Assessment of Musculoskeletal function

• Anatomic and physiologic overview

♥ The musculoskeletal system includes the bones, joints, muscles,

tendons, ligaments, and bursae of the body.
♥ The bony structure provides protection for vital organs, including the
brain, heart, and lungs.
♥ The bony skeleton provides a sturdy framework to support body
structures.
♥ The bone matrix stores calcium, phosphorus, magnesium and fluoride.
♥ The red bone marrow located within bone cavities produces red and
white blood cells in a process called hematopoiesis.
♥ Joints hold the bones together and allow the body to move.
♥ The muscles attached to the skeleton contract, moving the bones and
producing heat, which helps to maintain body temperature.

• Structure and function of the skeletal system

♥ There are 206 bones in the human body, divided into four categories:
 Long bones (femur)
 Short bones (metacarpals)
 Flat bones (sternum)
 Irregular bones (vertebrae)
♥ Bones are constructed of cancellous (trabecular) or cortical (compact)
bone tissue.
♥ Diaphysis – shaft of long bones
♥ Epiphysis – ends of long bones
♥ Epiphyseal plate – separates the epiphyses from the diaphysis and is
the center for longitudinal growth in children.
♥ Cartilage – tough, elastic, avascular tissue.
♥ Long bones – are designed for weight bearing and movement.
♥ Short bones – cancellous bone covered by a layer of compact bone.
♥ Flat bones – important sites for hematopoiesis.
♥ Bone is composed of cells, protein matrix, and mineral deposits. The
cells are of three basic types:
 Osteoblasts – function in bone formation by secreting bone
matrix.
  Osteocytes – mature bone cells.
 Osteoclasts – multinuclear cells involved in destroying,
resorbing and remolding bone.
♥ Osteon – microscopic functioning unit of mature cortical bone.
♥ Lamellae – mineralized bone matrix.
♥ Periosteum – dense, fibrous membrane covering the bone.
♥ Endosteum – thin, vascular membrane that covers the marrow cavity
of long bones and the spaces in cancellous bone.
♥ Bone marrow – vascular tissue located in the medullary cavity of long
bones and in flat bones. Responsible for producing red and white blood
cells.

• Bone formation (osteogenesis)

♥ Ossification – process by which the bone matrix is formed and

hardening materials are deposited on the collagen fibers.
♥ Two basic process of ossification:
 Endochondral – a cartilage-like tissue (osteoid) is formed,
resorbed, and replaced by bone.
 Intramembranous – occurs when bone develops within
membrane, as in the bones of the face and skull.

• Bone maintenance

♥ The important regulating factors that determine the balance between

bone formation and bone resorption include:
 Local stress (weight bearing) – acts to stimulate bone
formation and remodeling. Weight-bearing bones are thick and
strong.
 Vitamin D (calcitriol) – functions to increase the amount of
calcium in the blood by promoting absorption of calcium from
the gastrointestinal tract.
 Parathyroid hormone – responds to low calcium levels in the
blood.
 Calcitonin – secreted in response to elevated blood calcium
levels, increases the deposit of calcium in bone.
 Blood supply – with diminished blood supply bone density
decreases.
• Bone healing

♥ Fracture healing occurs in four areas including:

 Bone marrow
 Bone cortex
 Periosteum
 External soft tissue
♥ Six stages of fracture healing:
1. Hematoma and inflammation
- There is a bleeding into the injured tissue and formation of
a fracture hematoma.
- The hematoma is the source of signaling molecules. The
injured area is invaded by macrophages (large white blood
cells), which debride the area.
- Inflammation, swelling, and pain are present.
2. Angiogenesis and cartilage formation
3. Cartilage calcification
- Chondrocytes in the cartilage callus form matrix vesicles,
which regulate calcification of the cartilage.
- Enzymes within these matrix vesicle prepare the cartilage
for calcium release and deposit.
4. Cartilage removal
5. Bone formation
- Minerals continue to be deposited until the bone is firmly
reunited.
- With major adult long bone fractures, ossification takes 3
to 4 months.
6. Remodeling
- The final stage of fracture repair.
- Remodeling is the new bone into its former structural
arrangement.
- Cancellous bone heals and remodels more rapidly than does
compact cortical bone.

• Structure and function of the articular system

♥ Joint (articulation) – the junction of two or more bones. Three basic

kinds of joints:
 Synarthrosis – immovable joints
  Amphiarthrosis – limited motion of joints
 Diarthrosis – freely movable joints
 Types of diarthrosis joints:

 Ball and socket joints – permit full freedom of

movement
 Hinge joints – permit bending in one direction only
 Saddle joints – allow movement in two planes at right
angles to each other
 Pivot joints – permit rotation for such activities as
turning a doorknob
 Gliding joints – allow for limited movement in all
directions
♥ joint capsule – tough, fibrous sheath that surrounds the articulating
bones.
♥ Synovium – secretes the lubricating and shock absorbing synovial fluid
into the joint capsule.
♥ Ligaments – fibrous connective tissue bands that bind the articulating
bones together.
♥ Bursa – a sac filled with synovial fluid that cushions the movement of
tendons, ligaments, and bones at a point of friction.

• Structure and function of the skeletal muscle system

♥ Tendons – cords of fibrous connective tissue that attach muscles to

bones, connective tissue, other muscles, soft tissue or skin.
♥ Fasciculi – parallel groups of muscle cells
♥ Fascia – fibrous tissue encasing fasciculi

• Skeletal muscle contraction

♥ Each muscle cell (also referred to as a muscle fiber) contains

myofibrils.
♥ Sarcomeres contain thick and thin actin filaments.
♥ Muscle fibers contract in response to electrical stimulation delivered
by an effector nerve cell at the motor end plate. When stimulated, the
muscle cell depolarize and generates an action potential manner similar
to that described for nerve cells. These actions potentials propagate
along the muscle cell membrane and lead to the release of calcium ions
that are stored in specialized organelles called Sarcoplasmic reticulum.
 ♥ Calcium is rapidly removed from the sacromeres by active
reaccumulation in the sarcoplasmic reticulum. When calcium
concentration in the sacromere decreases, the myosin and actin
filaments cease to interact, and the sarcomere returns to oits original
resting length (relaxation). Actin and myosin do not interact in the
absence of calcium.
♥ The primary source of energy for the muscle cells is adenosine
triphosphate (ATP), which is generated through the cellular oxidative
metabolism.
♥ At mow levels of activity (eg, sedentary activity), the skeletal muscle
synthesizes ATP from the oxidation of glucose to water and carbon
dioxide. During strenuous activity, when sufficient oxygen may not be
available, glucose is metabolized primarily to lactic acid.
♥ During isometric contraction, almost all of the energy is released in the
form of heat; during isotonic contraction, some of the energy is
expended in mechanical work.
♥ In some situations, such as shivering because of cold, the need to
generate heat is the primary stimulus for muscle contraction.

• Types of muscle contractions

♥ Isometric contraction – the length of the muscles remain constant

but the force generated by the muscles are increased.
♥ Isotonic contraction – shortening of the muscle with no increase in
tension within the muscle.

Ex. During walking, isotonic contraction results in shortening of the leg and
isometric contraction causes the stiff leg to push against the floor.

 Myoglobulin is a hemoglobin-like protein pigment present in striated

muscle cells that transports oxygen.
 Muscles containing large quantities og myoglobulin (red muscles) have
been observed to contract slowly and powerfully (eg, respiratory and
postural muscles)
 Muscles containing little myoglobulin (white muscles) contract quickly
(eg, extraocular eye muscles).

• Muscle tone
 ♥ Tone (tonus) – state of readiness
♥ Flaccid – muscle that is limp and without tone
♥ Spastic - muscle with greater-than-normal tone
♥ Atonic – soft and flabby muscles

• Muscle actions

♥ Synergists – muscles assisting the prime mover

♥ Antagonists – muscles causing movement opposite to that of the prime
mover.

• Exercise, disuse, and repair

♥ Muscles need to be exercised to maintain function and strength.

♥ Hypertrophy – increase in size of individual muscle fibers without an
increase in the number of muscle fibers.
♥ Atrophy – decrease in the size of the muscle.
♥ Bed rest and immobility cause loss of muscle mass and strength.

• Body movements produced by muscle contraction

♥ Fexion – bending at a joint (eg, elbow)

♥ Extension – straightening at a joint
♥ Abduction – moving away from midline
♥ Adduction – moving toward midline
♥ Rotation – turning around a specific axis (eg, shoulder joint)
♥ Circumduction – cone-like movement
♥ Supination – turning upward
♥ Pronation – turning downward
♥ Inversion – turning inward
♥ Eversion – turning outward
♥ Protraction – pushing forward
♥ Retraction – pulling backward

• Peripheral nerve function

Nerve Test of sensation Test of movement
Peroneal nerve Prick the skin centered Ask the patient to
between the great and dorsiflex the ankle and
second toe extend the toes.
Tibial nerve Prick the medial and Ask the patient to
lateral surface of the plantarflex toes and
sole ankle.
Radial nerve Prick the skin centered Ask the patient to
between the thumb and stretch out the thumb,
second finger then the wrist, and then
the fingers at the
metacarpal joints.
Ulnar nerve Prick the fat pad at the Ask the patient to
top of the small finger. spread all fingers.
Median nerve Prick the top or distal Ask the patient to
surface of the index touch the thumb to the
finger. little finger. Also
observe whether the
patient can flex the
wrist.

