Ch. 52 Assessment of the Musculoskeletal System

I. Intro

A. Includes

1. bones

2. joints

3. skeletal muscles

4. supporting structures (needed for movement)

B. Mobility (movement)

1. basic human need

2. needed to perform ADLs

3. immobility

decreased self esteem

decreased self worth

a. results from

trauma

disease

surgery

b. for extended period of time

other body systems can be affected

(1) skin breakdown

(2) constipation

(3) thrombus formation

(4) sensation problems

if nerves are damaged by trauma or disease

II. ANATOMY & PHYSIOLOGY REVIEW

A. Skeletal System

206 bones and multiple joints

growth and development during childhood and adolescence

1. Bones

a. Types & Structure

(1) classification/types

(a) shape

i) long bones

cylindric with rounded ends

i.e. femur

often bear weight

ii) short bones

small

i.e. phalanges

bear little or no weight

iii) flat bones

protect vital organs and usually contain blood forming cells

i.e. scapula

iv) irregular bones

unique shapes

i.e. carpal bones in wrist, small bones in the inner ear

v) sesamoid bones

least common type

develops within a tendon

i.e. patella

(b) structure/composition

i) tissue types

almost every bone has both tissue types but in varying quatities

i.e. long bone has a shaft (diaphysis) and two knoblike ends

(epiphyses)

(1) cortex

outer layer of bone

dense, compact bone tissue

structural unit is the haversian system

(a) haversian system

complex canal network containing microscopic blood vessels

these blood vessels supply nutrients and oxygen to bone &

lacunae (small cavities that house osteocytes, or bone cells)

canals run vertically in hard, cortical bone tissue

(2) medulla

inner layer

spongy, cancellous tissue

(a) contains trabeculae (large spaces)

filled with red and yellow marrow

i) red marrow

hematopoesis (blood cell production) site

ii) yellow marrow

contains fat cells

these can be dislodged and enter the blood stream to cause fat

embolism syndrome (FES) - life threatening complication

ii) volkmann's canals

connect bone marrow vessels with the haversian system and

periosteum (outermost covering of the bone)

(1) osteogenic cells

in deepest layer of periosteum

differentiate into

(a) osteoblasts (bone forming cells)

(b) osteoclasts (bone destroying cells)

iii) matrix (osteoid)

consists of collagen, mucopolysaccharide, and lipids

deposits of inorganic calcium salts (carbonate and phosphate) in the

matrix - provide the hardness of bone

iv) bone is a very vascular tissue

total blood flow between 200 and 400 mL/min

each bone has a main nutrient artery - enters near the middle of the

shaft and branches into ascending and descending vessels

very few nerve fibers are connected to bone

sympathetic nerve fibers control dilation of blood vessls

sensory nerve fibers transmit pain signals experienced by patients

who have primary lesions of the bone (bone tumors)

(1) these vessels supply:

(a) cortex

(b) marrow

(c) haversian system

b. Function

(1) The Skeletal System:

after puberty, bone reaches its maturity and maximal growth

bone is a dynamic tissue

it undergoes a continuous process of formation and resorption (destruction)

at equal rates until the age of 35

late years - bone resrption increases, leads to decreased bone mass,

predisposing patients to injury (esp older women)

(a) functions:

i) provides a framework for the body

allows the body to weight bearing or upright

ii) supports the surrounding tissues

i.e. muscle and tendons

iii) assists in the movement through muscle attachment and joint

formation

iv) protects vital organs

such as the heart and lungs

v) manufactures blood cells in bone marrow

vi) provides storage for mineral salts (calcium and phosphorus)

(b) numerous minerals and hormones affect bone growth and metabolism

i) calcium & phosphorus

bone accounts for 99% of calcium in body & bone accounts for

90% of phosphorus

calcium & phosphorus have inverse relationship (i.e. as calcium

rises, phosphorus decreases)

if calcium is decreased, the bone (which stores calcium) releases

calcium into the bloodstream in response to PTH stimulation

no calcium = no bone growth

Crohn’s/Ulcerative Colitis – don’t absorb calcium, prone

osteoporosis

osteoblasts - produce collagenous and noncollagenous proteins that

compose osteoid.

