Care of Clients with Problems In Inflammatory & Immunologic Response, Perception & Coordination (NCM104) Patients With Musculoskeletal

Alterations I

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Anatomy and Physiology of the Musculoskeletal System

Topics Discussed Here Are: 1. Anatomy and Physiology of the Musculoskeletal System a. Skeletal System b. Articulations 2. Assessment of Clients with Musculoskeletal Disorders a. History b. Physical Examination c. Diagnostic and Laboratory Testing

Bone Structures 1. Epiphysis o Rounded Portion at both ends o Function: Articulates as it joins with other joints 2. Diaphysis (Shaft) o At the center o Endosteum The canal inside of the bone, inside it is the medullary cavity o Location of the: Red Bone Marrow For Hematopoiesis During Newborn Stage Yellow Bone Marrow Replaces Red Bone Marrow Function: For FAT STORAGE 3. Medullary Cavity *****

TYPES of BONE CELLS 1. Osteoblasts Bone forming cells 2. Osteocytes Osteoblasts found in the bone matrix 3. Osteoclasts a. Cells that reabsorb (remove) damaged / old bones during periods of growth / repair b. For the process of remodeling Functions of Bones 1. Support and Protection a. Gives shape to the face, head, thorax and limbs b. Supports the body weight c. Protects the heart 2. Body Movement a. Together with muscles interact to form a mechanical device (Movement is due to muscular contractions) b. Flexion and extension 3. Blood cell formation Medullary cavity by Red Bone Marrow 4. Storage of organic salts like Calcium

Skeletal Organization 206 Bones

1. Axial Skeleton 80 Bones a. Skull 22 Bones 1) Cranium 8 Frontal Bone (1) Parietal Bone (2) Occipital Bone (1) Temporal Bone (2) Sphenoid Bone (1) Ethmoid Bone (1) 2) Facial Bones 14 b. Auditory Ossicles 6 [Malleus (Hammer), Incus (Anvil), Stapes (Stirrups)]

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Hyoid 1 = Responsible for supporting the tongue, located at the neck between the JAW and LARYNX d. Vertebral Column 26 o Cervical 7 o Thoracic 12 o Lumbar 5 ***Sacral 1 (5 but fused) ***Coccyx 1 (4 but fused) e. Chest (Thoracic Cage) -25 o Sternum 1 o Ribs 24 True Ribs (Vertebrosternal) Joins/Attaches directly to the sternum False Ribs (Vertebrochondral) False because their cartilages do not reach the sternum directly Floating Ribs Last 2 (At times 3) Rationale: Because they do not have any cartilaginous form of attachment Appendicular Skeleton 126 Bones a. Pectoral / Shoulder Girdle 4 (Function: To support the upper extremity and serve for attachment) o Clavicle / Collar Bone 2 (Function: To keep the shoulders in place) o Scapula / Shoulder Blades 2 b. Upper Limbs 60 o Humerus 2 (From Scapula to Elbows, COUNTERPART of Femur) o Radius 2 (At thumb site) o Ulna 2 (Longer than the Radius) o Hand 54 Carpals 16 (Make up the PALM) Metacarpals 10 Phalanges 28 c. Pelvic Girdle (Coxa) 2 o Functions: To support the trunk of the body Provides attachment to lower limb Serves as a protection a. Urinary Bladder b. Large Intestines (a part) c. Reproductive organs d. Lower Limbs 58 o Femur / Thigh Bone 2 (Counterpart of Humerus) PAKIDAGDAG: Considered as the LONGEST Bone of the BODY Para sa LOWER LIMBS From the Hips to the Knee Patella 2 o Tibia / Shin 2 (Medial Side!) So 60 ung lower limbs o Fibula 2 (Lateral Side!) o Foot 52 Ankle (Tarsals) 14 Instep (Metatarsals) 10 (Counterpart of PALM) Toes (Phalanges) 28

c.

Joints / Articulations
Definition Functional Junction between bones, it is the point of union between 2 bones o Muscle-to-Bone = Connected by TENDONS o Bone-to-Bone = Connected by LIGAMENTS Synovial Space o Space found at the point of union of 2 bones o Supposed to be big enough to promote free movement (Fremitus)

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Synovial Fluid o Found at the Synovial Space o Characteristics: Less viscous because if it is HIGHLY VISCOUS it fails as a LUBRICANT Prevents friction as the bones move Supposed to be CLEAR! If THICKENS it creates FREMITUS/CREPITUS Cloudy / Turbid There is an INFECTIOUS PROCESS Functions of the Synovial Space 1. Binds parts of the skeletal system 2. Makes possible bone growth 3. Permits parts of the skeleton to shape during childbirth 4. Enables the body to move in response to skeletal muscle contractions Types of Joints 1. According to Degree of Movement a. Synarthrosis / Immovable (Cranium) Synarthroses No Movement Example: Cranium b. Amphiarthrosis / Slightly Movable Amphiarthroses Allows LITTLE movement Example: Pelvic girdle during childbirth c. Diarthrosis / Freely Movable Diarthroses Allows full movement Includes: Ball & Socket Joint (Full freedom) a. Full freedom of movement b. Example: Hip joint, upper extremities Hinge Joint a. Permits bending in one direction only b. Example: Elbow and knee Saddle Joint a. Allows movement in 2 places at Right angles to each other b. Example: Joint at the base of the thumb Pivot Joint a. Characterized by articulation between the radius and ulna b. Allows us to open a door knob Gliding Joint a. Allows limited movement in all directions b. Example: Joints of the carpal bones of the wrist 2. According to Type of Tissue a. Fibrous Lies in between bones that are closely in contact with one another No appreciable movement Example: Skull b. Cartilaginous Allows limited movement Example: Symphysis Pubis c. Synovial Allows free movement

