NSG6020 Week 9 Integumentary and Musculoskeletal SystemsWeek 9 Lectures
The Integumentary and Musculoskeletal Systems
The Skin:
The skin is our largest organ. The average adult has approximately 20 square feet of surface area to
provide protection from outside stressors and adapt to environmental situations such as heat and cold.
The skin has two layers: the dermis and the epidermis. The epidermis is the thin, tough outer layer. It is
our first line of defense. The dermis, made mostly of collagen, provides elasticity and assists the dermis
in resisting tears or injuries.
Hair was once a necessary tool for humans, providing protection from cold, heat, or trauma. Many
cultures believe hair is necessary or preferred as part of psychological and cosmetic values. Hair is
actually threads of keratin that grow in cycles. Each hair has a different rest/grow cycle so that certain
hairs are always growing while others are dormant.
The nails are hard layers or plates of keratin, found on the fingers and toes. The color of the nail is a
reflection of the underlying nail bed.
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Development Notes – The Skin:
Newborns to Adolescents
The newborn is covered in lanugo, or fine downy hair that is eventually replaced by fine vellus hair
several months after birth. Vernix caseosa may cover the newborn or can be found in the body creases
at birth. Scalp hair may or may not be present at birth. The scalp hair is usually soft and is quickly lost at
the temples and occiput.
The skin of the newborn is thin and smooth but more permeable than the skin of an adult. It is easier for
the newborn to lose fluid and become dehydrated. Sebum is the source of milia and cradle cap in some
infants. The sweat glands function at a low level throughout childhood and impair the ability to respond
to heat or fever. The infant is more susceptible to cold as the subcutaneous tissue is minimal and the
skin cannot shiver effectively.
As the child ages, the skin produces additional pigment, becomes thicker, hair growth speeds up, and
the skin is better lubricated. Pubertal changes include development of the sweat glands to respond to
heat and emotional distress, i.e., sweaty palms. Acne develops in response to an increase in oilier skin.
Pregnant Females
Hormonal changes create hyperpigmentation around the areolae, nipples, and vulva. A linea nigra may
be found in the midline of the abdomen. Chloasma or rash of pregnancy may be found across the face.
The rapid skin expansion often results in striae gravidarum. This may be found on the abdomen, thighs,
or breasts.
The Older Adult
The skin is the visible reminder of the aging process. As the patient ages, the skin loses elasticity and
becomes wrinkled, dry, and paper thin. The slightest injury will leave senile purpura, or dark red
blotches on the skin. The hair may lose melanocytes and become gray or white. The texture of the hair
may be thin and fine. The thinning of the pubic and axillary hair can be attributed to the gradual
decrease in testosterone. The older female loses estrogen, which allows testosterone to be the
dominant unopposed hormone. The presence of testosterone without estrogen promotes the growth of
facial hair in the older female.
Transcultural Considerations – The Skin:
Hair care for different cultures should be considered. African American hair texture tends to be fragile
and requires specific care. The scalp and hair are dry and should be gently brushed, combed, and oiled
daily. Examine the condition of the hair of any culture for insight into self-care, nutrition, and general
health. If adequate nutrition and self-care has not been met, the hair tends to be dry, brittle, and fragile.
Hair loss is common in thyroid disorders.
The Musculoskeletal System:
As you know, the toe bone is connected to the foot bone, the foot bone is connected to the leg bone,
the leg bone is connected to the knee bone, and so on. The musculoskeletal system is responsible for
our upright ambulation, body support, and for movement. The musculoskeletal system also provides
protection for vital organs, and the bone marrow produces red blood cells and provides storage for
essential minerals such as calcium and phosphorus.
Our skeleton system has 206 bones, which are connected by ligaments. Muscles should be almost half of
our body weight, each connected to the bones by tendons. The bones, muscles, ligaments, and tendons
allow movement in the following directions: flexion, extensions, abduction, adduction, pronation,
supination, circumduction, inversion, eversion, rotation, protraction, retraction, elevation, and
depression.
This week will cover the assessment techniques and specific developmental changes for the
musculoskeletal system.
The temporal mandibular joint (TMJ) allows movement of the jaw for speaking and chewing. The TMJ
allows opening and closing (hinge action), protrusion and retraction (gliding), and side-to-side
movement of the lower jaw.
The 33 vertebrae that constitute the spinal column can be palpated down the midline of the back. There
are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae in the human skeletal
system. C7 and T1 are most visible and located at the base of the neck. T7 and T8 are normally found at
the inferior angle of the scapula. Imagine a line across the highest point of the iliac crests; this should
estimate the level of L4. Imagine a line from the two symmetric dimples that overlie the posterior
superior iliac spines for S2. If you viewed the spinal column from a lateral aspect, you would see the 4
normal curvatures of the spine. The cervical and lumbar curves are concave while the thoracic and
sacrococcygeal are convex. The spine can flex forward, extend backwards, rotate, and abduct, or move
side to side.
The shoulder joins the humerus to the scapula. The glenohumeral joint is supported by four muscles and
tendons that make up the rotator cuff. You can palpate the acromion process or the tip of the scapula at
the top of the shoulder. This should feel like a very firm bump or knob. The greater tubercle of the
humerus is located down and over from the acromion process followed by the coracoids process of the
scapula on the medial aspect of the shoulder.
The elbow articulates the humerus, radius, and ulna. The elbow provides hinge action for flexion and
extension of the ulna and radius. The olecranon bursa is situated between the olecranon process and
the skin. The medial and lateral epicondyles of the humerus as well as the olecranon process of the ulna
are palpable on examination of the elbow. The radius and ulna allow pronation and supination of the
hand and forearm.
Over half of the bones in the human skeleton are located in the hands and feet. The radiocarpal joint
joins the radius to the carpal bones at the thumb. This joint is palpable at the dorsum of the wrist. The
midcarpal joint is the articulation of the two parallel rows of carpal bones. This joint allows for flexion,
extension, and some rotational movements. The metacarpophalangeal and interphalangeal joints allow
flexion and extension of the fingers.
The hip articulates the acetabulum and the head of the femur. You may palpate the iliac crest from the
anterior superior iliac spine to the posterior. The ischial tuberosity is found under the gluteus maximus
muscle and may be palpable when the hip is flexed. The greater trochanter is found below the iliac crest
and in between the superior iliac spine and ischial tuberosity. The greater trochanter may be palpated
when the patient is standing. It should feel like a flat depression on the upper lateral aspect of the thigh.
Patient girth and mobility may affect palpation of these landmarks.
The knee is the articulation of the femur, the tibia, and the patella. The knee is the largest joint in the
body, providing flexion and extension of the lower extremity. The synovial membrane forms a pouch or
sac at the superior border of the patella (suprapatellar pouch). This pouch may extend as far as 6
centimeters behind the quadriceps muscle. The medial and lateral menisci provide cushion between the
tibia and femur. The cruciate ligaments cross inside the knee, providing control of rotation, anterior and
posterior stability. The collateral ligaments connect the knee joint at both sides providing medial and
lateral stability. The collateral ligaments help prevent dislocation. The prepatellar bursa is found
between the patella and the skin and is usually palpable. The infrapatellar fat pad is found below the
patella behind the patellar ligament. Landmarks of the knee begin with the quadriceps muscle on the
anterior and lateral thigh. The four heads of this large muscle move into a common tendon that travels
downwards to enclose the patella. The tendon inserts down on the tibial tuberosity, which is palpable as
a bony prominence in the midline just below the patella. The lateral and medial condyles of the tibia
may be palpated as the knee is moved side to side. The medial and lateral epicondyles of the femur are
superior on either side of the patella.
