Assessment and Diagnostic Examination of The Musculoskeletal System

Anatomic and Physiologic Overview

The musculoskeletal system serves various functions:

1. provides protection for organs, including the brain, heart, and lungs;
2. serves as a framework to support body structures;
3. makes mobility possible through muscles, tendons, bones, and joints, which also produces heat for maintaining body temperature;
4. aids in venous return of deoxygenated blood by massaging the venous vasculature; and
5. is a reservoir for immature blood cells and essential minerals including calcium (more than 98% of total body content), phosphorus, magnesium, and fluoride.

Structure and Function of the Skeletal System

The adult human body contains 206 bones of varying classifications according to shape:

1. Long: mainly found in the extremities like the femur, and are shaped like rods or shafts with rounded ends.
   • The “shaft” is known as the diaphysis and is primarily composed of cortical bone, a compact type of bone tissue.
   • The ends of the bone are called epiphyses and are primarily composed of porous and spongy cancellous (trabecular) bone.
   • In childhood and adolescence, the diaphysis and epiphyses are separated by the growth plate, or the epiphyseal plate. It is composed of cartilage that nurtures and facilitates longitudinal growth before becoming calcified in adults.
   • The ends of long bones are covered at the joints by articular cartilage, a tough, elastic, and avascular tissue.
2. Short: smaller bones located in the ankle and hand e.g. the metacarpals.
3. Flat: found in regions essential for protection e.g. the sternum of the ribcage or the skull.
4. Irregular: any bones not categorized under any of the previous three, like the vertebrae or the bones of the jaw.

Bone Composition

The shape and construction of specific bones are determined by its function and the forces exerted on it. Bones may either be constructed from strong cortical bone or the spongy cancellous bone.

• Cortical bone exists in areas where support is needed, such as in the long bones used for weight-bearing and movement.
• Cancellous bone exists where hematopoiesis and bone formation occur. In the flat bones used for protection while also being important sites of hematopoiesis, cancellous bone is layered between compact bone. Short bones are often cancellous bone covered by a layer of cortical bone.
• Irregular bones are often similar to flat bones in structure.

Bone Composition

Bone is composed of cells, protein matrix, and mineral deposits.

• Osteoblasts function in bone formation by secreting bone matrix. Bone matrix consists of collagen and ground substances that provide a framework in which inorganic materials (calcium, phosphorus) are deposited.
• Osteocytes are mature bone cells involved in bone maintenance, and are located in lacunae.
• Osteoclasts, located in shallow Hollowship’s lacunae (small pits in bones), are multinuclear cells involved in dissolving (bone matrix is dissolved to maintain the marrow cavity) and resorbing bone.
• Osteons are the microscopic functioning units of mature cortical bone, or the haversian system.
  • In the center of the osteon (the haversian canal) is a capillary. Surrounding these are lamellae: circles of mineralized bone matrix. In the lamellae are the lacunae that contain osteocytes. The osteocytes are nourished through canaliculi (canals) that communicate with adjacent blood vessels.
• Within cancellous bone, lacunae are layered in irregular lattice networks known as trabeculae. Red bone marrow fills the lattice network.
  • Red bone marrow is a vascular tissue that covers the medullary cavity of long bones and in flat bones. These are mainly located in the sternum, ilium, vertebrae, and ribs. These produce red blood cells, white blood cells, and platelets through the process of hematopoiesis. In adults, the long bones are filled with fatty, yellow marrow.

The bone is covered by a layer of dense fibrous membrane called the periosteum. This contains nerves, blood vessels, and lymphatics, and attachments points for tendons and ligaments. The periosteum nourishes the bone. The endosteum is a thin, vascular membrane that covers the marrow cavity of long bones and the spaces in cancellous bone.

Bone Formation

Osteogenesis begins before birth. Ossification is the process by which bone matrix is formed and hard minerals are bound to collagen fibers. These mineral components give both its characteristic strength, while proteinaceous collagen give bone its resilience.

Bone Maintenance

Bones are dynamic tissues in a constant state of turnover; old bone is removed and new bone is added (bone remodeling).

• In children, bone is formed more than bone is dissolved. Bones become larger, heavier, and denser and peak in size and density by 20 years of life.
• Complete bone turnover occurs approximately every 10 years.

