CHAPTER 14
MUSCULOSKELETAL SYSTEM
CONCEPT OVERVIEW
• Motion:
• Mechanisms that facilitate and impair mobility.
• Interrelated concepts include:
• Oxygenation of blood to tissues.
• Intracranial regulation by brain, spinal cord, and peripheral
nerves.
• Pain from motion can limit movement.
• Nutrition must be adequate.
• Excessive weight can damage joints.
• Elimination—Risk of constipation due to limited mobility.
ANATOMY AND PHYSIOLOGY:
SKELETON OVERVIEW (1 OF 2)
• Functions of bones include:
• Support for soft tissues and organs.
• Protection of organs—brain and spinal cord.
• Body movement and hematopoiesis.
• Continual remodeling and changing collagen and
mineral composition to accommodate stress placed
upon them.
ANATOMY AND PHYSIOLOGY:
SKELETON OVERVIEW (2 OF 2)
• Function dictates shape and surface features.
• Long bones act as levers and have a flat surface for attachment
of muscles with grooves at end for tendon or nerve.
• Examples of long bones are humerus, femur, fibula, and
phalanges.
• Short bones, such as carpal and tarsal bones, are cube
shaped.
• Flat bones make up cranium, ribs, and scapula.
• Vertebrae are irregular bones.
ANATOMY AND PHYSIOLOGY:
SKELETON DIVISIONS
• Human skeleton has two major divisions:
•
•
Axial skeleton:
•
Facial bones
•
Auditory ossicles
•
Vertebrae
•
Ribs
•
Sternum
•
Hyoid bone
Appendicular skeleton:
•
Scapula
•
Clavicle
•
Bones of pelvis and legs
ANATOMY AND PHYSIOLOGY:
SKELETAL MUSCLES
• Composed of muscle fibers that attach to bones to
facilitate movement.
• All are under voluntary control.
• Some move by reflex.
• Muscles attach to bone, ligament, tendon, or fascia.
• Muscle fibers arranged parallel to long axis of bones to
which attached or are obliquely attached.
ANATOMY AND PHYSIOLOGY: JOINTS
• Articulations where two or more bones come together; hold
bones together while allowing movement.
• Classified in two ways:
• By type of material between bones: Fibrous, cartilaginous,
or synovial.
• By degree of movement:
• Synarthrodial—Immovable joints (sutures of skull).
• Amphiarthrodial—Slightly movable joint (symphysis
pubis).
• Diarthrodial—Freely movable joints (knee joint).
ANATOMY AND PHYSIOLOGY:
JOINTS—TYPE OF MOVEMENT
• Diarthrodial classified by type of movement:
• Hinge joints permit extension and flexion; some allow
hyperextension.
• Pivot joints permit movement of one bone with a ring or notch of
another bone.
• Condyloid or ellipsoidal joints: Condyle of one bone fits into
elliptically shaped articulating bone.
• Ball-and-socket joints: Ball-shaped bone fits into concave area of
articulating bone.
• Gliding joints permit movement along axes through flat
articulating surfaces such as joints between two vertebrae.
ANATOMY AND PHYSIOLOGY:
JOINT—DIARTHRODIAL JOINTS
• Diarthrodial joints are synovial joints because they are
lined with synovial fluid lubricating joint to facilitate
movement.
• Meniscus is pad of cartilage that cushions joint of some
synovial joints (knee).
• Joint capsule, an extension of periosteum, is a covering
surrounding joint; ligaments also encase capsule to add
strength.
LIGAMENTS AND TENDONS
• Difference more functional than structural.
• Ligaments are strong, dense, flexible bands of connective
tissue that hold bones together.
• Provide support by encircling joint, gripping it obliquely,
or lying parallel to bone ends across joint.
• Allow some movements while restricting others.
• Tendons are strong, nonelastic cords of collagen that attach
muscles to bones.
• Tendons support bone movement in response to skeletal
muscle contractions.
• Transmit remarkable force from contracting muscles to
bone without sustaining injury themselves.
ANATOMY AND PHYSIOLOGY: CARTILAGE
• Cartilage: Semismooth, gel-like supporting tissue; strong and able to
support weight.
• Flexibility of cartilage allows thorax to move when lungs expand
and contract.
• Forms cap over ends of long bones for smooth articulation
surface.