osteoclasts – actively resorb mineralized tissue

these are antagonists, important for balance

Liver Mj

Vitamin D Mj

Kidney Mj

Intestine Mj

Parathyroid MjGland Mj

Bone Mj

Serum MjCalcium Mj

+ Mj- Mj

+ = Simulation Mj

- Mj = Inhibition Mj

Kidneys release hormone Mjto activate Vitamin D Mj

Kidneys release hormone Mjto activate Vitamin D Mj

Low Ca++ Mj

Increase Mjabsorption of Mj

Ca++ Mj

Bone Mjresorption of Mj

Ca++ Mj

High Ca++ Mj

Bone remodeling –

in the remodeling sequence, bone sections are removed by bone-resorbing cells (osteoclasts) and

replaced with a new section laid down by bone-forming cells (osteoblasts)

cells work in response to signals generated in that environment

1st phase of remodeling is mediated only by the multinucleated osteoclastic cells

they are activated, scoop out bone and resorb it

then the work of the osteoblasts begins

they form new bone that replaces bone removed by the resorption process

the sequence takes 4 to 5 months

1st 24 hours – start healing

4-6 weeks – most are healed enough to weight bear

3 months – as hard as it was when you fractured it

ii) calcitonin

work to maintain equilibrium when serum levels are altered

produced by thyroid gland and decreases serum calcium

concentration if above normal

inhibits bone resorption

increases renal excretion of calcium and phosphorus

iii) vitamin D

produced in body and transported in blood

promotes absorption of calcium and phosphorus from the small

intestine

enhance PTH activity to release calcium from the bone

decreased level - osteomalacia (softening of the bone) in the adult

iv) parathyroid hormone (PTH)

work to maintain equilibrium when serum calcium levels are altered

secreted when calcium levels drop

stimulates osteoclastic activity and release calcium into the blood

reduces renal excretion of calcium and eases its absorption from the

intestine

if levels increase, PTH diminishes - preserves the bone calcium

supply (feedback loop system)

calcium police = regulate absorption and reabsorption of calcium

v) growth hormone

secreted by the anterior lobe of the pituitary gland

responsible for increasing bone length and determining the amount

of bone matrix formed before puberty

in childhood, increased secretion = gigantism; decreased secretion =

dwarfism

in an adult, an increase = acromegaly (characterized by bone and

soft tissue deformities)

vi) adrenal glucocorticoids

regulate protein metabolism

increase or decrease catabolism to reduce or intensify the organic

matrix of the bone

also aid in regulating intestinal calcium and phosphorus absorption

vii) estrogens and androgens

estrogens - stimulates osteoblastic (bone-building) activity, inhibits

PTH

in menopause estrogen decreases, women vulnerable to low calcium

levels with increased bone loss (osteoporosis)

androgens - (testosterone) promote anabolism (body tissue building)

and increase bone mass

viii) thyroxine

principal hormone secreted by thyroid gland

primary function - increase the rate of protein synthesis in all types

of tissue (including bone)

ix) insulin

works with growth hormone to build and maintain healthy bone

tissue

2. Joints

space in which two or more bones come together

aka "articulation" of the joint

major function - provide movement and flexibility in the body

a. 3 types

(1) Synarthrodial

synarthrosis = completely immovable (i.e. cranium)

(2) Amphiarthrodial

amphiarthrosis = slightly movable (i.e. pelvis)

(3) Diarthrodial (synovial)

diarthrosis = freely movable (i.e. elbow and knee)

most conmonly involved in disease or injury

(a) only type lined with synovium

a membrane that secretes synovial fluid for lubrication and shock

absorption

lines inner portion of joint capsule (does not extend to spongy bone ends)