Multiple factors affect the balance of bone formation and resorption: physical activity, dietary intake of certain nutrients, and hormones:

1. Physical Activity: particularly from weight-bearing activities, this stimulates bone formation and remodeling. Bones subjected to weight-bearing tend to be thick and strong; people who are unable to participate in these activities e.g. bed-ridden, disabled, lose bone mass, becoming osteopenic and weak, increasing risk for fractures.
2. Nutritional Intake: good dietary habits are integral to bone health.
   • 1000 to 1200 mg of Calcium daily is essential for maintaining adult bone mass. Food sources include low-fat milk, yogurt, cheese, and other milk products. Some foods also have added calcium e.g. orange juice, cereals, and bread.
   • 600 IU of Vitamin D daily plays a vital role in calcium absorption and bone health. Individuals 50 years or older require a higher daily intake of 800 to 1000 IU to ensure good bone health. Food sources include vitamin-D fortified milk and cereals, egg yolks, salt-water fish, and liver.
3. Hormones:
   • Calcitriol, the activated form of Vitamin D, functions to increase the amount of calcium absorbed in the GIT. It also facilitates mineralization of osteoid tissue.
     • Deficiency results in bone mineralization deficit, deformity, and fracture. Also read: Osteomalacia or Rickets.
   • Parathyroid Hormone and Calcitonin are the major hormonal regulators for calcium homeostasis. PTH mobilizes calcium, promoting demineralization of the bone and the formation of bone cysts. Calcitonin reacts to elevated calcium levels, inhibiting resorption and increasing deposition of calcium into bone. Also read: parathyroid disorders.
   • Thyroid Hormone and Cortisol have multisystemic effects with specific effects on bones.
     • Excessive thyroid hormone, e.g. in Graves’ disease, can result in increased bone resorption and decreased bone formation.
     • Increased levels of cortisol have the same effects. Long-term synthetic cortisol or corticosteroid therapy produce an increased risk for steroid-induced osteopenia and fractures.
   • Growth Hormone has direct (stimulates bone growth) and indirect effects on skeletal growth and remodeling. It stimulates the liver, and to a lesser degree, the bones to produce an Insulinlike Growth Factor 1 (IGF-I) that accelerates bone modeling in children and adolescents.
     • It is believed that low levels of both GH and IGF-I related to aging decreases bone formation and results in osteopenia.
   • Sex Hormones (Estrogen, Testosterone) are important to bone remodeling.
     • Estrogen stimulates osteoblasts (formation) and inhibits osteoclasts (resorption).
     • Testosterone has direct and indirect effects on bone growth. It stimulates skeletal growth in adolescence and skeletal muscle growth throughout life. As a result of skeletal muscle growth, bones are subjected to heavier weight-bearing activities, and results in more bone formation.
       • Testosterone converts to bone-preserving estrogen in adipose tissue for aging men.

Bone Healing

Most fractures (breaks in bone) heal through a combination of intermembranous and endochondral ossification processes. When damaged, the bone begins a healing process to reestablish continuity and strength. The bone regenerates, and does not utilize scar tissue.

• Endothelial cells in the bone marrow rapidly differentiate into osteoblasts
• Osteons are formed in the bone cortex
• A hard callus (fibrous tissue) is formed through intramembranous ossification peripheral to the fracture, and is where cartilage is formed through endochondral ossification adjacent to the fracture and soft tissue, where a bridging callus forms, providing stability.

Healing occurs in four stages, similar to injuries in other parts of the body:

1. Hematoma Formation: during the first 1 to 2 days. Bleeding into the injured tissue and local vasoconstriction occur. A hematoma forms. Cytokines are released, initiating the healing process by stimulating fibroblasts to proliferate, causing angiogenesis. Granulation tissue begins to form in the clot and becomes dense. Simultaneously, degranulated platelets and inflammatory cells release growth factor, which stimulate the generation of osteoclasts and osteoblasts.
2. Inflammatory Phase: with the formation of granulation tissue, fibroblasts (fibrocartilaginous soft callus bridge connecting bone fragments) and osteoblasts (new bone) migrate into the fractured site and begins reconstruction. Girth may be restored within three weeks, but weight-bearing ability is still impaired.
3. Reparative Phase: often within three to four weeks, a firm bony union is formed. Mature bone gradually replaces the fibrocartilaginous callus and the excess callus is reabsorbed by the osteoclasts. The fracture site appears immovable. Cast removal may be safe if used. X-rays show alignment.
4. Remodeling: necrotic bone is removed by the osteoclasts. Compact bone replaces spongy bone around the periphery of the fracture, resulting in a thickened area on the surface of the bone that may remain after healing. This may take months to years, depending on the extent of modification, function of the bone, and functional stresses. Monitoring is done with serial x-rays to check for progress. Various factors can alter progress, including the type of bone, adequacy of blood supply, condition of fragments, and immobility of the fracture site.
   • If external or internal fixation is used, bone fragments can be placed in direct contact and alignment with each other, minimizing cartilaginous callous formation.