• Physical assessment:

• Posture
♥ The normal curvature of the spine is convex through the thoracic
portion and concave through the cervical and lumbar portions.
♥ Common deformities of the spine include:
 Kyphosis – increased forward curvature of the thoracic spine
 Lordosis – or sway back, an exaggerated curvature of the
lumbar spine
 Scoliosis – lateral curving deviation of the spine

• Gait
♥ Gait is assessed by having the patient walk away from the examiner
for a short distance.
♥ The examiner observes the patient’s gait for smoothness and rhythm.
♥ Any unsteadiness or irregular movements are considered abnormal.
• Bone integrity
♥ The bony skeleton is assessed for deformities and alignment.
♥ Symmetric parts of the body are compared.

• Joint function
♥ The articular system is evaluated by noting the range of motion,
deformity, stability, and nodular formation.
♥ Range of motion is evaluated both actively and passively.
♥ Goniometer – a protractor designed for evaluating joint motion.

• Muscle strength and size

♥ The muscular system is assessed by noting the patient’s ability to
change position, muscular strength and coordination, and the size of
individual muscles.

• Skin
♥ The nurse inspects the skin for edema, temperature, and color.

• Diagnostic evaluation

• Imaging procedures

♥ X-ray studies
 Bone x-rays determine bone density, texture, erosion, and changes
in bone relationships.
 Multiple x-ray are needed for full assessment of the structure
being examined.
 X-ray study of the cortex of the bone reveals any widening,
narrowing, or signs of irregularity.
 Joint x-ray reveal fluid, irregularity, spur formation, narrowing,
and changes in the joint structure.

♥ Computed tomography
 CT scan shows in detail a specific plane of involved bone and can
reveal tumors of the soft tissue or injuries to the ligaments or
tendons.
 Identify the location and extent of fractures in areas that are
difficult to evaluate (eg, acetabulum). CT studies, which mat be
 performed with or without the use of contrast agents, last about 1
hour.

♥ Magnetic resonance imaging

 Jewelry, hair clips, hearing aids, credit cards with magnetic strips,
and other metal-containing objects must be removed before the
MRI is done; otherwise they can become dangerous projectile
objects.

♥ Arthrography
 Is useful in identifying acute or chronic tears of the joint capsule
or supporting ligaments of the knee, shoulder, ankle, hip or wrist.
 A radiopaque substance or air is injected into the joint cavity to
outline soft tissue structures and the contour of the joint.

♥ Bone densitometry
 Is used to estimate bone mineral density (BMD). This can be done
through the use of x-rays or ultrasound.
 Dual-energy x-ray absorptiometry (DEXA) determines bone
mineral density at the wrist, hip or spine to estimate the extent of
osteopososis and to monitor a patient’s response to treatment for
osteoporosis.
 Bone sonometry (ultrasound) measures heel bone quantity and
quality and is used to estimate BMD and the risk of fracture for
people with osteoporosis.
 Bone density sonography is a cost-effective, readily available
screening tool for disgnosing osteoporosis and predicting a person’s
risk for fracture.

♥ Nursing interventions:
♥ Before the patient undergoes an imaging study, the nurse should
assess for conditions that may require special considerations during
the study or that may be contraindications to the study.
♥ It is essential that the patient remove all jewelry, hair clips, hearing
aids, and other metal before having an MRI.
♥ If contrast agent will be used, the nurse should carefully assess the
patient for possible allergy.
 • Nuclear studies

♥ Bone scan
 Is performed to detect metastatic and primary bone tumors,
osteomyelitis, certain faractures, and aseptic necrosis.

♥ Nursing interventions:
♥ Before a bone scan, the nurse should ask about possible allergy to
radioisotope.
♥ Assess for any condition that would contraindicate performing the
procedure.
♥ Encourage the patient to drink plenty of fluids.
♥ Ask the patient to empty the bladder before the procedure.

• Endoscopic studies

♥ Arthroscopy
 Is a procedure that allows direct visualization of a joint to
diagnose joint disorders.
 The procedure is carried out in the operating room under sterile
conditions; injection of a local anesthetic into the joint or general
anesthesia is used.
 A large-bore needle is inserted, and the joint is distended with
saline.
 The arthroscope is introduced, and joint structures, synovium and
articular surfaces are visualized.
 After the procedure, the puncture wound is closed with adhesive
strips or sutures and covered with a sterile dressing.

♥ Nursing interventions:
♥ Wrap the joint with a compression dressing to control swelling.
♥ Apply ice to control edema.
♥ Extend and elevate the joint.
♥ Explain to the patient and family the symptoms to watch for to
determine occurrence of complications.

• Other studies

♥ Arthrocentesis
  (joint aspiration) is carried out to obtain synovial fluid for
purposes of examination or to relieve pain due to effusion.

♥ Electromyography
 Provides information about the electrical potential of the muscles
and the nerves leading to them.

♥ Biopsy
 May be performed to determine the structure and composition of
bone marrow, bone, muscle or synovium to help siagnose specific
disease.
 The nurse monitors the biopsy site for edema, bleeding and edema.
 Analgesics are administered as prescribed for comfort.

♥ Laboratory studies
 Blood and urine
o CBC, hemoglobin level, WBC
Before surgery, coagulation studies are performed to detect bleeding
tendencies.
 Serum calcium level
 Serum phosphorus level
 Acid phosphatase is elevated in Paget’s disease and metastatic cancer.
 Alkaline phosphatase is elevated during early fracture healing and in
disease with increased osteoblastic activity (eg, metastatic bone
tumors)
 Bone metabolism may be evaluated through thyroid studies and
determination of calcitonin, parathyroid hormone and vitamin D levels
 Serum enzymes
 Aldolase is elevated in muscle disease (eg, muscular dystrophy, skeletal
muscle necrosis)
 Serumosteocalcin (bone GLA protein) indicates the rate of bones
turnover.

• Musculoskeletal System
 ♥ Action taken as a result of nervous system stimulation is largely the
function of the musculoskeletal system.
♥ This system enables the human organism to move the glands and organs
to function.
♥ It carries out the direction of the nervous and endocrine system.

• MUSCLES
♥ carry out movements of the body. 3 Types:

1. SMOOTH
♥ This type of muscle is also called visceral, plain and involuntary
muscles.
♥ This muscle is present as sheets in the walls of the blood vessels,
the gastrointestinal tract, urinary bladder, ducts of the
reproductive system, ureters, respiratory passages, lymphatic
vessels, capsule of the spleen, around hair follicles, within
connective tissue of the skin and within the eyeball.
♥ It is not under voluntary control.

2. CARDIAC MUSCLE
♥ This type of muscle is also called striated involuntary or heart
muscle.
♥ It beats spontaneously and in rhythm.

3. SKELETAL MUSCLE
♥ This type of muscle is striated voluntary and attached to bones.
♥ It is composed of parallel bundles of fibers which are the units of
histological organization.
♥ Skeletal muscles are attached to the skeleton and permit
movements.
♥ The are excitable and capable of contraction or extension.
♥ Arrangement of the skeleton is usually in antagonistic pairs so that
one muscle is extended while the other contracts. After a force
that has been applied to a muscle is released, the muscle will return
to its normal length because of the characteristics of elasticity.
The muscles are attached to the bones at points of insertion by
strong fibrous tendons. Each muscle also has a point of origin, which
is usually more fixed than the point of insertion.
 ♥ Muscle contraction is initiated by a nerve impulse that reaches the
muscle fiber at the myoneural junction. The nerves are located in
the middle of the fiber so that the impulse spread out toward both
ends, allowing for more coincident contraction of all sacromeres.
Energy for contraction is supplied by the breakdown of ATP. Oxygen
and glucose are also needed for this reaction.

• Skeletal muscles are divided according to the following:

1. According to location
a. Intercostal – muscle between ribs
b. Femoris – muscle in the femur
c. Brachii – muscle in the arm

2. According to direction of fibers

a. Rectus – straight
b. Transverse – across
c. Oblique – oblique, diagonal

3. According to the type of action performed

a. Abductor – muscle which move limb (or other part) away from
the midline of body.
b. Flexor – muscle which bend a limb at a joint
c. Levator – muscle which lift a part eg, eyelid
d. Extensor – muscle which straighten a limb at a joint
e. Adductor – muscle which move a limb (or other part) towards
the midline.

4. According to the shape or size

a. Deltoid – from greek letter “delta”
b. Trapezius – four-sided
c. Maximus – largest
d. Longus – longest
e. Minimus – smallest
f. Brevis – short
g. Fusiform – spindle shaped
h. Rhomboid – quadrilateral

5. According to the number of the heads or origin

 a. Biceps – muscle with 2 heads
b. Triceps – muscle with 3 heads
c. Quadriceps – muscle with 4 heads

• A skeletal muscle has 3 parts namely:

1. Origin, the end which is the more fixed point of attachment
2. Insertion, the end which is freely movable.
3. Body or Belly, the portion between the origin and insertion.

• Attachment of skeletal muscle may either be tendons or

fasciae.
1. Tendons attach muscle to bone. Broad sheats of tendons are termed
aponeurosis.
2. Fasciae (singular fascia) are tough fibrous connective tissues which
separate muscles from one another and hold them in position.

