66
Assessment: Musculoskeletal System
Colleen Walsh
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Safety
Mobility
LEARNING OUTCOMES
1. Describe the gross and microscopic anatomy of bone. 6. Perform a physical assessment of the musculoskeletal
2. Explain the classification system for joints and movements system using appropriate techniques.
at synovial joints. 7. Distinguish normal from abnormal findings of a physical
3. Describe the functions of cartilage, muscles, ligaments, assessment of the musculoskeletal system.
tendons, fascia, and bursae. 8. Describe the purpose, significance of results, and nursing
4. Link age-related changes in the musculoskeletal system to responsibilities related to diagnostic studies of the
the differences in assessment findings. musculoskeletal system.
5. Obtain significant subjective and objective assessment data
related to the musculoskeletal system from a patient.
KEY TERMS
ankylosis, Table 66.6 isometric contractions
arthrocentesis, Table 66.9 isotonic contractions
arthroscopy, Table 66.9 kyphosis, Table 66.6
atrophy, Table 66.6 lordosis, Table 66.6
bone remodeling range of motion (ROM)
contracture, Table 66.6 scoliosis
crepitation, Table 66.6 x-ray
The musculoskeletal system is composed of voluntary muscle mineral storage. Bones provide the supporting framework
and 6 types of connective tissue: bone, cartilage, ligaments, ten- that keeps the body from collapsing. It allows the body to
dons, fascia, and bursae. The purpose of the musculoskeletal bear weight. Bones protect underlying vital organs and tis-
system is to protect body organs, provide support and stability sues. For example, the skull encloses the brain and vertebrae
for the body, store minerals, and allow coordinated movement. surround the spinal cord. The rib cage protects the lungs and
This chapter reviews the structure and function of the musculo- heart.
skeletal system to enable nursing assessment and evaluation of Bones serve as a point of attachment for muscles and liga-
assessment findings. ments. Muscles are connected to bones by tendons. Bones act
as a lever for muscles. Movement occurs because of muscle con-
STRUCTURES AND FUNCTIONS OF tractions applied to these levers. Ligaments provide stability to
joints. Bone marrow contains the tissues responsible for making
MUSCULOSKELETAL SYSTEM
red and white blood cells. Bones serve as a storage site for inor-
Bone ganic minerals, including calcium and phosphorus.1
Function Bone is a dynamic tissue that continuously changes form
The main functions of bone are support, protection of inter- and composition. It contains both organic material (collagen)
nal organs, voluntary movement, blood cell production, and and inorganic material (calcium, phosphate). The internal and
1622
, CHAPTER 66 Assessment: Musculoskeletal System 1623
canals (canaliculi) extend from the Haversian canals to the lacu-
nae, where mature bone cells are embedded.
Osteon (Haversian
system)
Cancellous bone has a different structure. The lamel-
Periosteum lae occur along the lines of maximum stress placed on the
bone. Cancellous bone is filled with red or yellow marrow.
Blood reaches the bone cells by passing through spaces in
the marrow.
The 3 types of bone cells are osteoblasts, osteocytes, and
Canaliculi osteoclasts.2 Osteoblasts make organic bone matrix (collagen).
They are the basic bone-forming cells. Osteocytes are mature
bone cells. Osteoclasts take part in bone remodeling by helping
Blood vessels breakdown bone tissue. Bone remodeling is the removal of old
bone by osteoclasts (resorption) and the deposit of new bone
A by osteoblasts (ossification). The inner layer of bone is made
mostly of osteoblasts with a few osteoclasts.
Articular cartilage
Epiphysis Spongy bone Gross Structure
Metaphysis Epiphyseal line The anatomic structure of bone is best represented by a typical
Red marrow long bone, such as the tibia (Fig. 66.1B). Each long bone consists
cavities of the epiphysis, diaphysis, and metaphysis. The epiphysis, the
widened area at each end of a long bone, is made mostly of can-
Compact bone cellous bone. The wide epiphysis allows greater weight distribu-
Medullary
cavity
tion and provides stability for the joint. The epiphysis is a main
location for muscle attachment. Articular cartilage covers the
Endosteum ends of the epiphysis. It provides a smooth, low-friction surface
for joint movement.