---

Assessment

1. Health History: musculoskeletal disorders may be stable or progressive, characterized by symptom-free periods as well as fluctuations in symptoms.
   • Details about onset, character, severity, location, duration, and frequency of S/S.
   • Note its associated complaints: precipitating, aggravating, and relieving factors;
   • Progression, remission, and exacerbation.
   • Presence or absence of similar symptoms in family members.
2. Common Symptoms:
   • Pain and Tenderness: bone pain is typically described as a dull, deep ache that is “boring” in nature. It is not typically related to movement and may interfere with sleep. Rest relieves most musculoskeletal pain.
     • Muscular pain is described as soreness or aching, potentially referred to as “muscle cramps”.
     • Fracture pain is described as sharp, piercing, and relieved by immobilization.
     • Bone infection (Osteomyelitis) may also result in sharp pain with muscle spasms or pressure on a sensory nerve.
     • Joint pain is felt around or in the joint and typically worsens with movement.
     • Pain that increases with activity indicates joint sprain, muscle strain, or compartment syndrome.
     • Steadily increasing pain points to progressing infection, a malignant tumor, or neurovascular complications.
     • Radiating pain is found in conditions that place pressure on a nerve root.
     • The time of day in which pain occurs may also be important: inflammatory rheumatic disorders experience worse pain in the morning, especially upon walking. Tendonitis worsens during the early morning and eases by midday. Osteoarthritis worsens as the day progresses.
     • Some assessment focuses include:
       • Is the body in alignment?
       • Are the joints symmetrical or are bony deformities present?
       • Is there any inflammation or arthritis, swelling, warmth, tenderness, or redness?
       • Is there pressure from traction, bed linens, a cast, or other appliances?
       • Is there tension on the skin at a pin site?
   • Altered Sensations: sensory disturbances are frequently associated with musculoskeletal problems. Paresthesias may be described as sensations of burning, tingling, or numbness. These may be caused by pressure on nerves or circulatory impairment. Assess the patient’s neurovascular status in the affected area.
     • Soft tissue swelling or direct trauma to neurovascular structures may impair their function.
     • Some assessment focuses include:
       • Is the patient experiencing abnormal sensations, such as burning, tingling, or numbness?
       • If the abnormal sensation involves an extremity, how does this feeling compare to sensation in the unaffected extremity?
       • When did the condition begin? Is it getting worse?
       • Does the patient also have pain?
3. Past Health, Social, and Family History:
   • Occupation, exercise patterns, alcohol consumption, tobacco use, and dietary intake (Vit. D, Calcium).
   • Concurrent health conditions: diabetes, heart disease, COPD, infection, preexisting disability
   • Related problems (familial or genetic abnormalities)
   • Any history of trauma, or injuries (e.g. falls)
4. Fracture Risk Assessment Tool (FRAX): a tool to predict a patient’s 10-year risk for fractures of the hip or other major bones (spine, forearm, shoulder). The data required includes age, gender, BMI, history, parental history of hip fractures, cigarette use, corticosteroid use, history of RA, alcohol intake of 3 or more drinks per day, and history of secondary causes/risks for osteoporosis. Bone Mineral Density (BMD) based on bone densitometry results may be used as risk assessment if hip-based.
5. Assess for osteoporosis if the patient is a postmenopausal woman over the age of 50, has low BMD, and those with secondary causes/risks for osteoporosis.

