肌肉骨骼系統 Musculoskeletal System 骨科專科護理師 2011.04.22

前言 全身共206塊骨頭及多於600條肌肉 肌肉骨骼的基本功能單位：關節及其滑液囊，關節囊及韌帶與肌肉

Structure Joints Nonsynovial or synovial joints Cartilage Ligament Bursa Muscles Fasciculi Tendon Skeletal muscle movements Slide 22-3

Structure Spine Vertebrae Landmarks of the spine Intervertebral disks Shoulder Glenohumeral joint Rotator cuff Subacromial bursa Acromion process Greater tubercle of the humerus Coracoid process Slide 22-4

Structure Elbow Medial and lateral epicondyles Olecranon process of ulna Wrist and carpals Radiocarpal joint Midcarpal joint Metacarpophalangeal joints Interphalangeal joints Slide 22-5

Structure Hip Acetabulum and head of femur Anterior superior iliac spine Ischial tuberosity Greater trochanter of femur Slide 22-6

Structure Knee Femur, tibia, and patella Suprapatellar pouch Medial and lateral menisci Cruciate ligaments Prepatellar bursa Quadriceps muscle Slide 22-7

Structure Ankle and foot Tibiotalar joint Medial and lateral malleolus Metatarsals Slide 22-8

Subjective Data— Health History Questions Pain (cramps) Joint stiffness Redness and swelling Deformity Immobility Sensory changes Weakness

Subjective Data— Health History Questions 藥物史 創傷史 (fractures, sprains, dislocations) 內分泌異常 血液異常 皮膚或自體免疫疾病

Subjective Data— Health History Questions 家族史 心理社會史 日常活動 年齡及性別

Objective Data— The Physical Exam 評估工具 軟皮尺 測角器 筆 叩診槌

Objective Data— The Physical Exam 對稱(Symmetry) 變形(Deformities)  周圍組織狀況：skin changes、subcutaneous nodules、muscle atrophy 輾輒聲(Crepitation)：在關節或肌腱活動時，可以感覺到甚至聽到嘎輒或摩擦的聲音 運動範圍限制：有無不正常的運動 肌肉力量(Muscle strength)、肢體大小及長度 發炎徵兆(Inflammation sign)：swelling、warmth、tenderness、redness

Objective Data— The Physical Exam Inspection Palpation Percussion Range of motion (AROM; PROM) Muscle strength

Inspection 觀察評估站立及走路的姿勢 身體前後之骨骼排列及連合性

Inspection 是否對稱(Symmetry)、大小、形狀、長短(Leg lengrth discrepancy) 是否變形(Deformities)  是否腫脹(swelling)積水(effusion) 是否萎縮( arthrophy) 是否有疤痕(scars)

Inspection 是否有不自主運動 皮膚顏色、是否瘀血 周圍組織狀況 肢體長度及周徑測量 肌力大小測量

Inspection femoral neck fr:外旋 P/3-M/3 Femur fr:內收 femoral shaft fr:遠端內收足部外旋 femur condylar fr:knee valgus or varus shoulder dislocation:漢密爾頓式量尺徵候 陽性(Hamilton’s ruler sign ) forearm fr:旋轉(上段—旋後)(下段—旋前) Colle’s fr:向後彎曲、餐叉狀變形(dinner fork deformity)

Inspection --變形(Deformities) femoral neck fr:外旋 P/3-M/3 Femur fr:內收 femoral shaft fr:遠端內收足部外旋 femur condylar fr:knee valgus or varus forearm fr:旋轉(上段—旋後)(下段—旋前) Colle’s fr:向後彎曲、餐叉狀變形(dinner fork deformity)

Inspection 皮膚的完整度 末稍的血液循環 末稍的運動與感覺神經功能 肌肉及肌腱的功能與完整度 傷口位置/性質/大小/污染程度/有無bone exposure/有無tendon exposure 末稍的血液循環 末稍的運動與感覺神經功能 肌肉及肌腱的功能與完整度

Inspection--末稍的血液循環之評估 常見的動脈傷害 腋動脈—shoulder dislocation 臂動脈(Brachial A.)—孩童的 humeral supracondylar fr 膕動脈(Popliteal A.)—knee joint fracture or dislocation 股動脈—femur fracture

Inspection— 末稍的運動與感覺 神經功能之評估 知覺功能檢查 運動功能檢查 損傷之症狀

Inspection— 末稍的運動與感覺 神經功能之評估 橈神經 拇指與食指背面間隙 請病人拇指翹起 前臂橈骨手術或肱骨骨折合併症，易造成垂腕或拇指無法伸展

Palpation 壓痛、大小、腫塊、溫度、積水、摩擦音

Percussion 脊椎叩診

Range of motion Slide 22-26 26

Muscle testing— 肌肉力量評估記錄法 5 Normal 100 活動、抗重力、抗阻力正常 4 Good 75 抗重力正常，抗阻力能力較弱 3 Fair 50 抗重力正常，但無法抗阻力 2 Poor 25 可活動，但無法抗重力 1 Trace 10 零星肌肉收縮，無肢體活動 0 Zero 0 毫無任何肌肉收縮

示範:Wrist and Hand Inspect joints on dorsal and palmar sides Palpate each joint Motion and expected range Bend hand up, down Bend fingers up, down Turn hands out, in Spread fingers, make fist Touch thumb to each finger Phalen’s test Tinel’s sign

Abnormal Findings Abnormalities of the Wrist and Hand Ganglion cyst Colles’ fracture Carpal tunnel syndrome Dupuytren’s contracture Swan-neck and boutonniere deformities Ulnar deviation or drift Degenerative joint disease or osteoarthritis Acute rheumatoid arthritis Syndactyly Polydactyly Slide 22-29

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