Diaphysis The diaphysis is the main shaft of the long bone. It provides
Yellow marrow
structural support and is composed of cortical bone. The tubu-
lar structure of the diaphysis allows it to withstand bending and
Periosteum twisting forces more easily. The metaphysis is the flared area
between the epiphysis and diaphysis. It is composed of cancel-
lous bone.
The epiphyseal plate (physis or growth plate) is the cartilag-
inous area between the epiphysis and metaphysis. In skeletally
immature children who still have open growth plates, the epiph-
Metaphysis yseal plate actively makes chondrocytes that become mature
bone. Chondrocyte division causes longitudinal bone growth in
Epiphysis
B children. Injury to the epiphyseal plate in a growing child can
Fig. 66.1 Bone structure. (A) Cortical bone showing numerous struc-
cause the formation of new bone to stop at the growth plate.
tural units called osteons. (B) Anatomy of a long bone (tibia) showing This leads to a shorter extremity and may contribute to major
cancellous and compact bone. (A, From Patton KT, Thibodeau GA: Anat- functional problems. In the adult, the metaphysis and epiphysis
omy and physiology, ed 9, St Louis, 2016, Mosby. B, From Patton KT, become joined when chondrocyte formation at the growth plate
Thibodeau GA: The human body in health and disease, ed 7, St Louis, stops and bone formation is complete.
2018, Mosby.)
The periosteum is composed of fibrous connective tissue that
covers the bone. Tiny blood vessels penetrate the periosteum
external growth and remodeling of bone are ongoing processes to bring nutrition to underlying bone. Musculotendinous fibers
that vary throughout the life span. attach to the outer layer of the periosteum. Collagen bundles
attach the inner layer of the periosteum to the bone. There is no
Microscopic Structure periosteum on the articular surfaces of long bones. These bone
We classify bone according to structure as cortical (compact ends are covered by articular cartilage.3
and dense) or cancellous (spongy). In cortical bone, cylindrical The medullary (marrow) cavity in the center of the diaph-
structural units called osteons (Haversian systems) fit closely ysis contains either red or yellow bone marrow.2 In adults, red
together to create a dense bone structure (Fig. 66.1A). Within marrow is found mainly in the flat bones, such as the pelvis,
the systems, the Haversian canals run parallel to the bone’s long sternum, and scapula, and cancellous bone at the epiphyseal
axis. They contain the blood vessels that travel to the bone’s inte- ends of long bones, such as the femur and humerus. Red bone
rior from the periosteum. Surrounding each osteon are concen- marrow is involved in blood cell production (hematopoiesis).
tric rings called lamellae, which indicate mature bone. Smaller In the adult, the medullary cavity of long bones contains yellow
, 1624 SECTION 12 Problems Related to Movement and Coordination
Joint cavity (filled with
synovial fluid)
A
A Fibrous
connective Bone
tissue
Synovial
Bursa membrane
Blood vessel
Cartilage
Nerve
B Vertebrae
Joint
capsule
B
Vascular
D C interface
C Cartilage Tendon
sheath
Pubis
E Cartilage Periosteum
Articular cartilage
Bone
Greater trochanter Fig. 66.3 Structure of diarthrodial (synovial) joint.
D E
connective tissue, which joins the 2 bones together to form a
Femur
cavity (Fig. 66.3). The capsule is lined by a synovial membrane,
Cartilage which secretes thick synovial fluid. This fluid lubricates the
joint, reduces friction, and allows opposing surfaces to slide
Fig. 66.2 Classification of joints. (A–C) Synarthrotic (immovable) and smoothly over each other. It supplies oxygen and nutrients to
amphiarthrotic (slightly movable) joints. (D and E) Diarthrodial (freely and removes carbon dioxide and metabolic wastes from the
movable) joints. chondrocytes within articular cartilage. The end of each bone is
covered with articular (hyaline) cartilage. Supporting structures
bone marrow (mainly adipose tissue). It serves as a storage site (e.g., ligaments, tendons) reinforce the joint capsule. They pro-
for triglycerides.4 Yellow marrow is involved in hematopoiesis vide limits and stability to joint movement. Types of diarthro-
in times of great blood cell need. dial joints are shown in Fig. 66.4.
