lecture 7 - musculoskeletal

8/14/2019 Lecture 7 - Musculoskeletal

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Review of Human SkeletalReview of Human SkeletalAnatomyAnatomy

Mark Anthony R. Rivera, MD RN CST

Lecturer, College of Nursing

Our Lady of Fatima University


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Assessment of the

Musculoskeletal SystemMusculoskeletal System


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The Body Axis

The body is made up of the skull, vertebralcolumn, ribs, and coccyx (tailbone)

Skull is made up of the cranium, which

protects the brain, and the face. Vertebral column is the backbone. It has

33 vertebrae

Vertebrae are small, rigid bones thatstack together

The ribs protect the heart and lungs. Thereare 12 pairs.


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Arm

At the tips of your fingers are the phalanges.

Long, slender, lightweight.

Phalanges are connected to metacarpal bones.

Metacarpals are framework of the palm.

Metacarpals branch off from the carpal bones.

8 of them; pebble-ish

The carpal bones are below the ulna and the radius.

If your palm is face-up and your arm extended, your elbow

is your ulna. The ulna and the radius are connected to the humerus.

The humerus in turn connects to the scapula.

The scapula is held in place by muscles.

The scapula is then connected to the clavicle, or collarbone.


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Legs

At the tips of your toes are the phalanges.

These connect to the metatarsals.

Which in turn connect to the tarsals.

7 tarsals, only 1 is heel.

Connected to the tarsals are the tibia and fibula.

Tibia is the shin bone.

At the knee, the tibia and fibula are separated from the femur by a large section of cartilage.

On this cartilage rests the patella. The femur is then connected to the coxal bone, which is

connected to the sacrum

Femur is the largest bone in the body.


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Skeletal System

Bone types Bone structure Bone function

Bone growth and metabolism

affected by:1. calcium and phosphorous,2. calcitonin,3. vitamin D,4. parathyroid hormone,5. growth hormone,6. glucocorticoids,7. estrogens and androgens,8. thyroxine, and

9. insulin


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Bones

Support the body and anchor muscles.

Ligaments link bones to other bones.

Tendons link bones to muscle

Two types of bones Compact Bone

Spongy Bone

Inside bones is a central shaft. This is the marrowcavity where fat is stored.

Bone matrixes contain the bones proteins andminerals. These heal bone and maintain healthiness.


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2 Major Types of Bone

Compact

Has few and very smallspaces inside.

Made of osteons.

Spongy

Has many largespaces. It contains redmarrow where redblood cells are made.

Made of trabeculae.


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Joint types

Ball and socket

Pivot

Saddle

Ellipsoid

Hinge

Plane

Arm

Neck

Thumb

Knuckles

Knee

Ankle


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MUSCULAR SYSTEMMUSCULAR SYSTEM


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Muscular System

Structure

Function

Supporting structures

Musculoskeletal changes associated with aging

Cultural considerations

Movements to

know!

Know aging changes vs.


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List of major muscles

Biceps brachiiInner armTriceps brachiiBack of armDeltoidUpper armTrapeziusBase of neckScientific NameCommon Name

Biceps femorisBack part of the upper legSartoris and Rectus femorisFront part of the upper legGluteus maximusButtAbdominal musclesStomachLatissimus dorsiBack


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Muscles

In humans with hard skeletons, muscles arein antagonistic pairs

e.g. shin and calf muscles

The skeletal muscles are muscles that areattached to bones. These move the skeleton.

Made of muscle fibers, multi-nuclei cells.

The plasma membranes enclose longbundles called fibrils.


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Muscles Cont.

They work by shortening (contracting) andlengthening (flexing)

The energy is supplied my mitochondria in

the fibrils. Muscle contraction is called Sliding

Filament Mechanism, where filaments incells slide past each other.

Cardiac muscle is electrically connected.


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Different Types

Smooth

Found in hollowbody organs likedigestive tractand bloodvessels.

Have 1 nucleus.

Skeletal

Composed of long fibers.

Controlsvoluntary

movement.

Cardiac

Central nuclei.


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Muscle energy

The Immediate Energy System is a quick blast of muscle power. This uses fast-twitch fibers.

The Glycotic Energy System splits glucose byglycolysis in the muscles.