(b) articular cartilage

collagen fiber matrix with a complex ground substance within

(c) synovitis (synovial inflammation)

common in patients with inflammatory arthritis

accompanied by breakdown of carilage

(d) bursae (small sacs lined with synovial membrane)

located at joints and bony prominences

prevent friction between bone and adjacent structures

i) bursitis - inflammation of bursae

(e) joints described by their anatomic structure

i) ball and socket (shoulder, hip)

permit movement in any direction

ii) hinge (elbow)

allow flexion and extension (in one plane)

iii) condylar (knee)

rotates (slightly), extends and flexes

iv) biaxial (wrist)

gliding

v) pivot (radioulnar)

permit only rotation

B. Muscular System

1. 3 types of muscle in the body

a. Smooth

non stirated, involuntary muscle

responsible for contractions of organs and blood vessels

controlled by autonomic nervous system

b. Cardiac

striated, involuntary muscle

controlled by autonomic nervous system

c. Skeletal

striated, voluntary muscle

controlled by the central and peripheral nervous systems

motor end plate - junction of a peripheral motor nerve and the muscle cells that

it supplies

fasciculi - connective tissue bundles that hold muscle fibers together

entire muscle surrounded by dense, fibrous tissue or fascia which contains the

muscle's blood, lymph and nerve supply

main function - movement of the body and its parts

adjacent muscle tissue to injury or disease in bones, joints and supporting

structures are often involved (limiting mobility)

during aging process - muscle fibers decrease in size and number

atrophy - results when muscles are not regularly exercised and they deteriorate

from disuse

PROPERTIES OF THE THREE DIFFERENT MUSCLE TYPES

**KNOW HOW MUSCLES CONTRACT**

Skeletal Cardiac Smooth

Histologic

appearance

Cross-striated, multinucleated

muscle fibers

Cross-striated, single nucleated

muscle fibers containing

intercalated disc

Non-striated, spindle cells with a

single nucleus

Site skeletal coverings muscular component of the

heart

found in wall of blood vessel,

airways glands, and walls of

hollow organs

Control

voluntary/reflex: contolled by

somatic nervous system

self-regulated by pacemaker

cells; heart rate can be altered

by autonomic nervous system

Involuntary control or regulation

by inhrent contraction initiation

(visceral smooth muscle)

nature of the

contraction

rapid contraction and

relaxation

spontaneous and thythmic

contraction slow and sustained contraction

Function

voluntary movement of skeletal

and posture maintenance

contraction pump blood around

the body

related to the structure (e.g.

regulation of blood wessel

diameter, hair erection)

2. supporting structures

very susceptible to injury

a. tendons

bands of tough fibrous tissue that attach to bones

b. ligaments

attach bones to other bones at joints

3. physiology of skeletal muscle contraction

fatigue – lose muscle contraction

spasm – group exhausts reserves of energy and no longer wants to work together (twitching,

cramps)

excitation - change in action potential, changes permeability of the cell to allow

movement of Na and K

coupling – migration of Ca, coupling with Ca and muscle proteins, depolarization

contraction – binding of muscle proteins (actin + myosin) causing the muscle to

lengthen

relaxation – Ca is absorbed by the sarcoplasmic teticulum (muscle protein) causing

the muscle to lengthen

muscle metabolism – Na/K ATPase (protein that results in energy production)

pump, balance between intra and extracellular electrolytes (Na, K, Cl)

III. MUSCULOSKELETAL CHANGES ASSOCIATED WITH AGING

A. osteopenia - decreased bone density (bone loss)

occurs as you age

esp seen in white, thin women

B. osteoporosis = severe osteopenia

causes posture and gait changes

predisposition to fractures

C. synovial joint cartilage becomes less elastic and compressible

as a result, joint cartilage becomes damaged, leading to OA

genetic defects may contribute

most commonly affects weight bearing joints (hips, knee, cervical and lumbar spine) but

joints in the shoulder and UE can also be affected

D. muscle tissue atrophy

increased activity and excercise can slow progression and restore strength

decreased coordination, loss of strength, gait changes, r/f falls with injury

aging boneso loss of bone tissue

less stiff less strong more brittle

o bone remodeling takes longero stem cells in bone marrow are less efficiento postural changeso increased risk of fractures (osteoporosis)

aging joints:o cartilage becomes more rigid, fragile, and susceptible to fibrillation, water

decreases in cartilage synovial joint cartilage:

o less elastic and compressibleo osteoarthritis

aging muscle:o muscle fiber composition changeo changes in the muscle proteins

changes result:o decreased coordinationo muscle strength losso gait changeso predisposition to falls with injury

IV.