Physical Assessment

1. 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: rounding of the back from increased forward curvature of the thoracic spine; hunchback. This may occur at any age from degenerative diseases of the spine (e.g. arthritis, disc degeneration, fractures r/t osteoporosis, and injury or trauma) or other neurovascular diseases.
   • Lordosis: exaggerated curvature of the lumbar spine. This may occur at any age. Common causes include tight low back muscles, excessive visceral fat, and pregnancy.
   • Scoliosis: lateral curving deviation of the spine. This may be congenital, idiopathic, or from damage to paraspinal muscles (e.g. muscular dystrophy).
   • During inspection, the spine, back, buttocks, and legs are exposed. Standing and trunk symmetry are noted from posterior and lateral views. Differences in the height of the shoulders or iliac crests are noted. Shoulder and hip symmetry, as well as the line of the vertebral column, is inspected twice with the patient erect, then while bending forward.
     • Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders are not level, the waistline is asymmetric, and a prominent scapula (especially noticeable when bent forward).
     • Inspection should also be done with the patient bending backwards with support from the nurse.
2. Gait: assess gait by having the patient walk away from the examiner for a short distance. Observe the gait for smoothness and rhythm. Any unsteadiness or irregular movements (frequently noted in older adult patients) are considered abnormal.
   • A limping motion is most frequently caused by painful weight bearing. In such instances, the patient can usually pinpoint the area of discomfort, thus guiding further examination.
   • A limp may be observed if one extremity is shorter than another, with the hip dropping downward on the affected side with each step.
   • In a normal gait, the knee should flex: limited joint motion may interrupt the smooth pattern of gait.
   • Other neurologic conditions are also associated with abnormal gaits, such as spastic hemiparesis gait (from a stroke), steppage gait (from lower motor neuron disease), and a shuffling gait (found in Parkinson’s Disease).
3. Bone Integrity: assess for deformities and alignment. Compare symmetries between parts of the body such as extremities. Abnormal bony growths due to tumors may be observed.
   • Shortened extremities, amputations, and abnormal alignment are noted.
   • Fracture findings may include abnormal angulation of long bones, motion found at points other than joints, and crepitus (grating/crackling sensation or sound) at the point of abnormal motion.
   • The nurse should assess the following:
     • If the affected part is an extremity, how does its overall appearance compare to the unaffected extremity?
     • Can the patient move the affect part? If an extremity is involved, does each toe or finger have normal sensation and motion, and is the skin warm or cool?
     • What is the color of the part distal to the affected area? Is it pale? Dusky? Mottled? Cyanotic?
     • Does rapid capillary refill occur? (The nurse can gently squeeze a nail until it blanches, then release the pressure. The amount of time for the color under the nail to return to normal is noted. Color normally returns within 3 seconds. The return of color is evidence of capillary refill.)
     • Is a pulse distal to the affected area palpable? If the affected area is an extremity, how does the pulse compare to the pulse of the unaffected extremity?
     • Is edema present?
     • Is any constrictive device or clothing causing nerve or vascular compression?
     • Does elevating the affected part or modifying its position affect the symptoms?
4. Joint Function: note the range of motion, deformity, stability, tenderness, and nodular formation.
   • ROM is evaluated actively and passively. The nurse should be familiar with the normal ROM of major joints. Precise measurements may be made using a goniometer.
   • Limitations may exist from skeletal deformity, joint pathology, or contractures (shortening of surrounding joint structures) of the muscle, tendons, or joint capsules.
   • If compromised, the joint is examined for effusion (suspected if swollen and normal bony landmarks are obscured), swelling, and increased temperature that may reflect active inflammation.
   • Patellar Joint Effusion may manifest as knee ballottement or the balloon sign. Consultation with a specialist is indicated.
   • Joint Deformity may be caused by contractures, dislocation, subluxation, or disruption of structures surrounding the joint.
   • Weakness may indicate the need for an external supporting appliance.
   • Palpation during passive movement provides information about integrity: motion is normally smooth. Snapping or cracking may indicate ligament slippage. Crepitus indicates a disorder that produces rough deformity of the articular surfaces.
   • Nodules may form, such as the characteristic nodules of rheumatoid arthritis, gout, and osteoarthritis
     • Rheumatoid Arthritis has characteristic soft subcutaneous nodules on the extensor tendons for the joint.
     • Gout nodules are hard and lie within and immediately adjacent to the joint capsule itself.
     • Osteoarthritic nodules are hard and painless, and represent bony overgrowth resulting from destruction of the cartilaginous surface of bone within the joint capsule.
5. Muscle Strength and Size: note muscular strength and coordination, size, and ability to change positions. Weakness can indicate a variety of conditions, such as polyneuropathy, electrolyte imbalances (particularly of potassium and calcium), Myasthenia Gravis, poliomyelitis, and muscular dystrophy.
   • Have the patient perform certain maneuvers with and without added resistance from the nurse. A simple handshake can provide an indication of grasp strength.
   • Clonus (rhythmic contractions) of the ankle or wrist may be elicited by sudden, forceful, sustained dorsiflexion of the foot or extension of the wrist.
   • Fasciculation (involuntary muscle twitching) may be observed.
   • Measure extremity girth (the maximum circumference) compared to the unaffected extremity to monitor for increases in size from rehabilitation, edema, or bleeding; or decreases in size from atrophy. Note location or landmark of measurement for consistency.
6. Skin: inspect the skin for edema, temperature, and color. Palpation of the skin may reveal warmer areas that suggest increased perfusion or inflammation, or cooler areas that suggest decreased perfusion, and wether edema is present.
   • Cuts, bruises, skin color, and evidence of decreased circulation or inflammation can influence nursing management of musculoskeletal disorders.
7. Neurovascular Status: obtained frequently in musculoskeletal disorders, especially for fractures because of the risk of tissue and nerve damage.
   • The nurse should be aware of the symptoms of compartment syndrome (), a result of increased pressure in a muscle compartment, resulting in nerve and muscle anoxia and necrosis. Function can be permanently lost if uncorrected for 6 hours. Neurovascular assessment is often coined as Circulation, Motion, Sensation (CMS) Assessment.

