MUSCULOSKELETAL

DISORDERS
Functions of Musculoskeletal System:
1. It provides protection for vital organs,
including the brain, heart, lungs.
2. It provides a sturdy framework to support
body structures.
3. It also makes mobility possible.
4. It serves as reservoir for immature blood
cells and essential minerals, including
calcium, phosphorous, magnesium and
fluoride.
 Components of Musculoskeletal System:
1. Bones
2. Joints
3. Muscles
4. Tendons
5. Ligaments
6. Bursae of the body
PHYSICAL ASSESSMENT
An examination of the musculoskeletal
system ranges from a basic assessment
of functional capabilities to sophisticated
physical examination maneuvers that
facilitate diagnosis of specific bone,
muscle, and joint disorders.
Nursing assessment is primarily a
functional evaluation, focusing on the
patient’s ability to perform activities of
daily living.
Techniques of inspection and palpation
are used to evaluate the patient’s posture,
gait, bone integrity, joint function, and
muscle strength and size.
Posture:
The normal curvature of the spine is
convex through the thoracic
portion and concave through the cervical
and lumbar portions.
During inspection:
1. The spine, the entire back, buttocks, and
legs are exposed.
2. The examiner inspects the spinal curves
and trunk symmetry from posterior and
lateral views.
3. Standing behind the patient, the
examiner notes any differences in the
height of the shoulders or iliac crests.
4. The gluteal folds are normally
symmetric. Shoulder and hip symmetry, as
well as the line of the
vertebral column, are inspected with the
patient erect and with the patient bending
forward (flexion).
 Older adults experience a loss in
height due to loss of vertebral cartilage
and osteoporosis-related vertebral
fractures. Therefore, an adult’s height
should be measured periodically.
Common deformities of the spine:
1. Kyphosis - an increased forward
curvature of the thoracic spine.
2. Lordosis, or swayback - an
exaggerated curvature of the lumbar
spine.
3. Scoliosis, a lateral - curving deviation of
the spine.
Gait
1. Assessed by having the patient walk
away from the examiner for a short
distance.
2. The examiner observes the patient’s gait
for smoothness and rhythm.
3. Any unsteadiness or irregular movements
(frequently noted in elderly patients) are
considered abnormal.
Bone Integrity
1. The bony skeleton is assessed for
deformities and alignment.
2. Symmetric parts of the body are
compared.
3. Abnormal bony growths due to bone
tumors may be observed.
4. Shortened extremities, amputations, and
body parts that are not in anatomic
alignment are noted.
Fracture findings may include:
1. Abnormal angulations of long bones.
2. Motion at points other than joints.
3. Crepitus (a grating sound) at the point of
abnormal motion.
Joint Function:
1. The articular system is evaluated by
noting range of motion, deformity,
stability, and nodular formation.
2. Range of motion is evaluated both
actively (the joint is moved by the muscles
surrounding the joint) and passively (the
joint is moved by the examiner).
 Precise measurement of range of
motion can be made by a goniometer (a
protractor designed for evaluating joint
motion).
Joint deformity may be caused by:
1. Contracture (shortening of
surrounding joint structures).
2. Dislocation (complete separation of
joint surfaces).
3. Subluxation (partial separation of
articular surfaces).
4. Disruption of structures surrounding the
joint.
Palpation of the joint while it is passively
moved provides information about the
integrity of the joint.
Normally, the joint moves smoothly.
A snap or crack may indicate that a
ligament is slipping over a bony
prominence.
Slightly roughened surfaces, as in arthritic
conditions, result in crepitus (grating,
crackling sound or sensation) as the
irregular joint surfaces move across one
another.
Muscle Strength and Size:
1. The muscular system is assessed by
noting the patient’s ability to change
position, muscular strength and
coordination, and the size of individual
muscles.
2. Weakness of a group of muscles
might indicate a variety of conditions,
The nurse assesses muscle strength by
having the patient perform certain
maneuvers with and without added
resistance.
For example:
>When the biceps are tested, the patient is
asked to extend the arm
fully and then to flex it against resistance
applied by the nurse.
>A simple handshake may provide an
indication of grasp strength.
Conditions:
1. The nurse may elicit muscle clonus
(rhythmic contractions of a muscle) in the
ankle or wrist by sudden, forceful,
sustained dorsiflexion of the foot or
extension of the wrist.
2. Fasciculations (involuntary twitching of
muscle fiber groups) may be observed.
For ease of serial assessment, the nurse
may indicate the point of measurement by
marking the skin.
Variations in size greater than 1 cm are
considered significant.
Skin:
1. In addition to assessing the
musculoskeletal system, the nurse
inspects the skin for edema,
temperature, and color.
2. Palpation of the skin can reveal whether
any areas are warmer, suggesting
increased perfusion or infection, or
cooler, suggesting decreased perfusion,
and whether edema is present.
Neurovascular Status:
It is important for the nurse to perform
frequent neurovascular
assessments of patients with
musculoskeletal disorders (especially
of those with fractures) because of the risk
of tissue and nerve damage.
 This major neurovascular problem is
caused by pressure within a muscle
compartment that increases to
such an extent that microcirculation
diminishes, leading to nerve
and muscle anoxia and necrosis. Function
can be permanently lost if the anoxic
situation continues for longer than 6 hours.
The Patient With Musculoskeletal Injury:
1. Special precautions must be taken when
assessing a trauma patient.