ASSESSMENT METHODSA. Patient History (Personal)

detailed, accurate history

o reveals info that can direct physical assessment

o accidents, illnesses, lifestyle and drugs can contribute

o young men - greatest r/f trauma r/t motor vehible crashes

o older adults - greatest risk for falls tat result in fractures and soft-tissue injury

ask about traumatic injuries and sports activities (no matter when they occurred) - can

cause OA years after

o injuries to spine 30 years ago could be causing lower back pain

o previous or current dz - diabetes (r/f osteomyelitis, slowed healing)

ask about previous hospitalizations/illnesses/complications

ask about ability to perform ADLs independently (use of assistive/adaptive devices are

used)

ask about current lifestyle

o weight bearing activities - reduce risks for osteoporosis &maintain muscle

strength

o high impact sports - injury to soft tissues and bone

o tobacco use - slows healing of musculoskeletal injuries

o excess alcohol - can decrease vitamins and nutrients needed for bone and muscle

tissue growth

ask about occupation/work life - can cause/contribute to injury

o manual labor = fractures

o computer = carpal tunnel [an entrapment of the median nerve in the wrist] or neck

pain

o construction & health care workers = back injury r/t prolonged standing or excess

lifting

o amateur & prof athletes = acute injuries [joint dislocations, fractures] and chronic

disorders [joint cartilage trauma] could lead to OA)

ask about allergies - part allergies to dairy products (could cause decreased calcium

intake)

ask about drug use previous and current use of drugs (prescribed, OTC, illicit) - some

drugs like steroids can negatively affect calcium metabolism and promote bone loss

some drugs used may be taken to relieve pain - ask about herbs, vitamins/minerals,

biologic compounds (used for arthritis & other problems- glucosamine, chondroitin)

complementary and alternative therapies - commonly used for various types of arthritis

and arthralgias (joint aching)

1. Nutrition/Dietary History

determine any risks of inadequate nutrient intake

most people (esp women) do not get enough calcium in their diet

determine if the patient has had a significant weight gain or loss

food recall - ID deficiencies and excess in diet (lactose intolerance is common

problem that can cause inadequate calcium intake)

undernutrition – (seen in low socioeconomic classes) can't afford foods with adequate

nutrition (esp older adults)

inadequate protein or insufficient vitamin C & D - slows bone and tissue healing

obesity - excess stress and strain on bones & joints leading to fractures and trauma to

joint cartilage (good in a sense because it provides stress to keep bones healthy)

obesity also inhibits mobility (predisposes to respiratory and circulatory probs)

eating disorders (anorexia, bulimea) - r/f osteoporosis r/t decreased calcium and vit d

intake

insufficient vit D = rickets

2. Family History & Genetic Risk

ID disorders with familial or genetic tendency

osteoporosis, gout - occur in several generations of family

osteogenic sarcoma - bone cancer, influenced TP53 gene mutation

+ family history increases risk

3. Current Health Problems

most common reports - pain, weakness (impair mobility)

ask:

o data & time of onset

o factors that cause or make problem worse

o course of the problem (intermittent/continuous)

o clinical manifestations (subjective) and pattern of their occurence

o measures that improve manifestations (heat, ice)

pain assessment - can present many challenges, can be r/t bone, muscle, joint

problems

o ask pt to use pain scale to rate pain level

o pain - acute or chronic (depends on onset, duration)

o pain with movement - fracture

o quality of pain - dull, burning, aching or stabbing

o location of pain, areas to which it radiates

o have pt describe in own words and points to location

weakness - may be r/t individual muscles or muscle groups, proximal or distal

muscles or muscle groups

o proximal weakness may indicate myopathy (a problem in muscle tissue)

o distal muscle weakness may indicate neuropathy (a problem in nerve tissue)