• Muscles are also named according to movement

1. Prime mover or agonist muscle which execute actual movement e.g.,
the biceps in flexion of elbow
2. Antagonist muscle that acts against the prime mover, e.g., the
triceps in flexion
3. Synergist muscle that enables prime mover e.g., perform the action
efficiently and smoothly.
4. Fixator muscle which studies the bone giving origin to the prime
mover so that the insertion will move.

• SKELETON

♥ The bone consist of cells, fibers and ground substances.

♥ It is calcified, making it hard substance suited for supportive and
protective functions.
♥ Bone tissue is nourished by the haversian system. i.e., a network of
minute canals traversed with blood vessels.
♥ Bone tissue is constantly crerated and reabsorbed.
♥ These 2 processes: i.e., bone creation (deposition) by osteoblasts and
bone reabsorption, determine skeletal bone size and strength.
I. SKELETAL FUNCTION
1. Provides attachment of muscles, tendons and ligaments
 2. Protects delicate4 organs of the body (e.g., brain, heart, lungs and
other soft tissue)
3. Stores minerals salts, e.g., calcium, phosphorous and release them
whenever necessary.
4. Encloses bone marrow which is responsible for production of blood
corpuscles.
5. Assists with movement by providing leverage and attachment for
muscles.

II. BONE HISTOLOGY

 Histologically, bones consist of 2 types
1. Compact bone i.e., strong and dense with closely spaced lamellae
(concentric layers of mineral depositions).
2. Cancellous i.e., spongy appearance with more widely spaced lamellae.
 Between layers of lamellae are small cavities called lacunae. Suspended
in tisuue fluid within each lacuna is an osteocyte (mature bone forming
cells). Tiny canals (canaliculi) connects the lacunae and hence the
osteocytes.
 Red bone marrow has a hematopoietic function (manufactures red and
white blood cells) and is located in cancellous bone spaces.
 Yellow marrow occurs in the shaft of long bones and extends into the
haversian systems. Yellow marrow is connective tissue composed of fat
cells. Blood supply to bone comes:
(a) via arterioles through the haversian canals,
(b) via vessels in the periosteum that center bone through the minute
Volkmann;s Canals,
(c) via blood vessels in the marrow and bone ends.
 Bone is supplied with a network of sensory nerves.

III. BONE CLASSIFICATION ACCORDING TO SHAPE

1. Long bones – consist of epiphysis, articular cartilage, diaphysis,

periosteum and medullary cavity. This type is found in the extremities
and as levers.
Example: humerus, radius, fibula

 EPIPHYSIS – End of long bones and is composed of cancellous

bone.
  ARTICULAR CARTILAGE – Covers long bone ends and provides
smooth surfaces for joint movement.
 DIAPHYSIS – Main shaft of a long bone and is composed of
compact bone. It provides structural support.
 METAPHYSIS – Flared port of a long bone between the
epiphysis and diaphysis.
 MEDULLARY CAVITY (MARROW) – Is in the center of the
diaphysis.

2. Short bones – consist of cancellous bone covered by a thin layer of

compact tissue. These type of bones are cube-shaped and provide
strength.
Example: carapls, tarsals, palanches
3. Flat bones – consist of cancellous bone encased in two flat plates of
compact bone. These bones protect delicate organs.
Example – skull, scapula, ribs, sternum
4. Irregular bones – are bones of no definite shape. The thinner part
consist of two plates of compact bone with cancellous bone between
them while the bulky part consist of cancellous bone surrounded by a
layer of compact bone.
Example: skull and vertebrae
5. Sesamoid bones – are rounded, bones which develop in the capsules of
joints or in tendons. The function of this bone is to eliminate friction
and increase leverage of muscle.
Example: patella, knee cap

IV. DIVISION OF HUMAN SKELETON

- There are a total of 206 bones in the human body. The skeleton
has been divided into axial and appendicular skeleton.

A. AXIAL SKELETON
- The axial skeleton comprises the bones of the vertebral column,
thorax and skull. It has a total of 80 bones: 29 bones of the
skull (8 cranial, 14 bones of the face, 6 bones of the middle
ears and 1 hyoid bone): 26 bones of the thorax (sternum and
ribs)

SKULL BONES
 - The skull includes the cranial and facial bones joined together
by the mandible (lower jaw). There is a total of 29 skull bones.
1.)Cranial bones
a. Frontal bone- forms the forehead, roof of the nasal cavity and
the orbits
b. Parietal bone – forms the sides and roof of the cranium and are
joined at the sagittal suture in the midline
c. Occipital bone – forms the back and base of the cranium and
joints the parietal bone anteriorly at the lambdoid through
which the spinal cord joints the medulla oblongata of the brain.
d. Temporal bone – helps to form the sides and base of the
cranium.
e. Spheroid bone – forms the anterior portion of the base of the
cranium.
f. Ethmoid bone – principal supporting structure of the nasal
cavity and contributes to the formation of the orbits.

Structure between Cranial bones

Sutures – the articulation between the cranial bones.
a. coronal suture between the frontal and parietal bones
b. lambdoid suture between parietal bones and occipital bones
c. squamous suture between part of the temporal and parietal
d. sagittal suture units parietal bones.

Fontanels are soft boneless areas in the skull which are later closed up by
the formation of cranial bones, occurring at birth. There are usually 6
fontanels, namely:
a. Anterior or bregmatic fontanel the largest and diamond shape located
at junctions of the coronal, sagittal and frontal sutures which closes
at the middle of the second year of life at 18th months stage.
b. Posterior fontanel – triangular in shape, located at the union of
sagittal and lambdoid sutures. Closes one month after birth.
c. Anterol lateral and posterolateral – on each side of the skull; normally
closed a month or two after birth.

2.) Skull bones

 - the facial bones consist of 1 mandible 1 vomer, 2 maxillary, 2
xygomatic. 2 nasal, 2 lacrimal, 2 inferior nasal conchae and 2
palatine.
a. Mandile – the strongest and the longest bone of the face. It is
the bone of the lower jaw.
b. Maxilla – the upper jaw is formed by the fusion of two maxillae
which articulate with the frontal bone.
c. Nasal bone – paired nasal bones join to form the bridge of the
nose.
d. Palatine bone – two bones forming the posterior of the roof of
the mouth or hard palate.
e. Zygomatic bone – the two bones forming the prominence of the
cheek called malar bones and rest upon the maxillae articulating
with their zygomatic processes.
f. Lacrimal bone – the paired bone make up part of the orbit at
the inner angle of the eye.
g. Nasal Conchae or Inferior Turbinae bones – lies immediately
below each nostril on the lateral side.
h. Vomer – constitutes the lower posterior portion of the nasal
septum.

3.) Bones of the middle ear

- A chain of three small bones extends acroos the middle ear.
These are the smallest bones of the body known as the ear
ossicles.
a. Hammer or malleus
b. Anvil or Incus
c. Stirrup or stapes

4.) Hyoid bone

VERTEBRAL COLUMN
- The vertebral column or backbone extends the full length of
the back. The vertebrae are grouped based on their location –
cervical, 12 thoracic, 5 lumbar and 1 coccyx.
1. Cervical vertebrae – smallest vertebrae, having oblong bodies
which are broader from side to side.
 2. Thoracic Vertebrae – their bodies are no longer and more
rounded than those of the cervical region.
3. Lumbar Vertebrae – largest and strongest of all vertebrae.
4. Sacrum – lies below the 5th lumbar vertebrae and is triangular in
shape.
5. Coccyx – is formed by the fusion of four rudimentary coccygeal
vertebrae or segments and is attached to the tip of the s
acrum.
THORAX
- The thorax encloses and protects the lungs and other
structures of the chest cavity. It provides support for the
bones of the shoulder girdle and upper extremities. Red blood
corpuscles are formed in the red bone marrow of the ribs and
sternum.
1.) Sternum – lies in the midline of the thorax in front.
2.) Ribs – are long slender and curved bones attached to the
thoracic vertebrae.
a. True ribs – first 7 pairs are attached to the sternum
b. False ribs – the 8th, 9th, and 10th pairs and are attached to the
7th ribs by the costal cartilage.
c. Free or floating ribs – last 2 pairs and are attached in front.
- The spaces between the ribs are called intercostals spaces and
are filled with muscle.

B. APPENDICULAR SKELETON
- The appendicular skeleton is composed of bones of the upper
and lower extremities including the shoulder and pelvic girdles.