The Oxidative Energy System (Aerobic Energy System)is for prolonged muscle use, like marathons. This usesslow-twitch fibers.

Slow-twitch fibers are packed with mitochondriaand myoglobin.

Fast oxidative-glycolytic muscle fibers are moderatelypowerful and last for a moderate amount of time.


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Assessments

Family history and genetic risk

Personal history

Dietary history

Socioeconomic status and ability to afford food

Current health problems including obesity


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Physical Assessment

General inspection

Posture

Abnormality in gait such as antalgic gait or lurch

Goniometer, which provides a measure of ROM Head and neck: evaluate the temporomandibular joints

Spine: lordosis, scoliosis

Upper extremities Lower extremities

)


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Diagnostic Assessment

Laboratory tests: serum calcium andphosphorus, alkaline phosphatase, serummuscle enzymes

Radiographic examinations: standardradiography, tomography and xeroradiography,myelography, arthrography, and CT

Other diagnostic tests: bone and muscle biopsy


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Arthroscopy

Fiberoptic tube is insertedinto a joint for directvisualization.

Client must be able to flexthe knee; exercises areprescribed for ROM.

Evaluate theneurovascular status of

the affected limbfrequently.

Analgesics areprescribed.

Monitor for complications.


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Other Tests

Bone scan

Gallium or thallium scan

Magnetic resonance imaging

Ultrasonography


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Osteoporosis

Metabolic disease, in which bone demineralizationresults in decreased density and subsequent fractures

Osteopenia (low bone mass), which occurs when thereis a disruption in the bone remodeling process


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Classification of Osteoporosis

Generalized osteoporosis occurs mostcommonly in postmenopausal women and menin their 60s and 70s.

Secondary osteoporosis results from anassociated medical condition such ashyperparathyroidism, long-term drug therapy,long-term immobility.

Regional osteoporosis occurs when a limb isimmobilized.


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Health Promotion/Illness Prevention

Ensure adequate calcium intake.

Avoid sedentary life style.

Continue program of weight-bearing exercises.Unchangeable risk factors for osteoporosis include female

gender, older age, small or thin body size, Caucasian and Asian

ethnicity, and family history of fractures.

Modifiable risk factors include a diet low in calcium and vitamin

D, use of certain medications, an inactive lifestyle or extended

bed rest, cigarette smoking, and excessive alcohol

consumption.


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Assessment

Physical assessment

Psychosocial assessment

Laboratory assessment

Radiographic assessment


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Drug Therapy

Hormone replacement therapy Parathyroid hormone

Calcium and vitamin D

Bisphosphonates

Selective estrogen receptor modulators

Calcitonin Other agents used with varying results


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Fall Prevention

Hazard-free environment

High-risk assessment through programs such asFalling Star protocol

Hip protectors that prevent hip fracture in case of a fall


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Flexibility and Strength

Chronic Health Conditions-HTN

Cardiac Arrhythmiasperipheral neuropathies

FallContributors

Uneven surfacesNo HandrailsBad lighting

Slick Surfaces

Outdoors

Poor LightingClutter

Extension CordsUnstable Handrails

Scatter rugsPetsIndoors

Medications

HealthConditions


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Others

Exercise

Pain man agement

Orthotic devices
http://depts.washington.edu/bonebiohttp://depts.washington.edu/bonebiohttp://depts.washington.edu/bonebio


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Osteomyelitis

Osteomyelitis is an acute or chronic inflammatory processof the bone and its structures secondary to infection withpyogenic organisms.

Infection of bone with rich vascular supply frombacteremia, UTI, long term IV caths, Salmonella from GI,poor dental hygiene, MRSA

Trauma admits bacteria such as Pseudomonas directly.

Acute -> high temp, swelling, bone pain

Chronic -> skin ulceration, sinus tract, local pain, drainage

AB Tx IV, Infection control, > 3 months, surg debridementor bone grafts, amputation.


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Padgets Disease

Metabolic disorder of bone remodeling in whichbone deposits are weak, enlarged anddisorganized.

2nd most common bone disease in elderly.

Cause unknown but may be latent viralappearing > 80 yrs.

80% asymptomatic; affects bone in skull,

vertebrae, long bones, hip joint etc. Tx- symptomatic for pain- NSAIDS, calcitonin,

Fosamax.


