The skeletal system has four components: bones, cartilage, tendons, and ligaments. It provides support, protection, movement, mineral homeostasis, blood cell production, and triglyceride storage. There are three types of muscle tissue: skeletal, smooth, and cardiac. Skeletal muscle is responsible for locomotion and other movements while cardiac muscle contracts the heart and smooth muscle regulates organs and blood vessels. Joints allow movement and are classified as fibrous, cartilaginous, or synovial joints which can be immovable, slightly movable, or freely movable. A variety of diagnostic tests assess the musculoskeleton including arthrocentesis, arthroscopy, bone density tests, bone scans, gallium/thall

1. ANATOMY AND PHYSIOLOGY
JOFRED M. MARTINEZ, RN, MAN
University of San Agustin Review Center
Iloilo City, Philippines

2. The skeletal system has four components:
bones, cartilage, tendons, and ligaments.
Functions
Support
Protection
Movement
Mineral homeostasis
Blood cell production
Triglyceride storage

3. Bone cells are categorized as osteoblasts, osteocytes, and osteoclasts.
Ossification or osteogenesis , is the formation of bone by osteoblasts.

4. Once an osteoblast becomes surrounded by bone matrix,
it is referred to as an osteocyte.

5. Osteoclasts are bone-destroying cells.

6. Bone Structures
 Compact (cortical) bone, forms the
outer shell of a bone, has a
densely packed, calcified
intercellular matrix.
 Cancellous (spongy) bone is found
in the interior of bones and is
composed of trabeculae, or
spicules.

7. Bones can be classified according to the amount of bone matrix
relative to the amount of space within the bone.
Spongy bone consists of
interconnecting rods or plates of
bone called trabeculae.

8. Compact bone consists mainly of osteons.
An osteon, or haversian system, consists of a single central canal, its
contents, and associated concentric lamellae and osteocytes.

9. Bone Shapes
Individual bones are classified
according to shape:
long, flat, short, or irregular

10. Bone Anatomy

11. Gross Anatomy

12. Factors Affecting Bone Growth
Minerals
 Calcium and phosphorus make bone
extracellular matrix hard.
 Magnesium helps form bone extracellular
matrix.
 Fluoride helps strengthen bone
extracellular matrix.
 Manganese activates enzymes involved in
synthesis of bone extracellular matrix.

13. Factors Affecting Bone Growth
Nutrition
 Vitamin A needed for the activity of
osteoblasts during remodeling of bone.
 Vitamin D helps build bone by increasing
absorption of calcium from
gastrointestinal tract into blood.
 Vitamin C is necessary for collagen
synthesis by osteoblasts.
 Vitamins K and B12 needed for synthesis of
bone proteins.

14. Factors Affecting Bone Growth
Hormones
 Growth hormone increases general tissue
growth.
 Insulin like growth factors (IGFs) promotes
normal bone growth.
 Thyroid hormone is required for normal
growth of all tissues, including cartilage.
 Insulin promotes normal bone growth by
increasing the synthesis of bone proteins.

15. Factors Affecting Bone Growth
Hormones
 Sex hormones (estrogens and
testosterone); stimulate osteoblasts and
promote the sudden “growth spurt” that
occurs during the teenage years.
 Parathyroid hormone (PTH) promotes bone
resorption by osteoclasts; enhances
recovery of calcium ions from urine;
promotes formation of the active form of
vitamin D (calcitriol).

16. Factors Affecting Bone Growth
Hormones
 Calcitonin (CT) Secreted by the thyroid
gland; inhibits bone resorption by
osteoclasts.

17. Factors Affecting Bone Growth
Exercise
 Weight-bearing activities stimulate
osteoblasts and, consequently, help build
thicker, stronger bones and retard loss of
bone mass that occurs as people age.

18. Bone Remodeling

19. Bone Healing

20. There are three types of muscle tissue: skeletal, smooth, and cardiac.
Functions
Movement of the body
Maintenance of posture
Respiration
Production of body heat
Communication
Constriction of organs and vessels
Contraction of the heart

21. The major characteristics of muscle tissue are
skeletal, smooth, and cardiac muscle.
 Skeletal muscle, with its associated connective tissue, constitutes
about 40% of the body’s weight.
Is responsible for locomotion, facial expressions, posture,
respiratory functions, and many other body movements.
 Cardiac muscle is found only in the heart, and its contractions
provide the major force for moving blood through the circulatory
system.

22. The major characteristics of muscle tissue are
skeletal, smooth, and cardiac muscle.
 Smooth muscle is found in the walls of hollow organs and tubes,
in the interior of the eye, and in the walls of blood vessels, among
other areas.
 Is responsible for propelling urine through the urinary tract,
mixing food in the stomach and the small intestine, dilating and
constricting the pupil of the eye, and regulating the flow of blood
through blood vessels.