1. Bones of the Upper Extremity

a. Shoulder girdle – this is made of clavicle and scapula on each
side of the body. It serves to attach the bones of the upper
extremities to the axial division of the skeleton and provides
places for muscle attachments.
1.) Clavicle – known as the collar bone located at the root of the
neck and anterior to the first rib.
2.) Scapula – a large flat triangular bone located on the dorsal
portion of the thorax covering the area from the 2nd rib to the
 7th rib. It serves as the origin for some muscles that move the
arm.
b. Humerus – long bone of the upper arm
c. Radium – lies on the lateral thumb side of the forearm
d. Ulna – lies on the medial side of the forearm
e. Carpals – there are 8 in each extremity
f. Metacarpals – the palm of the hand consist of 5 metacarpal
bones, each with a base, shaft and head.
2. Bones of the Lower Extremity
a. Pelvic Girdle – supports the trunk and provides attachment for the
legs. It is made up of hip bone or os coxae on each side of the body.
This is the broadest bone of the body.
• Ilium – uppermost and largest portion of the pelvic bone
• Ischium – lowest and strongest portion of the pelvic bone
• Pubic – lies superior and slightly anterior to the ischium. Between the
pubis and the ischium is an obturator foramen.
b. Femur – form the bone of the thigh. It is the heartiest, largest and
strongest bone in the body. It transmits the entire weight of the trunk
from the hip to the tibia.

c. Patella or knee cap – largest seasamoid bone in the body and is

embedded in the tendon of the quadriceps femoris. It is movable and
serves to increase leverage of muscles that straighten the knee.

d. Bones of the leg

• Tibia – medial and larger bone of the leg also known as skin bone
• Fibula – a long, slender bone on the lateral side of the leg.

e. Bones of the foot

• Tarsal bone – 7 in each foot are arranged in the hindfoot and
forefoot.
• Metatarsals – bases of the inner three five metatarsals articular with
the 3 cuneiform bones and those of the outer teo warticulates with
the cuboid.
• Phalanges – there are 14 in each foot, 2 of which are in the great toes
and 3 in each of the other toes.
• DIAGNOSTIC ASSESSMENT

1. Radiologic Studies
a. Roentgenograms (X-ray films) to establish presence of musculo-
skeletal problems, follow its progress and evaluate treatment
effectiveness.
• Plain X-ray film is common – usually from antero-posterior
(AP) and/or lateral view.
b. Arthrography – injection of a dye or air in the joint for x-ray
study
c. Myelography – examines the spinal cord after introduction of
the contrast medium.
d. CT Scan – useful is assessing some bone and soft tissue tumors
and some spinal fractures.

2. Blood Studies
a. ESR – non-specific test for inflammation
b. Uric Acid – usually elevated in gout
c. Antinuclear antibody – assess presence of antibodies capable of
destroying cell nuclei.
- positive in about 94% of clients with SLE
d. Anti DNA – detects serum antibodies that react with DNA
- most specific test for SLE
e. Test of Mineral Metabolism
• Calcium – decreased levels found in osteomalacia,
hypoparathyroidism.
- increased levels found in bone tumors, acute osteoporosis,
hyperparathyroidism.
• Phosphorus – increased levels found in healing fractures,
chronic renal disease.
f. Muscle Enzyme tests
• Creatine Phosphorus – highest concentration found in
skeletal muscle.
- increased levels found in traumatic injuries, progressive
muscular dystrophy
• Adolase – useful in monitoring muscular dystrophy and
dermatomyositis
 3. Arthroscopy – direct visualization of a joint usong an arthroscope
after injection of local anesthesia.

4. Arthrocentesis – method of aspirating synovial fluid, blood or pus

via a needle inserted into the joint cavity.

5. EMG – Electromyelography – non-invasive test that graphically

records the electrical activity of the muscle at rest and during
contraction.

6. Bone scanning – radio isotope that are “taken up” by bones are
injected intravenous (usually Na pertechnetae 99 MTc).

Musculoskeletal care modalities

• Managing care of the patient in a cast

Cast
♥ Is a rigid external immobilizing device that is molded to the contours
of the body.
♥ Its purposes are to immobilize a body part in a specific position and
apply uniform pressure on encased soft tissue.
♥ A cast is used specifically to:
 Immobilized a reduced fracture
 Correct a deformity
 Apply uniform pressure to underlying soft tissue
 Support and stabilize weakened joints.
♥ Generally, casts permit mobilization of the patient while restricting
movements of a body part.

• Types of Cast
1.) TRUNK
• Collar cast affectations of the cervical spine
• Minerva Cast – affectations of the upper dorsal and cervical spine
• Trauma
• POtt’s disease
• Scoliosis
 • Rizzers Jacket Cast – scoliosis
• Plaster Shell – surgeries involving the spine
• Body cast – affectations of the lower dorso – lumbar spine
• Shoulder apica – affectations on shoulder joint, upper portion of the
humerus

• Observations of Pateints with Cast involving the trunk

1. Signs or respiratory distress
2. Signs of cast syndrome
• Prolonged nausea and vomiting
• Repeated vomiting
• Abdominal distention
• Vague abdominal pain
• Absence of bowel sound
3. Pressure on the chin, jaw, ear, face, axilla, clavicular area,
anterior-superior iliac crest, groin, buttocks
4. Urinary and bowel disturbance
5. Signs of Plaster Sore
• Itchiness and burning sensation
• Severe pain
• Rise of temperature
• Disturbed sleep
• Restlessness
• Offensive odor
• Discharge on case

2.) UNDER EXTREMITY – CIRCULAR CAST

a. Short Arm circular cast – affections of the wrist and fingers
b. Long Arm Circular Cast – affections on the forearm
c. Hanging Cast – fracture of radius – ulnar with callus

3.) LOWER EXTREMITY – CIRCULAR CAST

a. Short leg circular cast (boot cast) – affections of ankle and toes
b. Walking Cast – affections of the ankle with callus formation
c. PTB Patellar Tendon Bearing Cast – fracture of the tibia – fibula with
callus
d. Long Leg Circular Cast – fracture of tibia – fibula
e. Quadrilateral Cast – fracture of the shaft femur with good callus
formation
f. Cylinder Cast – fracture of patella

• OBSERVATIONS ON PATIENT’S CASTED EXTREMITY

1. Signs of impaired circulation on toes and fingers
a. color- cyanosis of the skin
b. temperature – coldness of the skin
c. movement – loss of function
d. sensation – numbness
e. pulsation – pulselessness in extremity
f. severe pain
g. marked swelling

2. Nerve damage due to pressure in a nerve as it passes over body

prominence.
a. increasing pain, persistent and localized
b. numbness
c. feeling of deep pressure
d. paresthesias
e. motor weakness or paralysis

3. Infection, tissue necrosis due to skin breakdown

a. unpleasant odor over the cast or at edges of cast
b. drainage through cast
c. sudden unexplained fever
d. hot spot on cast over lesion

4. Pressure on axilla, elbow, wrist, metacarpals, iliac crest, groin, knee, ankle
and metatarsals.

• GUIDELINES FOR BIVALVING A CAST

♥ When cutting a cast in half (bivalving), the physician or nurse
practitioner proceeds as follows:
1. With a cast cutter, a longitudinal cut is made to divide the cast in half.
2. The underpadding is cut with scissors.
 3. The cast is spread apart with a cast spreaders to relieve pressure and
to inspect and treat the skin without interrupting the reduction and
alignment of the bone.
4. After the pressure is relieved, the anterior and posterior parts of the
cast are secured together with an elastic compression bandage to
maintain immobilization.
5. to control swelling and promote circulation, the extremity is elevated
(but no higher than heart level, to minimize the affect of gravity on
perfusion of the tissue).

4.) SPICA TYPE

• Single spica – affections of the hip and femur
• 1 & ½ hip spica
• Double hip spica
• Frog Cast – congenital hip dislocation
• Panatalon Case – fracture of the pelvis

• Observations on patients in spica type

1. Signs of respiratory distress
2. Signs of cast syndrome
3. Signs of impaired circulation on toes
4. signs of urinary – bowel disturbance
5. signs of infection – tissue necrosis
6. pressure around edge of cast below nipple axillary, iliac crest,
buttocks, sacral, groin, knee and metatarsals.

• Casting materials
Non plaster
♥ Referred to as fiberglass casts, these water-activated
polyurethane materials have the versatility of plaster but are
lighter in weight, stronger, water resistant, and durable.
♥ They are used for non displaced fractures with minimal swelling
and for long term wear.

Plaster
♥ The traditional cast is made of plaster. Rolls of plaster bandage
are wet in cool water and applied smoothly to the body.
♥ A crystallizing reaction occurs, and heat is given off.
• SPLINT OR POSTERIOR MOLD

I. UPPER EXTREMITY

a. Short arm posterior mold – affections of the wrist and infection, open
wounds
b. Long arm, posterior mold – infections of the forearm, open wounds
c. Sugar tong – affections of the shoulder, upper portion of humerus with
infections, open wounds.
d. Abduction Splint – fracture of the neck of humerus
e. Cock-up-splint – fracture of the neck of humerus
f. Banjo splint – brachial nerve paralysis
g. Dennis Browne splint – congenital clubfoot

II. LOWER EXTREMITY

a. Short leg posterior mold – affections of the ankle and toes with
infections, open wounds.
b. Long leg posterior mold – affections of the knees, tibia – fibula with
infections, open wounds
c. Night splint – post polio with residual paralysis of lower extremity
d. Spica Mold – affections of the hip, femur-like septic hip,
osteomyelitis

NOTE: Observations same as in a circular type of cast for upper and lower
extremity.

• BRACES
Types:
a. Milwaukee brace – scoliosis
b. Taylor body brace – Potts disease on thoracic vertebrae
c. Jawet brace – compression fracture of vertebral body
d. Shantz collar – cervical spine affection
e. SOMI – sterno occipito madibular immobilizer – cervical spine
affection
f. Forester – cervico thoraco-lumbar affections
g. Chair back – dorso-lumbar affections
• TRACTION
♥ is an act pulling and drawing which is associated with counter traction.