o weakness in LE may increase r/f falls and injury

o in UE may interfere with ADLs

B. Assessment of the Skeletal System

bones, joints, and muscles are usually assessed at same time, head to toe

ea described separately for emphasis, understanding

inspection, palpation, ROM used

1. General Inspection

observe posture, gait, general mobility for gross deformities and impairment

note unusual findings, coordinate with PT/OT for in depth assessment

a. Posture & Gait

posture - person's body build and alignment when standing and walking

assess:

o curvature of the spine

o length, shape, symmetry of extremities

most w/musculoskeletal problems eventually have probs with gait

o 2 phases of normal, automatic gait: (1) stance (2) swing phase

o evaluate balance, steadiness, ease and length of stride

o limp or other asymmetric leg movement or deformity noted

o antalgic gait - abnormality in the stance phase of gait (when part of one

leg is painful, patient shortens the stance phase on affected side)

o lurch - abnormality in swing phase (muscles in buttocks and/or legs are

too weak to allow the person to change weight from one foot to the other,

shoulders are moved wither side to side or front to back for help in

shifting the weight from one leg to the other)

o some have a combo - chronic hip pain and muscle atrophy from arthritic

disorders

b. Mobility and Functional Assessment/Movement

assess need for ambulatory aids (canes and walkers) during transfer or while

walking and climbing stairs

observe ability to perform ADLs

pain and deformity may limit these

coordinate with PT & OT to assess the patient's functional status

assess major bones, joints, muscles by inspection, palpation, ROM

pay attention to areas that are affected or may be affected according to pt hx or

current prob

goniometer - tool used to provide an exact measurement of flexion and extension

or joint ROM

active ROM (AROM) evaluation - ask pt to move each joint through ROM by

themselves

if they can't do it themselves, ask to relax muscles in extremity, hold joint with

one hand on top and one below, and allow passive ROM (PROM) to evaluate

joint mobility

circumduction - evaluated in shoulder by having the patient move the arm in

circles from shoulder joint

limit in ROM may not be significant if there is no limit in function to meet

personal needs

for ea. anatomic location - observe skin for color, elasticity, and lesions (r/t

musculoskeletal dysfunction)

i.e. redness or warmth - indicate an inflammatory process and/or pressure injury

to the skin

c. Specific Assessments

pain or weakness in face or neck - inspect and palpate this area for tenderness

and masses

o open mouth while palpating temporomandibular joints (TMJ)

o common abnormal findings: tenderness or pain, crepitus (grating sound),

and a spongy swelling caused by excess synovium and fluid

inspect and palpate ea vertebrae of the spine in the neck - be cautious and gentle

if pain if present

o clinical findings: malalignment, tenderness, inability to flex, extend, and

rotate neck

o muscle and nerve pain often accompany neck pain if spinal nerves are

involved

o thoracic spine, lumbar spine, sacral spine - evaluated in the same manner

as the neck

o spinal alignment problems are common

o place both hands over the posterior iliac crest with the thumbs over the

lumbosacral area

o apply pressure with the thumbs along the lumbosacral spine to elicit

tenderness

o usually no discomfort until the area is palpated

o lordosis - common finding with abdominal obesity

o scoliosis - flex forward from the hips and inspect for a lateral curve in the

spine

if extremities affected - assess arms or legs at the same time (compare)

o inspect, palpate both shoulders for size, swelling, deformity, poor

alignment, tenderness or pain, and mobility

assessment of hand - most critical part of the exam

o inspect and palpate metacarpophalangeal (MCP), proximal

interphalangeal (PIP), distal interphalangeal (DIP)

o same digits compared on R and L hand

o determine ROM by observing active movement, if not possible, evaluate

passive

o quick ROM assessment - ask pt to make a fist then place ea finger next to

the thumb (if able, ROM is not seriously restricted)