23. Properties of Muscular Tissue
 Electrical excitability is the ability to respond to certain stimuli by
producing electrical signals called action potentials.
 Contractility is the ability of muscular tissue to contract forcefully
when stimulated by an action potential.
 Extensibility is the ability of muscular tissue to stretch without
being damaged.
 Elasticity is the ability of muscular tissue to return to its original
length and shape after contraction or extension.

24. Skeletal Muscle Structure
 Muscles are attached to
bones by tendons.
 Muscle contraction causes
most body movements by
pulling one of the bones
toward the other across a
movable joint.

25. Superficial Muscle Structure

26. Skeletal Muscle Structure
 A muscle is composed of
muscle fasciculi, each
surrounded by perimysium.
 At the level of the
perimysium, axons of
neurons branch, and each
branch extends to a muscle
fiber.

27. Parts of a Muscle
 The muscle fiber contains
several myofibrils.
 A single sarcomere of a
myofibril is composed of
actin myofilaments and myosin
myofilaments.

28. Joints and Movement
Joints are classified structurally as
fibrous, cartilaginous, or synovial.

29. Functional Classification of Joints
Type Description Examples
Synarthrosis Immovable joint Skull sutures
Epiphyseal plates
Joint between first rib and
manubrium of sternum
Amphiarthrosis Slightly movable joint Vertebral joints
Joint of the symphysis pubis
Diarthrosis Freely movable joint Joints of the extremities
Shoulder joints
Hip joints

30. Types of Synovial Joints

31. Types of Synovial Joints

32. Types of Synovial Joints

33. Range of Motion
 Active range of motion is the amount of movement accomplished
by contracting the muscles that normally act across a joint.
 Passive range of motion is the amount of movement accomplished
when the structures that meet at the joint are moved by an
outside force.

34. Types of Movement

35. Types of Movement

36. Types of Movement

37. Types of Movement

38. Types of Movement

39. Types of Movement

40. Types of Movement

41. Types of Movement

42. Types of Movement

43. Types of Movement

44. Aging and the Joints
SYSTEM STRUCTURAL CHANGES FUNCTIONAL CHANGES
Bones • Gradual, progressive loss
of bone mass after age 30
• Vertebrae collapse
• Bones fragile and prone to
fracture: vertebrae, hip, wrist
Muscles • Increase in collagen and
resultant fibrosis
• Muscles diminish in size
(atrophy); wasting
• Tendons less elastic
• Loss of strength and flexibility
• Weakness
• Fatigue
• Stumbling
• Falls

45. Aging and the Joints
SYSTEM STRUCTURAL CHANGES FUNCTIONAL CHANGES
Joints • Cartilage—progressive
deterioration
• Thinning of intervertebral
disks
• Stiffness, reduced flexibility, and
pain interfere with activities of
daily living
Ligaments • Lax ligaments (less-than-
normal strength;
weakness)
• Postural joint abnormality
• Weakness

46. References
1. LeMone, P. et al. (2011). Medical-Surgical Nursing: Critical Thinking
in Client Care. 5th Edition. New Jersey: Pearson Education, Inc.
2. Seeley. R. et al. (2014). Seeley’s Anatomy and Physiology. 10th
Edition. New York: McGraw-Hill Companies, Inc.
3. Tortora, G. & Derrickson, B. (2009). Principles of Anatomy and
Physiology. 12th Edition. New Jersey: John Wiley and Sons, Inc.

47. ASSESSING MUSCULOSKELETAL FUNCTION
JOFRED M. MARTINEZ, RN, MAN
University of San Agustin Review Center
Iloilo City, Philippines

48. Diagnostic Tests
Test Purpose Nursing Interventions
Arthrocentesis Obtain synovial fluid
from a joint for
diagnosis or to
remove excess fluid.
After the procedure, apply a
compression dressing and
tell the patient to report any
bleeding and leakage of
fluid.

49. Diagnostic Tests
Test Purpose Nursing Interventions
Arthroscopy  Used to perform
surgery and diagnose
diseases of the patella,
meniscus, and synovial
and extrasynovial
membranes.
 Fluid may be drained
from the joint and
tissue removed for
biopsy.
 If general anesthesia is used,
tell the patient not to eat or
drink fluids after midnight prior
to the procedure.
 Following the procedure,
assess for bleeding and
swelling, apply ice to the area if
prescribed, and instruct patient
to avoid excessive use of the
joint for 2 to 3 days.

50. Diagnostic Tests
Test Purpose Nursing Interventions
Bone density (BD)
 Dual energy x-ray
absorptiometry
(DEXA)
 Quantitative
ultrasound (QUS)
 Bone mineral density
(BMD)
 Bone absorptiometry
 Evaluate bone mineral
density and to
evaluate degree of
osteoporosis. DEXA
can calculate the size
and thickness of bone.
 Normal Value: 1
standard deviation
below peak bone
mass.
 Instruct patient to remove
all metal objects from the
area to be scanned.

