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Anatomy & Structure Overview
Key Joints & Structures TEMPOROMANDIBULAR JOINT (TMJ) Articulation of mandible and temporal bone. Anterior to tragus of ear. Allows: hinge (open/close), glide (protrusion/retraction), side-to-side movement. SPINE — 33 VERTEBRAE 7 cervical · 12 thoracic · 5 lumbar · 5 sacral · 3–4 coccygeal. Double-S curve: cervical & lumbar concave (inward); thoracic & sacral convex. Landmarks: C7/T1 prominent at base of neck; T7/T8 = inferior scapular angle; L4 = iliac crest line. N S G 3 1 6 0 · H E A L T H A S S E S S M E N T · G A L E N C O L L E G E O F N U R S I N G
Chapter 23: Musculoskeletal System
Comprehensive Study Guide
Jarvis & Eckhardt (2024) · 9th Edition · pp. 573–627 · Exam 4 (Unit 10 content) Unit 10 USLO 1 – Safe Assessment Techniques & CPE Unit 10 USLO 2 – Report Abnormal Findings Unit 10 USLO 3 – Documentation (SOAP) Unit 10 USLO 4 – Culture, Age & Ethnic Differences
SHOULDER (GLENOHUMERAL JOINT) Ball-and-socket = greatest ROM of any joint. Rotator cuff = SITS muscles (Supraspinatus, Infraspinatus, Teres minor, Subscapularis). Stabilizes humeral head in shallow glenoid fossa. ELBOW Hinge joint — flexion/extension. Landmarks: medial & lateral epicondyles, olecranon process. Ulnar nerve runs between olecranon and medial epicondyle ("funny bone"). WRIST & HAND Radiocarpal joint = condyloid — flexion/extension, radial/ulnar deviation. 206 bones in body; over half in hands and feet. Normal functional position: wrist in slight extension. HIP Ball-and-socket — wide ROM. More stable than shoulder due to deep femoral head insertion, powerful muscles, and strong capsule. Three bursae facilitate movement. KNEE — LARGEST JOINT Hinge joint — flexion/extension. Structures: medial & lateral menisci (cushion), cruciate ligaments (anterior/posterior stability), collateral ligaments (medial/lateral stability), suprapatellar pouch. ANKLE & FOOT Tibiotalar joint = hinge — dorsiflexion & plantar flexion. Landmarks: medial malleolus, lateral malleolus. Calcaneus = heel bone. Subtalar joint = inversion/eversion.
Subjective Data — Health History
RATIONALE Fracture = sharp pain that ↑ with movement. Other bone pain = "dull and deep," unrelated to movement. Low back pain with radiation → herniated disc, osteoporosis, lumbar stenosis. Anxiety can accompany chronic pain.
5. FUNCTIONAL ASSESSMENT (ADLS) Bathing, toileting, dressing, grooming, eating, mobility, communicating — which are limited? RATIONALE Screens safety of independent living and quality of life. Documents self-care deficits and impaired physical mobility or verbal communication. 6. PATIENT-CENTERED CARE Occupational hazards (heavy li"ing, repetitive motion)? Exercise program (type, frequency, warm-up)? Diet (calcium, protein)? Medications (NSAIDs, bisphosphonates, supplements)? Smoking? Alcohol? RATIONALE Occupational stress → back pain or carpal tunnel. Regular exercise ↑ bone strength, reduces fracture risk. NSAIDs → GI bleeding. Bisphosphonates = first- line osteoporosis therapy. Smoking + heavy alcohol → ↓ BMD, ↑ fracture risk, ↑ falls.