The ankle articulates the tibia, fibula, and talus; a hinge joint that allows dorsiflexion and plantar flexion.
The medial malleolus and the lateral malleolus are the two bony landmarks on either side of the ankle.
The medial and lateral ligaments provide lateral stability of the ankle. The subtalar joint, below the
ankle, allows inversion and eversion of the foot. Weight bearing is distributed between the heads of the
metatarsals and the calcaneus or heel.
Developmental Notes across the Lifespan – The Musculoskeletal System
Infants and Children
The fetus has developed a cartilage skeleton by 3 months gestation. The cartilage gradually ossifies
during the remaining gestational period, followed by rapid bone growth immediately after birth. Bone
growth continues at a steady rate until adolescence, at which time another growth spurt occurs.
Long bones grow by length and width. The epiphyses or growth plates see longitudinal growth, whereas
bony tissue that is deposited around the bone shaft provides width. The last epiphysis closes around age
20 years. Prior to that time, any injury to the ends of the long bones puts the child at risk for bone
deformity.
At birth, there is only a single curve of the spine. At age 3 to 4 months, the anterior cervical curve
develops as the baby begins to lift its head. At age 12 to 18 months, the toddler who is learning to walk
develops the anterior curve in the lumbar region.
The Pregnant Female
The pregnant female undergoes numerous changes in the body during the gestational period. These
changes include increased mobility of the joints and relaxation of ligaments and tendons. The most
visible change in posture is the lordosis of the spine. The lordosis allows for the growing fetus by shifting
the weight back onto the lower extremities and placing increased pressure on the low back musculature.
This can trigger low back pain in many pregnant females. The cervical spine may flex forward and the
shoulders gradually slump in response to the lordosis. These changes can create pressure on the ulnar
and median nerves in the third trimester, leading to pregnancy induced carpal tunnel syndrome.
The Older Adult
Resorption of bone (loss of bone matrix) occurs more rapidly than bone deposition (bone growth) in the
older adult. The result is a loss of bone density or osteoporosis. The early loss of bone is osteopenia.
Females are more likely to have osteoporosis than males and more so in Caucasians than African
Americans. Asians have higher risk of osteoporosis than Caucasians. Risk factors for osteoporosis include
age, postmenopausal state, prior or current history of tobacco use, race, small bone frame, female sex,
and family history of osteoporosis. Males who have low testosterone, small bone frame, and history or
current use of tobacco products are at higher risk of developing osteoporosis.
Height is lost from osteoporotic changes in the vertebral column. Kyphosis, or Dowager’s hump, of the
thoracic spine may be seen in males and females alike. This is a complication of osteoporosis.
Bone mineral densities should be ordered with vertebral fracture assessment scores in order to evaluate
the level of bone loss. Vitamin D levels should be checked, with > 15 ng/dl being the goal for ages 4
years and up. This would be a minimum of 400 international units (IU) daily. It may be acquired through
dietary measures or supplements (http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/).
History – Integumentary and Musculoskeletal
Integumentary History of Present Illness (Subjective Data)
Ask about previous skin conditions or problems. What was the problem? When did it happen? How long
did you have the skin problem? How was it treated? Was the treatment successful? Has it recurred? Any
personal and/or family history of allergies or skin problems? Do you have any known environmental or
medical allergies? Do you have any birthmarks or tattoos? Are there any lesions that you are concerned
about today?
Have you noticed any changes in your skin color? How about changes in moles? Include itching,
bleeding, or change in color or size. When did this start? Do you have sores that will not heal?
Have you noticed any dryness to your skin? How about skin texture changes? Does this seem to be
seasonal? Do you find that you have more itching with this dryness? How severe is the itching? Does it
awaken you at night? Where are the dry spots or itching located? Are there any recent changes in your
lotions, soap, detergent, medications, etc.? Have you tried any prescription or over-the-counter (OTC)
medications for the problem? Did these items help?
Have you noticed any bruising? Where have you noticed the bruises? Do you know how the bruises
were inflicted? How long have you had these bruises?
Do you have a skin rash or lesion? When did you first notice the rash or lesion? Where is it located?
Does anything make it better or worse? Any itching associated with the rash or lesion? What color or
colors is the rash or lesion? Has the rash or lesion spread to other areas?
Ask the patient to describe the color and shape, and if there is any drainage. Does anyone else in his or
her family have a similar problem? Have they recently traveled, including camping, or taken part in
outdoor sports/activities? Have they used any new detergents, soaps, lotions, powders, or makeup?
Have they tried new medication or foods, or acquired a new pet? Does stress affect the rash at all?
How? Does anything make the rash better or worse? Ask specifically about OTC treatments as well as
prescriptions. Are there any associated signs and symptoms such as sinus problems, cough, or fever?
Any new stressors that you are aware of?
If you have not asked already, inquire about current medications, both prescription and OTC. Some
generic medications may have changed manufacturers and now have a different color. A dye change
may trigger an allergic reaction. Ask how long the patient has been taking each medication. Inquire
about change in shape, color, or texture of the nails.
Are you exposed to chemicals or other irritants at your work? Do you have any hobbies that might use
irritants such as painting, household repairs, furniture refinishing, gardening, farming, or automotive
work?
Ask specifically about sun exposure. This should include all forms of ultraviolet rays, such as tanning
beds. Do you use a sunscreen? What strength? How often and to what parts of the body do you apply
sunscreen? A minimum of 30 sunscreen protection factor (SPF) should be applied liberally to all exposed
areas of the body. Repeat at least every 2 hours while outside and after water activities. Are there any
recent insect bites? This includes ant bites, bees, ticks, mosquitoes, horseflies, etc.
Have you worked outside, walked in a wooded area, or been exposed to plants or animals recently? Did
you notice the rash before or after this activity?
What is your daily routine for skin, nail, and hair care? What type of products do you use? How often do
you have a manicure or pedicure? Do you have this done at a salon or at home? Do you check your skin
for changes? How often? Do you have annual examinations by a health care provider? Do you see a
dermatologist?
Infants and Children
Ask the parents if there are any birthmarks that they have noticed. Did the child have problems with
blueness at birth? How long did this last? Do they remember the child’s Apgar score at birth?
Did the infant experience jaundice? What day did the jaundice occur? How was it treated?
Are there any rashes or sores? Have you noticed any triggers for the rashes or sores? What was the last
food or drink that you introduced? When was the new item(s) introduced?
Have you noticed a diaper rash? Is this a constant problem or intermittent? What do you treat the
diaper rash with? Is it effective? What type of diapers do you use? How do you clean the baby when you
change the diaper? Have you changed diaper brands, soaps, lotions, or creams recently? What effect did
these changes have on the rash?
Tell me about bumps or bruises that you have noticed on your child. How did these occur? How long
have they been present? Any burns or other trauma? How did these happen? How have you treated
them? Keep in mind warning signs of physical abuse but also the normal bumps and bruises of a toddler.
Common findings in child abuse are straight lines from whippings, hand- or finger-shaped bruises,
cigarette burns, and bruising above the knees or elbows.
Do you know if the child has been exposed to lice, scabies, impetigo, chicken pox, measles, or scarlet
fever? How about irritating plants, such as poison oak or poison ivy?
