NLE Musculoskeletal Nursing — Musculoskeletal Assessment and DiagnosticsSummary

Bone is living, vascular connective tissue constantly undergoing remodeling through balanced activity of osteoblasts (bone-building cells) and osteoclasts (bone-resorbing cells). Calcium and phosphorus are stored within the bone matrix and regulated by parathyroid hormone (PTH—increases serum calcium and phosphorus), calcitonin (lowers serum calcium), and vitamin D (enhances calcium and phosphorus absorption). This dynamic process maintains skeletal strength and mineral homeostasis. In the elderly or those immobilized for prolonged periods, osteoclast activity exceeds osteoblast activity, leading to osteoporosis—a critical risk factor for pathological fractures in Philippine geriatric populations.

Joints are classified by degree of movement: synarthrodial joints (immovable; example: skull sutures) allow no motion; amphiarthrodial joints (slightly movable; example: vertebral discs) allow limited motion; and diarthrodial (synovial) joints (freely movable; example: knee, hip, shoulder) permit full range of motion. Synovial joints possess a cartilage-lined articular surface, a synovial membrane that secretes lubricating synovial fluid, and supporting structures—tendons (attach muscle to bone), ligaments (attach bone to bone or provide joint stability), articular cartilage (shock absorption and frictionless movement), and bursae (fluid-filled sacs that reduce friction between moving structures). Understanding joint anatomy is critical for assessing range of motion limitations and recognizing structural injuries.

The neurovascular check is the most critical nursing assessment in orthopedic care. It uses the 5–6 Ps mnemonic to detect early signs of compartment syndrome and other perfusion emergencies: Pain (especially pain on passive stretch of digits—the earliest warning sign and most sensitive indicator), Pallor (pale, dusky, or cyanotic skin; check capillary refill, normally under 3 seconds), Pulselessness (diminished or absent distal pulse; a late and ominous sign), Paresthesia (numbness, tingling, pins-and-needles sensation), Paralysis (inability to move digits; a late sign indicating severe nerve damage), and Poikilothermia (coldness of the affected part). Always compare the affected extremity with the contralateral unaffected limb. Increasing or severe pain—especially pain disproportionate to the clinical findings or pain on passive stretch—is the earliest and most reliable warning sign of compartment syndrome, a surgical emergency where increased pressure within a closed fascial space compromises microvascular perfusion. Deterioration in any finding must be reported immediately because permanent nerve and muscle damage can occur within 4–8 hours of ischemia.

Range of motion is assessed actively (patient performs the movement) and passively (examiner moves the joint). Document movements specific to each joint: flexion (decrease in joint angle), extension (increase in joint angle), abduction (movement away from midline), adduction (movement toward midline), internal rotation (medial rotation), external rotation (lateral rotation), and at the forearm, pronation (palm down) and supination (palm up). A goniometer measures joint angles precisely in degrees. Limited ROM may reflect pain, joint effusion, contracture, muscle weakness, or mechanical blockage. Never force a joint against resistance or through pain; this risks further injury. Always compare the affected side with the unaffected side. Assessment of ROM is essential for establishing baseline function, monitoring recovery, and identifying functional limitations for activities of daily living (ADLs).

Gait assessment evaluates the patient's walking pattern by observing two phases: stance phase (foot is in contact with the ground; normally 60% of the gait cycle) and swing phase (foot is moving forward; normally 40% of the gait cycle). During inspection, note symmetry, stride length (distance covered in one gait cycle), arm swing, posture, and use of assistive devices. Compare right and left sides for balance and coordination. Common abnormal gait patterns include: antalgic gait (shortened stance phase on the painful limb to limit weight-bearing; typical of acute pain or fracture), shuffling gait (characteristic of Parkinson disease and other neurological conditions), wide-based ataxic gait (broad stance base with unsteady, uncoordinated movement; seen in cerebellar disorders), and Trendelenburg gait (hip drops on the non-weight-bearing side due to weak hip abductors). Always guard the patient during gait assessment to prevent falls, and assess fall risk using validated tools such as the Timed Up and Go (TUG) test in community settings.

