Chapter 52

1. Chapter 52 Assessment of the Musculoskeletal System

2. Skeletal System • Bone types • Bone structure • Bone function • Bone growth and metabolism affected by calcium and phosphorus, calcitonin, vitamin D, parathyroid hormone, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin

3. Bone Structure

4. Joints • Types include synarthrodial, amphiarthrodial, diarthrodial. • Structure synovial joint. • Subtyped by anatomic structure: • Ball-and-socket • Hinge • Condylar • Biaxial • Pivot

5. Structure Diarthrodial Joint

6. Muscular System Assessment • Patient history • Nutritional history • Family history and genetic risk • General inspection: • Posture and gait

7. Muscular System Assessment (Cont.)

8. Specific Assessments • Face and neck • Spine • Hand • Hip • Ankles, feet • Neurovascular assessment • Psychosocial assessment

9. Diagnostic Assessment • Laboratory tests—serum calcium and phosphorus, alkaline phosphatase, serum muscle enzymes • Radiographic examinations—standard radiography, bone density, tomography and xeroradiography, myelography, arthrography, and CT • Other diagnostic tests—bone and muscle biopsy

10. Electromyography • EMG aids in the diagnosis of neuromuscular, lower motor neuron, and peripheral nerve disorders; usually with nerve conduction studies. • Low electrical currents are passed through flat electrodes placed along the nerve. • If needles are used, inspect needle sites for hematoma formation.

11. Arthroscopy • Fiberoptic tube is inserted into a joint for direct visualization. • Patient must be able to flex the knee; exercises are prescribed for ROM. • Evaluate the neurovascular status of the affected limb frequently. • Analgesics are prescribed. • Monitor for complications.

12. Arthroscopy (Cont’d)

13. Other Tests • Bone scan • Gallium or thallium scan • Magnetic resonance imaging • Ultrasonography

14. Chapter 53 Care of Patients with Musculoskeletal Problems

15. Osteoporosis • Chronic metabolic disease, in which bone loss causes decreased density and possible fracture • Osteopenia (low bone mass), which occurs when osteoclastic activity is greater than osteoblastic activity

16. Osteoporosis (Cont’d)

17. Osteoporosis (Cont’d) • Etiology and genetic risk • Genetic considerations • Incidence/prevalence • Cultural considerations

18. Classification of Osteoporosis • Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. • Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility. • Regional osteoporosis occurs when a limb is immobilized.

19. Health Promotion/Illness Prevention • Teaching should begin with young women who begin to lose bone after 30 years of age. • The focus of osteoporosis prevention is to decrease modifiable risk factors. • Ensure adequate calcium intake. • Avoid sedentary lifestyle. • Continue program of weight-bearing exercises.

20. Assessment • Physical assessment • Psychosocial assessment • Laboratory assessment • Imaging assessment: • DXA • QCT • QUS

21. Osteoporosis: Interventions • Nutrition therapy • Exercise • Other lifestyle changes

22. Osteoporosis: Drug Therapy • Calcium and vitamin D supplements • Estrogen or hormone therapy • Bisphosphonates • Selective estrogen receptor modulators • Calcitonin • Other agents used with varying results

23. Osteoporosis: Surgical Interventions • Vertebroplasty • Kyphoplasty

24. Osteomalacia • Loss of bone related to vitamin D deficiency • Bone softens because of inadequate deposits of calcium and phosphorus in the bone matrix • Rickets

25. Collaborative Care • Assessment • The major treatment for osteomalacia is vitamin D

26. Paget’s Disease of the Bone • Chronic metabolic disorder in which bone is excessively broken down and reformed • Genetic considerations • Collaborative care: • Physical assessment • Diagnostic assessment

27. Paget’s Disease: Nonsurgical Management • Analgesics • Decrease bone resorption • Selected bisphosphonates • Calcitonin • Plicamycin • Diet therapy • Nonpharmacologic pain-relief measures

28. Paget’s Disease: Surgical Management • Tibial osteotomy • Partial or total joint replacement • Surgical decompression and stabilization of the spine

29. Osteomyelitis • Infection in bony tissue

30. Osteomyelitis: Collaborative Care • Assessment • Antibiotic therapy • Hyperbaric oxygen therapy • Surgical management: • Sequestrectomy • Microvascular bone transfers

31. Benign Bone Tumors • Often asymptomatic and may be discovered on routine x-ray or as a cause of pathologic fracture: • Chrondrogenic tumors—from cartilage • Osteogenic tumors—from bone • Fibrogenic tumors—from fibrous tissue; most commonly found in children

32. Interventions • Non-drug pain-relief measures • Drug therapy—analgesics, NSAIDs • Surgical therapy—curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis

33. Bone Cancer • Primary tumors • Metastatic lesions • Pathophysiology • Assessment • Nonsurgical management: • Drug therapy • Radiation therapy

34. Bone Cancer: Surgical Management • Preoperative care • Operative procedure • Postoperative care

35. Bone Cancer: Community-Based Care • Home care management • Health teaching • Health care resources

36. Disorders of the Hand • Dupuytren's contracture—slowly progressive contracture of the palmar fascia resulting in flexion of the fourth or fifth digit of the hand

37. Ganglion • Round, benign cyst often found on a wrist or foot joint or tendon

39. Disorders of the Foot • Hallux valgus • Hammertoe • Morton’s neuroma • Tarsal tunnel syndrome • Plantar fasciitis • Other problems of the foot

40. Foot

41. Scoliosis • Changes in muscles and ligaments on the concave side of the spinal column

43. Scoliosis (Cont’d) • Pathophysiology • History • Treatment of children • Treatment of adults

44. Progressive Muscular Dystrophies • Pathophysiology • Genetic considerations • Diagnosis • Management • Nursing interventions