Are immunizations up to date?
Have you noticed any repetitive habits, such as hair twisting or twirling, nail biting, or rubbing of the skin
or the head on the mattress?
How much sun exposure does your child have? What SPF sunscreen do you use? Tell me how you apply
the sunscreen. How often do you reapply the sunscreen? Has the child ever had sunburn? How did you
treat the sunburn?
Adolescents
Have you had problems with acne? How did you treat it? How long have you had problems with your
acne? How do you feel about the acne? Have you tried prescription or OTC medications for acne? What
kind, when, and what were the results? What is your daily skin care routine?
The Older Adult
Tell me about any skin changes you have noticed over the past 6 to 12 months. Have you found that it
takes longer for sores to heal? Do you have any sores right now? Have you had any itching or skin pain?
Have you had any changes in your feet, including itching or bunions? Have you had to change shoes
because of discomfort or irritations?
Do you have a history of diabetes, peripheral vascular disease, or frequent falls?
Tell me about your daily skin care routine. What products do you use? How often do you bathe? Do you
take a shower, bath, or “sponge bath”? Older adults may not bathe daily due to an increase in dry skin
or to physical limitations.
Musculoskeletal History of Present Illness (Subjective Data)
Joints
Do you have any pain or problems with your joints? Which ones; is it on either side or just one side?
Describe the pain: Dull, aching, throbbing, shooting, brief, nagging, sharp, dull, or stiff? On a scale of 1 to
10, with 1 being the least pain you have ever had and 10 being the worst pain ever, what is your pain
level now and at the height of the pain episode?
When did this pain begin? How long does it last? Does it occur at a particular time of day? How often do
you experience this pain? Are there any triggers or alleviating factors? Does rest or position change
help? Do you take any OTC or prescription medications for pain? Do these help? Have you tried
elevating the part, applying heat and or ice, or splinting/wrapping?
Have you noticed any fever, chills, rash, sore throat, repetitive activity, or recent trauma?
Are your joints stiff? Have you noticed any heat, redness, or swelling of your joints?
Are you limited in movement of any joints? Which ones? Does any activity give you difficulty?
Muscles
Do you have any problems with your muscles, such as pain or cramping? Which muscles?
If pain is noted in the calf muscles: Does the pain occur with walking? Does it resolve with rest? Have
you noticed any fever, chills, or other flu-like symptoms?
What medications, both prescription and OTC, are you currently taking? When was your last dose?
Some prescription and OTC medications can cause muscle cramps and myalgias. Be alert for
hypokalemia, hypocalcemia, and hypomagnesium. This may be related to dehydration, a result of crash
dieting, medication induced, etc.
Have you noticed any “weakness” of your muscles? If so, where? How long has it been present? Have
you noticed a change in the size of your muscles?
Bones
Do you have any bone pain? Where? How long have you had this pain? Does movement change the
pain? If so, how? Does anything specific make the pain better or worse? Have you tried any medications
including OTC medicines? What were the results?
Have you had any injuries to your bones? When, and which bones? What was the treatment? Do you
have any deformities? Does the deformity affect a joint and its mobility? Any previous sprains or strains?
Which part of the body? How was the sprain or strain treated?
Have any of your previous injuries caused lingering problems? Any limitations of your daily activities due
to the previous injury or pain?
Do you have any back pain? Show me where your back hurts. Does the pain radiate? Where? Describe
the pain: Is it shooting, dull, aching, stabbing, etc.? Have you noticed any numbness or tingling of the
lower extremities? Do you limp? Does the limp go away after you walk a short distance or does it
persist?
Functional Assessment
Ask specifically about activities of daily living. First, ask the general category; then, if a positive response
is elicited, inquire about each activity in the category. Does your joint or muscle problem cause
problems with:
Bathing: Getting in and out of the tub, turning the faucets?
Toileting: Urinating, having a bowel movement, getting on or off the toilet without assistance, cleaning
or wiping yourself?
Dressing: Fastening buttons, zipping a zipper, fastening a necklace or button behind your neck, pulling
your dress or sweater over your head, pulling up your pants, putting on your socks, tying your shoes,
finding shoes that fit comfortably?
Grooming: Shaving, brushing hair or fixing hair, brushing teeth, applying makeup?
Eating: Preparing food or meals, pouring liquids, cutting up foods, getting the food to your mouth,
drinking?
Mobility: Walking, walking up or down stairs, getting in or out of beds, getting out of the house?
Communicating: Talking, using the phone, writing, using the computer?
Ask the patient about his or her self-care activities. Does the patient follow an exercise routine? What is
the program and how often is it followed (length of time and number of days per week)? Does his or her
job involve lifting or repetitive motions? Has the patient tried anything to improve the work station and
alleviate stressors?
If you have not already asked, inquire about medications, both prescription and OTC. If antiinflammatory drugs are used, ask about gastrointestinal upset or irritation from the medications.
Inquire about self-esteem concerns. Chronic pain and/or disability can lead to depression and selfisolation.
Infants and Children
Did your baby experience any trauma during labor and delivery that you are aware of? Were forceps
used to deliver the infant? Was the baby born headfirst at delivery? Difficult or traumatic deliveries can
result in fractures, such as clavicular or humeral fractures.
Did the infant require extra care immediately after birth, such as resuscitation or oxygen? Anoxic injury
can cause hypotonia of the muscles. If cardiac compressions were required, rib cage injuries may be
present.
Did your baby achieve the suggested motor skill milestones as your other children or as compared to
national standards? Did your pediatrician discuss these milestones with you?
Has your child had any broken bones, sprains, or dislocations? How were these injuries treated? Are
there any residual problems?
Have you noticed any bony deformities on your child? Where? How about curving of the spine or pants
that fit “unevenly”? Are the feet shaped “normally”? Have you sought treatment for these problems?
Has your child been screened for scoliosis?
Adolescents
Do or have you participated in sports at school? How often do you play? Do you have to have special
equipment to play? Tell me about the equipment. Do you have a training program for this sport?
How do you warm up before playing a sport? Do you have a “cool down” session?
What do you do if you get hurt? Have you been hurt before? What happened?
How do you fit in sports with your other school activities? Does playing sports affect your homework or
school grades?
The Older Adult
Use your functional assessment questions for the older adult. You should also ask about the following:
Have you experienced any change in weakness over the past six months or year?
Have you noticed any increase in falls or gait changes in the past 12 months?
Do you use a cane, walker, or rolling walker to help you get around?
Physical Exam – Integumentary and Musculoskeletal Systems
The Integumentary System – Physical Exam
You should integrate the skin exam throughout the physical exam process, instead of making it a
separate part. Lift and open clothing that cover parts of skin in order to thoroughly examine the skin.
Remove shoes and socks to inspect the feet, check pulses, and evaluate nail bed and sensation as the
last part of the examination.
Your patient may present with a specific skin complaint. This would prompt a focused or regional skin
examination. Your first look at the area in question should be conducted standing back from a short
distance, then move in for a closer inspection.
Inspection and Palpation
Note the skin tone, color, and lesions. This would include moles, birthmarks, and freckles. Moles may be
tan to dark brown in color, and flat or raised. Birthmarks are tan to brown in color, appear flat, and may
be irregular in shape. Freckles are brown, flat macules that are found on sun-exposed skin.
The ABCDE danger signs of skin lesions should be kept in mind during the examination.
