NCLEX: Musculoskeletal disorders

A look at musculoskeletal disorders

Be prepared to call on the full range of your nursing skills when providing musculoskeletal care. Why? Because some musculoskeletal problems are subtle and difficult to assess, whereas others are obvious, even traumatic, affecting the patient emotionally as well as physically.

Anatomy and physiology

The three main parts of the musculoskeletal system are the bones, joints, and muscles.

Bones

The 206 bones of the skeleton support the organs and tissues and form the body’s framework. The bones also serve as storage sites for minerals and produce blood cells.

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Bone function
Bones perform anatomic (mechanical) and physiologic functions, including:
• stabilizing and supporting the body
• providing a surface for muscle, ligament, and tendon attachment
• moving through “lever” action when contracted
• producing red blood cells (RBCs) in the bone marrow (hematopoiesis)
• storing mineral salts, including about 99% of the body’s calcium
• protecting internal tissues and organs (for example, the 33 vertebrae surrounding and protecting the spinal cord).

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Joints

The junction of two or more bones is called a joint. Joints stabilize the bones and allow a specific type of movement. There are two types of joints:

  • nonsynovial
  • synovial.

In nonsynovial joints, the bones are connected by fibrous tissue or cartilage. They may be immovable, like the sutures in the skull, or slightly movable, like the vertebrae.

Free to be…a synovial joint

Synovial joints move freely. The bones are separate from each
other and meet in a cavity filled with synovial fluid, a lubricant.
A layer of resilient cartilage covers the surfaces of opposing bones.
This cartilage cushions the bones and allows full joint movement
by making the surfaces of the bones smooth.

Some popular joints

Synovial joints come in several types, including ball-and-socket joints and hinge joints.
Ball-and-socket joints (found in the shoulders and hips) allow for:

  • flexion (bending, which decreases the joint angle)
  • extension (straightening, which increases the joint angle)
  • adduction (moving toward midline)
  • abduction (moving away from midline).

These joints also rotate in their sockets and are assessed by their degree of internal and external rotation. Hinge joints, such as the knee and elbow, usually move in flexion and extension only.

We’ve got you surrounded

Synovial joints are surrounded by a fibrous capsule that stabilizes the joint structures. The capsule also surrounds the joint’s ligaments (the tough, fibrous bands that join one bone to another).

Muscles

Skeletal muscles are groups of contractile cells or fibers. These fibers contract and produce skeletal movement when they receive a stimulus from the central nervous system (CNS). The CNS is responsible for involuntary and voluntary muscle function. Skeletal muscles also maintain posture and generate body heat.

Tough guy, huh?

Tendons are tough, fibrous portions of muscle that attach the muscles to bone. Bursae — sacs filled with friction reducing synovial fluid — are located in areas of high friction such as the knee.

Muscle movements
Skeletal muscle allows several types of movement. A muscle’s functional name comes from the type of movement it permits. For example, a flexor muscle permits bending (flexion), an abductor muscle permits movement away from a body axis (abduction), and a circumductor muscle allows a circular movement (circumduction).

Assessment

Your sharp assessment skills will help you uncover musculoskeletal abnormalities and evaluate the patient’s ability to perform activities of daily living (ADLs). However, because many musculoskeletal injuries are emergencies, you might not have time for a thorough patient history and physical examination.

Patient history

If possible, question the patient about his current illness, past illnesses, medications, and family and social history.

Current illness
Ask the patient about his chief complaint. Patients with joint injuries usually complain of pain, swelling, or stiffness; those with bone fractures have sharp pain when they move the affected area. Muscular injury is commonly accompanied by pain, swelling, and weakness.
Ask the patient if his ability to carry out ADLs is affected. Is pain more intense or has he noticed grating sounds when he moves certain parts of his body? Does he use ice, heat, or other remedies to treat the problem? Is pain worse in the morning?

Past health history
Inquire whether the patient has ever had gout, arthritis, tuberculosis (TB), or cancer, which may have bony metastases. Has he been diagnosed with osteoporosis?