---

Diagnostic Tests

X-ray

An observation of bone density, texture, erosion, alignment, swelling, and intactness. The condition of joints (size of space, smoothness of articular cartilage, synovial swelling, irregularity, spur formation, narrowing) can be determined. Serial x-rays may be used for monitoring patient recovery.

• Inform the client that the radiation exposure is low and not dangerous.
• Remove all jewelry
• Instruct the patient to remain still.
• Determine if the patient is pregnant: if so, a protective shield may be work over areas not being scanned (abdomen, ovaries, etc.)

Computed Tomography Scan

A CT scan with or without contrast agents (oral or IV), producing a more detailed cross-sectional image o the body. These can be used to visualize and assess tumors; injuries to soft tissue, ligaments, or tendons; and severe trauma to the chest, abdomen, pelvis, head, or spinal cord. It is used to identify the location and extent of fractures in areas that are difficulty to evaluate (e.g. the acetabulum) and not visible on x-rays.

Magnetic Resonance Imaging

An MRI is a non-invasive imaging technique that uses magnetic fields and radio waves to create high-resolution pictures of bones and soft tissues. It can be used to visualize and assess torn muscles, ligaments, and cartilage; herniated discs; and a variety of help or pelvic conditions.

• The MRI scanner is noisy and may take 30 to 90 minutes to complete the test. Inform the patient to remain as still as possible.
• A powerful electromagnet is used, and such is disallowed for patients with metal implants. All metal-containing items are removed as they may cause burns or be damaged. This includes things like credit cards and transdermal patches with aluminized backing.
• If IV contrasts are used, a consent form is required.
• If claustrophobia is an issue with MRI machines, there are open-type MRI machines, but they utilize lower-intensity magnetic fields and thus produce a lower-quality image. They are also quieter.

Bone Scan/Nuclear Scan/Scintigraphy

A radiotracer is injected into the vein, and emits gamma radiation as it decays. A gamma camera scans the areas that absorb the tracer and creates an image of cold and hotspots. Scans can detect problems days to months earlier than a regular X-ray (e.g. a stress fracture may be detected despite no findings in a standard x-ray). These scans are done to evaluate damage to the bones, detect metastatic cancer, and monitor conditions that can affect the bone e.g. infection (aseptic osteomyelitis) and trauma.

1. Cold Spots: little or no tracer absorbed in an area makes it appear dark, which may indicate a lack of blood supply to the bone (bone infarction) or some types of cancer.
2. Hot Spots: increased tracer absorption may show areas of increased metabolism; rapid bone growth or repair. These appear bright, and can indicate the presence of a tumor (osteosarcoma), a fracture, or an infection (inflammatory skeletal disease; osteomyelitis).

