Musculoskeletal System Review: Anatomy, Physiology, Assessment and Diagnostics
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The document provides an overview of the musculoskeletal system, including its anatomy, physiology, assessment, diagnostic tests, and age-related changes. Key points include: - The skeletal and muscular systems make up the musculoskeletal system, with bones, cartilage, tendons, ligaments, and joints. - Assessment involves history, physical exam including gait, posture, range of motion, and related systems. Diagnostic tests include radiography, MRI, lab tests, and invasive procedures. - Age-related changes consist of decreased bone density, increased prominence, kyphosis, cartilage degeneration, decreased range of motion, muscle atrophy, and slowed movement.
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Musculoskeletal System Review: Anatomy, Physiology, Assessment and Diagnostics
- 2. Musculoskeletal System ReviewMusculoskeletal System Review Anatomy: Skeletal system ◦ Bones ◦ Cartilage ◦ Tendons ◦ Ligaments ◦ Joints Muscular system ◦ Muscles Physiology: Calcium storage Hematopoesis Protection Form/framework Joint articulation
- 3. Skeletal systemSkeletal system ◦ Endoskeleton 206 bones Axial skeleton – 80 bones Skull Vertebral column Thorax Appendicular skeleton – 126 bones Bones of extremities Shoulders pelvis
- 5. BonesBones Long – tibia, femur Short – carpals, tarsals Flat – ribs, cranium Irregular – ear ossicles, facial bones
- 16. Composition of boneComposition of bone Collagen (steel rod) ◦ tensile strength Inorganic salts ( cement, sand & gravel) ◦ Hydroxyapatite (calcium and phosphate) Withstand compression Cells ◦ Osteoblast ◦ Osteocytes ◦ osteoclasts
- 22. Primary cartilaginous joints (= synchondroses):
- 29. Bone is dynamic–Bone is dynamic– continual activity of osteoblasts and osteoclasts
- 30. AssessmentAssessment History ◦ Biographic and demographic data Age Gender Place of living Occupation Hobbies
- 31. Current healthCurrent health Chief complaint ◦ Pain ◦ Joint stiffness ◦ Swelling ◦ Deformity / immobility ◦ Infection ◦ Sensory changes
- 32. PainPain 5th vital sign Location / duration / radiation Alleviating / aggravating factors OTC Associated infection Rate on 0-10 pain scale Aches – muscular Sharp pain – fracture or infection Throbbing – bone related
- 33. Joint stiffnessJoint stiffness Local / systemic Associated muscle weaknesss Specific joints Constant / episodic Alleviating / aggravating factors Crepitus Deformity
- 34. Sensory changesSensory changes Fractures / tumors/ surgical swelling h/o back pain ◦ Injury Tingling Burning Radiating weakness
- 35. Deformity / immobilityDeformity / immobility Location Sudden / gradual ( tumor) ADLs limited Assistive device use ROM - goniometer
- 36. InfectionInfection Location Duration Implanted device Previous history Fever/ chills Pain under cast
- 37. Review of systemsReview of systems Past Medical- surgical history Childhood h/o asthma, seizure (osteomalacia), DM, trauma Family history Allergy Medications Dietary habits Social history
- 38. Review of systemsReview of systems Reactive arthritis ◦ Pain / burning urination ◦ conjuctivitis Gout ◦ Tachycardia / hypertension Carpel tunnel syndrome ◦ Wasting of thenar muscle Electrolyte imbalance ◦ Paresthesia, increased DTR Rheumatic fever
- 39. Physical examinationPhysical examination Observe, inspect and palpate ◦ Muscle mass Symmetry Involuntary movements Tenderness Tone and strength ◦ Joints ◦ Bones Deformity Limb length discrepancy
- 40. General examinationGeneral examination Gait Body mobility ◦ Upper body ◦ chest, back and lower extremity Posture ◦ Body build, contours alignment, spine Joint motion Balance Spinal deformities
- 41. GaitGait 1. The base is as wide as the shoulder width 2. Foot placement is accurate 3. Walk is smooth, even and well-balanced 4. Associated movements, such as arm swing, are present.
- 46. Gait AbnormalitiesGait Abnormalities Unusual and uncontrollable walking patterns, usually caused by disease or injury. ◦ Propulsive ◦ Scissors ◦ Spastic ◦ Steppage ◦ Waddling
- 50. PosturePosture Normal - Comfortably erect Look for straight lines across body parts Normal Aging
- 51. Lordosis - Increased Curvature of the SpineLordosis - Increased Curvature of the Spine
- 52. Kyphosis is a curving of the spine that causes aKyphosis is a curving of the spine that causes a bowing of the back, which leads to a hunchbackbowing of the back, which leads to a hunchback or slouching posture.or slouching posture.
