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Review of Human SkeletalReview of Human SkeletalAnatomyAnatomy
Mark Anthony R. Rivera, MD RN CST
Lecturer, College of Nursing
Our Lady of Fatima University
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Assessment of the
Musculoskeletal SystemMusculoskeletal System
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The Body Axis
The body is made up of the skull, vertebralcolumn, ribs, and coccyx (tailbone)
Skull is made up of the cranium, which
protects the brain, and the face. Vertebral column is the backbone. It has
33 vertebrae
Vertebrae are small, rigid bones thatstack together
The ribs protect the heart and lungs. Thereare 12 pairs.
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Arm
At the tips of your fingers are the phalanges.
Long, slender, lightweight.
Phalanges are connected to metacarpal bones.
Metacarpals are framework of the palm.
Metacarpals branch off from the carpal bones.
8 of them; pebble-ish
The carpal bones are below the ulna and the radius.
If your palm is face-up and your arm extended, your elbow
is your ulna. The ulna and the radius are connected to the humerus.
The humerus in turn connects to the scapula.
The scapula is held in place by muscles.
The scapula is then connected to the clavicle, or collarbone.
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Legs
At the tips of your toes are the phalanges.
These connect to the metatarsals.
Which in turn connect to the tarsals.
7 tarsals, only 1 is heel.
Connected to the tarsals are the tibia and fibula.
Tibia is the shin bone.
At the knee, the tibia and fibula are separated from the femur by a large section of cartilage.
On this cartilage rests the patella. The femur is then connected to the coxal bone, which is
connected to the sacrum
Femur is the largest bone in the body.
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Skeletal System
Bone types Bone structure Bone function
Bone growth and metabolism
affected by:1. calcium and phosphorous,2. calcitonin,3. vitamin D,4. parathyroid hormone,5. growth hormone,6. glucocorticoids,7. estrogens and androgens,8. thyroxine, and
9. insulin
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Bones
Support the body and anchor muscles.
Ligaments link bones to other bones.
Tendons link bones to muscle
Two types of bones Compact Bone
Spongy Bone
Inside bones is a central shaft. This is the marrowcavity where fat is stored.
Bone matrixes contain the bones proteins andminerals. These heal bone and maintain healthiness.
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2 Major Types of Bone
Compact
Has few and very smallspaces inside.
Made of osteons.
Spongy
Has many largespaces. It contains redmarrow where redblood cells are made.
Made of trabeculae.
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Joint types
Ball and socket
Pivot
Saddle
Ellipsoid
Hinge
Plane
Arm
Neck
Thumb
Knuckles
Knee
Ankle
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MUSCULAR SYSTEMMUSCULAR SYSTEM
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Muscular System
Structure
Function
Supporting structures
Musculoskeletal changes associated with aging
Cultural considerations
Movements to
know!
Know aging changes vs.
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List of major muscles
Biceps brachiiInner armTriceps brachiiBack of armDeltoidUpper armTrapeziusBase of neckScientific NameCommon Name
Biceps femorisBack part of the upper legSartoris and Rectus femorisFront part of the upper legGluteus maximusButtAbdominal musclesStomachLatissimus dorsiBack
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Muscles
In humans with hard skeletons, muscles arein antagonistic pairs
e.g. shin and calf muscles
The skeletal muscles are muscles that areattached to bones. These move the skeleton.
Made of muscle fibers, multi-nuclei cells.
The plasma membranes enclose longbundles called fibrils.
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Muscles Cont.
They work by shortening (contracting) andlengthening (flexing)
The energy is supplied my mitochondria in
the fibrils. Muscle contraction is called Sliding
Filament Mechanism, where filaments incells slide past each other.
Cardiac muscle is electrically connected.
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Different Types
Smooth
Found in hollowbody organs likedigestive tractand bloodvessels.
Have 1 nucleus.
Skeletal
Composed of long fibers.
Controlsvoluntary
movement.
Cardiac
Central nuclei.
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Muscle energy
The Immediate Energy System is a quick blast of muscle power. This uses fast-twitch fibers.
The Glycotic Energy System splits glucose byglycolysis in the muscles.
The Oxidative Energy System (Aerobic Energy System)is for prolonged muscle use, like marathons. This usesslow-twitch fibers.