51. Diagnostic Tests
Test Purpose Nursing Interventions
Bone scan
(Nuclear medicine
scans)
 Uptake is increased in
osteomyelitis,
osteoporosis, cancers
of the bone, and in
some fractures.
 Uptake is decreased
in avascular necrosis.
 No special preparation is
needed; tell patient to
increase oral fluids after
the test to aid in
excretion of the
radioisotope.

52. Diagnostic Tests
Test Purpose Nursing Interventions
Gallium/Thallium
Scans
 Gallium concentrates
in areas of tumors,
inflammation, and
infections.
 Thallium detects
osteosarcoma.
 Check if facility
recommends that
children and pregnant
women stay a few feet
away from the patient for
the first 48 hours

53. Diagnostic Tests
Test Purpose Nursing Interventions
Computed
tomography (CT)
scan—long
bones and
joints, spine
 Provides a three
dimensional picture
used to evaluate
musculoskeletal trauma
and bony abnormalities.
 CT of the spine can
identify tumors, cysts,
vascular malformations,
and herniated
intervertebral disk.
 If contrast dye is used,
assess for allergy to iodine,
seafood, or x-ray dye.
 Assess medications: oral
hypoglycemic agents are
contraindicated for use with
iodinated contrast.
 Have spine x-rays available.
If scheduling myelogram
and spine CT, patient should
have myelogram first.

54. Diagnostic Tests
Test Purpose Nursing Interventions
Computed
tomography
(CT) scan—
long bones and
joints, spine
 If long-bone and joint CT,
nuclear medicine tests to
locate “hot spots” should be
done before CT.
 After the test, if contrast dye
was used, monitor for
delayed allergic reaction
(rash, itching, headache,
vomiting) and instruct patient
to increase fluid intake.

55. Diagnostic Tests
Test Purpose Nursing Interventions
Electromyogram
(EMG)
 Measures the
electrical
activity of
skeletal
muscles at rest
and during
contraction.
 Tell the patient not to drink fluids
containing caffeine or to smoke for 3
hours before the test, and not to take
medications such as muscle
relaxants, anticholinergics, or
cholinergics.
 If serum enzymes such as SGOT, CPK,
or LDH are ordered, the specimen
should be drawn before the EMG or
5 to 10 days after the EMG.

56. Diagnostic Tests
Test Purpose Nursing Interventions
Magnetic
resonance
imaging (MRI)
 Used in diagnosis
and evaluation of
avascular necrosis,
osteomyelitis,
tumors, disk
abnormalities, and
tears in ligament or
cartilage.
 Inform patient of need to lie still
during the examination.
 Assess for any metallic implants
(such as pacemakers, clips on
brain aneurysms, body piercings,
tattoos, shrapnel). If present,
notify imaging physician.
 Remove transdermal medication
patches (both OTC and
prescribed) unless otherwise
ordered (FDA, 2009).

57. Diagnostic Tests
Test Purpose Nursing Interventions
Magnetic
resonance
imaging (MRI)
 Replace the patch following the
procedure.
 Tell the patient to inform the staff
about the patch when making the
appointment and when completing the
admission information.
 Ask if patient is pregnant; if so the test
is not performed. Ask about
claustrophobia; if a problem request
patient to ask for a relaxing medication
to take prior to the MRI.

58. Diagnostic Tests
Test Purpose Nursing Interventions
Skeletal x-ray  Identify and
evaluate bone
density and
structure.
 Ask women if they are pregnant;
x-rays should be avoided during
the first trimester.
 No special preparation is
needed for skeletal x-rays.

59. Diagnostic Tests
Test Purpose Nursing Interventions
Somatosensory
evoked potential
(SSEP)
 Measures nerve conduction
along pathways to evaluate
evoked potential of muscle
contractions.
 Used to identify dysfunction
of lower motor neurons as
well as muscle disease.
 No special
preparation is
needed.

60. Diagnostic Tests
Test Purpose Nursing Interventions
Bone or Muscle
Biopsy
 Involves needle
aspiration (closed) or
surgical extraction
(open) of bone or
muscle tissue.
 Monitor site of biopsy
for bleeding.
 Provide normal wound
care for open biopsy.
 Perform neurovascular
assessments as
needed.

