nursing review of anatomy and physiology

8/2/2019 Nursing Review of Anatomy and Physiology

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Anatomy and Physiology

MSK


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Anatomical Terms

Sagittal Plane vertical plane passing throughthe center of the body dividing it into right andleft halves

Coronal plane imaginary vertical plane at right

angle to the sagittal plane

Horizontal or transverse plane at right anglesto both the median and coronal planes


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Figure 1.


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Terms related to movement

Flexion movement that takes place in thesagittal plane, usually an anterior movement

Extension - straightening of a joint, usuallytakes place in a posterior direction

Abduction movement away from the midline

Adduction movement towards the midline


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Rotation movement of a part of the bodyaround its long axis

Medial rotation - anterior surface faces mediallyLateral rotation anterior surface faces laterally

Circumduction combination of fl, ext, add, abd.

Protraction to move forward

Retraction to move backward


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Inversion sole faces medially

Eversion - sole faces laterally


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Skin

Epidermis :

a) stratum corneum responsible for the waterproof characteristics of the skin

b) stratum lucidum present only in the sole

and palm

c) stratum granulosum water retention andheat regulation


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Skin

d) stratum spinosum protects the basal layer

e) stratum basale/germinativum regenerativelayer

Dermis contains network of blood vessels,lymphatics, nerve endings, collagen and elasticfibers


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Figure 2. skin


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Bone

- Living tissue with a calcified extracellularcomponents that adapts to stress applied to it

Development:

membranous direct transformation of

condensed mesenchyme

endochondral formed by replacing pre-formed cartilage model


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Bone

Macroscopic appearance:

compact bone - ivory surface layer of maturebone

Trabecular bone/cancellous/spongy bone interior of mature bone


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Bone

Cellular components:

Osteoblast bone builders

Osteoclast bone sculptors, found in howships

lacunae

Osteocytes osteoblasts incorporated in thematrix of bone


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Composition of bone

Hydroxyapatite resp. for bone hardness

- composed of calcium, phosphate, and carbonate

- 70% of the weight of bone

Type 1 collagen 90% of the organic component

of bone


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Haversian system


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Regional classification of bones

1. Axial bones

skull

- cranium and face 22

- auditory ossicles 6

- hyoid 1

vertebrae 26 Ribs 24

Sternum 1


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Regional classificaation of bones

2. Appendicular bones

Upper limb 64 bones

Lower limb 62 bones


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Types of boneaccording to general shapeLong bones humerus, femur, fibula

Flat bones skull bones, sternum,

Short bones carpal bones

Irregular bones vertebra, pelvis

Pneumatic bones - sinuses


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Clinical correlation

Fracture break on the normal continuity of thebone

May be open or close

May be classified according to completeness ordisplacement

SSx: abnormal mobility,crepitus, swelling,ecchymosis, deformity, pain, tenderness, mmspasm


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Fracture Classification

Open Fx Gustilo ClassificationType 1 1 cm wound or less

Type 2 - >1 cm wound with moderate softtissue damage

Type 3 Extensive soft tse damage andcrushing due to high velocity trauma

A adequate coverage

B bone exposed with periosteal strippingC Circulation disrupted; arterial repair

required


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Transverse

Spiral

Oblique

Comminuted

Displaced


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Stages of fracture healing

1. Hematoma formation begins within 24 hrs

2. Granulation tissue formation proliferation ofyoung fibroblast, ingrowths of capillaries 24

to 72 hrs

3. Callus formation complex structure formed

by the granulation tissue,osteoblastproliferation, at the end of this stage the twoends move as one but cannot withstand stress(3 14 days)


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Stages of fracture healing

4. Consolidation broken bone ends are bridged,there is already a well formed bone, 2 6 weeks

5. Remodelling final stage of healing where thebroken bone fragments are absorbed (6 wks 2

yrs)


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Principles of fracture treatment

Reduction (close or open) to regain alignment

Fixation to maintain reduction and preventany harmful stress until union has occurred

- external : POP, fiber glass, cast, braces

- internal : screws, plates, IM nails


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Principles

Traction:

1. skin traction done by means of adhesive orreinforced foam rubber strips and encircling

elastic bandage- use when not more than 5 or 6 lbs pull isrequired

Bucks traction used to exert traction in thelong axis of the lower limb with knee and hip innormal position


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Principles

Russel traction done for older children, madeup of rope and pulley arrangement with head

halter for cervical injury and canvass girdle forpelvis

Bryants traction for children below 3 yearsold; usually with femoral shaft fracture, hip inflexed position