• Reinforces respiratory passages of nose, larynx, trachea, and
bronchi.
• Receives nutrition forced from synovial fluid that is forced into it
during movement and weight-bearing activities that are essential
to maintaining cartilage health.
ANATOMY AND PHYSIOLOGY: BURSAE
• Bursae are small sacs in connective tissues adjacent to
some joints (shoulders and knees).
• Bursa lined with synovial membrane containing
synovial fluid acting as lubricant for joint.
• Functions to reduce friction when muscles or tendons
rub against other muscles, tendons, or bones.
ANATOMY AND PHYSIOLOGY:
AXIAL SKELETON AND SUPPORTING STRUCTURES—
SKULL AND NECK (1 OF 2)
• Skull and neck:
• Six cranial bones are fused together: One frontal, two parietal,
two temporal, and one occipital.
• Face consists of 14 bones: 2 nasal, 1 frontal, 2 lacrimal, 1
sphenoid, 2 zygomatic, 2 maxillary, and mandible (movable).
• Neck supported by cervical vertebrae, ligaments, and
sternocleidomastoid and trapezius muscles.
• Greatest mobility at level of C4 to 5 or C5 to 6.
• Movements permitted include flexion, extension, and hyperflexion, and
lateral flexion and rotation.
ANATOMY AND PHYSIOLOGY:
AXIAL SKELETON AND SUPPORTING STRUCTURES—
SKULL AND NECK (2 OF 2)
• Sternocleidomastoid muscle supports neck from upper
sternum and anterior clavicle to mastoid process.
• Trapezius links scapula, lateral third of clavicle, and vertebrae,
extending to occipital prominence.
ANATOMY AND PHYSIOLOGY:
AXIAL SKELETON AND SUPPORTING STRUCTURES—
TRUNK, PELVIS, SPINE
• Trunk formed by vertebrae, ribs, and sternum of axial
skeleton, and scapula and clavicle of appendicular skeleton.
• Pelvis is part of appendicular skeleton.
• Spine composed of 7 cervical, 12 thoracic, 5 lumbar, and 5
sacral vertebrae.
• Cervical, thoracic, and lumbar are separated from each other by
fibrocartilaginous disks; sacral vertebrae are fused.
• Vertebrae with disks move slightly over one another permitting
flexion, hyperextension, lateral bending, and rotation; cervical joints
are most active.
ANATOMY AND PHYSIOLOGY: APPENDICULAR SKELETON
AND SUPPORTING STRUCTURES—SHOULDER AND
UPPER ARM
• Upper extremities: Shoulder:
• Shoulder joint, also called glenohumeral joint, is point where
humerus and glenoid fossa of scapula articulate.
• Acromial and coracoid processes and surrounding ligaments
protect ball-and-socket joint and permit flexion, extension
and hyperextension, abduction and adduction, and internal
and external rotation.
• Two other joints contribute to shoulder movement:
• Acromioclavicular joint, between acromial process and clavicle.
• Sternoclavicular joint, between sternal manubrium and
clavicle.
ANATOMY AND PHYSIOLOGY: APPENDICULAR SKELETON
AND SUPPORTING STRUCTURES—ELBOW, FOREARM,
AND WRIST
• Upper extremities: Elbow and wrist:
• Elbow joint consists of humerus, radius, and ulna in a
single synovial cavity protected by ligaments and bursa
between olecranon and skin.
• Elbow is hinge joint permitting extension, flexion, and sometimes
hyperextension; pronation and supination of forearm provided also.
• Wrist joints radius and carpal bones with disks of wrist,
ligaments, and fibrous capsule forming a condyloid joint.
• Permits flexion, extension, and hyperextension, as well as radial
and ulnar flexion, also called radial deviation and ulnar deviation.
ANATOMY AND PHYSIOLOGY: APPENDICULAR SKELETON
AND SUPPORTING STRUCTURES—HAND (1 OF 2)
• Upper extremities: Hand:
• Small, subtle movements or articulations within hand
between carpals and metacarpals, between metacarpals
and proximal phalanges, and between middle and distal
phalanges.
• Ligaments protect diarthrotic joints, which allow
flexion, extension, and hyperextension.
• Fingers are able to flex and extend, abduct, and
adduct.