- 53. Scoliosis – curvature of the spine awayScoliosis – curvature of the spine away from middle or sidewaysfrom middle or sideways
- 55. kyphosiskyphosis
- 56. kyphosiskyphosis
- 60. Genuvarum and genuvalgumGenuvarum and genuvalgum
- 61. MusclesMuscles Muscle mass ◦ Symmetrical, smooth and firm Strength ◦ 0 -5 scale
- 63. Joints and bonesJoints and bones
- 64. Examination of JointsExamination of Joints Inspection ◦ Symmetry ◦ Size and contour ◦ Redness ◦ Atrophy ◦ Deformity ◦ Swelling Palpation ◦ Crepitus, thickening, swelling or tenderness ◦ ROM
- 65. Range of MotionRange of Motion Full Mobility of each joint Deliberate, accurate, smooth, and coordinated No involuntary movement
- 67. Related systemsRelated systems Neurovascular ◦ Pain ◦ Poikilothermia ◦ Pulselessness ◦ Paralysis ◦ Paresthesia ◦ Pallor ◦ Capillary refill Peripheral nerve assessment
- 68. Musculoskeletal System: RadiographicMusculoskeletal System: Radiographic ExaminationsExaminations Standard x-ray CAT scan ◦ soft tissue tumors, spinal fractures Dual-energy X-ray Absorptiometry(DEXA) ◦ Measures bone loss ◦ Gold std. test for osteoporosis MRI ◦ Details of bone, ligaments, tendons, muscles ◦ CI – metal implants
- 69. Standard x-ray & CAT scanStandard x-ray & CAT scan
- 70. CAT scanCAT scan
- 71. Dual-energy X-ray Absorptiometry(DEXA)Dual-energy X-ray Absorptiometry(DEXA)
- 75. MRIMRI
- 76. MRIMRI
- 77. Lachman’s testLachman’s test Evaluates injury to the anterior cruciate ligament
- 79. For evaluating meniscal injuryFor evaluating meniscal injury patient lie supine with knee flexed. The examiner places one hand on the heel and another along the medial aspect of the knee The knee is extended from a fully flexed position while internally rotating the tibia. The test is repeated while externally rotating the tibia. A positive sign is indicated by a “popping” and sensation of symptoms along the joint line, often accompanied by an inability to fully extend the knee.
- 81. Drawer signDrawer sign Proximal aspect of tibia pulled forward Forward movement >6 mm – ACL tear Same maneuver Pushing back on tibia – posterior cruciate ligament injury
- 88. Electromyelogram and nerveElectromyelogram and nerve conduction testconduction test
- 90. Musculoskeletal System: OtherMusculoskeletal System: Other Diagnostic TestsDiagnostic Tests Indium Scan ◦ Indium III – connected to leukocytes ◦ Determine infections Bone scans ◦ Injection of radioisotopes Detect malignancies Stress fracture osteomyelitis
- 91. Musculoskeletal System: Diagnostic LabMusculoskeletal System: Diagnostic Lab TestsTests Measures of inflammation ◦ ANA ◦ CRP ◦ ESR ◦ RF CBC Serum Calcium Serum Phosphorus Alkaline Phosphatase (ALP)
- 92. Musculoskeletal System: Diagnostic LabMusculoskeletal System: Diagnostic Lab TestsTests Serum Muscle Enzymes: muscular dystrophy ◦ Creatine Kinase ◦ Lactate dehydrogenase (LDH) ◦ Aspartate aminotransferase (AST) ◦ Aldolase A (ALD)
- 93. Musculoskeletal System: Age RelatedMusculoskeletal System: Age Related ChangesChanges Decreased bone density Increased bone prominence Kyphosis Cartilage degeneration Decreased ROM Muscle atrophy (decreased strength) Slowed movement
Editor's Notes
- Gait Abnomalities
- injuries to the legs, feet, brain, spine, or inner ear Propulsive gait -- a stooped, rigid posture, with the head and neck bent forward Scissors gait -- legs flexed slightly at the hips and knees, giving the appearance of crouching, with the knees and thighs hitting or crossing in a scissors-like movement Spastic gait -- a stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction Steppage gait -- foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking Herniated lumbar disk Waddling gait -- a distinctive duck-like walk that may appear in childhood or later in life Hip dysplasia Spinal muscular atrophy
- Stance widens as they try to steady themselves
- Treatment Return to top Treatment depends on the cause of the disorder: Congenital kyphosis requires corrective surgery at an early age. Scheuermann's disease is initially treated with a brace and physical therapy. Occasionally surgery is needed for large (greater than 60 degrees), painful curves. Multiple compression fractures from osteoporosis can be left alone if there is no neurologic problems or pain, but the osteoporosis needs to be treated to help prevent future fractures. For debilitating deformity or pain, surgery is an option. Kyphosis caused by infection or tumor needs to be treated more aggressively, often with surgery and medications. Treatment for other types of kyphosis depends on the cause. Surgery may be necessary if neurological symptoms develop. Expectations (prognosis) Return to top Adolescents with Scheuermann's disease tend do well even if they need surgery, and the disease stops once they stop growing. If the kyphosis is due to degenerative joint disease or multiple compression fractures, correction of the defect is not possible without surgery, and improvement of pain is less reliable. Complications Return to top Disabling back pain Neurological symptoms including leg weakness or paralysis Decreased lung capacity Round back deformity