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Principles

Skeletal traction

- balanced skeletal traction thomas splint andpearson attachment

- Cruthfield tong used for fracture of the

cervical spine


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Figure 3 tractions


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Traction Apparatus

WeightsShould hang free

Must be securedAvoid bumping or knocking

Should not be a pendulum

Should not be removed unless ordered by attending

or emergency


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Ropes

There should be no frayed spots or knots in the

running lengthshould not drag on the bedclothes or the bed

frame

No ropes should rest against one another

Pulleys. The rope should rest securely in thepulley grooves. Pulley clamps must be securely

attached to the bed frame and must not bemoved unless ordered


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Spreader Bars. The spreader bars shouldcause no pressure on adjacent skin areas

Footplate. The footplate should maintain andsupport the foot in a neutral position, with no

pressure on either side of the foot, the heel, orthe toes. It must not rest against the foot of thebed, as this interferes with the traction pull.


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. Footplate. The footplate should maintain andsupport the foot in a neutral position, with nopressure on either side of the foot, the heel, orthe toes. It must not rest against the foot of thebed, as this interferes with the traction pull.

. Trapeze. The trapeze should be suspendedfrom the overhead bar of the bed frame so thatthe patient can reach and grasp it without strain

and without twisting out of proper alignment.


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Hammocks, Slings, and Halters. Theseshould be free of wrinkles and cause no pressure

on bony prominence or joints. If paddingmaterial is used, it must be clean, dry, and freeof wrinkles and crumbs.


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Skeletal traction

Always check the insertion sites for signs ofinfection

Daily dressing


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Castsa. Short leg cast--extends from below the knee to

the base of the toes.

b. Long leg cast--extends from the upper ormiddle thigh to the base of the toes.

c. Short arm cast--extends from below the elbow

to the palm.d. Thumb spica or gauntlet cast--extends from

below the elbow to the palm and includes thethumb


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Long arm cast--extends from axilla to palm, withthe elbow normally immobilized at a right angle.

Walking cast--a short or long leg cast with arubber or metal walking device attached to thefoot.

Body cast--encases the trunk.h. Shoulder spica cast--a body cast that encases

the trunk, shoulder, and elbow.

i. Hip spica cast--a body cast that encases thetrunk and one or both lower extremities


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Care of new castExpose to air , should not be covered

Handle a wet cast carefully

Support the cast

Instruct the patient on its care

Elevate the involved extremity once cast is dry

Check for sharp edgesCheck circulation


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Once dry:

Check for sharp edges

Check for loose bits inside the cast

Check circulation, nerve integrity

Check for odor

Check integrity of the castPt education


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After cast removalSupport the extremity

Encourage exercise/use of extremity

Avoid vigorous attempts to remove dead skincells, crusted exudates


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Ambulatory aidsCrutches inc. base of support,moderate degree

of stability, relieve weight bearing on the lower

extremities

Measurement : subtract 16 inches from the

patients height, alt: 2 inches below axilla to apoint 6 inches in front and 2 inches lateral to thefoot, supine: axilla to a point 6 8 inches lateralto the heel


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Ambulatory AidsCanes widen base of support, provide limited

stability and unweighing (30%)

Measurement: greater trochanter to a point 6inches to the side of toes

Types: standard cane, quad cane

Gait : held in the hand opposite the involvedextremity, cane and involved extremity advencedtogether, followed by uninvolved


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Ambulatory aidsForearm crutches: the cuff should cover the

proximal third of the forearm, about 1 1and a

half inches below the elbow

Axillary crutches: provide increased trunk support

over forearm crutchesMay be difficult to use in small areas

Prolonged leaning on the axillary bar can resultin vascular or nerve damage


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Ambulatory aidsForearm crutches: have forearm cuff and a hand

grip

Provide less stability but increased ease ofmovement

Frees hand for use without dropping the crutch

Forearm platform cruthches used for patientswho cannot bear weight through their hands


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Ambulatory AidsWalkers:

-widen base of support

- provide increased lateral and anterior stability

- can reduce weight bearing on one or both LE

- frequently prescribed for patients with

debilitating conditions, poor balance, or lowerextremity injury when use of crutches isprecluded


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Ambulatory aidsTypes:

Folding collapsible, mobility in community,

carsRolling available with either two or four

wheels , facilitates walking as a continues

movementReciprocal walker hinged, allows advancement

of one side of walker one at a time


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Ambulatory aidsStair climbing walker has two posterior

extensions and additional hand grips off of the

rear legs for use on stairsHemi walker modified for use with one hand

only, hand grip is located in center front ofwalker


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Sample ambulatory aids


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Gait patternsWeight bearing status:

Non- weight bearing

Partial weight bearing

Full weight bearing


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Gait patternsFour point gait

Indication: weakness in both legs or poor

coordinationPattern sequence: left crutch, right foot, right

crutch, left foot

Advantages: excellent stability, always have 3 pt

contact with the ground

Disadvantages: slow walking speed


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Gait patternsThree - point gait

Indication: Inability to bear weight on one leg

Pattern sequence: first move both crutches andthe weaker limb forward, then bear all your weightdown through the crutches, and move theunaffected leg forward

Advantage: eliminates all weight bearing on theaffected leg

Disadvantage: good balance is required


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Gait patternTwo point gait

Indication: weakness in both legs or poor

coordinationPattern sequence: L crutch and R foot

together,then R crutch and L foot together

Advantage: faster than 4 point gait

Disadvantage; may be difficult to learn the pattern


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Gait patterns

Swing through gaitIndication: inability to fully weight bear on both

legs

Pattern sequence: advance both crutches forward

then while bearing all weight down through bothcrutches, swing both legs forward at the same timepast the crutches

Advantage: fastest gaitDisadvantage: energy consuming, requires good

UE strenght


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Gait patternSwing to gait

Indication: patients with weakness of both lower

extremitiesPattern sequence: same as swing through but legs

are not brought forward past the crutches.

Advantage: easy to learn

Disadvantage: requires good UE strenght


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Gait patternsTripod gait

Indication: initial pattern for patients with

paraplegia learning to do swing to gait patternPattern sequence: advance L crutch, then right

crutch, then drag both legs to the crutches

Advantage: provides good stability

Disadvantage: very energy consuming


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Gait patternsStairs: good go to heaven, the bad go to hell

Guarding:

Level surfaces: stand slightly behind and to oneside , typically on the involved side

Stairs: below the patient

Ascent: behind and on the involved side

Descent: in front and on the involved side


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JointsSite where two or more joints meet

Classification:

Fibrous: joined by fibrous tse, very littlemovement , ex: sutures, inf. tibiofibular jt.

Cartilaginous: may be primary or secondary

Primary if the bones are united by a plate or bar ofhayline cartilage e.g.: union between epiphysis anddiaphysis


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Secondary if bones are united by fribrocartillage

e.g.: symphysis pubis

Synovial Joint joint cavity lined by synovium,posses joint capsule, surfaces lubricated by

synovial fluid

types: hinge, ball and socket, saddle jt, ellipsoid,condyloid, pivot, plane jt


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Type of synovial jointPlane : articular surfaces are flat or almost flat.

- Sternoclavicular and acriomioclavicular jt

Hinge : resemble hinge of a door

- elbow, knee, ankle

Pivot : central bony pivot surrounded by a bonyligamentous ring

- Atlantoaxial and sup. Radioulnar jts


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Condyloid : have two distinct convex surfaces

that articulate with two distinct concave surfaces- MCP jt

Ellipsoid : elliptical convex articular surface thatfits into an elliptical concave surface

- Wrist jointSaddle joint : surfaces are reciprocally concave-

convex. Example CMC of the thumb

Ball and socket shoulder and hip


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Types of joint


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ArthritisInflammation of the joint

Non inflammatory idopathic, posttraumatic,congenital

Inflammatory most common is RA


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Rheumatoid arthritisSym. Inflammatory arthritis involving small and

large jts of at least 6 wks duration

Diagnostic criteria:

Morning stiffness

Arthritis of at least 3 areas lasting greater than 6wks

Involvement of hand joints > 6wks

Must be symmetrical


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Rheumatoid nodules

RF (+)

Xray evidenceAt least 4/7 to make a diagnosis

Commonly affected jts : wrists, MCP, PIP, ankle,mtp, knees, shoulder, hips, elbow


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Systemic manifestations:Anorexia, weight loss, fatigue

Bouchards node osteophyte formation aroundPIPHeberdens node enlargement of DIPOpera glass hand severe destruction and

resorption of synovial jt folded telescopeappearancePeripheral neuropathies mild and in the elderlyScleritis, episcleritis


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ManagementAspirin, salicylates