ANATOMY AND PHYSIOLOGY:
APPENDICULAR SKELETON AND SUPPORTING
STRUCTURES—HAND (1 OF 2)
• Upper extremities: Hand:
• Names of joints in hand describe location:
• Distal interphalangeal (DIP) joint is distal joint of
fingers.
• Proximal interphalangeal (PIP) joint is middle joint of
each finger.
• Metacarpophalangeal (MCP) joint attaches metacarpal
to carpal joint.
ANATOMY AND PHYSIOLOGY:
APPENDICULAR SKELETON AND SUPPORTING
STRUCTURES—HIP AND THIGH
• Lower extremities: Hip and thigh:
• Acetabulum and femur form hip joint.
• Protected by fibrous capsule and three bursae.
• Three ligaments stabilize head of femur in joint capsule.
• Ball-and-socket joint—flexion, extension, and
hyperextension, abduction and adduction, internal and
external rotation, and circumduction.
ANATOMY AND PHYSIOLOGY:
APPENDICULAR SKELETON AND SUPPORTING
STRUCTURES—KNEE AND LOWER LEG
• Lower extremities: Knee and lower leg:
• Hinge joint is point of articulation between femur, tibia, and patella.
• Medial and lateral menisci (fibrous cartilage) cushion tibia and femur
and connect to articulated capsule.
• Ligaments provide stability.
• Bursae reduce friction between femur and tibia.
• Movements include flexion, extension, and sometimes
hyperextension.
ANATOMY AND PHYSIOLOGY:
APPENDICULAR SKELETON AND SUPPORTING
STRUCTURES—ANKLE
• Lower extremities: Ankle:
• Ankle joint (tibiotalar) is hinge joint; flexion (dorsiflexion)
and extension in one plane (plantar flexion).
• Protective medial and lateral ligaments join tibia, fibula,
and talus to form ankle joint.
• Smaller joints, subtalar (talocalcaneal) and
talonavicular (transverse tarsal) within ankle permit
pivot or rotation movement, producing inversion and
eversion, and adduction and abduction.
ANATOMY AND PHYSIOLOGY: APPENDICULAR SKELETON
AND SUPPORTING STRUCTURES—FOOT (1 OF 2)
• Lower extremities: Foot:
• Five metatarsal bones form sole of foot.
• Names of joints in feet describe their location.
• Interphalangeal joint is between distal phalanx and
proximal phalanx.
• Metatarsophalangeal joint is between proximal phalanx
and first metatarsal.
• Tarsometatarsal joint attaches first metatarsal to tarsal.
ANATOMY AND PHYSIOLOGY:
APPENDICULAR SKELETON AND SUPPORTING
STRUCTURES—FOOT (2 OF 2)
• Lower extremities: Foot:
• Foot has gliding joint allowing inversion and eversion of
foot.
• Toes are condyloid joints allowing flexion and extension, as
well as abduction and adduction.
GENERAL HEALTH HISTORY:
PRESENT HEALTH STATUS
• Any chronic diseases?
• Loss of bone density or osteoporosis?
• Take medications?
• What, and how often?
• Take as prescribed?
• Changes in ability to move/participate in usual activities?
• Changes in muscle strength?
• How did you adapt to changes?
GENERAL HEALTH HISTORY:
PAST HEALTH HISTORY
• Have you ever had accidents or trauma?
• Any continuing problems?
• Have you had surgery on bones or joints?
• What was the outcome?
GENERAL HEALTH HISTORY:
FAMILY HISTORY
• Is there a history of curvature of spine or back problems in
your family?
• Is there history of:
• Arthritis?
• Rheumatoid arthritis?
• Osteoarthritis?
• Gout?
GENERAL HEALTH HISTORY: PERSONAL AND
PSYCHOSOCIAL HISTORY
• Do you exercise?
• How often?
• Sports?
• Which ones, and how often?
• Protect yourself from injury while exercising or playing
sports?
• Do you lift, push, pull, bend, or stoop frequently as part of daily
routine at home or work?
• How do you protect yourself from muscle strain or injury?
PROBLEM-BASED HISTORY: PAIN
• Where was pain felt?
•
When was it first noticed?
•
Is it related to movement?
• Did pain occur suddenly or gradually?
•
When during day, when do you feel pain?