2. If there is injury to an extremity, it is
important to assess for soft tissue trauma,
deformity, and neurovascular status.
If the patient has a possible cervical spine
injury and is wearing a cervical
collar, the collar must not be removed until
the absence of spinal cord injury is
confirmed on x-ray.
When the cervical collar is removed, the
cervical spine area is gently assessed for
swelling, tenderness, and deformity.
With pelvic trauma, abdominal organ
injuries may occur. The patient is
assessed for abdominal pain, tenderness,
hematomas, and the presence or absence
of femoral pulses.
If blood is present at the urinary meatus,
the nurse should suspect
bladder and urethral injury, and the patient
should not be catheterized.
Instead, such findings should be reported
immediately to the primary health care
provider.
Diagnostic Evaluation:
IMAGING PROCEDURE
X-ray Studies - important in evaluating
patients with musculoskeletal disorders.
Bone x-rays determine bone density,
texture, erosion, and changes in bone
relationships.
Computed Tomography (CT) scan shows
in detail a specific plane of involved bone
and can reveal tumors of the soft tissue or
injuries to the ligaments or tendons.
It is used to identify the location
and extent of fractures in areas that are
difficult to evaluate.
Magnetic Resonance Imaging (MRI) - is a
noninvasive imaging technique that uses
magnetic fields, radio waves, and
computers to demonstrate abnormalities
( tumors or narrowing of tissue pathways
through bone) of soft tissues such as
muscle, tendon, cartilage, nerve, and fat.
Because an electromagnet is used,
patients with any metal implants, clips, or
pacemakers are not candidates for MRI.
Arthrography - is useful in identifying acute
or chronic tears of the joint capsule or
supporting ligaments of the knee,
shoulder, ankle, hip, or wrist.
A radiopaque substance or air is injected
into the joint cavity to outline soft tissue
structures and the contour
of the joint.
Bone Densitometry - is used to estimate
bone mineral density
(BMD).
This can be done through the use of x-rays or
ultrasound.
Dual-energy x-ray absorptiometry (DEXA)
determines bone mineral density at the
wrist, hip, or spine to estimate the extent of
osteoporosis and to monitor a patient’s
response to treatment for
osteoporosis.
Bone sonometry (ultrasound) measures
heel bone quantity and quality and is used
to estimate BMD and the risk of
fracture for people with osteoporosis.
Bone density sonography is a cost-
effective, readily available screening tool
for diagnosing osteoporosis and predicting
a person’s risk for fracture.
NUCLEAR STUDIES
Bone Scan - is performed to detect
metastatic and primary bone tumors,
osteomyelitis, certain fractures, and aseptic
necrosis.
A bone-seeking radioisotope is injected
intravenously.
The scan is performed 2 to 3 hours after the
injection. At this point, distribution
and concentration of the isotope in the bone
are determined.
NURSING INTERVENTIONS:
Before the patient undergoes a bone scan,
the nurse should inquire
about possible allergy to the radioisotope
and should assess for any condition that
would contraindicate performing the
procedure (eg, pregnancy).
ENDOSCOPIC STUDIES:
Arthroscopy - is a procedure that allows direct
visualization of a joint to diagnose joint disorders.
Treatment of tears, defects, and disease processes
may be performed through the arthroscope.
The procedure is carried out in the operating room
under sterile conditions; injection of a local
anesthetic into the joint or general anesthesia is
used.
A large-bore needle is inserted, and the joint is
distended with saline.
NURSING INTERVENTIONS:
1. The joint is wrapped with a compression
dressing to control swelling.
2. Ice may be applied to control edema and
discomfort.
3. The joint is kept extended and elevated to
reduce swelling.
4. It is important to monitor neurovascular
function.
5. The nurse administers prescribed analgesics to
control discomfort.
6. Patient can resume activity and what weight-
bearing limits as prescribed.
OTHER STUDIES:
Arthrocentesis (joint aspiration) is carried out to
obtain synovial fluid for purposes of examination
or to relieve pain due to effusion.
Normally, synovial fluid is clear, pale, straw-
colored, and scanty in volume.
Anti-inflammatory medications may be injected
into the joint.
A sterile dressing is applied after aspiration.
Electromyography (EMG) provides
information about the electrical potential of the
muscles and the nerves leading to them.
The test is done to evaluate muscle weakness,
pain, and disability.
The purpose of the procedure is to determine
any abnormality of function and to differentiate
muscle and nerve problems.
Biopsy - may be performed to determine the
structure and composition of bone marrow,
bone, muscle, or synovium to help diagnose
specific diseases.
>The nurse monitors the biopsy site for edema,
bleeding, pain, and infection.
> Ice is applied as prescribed to control bleeding
and edema.
> Analgesics are administered as prescribed for
comfort.
LABORATORY STUDIES:
1. Blood and urine can provide information
about a primary musculoskeletal problem
(Paget’s disease), a developing complication
(infection).
2. The complete blood count includes the
hemoglobin level (which is frequently lower after
bleeding associated with trauma and surgery)
and the white blood cell count
(which is elevated in acute infections, trauma,
acute hemorrhage, and tissue necrosis).
3. Blood chemistry studies provide data about a
wide variety of musculoskeletal conditions.
4. Specific serum biochemical markers can be
used to provide information about bone
formation; these include bone-specific alkaline
phosphatase and osteocalcin from osteoblasts,
and procollagen
1 carboxyterminal propeptide and procollagen 1
aminoterminal
propeptide from the bone matrix.
THANK YOU……