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Classification of Fractures

A fracture is a break or disruption in the continuityof a bone.

Types of fractures include:

Complete

Incomplete

Open or compound

Closed or simple

Pathologic (spontaneous) Fatigue or stress

Compression


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Stages of Bone Healing

Hematoma formation within 48 to 72 hr after injury

Hematoma to granulation tissue

Callus formation

Osteoblastic proliferation

Bone remodeling

Bone healing completed within about 6 weeks;up to 6 months in the older person


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Acute Compartment Syndrome

Serious condition in whichincreased pressure withinone or more compartmentscauses massivecompromise of circulation tothe area

Prevention of pressurebuildup of blood or fluidaccumulation

Pathophysiologic changessometimes referred to asischemia-edema cycle


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Emergency Care

Within 4 to 6 hr after the onset of acutecompartment syndrome, neuromuscular damageis irreversible; the limb can become uselesswithin 24 to 48 hr.

Monitor compartment pressures.

Fasciotomy may be performed to relievepressure.

Pack and dress the wound after fasciotomy.

P ibl R lt f A t C t t


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Possible Results of Acute CompartmentSyndrome

Infection

Motor weakness

Volkmanns contractures

Myoglobinuric renal failure, known asrhabdomyolysis


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Other Complications of Fractures

Shock Fat embolism syndrome: serious complication

resulting from a fracture; fat globules arereleased from yellow bone marrow intobloodstream

Venous thromboembolism

Infection

Ischemic necrosis Fracture blisters, delayed union, nonunion,

and malunion


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Musculoskeletal Assessment

Change in bone alignment Alteration in length of extremity

Change in shape of bone

Pain upon movement Decreased ROM

Crepitation

Ecchymotic skin Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site


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Special Assessment Considerations

For fractures of the shoulder and upper arm,assess client in sitting or standing position.

Support the affected arm to promote comfort.

For distal areas of the arm, assess client in asupine position.

For fracture of lower extremities and pelvis,

client is in supine position.


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Casts

Rigid device that immobilizes the affected body part whileallowing other body parts to move

Cast materials: plaster, fiberglass, polyester-cotton

Types of casts for various parts of the body: arm, leg,brace, body

Cast care and client education

Cast complications: infection, circulation impairment,peripheral nerve damage, complications of immobility


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Operative Procedures

Open reduction with internalfixation (ORIF)

External fixation

Postoperative care: similar to thatfor any surgery; certain

complications specific to fracturesand musculoskeletal surgeryinclude fat embolism and venousthromboembolism


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Procedures for Nonunion

Electrical bone stimulation

Bone grafting

Bone banking


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Acute Pain

Interventions include: Reduction and immobilization of fracture

Assessment of pain

Drug therapy: opioid and nonopioid drugs

Complementary and alternative therapies: ice,heat, elevation of body part, massage, baths,back rub, therapeutic touch, distraction, imagery,music therapy, relaxation techniques


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Risk for Infection

Interventions include: Apply strict aseptic technique for dressing

changes and wound irrigations.

Assess for local inflammation Report purulent drainage immediately to

health care provider.

Assess for pneumonia and urinary tractinfection.

Administer broad-spectrum antibioticsprophylactically.


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Impaired Physical Mobility

Interventions include: Use of crutches to promote mobility

Use of walkers and canes to promote mobility

Imbalanced Nutrition: Less Than Body


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Imbalanced Nutrition: Less Than BodyRequirements

Interventions include: Diet high in protein, calories, and calcium,

supplemental vitamins B and C

Frequent small feedings and supplements of high-protein liquids

Intake of foods high in iron


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Fractures of the Hip

Intracapsular or extracapsular Treatment of choice: surgical repair, when possible, to allow the

older client to get out of bed

Open reduction with internal fixation

Intramedullary rod, pins, a prosthesis, or a fixed sliding plate

Prosthetic device

NNormal --------------------------------- Fracture-------------------------- ORIF


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Fractures of the Pelvis

Associated internal damage the chief concern infracture management of pelvic fractures

Nonweight-bearing fracture of the pelvis

Weight-bearing fracture of the pelvis


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Compression Fractures of the Spine

Most are associated with osteoporosis rather than acute spinal injury.

Multiple hairline fractures result when bone

mass diminishes. Nonsurgical management includes bedrest,

analgesics, and physical therapy.

