Exam (elaborations)
NR 509 Week 3: The Musculoskeletal System
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- IHuman Case Study
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- South University
NR 509 Week 3: The Musculoskeletal System
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NR 509 Week 3: The Musculoskeletal SystemTable of Contents
Note
For learning purposes in this course, the weekly lessons are divided by body systems and focused on specific objective physical examination techniques. The lessons are adjunct to the assigned reading and by no means a substitution. Therefore, it is incumbent upon you to fully comprehend the associated subjective health history, health promotion, and anatomy and physiology as outlined in each textbook chapter. By the end of the course, you will be proficient with conducting a complete physical examination.
Advanced Practice Assessment Techniques
Assessment of the musculoskeletal system involves evaluating for issues of the bones, joints, skeletal muscles, ligaments and tendons, and cartilage throughout the body. As a
clinician, you need to be aware of the expected anatomy and physiology of each structure within the musculoskeletal system, including the expected range of motion (ROM) of each joint. When abnormalities or limitations are discovered on assessment, diagnostic reasoning skills must be applied to determine how to best utilize the data. Your examination should be systematic. Include inspection, palpation of bony structures
and related joint and soft tissue structures, assessment of range of motion, and special maneuvers to test specific movements. Recall that the anatomical shape of each joint determines its range of motion. There are two phases to range of motion: active (by the patient) and passive (by the examiner). There are specific differences in approach to assessment, as well as expected findings, across the lifespan. As you review the required readings this week, be alert for special considerations that relate to special patient populations. Review the videos below which demonstrate examination of the entire musculoskeletal systems and then practice your assessment skills. Continue to practice your skills until you can comfortably repeat a return demonstration of the entire assessment.
The Hip Examination
The hip joint is deeply embedded in the pelvis and is notable for its strength, stability, and wide range of motion. The stability of the hip joint, essential for weight bearing, arises from the deep fit of the head of the femur into the acetabulum, its strong fibrous articular capsule, and the powerful muscles crossing the joint and inserting below the femoral head, providing leverage for movement of the femur.
Often, the examiner must assist the patient with movements of the hip, so further detail is provided below for flexion, abduction, adduction, and external and internal rotation. Meta-analyses suggest that no single test discriminates specific hip pathology.
Flexion: With the patient supine, place your hand under the patient's lumbar spine. Ask the patient to bend each knee in turn up to the chest and pull it firmly against the abdomen. Note that the hip can flex further when the knee is flexed because the hamstrings are relaxed. When the back touches your hand, indicating normal flattening
of the lumbar lordosis, further flexion must arise from the hip joint itself.
Extension: With the patient lying face down, extend the thigh toward you in a posterior
direction. Alternatively, carefully position the supine patient near the edge of the table and extend the leg posteriorly.
Abduction: Stabilize the pelvis by pressing down on the opposite anterior - superior iliac spine with one hand. With the other hand, grasp the ankle and abduct the extended leg until you feel the iliac spine move. This movement marks the limit of hip abduction.
Adduction: With the patient supine, stabilize the pelvis, hold one ankle, and move the leg medially across the body and over the opposite extremity.
External and internal rotation : Flex the leg to 90° at hip and knee, stabilize the thigh with one hand, grasp the ankle with the other, and swing the lower leg medially for external rotation at the hip, and laterally for internal rotation. Although confusing at first,
it is the motion of the head of the femur in the acetabulum that identifies these movements.
The Knee Examination
The knee joint is the largest joint in the body. It is a hinge joint involving three bones: the femur, the tibia, and the patella (or knee cap), with three articular surfaces, two between the femur and the tibia and one between the femur and the patella. Note how the two rounded condyles of the femur rest on the relatively
flat tibial plateau. There is no inherent stability in the knee joint itself, making it dependent on four ligaments to hold its articulating femur and tibia in place. This feature, in addition to the lever action of the femur on the tibia and the lack of padding from overlying fat or muscle, makes the knee highly vulnerable to injury. Learn to examine "the seven structures of the knee": the medial and lateral menisci, the LCL and MCL, the ACL and PCL, and the patellar tendon. The ACL and PCL are not palpable but are tested by specific maneuvers. Palpation and special maneuvers of these structures are especially helpful in primary care diagnosis.
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