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MUSCULOSKELETAL SYSTEM

165

Table 3-2. Lower-Quarter Screen

Nervc

Deep Tendon

Root

Myorome

Dermarome

Reflex

L 1

Hip flexion

Antero-superior thigh just

None

below the inguinal ligament

L2

Hip flexion

Anterior medial thigh 2.5 in.

None

below the anterior superior

iliac spine

L3

Knee extension

Middle third of anterior thigh

None

with L4

L4

Knee extension

Pacclla and medial malleolus

Patellar

with L3 and LS

tendon

L4,S

Ankle

None

dorsiflexion

LS

Great toe

Fibular head and dorsum of

Posterior

extension

foot

tibialis

51

Ankle plantar

Lateral malleolus and plantar

Achilles ten-

flexion

surface of foot

don

Sources: Adapted from ML Palmer, ME Epler (cds). Clinical Assessmem Procedures

in Physical Therapy. Philadelphia: Lippincotf, 1990;33; and data from S HoppenfeId. Physical Examination of the Spine and Extremities. Norwalk, CT: Appleron & Lange, 1976.

in terms of qualiry or movement through an ROM (e.g.,

active hip flexion is one-third range in supine).

• Sen ory testing is especially important over moderately

or severely edematous areas, especially the distal extremities. The patient may not be aware of subtle changes in sensation.

•

Girth measurements may be taken if edema of an

extremity subjectively appears to increase.

Functional Mobility and Safety

Functional mobility, including bed mobility, transfers, and ambulation on level surfaces and stairs, should be evaluated according to activity level, medical-surgical stabiliry, and prior functional level.

Safety is a key component of function. Evaluate the patient'S willing-

166

AClffE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table 3-3. Normal Range of Morion Values Mosr Applicable

in the Acute Care Setting

Joint

Normal Range of Morion (Degrees)

Shoulder

Flexion/extension

0-18010-60

Abduction

0-180

Internal/external rotation

0-7010-90

Elbow

Flexion

0-150

Forearm

Pronation/supination

0-8010-80

Wrist

Flexionlextension

0-8010-70

Hip

Flexion/extension

0-120/0-30

Abducrion

0-45

Internal/external rotation

0-4510-45

Knee

Flexion

0-135

Ankle

Dorsiflexion/plantar flexion

0-2010-45

ness to follow precautions with consistency. Observe for the patient'S

ability to maintain weight bearing or comply with equipment use.

Monitor the patient'S self-awareness of risk for falls, speed of movement, onset of fatigue, and body mechanics.

Clinical Tip

•

Safety awareness, or lack thereof, can be difficult to

document. Try to describe a patient'S level of safety awareness as objectively as possible (e.g., patient leaned on roiling tray table, unaware it could move).

• Nearly all patients will fear movement out of bed for

the first time to some degree, especially if a fall or traumatic event led to the hospital admission. This is particularly true with elders. Before mobilization, use strategies to decrease fear. This includes an explanation of the treatment before mobilizing the patient and of the sensations

MUSCULOSKELETAL SYSTEM

167

the patient may feel (e.g., "Your foot will throb a little

when you lower it to the floor.").

Because orthopedic injuries can often be the final result of other

medical problems (e.g., balance disorders or visual or sensory impairments), it is important that the therapist take a thorough history, perform a musculoskeletal screen, and critically observe the patient's functional mobility. Medical problems may be subtle in presentation

but may dramatically influence the patient's capabilities, especially with

new variables, such as pain or the presence of a cast. Collectively, these

factors lead to a decreased functional level.

Clinical Tip

It may be the physical therapist who first appreciates an

additional fracture, neurologic deficit, or pertinent piece of

medical or social history. Any and all abnormal findings

should be reported to the nurse or physician.

Diagnostic Tests

The mOSt commonly used diagnostic tests for the musculoskeletal system are listed in the following sections. These tests may be repeated during or after a hospital stay to assess bone and soft tissue healing

and disease progression, or whether there is a sudden change in vascular or neurological status postoperatively.

Radiography

More commonly known as x-rays or plain films, radiographic photographs are the mainstay in the detection of fracture, dislocation, bone loss, or foreign bodies or air in tissue. Sequential x-rays are standard

intra- or postoperatively to evaluate component position with joint

arthroplasty, placement of orthopedic hardware, or fracture reduction. X-rays may also detect soft tissue injuries, such as joint effusion, tendon calcification, or the presence of ectopic bone.'

Computed Tomography

Computed tomography (CT) is the diagnostic test of choice for the

evaluation of conical bone in certain circumstances. For fracture and

168 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

dislocations, CT can provide three-dimensional views for the spatial

relationship of fracture fragments or to further evaluate fracture in