Slow-twitch fibers are packed with mitochondriaand myoglobin.
Fast oxidative-glycolytic muscle fibers are moderatelypowerful and last for a moderate amount of time.
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Assessments
Family history and genetic risk
Personal history
Dietary history
Socioeconomic status and ability to afford food
Current health problems including obesity
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Physical Assessment
General inspection
Posture
Abnormality in gait such as antalgic gait or lurch
Goniometer, which provides a measure of ROM Head and neck: evaluate the temporomandibular joints
Spine: lordosis, scoliosis
Upper extremities Lower extremities
)
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Diagnostic Assessment
Laboratory tests: serum calcium andphosphorus, alkaline phosphatase, serummuscle enzymes
Radiographic examinations: standardradiography, tomography and xeroradiography,myelography, arthrography, and CT
Other diagnostic tests: bone and muscle biopsy
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Arthroscopy
Fiberoptic tube is insertedinto a joint for directvisualization.
Client must be able to flexthe knee; exercises areprescribed for ROM.
Evaluate theneurovascular status of
the affected limbfrequently.
Analgesics areprescribed.
Monitor for complications.
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Other Tests
Bone scan
Gallium or thallium scan
Magnetic resonance imaging
Ultrasonography
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Osteoporosis
Metabolic disease, in which bone demineralizationresults in decreased density and subsequent fractures
Osteopenia (low bone mass), which occurs when thereis a disruption in the bone remodeling process
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Classification of Osteoporosis
Generalized osteoporosis occurs mostcommonly in postmenopausal women and menin their 60s and 70s.
Secondary osteoporosis results from anassociated medical condition such ashyperparathyroidism, long-term drug therapy,long-term immobility.
Regional osteoporosis occurs when a limb isimmobilized.
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Health Promotion/Illness Prevention
Ensure adequate calcium intake.
Avoid sedentary life style.
Continue program of weight-bearing exercises.Unchangeable risk factors for osteoporosis include female
gender, older age, small or thin body size, Caucasian and Asian
ethnicity, and family history of fractures.
Modifiable risk factors include a diet low in calcium and vitamin
D, use of certain medications, an inactive lifestyle or extended
bed rest, cigarette smoking, and excessive alcohol
consumption.
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Assessment
Physical assessment
Psychosocial assessment
Laboratory assessment
Radiographic assessment
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Drug Therapy
Hormone replacement therapy Parathyroid hormone
Calcium and vitamin D
Bisphosphonates
Selective estrogen receptor modulators
Calcitonin Other agents used with varying results
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Fall Prevention
Hazard-free environment
High-risk assessment through programs such asFalling Star protocol
Hip protectors that prevent hip fracture in case of a fall
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Flexibility and Strength
Chronic Health Conditions-HTN
Cardiac Arrhythmiasperipheral neuropathies
FallContributors
Uneven surfacesNo HandrailsBad lighting
Slick Surfaces
Outdoors
Poor LightingClutter
Extension CordsUnstable Handrails
Scatter rugsPetsIndoors
Medications
HealthConditions
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Others
Exercise
Pain man agement
Orthotic devices
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Osteomyelitis
Osteomyelitis is an acute or chronic inflammatory processof the bone and its structures secondary to infection withpyogenic organisms.
Infection of bone with rich vascular supply frombacteremia, UTI, long term IV caths, Salmonella from GI,poor dental hygiene, MRSA
Trauma admits bacteria such as Pseudomonas directly.
Acute -> high temp, swelling, bone pain
Chronic -> skin ulceration, sinus tract, local pain, drainage
AB Tx IV, Infection control, > 3 months, surg debridementor bone grafts, amputation.
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Padgets Disease
Metabolic disorder of bone remodeling in whichbone deposits are weak, enlarged anddisorganized.
2nd most common bone disease in elderly.
Cause unknown but may be latent viralappearing > 80 yrs.
80% asymptomatic; affects bone in skull,
vertebrae, long bones, hip joint etc. Tx- symptomatic for pain- NSAIDS, calcitonin,
Fosamax.
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Classification of Fractures
A fracture is a break or disruption in the continuityof a bone.