Asymmetry of a pigmented lesion (not round or oval)
Border irregularity (look for raised borders, notching, scalloping, ragged edges, and poorly defined
or blurred margins)
Color variation (tan, black, brown, blue, red, white, or combination of colors)
Diameter of 6 millimeters or more (the size of the end of a pencil eraser)
Elevation and enlargement (change in size; new nevi or lesion; new itching, burning, or bleeding)
Note any widespread color changes over the body. Is this an expected finding or not? Dark-skinned
patients should have their oral mucosa, sclera, nail beds, and palmar and plantar areas assessed for
color changes.
Pallor may be triggered by extreme stress or shock, anemia, or arterial insufficiency. For dark-skinned
patients, the skin may be more lackluster and have a yellowish, ashen, or gray appearance. Check the
oral mucosa, sclera, nail beds, and palmar and plantar areas for changes as well.
Erythema is an expected response to fever, localized inflammation, and as emotional responses such as
blushing or anger. Erythema is a response to rosacea as well. The patient with rosacea can experience
involuntary flushing of the face without triggers or maintain a constant ruddiness of the facial skin. You
should palpate for suspected erythema in the dark-skinned patient, as the erythema may not be readily
visible. The inflamed skin is firm and may feel warmer and taut to palpation.
Cyanosis indicates decreased perfusion. Cyanosis is a predictable factor but may be a nonspecific
finding. The anemic patient may not demonstrate cyanosis but still have hypoxia due to lack of
hemoglobin. Mediterranean descendants may have a bluish coloration of the lips as a normal finding.
Change in level of consciousness, respiratory distress, extreme fatigue, slurring of speech, and other
symptoms may indicate cyanosis in the dark-skinned person.
Jaundice is noted when bilirubin levels are elevated in the bloodstream. Jaundice is not a normal finding
unless it is physiologic jaundice in the newborn. Jaundice can be first noted at the junction of the hard
and soft palates, and then the sclera. Dark-skinned patients may have yellow subconjunctival fatty
deposits that should not be confused with true jaundice. Scleral jaundice will be present up to the iris.
Calluses on the palmar and plantar surfaces may appear yellow and should not be taken as a sign of
jaundice. If possible, evaluate the skin in natural daylight for the best assessment of jaundice.
The skin should feel warm and equal bilateral, fairly smooth to touch. Hands and feet may feel slightly
cooler than other areas.
Diaphoresis may be present if the patient has a high metabolic rate from fever or strenuous activity.
Strenuous activity can be walking or even breathing if the patient is acutely ill.
Edema may be present and should be graded on the following scale:
1+ mild pitting, slight indentation, no visible swelling of the leg
2+ moderate pitting, indentations resolve rapidly
3+ deep pitting, indentation remains for a brief time, leg appears swollen
4+ very deep pitting, indentation remains, leg is very swollen
This scale can be subjective but can be used for evaluation and documentation.
Evaluate turgor by pinching a large fold of skin on the anterior chest wall, just below the clavicle. The
skin should promptly return to the original state when released, an indication of good turgor. Slow
return of the skin to the original state is indicative of dehydration.
Cherry or senile angiomas are tiny bright red dots that are usually found on the trunk in adults age 30
years and older. These angiomas tend to increase in size and quantity as the patient ages but are not
significant, except for cosmetic purposes.
Note any ecchymotic patterns, keeping in mind that some bruising may be present due to daily
activities. Venous varicosities are not a normal finding and should be documented.
Tattoos, including cosmetic tattoos, should be documented.
Document the following information about any lesions that may be present:
Color, elevation, pattern or shape, size in centimeters, location and distribution on the body, and any
exudate or drainage to include color and odor.
Palpate the lesion(s) while wearing gloves. You may evaluate depth by rolling the lesion between your
thumb and forefinger. Gently scrape the lesion to assess for flaking, scaling, drainage, bleeding, and the
base of the lesion. Is the surrounding area erythematous or warm? Does the lesion blanch to pressure?
A magnifier glass and good light source should be used for closer inspection of lesions. A Wood’s light
may be helpful to evaluate fluorescing lesions. If scrapings are taken, a potassium hydroxide (KOH)
preparation can be used to diagnose fungal infections. A scraping is best obtained by using a sharp
sterile blade to scrape lightly across the edge of a lesion, taking care not to “dig in” while gently
scraping. Place the scrapings on a clean slide and add a drop of 10 to 20 percent KOH and send the slide
to the lab. The KOH solution will dissolve any nonfungal material that may be present, leaving the fungal
material for evaluation.
Hair
Inspect and palpate the hair color, length, texture, and distribution. Assess the scalp for any lesions,
trauma, erythema, or edema.
Nails
The nail surface should be flat or slightly curved, while the nail folds are smooth and rounded. No
discoloration, pitting, flaking, or splitting. The nail should be firmly attached to the nail bed. Capillary
refill to the nail bed should be brisk.
The Self-Skin Exam
Review the ABCDE rule for skin lesions with the patient. Then, discuss the self-skin exam he or she
should be conducting at home. The patient will need a full-length mirror and a small handheld mirror
and be in a well-lit room. The patient should undress completely, and then begin by examining the
hands (back and front), in between the fingers, and the forearms. The patient will face the mirror, bend
the elbows, and examine the posterior forearms. He or she should stand in front of the mirror and look
at the entire body, starting at the head and moving down to the feet. Next, he or she will turn to one
side, examine the skin from the lateral aspect, and then rotate to the other side, again head to toe.
Next, the patient will turn the back to the mirror and examine the buttocks, posterior thighs, and lower
legs. The handheld mirror should be used to examine the upper torso. The handheld mirror can be used
to assess the scalp as well. A blow dryer on cool setting can be used to lift and separate the hair to
facilitate the assessment. Finally, the patient should sit on a chair or the edge of the bed and examine
the inside of each leg, the plantar surface of the feet, and in between the toes. The small handheld
mirror may be useful for this part as well.
Infants
African-American infants may have lighter skin color than the parents due to lack of functioning
pigment. The Mongolian spot is a hyperpigmentation that is found in 90% of African American infants,
80% of Asians and Native Americans, and 9% of Caucasians. This blue-black to purple lesion is typically
found across the sacrum and/or buttocks. It may be located on the thighs, abdomen, shoulders, or arms.
The Mongolian spot will fade during the first year but will still be visible throughout adulthood. Do not
confuse the Mongolian spot for ecchymosis or trauma from child abuse NSG6020 Week 9 Integumentary and Musculoskeletal Systems.
“Café au lait spots” are round or oval patches of light brown pigmentation that may be present on any
area of the body. The café au lait spots are considered normal, measuring less than 1.5 centimeters at
the widest diameter. If there are 6 or more café au lait spots present, consider neurofibromatosis.
The newborn’s skin tends to be beefy red for the first 24 hours after birth with a gradual fade to its
normal color. There may be flushing of the lower body while the upper body blanches while the infant is
in a side-lying position. This is a transient event, with the source of the color change being unknown.
Erythema toxicum is the appearance of tiny red macules and papules scattered across the face, chest,
back, and buttocks. This rash may appear in the first 3 to 4 days of life and gives a “flea bite” appearance
to the infant. This rash resolves spontaneously without treatment.
Physiologic jaundice is found in approximately half of all newborns. The typical onset is on the third or
fourth day of life due to increased quantity of red blood cells that hemolyze and then are metabolized
by the liver and spleen. The residual is turned into bilirubin.
