Musculoskeletal System

BY: Darren Ashley Umali

Inroduction
Millions of Americans experience annually Multiple MOI
Falls, crashes, violence, etc. Multi-system trauma

Anatomy & Physiology

Musculoskeletal system provides: Musculoskeletal system provides support for body protection of internal organs mobility to engage in physical activities production of RBCs storage of minerals

For proper functioning, must be integration between neurologic and musculoskeletal systems M-S system provides mobility and stability through the integration of muscles, bones and joints which are assessed together

Functions of the Musculoskeletal System

it supports the sorrounding tissues.
It protects vital organs and other soft tissues cof the body. It assists in body movements, giving attachment to the muscles, thus providing leverage. It manufactures blood cells.This hematopoietic function occurs in the red bone marrow. It provides storage for mineral salts, specifically phosphorus and calcium which supply body needs.

The Skull

Anatomy and Physiology of Synovial Joints

1. 2. 3. 4. 5. 6. The synovial fluid is a viscous lubricant found in all synovial joint cartilages The articular cartilage acts as a cushion, providing a smooth gliding surface. Synovial joint is also present in the synovial membrane. This membrane surrounds the cavities and slips in and out of the openings caused by movement. Ligaments help to maintain the relationships between bones and limit motion. Articular muscles function to maintain the stability of joints by relaxation and contraction to insure firm contact throughout the articular surface. Joint is the functional unit of the MS system

Joints

Regulation Movement
tendons - join muscle to bone ligaments and muscles give joint stability cartilage - pads joints during weight bearing

Movements of Synovial Joints

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Flexion decreasing angle between 2 bones. Extension- increasing angle between 2 bones. Abduction- the bones moves away from the midline. Adduction - bone moves toward the midline. Rotation - the bones moves around the central axis. Circumduction - bone describes the surface of a cone. Supination- the palm is turned upward. Pronation the palm is turned downward. Eversion the sole of the foot is turned outward. Inversion the sole of the foot is moved inward.

Movements of Synovial Joints

11. Depression- lowering a part of the body. 12. Elevation- raising a part of the body. 13. Retraction- moving a part of the body backward on a plane parallel to the ground 14. Protration- moving a part of the body forward on a plane parallel to the ground

Types of Joints
1. Ball and Socket Joint- provides the widest of motion, with movement. Example: hip, joints

2.
3.

Hinge Joint- the motion is limited to flexion and extension. Example: elbow joint
Pivot Joint- motion is limited to rotation; the joint is
formed by a pivotlike process which rotates within a bony fossa around a longitudinal axis. Example: atlas and axis.

4.

Condyloid- an oval-shaped condyle that fits into elliptical cavity. Example: The wrist joint between the radius and
carpal bones. Saddle Joint- tjis type of joint moves in one direction, concave and convex, a unique joint of the thumb.

5.

6.Gliding Joint- is formed by the opposing plane surfaces or slightly convex and concave. Example: intervertebral joint

Joint Structure

Example Temporomandibular joint

Objective Data
Temporomandibular joint Inspect area anterior to ear while seated Place tips of 1st two fingers in front of ear & drop to depressed area over joint Ask client to perform active ROM Open mouth maximally Partially open mouth Protrude lower jaw & move it side to side Normal: smooth motion of mandible, audible click or snap may occur Abnormal: swelling, crepitus, pain

Objective Data
Cervical spine
Inspect head & neck alignment
Spine should be straight, head erect

Palpate spinous processes, sternomastoid, trapezius, & paravertebral muscles

Should be firm, no spasm or tenderness

Growth & Formation of Bones

The cartilage skeleton is found in the embryo at the end of three months during the prenal age. Vertical growth continues at age 15 for girls and 16 for boys and modeling and shaping continue to about 21 years of age. Bone consists of protein matrix (the ground substance in which cells are embedded) and salts, primarily hydroxyapatite(makes up the major portion of salts present in bone). Small amount of calcium carbonate are also present. Deposition (salt) of bone is regulated by both stress and injury. Bone develops from spindle-shaped cells called osteoblasts, which are found beneath the fibro-vascular membrane covering the bone (perosteum) and in the endosteum. Osteoblasts are responsible for reabsorbing bone. This is brought about by the secretion of enzymes which digest the protein portion of bone and split the salts. Intramembranous ossification( conversation of fibrous tissue or cartillage into bone or bony substances) is the process by which the bones of the face and skull are formed