• Does pain move from one joint to another?
•
Any injury, overuse, or strain of muscles or joints?
• What makes pain worse?
•
Does pain shoot to another part of your body?
• What was done to relieve the pain?
•
How effective was that?
PROBLEM-BASED HISTORY:
PROBLEMS WITH MOVEMENT
•
How long have you had movement problems?
•
Are joints swollen, red, or hot to touch?
•
Have you had a recent sore throat?
•
Muscle weakness?
•
•
Which ones?
•
Does it get worse throughout day?
Do knees or ankles give way with pressure?
•
•
What do you think makes it happen?
Joints felt as if locked and will not move?
•
When?
•
What relieves it?
•
What makes it worse?
PROBLEM-BASED HISTORY:
PROBLEMS WITH DAILY ACTIVITIES
• Are activities limited by musculoskeletal disorder?
• To what extent are activities limited?
• How do you compensate?
• Note that any impaired mobility or function may cause a selfcare deficit.
• For patients who have chronic disability or crippling disease:
• How has illness affected interactions with family?
• Has it affected relationships with friends?
EXAMINATION: OVERVIEW (1 OF 2)
• To examine musculoskeletal system, use a cephalocaudal
organization with side-to-side comparisons for examining
bones, muscles, and joints.
• Because there are often no “normals” for musculoskeletal
system, normality is established best by comparing with
other side.
EXAMINATION: OVERVIEW (2 OF 2)
• Cephalocaudal organization with side-to-side comparison
(no normals).
• Techniques used depend on reason for examination,
setting, condition and age of the patient, and skill of the
nurse.
• Findings during examination may warrant use of additional
techniques.
• Nurse determines which techniques should be indicated
for each examination.
EXAMINATION: PROCEDURES AND TECHNIQUES (1
OF 2)
• Inspect axial skeleton and extremities for alignment,
contour, symmetry, size, and gross deformities:
• Body symmetric, straight spine (normal curves), knees
straight line (hips and ankles), feet flat, forward.
• Inspect muscles for size and symmetry:
• Bilateral symmetry, muscle circumference.
EXAMINATION: PROCEDURES AND TECHNIQUES (2
OF 2)
• Palpate bones for tenderness; joints and muscles for
tenderness, heat, edema, tone.
• Bones nontender, joints or muscles same temp as
tissue, no tenderness or edema on palpation; firm
muscles.
• Observe range of motion and palpate major joints and
adjacent muscles for tenderness on movement, joint
stability, and deformity.
• Test muscle strength, and compare sides.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (1 OF 13)
• Observe gait for conformity, symmetry, and rhythm.
• Conformity, regular smooth rhythm, leg swing, length
symmetry, smooth swaying, or symmetric arm swing.
• Inspect face and neck musculature for symmetry.
• Palpate temporomandibular joint for movement, sounds,
and tenderness.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (2 OF 13)
• Observe jaw for range of motion.
• Motion smooth, without pain.
• Protrude and retract chin without difficulty or pain.
• Palpate neck for pain.
• Soft and firm without masses, pain, or spasms.
• Observe neck for range of motion.
• Test neck muscles for strength.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (3 OF 13)
• Inspect shoulders and cervical, thoracic, and lumbar spine
for alignment and symmetry:
• Vertebrae aligned in straight line, shoulders level.
• Observe range of motion of thoracic and lumbar spine:
• 75 degrees of flexion while touching toes, 30 degrees
back from neutral with hyperextension, and 35 degrees
lateral flexion.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (4 OF 13)
• Palpate posterior neck, spinal processes, paravertebral
muscles for alignment and tenderness.
• Spine straight and nontender.
• Percuss spinal processes for tenderness.
• No muscle spasm or tenderness.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (5 OF 13)
• Inspect shoulders and shoulder girdle for equality of height and
contour.
• Structures smooth, regular, bilaterally symmetrical;
shoulders level, rounded, firm, smooth contour, no bony
prominences.
• Each shoulder equidistant from vertebral columns.
• Palpate the shoulders for firmness, fullness, tenderness, and
masses.
• Nontender, smooth, firm, full without masses, bilaterally
symmetrical; larger on dominant side.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (6 OF 13)
• Test trapezius muscles for strength.