Carotenemia will produce a yellow orange color of the skin in fair-skinned infants as a result of ingesting
large quantities of carotene-rich foods. The soles of the feet, palms of the hands, forehead, tip of the
nose, nasolabial folds, the chin, posterior auricular area, and the knuckles of the hands will show the
most discoloration. The hyperpigmentation resolves within 4 to 6 weeks of removing the excess
carotene-rich foods from the diet.
Look for any skin defects, especially over the spine.
Turgor should be evaluated over the abdomen, not the forearm.
Birthmarks are common in the infant. These may include a “stork bite” or salmon patch, port-wine stain,
strawberry mark, or cavernous hemangioma. The salmon patch usually fades within the first year. The
other birthmarks may require referral, depending upon location and/or size.
Adolescents
Acne is present in almost all teenagers, although the severity is varied. Acne lesions may begin as early
as 7 or 8 years of age, peaking between ages 14–16 years in girls and 16–19 years in males. The typical
location for acne is the face, although there may be lesions present on the chest, back, and shoulders.
Discuss skin care routine and possible treatment options for the teen who is concerned about the acne.
The Pregnant Female NSG6020 Week 9 Integumentary and Musculoskeletal Systems
Striae may be found on the breasts, abdomen, and thighs. These silvery pink stretch marks occur in over
half of all pregnancies. The linea nigra, or brownish black line on the abdomen, follows the midline and
is a normal finding. Chloasma is an irregular brownish discoloration on the face, also known as the mask
of pregnancy. Chloasma may also be seen in females who are taking oral contraceptive pills. This rash
should disappear after the pregnancy or cessation of the pills. The face, neck, upper chest, and arms are
common locations for vascular spiders that occur during pregnancy. These lesions are characterized by
their minute red centers with radiating branches.
The Older Adult
Senile lentigines or liver spots: Small, flat, brown macules that are a result of long-term sun exposure.
The forearms and hands are common locations for these benign lesions.
Keratoses: Raised, scaly, crusted, wart like, thickened lesions. Seborrheic keratoses appear dark and
greasy, and have a “stuck on” appearance. These benign lesions appear primarily on the trunk but may
also be found on the face, hands, and arms. Seborrheic keratoses are not a result of sun exposure.
Actinic (senile or solar) keratoses are less common and are a result of sun exposure. These lesions are
reddish tan, scaly, raised, and roughened. The solar keratosis may have a silvery white scale to the top.
These are premalignant lesions and may develop into squamous cell carcinoma.
The elderly tend to have drier skin due to a decrease in the number and production of the sweat glands.
The mobility and turgor are also affected.
Skin tags or acrochordons are polyp-like skin overgrowths that are commonly found on the eyelids,
cheeks, neck, axillae, and trunk. These tags can be bothersome to the patients, as they can “catch” on
jewelry or clothing, be rubbed to the point of irritation and bleeding, or grow large enough to be painful.
These benign lesions can be removed.
The nails of the older adult may be brittle and yellowed. The toenails may be thickened due to aging,
peripheral vascular disease, or onychomycosis. Scrapings from under the toenails may be obtained to
evaluate for fungus and allow for treatment.
Lesions- Shapes and Configurations:
Descriptive Terms for the Integumentary System NSG6020 Week 9 Integumentary and Musculoskeletal Systems
The following are common shapes and configurations of lesions:
Annular: Circular, begins in the center and spreads to the periphery. An example would be tinea
corporis, tinea versicolor, and pityriasisrosea.
Confluent: The lesions run together. An example would be hives or urticaria.
Discrete: Distinct, individual lesions that remain separate, such as molluscum.
Grouped: Clusters of lesions, such as the vesicles found with herpes zoster.
Gyrate: Twisted, coiled, or snake like.
Target: Also known as iris, as it looks like the iris of the eye. Concentric rings of color in the
lesion, for example, erythema multiform.
Linear: Scratch, streak, line, or stripe. Poison ivy is a contact dermatitis that has groups of
lesions that follow a linear form.
Polycyclic: Annular or circular lesions that grow together. An example is psoriasis.
Zoesteriform: Linear arrangement along a nerve or dermatome. An example is the grouping of
vesicles found on a specific dermatome such as herpes zoster.
Primary Skin Lesions:
Primary skin lesions can be described as follows:
Macule: A color change only. The lesion is flat, well circumscribed, and less than 1 centimeter in size.
Examples include flat nevi, freckles, petechiae, measles, and scarlet fever.
Patch: Macules that are larger than 1 centimeter. Examples are Mongolian spots, vitiligo, café au lait
spots, and chlosasma.
Papule: A solid, elevated, well circumscribed lesion, less than 1 centimeter in diameter. Examples
include elevated nevus (mole), lichen planus, molluscum, and verruca.
Plaque: Papules coalesce to form surface elevation wider than 1 centimeter. These tend to be plateaulike, disc-shaped lesions. An example would be psoriasis.
Nodule: A solid, hard, elevated lesion. It may be hard or soft to touch, larger than 1 centimeter. This
lesion may be deeper than a papule. Examples include xanthoma, fibroma, and intradermal nevi.
Tumor: This lesion is more than a few centimeters in diameter, may be firm or soft, benign or malignant.
An example may be a lipoma or hemangioma as well as cancerous tumors.
Wheal: A superficial, raised, transient, and erythematous lesion. It is irregular in shape due to edema.
Examples may be mosquito bites, allergic reactions, and dermographism.
Urticaria: Also known as hives. Wheals that coalesce or join together to form an extensive reaction.
Hives tend to be extremely pruritic.
Vesicle: An elevated cavity that contains free fluid up to 1 centimeter. Clear fluid will be expressed if the
lesion ruptures. Examples include herpes simplex, early varicella lesions, herpes zoster, and contact
dermatitis.
Bulla: Vesicles that are larger than 1 centimeter in diameter, single chambered or unilocular, superficial,
and easily ruptured. Examples include friction blister, pemphigus, burns, and contact dermatitis.
Cyst: An encapsulated, fluid-filled cavity in the dermis or subcutaneous layer, creating tensely elevated
skin. An example would be a sebaceous cyst.
Pustule: A pus-filled cavity. These tend to be elevated and well circumscribed. Examples include
impetigo and acne. NSG6020 Week 9 Integumentary and Musculoskeletal Systems
Crust: Thickened, dried exudate that is left when vesicles or pustules burst or dry up. Crusts may be
reddish brown, honey colored, or yellow. Examples include impetigo, weeping eczematous dermatitis,
and scabs following abrasions.
Scale: Compact flakes of dry skin. May be dry or greasy, silvery or white. These are produced from the
shedding of dead excess keratin cells. Examples include psoriasis, seborrheic dermatitis, eczema, and dry
skin.
Fissure: A linear crack with abrupt edges that may be dry or moist, and extends into the dermis.
Examples include cheilosis at the corners of the mouth and athlete’s foot.
Erosion: A scooped out but shallow depression. This moist, superficial lesion does not bleed, and heals
without scarring, as it does not extend into the dermis.
Ulcer: A deeper depression that does extend into the dermis. Irregular in shape, may bleed, leaves a scar
when healed. Examples include stasis ulcers, pressure sores, and chancre.
Scar: Connective tissue or collagen that replaces normal tissue after trauma. Examples include healed
surgical incision and acne.
Lichenification: A result of prolonged scratching. Thickening of the skin with tightly packed papules with
a moss- or lichen-like appearance.