Physiology of Bone
Lack of Calcium results in: 1. Depolarization of nerve fiber membranes with transmission of unconrtolled impulses. Under these conditions, tetany,or spasm of the skeletal musculature occurs. 2. Weakening of cardiac muscle with a consequent inadequate supply of blood to the total body circulation. 3. Interference wit the process of blood coagulation. 90% of the total calcium of the body exists in the bone, which is present in the blood plasma and in fluid, where the ionized form of calcium participates in vital chemical reactions.

Classification of Bones
1. Long Bones- consists of long shafts and two extremities.
The shaft consists of diaphysis, a compact bone and the metaphysis, the flared portion at each end of the diaphysis which is composed of cancellous bone. the spongy or cancellous tissues of a typical short bone.

2. 3. 4. 5.

Short Bones- a thin layer of compact tissues which covers Irregular Bones- are bones of peculiar shape, like the
bones of vertebrae and ossicles of the ear.

Sesamoid Bones- are bones that are smail, rounded and

are enclosed in tendon and facial tissues.
scapula

Flat Bones- for extensive muscle attachment, e.g ribs,

 Bone Structure
Diaphysis Epiphysis Metaphysis

Musculoskeletal
End of a long bone Between epiphysis and diaphysis Growth plate Contains bone marrow

System

Medullary canal Periosteum Cartilage

Fibrous covering of diaphysis Connective tissue that provides a smooth articulation surface for other bones

 Joint Injury
Bone Injury

Sprain Subluxation Dislocation

Open fracture Closed fracture Hairline fracture Impacted fracture Transverse

Healing of Fracture
1. Stage of the hematoma- Bleeding occurs from damaged structures and a blood clot or hematoma form between and around the bone 2. Stage of granulation- the clot is invaded by cells and new capillaries. 3. Callus formation- a large mass of loosely woven bone forms, subsequently remodelling in accordance with Wolffs Law. Wolffs Law reflects that the role of mechanical force acting on a bone and its structure is dependent on its function

Complications of fx
blood vessel & nerve damage
Fat embolus disability or deformity

Injuries
Sprain Strain Dislocation Closed fracture Open fracture

Sprains & Strains

Sprain
Joint injury with tearing of ligaments

Strain
Stretching or tearing of a muscle

Fractures
Closed fracture
does not break the skin

Nondisplaced fracture -Simple crack

Displaced fracture -deformity

Open fracture
External wound

Closed fracture
Signs & symptoms
Pain Edema Possible deformity Contusion Loss of motion false motion Crepitus Guarding

Treatment - immobilize, ice, elevate if possible.

Open fracture
Signs & symptoms
Pain Deformity Break in skin and/or exposed bone Treatment - dressing, immobilize, ice, & elevate if possible

Bleeding (internal)
Bones have a blood supply!
Fractures bleed internally Femur - 1 liter Pelvis - 1 liter Tibia - 500 cc

Tips & other stuff

Depressed skull fracture Basilar skull fracture Angulation or angulated extremity Flail Chest

Musculoskeletal Injury Management

Care for Specific Joint Injuries Hip Knee Ankle Foot Shoulder Elbow Wrist/Hand Finger

Hip Fractures
Common in the elderly. May be able to support weight.
Ability to walk does not rule out fracture.

Leg often externally rotated. May refer pain to the knee. Use other leg for splint. Use vacuum mattress if available.

Hip Dislocation
Orthopedic emergency Posterior dislocation most common Hip flexed and leg rotated internally Severe pain on attempts to straighten

Hip Dislocation Management

Splint in most comfortable position. Document sensation and pulse. Prompt transport. Be alert for associated knee injuries or fractures

Knee Fracture or Dislocation

Orthopedic emergency Frequently causes vascular injury Dislocation associated with 50% rate of amputation of leg

Knee Fracture or Dislocation Management

Obvious dislocation without distal pulse:
Apply gentle traction along the long axis of the joint.

