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Musculoskeletal Assessment

STUDY
PLAY
Musculoskeletal System
Consists of BONES, SKELETAL MUSCLES and JOINTS
Joints
Articulation of two or more bones
Functions of the Musculoskeletal System
~Provides structure, support and movement for the body
~Allows the body to maintain posture and position
~Supports and protects organs and soft tissues
~Guards entrances and exits to digestive and urinary systems
~Produces red blood cells- hematopoiesis
~Stores fat and minerals
~Generates heat
Skeleton
Is composed of 206 BONES; Provides support for the soft tissue and organs of the body
Types of Bones:
~Long (femur)
~Short (tarsals)
~Flat (sternum)
~Irregular (skull)
~Ligaments
Ligaments
Connect BONE to BONE
Skeletal Muscles
Composed of fibers and tendons
Tendons
Connect BONE to MUSCLE
Non-synovial joints
Non-movable or slightly movable joints
Ex: Sutures of skull and vertebrae
Synovial joints
Movable joint lubricated by synovial fluid
Flexion
Bending a limb at the joint
Extension
Straightening a limb at a joint
Rotation
Moving the head around a central axis
Circumduction
Moving the arm or leg in a circle around the shoulder or hip
Elevation
Raising a part of the body
Depression
Lowering a part of the body
Protraction
Moving a body part foward and parallel to the ground (FROWNING)
Retraction
Moving a body part backward and parallel to the ground (SMILING)
ABduction
Moving a limb AWAY from the body
ADduction
Moving a limb TOWARD the body
Pronation
Turning the forearm so that the palm is DOWN
Supination
Turning the forearm so that the palm is UP
Inversion
Moving the plantar surface(sole) of the foot INWARD at the ankle
Eversion
Moving the plantar surface (sole) of the foot OUTWARD at the ankle
Need for FULL MS Assessment
If patient has COMPLAINTS, DISEASE or difficulty ADLs
Screening/Mini Assessment
~Inspection/palpations of major joints and muscles
~Functional ROM
~Muscle strength in arms and legs
Objective Data
~Ensure patient is comfortable
~Use a CEPHALOCAUDAL approach (Head to Toe)
~Always COMPARE WITH THE OPPOSITE SIDE (unaffected side)
~Assess painful areas LAST
Inspection
~Size
~Contour
~Color
~Swelling (Edema)
~Masses
~Deformities
Palpation
~Temperature
~Swelling (Edema)
~Tenderness
~Masses
~ROM
~Strength
Swelling Grade Scale
0 = none
1 = mild
2 = moderate
3 = marked
4 = maximum
Range of Motion (ROM)
Measured in degrees with a GONIOMETER
Active = patient does on own
Passive = nurse helps patient perform - is usually greater than active
~Describe limitations in a narrative note
~May also complain of pain and stiffness
Muscle Strength
Graded on scale 0-5
(Muscle Strength Scale) 0
No muscle contraction
(Muscle Strength Scale) 1
Palpable muscle contraction, but no movement
(Muscle Strength Scale) 2
Full ROM without gravity (passive ROM)
(Muscle Strength Scale) 3
Full ROM with gravity
(Muscle Strength Scale) 4
Full ROM with moderate resistance
(Muscle Strength Scale) 5
Full ROM with full resistance
Joints/Muscles to be assessed
~Cervical Spine
~Shoulders
~Elbows
~Wrist/Hands
~Spine
~Hips/Knees
~Ankles/Feet
Cervical Spine
I: Observe alignment of head
P: Spinous processes, muscles
ROM: flexion, neutral (extension), hypertension, lateral bend, rotation
Torticollis
A shortening or twisting in one sternomastoid muscle - probably injured by intrauterine malposition

Abnormality: Cervical Spine
Shoulders
I: Shape, size, symmetry
P: Sternoclavicular joint to clavicle to acromioclavicular joint, check for crepitus
ROM: flexion, neutral (extension), hypertension, internal/external rotation, ABduction, ADduction, circumduction, elevation, depression
Rotator cuff tears, DJD, strains/sprains
Pain without palpation or movement; Referred pain from increased intra-abdominal pressure, cardiac ischemia, hiatal hernias, or GI disease
Abnormalities: Shoulders
Elbows
I: Symmetrical
P: Grooves on sides of olecranon process for pain, tenderness, swelling or crepitus
ROM: Flexion, hyperextension, extension (neutral), pronation, supination
Muscle strength
Lateral or Medial Epicondylitis (Tennis Elbow)/ Rheumatoid Arthritis
Abnormalities: Elbows
Wrist/Hands/Fingers
I: Symmetry, swelling, color, deformity
P: Temperature, dorsum of hand and interphalangeal joints (1 at a time)
ROM: Flexion and extension of wrist and fingers, hyperextension of wrist, ulnar/radial deviation, ABduction, ADduction, opposition
Muscle strength
Carpel Tunnel Syndrome
Compression of the medial nerve leading to decreased motor function of thenar eminence; Pain, numbess

Abnormality: Wrist/Hands/Fingers
Carpel Tunnel Syndrome Test: Phalen's sign
Bend wrists downward and press backs of hands together; Symptoms within 60 seconds test is +
Carpel Tunnel Syndrome: Tinel's sign
MORE predictive than Phalen's
Percuss lightly over the median nerve in each wrist; Pain, numbess or tingling with percussion is +
Dupuytren's Contracture
Flexion contracture of the fingers; Impaired ROM
May be inherited or occur with diabetes or cirrhosis r/t alcoholism or caused by compartment syndrome of forearm

Abnormality: Wrist/Hand/Finger
Rheumatoid Arthritis
WORST of arthritises
Ulnar deviation; Swelling in the joints
Flexion contractures
Swan-Neck Deformity
Boutonniere Deformity