evaluation of hip - relies primarily on degree of mobility bc joint is deep and

difficult to inspect or palpate

o hip pain is usually in the groin or has pain that radiates to the knee

o assessment - have pt sit and have knee flexed

o effusion (fluid accumulation) is easily seen in knee

o limitations in movement with pain are common

o poor alignment - genu valgum (knock-knee) or genu varum

(bowlegged) deformities

ankles and feet exams often neglected - contain multiple bones and joints that

disease and injury can affect

o observe and palpate each joint and test for ROM if feet are affected

d. Neurovascular Assessment

assessment of peripheral vascular and nerve integrity

begin with injured site, compare extremities

neurovascular assessment - palpate pulses below level of injury, assessment of

sensation, movement, color, temperature, pain in the injured part

if pulses are not palpated a Doppler should be used to find pulses in the

extremities

C. Assessment of the Muscular System

notice size, shape, tone and strength of major skeletal muscles

circumference of ea muscle may be measured and compared - gives an estimation of

muscle mass (only if abnormalities seen)

ask pt to demonstrate muscle strength - apply resistance to extremity and ask pt to move

against resistance (not easily quantified) - Lovett's Scale (0-5)

D. Psychosocial Assessment

clues for anticipating psychosocial problems - long work absence or permanent disability

could mean career loss

further stress if chronic pain continues and pt can not cope with stressors

anxiety & depression common with chronic pain

deformities resulting from musculoskeletal dz/injury (amputation) can effect body image

and self concept

help pt ID support systems and coping mechanisms that may be useful

encourage verbalization of feelings related to loss and body image changes

refer for psychological or spiritual counseling if needed

E. Diagnostic Assessment

1. Laboratory Assessment – Chart 52-3 test for “skeletal muscle health”

1. Laboratory Assessment

no special patient prep or follow up for any of tests in chart 52-3

teach purpose of test and the procedure they should expect

additional tests for CTDs like RA

a. Serum Calcium and Phosphorus

disorders of bone and parathyroid gland - alteration of serum calcium or

phosphorus level

monitor these electrolytes

b. alkaline phosphatase (ALP)

enzyme normally present in blood

ALP increases with bone or liver damage

in metabolic bone disease and bone cancer the enzyme concentration rises in

proportion to osteoblastic activity (bone formation)

normally slightly increased in older adults

c. muscle enzymes

major enzymes affected in skeletal muscle injury or disease

as a result of damage, muscle tissue releases additional amounts of these

enzymes, increases serum levels

enzymes increase in heart attack, trauma

(1) creatine kinase (CK-MM)

begins to rise 2-4 hours after muscle injury

elevated early in muscle disease (MD)

CK molecule has 2 subunits: (1) M - muscle & (2) B - brain

3 isoenzymes have been IDed

CK (CK-MM, or CK3) is the only isoenzyme that rises in concentration with

damage to skeletal muscle

(2) aspartate aminotransferase (AST)

moderately elevated (3-5x normal) in certain muscle dz (MD)

(3) aldolase (ALD)

levels of isoenzyme aldolase A (ALD-A) increases in certain muscle dz

(MD)

(4) lactic dehydrogenase (LDH)

LDH5 increases in certain muscle dz

2. Imaging Assessment

skeleton very visible on standard X-rays

anteroposterior and lateral projections are most common initial views

bone density, alignment, swelling and intactness can be seen

can determine conditions of joints - size of joint space, smoothness of articular

cartilage and synovial selling

soft tissue involvement may be seen but not clearly differentiated

"x-ray table is hard and cold", "remain still during filming"

try to keep older adults/those at risk for hypothermia as warm as possible - use

blankets

standard xrays - superimpose one structure on another

tomography - planes produced or slices for focus and blurs the images of other

structures

o helpful to view detailed musculoskeletal system (bc many close structures

make visualization difficult)

xeroradiography - highlights contrast between structures, clearly see margins and

edges *edge enhancement*

o higher radiation dose to the patient

o inability of test to determine tissue densities

myelography - injection of contrast medium into the subarachnoid space of the spine