Excoriation: Abrasion that is superficial. This is usually self-inflicted as from intense scratching or
irritation. Examples include insect bites, scabies, dermatitis, and varicella.
Atrophic scar: Depression of the skin along with thinning of the epidermis. Example includes striae.
Keloid: Elevation of skin level by excess scar tissue. May develop or grow long after original injury is
healed. May appear smooth, rubbery, or claw like. There is a higher incidence of keloids among African
Americans.
Integumentary Exam Checklist:
The examination checklist includes the following:
Inspect
The skin: Color, general pigmentation, any hypo- or hyperpigmentation, or any abnormal color changes.
The hair: Color, distribution, any scalp lesions. NSG6020 Week 9 Integumentary and Musculoskeletal Systems
Palpate
The skin: Temperature of the skin, moisture, texture, thickness, edema, turgor, vascularity, or bruising.
Note hygiene.
The hair: Texture or any scalp lesions.
Lesions
The skin and scalp: Note and document color, shape, configuration, size, location, and distribution on
the body.
Nails
Inspect and palpate the shape, contour, consistency, and color of the nails.
Teach skin self-examination to the patient.
The Musculoskeletal System – Physical Exam:
The majority of patients will need a musculoskeletal screening exam. You may inspect and palpate the
joints of each body region and observe the range of motion (ROM) of the joints.
You should perform age-specific screening measures for each age group as indicated.
Provide draping to maintain privacy as you examine the indicated area(s). Compare the affected area or
joint to the corresponding opposite area or joint (normal versus abnormal).
Inspect: Note size of area and contour of joint, skin, and tissues. Note any color, edema, deformity, or
masses.
Palpate: Each joint, noting skin temperature, muscles, bones, and articulation. The synovial membrane
is not usually palpable. It may feel boggy or dough-like if thickened.
ROM: Request the patient perform active ROM for the joint. If active ROM is not possible, then try
passive ROM noting any limitations.
ROM of a joint should not elicit pain or tenderness. Note any positive pain or tenderness as well as
crepitus on examination.
Muscle Testing
Examine the muscles for each joint assessed by asking the patient to resist your application of opposing
force. Grade the muscle strength according to level of resistance. You may use the following scale to
assess muscle strength.
Grade Description Assessment Percent Normal
5 Full ROM against gravity/full resistance
Normal
100
4 Full ROM against gravity/some resistance
Good
75
3 Full ROM with gravity
Fair
50
2 Full ROM with gravity eliminated (passive)
Poor
25
1 Slight contraction
Trace
10
0 No contraction
Zero
0
Temporal Mandibular Joint
The patient should be seated at a level that is comfortable for you to reach for assessment. Inspect the
TMJ area; use the tips of your first two fingers to palpate the TMJ. Ask the patient to open and close the
mouth while moving your fingers into the depression left with movement. Instruct the patient to open
the lower jaw, move it side to side, and “stick out” the lower jaw. No deviation should be noted and
movement should be free of pain. A snap or click may be palpable or audible during assessment and is a
normal finding in many patients.
While assessing the TMJ, palpate the temporalis and masseter muscles by asking the patient to clench
his or her teeth. Note symmetry for left and right sides. Ask the patient to move the jaw right and left
against resistance as well as opening the mouth against resistance. These actions evaluate the TMJ and
cranial nerve 5 (CN V). NSG6020 Week 9 Integumentary and Musculoskeletal Systems
Cervical Spine
Inspect head and neck alignment. Palpate the spinal processes, the sternomastoid, trapezius, and
paravertebral muscles. The muscles and spinal processes should be firm without tenderness or muscle
spasm. Instruct the patient to perform ROM of the neck and head: Touching chin to chest, pointing chin
toward the ceiling, touching each ear to the corresponding shoulder without lifting the shoulder, and
turning the chin towards each shoulder. Ask the patient to repeat the ROM actions while you apply
opposing force. The patient should be able to maintain the flexion against your force. These actions
evaluate CN XI (spinal accessory).
Upper Extremities
Shoulders
Inspect and compare both shoulders from the anterior and posterior view. Look for equality of
landmarks, any edema, discoloration, atrophy, or deformity. Check the subacromial bursa for any
swelling. If the patient complains of any shoulder pain, ask the patient to point out the location of the
pain with the unaffected hand. Pain that is referred from another site is not reproducible by palpation or
motion during the exam of the shoulder.
Palpate both shoulders, noting any spasm, atrophy, crepitus, heat, edema, or tenderness. Palpate the
clavicle, acromioclavicular joint, scapula, greater tubercle of the humerus, area of the subacromial
bursa, the biceps groove, and the anterior aspect of the glenohumeral joint. No adenopathy or masses
should be palpable.
Ask the patient to perform ROM by conducting forward flexion and hyperextension (keep both arms
straight as he or she swings the arms up past the head, back down, and behind the back in an arc);
internal rotation (reach behind with right arm to touch right scapula and then the same with the left
arm, forming a 90-degree angle); with arms straight at the side, swinging arms up above the head from a
side position, creating a 180-degree arc, and then across each side (abduction and adduction); the final
move is to form a 90-degree angle with both arms by clasping the hands behind the neck.
Evaluate strength by instructing the patient to shrug his or her shoulders against resistance. This also
tests CN CI, spinal accessory.
Elbow
Inspect size, shape, and mobility of the elbow while flexed and when extended. Note any erythema,
edema, or deformity. Note any olecranon bursa edema. Palpate the elbow with your thumb and
forefingers. Note any erythema, edema, warmth, or adenopathy. Evaluate ROM by asking the patient to
flex and extend the forearm/elbow then by pronation and supination of the forearm. Grasp the patient’s
arm with one hand, flex the elbow forming a 90-degree angle, and then instruct the patient to extend
the forearm or elbow against your applied resistance. Grade the strength of the musculature.
Wrists and Hands
Inspect wrists and hands, noting contour, shape, and position. No erythema, edema, or nodules should
be present. The skin should be smooth, without lesions. Palpate each joint of the wrist and hand. The
joint should feel smooth, without edema, bogginess, tenderness, or nodules. No excessive warmth or
erythema should be noted. Palpate the metacarpophalangeal joints with your thumbs just below and
lateral to the knuckles. Use your thumb and first finger to palpate the sides of the interphalangeal joints.
Note any thickening, erythema, tenderness, warmth, or edema. Herbenden’s and Bouchard’s nodes are
firm, nontender, and without erythema. These nodules are found with osteoarthritis.
Evaluate ROM of the hand and wrist by asking the patient to flex and extend the hand, bend the hand,
extend the hand, spread apart the fingers, make a fist, and touch the thumb to each finger base (gross
motor and fine motor movements). To test musculature, place the patient’s forearm palm up on the
table. Place your hand on the patient’s midforearm to stabilize the arm. Ask the patient to flex the wrist
against your applied resistance at the palm.
Phalen’s test: Ask the patient to place the backs of the hands together forming a 90-degree angle. The
position should be held for up to 60 seconds. There should be no burning or numbness of the hands and
fingers during this 1-minute test. A positive Phalen’s test is suspicious for carpal tunnel syndrome.
Further workup is advised.