- There are three general causes of scoliosis: Congenital scoliosis is due to a problem with the formation of vertebrae or fused ribs during prenatal development. Neuromuscular scoliosis is caused by problems such as poor muscle control or muscular weakness or paralysis due to diseases such as cerebral palsy, muscular dystrophy, spina bifida, and polio. Idiopathic scoliosis is of unknown cause, and appears in a previously straight spine. Idiopathic scoliosis in adolescents is the most common type. Some people may be prone to the curving of the spine. Most cases occur in girls. Curves generally worsen during growth spurts. Scoliosis in infants and juveniles are less common. They commonly affect a similar number of boys and girls. Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. Untrained observers usually can't notice the curving. Routine scoliosis screening is now done in middle and junior high schools. Many cases, which previously would have gone undetected until they were more advanced, are now being caught at an early stage. There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation results. The greater the initial curve of the spine, the greater the chance the scoliosis will get worse after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) may cause breathing problems. Symptoms Return to top The spine curves abnormally to the side (laterally) Shoulders or hips appearing uneven Backache or low-back pain Fatigue Treatment depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do. Most cases of adolescent idiopathic scoliosis (less than 20 degrees) require no treatment, but should be checked often, about every 6 months. As curves get worse (above 25 to 30 degrees in a child who is still growing), bracing is usually recommended to help slow the progression of the curve. There are many different kinds of braces used. The Boston Brace, Wilmington Brace, Milwaukee Brace, and Charleston Brace are named for the centers where they were developed. Each brace looks different. There are different ways of using each type properly. The selection of a brace and the manner in which it is used depends on many factors, including the specific characteristics of your curve. The exact brace will be decided on by the patient and health care practioner. A back brace does not reverse the curve. Instead, it uses pressure to help straighten the spine. The brace can be adjusted with growth. Bracing does not work in congenital or neuromuscular scoliosis, and is less effective in infantile and juvenile idiopathic scoliosis. Curves of 40 degrees or greater usually require surgery because curves this large have a high risk of getting worse even after bone growth stops. Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is done through a cut in the back, on the abdomen, or beneath the ribs. A brace may be required to stabilize the spine after surgery.
- Each joint is in the book
- Extension Abduction Adduction Hyperextension Internal rotation External rotation Atrophy Hypertrophy
- The knee is flexed at 20–30 degrees with the patient supine.[2] The examiner should place one hand behind the tibia and the other grasping the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity.[3] The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement ("firm endpoint") while an ACL-deficient knee will demonstrate increased forward translation without a decisive 'end-point' - a soft or mushy endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL ("soft endpoint"), as does 10 mm of total anterior translation. An instrument called a "KT-1000" can be used to determine the magnitude of movement in mm. This test can be done in either an on-field evaluation in acute injury, or in a clinical setting when a patient presents for follow-up with knee pain.
- To perform the test, the knee is held by one hand, which is placed along the joint line, and flexed to complete flexion while the foot is held by the sole with the other hand. The examiner then places one hand on the medial side of the knee to provide a varus stress, pushing knee laterally. The other hand rotates the leg externally while extending the knee.[2] If pain or a "click" is felt, this constitutes a "positive McMurray test" for a tear in the medial meniscus.
- The Lachman test is a clinical test used to diagnose injury of the anterior cruciate ligament (ACL). It is recognized as reliable, sensitive, and usually superior to the anterior drawer test.[1] The knee is flexed at 20–30 degrees with the patient supine.[2] The examiner should place one hand behind the tibia and the other grasping the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity.[3] The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement ("firm endpoint") while an ACL-deficient knee will demonstrate increased forward translation without a decisive 'end-point' - a soft or mushy endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL ("soft endpoint"), as does 10 mm of total anterior translation. An instrument called a "KT-1000" can be used to determine the magnitude of movement in mm.