Types Cartilage
The skeleton consists of 206 bones. We classify bones by shape The 3 types of cartilage are hyaline, elastic, and fibrous. Hyaline
as long, short, flat, irregular, or seismoid. cartilage is the most common. It has a moderate amount of col-
Long bones have a central shaft (diaphysis) and 2 widened lagen fibers. It is found in the trachea, bronchi, nose, epiphyseal
ends (epiphyses) (Fig. 66.1B). Examples include the femur, plate, and articular surfaces of bones.
humerus, and tibia. Short bones are composed of cancellous Elastic cartilage, which has both collagen and elastic fibers,
bone covered by a thin layer of compact bone. Examples include is more flexible than hyaline cartilage. It is found in the ear, epi-
the carpals in the hand and tarsals in the foot. glottis, and larynx.
Flat bones have 2 layers of compact bone separated by a layer Fibrous cartilage (fibrocartilage) consists mostly of colla-
of cancellous bone. Flat bones include the pelvis, skull, sternum, gen fibers. It is a tough tissue that often functions as a shock
ribs, vertebrae, and scapula. The spaces in the cancellous bone absorber. Fibrous cartilage is found between the vertebral discs.
contain bone marrow. Irregular bones appear in a variety of It forms a protective cushion between the bones of the pelvic
shapes and sizes. Examples include the sacrum, mandible, and girdle, knee, and shoulder.
ear ossicles. Sesamoid bones are round or oval bones (such as the Cartilage in synovial joints serves as a support for soft tissue
patella), which develop in tendons.3 and provides the articular surface for joint movement. It pro-
tects underlying tissues. Because articular cartilage is avascular,
Joints it must receive nourishment by the diffusion of material from
A joint (articulation) is a place where the ends of 2 bones are the synovial fluid. The lack of a direct blood supply contrib-
close and move in relation to each other. Joints are classified by utes to the slow metabolism of cartilage cells and explains why
the degree of movement that they allow (Fig. 66.2). healing and repair of cartilage tissue occur slowly. The cartilage
The most common joint is the freely movable diarthrodial in the epiphyseal plate is involved in the growth of long bones
(synovial) type. Each joint is enclosed in a capsule of fibrous before reaching physical maturity.5
Assessment: Musculoskeletal System
Colleen Walsh
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Functional Ability Safety
Mobility
LEARNING OUTCOMES
1. Describe the gross and microscopic anatomy of bone. 6. Perform a physical assessment of the musculoskeletal
2. Explain the classification system for joints and movements system using appropriate techniques.
at synovial joints. 7. Distinguish normal from abnormal findings of a physical
3. Describe the functions of cartilage, muscles, ligaments, assessment of the musculoskeletal system.
tendons, fascia, and bursae. 8. Describe the purpose, significance of results, and nursing
4. Link age-related changes in the musculoskeletal system to responsibilities related to diagnostic studies of the
the differences in assessment findings. musculoskeletal system.
5. Obtain significant subjective and objective assessment data
related to the musculoskeletal system from a patient.
KEY TERMS
ankylosis, Table 66.6 isometric contractions
arthrocentesis, Table 66.9 isotonic contractions
arthroscopy, Table 66.9 kyphosis, Table 66.6
atrophy, Table 66.6 lordosis, Table 66.6
bone remodeling range of motion (ROM)
contracture, Table 66.6 scoliosis
crepitation, Table 66.6 x-ray
The musculoskeletal system is composed of voluntary muscle mineral storage. Bones provide the supporting framework
and 6 types of connective tissue: bone, cartilage, ligaments, ten- that keeps the body from collapsing. It allows the body to
dons, fascia, and bursae. The purpose of the musculoskeletal bear weight. Bones protect underlying vital organs and tis-
system is to protect body organs, provide support and stability sues. For example, the skull encloses the brain and vertebrae
for the body, store minerals, and allow coordinated movement. surround the spinal cord. The rib cage protects the lungs and
This chapter reviews the structure and function of the musculo- heart.
skeletal system to enable nursing assessment and evaluation of Bones serve as a point of attachment for muscles and liga-
assessment findings. ments. Muscles are connected to bones by tendons. Bones act
as a lever for muscles. Movement occurs because of muscle con-
STRUCTURES AND FUNCTIONS OF tractions applied to these levers. Ligaments provide stability to
joints. Bone marrow contains the tissues responsible for making
MUSCULOSKELETAL SYSTEM
red and white blood cells. Bones serve as a storage site for inor-
Bone ganic minerals, including calcium and phosphorus.1
Function Bone is a dynamic tissue that continuously changes form
The main functions of bone are support, protection of inter- and composition. It contains both organic material (collagen)
nal organs, voluntary movement, blood cell production, and and inorganic material (calcium, phosphate). The internal and
1622
, CHAPTER 66 Assessment: Musculoskeletal System 1623
canals (canaliculi) extend from the Haversian canals to the lacu-
nae, where mature bone cells are embedded.