• Observe shoulders for range of motion:
• 180 degrees straight extension, 50 degrees back
hyperextension, 180 degrees shoulder abduction, 50
degrees adduction, 90 degrees external or internal rotation.
• Test arms for muscle strength.
• Palpate elbows for tenderness, edema, and nodules.
• Observe the elbows for range of motion.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (7 OF 13)
• Inspect joints of wrists and hands for position, contour, and
number of digits.
• Palpate each joint of hand and wrist for surface characteristics
and tenderness.
• Test for muscle strength and observe for range of motion of
wrists and fingers.
• Symmetrical flexion or extension, able to overcome resistance;
bilaterally equal grip strength.
• 70 degrees hyperextension; 90 degrees palmar flexion, 90 degrees
metacarpophalangeal joint flexion, 30 degrees extension; 50 to 60
degrees ulnar, 20 degrees radial deviation.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL REGIONS (8
OF 13)
• Inspect hips for symmetry and palpate hips for stability
and tenderness.
• Observe hips for range of motion:
• 120 degrees flexion from straight extended position.
• 90 degrees hip flexion from straight extended position.
• 45 degrees external hip rotation from straight midline position.
• 40 degrees internal hip rotation from straight midline position.
• 45 degrees abduction, 30 degrees adduction.
• 30 degrees hyperextension.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (9 OF 13)
• Test hips for muscle strength:
• Raise leg from supine position; should be able to
overcome resistance.
• Extend leg from sitting position; should be able to
maintain extension.
• Bend knee; should be able to maintain flexion.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (10 OF 13)
• Inspect knees for symmetry and alignment.
• Knees lined with tibia; ankle without medial or lateral
deviation.
• Palpate knees for contour, tenderness, and edema.
• Suprapatellar pouch should be smooth, nontender,
nonedematous.
• Medial and lateral aspects of tibiofemoral joint space
should be nonedematous, nontender.
• Popliteal space should be smooth, nontender.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL
REGIONS (11 OF 13)
• Observe knees for range of motion:
• 130 degrees flexion from straight extended position.
• 15 degrees if able to hyperextend from midline.
• Test leg muscles for strength.
• Should maintain flexion and extension against
resistance.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL REGIONS
(12 OF 13)
• Inspect ankles and feet for contour, alignment, number of
toes.
• Palpate ankles and feet for contour, edema, and
tenderness.
• Ankles should be smooth without deformity.
• Feet should be straight, aligned with long axis of lower
leg.
• Five toes.
• Structures should be smooth, nonedematous, and
nontender.
EXAMINATION OF SPECIFIC MUSCULOSKELETAL REGIONS
(13 OF 13)
• Observe ankles and feet for range of motion:
• 20 degrees dorsiflexion, 45 degrees plantar flexion
from midline.
• 20 degrees eversion, 30 degrees inversion from
midline.
• 10 degrees abduction, 20 degrees adduction.
• Equal bilateral flexion and extension of toes.
• Test ankles and feet muscles for strength.
• Should be able to walk on toes, heels, and inside and
outside of foot.
TECHNIQUES PERFORMED BY ADVANCED PRACTICE
REGISTERED NURSES (1 OF 6)
• Assess for carpal tunnel syndrome:
• Done when patient complains of numbness, tingling, or
pain over the palmar surface of the hands and first three
fingers and part of the fourth finger.
• Assessed for carpal tunnel syndrome by assessing the wrist
and palm on the affected hand.
TECHNIQUES PERFORMED BY ADVANCED PRACTICE
REGISTERED NURSES (2 OF 6)
• Assess for rotator cuff damage:
• When the patient complains of shoulder pain, the
APRN adducts the patient’s affected arm and asks the
patient to lower the arm slowly.
TECHNIQUES PERFORMED BY ADVANCED PRACTICE
REGISTERED NURSES (3 OF 6)
• Assess for knee effusion:
• When fluid in the knee joint is suspected, the APRN
palpates the knee joint to determine the presence of a
small or large amount of fluid.
TECHNIQUES PERFORMED BY ADVANCED PRACTICE
REGISTERED NURSES (4 OF 6)
• Assess knee stability:
• This assessment is performed when trauma to the knee is
suspected.
• The APRN adducts the lower leg to detect abnormal
movement of the collateral and cruciate ligaments.