Types of fractures include:
Complete
Incomplete
Open or compound
Closed or simple
Pathologic (spontaneous) Fatigue or stress
Compression
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Stages of Bone Healing
Hematoma formation within 48 to 72 hr after injury
Hematoma to granulation tissue
Callus formation
Osteoblastic proliferation
Bone remodeling
Bone healing completed within about 6 weeks;up to 6 months in the older person
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Acute Compartment Syndrome
Serious condition in whichincreased pressure withinone or more compartmentscauses massivecompromise of circulation tothe area
Prevention of pressurebuildup of blood or fluidaccumulation
Pathophysiologic changessometimes referred to asischemia-edema cycle
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Emergency Care
Within 4 to 6 hr after the onset of acutecompartment syndrome, neuromuscular damageis irreversible; the limb can become uselesswithin 24 to 48 hr.
Monitor compartment pressures.
Fasciotomy may be performed to relievepressure.
Pack and dress the wound after fasciotomy.
P ibl R lt f A t C t t
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Possible Results of Acute CompartmentSyndrome
Infection
Motor weakness
Volkmanns contractures
Myoglobinuric renal failure, known asrhabdomyolysis
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Other Complications of Fractures
Shock Fat embolism syndrome: serious complication
resulting from a fracture; fat globules arereleased from yellow bone marrow intobloodstream
Venous thromboembolism
Infection
Ischemic necrosis Fracture blisters, delayed union, nonunion,
and malunion
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Musculoskeletal Assessment
Change in bone alignment Alteration in length of extremity
Change in shape of bone
Pain upon movement Decreased ROM
Crepitation
Ecchymotic skin Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site
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Special Assessment Considerations
For fractures of the shoulder and upper arm,assess client in sitting or standing position.
Support the affected arm to promote comfort.
For distal areas of the arm, assess client in asupine position.
For fracture of lower extremities and pelvis,
client is in supine position.
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Casts
Rigid device that immobilizes the affected body part whileallowing other body parts to move
Cast materials: plaster, fiberglass, polyester-cotton
Types of casts for various parts of the body: arm, leg,brace, body
Cast care and client education
Cast complications: infection, circulation impairment,peripheral nerve damage, complications of immobility
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Operative Procedures
Open reduction with internalfixation (ORIF)
External fixation
Postoperative care: similar to thatfor any surgery; certain
complications specific to fracturesand musculoskeletal surgeryinclude fat embolism and venousthromboembolism
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Procedures for Nonunion
Electrical bone stimulation
Bone grafting
Bone banking
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Acute Pain
Interventions include: Reduction and immobilization of fracture
Assessment of pain
Drug therapy: opioid and nonopioid drugs
Complementary and alternative therapies: ice,heat, elevation of body part, massage, baths,back rub, therapeutic touch, distraction, imagery,music therapy, relaxation techniques
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Risk for Infection
Interventions include: Apply strict aseptic technique for dressing
changes and wound irrigations.
Assess for local inflammation Report purulent drainage immediately to
health care provider.
Assess for pneumonia and urinary tractinfection.
Administer broad-spectrum antibioticsprophylactically.
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Impaired Physical Mobility
Interventions include: Use of crutches to promote mobility
Use of walkers and canes to promote mobility
Imbalanced Nutrition: Less Than Body
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Imbalanced Nutrition: Less Than BodyRequirements
Interventions include: Diet high in protein, calories, and calcium,
supplemental vitamins B and C
Frequent small feedings and supplements of high-protein liquids
Intake of foods high in iron
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Fractures of the Hip
Intracapsular or extracapsular Treatment of choice: surgical repair, when possible, to allow the
older client to get out of bed
Open reduction with internal fixation
Intramedullary rod, pins, a prosthesis, or a fixed sliding plate
Prosthetic device
NNormal --------------------------------- Fracture-------------------------- ORIF
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Fractures of the Pelvis
Associated internal damage the chief concern infracture management of pelvic fractures
Nonweight-bearing fracture of the pelvis
Weight-bearing fracture of the pelvis
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Compression Fractures of the Spine
Most are associated with osteoporosis rather than acute spinal injury.
Multiple hairline fractures result when bone
mass diminishes. Nonsurgical management includes bedrest,
analgesics, and physical therapy.