Osteon (Haversian
system)
Cancellous bone has a different structure. The lamel-
Periosteum lae occur along the lines of maximum stress placed on the
bone. Cancellous bone is filled with red or yellow marrow.
Blood reaches the bone cells by passing through spaces in
the marrow.
The 3 types of bone cells are osteoblasts, osteocytes, and
Canaliculi osteoclasts.2 Osteoblasts make organic bone matrix (collagen).
They are the basic bone-forming cells. Osteocytes are mature
bone cells. Osteoclasts take part in bone remodeling by helping
Blood vessels breakdown bone tissue. Bone remodeling is the removal of old
bone by osteoclasts (resorption) and the deposit of new bone
A by osteoblasts (ossification). The inner layer of bone is made
mostly of osteoblasts with a few osteoclasts.
Articular cartilage
Epiphysis Spongy bone Gross Structure
Metaphysis Epiphyseal line The anatomic structure of bone is best represented by a typical
Red marrow long bone, such as the tibia (Fig. 66.1B). Each long bone consists
cavities of the epiphysis, diaphysis, and metaphysis. The epiphysis, the
widened area at each end of a long bone, is made mostly of can-
Compact bone cellous bone. The wide epiphysis allows greater weight distribu-
Medullary
cavity
tion and provides stability for the joint. The epiphysis is a main
location for muscle attachment. Articular cartilage covers the
Endosteum ends of the epiphysis. It provides a smooth, low-friction surface
for joint movement.
Diaphysis The diaphysis is the main shaft of the long bone. It provides
Yellow marrow
structural support and is composed of cortical bone. The tubu-
lar structure of the diaphysis allows it to withstand bending and
Periosteum twisting forces more easily. The metaphysis is the flared area
between the epiphysis and diaphysis. It is composed of cancel-
lous bone.
The epiphyseal plate (physis or growth plate) is the cartilag-
inous area between the epiphysis and metaphysis. In skeletally
immature children who still have open growth plates, the epiph-
Metaphysis yseal plate actively makes chondrocytes that become mature
bone. Chondrocyte division causes longitudinal bone growth in
Epiphysis
B children. Injury to the epiphyseal plate in a growing child can
Fig. 66.1 Bone structure. (A) Cortical bone showing numerous struc-
cause the formation of new bone to stop at the growth plate.
tural units called osteons. (B) Anatomy of a long bone (tibia) showing This leads to a shorter extremity and may contribute to major
cancellous and compact bone. (A, From Patton KT, Thibodeau GA: Anat- functional problems. In the adult, the metaphysis and epiphysis
omy and physiology, ed 9, St Louis, 2016, Mosby. B, From Patton KT, become joined when chondrocyte formation at the growth plate
Thibodeau GA: The human body in health and disease, ed 7, St Louis, stops and bone formation is complete.
2018, Mosby.)
The periosteum is composed of fibrous connective tissue that
covers the bone. Tiny blood vessels penetrate the periosteum
external growth and remodeling of bone are ongoing processes to bring nutrition to underlying bone. Musculotendinous fibers
that vary throughout the life span. attach to the outer layer of the periosteum. Collagen bundles
attach the inner layer of the periosteum to the bone. There is no
Microscopic Structure periosteum on the articular surfaces of long bones. These bone
We classify bone according to structure as cortical (compact ends are covered by articular cartilage.3
and dense) or cancellous (spongy). In cortical bone, cylindrical The medullary (marrow) cavity in the center of the diaph-
structural units called osteons (Haversian systems) fit closely ysis contains either red or yellow bone marrow.2 In adults, red
together to create a dense bone structure (Fig. 66.1A). Within marrow is found mainly in the flat bones, such as the pelvis,
the systems, the Haversian canals run parallel to the bone’s long sternum, and scapula, and cancellous bone at the epiphyseal
axis. They contain the blood vessels that travel to the bone’s inte- ends of long bones, such as the femur and humerus. Red bone
rior from the periosteum. Surrounding each osteon are concen- marrow is involved in blood cell production (hematopoiesis).