• The affected knee is manipulated forward and backward to
assess for abnormal movement of the anterior and
posterior cruciate ligaments.
TECHNIQUES PERFORMED BY ADVANCED PRACTICE
REGISTERED NURSES (5 OF 6)
• Meniscal damage or tear:
• Assessment for damage of the meniscus performed by
rotating the knee with the patient in a supine position to
determine pain, audible clicks, or locking of the knee.
• Assessment of a meniscal tear is performed when the
patient is unable to bear weight on or flex the knee.
TECHNIQUES PERFORMED BY ADVANCED PRACTICE
REGISTERED NURSES (6 OF 6)
• Assess for hip flexion contracture:
• When the patient is lying supine with one leg extended,
the APRN flexes the other knee to the chest and watches
the movement of the extended leg.
• If the extended leg lifts off the examination table, the
patient has a hip flexion contracture.
AGE-RELATED VARIATIONS:
INFANTS, CHILDREN, AND ADOLESCENTS
• Several differences in assessment for infants and young
children.
• Infants’ movement is assessed during voluntary
movement, and hip joints and feet are assessed for
abnormalities.
• Children’s motor development compared with
standardized tables for age and sequences.
• Musculoskeletal assessment of older child and adolescent
follows same procedures as that for adults and reveals
similar expected findings.
AGE-RELATED VARIATIONS:
OLDER ADULTS
• Assessing musculoskeletal system of older adults usually
follows same procedures as that for younger adults.
• Older adults may be slower at performing range-ofmotion, and muscle strength may be less than a younger
adult.
COMMON PROBLEMS AND CONDITIONS: BONES—
FRACTURE
• Fracture is partial or complete break in continuity of a
bone.
• Skin intact in closed fracture; skin broken in open
fracture.
• Pathologic fracture results from weakness in bone,
(osteoporosis or neoplasm).
• Clinical findings:
• Pain caused by muscle spasm is common.
• Deformity or loss of function caused by tissue
shortening around bone and localized edema.
COMMON PROBLEMS AND CONDITIONS: BONES—
OSTEOPOROSIS
• Osteoporosis is loss of bone density and decreased bone
strength results in osteoporosis.
• Causes include factors associated with aging: Decline of
estrogen and relationship to calcium deficit, and lack of
exercise.
• Clinical findings:
• Osteoporosis occurs without signs or symptoms; patients
may not know until they realize loss of height, have
spontaneous fracture from brittle bones, or develop
kyphosis (convex curvature of thoracic spine).
COMMON PROBLEMS AND CONDITIONS: JOINTS—
RHEUMATOID ARTHRITIS (1 OF 2)
• Rheumatoid arthritis (RA) is chronic, autoimmune inflammatory
disease of connective tissue.
• Onset is usually gradual with fatigue, morning stiffness,
diffuse muscle ache, and weakness.
• Synovial lining inflamed with deterioration of cartilage and
erosion of surfaces (spurs).
• Ligaments and tendons around joints become fibrotic and
shortened (contractures and joint subluxation).
COMMON PROBLEMS AND CONDITIONS: JOINTS—
RHEUMATOID ARTHRITIS (2 OF 2)
• Clinical findings:
• Joint involvement is bilateral.
• Symptoms are pain, edema, and stiffness of fingers, wrists,
ankles, feet, and knees.
• Systemic symptoms caused by autoimmune response include
low-grade fever and fatigue.
• As disease continues, ulnar deviation, swan-neck deformity, and
boutonnière deformity may be observed.
COMMON PROBLEMS AND CONDITIONS: JOINTS—
OSTEOARTHRITIS (1 OF 2)
• Osteoarthritis is degenerative change in articular cartilage.
• Affects weight-bearing joints (vertebrae, hips, knees, and
ankles); also hands and fingers.
• Affects joints with repetitive movement, those used playing
sports on a regular basis.
• As cartilage wears away, bones move against each other
(joint inflammation).
• Joint involvement may be unilateral or bilateral.
COMMON PROBLEMS AND CONDITIONS: JOINTS—
OSTEOARTHRITIS (2 OF 2)
• Clinical findings:
• Symptoms include joint edema and aching pain.
• Joint deformities of fingers develop:
• Heberden’s nodes in distal interphalangeal joints.