Info on injuries

Ask whether he has had a recent blunt or penetrating trauma. If so, how did it happen? For example, did he suffer knee and hip injuries after being hit by a car, or did he fall from a ladder and land on his coccyx? This information will help guide your assessment and predict hidden trauma.
Also ask the patient whether he uses an assistive device, such as a cane, walker, or brace. If so, watch him use the device to assess how he moves.

Medications
Question the patient about the medications he takes regularly. Many drugs can affect the musculoskeletal system. Corticosteroids, for example, can cause muscle weakness, myopathy, osteoporosis, pathologic fractures, and avascular necrosis of the heads of the femur and humerus.

Family history
Ask the patient if a family member suffers from joint disease. Disorders with a hereditary component include:
• gout
• osteoarthritis of the interphalangeal joints
• spondyloarthropathies (such as ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, and enteropathic arthritis)
• rheumatoid arthritis.

Social history
Ask the patient about his job, hobbies, and personal habits. Knitting, playing football or tennis, working at a computer, or doing construction work can all cause repetitive stress injuries or injure the musculoskeletal system in other ways. Even carrying a heavy knapsack or purse can cause injury or increase muscle size.

Physical examination

Perform a head-to-toe assessment, simultaneously evaluating the muscle and joint function of each body area. You’ll need to observe the patient’s posture, gait, and coordination, and inspect and palpate his muscles, joints, and bones.

Inspecting posture, gait, and coordination
Assessment begins the instant you see the patient. Good observation skills enable you to obtain a wealth of information about approximate muscle strength, facial muscle movement, body symmetry, and obvious physical or functional deformities or abnormalities. Assess the patient’s overall body symmetry as he assumes different postures and makes diverse movements. Note marked dissimilarities in side-to-side size, shape, and motion.

Posture
Posture is the attitude, or position, that body parts assume in relation to other body parts and to the external environment. Assessing posture includes inspecting spinal curvature and knee positioning.

Stand by your man (and woman)

To assess spinal curvature, instruct the patient to stand as straight as possible. Then stand at his side, behind his back, and in front of him, in that order, inspecting the spine for alignment and the shoulders, iliac crests, and scapulae for symmetry of position and height. When the patient stands, his thoracic spine should have a convex curvature and his lumbar spine should have a concave curvature. Next, have the patient bend forward from the waist with his arms relaxed and dangling. Stand behind him and inspect the straightness of his spine, noting flank and thorax position and symmetry.
Other normal findings include:
• a midline spine without lateral curvatures
• a concave lumbar curvature that changes to a convex curvature in the flexed position

• iliac crests, shoulders, and scapulae at the same horizontal level.

Gait
Direct the patient to walk away from you, turn around, and then walk back. Observe his posture, movement (such as pace and length of stride), foot position, coordination, and balance.

Smooth walker

Normal findings when walking include smooth, coordinated movements, the head leading the body when turning, and erect posture with approximately 2 to 4 (5 to 10 cm) of space between the feet. Be sure to remain close to an elderly or infirm patient and be ready to help if he should stumble or start to fall.

Coordination
Evaluate how well a patient’s muscles produce movement. Coordination results from neuromuscular integrity; a lack of muscular or nervous system integrity, or both, impairs the ability to make voluntary and productive movements.

You’re so fine and gross

Assess gross motor skills by having the patient perform body action involving the muscles and joints in natural directional movements, such as lifting the arm to the side and other range-ofmotion (ROM) exercises. Assess fine motor coordination by asking the patient to pick up a small object from a desk or table.

Inspecting and palpating muscles
Expect to perform inspection and palpation simultaneously during the musculoskeletal assessment. You’ll evaluate muscle tone, mass, and strength. Palpate the muscles gently, never forcing movement when the patient reports pain or when you feel resistance. Watch the patient’s face and body language for signs of discomfort — he may suffer silently.

Tone and mass
Muscle tone is the consistency or tension in the resting muscle. Test it by palpating a muscle at rest and by performing passive ROM exercises. To palpate a muscle at rest, feel from the muscle attachment at the bone to the edge of the muscle. A relaxed muscle should feel soft, pliable, and nontender; a contracted muscle should feel firm.