• PURPOSE/INDICATIONS
 For immobilization
 To prevent and correct deformity
 To maintain good alignment
 To give support to reduce pain and muscle spasm
 To reduce fracture

• PRINCIPLES OF TRACTION
1. Keep body alignment at normal – position the client in dorsal
recumbent
2. For every traction, there is always a counter traction
• use shock blocks
• use half ring Thomas splint
3. For traction to be effective, it must be applied continuously
4. The line of pull must be in line with deformity
5. Friction should be eliminated
• Weights should be hanging freely
• Rope of sash cord runs freely along the pulley
• Knots should be away from the pulley
• Weights should not be resting on the floor
• Observe the rope and bag weights for signs of wear and tear.

• TYPES OF TRACTION according to manner of application

1. Manual Traction – traction applied to the body by the hand of
operator
2. Skin Traction – traction applied at the surface of the skin and soft
tissue and indirectly to the bone using adhesive elastic bandage and
spreader
Examples: Bryant Traction, Russell Traction
3. Skeletal Traction – traction applied directly to the bone using pin,
wires, tongs
Example: Halo pelvic traction, Crutchfiels tong traction
4. Filled or adjustable traction – traction applied to the body using
devices like canvass, laces, buckles, leathers used according to the
side of the patient.
 Examples: Anklet Traction
Pelvic Strap Traction
Head Halter Traction

• NURSING DIAGNOSIS FOR CLIENTS IN TRACTION

1. Potential for immobility related to therapy
- provide for active motion of the unaffected joints
- deep breathing – coughing exercise
2. Potential for neurovascular compromise related to traction
3. Potential for skin breakdown related to pressure on soft tissues.
4. Potential for complication like
• Infection at the pin/wire site – inspect insertion sites carefully every
shift, cleanse sites with saline, peroxide or betadine, use antibiotic
ointments and dry sterile dressing if ordered.
• Pneumonia, atelectasis
• Contractures
• Constipation
• Bedstore
5. Potential for boredorm
6. Social isolation
7. Partial self-care deficit

Common musculoskeletal problems:

• Acute lower back pain
♥ Acute low back pain refers to patients who have a problem with their
back that occurred within hours to 1 month.
♥ Is the recent onset of back pain in the lumbar region.
♥ Pain in this area can derive from any of the region's structures,
including the spinal bones, the discs between the vertebrae, the
ligaments around the spine, the spinal cord and nerves, muscles of the
low back, internal organs of the pelvis and abdomen, and the skin
covering the lumbar area.
• Back pain is classified into three categories based on the
duration of symptoms:

♥ Acute back pain is arbitrarily defined as pain that has been present
for six weeks or less.
♥ Subacute back pain has a six- to 12-week duration.
♥ Chronic back pain lasts longer than 12 weeks.

Clinical manifestations:
Condition:
Nonspecific back pain
(mechanical back pain, facet
joint pain, osteoarthritis,
muscle sprains, spasms)
Sciatica (herniated disc)
Spine fracture (compression
fracture)
Spondylolysis
Malignant disease (multiple
myeloma), metastatic disease
Connective tissue disease
(systemic lupus
erythematosus)
Clinical clues:
No nerve root compromise,
localized pain over lumbosacral
area
Back-related lower extremity
symptoms and spasm in
radicular pattern, positive
straight leg raising test
History of trauma,
osteoporosis, localized pain
over spine
Affects young athletes
(gymnastics, football, weight
lifting); pain with spine
extension; oblique radiographs
show defect of pars
interarticularis
Unexplained weight loss,
fever, abnormal serum protein
electrophoresis pattern,
history of malignant disease
Fever, increased erythrocyte
sedimentation rate, positive
for antinuclear antibodies,
scleroderma, rheumatoid
arthritis
Infection (disc space, spinal
tuberculosis)
Abdominal aortic aneurysm
Cauda equina syndrome (spinal
stenosis)
Hyperparathyroidism
Ankylosing spondylitis
(morning stiffness)
Fever, parenteral drug abuse,
history of tuberculosis or
positive tuberculin test
Inability to find position of
comfort, back pain not
relieved by rest, pulsatile
mass in abdomen
Urinary retention, bladder or
bowel incontinence, saddle
anesthesia, severe and
progressive weakness of lower
extremities
Insidious, associated with
hypercalcemia, renal stones,
constipation
ostly men in their early 20s,
positive for HLA-B27 antigen,
positive family history,
increased erythrocyte
sedimentation rate

Common problems of the upper

extremity:
• Bursitis
♥ Whether you're at work or at play, if you overuse or repetitively
stress your body's joints, you may eventually develop a painful
inflammation called bursitis.
♥ You have more than 150 bursae in your body. These small, fluid-filled
sacs lubricate and cushion pressure points between your bones and the
tendons and muscles near your joints. They help your joints move with
ease.
 ♥ Bursitis occurs when a bursa becomes inflamed. When inflammation
occurs, movement or pressure is painful.
♥ Bursitis often affects the joints in your shoulders, elbows or hips. But
you can also have bursitis by your knee, heel and the base of your big
toe.
♥ Bursitis pain usually goes away within a few weeks or so with proper
treatment, but recurrent flare-ups of bursitis are common.

• Signs and symptoms

If you have bursitis, you may notice:

• A dull ache or stiffness in the area around your elbow, hip, knee,
shoulder, big toe or other joints
• A worsening of pain with movement or pressure
• An area that feels swollen or warm to the touch
• Occasional skin redness in the area of the inflamed bursa

• Tendinitis
♥ Tendinitis is inflammation or irritation of a tendon — any one of the
thick fibrous cords that attach muscles to bones.
♥ The condition, which causes pain and tenderness just outside a joint,
can occur in any of your body's tendons.
♥ Tendinitis is common around your shoulders, elbows, wrists and heels.

• Signs and Symptoms

Tendinitis that is produced near a joint aggravated by movement include

the following:

• Pain
• Tenderness
• Mild swelling, in some cases

Tendinitis in various locations in your body produces these specific types

of pain:
 • Tennis elbow. This type causes pain on the outer side of your forearm
near your elbow when you rotate your forearm or grip an object.
Golfer's elbow causes pain on the inner part of your elbow.
• Achilles tendinitis. This form causes pain just above your heel.
• Adductor tendinitis. This type leads to pain in your groin.
• Patellar tendinitis. In this type, you experience pain just below your
kneecap.
• Rotator cuff tendinitis. This tendinitis leads to shoulder pain.

• Carpal tunnel syndrome

♥ Bounded by bones and ligaments, the carpal tunnel is a narrow
passageway — about as big around as your thumb — located on the palm
side of your wrist.
♥ This tunnel protects a main nerve to your hand and nine tendons that
bend your fingers.
♥ Pressure placed on the nerve produces the numbness, pain and,
eventually, hand weakness that characterize carpal tunnel syndrome.

• Signs and symptoms

♥ Carpal tunnel syndrome typically starts gradually with a vague aching in
your wrist that can extend to your hand or forearm. Other common
carpal tunnel syndrome symptoms include:

• Tingling or numbness in your fingers or hand, especially your

thumb, index, middle or ring fingers, but not your little finger.
This sensation often occurs while driving a vehicle or holding a
phone or a newspaper or upon awakening. Many people "shake out"
their hands to relieve their symptoms.
• Pain radiating or extending from your wrist up your arm to your
shoulder or down into your palm or fingers, especially after
forceful or repetitive use. This usually occurs on palm side of
your forearm.
• A sense of weakness in your hands and a tendency to drop
objects.
• A constant loss of feeling in some fingers. This can occur if the
condition is advanced.
• Ganglion cysts
♥ Ganglion cysts are noncancerous fluid-filled lumps (cysts) that most
commonly develop along the tendons or joints of your wrists or hands.
♥ They may also appear in your feet.
♥ Ganglion cysts may develop suddenly or progress gradually.
♥ They occur when the lubricating fluid in your joints or around the
nearby tendons accumulates, giving rise to a cyst.
♥ The exact cause of this process is unknown.

• Signs and symptoms

♥ In most cases, ganglion cysts appear as raised lumps near your wrist or
finger joints.
♥ They are generally round, firm and smooth.
♥ Though they are fixed in one place, they may "give" a little when you
push against them.

• Dupuytren's contracture
♥ Dupuytren's contracture is a rare hand deformity in which the
connective tissue (fascia) under the skin of the palm thickens and
scars.
♥ Knots (nodes) and cords of tissue form under the skin, often pulling one
or more of the fingers into a bent (contracted) position.
♥ Though the fingers affected by Dupuytren's contracture bend
normally, they can't be straightened, making it difficult to use your
hand.

• Signs and symptoms

♥ Dupuytren's contracture usually begins as a thickening of the skin on
the palm of your hand. As Dupuytren's contracture progresses, the skin
on the palm of your hand may appear dimpled.
♥ A firm lump of tissue may form on your palm. This lump may be
sensitive to the touch, but usually isn't painful.
♥ In later stages of Dupuytren's contracture, cords of tissue form under
the skin on your palm. Cords may extend up to your fingers. As these
cords tighten, your fingers may be pulled toward your palm, sometimes
severely.
 ♥ The ring finger and the little finger are most commonly affected,
though the middle finger may also be involved. Only rarely are the
thumb and index finger affected.
♥ Dupuytren's contracture often affects both hands, though one hand is
usually affected more severely than the other.
♥ Dupuytren's contracture usually progresses slowly, over several years.
Occasionally it can develop over weeks or months. In some people it
progresses steadily and in others it may start and stop. However,
Dupuytren's contracture never regresses.

