip and the other on the opposite shoulder. Rotate the trunk by pulling the shoulder and then the hip posteriorly. Lateral bending : stabilize the pelvis ask patient to lean forward to both sides. Notice any tenderness, if radiating to the legs.

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Special Techniques Low back pain with radiation into the leg: for patient with low back pain Put patient in supine position, raise the patients ’ relaxed and straighten leg until pain occurs then dorseflex the foot. Record degree of elevation of leg when pain occurs and record quality and location of pain. Measuring the length of the legs for symmetry From the superior iliac crest to the medial malliolous

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