Plain radiography (X-ray) is the first-line imaging study for suspected fractures, dislocations, and bone alignment; it shows bony detail well but soft tissue poorly. No special patient preparation is required, but confirm non-pregnancy and remove metal objects. Computed tomography (CT) provides cross-sectional images with excellent detail for complex fractures (especially around joints) and spinal injuries; contrast may be used (assess for iodine/shellfish allergy and renal function before contrast administration). Magnetic resonance imaging (MRI) is the gold standard for soft-tissue visualization (ligaments, tendons, cartilage, herniated discs, tumors, osteomyelitis, nerve compression). Critical pre-MRI screening: remove all ferrous metal (jewelry, watches, hairpins) and screen for contraindicated implants (most pacemakers, cochlear implants, ferrous aneurysm clips). Warn patients about the enclosed space, loud noise, and possible metallic heating. Bone scan (skeletal scintigraphy) uses intravenous technetium-99m tracer; hot spots (increased uptake) indicate high bone turnover such as metastatic tumor, infection (osteomyelitis), or occult fracture; there is a 2–3 hour delay between injection and imaging (encourage fluids to distribute tracer and promote renal excretion; reassure patient that radiation dose is minimal). Dual-energy X-ray absorptiometry (DEXA) measures bone mineral density to diagnose osteoporosis; results are reported as a T-score (T-score ≤ -2.5 = osteoporosis; -1 to -2.5 = osteopenia).

Arthroscopy is a minimally invasive fiberoptic endoscopic procedure that allows visualization, biopsy, and surgical repair of internal joint structures (most commonly the knee, shoulder, hip, or ankle). Performed under anesthesia (local, regional, or general), it carries risks of infection, blood loss, and hemarthrosis (bleeding into joint). Pre-procedure: verify informed consent, keep patient NPO as ordered, document baseline neurovascular status. Post-procedure: perform frequent neurovascular checks distal to the site, apply compression dressing to control hemorrhage and swelling, apply ice as ordered, elevate the extremity above heart level, administer prescribed analgesics, and restrict strenuous activity. Teach the patient to report fever, increasing joint pain, swelling that does not improve with elevation and ice, or weakness—all signs of infection or hemarthrosis. Arthrocentesis is aspiration of synovial fluid from a joint cavity, performed for diagnostic analysis (to detect infection, gout crystals, or blood) or to relieve pain from effusion. Post-procedure care is similar to arthroscopy but typically less restrictive.

A cast is a rigid or semi-rigid immobilization device applied to reduce and hold a fracture or other injury in proper alignment to promote healing and prevent further injury. Casts are made of plaster of Paris (heavier, takes 24–72 hours to fully dry, moldable) or fiberglass (lighter, dries in 30 minutes, water-resistant). Nursing care of a wet cast: support with palms of hands (not fingertips, which create denting and pressure points); do not cover the cast while wet (allow air drying); elevate the extremity above heart level for the first 24–48 hours (reduces swelling); apply ice as prescribed. Assessment: perform frequent neurovascular checks distal to the cast; assess for a hot spot, foul odor, or drainage that may indicate infection or pressure ulcer under the cast (circle and date any drainage to monitor spread); assess for tight casting (impaired circulation) or loose casting (inadequate immobilization). Patient education: never insert objects into the cast to scratch (breaks skin, invites infection); keep the cast clean and dry (cover with plastic when bathing); report increasing pain, numbness, tingling, coolness, cyanosis, or swelling that does not resolve with elevation—all signs of vascular compromise. Reinforce activity restrictions and the importance of cast immobilization for healing.