If gentle traction does not restore the pulse:

Splint in place.

Prompt transport.

Foot or Hand Injury

Common industrial injury. Often disabling. Rarely life threatening. Splint foot with pillow. Splint hand in position of function.

Shoulder Injury
AC Separation
Sling and swathe.

Shoulder Dislocation
Use pillow with sling and swathe.

Fracture
Use sling and swathe.

Elbow Injury
Fracture or dislocation may cause neurovascular injury. Splint in position found. Transport promptly.

Forearm/Wrist Injury
Rigid Splint
Keep hand in position of function.

Air Splint
May be hard to reassess circulation.

Pillow

Assessment of injured extremities

PMSC
Pulse Movement Sensation Capillary refill Cold, blue, pulseless extremity has circulation problem

ALWAYS CHECK DISTAL FUNCTION BEFORE & AFTER SPLINTING !!!!!

AND DOCUMENT WHAT YOU FOUND !!

Splinting
Why we splint...
relieve pain reduce tissue/vessel damage during movement

Types of splints
Self splinting Pillows, blankets, & items of clothing Sling & swath Rigid
Cardboard plastic ladder

Air or vacuum Traction

Traction splints
Closed, mid-shaft femur fracture without hip, knee, or ankle injury.

General Principles of Splinting

Remove clothing area PMSC Dress all wounds Do not move the patient before splinting

General Principles of Splinting

Immobilize the joints Pad rigid splints Maintain manual immobilization.

Realign angulations PRN When in doubt, splint Reassess PMSC Immobilize all suspected spinal injuries in a neutral in-line position*
*pain, resistance, crepitus

Realignment issues
NEVER REALIGN A JOINT
NEVER REALIGN A INJURY WITH GOOD DISTAL FUNCTION Only pulseless, longbone fractures

Basic Realignment Steps

Have all equipment ready & in place Explain procedure to patient In 1 move, with gentle traction, align extremity (goal is anatomical position)
Use the least amount of force necessary. If resistance is met or pain increases, splint in deformed position.

Reassess distal function

Hazards of Improper Splinting

Further damage Delay in transport Reduction of distal circulation Aggravation of the injury Injury to tissue, nerves, blood vessels, or muscle

Remember
No matter how bad the fracture our priorities are the ABCs

Muscles

Types of Muscle
Skeletal (voluntary) muscle Attached to the bones of the body Smooth (involuntary) muscle -Carry out the automatic muscular functions of the body

Cardiac muscle -Involuntary muscle -Has own blood supply and electrical system -Can tolerate interruptions of blood supply for only very short periods

Sign & Symptoms

1. 2. 3. 4. 5. 6. Paralysis Weakness Pain Atrophy Spasm Cramps

Developmental Considerations
Infants & children
Skeleton is cartilage 3 mos. gestation Congenital hip dislocation Bone growth
Rapid during infancy Steady during childhood Rapid growth spurt in adolescence Occurs in 2 directions
Width or diameter Lengthening at epiphyses or growth plates

Screen for scoliosis starting at age 10-12

Developmental Considerations
Pregnancy
levels of circulating hormones joint mobility
Estrogen Relaxin Corticosteroids

Progressive lordosis
Anterior flexion of neck Slumping of shoulder girdle

Developmental Considerations
Aging adult
Bone loss (resorption) > new bone growth (deposition) loss of bone density (osteoporosis) Osteoporosis Females > males Whites > blacks height due to shortening vertebral column Kyphosis, backward head tilt, slight flexion of knees & hips

Developmental Considerations
Aging adult
Lose fat in face & forearms abdomen & hips Loss in muscle mass & some atrophy weakness Sedentary lifestyle hastens musculoskeletal changes of aging Exercise skeletal mass & delays osteoporosis
Esp. postmenopausal & older women

Subjective Data
Joints
Problems, pain Location, unilateral vs. bilateral Quality, severity, onset, time of day Aggravating factors Relieving factors Associated sx
Movement, rest, position, weather
Rest, medication, heat or ice Chills, fever, recent sore throat, trauma, repetitive activity Stiffness, edema, heat, redness, limited ROM, ADL

Subjective Data
Muscles
Problems, pain, cramping, weakness location
Muscle atrophy

Any calf pain?

