INTRODUCTION
The given study involves a 25-year old girl who has met with an accident and fell off the bike on a mountain her right side, while jumping over a curb and presents with a significantly large abrasion and ecchymotic area on the right thigh. She reports to have been wearing her helmet and no loss of consciousness and absence of any swelling. The patient may be evaluated and diagnosed for occurrence of musculoskeletal disorder for pain in her hip, arms and thigh.
ANATOMICAL COMPONENTS OF THE MUSCULOSKELETAL SYSTEM
The musculoskeletal system comprises of bones, muscles, joints, and the other connective tissue constituents combining these structures . Overall, the musculoskeletal system may be regarded as the process through which the body conducts all mechanical roles. Every joint in the system is deliberated to perform a particular combination of motions, and an intricate system of muscles, bursae and tendons generate and enhance the function. Any irregularities in the structural organization and functioning of these structures will generate impairment.
Besides supporting the body weight, the bones function in combination with the muscles to preserve the body position and generate exact and more controlled motions. Skeleton comprises of bones that contain two types of tissue each: compact bone that is comparatively solid and spongy bone that establishes a network of plates and struts . The outer region of the bone is made up of compact bone, while the interior of the bone is spongy. Every bone is encapsulated by a tough layer called periosteum that is a membrane comprising of collagen fibers combined with ligaments and tendons connected to the bones. The periosteum is composed of a system of blood vessels that provide nutrition and oxygen to the bone. The joints are surrounded by cartilage, which functions to offers a smooth surface for motion .
The pelvis protects the pelvic organs apart from functioning as a region of binding to the thigh and trunk muscles. The hip associates with the femur bone in the socket producing vacuum called as acetabulum . The iliofemoral ligament is the most robust ligaments in the hip protects the pelvis from rotation of the femur with bearing of excessive weight and curbs hyperextension.
Cartilage is a kind of connective tissue that forms a fixed gel-like material. The body comprises of three primary types of cartilage :
Hyaline cartilage is the most prevalent kind of cartilage that functions to provides firm but flexible support. For instance, the tips of ribs, where they converge with the sternum and some portion of nasal septum. Yet another example is articular cartilage, which encapsulates the ends of bones inside the joint. The exterior of articular cartilage is slippery and smooth and decreases friction during movement of the joint.
Elastic cartilage that functions in providing support but is able to withstand distortion in damage and revert back to its initial shape. The external flap of the ear is one place where elastic cartilage can be found.
Fibrocartilage restricts compression, precludes bone-to-bone interaction and curbs relative movement. Fibrocartilage is encountered within the knee joint, amongst the pubic bones of the pelvis, and in the middle of the spinal vertebrae.
Other constituents of the musculoskeletal system
Tendons, muscles, ligaments provide stability to the bones of the wrist. Muscles are of two kinds; intrinsic that are tiny and are restricted to the distal area of the long bones of the arm, while the extrinsic muscle is derived from the muscle belly of the arm and is embedded in the arm.
The region between the hip and the knee is the thigh comprising of longest bone of the body called femur. The adductors function in the hip and provide adduction to the thigh. The quadricep is toughest muscle of the thigh.
Nerves regulate the contraction of skeletal muscles, decipher the sensory information, and organize the actions of the body's organ systems .
HEALTH ASSESSMENT AND HISTORY
The 25-year old girl met with an accident and fell off the bike on her right side, while jumping over a curb and reported of a big abrasion and ecchymotic region on the right thigh with absence of swelling. The primary mechanism of injury would be established as a minor trauma to the right side. A coherent history of the mechanism of injury is crucial for the precise diagnosis in trauma. The intensity and direction of the forces involved in the injury are important parameters to consider. Symptoms such as swelling, pain and impairment of critical functions should be investigated. With regards to the pain, factors such as location, nature, aggravation, radiation and relieving conditions are of particular significance . Ecchymotic area on the right thigh is in accordance with bleeding underneath the skin and trauma to the tissue and may engage many bones . Disability to endure weight and limping is indicative of a hip fracture and pain that would affect mobility . Other questions that need to be addressed may be involvement of other physiological systems such as eyes, lungs, kidney etc.,
Medical History
. The nurse would need to interrogate into the past history of injury to any parts of the body such as shoulder, leg or hand . She would also need to reveal incidences of any past accidents, surgeries or chronic conditions. Congenital anomalies of the patient, if any, particularly related to the hip and legs should be questioned.