Traction applies a pulling force to a body part to reduce and align fractures, correct deformities, or relieve muscle spasm by applying longitudinal tension. Skin traction applies the pull through weights attached to the skin via a boot, adhesive strips, or adhesive bandage; used short-term with light weights (typically 2–3.5 kg); examples include Buck's traction for hip fractures and cervical traction for neck pain. Skeletal traction applies the pull directly to the bone through surgically inserted pins (e.g., halo pins), wires (e.g., Steinmann pins), or tongs; allows heavier, longer-term traction; carries a risk of pin-site infection. Universal traction principles: maintain the pull by ensuring weights hang freely and never rest on the floor or bed (loss of tension defeats the purpose); do not remove or add weights without a physician order; keep the patient in proper body alignment with countertraction (often provided by the patient's body weight and friction); keep ropes on the pulleys and knots secure; assess for signs of traction failure (loss of alignment, visible sagging of rope or weights). For skeletal traction: provide pin-site care using aseptic technique (assess for redness, swelling, drainage, or loosening; these are signs of infection); educate the patient about pin-site care and signs of infection. Assess for complications of immobility (pressure injury, deep vein thrombosis, constipation, pneumonia, contractures). Monitor neurovascular status regularly. Teach the patient the purpose of traction and reinforce activity restrictions.

After musculoskeletal injury or surgery, patients require training in safe use of ambulatory aids. Crutches are used when one or both legs cannot bear weight; proper fit is critical—there should be 2–3 finger-widths (approximately 5 cm) of space between the axilla and the axillary pad; weight is borne on the hands and upper arms, never on the axilla itself, because leaning directly on the axillary bar can compress the radial nerve and cause crutch palsy (wrist drop, inability to extend fingers). Gait patterns: three-point gait (both crutches and the affected leg advance together, then the strong leg swings through; used when one leg cannot bear weight), four-point gait (right crutch, left foot, left crutch, right foot; used when both legs can bear some weight but require support), two-point gait (right crutch and left foot advance together, then left crutch and right foot; faster than four-point). Stair climbing rule: up with the good, down with the bad (the strong leg leads going up the stairs, crutches and weak leg lead coming down). A walker provides the most stability; the patient lifts and advances the walker, then steps into it (appropriate for elderly or severely impaired patients). A cane is held on the strong (unaffected) side and advanced with the weak leg; provides less support than crutches or a walker but allows greater independence. Always teach and supervise gait training before the patient leaves the healthcare facility to prevent falls and promote safety in the home or community.

A focused musculoskeletal history begins with the chief complaint and uses PQRST framework for pain characterization: Provocation/Palliation (what makes pain worse or better?), Quality (sharp, dull, aching, burning?), Region/Radiation (where is the pain; does it radiate?), Severity (0–10 scale), and Timing (constant, intermittent, worse at certain times?). Ask about stiffness—morning stiffness that improves with activity is characteristic of rheumatoid arthritis, while stiffness that worsens after activity suggests osteoarthritis. Inquire about swelling, deformity, weakness, functional limitations in ADLs, mechanism of injury, occupational and recreational demands, fall history (particularly in elderly), calcium and vitamin D intake, and medications (corticosteroids weaken bone; anticoagulants increase bleeding risk). A thorough history guides physical examination and diagnostic testing and helps identify risk factors for musculoskeletal disease or fracture.

Common laboratory tests support musculoskeletal diagnosis: serum calcium (normal 8.5–10.5 mg/dL; elevated in hyperparathyroidism or immobilization; low in hypoparathyroidism or vitamin D deficiency), serum phosphorus (normal 2.5–4.5 mg/dL; inverse relationship with calcium), alkaline phosphatase (elevated during bone healing and in bone diseases such as Paget disease or metastatic cancer), serum uric acid (elevated in gout; normal <7 mg/dL in men, <6 mg/dL in women), erythrocyte sedimentation rate (ESR; elevated in inflammatory and infectious conditions; normal <20 mm/hour), C-reactive protein (CRP; a more specific marker of inflammation and infection), rheumatoid factor (RF; positive in rheumatoid arthritis, though 20% of RA patients are seronegative), and anti-CCP (anti-cyclic citrullinated peptide; highly specific for rheumatoid arthritis). These tests, combined with clinical findings, support diagnostic impression and guide treatment planning.