Tinel’s sign: Percussion of the median nerve at the base of the wrist should not produce any pain,
numbness, or tingling of the hand and fingers. A positive Tinel’s sign is suspicious for carpal tunnel
syndrome. Further workup is advised
Lower Extremities
Hip
Inspect the hip and spine together when the patient is standing. You will be able to view the iliac crests,
gluteal folds, and buttocks for symmetry as well. An even, smooth gait indicates equal leg length and hip
function.
The patient should be moved to a supine position for palpation of the hip joints. There should be no
tenderness or crepitus on palpation of a normal hip joint. Assess ROM of the hip by instructing the
patient to:
Perform a straight leg lift up to 90 degrees
Bend the knee to form a 90-degree angle and flex the knee towards the chest
Place the foot flat on the floor with the knee bent at a 90-degree angle
Flex the knee inward 40 degrees and outward 45 degrees
With the leg straight, move the leg out 45 degrees for abduction and inwards 30 degrees for
adduction
While lying prone, lift the straight leg up for a hyperextension of 15 degrees.
Limited internal rotation of the hip indicates hip disease. Limitation of abduction of the hip while supine
is the most commonly found problem in hip disease.
Knees
Allow the patient to remain supine with legs straight for inspection of the knees. The lower leg should
be in alignment with the knee and thigh. Note any edema, erythema, or deformity of the knee. Palpate
the quadriceps muscle for any atrophy. Begin above the knee on the anterior thigh and palpate with the
thumb and fingers by grasping the muscle. Continue downwards towards the knee noting the muscle
and tissue response. The joint should feel smooth and the muscles and tissues solid, without warmth,
tenderness, edema, or erythema. If edema is present, you should decide if it is from soft tissue or fluid
on the joint. Use the bulge sign and ballottement test for the assessment.
Bulge sign: Firmly stroke up on the medial aspect of the knee two or three times, displacing any fluid.
Tap the lateral aspect of the knee. Inspect the medial side for any bulge from a fluid wave—none should
be present. If a fluid wave is noted, this is a positive Bulge sign which occurs with edema of the
suprapatellar pouch.
Ballottement of the patella: Use your left hand to compress the suprapatellar pouch and push the
patella sharply against the femur with your right hand. If the patella does not move, no fluid is present.
If you elicit a tap as the patella moves the fluid to bump against the femur, this is a positive Ballottement
sign of the patella.
Hold your hand against the patella and have the patient flex and extend the knee. No crepitus should be
present. Crepitus is found with degenerative diseases of the knee.
Check muscle strength by asking the patient to maintain knee flexion while you try to pull the leg
forward. NSG6020 Week 9 Integumentary and Musculoskeletal Systems
McMurray’s test: To evaluate for a torn meniscus in the patient with a history of trauma that now has
complaints of the knee locking, knee giving way, or localized pain in the knee. Place the patient in a
supine position; you stand on the affected side. Hold the patient’s heel and flex the knee and hip. Place
your other hand on the knee with the fingers to the medial side; rotate the leg in and outward to loosen
the joint. Externally rotate the leg and apply inward or valgus pressure on the knee. Slowly extend the
knee. If a click is heard or palpated, this would be a positive McMurray’s test for a torn meniscus
Ankle and Foot
Inspect the ankle and foot while the patient is supine in a nonweightbearing position and when standing
or walking. Compare both feet for skin color, erythema, edema, pedal pulses, toes, and position of the
feet.
The toes should be straight and lie flat (no hammer toes). Note any ulcers, discoloration, calluses, or
bunions. Support the ankle with your fingers while palpating with your thumbs. No edema, tenderness,
or fullness should be palpated. Continue on to the metatarsophalangeal joints and plantar areas.
Examine ROM by asking the patient to perform dorsiflexion, plantar flexion, eversion (turning the soles
of the feet out) and inversion (turning the soles of the heel inwards), then to flex and straighten the
toes. Ask the patient to hold dorsiflexion and plantar flexion against resistance to assess muscle
strength.
Spine
The patient should be standing and draped in a gown that is open to the back. Inspect the spine, note
any curvatures. The convex thoracic curve and the concave lumbar curve are normal and should be seen
from the side view. Kyphosis is common in the older adult. Lordosis may be present in obese or
pregnant patients.
Palpate the spinal processes. These should be straight, without tenderness. The paravertebral muscles
should be smooth, without tenderness or spasm.
Ask the patient to bend forward and touch their toes to evaluate ROM of the spine. There should be a
single, convex, C-shaped curve noted. Hold the pelvis stable with your hands and instruct the patient to
rotate right to left and back again; then bend side to side to complete ROM of the spine.
Lasegue’s test or straight leg raise: Ask the patient to remain supine with legs extended on the table.
Lifting the leg straight should elicit no pain. Lift the affected leg with knee extended (leg straight) just
below the level of reproducing the pain. Hold the leg at this level, then dorsiflex the foot. If pain is
elicited, this suggests a herniated disc. If pain is elicited with straight leg lift with the unaffected leg, this
also suggests a herniated disc. Further evaluation is needed.
Measure true leg length by measuring between the fixed points of the anterior iliac spine to the medial
malleolus. Both measurements should be within 1 centimeter of each other.
Infants
Use a Denver Developmental II test to evaluate fine and gross motor skills in the child.
Examine the newborn while he or she is undressed and lying supine. Use a warming table to prevent loss
of body heat. Start at the feet and move upwards. Note any positional deformities, keeping in mind that
the newborn’s feet are often in a varus (apart) or valgus (together) position from fetal position in the
womb. You must determine if this is a temporary or fixed position. Scratch the outside bottom of the
foot to see if the foot returns to a normal right angle to the lower leg. This indicates that the varus or
valgus position is temporary and self-correctable. You may also hold the heel of the foot with one hand
and push the forefoot to the neutral position with the other hand. If the foot moves to the neutral
position easily without resistance, the foot is flexible.
Metatarsus adductus is commonly present from birth to three years of age. The forefoot angles inward
while the hindfoot is in alignment with the lower leg. This should correct itself spontaneously.
Place both feet flat on the table, and flex the knees by pushing upwards. Place your fingers on the
malleoli. An infant should have an imaginary parallel line connecting the four malleoli across the table.
Tibial torsion is present if the malleoli are not equal or level.
Assess the hips for congenital dislocation or dysplasia. The Ortolani test should be conducted with each
visit up to 1 year of age. The infant should be supine without a diaper on. Flex the knees while holding
your thumbs on the inner mid thighs and your fingers outside on the greater trochanter. Adduct the legs
until your thumbs touch, then gently lift and abduct the legs out and downwards so that the lateral
aspect of the knees touch the table. No sound should be elicited, and the movements should be smooth.
The Allis test compares leg lengths to evaluate for hip dislocation. Place the infant’s feet flat on the
exam table while flexing the knees upwards. The top of the knees should be level. An uneven knee
height is a positive Allis test and suggests hip dislocation is present in the hip of the lower knee.
Asymmetrical gluteal folds after 3 months of age may suggest hip dislocation.
Inspect the hands, arms, and fingers noting size, position, shape, and number of fingers and palmar
creases. Polydactyly is having supernumerary fingers or toes, and syndactyly is webbing between
adjacent fingers or toes. A simian crease is a single palmar crease that is found with Down’s syndrome
but is not a diagnostic measure of Down’s syndrome. The simian crease is accompanied by short, broad
fingers, incurving of little fingers, and low-set thumbs.
Palpate the clavicles as the clavicle is the bone most likely to be fractured during birth. Note ROM of the
upper extremities during the Moro reflex.