Minimally invasive surgeries are vertebroplastyand kyphoplasty, in which bone cement isinjected.


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Prostheses Devices to help shape and

shrink the residual limb andhelp client readapt

Wrapping of elasticbandages

Wrap residual limb in afigure eight pattern, nota circular one. Wrappingin a circular pattern willcut off the blood flowand cause harm.

The goal of wrapping is

to form a cone-shapedresidual limb. To do this,apply more pressure tothe bottom end of theresidual limb, and lesspressure to the topportion.

Individual fitting of therosthesis s ecial care


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Knee Injuries, Ligaments

When the anterior cruciate ligament is torn, asnap is felt, the knee gives way, swelling occurs,stiffness and pain follow.

Treatment can be nonsurgical or surgical.

Complete healing of knee ligaments after surgery can take 6 to 9 months.


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Tendon Ruptures

Rupture of the Achilles tendon is common inadults who participate in strenuous sports.

For severe damage, surgical repair is followed

by leg immobilized in a cast for 6 to 8 weeks. Tendon transplant may be needed.


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Strains

Excessive stretching of a muscle or tendonwhen it is weak or unstable

Classified according to severity: first-, second-,

and third-degree strain Management: cold and heat applications,

exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and

possible surgery


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Sprains

Excessive stretching of a ligament Treatment of sprains:

first-degree: rest, ice for 24 to 48 hr,compression bandage, and elevation

second-degree: immobilization, partial weightbearing as tear heals

third-degree: immobilization for 4 to 6 weeks,possible surgery


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Rotator Cuff Injuries

Shoulder pain; cannot initiate or maintainabduction of the arm at the shoulder

Drop arm test

Conservative treatment: nonsteroidal anti-inflammatory drugs, physical therapy, slingsupport, ice or heat applications during healing

Surgical repair for a complete tear


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Rheumatology

Connective tissue disease (CTD) is a major focus of rheumatology.

Rheumatic disease is any disease or condition

involving the musculoskeletal system. Arthritis means inflammation of one or more

joints.

(Continued)


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Collaborative Management of OA

History Physical assessment and clinical manifestations

Joint involvement

Heberden's nodes

Bouchards nodes

Joint effusions Atrophy of skeletal muscle


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Assessments of OA

Psychosocial Laboratory assessment of erythrocyte

sedimentation rate and C-reactive protein (maybe slightly elevated)

Radiographic assessment

Other diagnostic assessments

MR imaging CT studies


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Connective Tissue


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or Rheumatic Diseases

Rheumatoid Arthritis (RA) joint deformity

Lupus Erythematosis (SLE) - skin, heart, kidneys

Scleroderma - skin

Sjogrens Syndrome - dry mouth, dry eye -> systemic

Raynauds Disease- blood vessels

Inflammation of synovial joints due to an immune response withdegeneration as a secondary process. Blood vessels, heart, skinand kidneys may also be affected.


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Lab Studies

Creatinine ESR inflammation

RBC - RA and SLE

WBC SLE

Antinuclear Antibody (ANA) all

Rheumatoid Factor - > 80%

h d h


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Rheumatoid Arthritis

A most common connective tissue disease andthe most destructive to the joints

Chronic, progressive, systemic inflammatoryautoimmune disease primarily affecting thesynovial joints

Autoantibodies (rheumatoid factors) formed thatattack healthy tissue

Affects synovial tissue of any organ or bodysystem


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RA M di ti

Immunosuppressive

Methotrexate gold


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RA Medications

ASA NSAIDS

Antimalarials - visualchanges

Plaquenil Aralen

Gold administer withNSAIDS. Stomatitis,

diarrhea, proteinuria maybe a problem

Sulfasalazine

Penicillamine

gstandard for RA, usedalso in SLE

Imuran Cytoxan

Cyclosporin

Arava

Enbrel

Remicade

Corticosteroids

Prednisone

Prednisolone

Hydrocortisone

Topical

Capsaicin


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A t f L


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Assessments for Lupus

Psychosocial results can be devastating. Laboratory

Skin biopsy (only significant test to confirmdiagnosis)

Anti-Ro (SSA) test

Complete blood count

Body system functions


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lecture 7 - musculoskeletal

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