Nursing Considerations

• Before:
  • Due to the use of a contrast, a consent form is required.
  • Inform the physician if the patient is pregnant.
  • Determine any potential allergies to the contrast.
  • Inform the patient of indications, procedure, and provide reassurance that the radionuclide poses no radioactive threat.
  • Limit fluids for up to 4 hours before the test, as extra fluids will be prescribed after injection of the radiotracer to excrete excess radioactive substances into urine. Empty the bladder before the scan to remove obstruction of the pelvic bones by the radioactive urine.
• During:
  • Feelings of flushing and warmth are expected.
  • The patient may need to wait for 1 to 3 hours after injection, so a diversional activity may be required e.g. a book or audiotape.
  • Depending on the area being scanned, the patient may need to remove clothing. All jewelries should be removed.
• After:
  • The injection site might be sore or swelling may develop; relieve by applying moist, warm compresses to the arm.
  • Encourage the client to increase fluid intake the facilitate urinary excretion of the isotope. It should be excreted within 48 hours; the excretions are not harmful to others.

Bone Densinometry

Evaluation of an individual’s BMD, performed through X-rays or Ultrasound. The most common modality involves the use of Dual-Energy X-ray Absorptiometry (DEXA), Quantitative Computed Tomography (QCT), and quantitative ultrasound (QUS).

• DEXA measures BMD and predicts fracture risk through accurate monitoring of bone density changes in patients with osteoporosis who are undergoing treatment. It is the recommended diagnostic and monitoring method for osteoporosis. This measures the density of bones in the spine, hip, and wrist. A peripheral form (pDXA) may measure forearm, finger, or heel BMDs but is less accurate in projecting hip or spine fracture risk. The best bone site for monitoring osteoporosis with DEXA is the hip or spine.

Bone Biopsy

A biopsy is often done to tell the difference between cancerous and non-cancerous bone tumors and to identify other bone problems.

1. Closed Bone Biopsy: a bone biopsy inserts a needly through the skin and directly into the bone (via needle or drill biopsy) to obtain a sample.
   • A local anesthetic, IV pain medication, and sedatives may be given to reduce pain and anxiety.
   • There are no special preparation for a closed bone biopsy; the patient signs a consent form and wears a hospital gown.
   • If sedatives are used, the patient may stay longer and have someone drive them home.
2. Open Bone Biopsy: an incision exposes an area of the bone, where a sample is obtained.
   • General Anesthesia may be required for upper body biopsies; lower body biopsies may only require spinal anesthesia or nerve blocks.
   • NPO 8 to 12 hours before the procedure. Normal diet may be resumed after procedure. An overnight stay in the hospital may be required.
3. Post-biopsy: a bandage is placed over the site. Keep it covered and elevated for 24 to 48 hours.
   • Ice packs can prevent hematoma formation.
   • Monitor for redness, edema, bleeding, and pain.

Muscle Biopsy

A sample of the muscle may be obtained to identify or detect muscular disorders (muscular dystrophy, congenital myopathy), metabolic defects of the muscle, infections of the muscle, and differentiation between nerve and muscle disorders. More than one needle insertion may be needed to get an adequate sample.

• No fasting or other special preparations are usually necessary for a closed muscle biopsy. Management is the same as after a bone biopsy.

Electromyography (EMG)

A measurement of the electrical potential of skeletal muscles and the nerves leading up to them. A needle electrode is inserted into the muscle, and the patient is instructed to contract and relax the muscle multiple times. This is performed to evaluate muscle weakness, pain, and disability. These differentiate muscle and nerve problems, and determine abnormalities in functioning.

• If nerve function does not return within 4 months of injury, an EMG may be used to determine the extent of damage.
• An EMG is contraindicated in patients taking anticoagulant medications and any active skin infection, as the electrode may cause bleeding or infection within the muscle.
• A consent form is required. Avoid using any creams or lotions on the day of the test. No other special preparations are required.
• Afterwards, muscles may feel tender, bruised, or sore for a few days. Encourage rest and warm compresses.