Associated with walking? Relief with rest?

Associated symptoms
Fever, chills, flu-like symptoms

Subjective Data
Bones
Bone or back pain
Is pain affected by movement? Location, radiating pain, numbness & tingling, limping

Bone or joint deformity

Injury, trauma, ROM

Hx accidents or trauma
Fractures, joint strain, sprain, dislocation Date, tx, sequelae (problems or limitations)

Subjective Data
Functional assessment (ADL)
Bathing

Do joint (muscle, bone) problems limit ADLs?

Toileting Dressing
Getting in & out of tub, turning on faucets Urinating, moving bowels, getting on/off toilet, wiping self Buttons, zippers, fastening openings behind neck, pulling sweater over head, pulling up pants, tying shoes, getting shoes that fit

Subjective Data
Functional assessment (ADL)
Grooming Eating
Shaving, brushing teeth, brushing or grooming hair, applying make-up

Mobility

Preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking
Walking, going up or down stairs, getting in/out of bed, getting out of house Talking, using phone, writing

Communicating

Subjective Data
Self-care behaviors
Occupational hazards related to muscles & joints Exercise program
Heavy lifting, repetitive motion, chronic joint stress Efforts to alleviate above Type, frequency, warm-up Pain during exercise & tx ASA, NSAIDs, muscle relaxants, analgesics

Recent wt gain, usual diet Medications

If chronic disability, effect on interaction with family, friends, & view of self

Subjective Data
Infants & children
Infant trauma during L & D
Breech or forceps delivery Resuscitation Siblings, peers

Achievement of developmental milestones

Hx broken bones, dislocations & tx Hx bone deformity, spinal curvature, unusual shape of toes or feet & tx

Subjective Data
Adolescents
Involvement in sports during or after school Use of safety equipment, sports training program Type of daily warm-up Reporting of injuries Relation of sport to school demands & other activities

Subjective Data
Aging adult
Do in-depth functional assessment if needed Change or weakness in past months or years in falls or stumbling in past months or years Use of mobility aids
Cane, walker

Preparation
Screening
Sufficient for most people Inspection & palpation of joints integrated with each body region Observation of ROM Age-specific screening measures
Ortolanis maneuver infants Scoliosis screening - adolescents

Preparation
Complete musculoskeletal exam
Persons with joint disease Hx musculoskeletal symptoms Problems with ADL

Preparation
Make person comfortable Drape for full visualization of body part without exposing client Orderly approach Head-to-toe Proximal to distal Joint to be examined should be supported at rest Avoid rough manipulation Use firm support, gentle movement, gentle return to relaxed state Compare corresponding paired joints symmetry structure & function normal parameters for the joint

Objective Data
Inspection
Palpation
Note joint size & contour Inspect skin over joints for color, swelling, masses, or deformity

Palpate each joint Skin temperature, muscles, bony articulations, joint capsule Note heat, tenderness, edema, or masses Normal: joints nontender, no swelling Synovial membrane normally nonpalpable, if thickened doughy or boggy

Objective Data
Range of motion (ROM) Ask for active ROM while stabilizing body area proximal to area moved Know joint type & normal ROM Normal: no tenderness, pain, or crepitation Discrete crack during motion normal If limitation, gently attempt passive ROM Anchor joint with 1 hand while other hand slowly moves it to its limit Normal ranges for active & passive ROM should be same Goniometer: used to measure joint angles precisely

Goniometer

Objective Data
Muscle testing
Test strength of prime mover muscle groups for each joint Repeat motions elicited for active ROM
Ask person to flex & hold as you apply opposing force Normal: strength = bilaterally fully resist your opposing force May use grading system from 0 to 5

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