Examine the spine by lifting the infant up, supporting the head and abdomen. Note any cyst, mass,
dimple in the midline (dermoid sinus), or tufts of hair (possible spina bifida). None should be present.
ROM may be observed through spontaneous movement of the extremities. The infant’s muscle strength
can be assessed by lifting the baby under the axillae with your hands. The infant should wedge itself
between your hands as a normal musculature response.
Preschool and School-Age Children
Asses the back while the child is standing. The spine should be fairly straight, shoulders should be level
within approximately 1 centimeter, and scapulae should be symmetric in shape and height. Lordosis
may be present from the side view.
Genu varum, or a lateral bow-legged stance, is normal for the first year after the child begins to walk.
There should be more than 2.5 centimeters of space between the knees when the medial malleoli are
together. This should resolve spontaneously. Genu varnum is present in the child with rickets. Genu
valgum or “knock knees,” are noted when there is more than 2.5 centimeters of space between the
medial malleoli when the knees are together. Genu valgum may occur with rickets, poliomyelitis, and
syphilis. This is a normal occurrence between the ages of 24 and 42 months of age.
The following mnemonic device may help you differentiate between the two conditions:
Genu Varum: knees apart
Genu Valgum: knees together
Pes planus, or flat foot, is actually pronation or the turning in of the medial side of the foot. This is
common between one and two-and-a-half years of age due to the presence of a fat pad at the arch of
the foot. Pronation beyond 30 months of age should have further evaluation.
Pigeon toes, or toeing in, occurs when the child walks on the lateral side of the foot. This should resolve
spontaneously by 36 months of age, provided the foot is flexible. If the foot is fixed or the toeing in lasts
past 3 years of age, further evaluation is needed.
Trendelenburg’s sign can be used to evaluate for subluxation of the hip. Observe the child from behind
while he or she stands on one leg then shifts to the other leg. The iliac crests should remain level or
equal with weight distribution changes. If the pelvis drops, it is shifting toward the nonaffected or
“good” leg. The standing leg at the time of the pelvic drop would be the one with the subluxation.
Check the arms for ROM and any pain. Subluxation of the elbow may be present due to injury that was
incurred with dangling of the child by the arms or forceful removal of clothing.
Look for any enlargement of the tibial tubercles with accompanying tenderness, as this suggests
Osgood-Schlatter disease. Further workup is required.
Adolescents
Examine the adolescent for scoliosis in addition to the usual adult screen. The forward bend test should
begin at age 10 and be performed at least annually. You should assume a sitting position behind the
back of the standing child and ask him or her to stand with feet shoulder-width apart, then bend slowly
forward to touch the toes. Ask the child to hold the position for a few moments as you assess the spinal
column. The landmarks of the iliac crests, spine, rib cage, and scapulas should be even. If you question
curvature, you may mark each spinal process lightly with a felt tip marker. When the patient moves to
an upright standing position, the marks should be visible in a pattern. Even the slightest curve should be
visible by the dot method. NSG6020 Week 9 Integumentary and Musculoskeletal Systems
Sports-related injuries increase in the adolescent group; be prepared to evaluate for possible injuries.
The Pregnant Female
Postural changes associated with pregnancy include lordosis, anterior cervical flexion, possible Kyphosis,
and slumped shoulders. A waddling gait is present later in pregnancy.
The Older Adult
Loss of height due to vertebral bone loss is common in the older patient, as is kyphosis. ROM may be
limited due to arthritic conditions or weakening of muscles due to lack of activity. Perform at least a
brief functional assessment screen to determine home safety and the ability of the patient to care for
himself or herself physically.
Musculoskeletal Examination Checklist:
The examination checklist includes the following:
Inspect: Size and shape of each joint along with skin color and characteristics
Palpate: Skin, muscles, bony articulations, joint capsule of each joint
ROM: Active is preferred; passive if limited active ROM is noted; muscle testing with strength grading
Musculoskeletal Summary:
Be comfortable with a general musculoskeletal examination. Try to incorporate the musculoskeletal
exam into other parts of the exam in order to keep your patient as comfortable as possible. Document
normal and abnormal findings.
The following are some of the differential diagnoses that should be considered when conducting a
musculoskeletal exam:
Rheumatoid arthritis: Chronic, systemic inflammatory disease of the joints and associated connective
tissue. It is associated with fatigue, anorexia, weight loss, low-grade fever, and lymphadenopathy.
Ankylosing spondylitis: Chronic progressive inflammation of the spine, sacroiliac, and larger joints of the
extremities leading to bony ankylosis and deformity. This is a type of rheumatoid arthritis, more
commonly found in males in late adolescence or early adulthood.
Osteoarthritis: Localized, progressive, noninflammatory disease that is found with deterioration of the
articular cartilages and subchondral bone while osteophytes or new bone forms at the joint surfaces.
This disorder increases with age—almost every adult over the age of 60 years will have some evidence
of osteoarthritis on x-ray.
Osteoporosis or bone loss: The World Health Organization defines osteoporosis as falling 2.5 standard
deviations below the normal bone values of a 30-year-old Caucasian female. Osteopenia begins at 1.5
standard deviations below the normal bone values of a 30-year-old Caucasian female. This definition is
the standard to which all cases are subjected, regardless of age, sex, and race (Norman, 2010).
The bone density can be determined through a bone density scan. Appropriate treatment should be
prescribed according to bone density results. NSG6020 Week 9 Integumentary and Musculoskeletal Systems
Joint effusion or edema from excess fluid in the joint capsule may present in the shoulder, elbow, or
knee.
Rotator cuff tear is often a result of traumatic injury. A positive drop arm test is indicative of a torn
rotator cuff. If you passively abduct the arm at the shoulder and the patient “drops” the arm, it is a
positive drop arm test. The patient is unable to maintain or hold the arm in the elevated position due to
the rotator cuff tear.
Olecranon bursitis or inflammation of the olecranon bursa.
Gout: Erythema, heat, and pain over a joint due to uric acid inflammation. A common site for gout is in
the metatarsophalangeal (MTP) joint just below the great toe. Gout in the MTP joint is also known as
podagra.
Clubfoot: Congenital, rigid, and fixed malposition of the foot to include inversion, forefoot adduction,
and equines (foot points downward). This is a common birth defect, occurring as often as 1 to 3 out of
1000 live births. Males are more than twice as likely to have clubfoot as females.
Spina bifida: The incomplete closure of the posterior part of vertebrae resulting in a neural tube defect.
This can be as minor as a skin defect along the spine to as much as protrusion of the spinal sac that may
contain the spinal cord. The most serious type of spina bifida is myelomeningocele or the protrusion of
the meninges and neural tissue outside the body. The child with myelomeningocele is usually paralyzed
from the lesion down.
Coxaplana, or Legg-Calve-Perthes Syndrome: Avascular necrosis of the femoral head, primarily found in
males between the ages of 3 and 12 years. The peak age is 6 years. The blood supply to the femoral
epiphysis is interrupted in the inflammatory stage and bone growth stops. The blood supply resumes at
a later point but deformity may be present.
View the following video for more detail on musculoskeletal assessment:
Musculoskeletal/Upper Extremities
Click here to view a transcript for the video or see video within the course.
Reference:
Norman, J. (2010). Making the diagnosis of osteoporosis. Retrieved from http://
www.endocrineweb.com/osteoporosis/diagnosis.html NSG6020 Week 9 Integumentary and Musculoskeletal Systems