Common foot problems:

• Plantar fasciitis
♥ Most commonly, heel pain is caused by inflammation of the plantar
fascia — the tissue along the bottom of your foot that connects your
heel bone to your toes.
♥ Plantar fasciitis causes stabbing or burning pain that's usually worse in
the morning because the fascia tightens (contracts) overnight. Once
your foot limbers up, the pain of plantar fasciitis normally decreases,
but it may return after long periods of standing or after getting up
from a seated position.

• Signs and symptoms

♥ Sharp pain in the inside part of the bottom of your heel, which may feel
like a knife sticking in the bottom of your foot
♥ Heel pain that tends to be worse with the first few steps after
awakening, when climbing stairs or when standing on tiptoe
♥ Heel pain after long periods of standing or after getting up from a
seated position
♥ Heel pain after, but not usually during, exercise

♥ Mild swelling in your heel

• Corns and calluses
♥ Your skin often protects itself by building up corns and calluses —
thick, hardened layers of skin.
♥ Although corns and calluses can be unsightly, you need treatment only
if they cause discomfort.
♥ If you have diabetes or another condition that causes poor circulation
to your feet, you're at greater risk of complications.

• Signs and symptoms

♥ You may have a corn or callus if you notice:

 A thick, rough area of skin

 A hardened, raised bump
 Tenderness or pain under your skin
 Flaky, dry or waxy skin
♥ Corns and calluses are often confused, but they're not the same thing.

• Corns
♥ Are smaller than calluses and have a hard center surrounded by
inflamed skin.
♥ Corns usually develop on parts of your feet that don't bear
weight, such as the tops and sides of your toes.
♥ Corns can be painful when pushed or may cause a dull ache.

• Calluses
♥ Usually develop on the soles of the feet, especially under the
heels or balls, on the palms, or on the knees.
♥ Calluses are rarely painful and vary in size and shape.
♥ They can be more than an inch in diameter, making them larger
than corns.

• Ingrown toenails
 ♥ An ingrown toenail is a common condition in which the corner or side of
one of your toenails grows into the soft flesh of that toe.
♥ The result is pain, redness, swelling and, sometimes, an infection. An
ingrown toenail usually affects your big toe.

• Signs and symptoms

♥ Pain and tenderness in your toe along one or both sides of the nail
♥ Redness around your toenail
♥ Swelling of your toe around the nail
♥ Infection of the tissue around your toenail

• Hammertoe and mallet toe

♥ A hammertoe is a toe that's curled due to a bend in the middle joint of
a toe.
♥ Mallet toe is similar, but affects the upper joint of a toe.
♥ Both conditions are commonly caused by shoes that are too short or
heels that are too high. Under these conditions, your toe may be forced
against the front of your shoe, resulting in an unnatural bending of your
toe.

• Signs and symptoms

♥ A hammer-like or claw-like appearance of a toe
♥ In mallet toe, a deformity at the end of the toe, giving the toe a
mallet-like appearance
♥ Pain and difficulty moving the toe
♥ Corns and calluses resulting from the toe rubbing against the inside of
your footwear

• Bunions / hallux valgus

♥ A bunion is an abnormal, bony bump that forms on the joint at the base
of your big toe.
♥ Your big toe joint becomes enlarged, forcing the toe to crowd against
your other toes. This puts pressure on your big toe joint, pushing it
outward beyond the normal profile of your foot, and resulting in pain.
♥ Bunions can also occur on the joint of your little toe (bunionette).
♥ Bunions can occur for a number of reasons, but a common cause is
wearing shoes that fit too tightly. They can also develop as a result of
 inherited structural defect, injury, stress on your foot or another
medical condition.

• Signs and symptoms

♥ A bulging bump on the outside of the base of your big toe
♥ Swelling, redness or soreness around your big toe joint
♥ Thickening of the skin at the base of your big toe
♥ Corns or calluses — these develop where the first and second toes
overlap
♥ Persistent or intermittent pain
♥ Restricted movement of your big toe

• Morton's neuroma
♥ A neuroma is a noncancerous (benign) growth of nerve tissue that can
develop in various parts of your body.
♥ Morton's neuroma occurs in a nerve in your foot, often between your
third and fourth toes.
♥ The condition isn't a true tumor, but instead involves a thickening of
the tissue around one of the digital nerves leading to your toes.
♥ Morton's neuroma causes a sharp, burning pain in the ball of your foot.
Your toes also may sting, burn or feel numb if you have Morton's
neuroma.
♥ Also called plantar neuroma or intermetatarsal neuroma, Morton's
neuroma may occur in response to irritation, injury or pressure — such
as from wearing tightfitting shoes.

• Signs and symptoms

♥ A burning pain in the ball of your foot that may radiate into your toes
♥ Tingling or numbness in your toes
♥ At first, the pain may worsen when you wear tight or narrow shoes or
engage in activities that place pressure on your foot.

• Flatfeet / pes planus

♥ If you have flatfeet, the arch on the inside of your feet is flattened.
♥ Flatfeet usually doesn't cause a problem. However, flatfeet can
contribute to problems in your feet, ankles and knees.
• Signs and symptoms
♥ A flat look to one or both of your feet
♥ Uneven shoe wear and collapse of your shoe toward the inside of your
flat foot
♥ Lower leg pain or weakness
♥ Pain on the inside of your ankle
♥ Swelling along the inside of your ankle
♥ Foot pain

INFLAMMATORY CONDITIONS:
• TYPES

1. Arthritis – rheumatic disease involving joint symptoms and

abnormalities
2. Non-articular rhematic diseases – involves pathologic changes in
structures related to joints but not within joint themselves.
a. Fibrositis – connective tissue inflammation in any location especially
around the joints, and in or near the tendons, muscle sheats or
other fasciae layers.
b. Bursitin – inflammation of the bursa major. Bursa are located in
shoulder, elbow, hips, knees
c. Tendinitis – inflammation of the tendons.
d. Myositis – inflammation of voluntary muscles
e. Peritendinitis – inflammation of tendon sheats
f. Synovitis – inflammation of synovial membrane
g. Tenosinovitis – inflammation of tendon, tendon sheats, and synovial
membrane commonly in hands, wrists, ankle and feet.

• SIGNS AND SYMPTOMS

♥ Limited movement
♥ Loss of function
♥ Pain
♥ Swelling
 ♥ Redness

AUTO-IMMUNE DISORDERS:

• RHEUMATOID ARTHRITIS
♥ It is a connective tissue disease characterized by chronic inflammatory
changes in the synovial membrane and other structure.
♥ Is a chronic systemic disease although most prominent as a non
suppurative inflammation in the diarthroidal joints, may also be
manifested by lesion of the vasculature, lungs, nervous system, and
other major organs of the body.

• Etiology
♥ Exact cause is unknown
♥ Hereditary
♥ Infection
♥ Stress
♥ Metabolic disorder
♥ Auto-immune
♥ Allergic phenomenon

• Pathology

♥ 4 stages of rheumatoid arthritis:

STAGE 1 – SINOVITIS STAGE

- inflammation of the synovial membrane
- tissue thickens with edema and congestion of the synovial
membrane

STAGE 2 – PANNUS STAGE

- Thickened synovial tissue grows inward along the surface of the
articular cartilage
 - Pannus appears to be reddish, rough and adheres tightly to the
underlying cartilage and damages it.

STAGE 3 – FIBROUS ANKYLOSIS STAGE

- Granulation of tissue becomes invaded with tough fibrous tissue
and converted into scar tissue which inhibits joint movement.
- Cause subluxation and distortion of affected joints

STAGE 4 – BONY ANKYLOSIS

- there is form bony union as bone tissue calcifies and changes
into osseous tissues.

• PATHOPHYSIOLOGY

♥ The disease process with in the joints (intraarticular) begins as an

inflammation of the synovium wuth edema vascular congestion, fibrin
exudates and cellular infiltrate.
♥ Particularly damaging to joint tissue is the enzyme collagenase because
it breaks down collagen, the main structural protein of connective
tissue.
♥ RA may also affect other body system and rheumatoid nodules may
form in the heart, lung and spleen.

• Signs and Symptoms

1. Subcutaneous nodules – appear over tendon sheaths particularly over

pressure areas like the elbow
2. Painful, swollen joints especially proximal interphargeal joints of
fingers, wrist knees, feet and ankle.
3. Elevated body temperature
4. Morning stiffness
5. Paresthesias of hands and feet
6. Splenomegaly
7. Enlarged lymph nodes
8. Signs of anemia

♥ CLASSIC RA = Seven or more criteria observed

 ♥ DEFINITE RA = 5 criteria with joint signs or symptoms continues for
at least 6 weeks
♥ PROBABLE RA = 3 criteria with joint signs or symptoms continuous for
at least 6 weeks
♥ POSSIBLE RA = 2 criteria with joint signs or symptoms continuous for
at least 6 weeks.

