After you have successfully completed this chapter,you should be able to: Identify pertinent motor-musculoskeletal historyquestions obtain a motor-musculoskeletal history perform a physical assessment of the motor-musculoskeletal system document motor-musculoskeletal findings identify actual/potential health problems stated asnursing diagnoses differentiate between normal and abnormalfindings
Introduction:the musculoskeletal system provides shape and support to the body, allowsmovement, protectsthe internal organs, produces red blood cells in the bone marrow(hematopoiesis), and stores calcium and phosphorus in the bones. Although examiningthis system is usually only a small part of the overall physical assessment, everythingwe do depends on an intact musculoskeletal system. How extensive an assessmentyou perform depends largely on each patient’s problems and needs. Perform acomprehensive musculoskeletal assessment if you detect a musculoskeletalabnormality or uncover a symptom that suggests musculoskeletal involvement.Musculoskeletal problems are common in all age groups. Primary problems may resultfrom congenital, developmental, infectious, neoplastic, traumatic, or degenerativedisorders of the system itself. Secondary problems can result from disorders of otherbody systems. The goal of a complete musculoskeletal assessment is to detect riskfactors, potential problems, or musculoskeletal dysfunction early and then to planappropriate interventions, including teaching health promotion and diseaseprevention and implementing treatment measures. By doing so, you can play asignificant role in preventing pain and dysfunction in your patients.
RELATIONSHIP OF MUSCULOSKELETAL SYSTEM TO OTHER SYSTEMSENDOCRINEMS system provides protection to endocrine structures. Growth and sex hormones affect growthof MS system. Thyroid/parathyroid control calcium and calcitonin. LYMPHATIC/ HEMATOLOGICBone marrow produces blood cells and lymphocytes. Lymphatic system responds as a defensefor MS system.RESPIRATORYChest muscles and bones protect lungs. Muscles are essential for breathing. Respiratory systemprovides oxygen and removes carbon dioxide.INTEGUMENTARYSkin provides protective covering for muscles and joints. Skin provides vitamin D synthesisneeded for calcium and phosphorus bone growth.
CARDIOVASCULARDelivers nutrients to MS system and removes wastes. MS system provides calcium ifneeded for cardiac contraction. Contraction of muscles assists with venous return.GASTROINTESTINALProvides nutrients to MS system, especially calcium and phosphorus. Abdominalmuscles protect abdominal structures and organs.GENITOURINARYMS system protects renal structures. Kidneys reabsorb calcium and phosphorus asneeded.REPRODUCTIVEMS system protects reproductive organs. Sex hormones affect growth.
JOINT MOVEMENTS MOVEMENT DESCRIPTIONExtension Straightening or increasing the angle of a joint FlexionBending or decreasing the angle of a joint Hyperextension Straighteningbeyond the normal angle of a joint Abduction Moving away from themidline Adduction Moving toward the midline Circumduction Moving ina circular fashion Internal rotation Turning inward toward the midlineExternal rotation Turning outward away from the Midline PronationTurning down Supination Turning up Inversion Turning inward (medially)Eversion Turning outward (laterally) Retraction Moving backwardProtraction Moving forward Opposition Movement of thumb towardfingerpad Reposition Movement of thumb back to anatomic positionDepression Movement by lowering body part Elevation Movement byraising body part Ulnar deviation Movement of hand toward ulnar sideRadial deviation Movement of hand toward radial Side
TESTS FOR WRIST PROBLEMSPHALEN’S TEST. HAVE THE PATIENT FLEX THE HANDS BACK TOBACK AT A 90-DEGREE ANGLE AND HOLD THIS POSITION FORABOUT 1 MINUTE . IF THE PATIENT COMPLAINS OF NUMBNESSOR TINGLING ANYWHERE FROM THE THUMB TO THE RING FINGER,THE TEST IS POSITIVE FOR CARPAL TUNNEL SYNDROME.TINEL’S TEST. PERCUSS LIGHTLY OVER THE MEDIAN NERVE,LOCATED ON THE INNER ASPECT OF THE WRIST . IFNUMBNESS AND TINGLING OCCUR ON THE PALMAR ASPECT OF THEWRIST AND EXTEND FROM THE THUMB TO THE SECOND FINGER,THE TEST IS POSITIVE FOR CARPAL TUNNEL SYNDROME.