Objective Data — Exam Order for Every Joint
For EVERY Joint: Inspect → Palpate → ROM → Muscle Strength KEY PREPARATION RULES
Head-to-toe, proximal to distal. Compare corresponding paired joints — expect symmetry. Support each joint at rest; muscles must be relaxed. Avoid rough manipulation of inflamed areas — use firm support and gentle movement. Use goniometer if limitation in ROM is found. Muscle Strength Grade Description % Normal Assessment 5 Full ROM against gravity, full resistance 100% Normal 4 Full ROM against gravity, some resistance 75% Good 3 Full ROM with gravity 50% Fair 2 Full ROM with gravity eliminated (passive) 25% Poor 1 Slight contraction only 10% Trace 0 No contraction 0% Zero
Normal vs. Abnormal Findings — Joint by
Joint
Temporomandibular Joint (TMJ) NORMAL ABNORMAL RATIONALE Smooth motion of mandible. Audible/palpable click or snap in many healthy people as Swelling (round bulge — must be moderate to visible). Crepitus + pain during Tests CN V (trigeminal) — ask
NORMAL ABNORMAL RATIONALE No redness, atrophy, deformity, or swelling. Equal bony landmarks bilaterally. ROM: Forward flexion 180°, Hyperextension 50°, Internal rotation 90°, External rotation 90°, Abduction 180°, Adduction 50°. No crepitation on ROM. Redness. Inequality of bony landmarks = scoliosis. Atrophy (lack of fullness) = rotator cuff problem or disuse. Dislocated shoulder = loses rounded shape, looks flattened laterally. Swelling anteriorly = joint effusion (needs large amount to be visible). Subacromial bursa swelling = localized under deltoid. Rotator cuff lesion = limited abduction, pain, muscle spasm (forward flexion stays fairly normal). Positive drop arm test = rotator cuff tear. REFER Shoulder pain may be referred from hiatal hernia, cardiac, or pleural condition — serious. Local cause reproduces pain on palpation or motion. Cup hand over shoulder during ROM to detect crepitation. Elbow NORMAL ABNORMAL RATIONALE No deformity, redness, or swelling. Hollows present on either side of olecranon process. ROM: Flexion 150– 160°, Extension 0° (some healthy persons lack 5–10° or hyperextend 5–10°). Pronation/supination 90° each. Tissues and fat pads Subluxation = forearm dislocated posteriorly. Swelling/redness of olecranon bursa = olecranon bursitis (trauma, gout, RA). Effusion or synovial thickening = bulge or fullness in groove on either side of olecranon (gouty arthritis, Palpate with elbow flexed ~70°, as relaxed as possible. Epicondyles and head of radius are common sites
feel fairly solid. bursitis). So", boggy/fluctuant swelling in both grooves = synovial thickening or effusion. Subcutaneous nodules over olecranon = RA (raised, firm, nontender, skin moves freely). Epicondyle tenderness = "tennis elbow" (epicondylitis). Full extension a"er fall usually rules out fracture. REPORT of inflammation. Epicondylitis = pain at lateral epicondyle, radiates down forearm. Wrist & Hand NORMAL ABNORMAL RATIONALE Wrist in slight extension (functional position). Fingers straight, in same axis as forearm. No swelling, redness, deformity, or nodules. Smooth skin with knuckle wrinkles. Rounded thenar eminence (thumb side) and hypothenar eminence (little finger side). No synovial thickening or tenderness. ROM: Hyperextension 70°, Palmar flexion 90°, Ulnar deviation 50–60°, Radial deviation 20°, Finger flexion 90°, Hyperextension 30°. Ulnar deviation = fingers list to ulnar side (chronic RA). Ankylosis = wrist in extreme flexion (severe RA). Dupuytren contracture = flexion contracture of 4th, 5th digits. Swan-neck deformity = MCP flexion, PIP hyperextension, DIP flexion (RA). Boutonnière deformity = PIP flexion, DIP hyperextension (RA). Atrophy of thenar eminence = carpal tunnel syndrome. Ganglion cyst = round cystic nodule on dorsum of wrist. Heberden nodes (DIP) = hard, Loss of wrist hyperextension = most common and most significant functional wrist loss. Polydactyly = extra fingers. Syndactyly = webbed fingers. Single palmar crease = genetic disorders (Down syndrome).