PHYSICAL EXAMINATION
A general musculoskeletal examination involves a brief screening test of about 1-2 minutes, designed for routine evaluation. This is termed GALS, which is an abbreviation for Gait, Arms, legs and Spine. It is of considerable significance to record both positive and negative results from these assessment techniques .
Gait
The patient may be examined in the upright standing position for the tilt of the pelvis. The gait may be investigated to diagnose a limp caused due to damage to the hip joint or the muscles and nerves surrounding the joint. The patient may be asked to lie in a recumbent position on the table and to vigorously contract the first hip and then the other with the opposite hip completely extended. A 90o flexion with the knee straight should be conducted with the knee folded to 120 degrees or greater . The patient would be requested to walk and his gait would be evaluated. An antalgic or a painful gait would cause limping, whereas a weakness in the muscle would lead to Trendelenburg gait. .
Arms
Since the patient’s hand and wrist are injured during the accident, a detailed physical scrutiny of these joint would be necessary. This is conducted with patient’s arms placed on the pillow since it could generate pain with if the patient has physical problems with shoulder or elbow to hold their hand up for a long period of time .
Incidents of acute trauma to the site, such as a bike accident and tripping from the mountain, may cause de Quervain tenosynovitis. This is a condition caused by stenosing tenosynovitis of the preliminary section of the wrist. If the condition occurs in the patient in this case, she would most likely complain of pain in the dorsolateral region of the wrist with a movement of pain towards the thumb or the lateral forearm. The healthcare practitioner would have to examine her for occurrence of This condition may be best treated with nonsurgical treatment methods. These may include preventing repetitive thumb flexion, use of thumb splints and treatment with NSAID .
A test termed Finkelstein test, which involves ulnar deviation of the wrist, with the thumb placed in abduction by the contracted fingers of the same hand may generate pain.. Ulnar deviation is expected to be about 55 degrees and radial deviation is around 20 degrees. Restricted range of motion is indicative of dislocation and inflammation . The patient may have to be examined for tenderness and pain, triggering, snapping during motion of the thumb and finger and general sensation . The patient’s traumatic accident may have caused tenderness in the wrist.
Legs
The abrasion on the right thigh should be further measured in diameter and its exact location should be evaluated . Ecchymotic region on the right thigh is in accordance with bleeding underneath the skin and trauma to the tissue and may engage many bones. The patient’s limp will need to be evaluated to check if she is in the position to bear the weight, the lack of which is indicative of swelling or fracture that could elevate the pain and affect the mobility. The strength of the right leg should be evaluated .
Spine
Being a ball-and-socket joint, the hip has the ability to undergo complex movements like extension, flexion, abduction, adduction and rotation. Several specialized methods may be conducted surrounding the hip to describe particular anomalies . It would be necessary to examine the hips anteriorly and posteriorly and investigate the occurrence of any asymmetry in the iliac crests and the overall structure of the buttocks. .
Examination techniques for abduction of the hip are relatively convenient to conduct passively. The patient would be instructed to place the left hand on the ilium crest and grip the right leg by using the right hand. Slow abduction of the leg as far as possible without generating motion of the pelvis, should be feasible at 40 degrees or higher .