(usually by spinal puncture

o vertebral column, intravertebral disks, spinal nerve roots, and blood vessels

can be visualized

o less popular than it used to be, CT and MRI have replaced this invasive,

potentially painful and risky diagnostic techniques

o similar post-test care as lumbar puncture

except HOB elevated 30-50 degrees to prevent the contrast medium

from getting into the brain

arthogram - xray study of a joint after contrast medium (air or solution) injected to

enhance visualization

o double contrast arthrography - uses both air and contrast, may be

performed when a traumatic injury is suspected

o can often determine bone chips, torn ligaments or other loose bodies within

joint

o not commonly used bc of newer advances, most joints now studied with MRI

computed tomography (CT) scan - detects musculoskeletal problems, particularly

vertebral column and joints

o scanned images used to create additional images from other angles or to

create 3-D images and view complex structures from any view

o ask ab iodine-based contrast allergies

3. Nuclear Scans

bone scan - radionuclide test in which radioactive material is injected for viewing

the entire skeleton

o primary use - detect bone tumors, arthritis, osteomyelitis, osteoporosis,

vertebral compression fractures, and unexplained bone pain

o less common today - MRI is becoming more available

o may be useful for detecting hairline fractures in patients w/unexplained

bone pain and diffuse metastic bone dz

gallium and thallium scans - similar to bone scans

o more specific and sensitive in detecting bone problems

o gallium citrate (67Ga) is most commonly used, also migrates to brain,

liver, and breast tissues & used in examination of these when dz is

suspected

o thallium (201Tl) is better for pt with osteosarcoma and diagnosing extent

of dz, traditionally used for MI diagnosis but can be used for additional

evaluations of cancers of the bone

o bones take up gallium slowly - isotope administered 4-6 hours before scan

(cannot do other tests that require contrast media or isotopes during this

time)

o teach that radioactive material poses no threat - readily deteriorates in the

body

o gallium is excreted in intestinal tract - accumulates in feces after scan

o depending on tissue, pt is taken to nuclear medicine dept 4-6 hours after

injection

o procedure takes 30-60 minutes

o patient must lies still for accurate test results

o may be repeated at 24, 48 and 72 hours

o mild sedation may be needed - relaxation and cooperation (confused older

adults, those in severe pain)

o no special care required after test

o excreted in stool and urine, but no precautions while handling

o push fluids to facilitate urinary excretion

4. Magnetic Resonance Imaging (MRI)

w/ or w/o use of contrast media

used to diagnose musculoskeletal disorders

more accurate than CT and myelography for spinal and knee problems

most appropriate for joints, soft tissue, and bony tumors that involve soft tissue

(CT is best for injuries or pathologies that involve only the bone)

image produced through the interaction of magnetic fields, radio waves and

atomic nuclei showing hydrogen density

o radio waves bounce off body tissues, since ea has its own density,

computer can distinguish between normal and abnormal

for some tissues, cross sectional image is better than that produced by radiography

or CT

lack of hydrogen ions in cortical bones - easily distinguishable from soft tissue

particularly useful in IDing problems with muscles, tendons, ligaments

ensure pt removes all metal objects and checks for clothing zippers and zippers

and metal fasteners

joint implants made of titanium or stainless steel are safe

pacemakers, stents, surgical clips usually are not

open MRIs prevent claustrophobia with older, encased machines

The Patient Preparing for Magnetic Resonance Imaging

Is the patient pregnant?

Does the patient have ferromagnetic fragments or implants, such as an older-style aneurysm clip?

Does the patient have a pacemaker, stent, or electronic implant?

Can the patient lie still in the supine position for 45 to 60 minutes (may require sedation)?

Does the patient need life support equipment available?

Can the patient communicate clearly and understand verbal communication?

Did the patient get any tattoo more than 20 years ago? (If so, metal particles may be in the ink.)