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Assessment of Clients with Musculoskeletal Disorders

Assessment

History

1) Biographical and Demographic Data Clients Profile (Name, Age, Gender) 2) Current History a. Chief Complaint Main Reason why they sought consultation Describe the complaint When did the pain start? b. Clinical Manifestations Pain PQRST o Characteristics of Pain Bone Pain Dull, Deeply Seated, Boring There is discomfort but not enough to put the client in a debilitating position Cramping-muscular Disorder ? Fracture Pain Ask the client what joint is affected, it will inform Deeply seated, severity is SHARP you what type of arthritis it is Relieved by rest 1) BIG JOINTS = Osteoarthritis Sprain / Joint Pain 2) SMALL JOINTS = Rheumatoid Arthritis 3) BIG TOE = Gouty Arthritis Pain in increasing activity Pain is mild but progresses to moderate / severe Infection of Bones Pain + Fever / Dizziness (Systemic manifestations) Joint Stiffness o Rheumatoid Arthritis Pain at the morning, but better at the end of the day o Osteoarthritis Pain is aggravated by activity but is relieved by rest Sensory Changes o Areflexia o Hyperreflexia o Sensation o Feeling of heaviness o Tingling sensation Swelling - in Size Deformity and ROM o Assess if there is swelling of a joint o How far is the reduction in terms of range of motion o Deformity: Look at the knees (knee effusion?) associated with OSTEOARTHRITIS 3) Review of Systems a. Medical History Childhood illnesses Any history of a fall / fracture? b. Surgical History Did the client fall from a tree and had a surgical procedure on the head? Eventful Some complex; Non-Eventful None c. Allergies Drugs / Food d. Medications

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f.

Did the client receive any anti-Hypertensive drugs? o Prednisone o Decadron o NSAIDs o Vitamin B Supplement May have had tingling / numbness Dietary Habits Does the client drink milk? o Milk contains Ca and Vitamin D Needed for BONE DEVELOPMENT Social History How often does the client drink alcohol? Did they ever take any hormonal replacement therapy?

Physical Examination
1) General Musculoskeletal Examination a. Posture Normal curvature of the spine o Assess from the BACK, SIDE and FRONT o Best assessed when the client is UNDRESSED Look at the shoulders (At the same level) Observe Hips Should be symmetrical Folds of Buttocks Should be symmetrical Shape of Legs o Lordosis High thoracic Normal: o Convex through Thoracic portion o Concave through Cervical and Lumbar Portion 1. Muscles Press the muscles, are there any mass? Flaccid? Muscle? (Softness/spasms) 2. Joints and Bones Joints: Assess for ROM with use of a Goniometer (Like a protractor) Bones: Presence of mass / tumor, palpate for pain o o o Kyphosis Forward curvature of the Thoracic Spine Lordosis / Swayback Exaggerated curvature of the Lumbar Spine Scoliosis Excessive Lateral curvature of the Spine *** During inspection of the spine, butt and legs are exposed! ***Assess for spinal curves and trunk symmetry

b.

Gait Have the client walk for a short distance and observe for smoothness and rhythm Let the client walk for 1 minute Infectious Process Limping usually is associated with painful bearing Bone Integrity Bone growth Symmetry in the length of extremities o Ask the client to stand, may have 1 leg longer than the other Joint Function Evaluated by noting ROM, Deformity, Stability and Nodule Formation o Knee Effusion ROM (Presence of fluid within patella of the knee) Balloon Sign 1. Massage the patella (knee), the fluid will move

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d.

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2. Assess if there was any change in shape Ballottement 1. Massage the patella 2. Push the patella upward towards the femur and if you feel fluid returning back to the patella it is (+) for Ballottement Sign e. Muscle Size and Strength Muscular Tone Palpate muscles while passively moving the relaxed extremity Muscular Strength Have client perform certain maneuvers with or without added resistance Muscle Clonus Done by sudden forceful, sustained DORSIFLEXION of the foot

Diagnostic Testing
1) Non-Invasive Tests a. X-Ray b. MRI c. EMG For SKELETAL MUSCLES! d. CAT Scan e. Bone Densitometry Older people with OSTEOPOROSIS are candidates Just like an x-ray procedure Rationale: To assess for the Bone Mineral Density Done to diagnose Osteoporosis 2) Invasive a. Arthroscopy Visualization of the joint Determines the cause of pain A tube is inserted into the synovial space with light, to know if bone has eroded b. Arthrocentesis / Joint Aspiration Aspiration of the synovial fluid Uses a spinal fluid ?

Laboratory Tests
o Complete Blood Count (CBC) [Extraction of Blood] a. White Blood Cell ( WBC = Osteomyelitis) b. Hemoglobin / RBC ( Hmg/RBC = Due to Bleeding, blood in synovial space) c. Blood Chemistry Serum Calcium Levels o If Decreased Bone Malignancy Osteomalacia / Bone Cancer Serum Phosphate Levels o If Increased Osteomalacia / Bone Cancer Serum Creatinine o If Increased Client has muscle damage NOT only for Kidney Disorders d. Bone Biopsy Getting a piece of tissue from the bone Malignancy = Osteosarcoma / Cancer ONLY TEST to know if (+) for CANCER

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