Abnormality: Wrist/Hand/Finger
Swan-Neck Deformity
Proximal interphalangeal (PIP) joints hyperextend while distal flex

Abnormality: Wrist/Hand/Finger
Boutonniere Deformity
PIP joint is flexed with the distal joint hyperextended

Abnormality: Wrist/Hand/Finger
Syndactyly
Webbed fingers

Abnormality: Wrist/Hand/Finger
Polydactyly
Extra digits

Abnormality: Wrist/Hand/Finger
Bouchard's and Heberden's Nodes
Occurs with osteoarthritis; Hard nodules over the proximal interphalangeal joint (PIP) = Bouchard's & distal interphalangeal joint (DIP) = Heberden's

Abnormality: Wrist/Hand/Fingers
Spine
I: Curvature, symmetrical, midline
P: vertebral processes
ROM: flexion, extension (neutral), hyperextension, lateral blend, rotation
Muscle strength
Kyphosis
Exaggerated thoracic curve

Abnormality: Spine
Lordosis
Exaggerated LUMBAR curve

Abnormality: Spine
Scoliosis
Curves to right or left causing an exaggerated thoracic convex curve
Straight Leg Raise or LaSegue's Test
Checks for HNP or herniated nucleus pulposus (herniated disk)

Special Test: Spine
Forward Bending Test
Screening for scoliosis

Special Test: Spine
Hips
I: Symmetry
P: Stability, pain, crepitus
ROM: Flexion, hyperextension, internal/external rotation, abduction, adduction, circumduction
Muscle strength

Special Consideration: Hip replacements
Patrick's Test
Assessing for hip joint or sacral injuries/pathologies

Special Test: Hip
Hip Replacement Consideration
~Should not flex hip past 90 degrees
~Should not internally rotate hip
~Should not allow hip to ADduct acorss midline of body (use ABduction pillow)
Knees
I: Symmetry, location
P: crepitus, pain, tenderness, stability
ROM: flexion, extension
Muscle Strength
Bursitis
Bursa of the knee is inflammed

Abnormality: Knee
Bowleg (genu varus)
Abnormality: Knee
Knock knees (genu valgus)
Abnormality: Knee
Ligament instability or tears
Abnormality: Knee
Meniscus tears
Abnormality: Knee
Bulge sign (detect small effusions) Ballotment Test (increased fluid)
Tests for fluid on the knee

Special Test: Knee
Drawer Test
Tests the Instability of the knee

Special Test: Knee
McMurray Test
Test for torn meniscus

Special Test: Knee
Ankles/Feet/Toes
I: Color, symmetry, alignment
P: one at a time, medial and lateral aspects, crepitus
ROM: plantar flexion, dorsiflexion, invert, evert, move toes
Muscle strength
Gout
Inflammation in joints as a result of ALTERED PURINE metabolism; Pain, edema, erthyema
Generally starts in the GREAT TOE
Abnormality: Ankles/Feet/Toes
Bunions
Abnormality: Ankles/Feet/Toes
Hammertoe
Abnormality: Ankles/Feet/Toes
Ganglia
Prevalent on the wrist; Painless mass from tendon sheaths (Fluid filled)
Subluxation
Partial dislocation
Crepitus
Dry crackling sound or sensation due to grating of ends of damaged bones
Ankylosis
Immobility, consolidation and fixation of a joint d/t disease, injury or surgery; Most often d/t chronic rheumatoid arthritis
Neurovascular Assessment
Assess and COMPARE bilateral extremities
Inspection
~Color
~Edema
~Alignment of limb in relationship to body
~Prescence of deformity
~Ability to move fingers/toes or wrist/ankles (PROM)
~Ask patient if there is any numbness or tingling

Palpation
~Most distal pulses
~Most distal corresponding pulses
~Temperature
~Capillary Refill or blanching
~Assess for sensation
~Have pt close eyes and ask if he/she can feel you touching his hand or foot and where you are touching
Homan's sign
Very unreliable but gives a way to assess for blood clot in the lower extremity

Assessment for Deep Vein Thrombosis (DVT) - the most common in the leg
Lifespan Consideration: Newborns
~Flat feet
~Bowlegged
~Check spine
~Physician or Nurse Practitioner assess hips for congenital hip dislocation until age 1- Ortolani's maneuver
Lifespan Considerations: Children
~Ligaments are stronger than bones
~Age 4 changes to knock knees and usually resolves in late childhood or early adolescence
~Screening (Scoliosis) - starts in middle school (age 11 or 12)
Lifespan Considerations: Pregnant Female
~Softened cartilage in the pelvis and increased mobility of the joints
~Lordosis (common)
~Shift in center of gravity
~Waddle
Lifespan Considerations: Older adults
~Decreased muscle mass, tone, strength
~Decrease cartilage
~Decreased bone density
~Changes in mobility and endurance
Men vs Women Considerations
~Men muscles are bigger, bones are more dense
~Women are more flexible, bone is less dense
Psychosocial Considerations
Mental health problems may promote inactivity or isolation; Health probelms may trigger mental health issues
Abuse
Cultural Considerations
African Americans have higher bone density than Europeans; Europeans have higher bone density than Asians
Risk Factor Considerations for MS Disease
~Family History (Congenital Abnormalities)
~Arthritis (Rheumatoid or Osteoarthritis)
~Activity (Lifestyle, tobacco, chronic illness and medication therapy)
~Nutrition (Diet, Weight)
Nursing Diagnosis R/T MS Disorders
~Impaired physical mobility
~Risk for potential for impaired neurovascular assessment
~Activity intolerance
~Acute or chronic pain
~Self-care deficit
~Risk for injury
~Impaired elimination pattern