palpation. REPORT the most sensitive early indicator of hip pathology. Knee NORMAL ABNORMAL RATIONALE Smooth skin, even coloring, no lesions. Lower leg extends in same axis as thigh. Distinct concavities (hollows) on either side of patella (peripatellar grooves). No atrophy of quadriceps. Solid, smooth tissues — no warmth, tenderness, thickening, or nodularity. ROM: Flexion 130– 150°, Extension 0° (or hyperextension up to 15°). Duck walk shows intact ligaments and no effusion. Shiny, atrophic skin. Swelling/inflammation. Genu varum (bowlegs) >2. cm between knees when malleoli together. Genu valgum (knock-knees) >2. cm between malleoli when knees together. Flexion contracture. Hollows disappear → bulge = synovial thickening or effusion. Quadriceps atrophy (first appears in vastus medialis). Bulge sign (+) = 4–8 mL effusion. Ballottement of patella (+) = large fluid collection. Irregular bony margins = OA. Pronounced crepitus = degenerative disease. Sudden locking = unable to extend, painful "pop" = meniscal tear. Sudden buckling = ligament injury. REFER Bulge sign = stroke medial aspect 2– times, then tap lateral — watch for bulge on medial side. Ballottement = compress suprapatellar pouch, push patella against femur. Presence of bulge sign identifies patients at high risk for progressive knee OA.
MCMURRAY TEST — MENISCAL TEAR Perform when patient reports trauma + locking/giving way/local knee pain. Patient supine, flex knee and hip, externally rotate leg, apply valgus stress, slowly extend. Normal: Leg extends smoothly, no pain. Positive: Audible or palpable "click" = torn meniscus → refer to orthopedics for imaging and possible surgical repair. Ottawa Knee Rules — refer for imaging if: (1) Isolated patella or fibula head pain; (2) Age ≥55; (3) Cannot flex to 90°; (4) Cannot bear weight for 4 steps. Ankle & Foot NORMAL ABNORMAL RATIONALE Foot aligned with long axis of lower leg. Weight bearing on middle of foot — heel through midfoot to between 2nd and 3rd toes. Toes point forward and lie flat. Smooth, even skin. Malleoli are smooth bony prominences. ROM: Plantar flexion 45°, Dorsiflexion 20°, Eversion 20°, Inversion 30°. Hallux valgus = great toe deviated away from midline
- bunion (inflamed bursa). Hammertoes = hyperextension MTP + flexion PIP. Calluses. Ulcers. Swelling/inflammation. Tenderness = arthritis or ligament trauma. Plantar fasciitis = localized tenderness under heel; worse in morning or a"er rest; "throbbing, searing, or piercing." Risk factors: obesity, high arch, running, prolonged standing on hard floors. Achilles tenosynovitis = linear swelling along tendon sheath. Acute gout = redness, swelling, warmth, extreme pain in MTP of great Inspect both sitting (non- weight-bearing) and standing/walking. Examine shoes — greatest wear on outside heel and inside toe is normal. Plantar fasciitis self- limiting (6– months). Gout = excess uric acid → urate crystals in joint; most prevalent inflammatory arthritis in the US.
chronic axial skeletal pain. REPORT STRAIGHT LEG RAISING (LASÈGUE TEST) — HERNIATED DISC / SCIATICA With patient supine, raise affected leg with knee extended. Normally no pain. Raise just short of pain point → dorsiflex foot. Positive: Reproduces or worsens sciatic pain and patient resists further elevation → strongly suggests herniated disc (especially if dorsiflexion ↑ pain). If raising the UNAFFECTED leg reproduces sciatic pain on the involved side → strongly suggests herniated nucleus pulposus. Refer. LEG LENGTH MEASUREMENT True leg length: Anterior superior iliac spine → medial malleolus (crossing medial knee side). Normal: equal or within 1 cm. If true lengths equal but legs look unequal → apparent leg length discrepancy (pelvic obliquity or hip adduction/flexion deformity).