Check out those muscles

Muscle mass is the size of a muscle. Assessment of muscle mass usually involves measuring the circumference of the thigh, calf, and upper arm. When measuring, mark landmarks with a pen to make sure you’re measuring at the same location on each side of the body.

Strength and joint ROM
Assessing joint ROM tests the joint’s function. Assessing muscle strength against resistance tests the function of the muscles surrounding the joint.

Inspecting and palpating joints and bones
When evaluating joint and bone characteristics and joint ROM, never force joint movement if you feel resistance or if the patient complains of pain.

Departures from the norm

Deviations include pain, swelling, stiffness, deformities, altered ROM, crepitation (a grating sound or sensation accompanying joint movement), ankylosis (joint fusion or fixation), and contracture (muscle shortening).

Cervical spine
Have the patient sit or stand. Inspect the cervical spine from behind, from the side, and while facing the patient.

Drawing the line

Observe the alignment of the head with the body. The nose should be in line with the midsternum and extend beyond the shoulders when viewed from the side. The head should align with the shoulders. Typically, the seventh cervical and first thoracic vertebrae appear more prominent than the others.

Clavicles
With the patient sitting or standing, inspect and palpate the length of the clavicles, including the sternoclavicular and acromioclavicular joints. Normal findings include firm, smooth, continuous bones.

Scapulae
To inspect and palpate the scapulae, sit directly behind the patient as he sits with his shoulders thrust backward. Usually, the scapulae are located over thoracic ribs two through seven. Check for an equal distance from the medial scapular edges to the midspinal line.

Ribs
Have the patient remain sitting. After assessing the scapulae, inspect and palpate the anterior, posterior, and lateral surfaces of the ribs. Normal findings include firm, smooth, continuous bones.

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Shoulders
With the patient still sitting, palpate the moving joints for crepitus. Inspect the skin overlying the shoulder joints for erythema, masses, or swelling.

Introducing the Ducts, Ad and Ab

Next, palpate the acromioclavicular joint and the area over the greater humeral tuberosity. Ask the patient to stand. Have him hold his arm at his side and then adduct his arm. Next, place your thumb on the anterior portion of the patient’s shoulder joint and your fingers on the posterior portion of the shoulder joint. Ask the patient to abduct his arm. Palpate the shoulder joint as he does so.

Stand and rotate

Now stand behind the patient. With your fingertips placed over the greater humeral tuberosity, instruct him to rotate each shoulder internally by moving the corresponding arm behind his back. This allows you to palpate a portion of the musculotendinous rotator cuff as well as the bony structures of the shoulder joint.

Elbows
With the patient sitting or standing, inspect joint contour and skin over each elbow. Palpate the elbows at rest and during movement.

Wrists
With the patient sitting or standing, inspect the wrists for masses, erythema, skeletal deformities, and swelling. Palpate the wrist at rest and during movement by gently grasping it between your thumb and fingers.

Fingers and thumbs
With the patient sitting or standing, inspect the fingers and thumbs of each hand for nodules, erythema, spacing, length, and skeletal deformities. Palpate the fingers and thumbs at rest and during movement.

Thoracic and lumbar spine
In addition to evaluating the curvatures of the thoracic and lumbar spine during the postural assessment, you’ll need to palpate the length of the spine for tenderness and vertebral alignment. With the patient standing, check for tenderness, percuss each spinous process (directly over the vertebral column) with the ulnar side of your fist. Note whether the patient can move with a full ROM while maintaining balance, smoothness, and coordination.

Hips and pelvis
With the patient sitting or standing, inspect and palpate over the bony prominences of the hips and pelvis: iliac crests, symphysis pubis, anterior spine, ischial tuberosities, and greater trochanters. Palpate the hip at rest and during movement.

Knees
Inspect the knees with the patient seated. Palpate the knee at rest and during movement. Inspect and palpate the pop liteal spaces behind the knee joint. Knee movements should be smooth.

Ankles and feet
With the patient sitting, inspect and palpate the ankles and feet at rest and during movement.

Toes
The patient may be sitting or lying supine for toe assessment. Inspect all toe surfaces. Palpate the toes at rest and during movement.

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