Rotation of motion (ROM) may be quantified with both the knee and the hip flexed at 90 degrees and the other leg should be completely extended. Internal rotation is measured by maneuvering the ankle externally at 40 degrees . External rotation is measured by moving the ankle inward, which should be possible to 45 degrees or greater. Any shortcomings in the external movement is indicative of hip fracture. Any sort of limitations to this movement is suggestive of hip disease. Rotation of the hip may also be measured with the patient lying prone on the table and the hip fully extended. In this case the knee on the side being measured should be flexed to 90 degrees and fully extended on the opposite side .
Flexion contracture of the hip is diagnosed by extending the opposite hip until the lumbar lordosis is flattened on the table . The patient is requested to cooperate in this evaluation method by holding the flexed knee. The leg on the side of the hip under consideration may then be slowly depressed to the table. In case of a contracture, this action may not be conducted entirely. Hyperextension of the hip can be examined by requesting the patient to lie in the supine position on the table and gradually lifting the leg being examined at 15 degrees or greater.
The nurse may request the patient to undergo Thomas’ test for fixed flexion damage of the hip . She may place one hand below the patient’s back to confirm the absence of any lumbar lordosis. The patient may then be instructed to completely flex one hip. Lifting up of the other leg on the couch may be indicative of fixed flexion deformity. In a normal hip, tilting of the pelvis causes extension, permitting the leg to stay on the couch .
The hip and the gluteal muscle strength may be performed using the Trendelenburg test that involves the patient alternatively standing on each leg by himself. In a normal test, the pelvis would stay still or rise, while in an abnormal condition, the pelvis would depress on the contralateral side . Occurrence of pain to the posterior hip and groin on palpation should be monitored.
PATIENT’S HISTORY
Social history
Of utmost importance would be to know the patient’s profession, daily occupational activities and nature of work, with reference to emotional and physical stress . Patient’s vulnerability to injury, occurrence of environmental hazards should be evaluated. Some questions related to the patient’s hobbies and recreational activities would be important to address. Information concerning smoking, or drug use and alcohol consumption may be informative. Some of the questions that need to be addressed by the examiner are whether the problem restricted to one region or involves may areas, whether it is a symmetrical problem, and whether the defect underlies the forces acting on the joint, in the joint, and whether any systemic symptoms like fever and rash are showing .
Family history
Her family history would reveal occurrence of diseases like arthritis or other disease such as cancer, diabetes . Investigation of incidences of any chronic disorders, the age and relationship of the patient with the diseased, and risk parameters for diseases such as arthritis, spondylitis or genetic disorders, would be critical information to collect. The patient should also be interrogated about the mother’s health during the pregnancy period with the patient.
DIAGNOSIS & LABORATORY TESTS
Biochemical tests and blood tests would be performed to assess the biochemical parameters and rule out any infections . Examination using X-rays would reveal occurrence of fractures in the right shoulder, right wrist and right hip. X-ray of the hip would exhibit degenerative alterations in the bony regions, if any, in the bony regions and condition of the pelvic ring. Wrist X-rays would exhibit fracture in the wrist.
Although there may be possibility of other hip disorder such as iliopsoas bursitis, which is a condition that may be caused due to traumatic incidents, the most likely diagnosis for the patient is fractures in the hip and wrist. More comprehensive examination such as CT scans may be ordered to get a closer picture of the bones or MRIs to examine the soft tissues such as ligaments and tendons and confirm the differential diagnosis .
CONCLUSION
The musculoskeletal system is an intricate system involving various structures of the body such as bones, muscles, tendons, cartilage, joints and the connective tissue holding these parts together and aid the body in performing coordinated mechanical functions . Abnormalities in any of these basic constituents of the musculoskeletal system could lead to serious disorders that need to be considered with appropriate health assessment, physical examination and diagnosis. These evaluations are important for appropriately and effectively treating the patient.
Works Cited
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Cleaveland Clinic. n.d. https://my.clevelandclinic.org/health/diseases_conditions/hic_musculoskeletal_pain/hic_Normal_Structure_and_Function_of_the_Musculoskeletal_System. 4 April 2016.
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