• Laboratory Diagnosis

♥ Elevated ESR
♥ Leukocytes
♥ Anemia
♥ Latex fixation test – presence of rheumatoid factor
♥ Narrowing of the joint spaces and crosion of articular surfaces on X-
ray examination
♥ Inflammatory changes in synovial tissue obtained by biopsy

• Nursing Interventions

1. Provide rest – keep joints as straight as possible. Prevent flexion

deformities – firm mattress, no pillows under his knees use footboard
and trochanter roll to prevent external rotation.
2. Relieve pain – by analgesics and NSAID, provide heat therapy as
ordered
- warm compresses.
- heat paraffin to 125 to 129 F (52-54 C)
3. Diet should be well balanced
4. Anemia should be treated
5. Maitain mobility – exercises are done slowly, increased gradually and
not carried past the point of being painful.
 Passive exercises
 Isometric Exercises – client exerts force without changing the
length of the muscle setting exercises, ( alternating tightening and
relaxing the muscle), gluteal muscles setting by contracting and
relaxing the buttocks, quadriceps setting – pressing the popliteal
space against the mattress.
 Resistive Exercises – those actively done by the client with manual
or mechanical resistance. To develop muscle strength.
 • Treatment
1. Analgesic – aspirin
2. Non-steroidal anti-inflammatory drugs (NSAID) – Indocin –
Indomethacin
3. Gold compounds – myochrysine – sodium thiomalate
4. Antimalaria drugs
Chloroquine
Hydroxychloroquine
5. Corticosteroids
6. Antacids
7. Paraffin dips of affected extremity for relief of joint pain by
providing uniform heat.
8. Surgery – when medical therapy fails to reduce inflammation
• Synovectomy – to remove access synovial fluid and tissue in order
to prevent recurrence of inflammation.
• Arthrotomy – opening in the joints to remove damaged tissue or
calcium deposits.
• Arthrodesis – fusion of the joint to give stability, correct
deformity and relieve pain.
• Arthroplasty – plastic reconstruction of a joint to permit
mobility and weight bearing and alleviate pain.

• SYSTEMIC LUPUS ERYTHEMATOSUS – SLE

♥ Chronic connective tissue disease involving multiple organ system.
♥ Is a chronic inflammatory disease of autoimmune origin that affects
primarily the skin, joints and kidneys, although it may affect virtually
every organ of the body.

• Clinical features

1. etiology not clearly understood – but believed to be auto-immune,

hereditary and viral cause, drug-induced
2. most frequently found in young woman with signs and symptoms
referable to joints and skin
3. remissions and exacerbation
 4. very difficult to validate diagnosis

 3 major areas are currently being researched as possible causes of SLE:

1. Genetic Factors – family members of persons with SLE have an increased
chance of developing the disease.
2. Environmental Factors – ultraviolet light is known to cause exacerbations.
3. Alteration in the Immune Response – cause immune complexes containing
antibodies to be deposited in tissue, causing tissue damage.

 Necrosis of the glomerular capillaries, inflammation of cerebral and ocular

blood vessels, necrosis of lymph nodes, vasculitis of the GI tract and pleura,
and degeneration of the basal layer of the skin.

• Signs and Symptoms:

1. Subjective:
• Malaise
• Photosensitivity
• Joint pain
2. Objective
• Fever
• Butterfly erythema on the face
• Positive LE prep.

•Diagnostic Tests
♥ Clinically documented multiorgan damage
♥ Positive fluorescent anti – nuclear antibody test (ANA)
♥ Increase ESR
♥ Elevated serum rheumatoid factor
♥ Increased WBC
♥ Decreased RBC and hemoglobin
♥ Renal function test is elevated
♥ Positive LE – cell test

• Treatment
♥ Corticosteroids and analgesics to reduce pain and inflammation
♥ Supportive therapy as major organs become affected (heart, kidneys,
CNS, GI)
• Nursing Care

1. Administer medications and observe for side effects .

2. Help the clients and family code with severity of the disease as well
as its poor prognosis.
3. Improve and maintain nutritional status.

METABOLIC CONDITIONS
• GOUTY ARTHRITIS
♥ Inflammation of the joints secondary to abnormal metabolism of uric
acid.
♥ Usually affects the big toe
♥ Is ametabolic disorder that develops as a result of prolonged
hyperuricemia (elevated serum uric acid ) caused by problems in
synthesizing purines or by poor renal excretion of uric acid.
♥ Incidence highest in males, a familial tendency has been demonstrated.
♥ May have deposition of uric acid crystal (tophi) in tissue or renal urate
lithiasis (kidney stone) may result from precipitation of uric acid in the
presence of a low urinary pH.

• Etiology
♥ Genetic defect in purine metabolism – overproduction of uric acid
♥ Decreased uric acid excretion – CRF
♥ Diet – high in purine

•Diagnostic Test
♥ Elevated ESR, WBC
♥ Increase serum uric acid levels
♥ Synovial fluid reveal urate crystals

• Signs and Symptoms

♥ Redness, swelling joints
♥ Joint pain
 ♥ Limited movement
♥ Tophi – urate crystals deposited in great toe, ankle, or increase wherein
there is dimished blood flow.

• Management
♥ Administration of anti-inflammatory and (ANTI GOUT) agents to
decrease synthesis of uric acid
- Purinase
- Llanol
- Synol
- Syloprim
- Allopurinol
♥ Salicytes
♥ NSAID
♥ alkaline-ash diet to increase the pH of urine to discourage precipitation
of uric acid and enhance the action of drugs (URICOSURIC AGENT)
increase excretion of uric acid
♥ Benemid - Probenecid
♥ Colsalide - Colchicine
♥ elimination of foods high in purines
♥ weight loss is encouraged if indicated
♥ Diet – low purine diet, alkaline ash diet – avoid shellfish, sardines, liver,
kidneys, internal organs

• Nursing Care:
1. Assess joint pain, motion and appearance
2. Administer anti- inflammatory agents such as Butazolicin,
oxypheabutazone (Tandearil), or endomethacin (Indocin) with antacids
or milk to prevent peptic ulcers. Observe therapeutic response.
3. Careful align joints so they are slightly flexed during acute stage,
encourage regular exercise, which is important for long term
management.
4. Use a bed cradle during the acute phase to keep pressue of sheets
off joints.
5. Increase fluid intake to 2000 to 3000 ml / day to prevent formation
of calculi
6. Instruct client to avoid high-purine foods suchs as organ meats,
anchovies, sardines and shellfish diet.
• OSTEOARTHRITIS
♥ Degenerative joint disease also known as osteoarthritis is an extremely
common disease that is probably as old as civilization.
♥ Women are more severely affected by the disease, although the
incidence rates are the same for males and females
♥ Primary joint disease is the most common type of noninflammatory joint
disease. Primary degenerative joint disease is distributed throughout
the central and peripheral joints of the body, usually affecting the
joints of the hand, wrist, neck, lumbar spine, hips, knees and ankle.
♥ The etiology is unknown, but age is an important factor in the
development of the disease.
♥ The quantity and quality of proteoglycans decrease with the aging
process and predispose the cartilage to breakdown and degenerate.

• Clinical Manifestations
1. Pain – worse with weight bearing, improves with rest.
2. Swelling and joint enlargement:
a. Heberden’s Nodes – bony protuberances occurring on the dorsal
surface of the distal interphalangeal joints of the finger.
b. Bouchard’s Nodes – bony protuberance occurring on the proximal
interphalangeal joints of the finger
c. Coxachrosis (Degenerative Joint Disease of the hip) – pain in the hip
on weight bearing, with pain progressing to include groin and medial
knee pain.
3. Muscular Atrophy – from disuse, joint instability and deformity
4. Decreased Range of Motion – depends on amount of destroyed
cartilage
5. Join stiffness – worse in the morning and after a period of rest or
disuse.

• CHARACTERISTIC PATHOLOGIC CHANGES AFFECTING

THE ARTICULAR CARTILAGE
1. Erosion of articular cartilage
2. Thickening of underneath the cartilage
 3. Medications to reduce symptoms such as analgesics, anti-inflammatory
agents, and steroids.
4. Exercise of affected extremities.
5. Surgical intervention
a. Synovectomy – removal of the enlarged synovial membrane before
bone and cartilage destruction occurs.
b. Arthrodeseis – fusion of a joint performed when the joint surfaces
are severely damaged, this leaves the client with no range of motion
of the affected joint.
c. Reconstructive Surgery – replacement of a badly damaged joint with a
prosthetic device.

• OSTEOPOROSIS
♥ A clinical condition in which there is a decrease in total amount of bone
to the point that factures occur with minor trauma.
♥ Calcium in the bone is depleted and the bone matrix fails to produce
replacement bone. The result is a weakening of the structure.

• Causes
♥ Exact cause is not known
♥ Nutritional deficiency – Vitamin C, calcium deficiency
♥ Endocrine disease – hyperthyroidism, hyperparathyroidism, cushing’s
syndrome, women past menopause
♥ Prolonged immobility – due to lack of normal stresses and strains.

• Signs and Symptoms

♥ Low back pain or musculo-skeletal aching
♥ Pathological fracture
♥ Increase in urinary calcium especially at night as calcium withdrawal
increase.

• Management
♥ Exercise with frequent rest periods
♥ Avoidance of severe fatigue
♥ Spinal support – corset or light brace in upright position
 ♥ Analgesic
♥ Muscle relaxants
♥ Adequate intake of protein, Vitamin D and Calcium
♥ Estrogen therapy to post menopausal women.

• OSTEOMALACIA
♥ Decalcification, softening of bones
♥ Defined as a defect in mineralization of adult bone, generally resulting
from abnormalities in Vitamin D metabolism.