Developmental Normal & Abnormal
Findings
— Unit 10 USLO 4 Age-Specific Physical Exam Findings Infants Normal: Feet in varus or valgus position (residual fetal positioning) — if flexible , self-correctable Metatarsus adductus (forefoot adduction) — present at birth, resolves by age 3 typically Single C-curve spine at birth; cervical curve develops at 3–4 months (li!s head); lumbar curve at 1–18 months (stands erect) Ortolani maneuver: smooth, no sound when hips abducted Allis test: knees at equal elevation Equal gluteal folds
Normal palm creases bilateral Clavicles smooth, regular, no crepitus Abnormal: Fixed foot deformity = assumes right angle only with forced manipulation or not at all Metatarsus varus = adduction + inversion of forefoot Tibial torsion >20° deviation or lateral malleolus anterior to medial Positive Ortolani sign = clunk as femoral head pops back → hip dislocation → REFER immediately Positive Allis sign = one knee significantly lower = hip dislocation Fractured clavicle = irregularity, crepitus, angulation; limited arm ROM; unilateral Moro reflex Tu! of hair over dimple in midline = spina bifida Small dimple in midline = dermoid sinus Mass (meningocele) Polydactyly = extra fingers/toes. Syndactyly = webbing Single palmar crease = Down syndrome and other genetic disorders Baby "slips" when li!ed by axillae = shoulder muscle weakness Children & Adolescents Normal: Lordosis common throughout childhood (more pronounced with protuberant abdomen) Genu varum (bowlegs) normal for 1 year a!er walking begins Genu valgum (knock-knees) normal between 2–3.5 years Flatfoot (pes planus) normal in infants, usually resolves by age 3 Pigeon toes common — usually corrects spontaneously if flexible Gait: broad-based 1–2 years, narrows by age 3 Subluxation of radial head most common ages 2–4 (nursemaid's elbow) Abnormal: Genu varum >2.5 cm between knees when malleoli together = abnormal a!er 1 year of walking; also with rickets Genu valgum >2.5 cm between malleoli when knees together = abnormal; rickets, poliomyelitis, syphilis Pes planus a!er age 3 = abnormal (may relate to Marfan syndrome, Down syndrome, cerebral palsy, obesity) Severe in-toeing or asymmetric = femoral anteversion, internal hip rotation Limp = trauma, fatigue, or hip disease
Genetics, Environment & Health Promotion
— Unit 10 USLO 4
Osteoporosis — Race, BMD & Prevention BONE MINERAL DENSITY (BMD) RACIAL DIFFERENCES Non-Hispanic Black adults = HIGHEST BMD, LOWEST bone loss. White women = most likely to develop osteoporosis. Asian women = similar BMD to White but lower osteoporosis rates. Black women and men have HIGHER mortality a"er hip fracture and longer hospital stays despite lower fracture risk. BMD of femoral neck peaks earlier than other skeletal sites. OSTEOPOROSIS SCREENING (USPSTF) All women ≥65 years → DXA scan. Postmenopausal women <65 at increased risk → DXA. Men: insufficient evidence for routine screening; base on clinical risk factors. FRAX algorithm: 10-year fracture probability. First-line treatment: bisphosphonates. Hormone therapy NOT recommended due to risk factors. PATIENT TEACHING — OSTEOPOROSIS PREVENTION Diet: Women ≤50 = 1000 mg/day calcium; >50 = 1200 mg/day. Men ≤70 = 1000 mg/day; >70 = 1200 mg/day. Vitamin D: 600 IU/day until age 70; 800 IU/day a"er 70. Dietary calcium better absorbed than supplements. Exercise: Moderate-to-high intensity for bone health. Strength + balance exercises help maintain bone and decrease fracture risk. Aim for 30 min/day, 5 days/week. Avoid: Smoking (↑ bone loss, ↑ fracture risk in older women). Moderate-to-heavy alcohol → ↑ falls risk. Fall Prevention: Review medications, annual vision/hearing check, safety-proof home (increase lighting, remove throw rugs, install grab bars).