Arthrogram/Arthrography

A contrast material or air is injected to study the joint space via an x-ray. This is used for any unexplained joint pain and progression of joint disease. These study the joint structures e.g. tendons, ligaments, cartilage, and the joint capsule. The joint is moved through its full range of motion to distribute the contrast agents. Any tears will produce visible leakage in the final image.

• Notify the physician if the patient is pregnant.
• Remove jewelries
• Activities can be resumed immediately after the procedure.
• A compression elastic bandage is often prescribed. The joint is usually rested for 12 hours and strenuous activity prohibited until approved by the primary provider. Inform the patient that crackling and clicking in the joint for 24 to 48 hours is normal (the contrast agent or air have not been absorbed)
• Mild analgesia, ice, and other additional comfort measures may be provided by the nurse.

Arthroscopy

Instrument/s are inserted into the joint (viewing scope, irrigating instrument, trimming instrument, etc.) to directly visualize (for diagnosis) or perform a surgical procedure (removal of loose bodies, assessment of abnormal articular cartilage) on a joint. It is an endoscopic examination of various joints done under GA or local anesthesia.

• A consent form is required.
• NPO for 8 to 12 hours before the procedure.
• Joint areas may require shaving.
• A sedative is given.
• A hospital gown should be worn.
• Afterwards, limit activity for 1 to 4 days. Walking without weight bearing is often permitted. A compression elastic wrap is worn for 2 to 4 days to control swelling. Elevate the extremity and place ice on the site. (Basically the RICE interventions).

Arthrocentesis

A closed joint aspiration of synovial fluid via a needle for diagnostic examination or direct relief from joint effusion. This is useful for septic arthritis and other inflammatory arthropathies or hemarthrosis. Synovial fluid is normally clear, pale, straw colored, and scanty in volume.

• Diagnosis of specific types of arthritis (rheumatoid arthritis)
• Check for crystals in the joint fluid, potentially a sign of gouty arthritis
• Reveals the presence of hemarthrosis (bleeding into the joint cavity), a sign of trauma or hemophilic disorders.
• Verify the presence of an infection, identify causative agents, and monitor progress of antibiotic therapy.
• Medications may also be directly injected into the joint space.

A consent form is required for the procedure.

• Shaving may be required. Antispasmodics may be given to alleviate discomfort during the procedure.
• Afterwards, a compression bandage applied is used. Rest the joint for 8 to 24 hours. Ice may be prescribed for 1 to 2 days post-procedure to diminish edema formation and pain.
• Take acetaminophen, ibuprofen, or some other mild pain killer for a day or two after the procedure.
• Instruct the client to notify the physician if any complications (fever, excessive bleeding, swelling, numbness, cool skin) occur.

Allergy Testing

For any test requiring contrast agents to be used, screen the patient for allergies.

Laboratory Studies

Studies of the patient’s blood and urine can identify the presence and amount of chemicals and other substances. The results may indicate a primary musculoskeletal problem (e.g. Paget’s disease of the bone), a developing complication (e.g. infection), the baseline for instituting therapy (e.g. anticoagulant therapy) or response to therapy and possible causes of bone loss.

• Coagulation studies are performed to detect bleeding tendencies before surgery.
• Serum Calcium Levels are altered in patients with osteomalacia, Parathyroid, Paget’s Disease, Metastatic Bone Tumors, or Prolonged Immobilization.
• Serum Phosphorus Levels are inversely related to calcium levels and are diminished in osteomalacia associated with malabsorption syndrome.
• Acid Phosphatase Levels are elevated in Paget’s disease and metastatic cancer.
• Alkaline Phosphatase Levels are elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g. metastatic bone tumors).
• Thyroid Studies and determination of Calcitonin, PTH, and Vit. D is used for evaluation of bone metabolism.
• Serum Enzyme Levels of Creatine Kinase and Aspartate Aminotransferase elevate in muscle damage.
• Serum Osteocalcin indicates the rate of bone turnover.
• Urine Calcium Levels increase with bone destruction (e.g. in parathyroid dysfunction, metastatic bone tumors, multiple myeloma).
• Bone resorption may be evaluated with specific urine and serum biochemical markers (N-telopeptide type 1 collagen [NTx], deoxypyridinoline [Dpd]).
• Elevated levels of bone-specific ALP, osteocalcin, and intact N-terminal propeptide of type 1 collagen (P1NP) reflect increased bone remodeling activity.