Is the patient claustrophobic? (Ask this question for closed MRI scanners)

5. Ultrasonography

sound waves produce and image of the tissue in ultrasonography

ultrasound procedure used to view:

o soft tissue disorders (masses, fluid accumulation)

o traumatic joint injuries

o osteomyelitis

o surgical hardware placement

jelly-like substance applied to the skin over the site to be examined promotes the

movement of a metal probe

no special pre or post test care necessary

quantatative ultrasound (QUS) - may be done for determining fractures or bone

density

F. Other Diagnostic Assessment

1. Biopsies

bone biopsy - the physician extracts a specimen of the bone tissue for microscopic

examination

o invasive test may confirm the presence of infection or neoplasm

o not commonly done today

o 1 of 2 techniques used to get specimen:

(1) needle (closed) biopsy

(2) incisional (open) biopsy

o important to watch for bleeding at the puncture site, tenderness, redness, or

warmth (infection indicators)

o mild analgesics may be used

muscle biopsy - done for diagnosis of atrophy (as in MD) and inflammation (as in

polymyositis)

o procedure and care are the same as bone biopsy

o diagnoses for chronic muscle dz

2. Electromyography (EMG)

evaluates diffuse or localized muscle weakness “quality of contration”

time it takes from nerve stimulation to the time the muscle contracts

usually accompanied by nerve conduction studies for determining the electrical

potential an individual muscle generates

helps in diagnosis of neuromuscular, lower motor neuron and peripheral nerve

disorders

contraindicated in pts undergoing anticoagulant therapy

may cause temporary discomfort, esp when subjected to electrical current

selected pts - mild sedation prescribed

may prescribe temporary discontinuation of muscle relaxants several days before to

prevent inaccurate test results

at bedside or in EMG lab

when EMG and nerve conduction are being done - nerve conduction is usually test

1st

flat electrodes placed along nerve, low electrical currents are passed thru electrodes to

nerve and muscle innervated

o if nerve conduction occurs - muscle contracts

testing muscle potential - small needle electrodes inserted, pt asked to perform

activities (minimal and maximal contraction tested), degree of nerve and muscle

activity recorded for later interpretation

complications: nurse provides comfort measures and inspects the needle sites for

hematoma formation (application of ice as prevention), pt may report increased pain

and anxiety after test

3. Arthroscopy

arthroscopy - may be used as a diagnostic test or a surgical procedure

arthroscope - fiberoptic tube inserted into a joint for direct visualization of the

ligaments, menisci, & articular surfaces of the joint (knee and shoulder most

common)

synovial biopsy and surgery to repair traumatic injury can be done through the

arthroscope as an ambulatory care procedure

a. Patient Preparation

knee is most commonly "scoped" so care r/t that joint

ambulatory basis or same day surgery

pt must be able to flex the knee atleast 40 degrees (so arthroscope can be

inserted)

knee can't be infected (may get worse from mechanical trauma of insertion)

procedure done for surgical repair - pt may have PT consult before arthroscopy to

learn exercises for after

o SLRs, and quad-sets are practiced in sets of 10 each

o ROM exercises also taught but may not be allowed immediately

nurse role: teach/reinforce exercises, reinforces procedure explanation and post-

test care, ensures pt signs informed consent

b. Procedure

usually given local, light general or epidural anesthesia, depending on the

purpose of the procedure

large pneumatic tourniquet - used around the thigh to minimize bleeding during

the procedure

drugs that promote vasoconstriction for control of bleeding may be used with

tourniquet

knee is flexed atleast 40 degrees and irrigated

arthroscope is inserted through a small incision is less than 1/4 inch long

multiple incisions may be needed - allow inspection at a variety of angles

after procedure a dressing may be applied depending on amt of manipulation

during test or surgery

c. Follow-Up Care

priority - evaluate neurovascular status of the patient's affected limb q hour or

according to agency/surgeon protocol

o monitor and doc distal pulses, warmth, color, capillary refill, pain,

movement and sensation of the affected extremity

encourage exercises that were taught prior to procedure

mild discomfort - mild analgesic (acetaminophen/Tylenol)

if post-op - may have short-term mobility restrictions

ice for 24 hours, elevated 12-24 hours

arthroscopic surgery - opioid-analgesic combo like oxycodone and

acetaminophen (Percocet, Tylox)

o complications not common

observe pt for swelling, increased joint pain r/t mechanical injury,

thrombophlebitis, infection

severe joint or limb pain - possible complcation - teach pt to

contact doctor immediately

surgeon sees pt 1 week after to check for complications