tric rings called lamellae, which indicate mature bone. Smaller In the adult, the medullary cavity of long bones contains yellow
, 1624 SECTION 12 Problems Related to Movement and Coordination
Joint cavity (filled with
synovial fluid)
A
A Fibrous
connective Bone
tissue
Synovial
Bursa membrane
Blood vessel
Cartilage
Nerve
B Vertebrae
Joint
capsule
B
Vascular
D C interface
C Cartilage Tendon
sheath
Pubis
E Cartilage Periosteum
Articular cartilage
Bone
Greater trochanter Fig. 66.3 Structure of diarthrodial (synovial) joint.
D E
connective tissue, which joins the 2 bones together to form a
Femur
cavity (Fig. 66.3). The capsule is lined by a synovial membrane,
Cartilage which secretes thick synovial fluid. This fluid lubricates the
joint, reduces friction, and allows opposing surfaces to slide
Fig. 66.2 Classification of joints. (A–C) Synarthrotic (immovable) and smoothly over each other. It supplies oxygen and nutrients to
amphiarthrotic (slightly movable) joints. (D and E) Diarthrodial (freely and removes carbon dioxide and metabolic wastes from the
movable) joints. chondrocytes within articular cartilage. The end of each bone is
covered with articular (hyaline) cartilage. Supporting structures
bone marrow (mainly adipose tissue). It serves as a storage site (e.g., ligaments, tendons) reinforce the joint capsule. They pro-
for triglycerides.4 Yellow marrow is involved in hematopoiesis vide limits and stability to joint movement. Types of diarthro-
in times of great blood cell need. dial joints are shown in Fig. 66.4.
Types Cartilage
The skeleton consists of 206 bones. We classify bones by shape The 3 types of cartilage are hyaline, elastic, and fibrous. Hyaline
as long, short, flat, irregular, or seismoid. cartilage is the most common. It has a moderate amount of col-
Long bones have a central shaft (diaphysis) and 2 widened lagen fibers. It is found in the trachea, bronchi, nose, epiphyseal
ends (epiphyses) (Fig. 66.1B). Examples include the femur, plate, and articular surfaces of bones.
humerus, and tibia. Short bones are composed of cancellous Elastic cartilage, which has both collagen and elastic fibers,
bone covered by a thin layer of compact bone. Examples include is more flexible than hyaline cartilage. It is found in the ear, epi-
the carpals in the hand and tarsals in the foot. glottis, and larynx.
Flat bones have 2 layers of compact bone separated by a layer Fibrous cartilage (fibrocartilage) consists mostly of colla-
of cancellous bone. Flat bones include the pelvis, skull, sternum, gen fibers. It is a tough tissue that often functions as a shock
ribs, vertebrae, and scapula. The spaces in the cancellous bone absorber. Fibrous cartilage is found between the vertebral discs.
contain bone marrow. Irregular bones appear in a variety of It forms a protective cushion between the bones of the pelvic
shapes and sizes. Examples include the sacrum, mandible, and girdle, knee, and shoulder.
ear ossicles. Sesamoid bones are round or oval bones (such as the Cartilage in synovial joints serves as a support for soft tissue
patella), which develop in tendons.3 and provides the articular surface for joint movement. It pro-
tects underlying tissues. Because articular cartilage is avascular,
Joints it must receive nourishment by the diffusion of material from
A joint (articulation) is a place where the ends of 2 bones are the synovial fluid. The lack of a direct blood supply contrib-
close and move in relation to each other. Joints are classified by utes to the slow metabolism of cartilage cells and explains why
the degree of movement that they allow (Fig. 66.2). healing and repair of cartilage tissue occur slowly. The cartilage
The most common joint is the freely movable diarthrodial in the epiphyseal plate is involved in the growth of long bones
(synovial) type. Each joint is enclosed in a capsule of fibrous before reaching physical maturity.5