• Cause
♥ Poor intake of Vitamin D
♥ Decrease exposure to sunlight
♥ Intestinal malabsorption
♥ Anticonvulsant therapy and hepatic and renal disease

• Signs and Symptoms

♥ Widespread softening of bones especially on spine, pelvis and lower
extremities
♥ Bones are deformed, maybe bent or flattened as the bone soften
♥ Pain
♥ Tenderness
♥ x-ray changes reveal pseudofractures or cyst formation

• Management
♥ Adequate nutrition
♥ Sunshine exposure
♥ Vitamin D supplements

INFECTIOUS CONDITIONS
• BACTERIAL ARTHRITIS
• Etiology
♥ invasion of the synovial membrane by microorganism, most often
Gonocossi, meningococci, coliforms, salmonellae and Haemophilus
Influenzae.

• Epidemiology
♥ susceptible to patient who had recent joint surgery and trauma,
intraarticular injections and rheumatoid arthritis.

• Pathophysiology
♥ synovial tissue respond to bacterial invasion by becoming inflamed. The
joint cavity may become involved, and pus will be present in the synovial
membrane and synovial fluid.
♥ patient complain of pain, swelling, and tenderness of the joint
♥ joint aspiration is helpful in making the diagnosisi if the presence of
organism can be demonstrated in the synovial fluid. White blood cell will
be high, and glucose content of fluid may be reduced.

• Medical Management
1. Appropriate antibiotic therapy.
2. Rest or immobilization of the joint.
3. Surgical drainage if infection does not respond to antibiotic therapy
4. Resumption of active range of motion when infection subsides and
motion can be tolerated.

• Nursing Management
1. Promoting rest of the affected joint.
2. Administering antibiotics and pain medication as prescribed.
3. Encouraging the patient to participate within restriction of prescribed
rest for joint.
4. Patient teaching:
a. Encouraging active joint motion when motion is permitted.
b. Instructing in proper administration of antibiotics if theraphy is to
be continued after discharge.
c. Assuring that patient is aware of plans for follow up with physician.
• OSTEOMYELITIS
♥ Bone infection from pyrogenic microorganism
♥ i.e., Staphylococcus Aureus – 90% of cases
♥ Streptococcus
♥ Salmonella
♥ although the development of osteomyelitis is often precipitated by a
traumatic event or is a complication of trauma. It is included with the
degenerative disorders because of its chronic and debilitating aspect.

• 2 Types

a. Exogenous Osteomyelitis – caused by pathogen from outside the body,

such as from an open fracture or surgical procedure.
b. Hemategenous Osteomyelitis – caused by blood-borne pathogen
originating from infectious site within the body. Examples include
sinus, ear, dental, respiratory and genitourinary infectious.

• Pathophysiology

- In hematogenous Osteomyelitis, the organism reach the bone

through the circulatory and lymphatic system. The bacteria
lodge in the small vessels of the bone, triggering an
inflammatory response.
- The femur, tibia, humerus and radius are commonly affectede.
- Bone inflammation is marked by edema, increased vasculature
and leukocyte activity. The infectious process weakens the
cortex, thereby increasing the risk of pathologic fracture.
- Brodie’s Abcesses are characteristic of chronic osteomyelitis.
- In cases of exogenous esteomyelitis, the infections begin in the
soft tissue and eventually forming abscess.
- Chronic Osteomyelitis is difficult to treat. Recurrent
infections, areas of dead bone (sequestrum), and scar tissues
are contributing factors to its resistance to treatment.
- Patient may report fever, malaise, anorexia and headache. The
affected body part maybe erythematous, tender and
 edematous. There maybe an opening in the skin, draining
purulent material.

• Signs and Symptoms

• Pain
• Heat, redness, swelling, tenderness
• Limited movement
• Rise in temperature, chills
• General body malaise and weakness
• Marked leukocytosis
• Elevated ESR
• Possibly, positive blood cultures

• Management
• Analgesic
• Anti-inflammatory
• Antibiotic especially Penicillin
• Wound Irrigation
• Incision and drainage
• Debridement
• Complete removal of dead bone and soft tissue
• Control of infection
• Elimination of dead space (after removal of necrotic bone)
• Sequestrectomy – surgical removal of the dead infected bone and
cartilage

• Nursing Care
• Use surgical aseptic technique when changing dressings
• Maintain functional body augment and promote comfort.
• Allow the client ample time to express feelings about long term
hospitalization.
• Utilize room deorizer is a foul odor is apparent
• Encourage nutrient dense diet to compensate for antibiotic impact on
nutritional status.
 • TB of the Spine – POTT’S Disease
- bone infection caused by invasion in the body by Kock’s bacillus

• Signs and Symptoms

• Muscle spasm
• Stiffness
• Tendency to reach things on the floor by bending the knees rather than
the back.
 Effects usually the lower dorsal spine and upper lumbar spine.
• Gibbus formation angulation or pronounce antero-posterior curve of the
spine as in hunchback due to collapse of the vertebrae
• Paralysis occasionally
• Afternoon fever

• Complications – abscess formation

1. Cervical region – pharynx respiratory problems.
2. Dorsal region – mediastinum and may rupture into the lungs.
3. Lumbar spine – lumbar muscles or gluteal region or may follow the
course of ilopsoas muscles and point in the groin (psoas abscess) -
most common.

• Management

1. Anti TB drugs
- Rifampicin
- PZA
- INH
2. Immobilization – Taylor body brace
3. Fresh air, sunshine and proper diet

• DYSPLASIA OF THE HIP

 Condition in which the head of the femur is improperly seated in the
acetabulum, or hip socket, of the pelvis
 Congenital or develop after birth
  Neonate: - due to laxity of ligament around the hip, allowing the
femoral head to be displaced from the acetabulum upon manipulation.
 Implementation: splinting of the hips with Pavlik harness to maintain
flesion and abduction and external rotation (neonatal period)
 Assessment: - infacnts has asymmetry of the gluteal and thigh skin
folds when the child is placed prone and the legs are extended against
the examining table.
 Limited range of motion in the affected hip.
 Asymmetric abduction of the affected hip when the child is placed
supine with the knees and hips flexed.
 Apparent short femur on the affected side.

• CONGENITAL HIP DYSPASIA

 Traction and surgery to release muscles and tendons
 Maintain abduction and external rotation ( application of double diapers
when changing the infant ).
 Following surgery, positioning and immobilization in a spica cast until
healing is achieved.
 Walking child has minimal to pronounced variation in gait with lurching
toward the affected side.
 Positive Trendelenburg sign
 Positive Barlow or Ortolani’s maneuver.

DEVELOPMENTAL ANOMALIES OF
THE EXTREMITIES
A. polydactyl – extra digits
B. Syndactyly – partial or complete fusion of two or more digits
C. Amelia – absence of a limb
D. Treatment – if possible, early correction and preparation for use of a
prosthesis.
• MUSCULO-SKELETAL CONDITIONS

• Traumatic Conditions
1. Contusion – an injury to soft tissue produced by blunt force, blow, kick or
fall.

• Signs and Symptoms

• Hemorrhage into the injured part (ecchymosis) from rupture of small
blood vessels
• Pain, swelling

• Treatment
• Elevate the affected part
• Cold compress to diminish edema formation
• Pressure bandage to reduce swelling
• Apply heat to affected area after 6 hours to promote absorption

2. Strain – injury to muscle or tendons. Treatment same as contusion

3. Sprain – injury to ligamentous structures surrounding a joint, caused by

wrenching or twisting

4. Dislocation – a condition in which the articular surfaces of the bones

forming the joints are no longer in anatomic contact with one another.

• Clinical Manifestations
• Change in contour of the joint
• Change in length of extremity
• Loss of normal movement
• Change in axis of dislocated bones.

5.Fracture – a break in the continuity of a bone

• General Classification
 a. Complete Fracture – fracture involving the entire cross-section of the
bones
b. Incomplete Fracture – a fracture involving only a portion of the cross
section of the bone.
c. Open Fracture (compound) – break in the bone, skin and there’s
communication between the fracture site and the external air.
d. Closed Fracture – (simple) – break in the bone, skin and there’s
communication between the fracture site and the external air.

• Specific types of fracture

a. Greenstick Fracture – fracture in which one side of a bone is broken,
the other side is being beat.
b. Comminuted – a fracture in which bone has splintered into fragments.
c. Depressed – a fracture in which a fragment is driven inward (fracture
of skull, facial bones)
d. Transverse – a break straight across the bone
e. Spiral – with the fracture lines partially encircling the bone
f. Spiral – with the line of fracture at an oblique angle to the bone shaft.

• Signs and Symptoms

1. Signs of local trauma (injury to soft tissue)
• pain
• tenderness
• swelling
• bruising
• muscle spasm
• redness
2. Due to damage to blood vessels
• bleeding
3. Crepitus sound – grafting sound produced as bones rub against each other
4. Shortening of extremity
5. Presence of deformity
6. Limited function/loss of function
7. Numbness if with injury to the nerves

• Complication of Fracture
1. Immediate
- shock
- fat embolism
- injury to skin, muscle, blood vessels and nerves
2. Early
- infection – gas gangrene, tetanus, osteomyelitis
3. Late
- non-union
- delayed union
- mal-union
- avascular necrosis of the bone

• MANAGEMENT OF FRACTURE (4 R’s)

1. RECOGNITION – of presence of fracture

2. REDUCTION
a. Closed Reduction – done by manipulation
b. Open Reduction
c. Traction

3. RETENTION
a. Cast
b. Traction
c. Braces and splints
d. Bandage

4. REHABILITATION – restoration to normal function