61. Blood Tests
Test Purpose Normal Value
Alkaline
phosphatase
(ALP)
Identify bone diseases. Increased in
bone cancer, Paget’s disease, healing
fractures, rheumatoid arthritis,
osteoporosis.
42–136 unit/L ALP1
20–130 unit/L ALP2
(increases slightly with aging)
Calcium (Ca) Monitor calcium levels and detect
calcium imbalances.
Decreased with lack of calcium and
vitamin D intake, and malabsorption
from the gastrointestinal tract. Increased
in bone cancer and multiple fractures.
4.5–5.5 mEq/L or
9–11 mg/dL (serum)

62. Blood Tests
Test Purpose Normal Value
Phosphorus (P),
phosphate (PO4)
To assess phosphorus levels.
Increased with bone tumors
and healing fractures.
1.7–2.6 mEq/L or
2.5–4.5 mg/dL
Rheumatoid
factor (RF)
To diagnose rheumatoid arthritis
(RA) (positive for RA at > 1:80).
Also increased in lupus
erythematosus and scleroderma.
< 1:20 titer

63. Blood Tests
Test Purpose Normal Value
Uric acid Diagnose and monitor the
treatment of gout.
Panic level considered > 12 mg/dL.
Male: 3.5–8.0 mg/dL
Female: 2.8–6.8 mg/dL
Human leukocyte
antigen
Diagnose diseases such as juvenile
RA or ankylosing spondylitis..
Match or no match;
no normal values (HLA)
Creatine kinase
(CK)
Diagnose muscle trauma or
disease.
Increased in muscular dystrophy
and traumatic injuries (specifically,
CPK-MM isoenzyme).
94%–100%

64. Subjective Health Assessment
Category What to Ask Rationale
Demographics Age, gender,
socioeconomic status
Increased age, being female, and
lower socioeconomic status increase
risk of musculoskeletal
injury/problems.
Occupation Enables nurse to begin planning for
discharge teaching if the patient has
to alter his or her employment.

65. Subjective Health Assessment
Category What to Ask Rationale
Previous Health
History
Allergies Prevents exposure to medication or
compounds used in diagnostic tests,
treatments, and therapies.
Activities patient
participates in
Provides information regarding the
level of activity the patient had before
the concern.
Smoking and a sedentary lifestyle are
risk factors for musculoskeletal
problems.

66. Subjective Health Assessment
Category What to Ask Rationale
Previous Health
History
Diet history Dietary intake such as calcium and
vitamin D influences some
musculoskeletal disorders.
Family history Some musculoskeletal conditions have
genetic and familial tendencies.

67. Subjective Health Assessment
Category What to Ask Rationale
History of Injury
or Present
Concern
History of the
injury (if there was
one)
Provides information that helps in the
diagnosis of the problem, as well as
making you aware of possible
complications of the injury.
Pain (use pain
assessment scale)
Provides information about severity of
the condition and effectiveness of the
treatment and therapy.

68. Subjective Health Assessment
Category What to Ask Rationale
Psychosocial
Assessment
Determine if deformities,
changes in body image,
self-concept,
socialization, or
employment are present.
The patient may need assistance
with strategies to cope with the
stress of a possible chronic
musculoskeletal condition.
Determine coping skills. Some musculoskeletal conditions
require lifestyle alterations that
can cause increased stress and
difficulties in coping.

69. Objective Health Assessment
Category What to Ask Rationale
Physical
Examination
Inspect, palpate, and
observe range of motion
(ROM) of affected areas.
Altered gait, tone, size, shape, posture,
contractures, deformities, ROM, pain,
and effects on ADLs can be determined.
Assess color, warmth,
circulation, and
movement of affected
areas.
Nerve function, sensation, movement,
weakness, and the potential
development of compartment
syndrome can be determined.
Palpate all pulses below
involved area.
Alterations may indicate altered vascular
integrity of affected area or demonstrate
developing compartment syndrome.

70. Objective Health Assessment

71. Objective Health Assessment

72. Muscle Grading Scale
Scale Assessment Description
0 (No visible) contraction; paralysis
1 Can feel contraction of muscle but there is no movement
of limb
2 Passive ROM
3 Full ROM against gravity
4 Full ROM against some resistance
5 Full ROM against full resistance

73. Neurovascular Assessment
Monitor Report
Color Pallor, cyanosis, redness, or discoloration
Temperature Unusual coolness or warmth
Pain Pain that is worse on passive motion; pain that no longer
responds to analgesics
Movement Alterations in movement
Sensation Alterations in feeling; tingling or paresthesias
Pulses Diminished or absent distal pulses
Capillary refill Nail bed that does not blanch in 3–5 seconds

74. References
1. LeMone, P. et al. (2011). Medical-Surgical Nursing: Critical
Thinking in Client Care. 5th Edition. New Jersey: Pearson
Education, Inc.
2. Smeltzer, S. C. et al. (2010). Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing. 12th Edition. Philadelphia: Lippincott
Williams and Wilkins.
3. Williams. L. S. & Hopper, P. D. (2011). Understanding Medical-
Surgical Nursing. 5th Edition. Philadelphia: F. A. Davis Company