Abnormal Findings — Conditions Reference
(Tables 23.1–23.9)
Major Conditions Affecting Multiple Joints (Table 23.1) RHEUMATOID ARTHRITIS (RA) Autoimmune, chronic inflammation. 2.5× more common in women. Peak ages 30– 60 (can occur at any age). SYMMETRIC, bilateral joint involvement. Heat, redness, swelling, painful motion. Morning stiffness >1 hour. Fatigue, anorexia, weight loss, low-grade fever, lymphadenopathy. ↑ Cardiovascular risk (heart attack, stroke). Associated: ulnar deviation, boutonnière/swan-neck deformities, rheumatoid nodules, crepitation. Treated with anti-inflammatory agents. OSTEOARTHRITIS (OA) Noninflammatory, progressive. Deterioration of articular cartilage + subchondral bone remodeling + osteophyte formation. ASYMMETRIC — commonly hands, knees, hips, spine. Risk: older age, female, obesity, genetics, joint injury. Stiffness, swelling with HARD bony protuberances, pain with motion, limited ROM. Heberden nodes (DIP) + Bouchard nodes (PIP). Radiographic findings may not match symptom severity. ANKYLOSING SPONDYLITIS (AS) Chronic inflamed vertebrae → bony fusion (ankylosis). Affects spine, pelvis, thoracic cage. Inflammatory back pain: dull, deep, lower back or buttocks. Morning stiffness ≥30 min (↓ with activity). Night awakening with pain. Onset ≤45 years. More common in males. Spasm pulls spine into forward flexion (obliterates cervical and lumbar curves). Complications: osteopenia, fragility fractures, neurologic issues (cauda equina syndrome). OSTEOPOROSIS ↓ Skeletal bone mass → low BMD → ↑ fracture risk (wrist, hip, vertebrae). Primarily postmenopausal White women. Risk factors: smaller height/weight, younger
S 45-year-old female with RA diagnosis × 3 years. "Swelling and burning pain in my hands" × 1 day. Morning stiffness 1–1. hrs. Joints warm, swollen, tender. Weight loss 15 lb over 4 years, fatigue. Takes aspirin for flare-ups. O Radiocarpal, MCP, and PIP joints red, swollen, tender. Spindle-shaped swelling of PIP joints 3rd digit right, 2nd digit left. Ulnar deviation of MCP joints. A Acute pain · Decreased physical mobility · Needs teaching: aspirin, exercise, rest periods. Case Study 3 — Nursemaid's Elbow (2-Year-Old) S Parents were swinging 2-year-old by hands — on last swing child cried and refused to use right arm. O Holding right arm extended, pronated, adducted. No visible swelling/deformity. Winces with palpation. Clunk heard on supination and flexion of right forearm. A Radial head subluxation (nursemaid's elbow) · Acute pain · Potential for injury R/T unstable joint.
CPE Critical Elements — Musculoskeletal
Assessment — Unit 10 USLO 1
NSG 3160 CPE — Musculoskeletal Critical Elements
- Inspect and palpate the spine for alignment.
- Palpate for muscle characteristics.
- Palpate joints for heat, tenderness, swelling, masses, deformity, crepitus, and resistance to pressure.
- Assess ROM of all joints (temporomandibular, cervical spine, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, spine).
- Inspect gait, posture, and ability to stand if applicable. GET UP AND GO TEST — AGING ADULT Time patient to rise from armchair, walk 10 feet, turn, walk back, sit down. Normal: Under 12 seconds (healthy adult >60 years). Abnormal: ≥12 seconds = ↑ risk of falls — REPORT and refer. NSG 3160 · Galen College of Nursing · Jarvis & Eckhardt (2024) Chapter 23 · pp. 573–627 · Unit 10 USLOs 1–