• Bouchard’s nodes in peripheral interphalangeal
joints.
COMMON PROBLEMS AND CONDITIONS: JOINTS—
BURSITIS
•
Bursitis is an inflammation of the bursa.
•
•
•
May be precipitated by arthritis, infection, injury, and excessive exercise.
Common sites:
•
Shoulder
•
Elbow
•
Hip
•
Knee
Clinical findings:
•
Pain
•
Limited motion
•
Edema
•
Point tenderness
•
Erythema of affected joint
COMMON PROBLEMS AND CONDITIONS: JOINTS—
GOUT (1 OF 2)
• Gout is hereditary disorder with increase in serum uric acid
due to increased production, or decreased excretion of
uric acid and urate salts.
• Thought to be caused by lack of an enzyme needed to
completely metabolize purines for renal excretion.
• Uric acids not only accumulate commonly in great toe but
also in other joints such as wrists, hands, ankles, and
knees.
COMMON PROBLEMS AND CONDITIONS: JOINTS—GOUT (2
OF 2)
• Clinical findings:
• Manifestations include erythema and edema of joints
that are very painful to move and limit range of
motion.
• Tophi, a sign of gout, are round, pea-like deposits of
uric acid in ear cartilage, or large, irregularly shaped
deposits in subcutaneous tissue or other joints.
• Kidney stones from uric acid crystals can cause
manifestations of flank pain, and costovertebral angle
tenderness.
COMMON PROBLEMS AND CONDITIONS: SPINE—
HNP (1 OF 2)
• Herniated nucleus pulposus (HNP) (also called herniated
disk and slipped disk) occurs when fibrocartilage
surrounding an intervertebral disk ruptures and nucleus
pulposus is displaced and compresses adjacent spinal
nerves.
• Rupture frequently occurs in lumbar spine with increased
strain on vertebrae, such as lifting a heavy object
improperly.
COMMON PROBLEMS AND CONDITIONS: SPINE—
HNP (2 OF 2)
• Clinical findings:
• Depends on location of affected disk.
• Patient may complain of numbness and radiating pain in
extremity from herniated lumbar disk.
• Straight leg raises cause pain in involved leg by putting
pressure on spinal nerve.
• Cervical herniated nucleus pulposus causes arm pain and
paresthesia.
• Deep tendon reflexes may be depressed or absent,
depending on spinal nerve root involved.
COMMON PROBLEMS AND CONDITIONS: SPINE—
SCOLIOSIS (1 OF 2)
• Scoliosis is S-shaped deformity of vertebrae.
• Skeletal deformity in three planes, usually lateral
curvature, spinal rotation (causing rib asymmetry), and
thoracic kyphosis.
• Evidence suggests that idiopathic scoliosis may be
genetic.
• Causes include congenital malformations of spine,
neuromuscular diseases, traumatic injury, and unequal
leg length.
• Structural scoliosis affects girls more than boys.
COMMON PROBLEMS AND CONDITIONS: SPINE—
SCOLIOSIS (2 OF 2)
• Clinical findings:
• Produces uneven shoulders and hip levels.
• Curvature less than 10% considered normal variation;
between 10% and 20% mild.
• Rotation deformity may also cause rib hump and flank
asymmetry on forward flexion.
• Depending on severity of curve, physiologic function of
lungs, spine, and pelvis may be compromised.
COMMON PROBLEMS AND CONDITIONS: LIGAMENTS
AND MUSCLES—CARPAL TUNNEL SYNDROME (1 OF 2)
• Carpal tunnel syndrome occurs when median nerve
compressed between flexor retinaculum (carpal
ligament) and other structures within carpal tunnel.
• May be caused by repetitive movements of hands
and arms, injury to wrist, and systemic disorders
such as rheumatoid arthritis, gout, and
hypothyroidism.
• It may also occur with fluid retention that occurs
with pregnancy and menopause.
COMMON PROBLEMS AND CONDITIONS: LIGAMENTS
AND MUSCLES—CARPAL TUNNEL SYNDROME (2 OF 2)
• Clinical findings:
• Manifestations include burning, numbness, and
tingling in hands, often at night.
• Patients report numbness, pain, and paresthesia
during Phalen’s sign or Tinel’s sign used to assess
for this disorder.