DMARDS gold, methotrexate, plaquenil

Rehabsurgery


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OsteoarthritisA form of chronic arthritis found in the middle

aged and elderly

Characterized by degenerative changes in thearticular cartillage and osteophyte formation

Primary no underlying cause

Secondary result of antecedent dse/injury


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Prevalence:M>F - M - >45 y.o.F=M in generalSSx:Early stage :

Stiffness of 1 or more joints associated with achingpainSlight enlargement of the affected jts which may be

slightly tender about the margins


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Bony enlargement of the DIP one of thecommonest sign

Late stage LOM and disability

Pain

Jt malalignmentCrepitation

Jt locking esp knees


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Early fatigue

Management

General measures:

Rest, weight reduction, brief ROM exercises

non- weight bearing

Drug therapy non specific, ASA drug of choice

Rehab


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Crystalline Arthropathies

Gout - monosodium urate

Pseudogout calcium pyrophosphate

Manifestation:

Abrupt onset, very painful, swollen, warm andtender joints may awaken sleep

Mild attacks resolve spontaneously 1 to 2 days

Severe attacks may last for a weekIn pseudogout may last for a month

Attacks may be provoked by trauma, currentillness

Labs elevated ESR, leukocytosis


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Usually monoarticular

Most common site 1st MTP but ca also involve

the ankles, knees, wrist, fingers, elbows

In pseudogout most common - knee

Elbows, wrist, ankle, shoulder, hip

Treatment of choice indomethacin 75 100mg, then 50 mg q 6


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Seronegative spondyloarthropatiesAnkylosing spondylitis HLA B27

Psoriatic arthritis

Inflammatory bowel dseReiters dse


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MuscleFunctional unit is the sarcomere

Type of fibers:

Type 1 or slow twitch muscles:

- aerobic

- fatigue resistant- high oxidative enzymes low in myosin ATPaseactivity


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Type 2 or fast twitch muscle

Anaerobic

Prone to fatigue

High in glycolytic enzyme and myosin ATPase

activity


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Sarcomere


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Skeletal MuscleEach muscle fiber is multinucleate and behaves

as a single unit. It contains bundles of myofibrils

surrounded SR and invaginated by transversetubules

Thick filaments present in the A band

Contains myosin

Each myosin molecule has 2 heads attached to asingle tail. The heads bind ATP and actin


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Thin filaments are anchored at the z lines

Present in the I bands

Contain actin, troponin, and tropomyosin

Troponin- a regulatory protein, a complex of threeglobular proteins

Troponin T attaches to tropomyosin

Troponin I inhibits interaction between actin andmyosin

Troponin C avidly binds to calcium


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Contraction

1. Action potentials in the muscle cell membraneinitiate depolarization of the T tubules

2. Depolarization of the T tubules opens Carelease channels in the SR

3. Increase intracellular calcium

4. Calcium binds to troponin C

5. Myosin heads interact with actin filaments6. relaxation


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Isometric contraction generation of tensionwithout shortening

Isotonic contraction shorten at a constantafterload

Atrophy decrease in muscle cell size

Hypertrophy increase in muscle cell size

Hyperplasia increase in the number of musclecells


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MMT0 (zero) no muscular contraction

1 (trace) a barely detectable flicker or trace ofcontraction

2 (poor) active movement, gravity eliminated

3 (fair) active movement against gravity


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4 (Good) active movement against gravity andsome resistance

5 (Normal) active movement against fullresistance


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Duchenne Muscular DystrophyMost common and most disabling of the

muscular dystrophies

Defect of the X chromosome at the Xp21 locusBegins in early childhood with relatively

progressive course

Muscle weakness is obvious at the age 4 -5

Death usually during adolescence seldomsurvive beyond 25 y.o.


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Common cause of death resp infection

Usually wheelchair bound by 10 -12

SSx:Pseudohypertrophy of calf muscle

Lordotic posture, protruded abdomen

Waddling gait

Gower sign


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Myasthenia gravisAn autoimmune disorder characterized by

weakness and execessive faigability often

confined to ocular,palatal,or pharyngeal muscleF>M

Destruction of Ach receptors

Most common SSx ptosis, diplopia, dysphagia,dysarthria, weakness

Later choking, nasal regurgitation


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Nasal speech, hanging jaw sign

Trident tongue one central and two

longitudinal furrows in the tongue

Management anticholinesterase ex.Neostigmine, pyridostigmine


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Head and NeckSkull bones of the head, face, mandible

Cranium head and face

Calvaria bones of head onlyLayers of the SCALP:

Skin

subCutaneous tissue

Aponeurosis

Loose areolar tissue

periosteum


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Areolar space dangerous space, infections mayspread from scalp to meninges via the emissary

veinsMuscles of facial expression supplied by the

facial nerve

Muscles of mastication supplied by yourtrigeminal nerve

Extraoccular muscles supplied by cranial nervesIII, IV, VI


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Eye closure muscles supplied by Cranial nerve7 (that is why eyelids lag in Bells palsy)

Eye opening cranial nerve 3


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Back and SpineMade up of 33 vertebrae

7 cervical

12 thoracic5 lumbar

5 sacral

4 coccygeal

28 inches in length, 4 curves on lateral view

Lordosis,kyphosis


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Parts of a typical vertebra

Body weight bearing portionPedicle short and thick posterior projections of

the body

Lamina flat part that unites the pedicles

Arch formed by the lamina and pediclesTransverse process arise at the jxn of pedicle

and lamina

Spinous process posteriorly directed processfrom midpoint of lamina


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The vertebra


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Cervical vertebrae1st, 2nd, 7th are atypicalGen. characteristics :

Has transverse foramen in the transverseprocessesBifid spinous processesSmall vertebral bodies

Atlas no body and spinous processAxis odontoid processVertebra prominens - landmark


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Thoracic VertebraePresence of costal facets

Heart shape body

Spinous process long and inclined downwards


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Lumbar vertebraLarge size largest and strongest

Body is kidney shape

Short spinous processPresence of mamillary process


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CorrelationPotts dse TB of the spine

Commonly seen in Children below 10 yrs old

Lower thoracic and upper lumbarUsually affects the vertebral body leads to

vertebral collapse and gibbus formation

MX : anti tb drugs for up to two years


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Disc Herniation90% occurs at the L4 L5, L5-S1 level

Common 30 50 y.o

SSx Recurrent episodes of back pain and pain in the

lower leg

Prolonged sitting/standing aggravates the pain

Sciatic pain


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Treatment:

Laminectomy

Laminotomyrehab

Sho lder


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ShoulderBall and socket joint

Commonly dislocated anteriorly

Rotator cuff

Supraspinatus

InfraspinatusTeres minor

Flexion: ant. Fibers of deltoid

Extension: teres major

Abduction: deltoidsAdduction: pectoralis


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ElbowHinge or ginglymus joint

Nursemaids elbow common 6 years old and

belowFlexion: biceps brachi, brachialis,

brachioradialis

Extension: triceps brachi and anconeus

Supination: supinator, biceps

Pronation: pronator teres


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Wrist JointCondyloid or ellipsoid joint

Carpal bones:from lateral to medial, proximal to

distal rowScaphoid (most commonly fractured), lunate

(most commonly dislocated), triquetrum, pisiform(smallest)

Trapezium, trapezoid, capitate, hamate

Hand


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Hand

Thenar emminence: copmosed of the muscles,abductor pollicis brevis, flexor pollicis brevis,opponens pollicis

Hypothenar eminence : abductor digiti minimi,flexor digiti minimi, opponens digiti minimi

All intrinsic muscles of the hand are supplied by

the ulnar nerve except AFOLS (thenar musclesand lumbricals 1 and 2) which is supplied by themedian nerve


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HandFlexion of PIP: flexor dig. Supeficialis

Flexion of DIP: flexor dig. Profundus

Radial nerve injury: wrist drop

Ulnar nerve: claw hand

Median nerve: ape hand


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hipBall and socket joint

Most commonly dislocated posteriorly

Femur longest bone in the bodyFlexion: iliopsoas

Extension: gluteus maximus

Abduction: gluteus mediusAdduction: adductors

k


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knee

Patella largest sesamoid bone in the bodyMedial meniscus usually damaged compared

to lateral meniscus because it is more fixed

Unhappy triad:

Tear involving the ant. Cruciate ligament, medialcollateral ligament, medial meniscus

Flexion: hamstring muscles

Extension: quadriceps femoris


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Ankle and footFoot 26 bones

Ant. Talofibular ligament most commonly

injured in ankle sprainsDorsiflexion: tibialis anterior and extensors of

digits

Plantarflexion: triceps surae


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Man go abroad to wonder at the height of themountain, the huge waves of the sea, the long

course of rivers, the vast compass of the ocean,the circular motion of the starsbut they passby themselves and dont even notice.

-Augustine-

nursing review of anatomy and physiology

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