Minimally invasive surgeries are vertebroplastyand kyphoplasty, in which bone cement isinjected.
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Prostheses Devices to help shape and
shrink the residual limb andhelp client readapt
Wrapping of elasticbandages
Wrap residual limb in afigure eight pattern, nota circular one. Wrappingin a circular pattern willcut off the blood flowand cause harm.
The goal of wrapping is
to form a cone-shapedresidual limb. To do this,apply more pressure tothe bottom end of theresidual limb, and lesspressure to the topportion.
Individual fitting of therosthesis s ecial care
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Knee Injuries, Ligaments
When the anterior cruciate ligament is torn, asnap is felt, the knee gives way, swelling occurs,stiffness and pain follow.
Treatment can be nonsurgical or surgical.
Complete healing of knee ligaments after surgery can take 6 to 9 months.
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Tendon Ruptures
Rupture of the Achilles tendon is common inadults who participate in strenuous sports.
For severe damage, surgical repair is followed
by leg immobilized in a cast for 6 to 8 weeks. Tendon transplant may be needed.
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Strains
Excessive stretching of a muscle or tendonwhen it is weak or unstable
Classified according to severity: first-, second-,
and third-degree strain Management: cold and heat applications,
exercise and activity limitations, anti-inflammatory drugs, muscle relaxants, and
possible surgery
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Sprains
Excessive stretching of a ligament Treatment of sprains:
first-degree: rest, ice for 24 to 48 hr,compression bandage, and elevation
second-degree: immobilization, partial weightbearing as tear heals
third-degree: immobilization for 4 to 6 weeks,possible surgery
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Rotator Cuff Injuries
Shoulder pain; cannot initiate or maintainabduction of the arm at the shoulder
Drop arm test
Conservative treatment: nonsteroidal anti-inflammatory drugs, physical therapy, slingsupport, ice or heat applications during healing
Surgical repair for a complete tear
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Rheumatology
Connective tissue disease (CTD) is a major focus of rheumatology.
Rheumatic disease is any disease or condition
involving the musculoskeletal system. Arthritis means inflammation of one or more
joints.
(Continued)
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Collaborative Management of OA
History Physical assessment and clinical manifestations
Joint involvement
Heberden's nodes
Bouchards nodes
Joint effusions Atrophy of skeletal muscle
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Assessments of OA
Psychosocial Laboratory assessment of erythrocyte
sedimentation rate and C-reactive protein (maybe slightly elevated)
Radiographic assessment
Other diagnostic assessments
MR imaging CT studies
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Connective Tissue
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or Rheumatic Diseases
Rheumatoid Arthritis (RA) joint deformity
Lupus Erythematosis (SLE) - skin, heart, kidneys
Scleroderma - skin
Sjogrens Syndrome - dry mouth, dry eye -> systemic
Raynauds Disease- blood vessels
Inflammation of synovial joints due to an immune response withdegeneration as a secondary process. Blood vessels, heart, skinand kidneys may also be affected.
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Lab Studies
Creatinine ESR inflammation
RBC - RA and SLE
WBC SLE
Antinuclear Antibody (ANA) all
Rheumatoid Factor - > 80%
h d h
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Rheumatoid Arthritis
A most common connective tissue disease andthe most destructive to the joints
Chronic, progressive, systemic inflammatoryautoimmune disease primarily affecting thesynovial joints
Autoantibodies (rheumatoid factors) formed thatattack healthy tissue
Affects synovial tissue of any organ or bodysystem
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RA M di ti
Immunosuppressive
Methotrexate gold
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RA Medications
ASA NSAIDS
Antimalarials - visualchanges
Plaquenil Aralen
Gold administer withNSAIDS. Stomatitis,
diarrhea, proteinuria maybe a problem
Sulfasalazine
Penicillamine
gstandard for RA, usedalso in SLE
Imuran Cytoxan
Cyclosporin
Arava
Enbrel
Remicade
Corticosteroids
Prednisone
Prednisolone
Hydrocortisone
Topical
Capsaicin
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A t f L
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Assessments for Lupus
Psychosocial results can be devastating. Laboratory
Skin biopsy (only significant test to confirmdiagnosis)
Anti-Ro (SSA) test
Complete blood count
Body system functions
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