TEST FOR ARM PROBLEMSPronator Drift. Perform this test if you detect muscle weakness of the arms. Havethe patient stand with armsextended, hands supinated, and eyes open and thenclosed for at least 20 to 30 seconds (Fig.20.10).Check for downward drift andpronation of the arms and hands. Pronation and drift of one arm is called pronatordrift and may indicate a mild hemiparesis. Flexion of the fingers and elbow mayaccompany pronator drift. A lateral and upward drift may also occur in patientswith loss of position sense. If your patient is able to hold her or his arms extendedwithout drift, gently tap downward on the arms. If she or he has normal musclestrength, coordination, and position sense, the arms will return to the horizontalposition. A weak arm is easily displaced and does not return to the horizontalposition. You can also assess drifting and weakness by having the patient hold hisor her arms over the head for 20 to 30 seconds. Then, try to force the arms downto the sides as the patient resists. Drifting or weakness may indicate ahemiparesis.
Test for Spinal ProblemsStraight Leg Raising (Lasègue’s Test). Performthis test when the patient complains of lowback pain that radiates down the leg (sciatica).This test checks for a herniated nucleuspulposus. Ask the patient to lie flat and raisethe affected leg to the point of pain(Fig.20.11).Pain and sciatica that intensify withdorsiflexion of the foot.
Tests for Hip Problems• Thomas Test. This test assesses for hip flexure contractures hidden by excessive lumbar lordosis. Have the patient lie supine with both legs extended and then flex one leg to her or his chest (Fig. 20.12).The test is positive if the opposite leg raises off the table. Repeat the same maneuver on the opposite side. Trendelenburg Test. This test is used to assess for a dislocated hip and gluteus medius muscle strength. Have patient stand erect and check the iliac crest—it should be level. Then, have the patient stand on one foot and check again. If the iliac crest remains level or drops on the side opposite the weight-bearing leg, the gluteus medius muscle is weak or the joint is not stable and there may be a hip dislocation on the weightbearing side.
Tests for Knee Problems• Perform one of the following two tests if you noted swelling secondary to fluid accumulation or soft tissue damage. Bulge Test. Perform this test if you suspect small amounts of fluid.With the patient supine, stroke the medial side of the knees upward several times to displace the fluid.Then, press the lateral side of the knee, and inspect for the appearance of a bulge on the medial side (Fig. 20.13). Patellar Ballottement. Perform this test if you suspect large amounts of fluid. With the patient supine, press firmly with your left thumb and index finger on each side of the patella (Fig. 20.14). This displaces fluid into the suprapatellar bursa between the femur and the patella. Then, gently tap on the kneecap. If fluid is present, the patella will bounce back to your finger (floating kneecap).
HELPFULHINT• Check for hollows on either side of the patella. If hollows are absent, fluid may be present. Lachman Test. If your patient complains that his or her knee gives way or buckles, test anterior,posterior,medial, and lateral stability. To test medial and lateral stability, have the patient extend the knee and attempt to abduct and adduct it. Normally, no movement should occur if the knee is stable. To assess the anterior and posterior plane, have the patient flex the knee at least 30 degrees. Stabilize and grasp the leg below the patella, and attempt to move it forward and back. If the joint is stable, no movement should occur (Fig. 20.15).Another similar test for stability of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) is the drawer test. With the patient’s knee flexed at a 90-degree angle, apply anterior and posterior pressure against the tibia, and feel for movement. Movement of the tibia is a positive draw sign, indicating an ACL or PCL tear.
To test stability of the collateral ligament, have the patient lie supine with theknee slightly flexed. Place your hand at the head of the fibula and applypressure medially; then reverse and apply pressure laterally. If the joint isunstable, movement will occur and create a palpable medial or lateral gap atthe joint. Perform one of the following tests if your patient complains of clicksor knee-locking and you suspect a torn meniscus. McMurray’s Test. To perform McMurray’s test, position the patient supinewith her or his knee fully flexed (Fig. 20.16). Place one hand on the heel andthe other on the knee and gently internally and externally rotate the foot asyou bring the leg to full extension. The test is positive if audible or palpableclicks occur or the knee locks.Apley’s Test. Position the patient supine with his or her knee flexed at 90degrees (Fig. 20.17).Place one hand on the heel and the other hand on theknee. Apply pressure with both hands and gently rotate the foot. The test ispositive if audible or palpable clicks occur.