Musculoskeletal System lecture 3.ppt

Musculoskeletal System
Assessment & Disorders
Dr Ibraheem Bashayreh, RN, PhD
Skeletal System
 Bone types
 Bone structure
 Bone function
 Bone growth and metabolism affected
by calcium and phosphorous,
calcitonin, vitamin D, parathyroid,
growth hormone, glucocorticoids,
estrogens and androgens, thyroxine,
and insulin.
Bones
 Human skeleton has 206 bones
 Provide structure and support for soft
tissue
 Protect vital organs
Figure 41-1 Bones of the human skeleton.
Figure 41-2 Classification of bones by shape.
Bones
 Compact bone
◦ Smooth and dense
◦ Forms shaft of long bones and outside
layer of other bones
 Spongy bone
◦ Contains spaces
◦ Spongy sections contain bone marrow
Bone Marrow
 Red bone marrow
◦ Found in flat bones of sternum, ribs, and
ileum
◦ Produces blood cells and hemoglobin
 Yellow bone marrow
◦ Found in shaft of long bones
◦ Contains fat and connective tissue
Joints (Articulations)
 Area where two or more bones meet
 Holds skeleton together while allowing
body to move
Joints
 Synarthrosis
◦ Immovable (e.g., skull)
 Amphiarthrosis
◦ Slightly movable (e.g., vertebral joints)
 Diarthrosis or synovial
◦ Freely movable (e.g., shoulders, hips)
Synovial Joints
 Found at all limb articulations
 Surface covered with cartilage
 Joint cavity covered with tough fibrous
capsule
 Cavity lined with synovial membrane
and filled with synovial fluid
Ligaments
 Bands of connective tissue that
connect bone to bone
 Either limit or enhance movement
 Provide joint stability
 Enhance joint strength
Tendons
 Fibrous connective tissue bands that
connect bone to muscles
 Enable bones to move when muscles
contract
Muscles
 Skeletal (voluntary)
◦ Allows voluntary movement
 Smooth (involuntary)
◦ Muscle movement controlled by internal
mechanism
◦ e.g., muscles in bladder wall and GI
system
 Cardiac (involuntary)
◦ Found in heart
Skeletal Muscle
 600 skeletal muscles
 Made up of thick bundles of parallel
fibers
 Each muscle fiber made up of smaller
structure myofibrils
 Myofibrils are strands of repeating
units called sarcomeres
Skeletal Muscle
 Skeletal muscle contracts with the
release of acetylcholine
 The more fibers that contract, the
stronger the muscle contraction
Changes in Older Adult
 Musculoskeletal changes can be due
to:
◦ Aging process
◦ Decreased activity
◦ Lifestyle factors
Changes in Older Adult
 Loss of bone mass in older women
 Joint and disk cartilage dehydrates
causing loss of flexibility contributes to
degenerative joint disease
(osteoarthritis); joints stiffen, lose
range of motion
Changes in Older Adult
 Cause stooped posture, changing
center of gravity
 Elderly at greater risk for falls
 Endocrine changes cause skeletal
muscle atrophy
 Muscle tone decreases
Assessment
 Health history
 Chief complaint
 Onset of problem
 Effect on ADLs
 Precipitating events, e.g., trauma
Assessment
 Examine complaints of pain for
location, duration, radiation character
(sharp dull), aggravating, or alleviating
factors
 Inquire about fever, fatigue, weight
changes, rash, or swelling
Physical Examination
 Posture
 Gait
 Ability to walk with or without assistive
devices
 Ability to feed, toilet, and dress self
 Muscle mass and symmetry
Musculoskeletal System lecture 3.ppt
Musculoskeletal System lecture 3.ppt
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Physical Examination
 Inspect and palpate bone, joints for
visible deformities, tenderness or pain,
swelling, warmth, and ROM
 Assess and compare corresponding
joints
 Palpate joints knees and shoulder for
crepitus
Physical Examination
 Never attempt to move a joint past
normal ROM or past point where
patient experiences pain
 Bulge sign and ballottement sign used
to assess for fluid in the knee joint
 Thomas test performed when hip
flexion contracture suspected
Figure 41-4 Checking for the bulge sign.
Figure 41-5 Checking for ballottement.
Diagnostic Tests
 Blood tests
 Arthrocentesis
 X-rays
 Bone density scan
 CT scan
 MRI
 Ultrasound
 Bone scan
Diagnostic Evaluation
 Imaging Procedures – CT, Bone Scan, MRI
 Nuclear Studies - radioisotope bone density,
 Endoscopic Studies –arthrocentesis,
arthroscopy
 Other Studies –biopsy, synovial fluid,
Arthrogram, venogram,
 Electromyography
 Myelography*
 Laboratory Studies
Musculoskeletal
Assessment – Diagnostic Test
 Laboratory
◦ Urine Tests
 24 hour creatine-
creatinine ratio
 Urine Uric acid –24
hr specimen
 Urine deoxypyridino-
line
 Laboratory
◦ Blood Tests
 Serum muscle
enzymes
 Rheumatoid Factor
 LE Prep/Antinuclear
Antibodies(ANA)
 Erythrocyte
Sedimentation Rate
 Calcium,
Phosphorous, Alkaline
phosphatase
Muscoluloskeletal
Assessment – Diagnostic
 Blood Tests
◦ CBC – Hgb, Hct
◦ Acid phosphatase
◦ Metabolic/Endocrine
◦ Enzymes
Increase creatine kinase,
serum increase
glutamin-oxaloacetic
due to muscle damage,
aldolase, SGOT
Musculoskeletal - Radiographic
 Standard radiography, tomography
and xeroradiography, myelography,
arthrography and CT
 Other diagnostic tests: bone and
muscle biopsy
Arthroscopy
 Fiberoptic tube is inserted into a joint
for direct visualization.
 Client must be able to flex the knee;
exercises are prescribed for ROM.
 Evaluate the neurovascular status of
the affected limb frequently.
 Analgesics are prescribed.
 Monitor for complications.
Musculoskeletal System lecture 3.ppt
Bone Scan
 Nuclear medicine procedure in which
amount of radioactive isotope taken
up by bones is evaluated
 Abnormal bone scans show hot spots
due to malignancies or infection
 Cold spot uptakes show areas of bone
that are ischemic
Arthroscopy
 Flexible fiberoptic endoscope used to
view joint structures and tissues
 Used to identify:
◦ Torn tendon and ligaments
◦ Injured meniscus
◦ Inflammatory joint changes
◦ Damaged cartilage
Interventions for Clients with
Musculoskeletal Trauma
Musculoskeletal Trauma
 Tissue is subjected to more force than
it can absorb
 Severity depends on:
◦ Amount of force
◦ Location of impact
Musculoskeletal Trauma
 Mild to severe
 Soft tissue
 Fractures
◦ Affect function of muscle, tendons, and
ligaments
 Complete amputation
Preventing Trauma
 Teach importance of using safety
equipment
◦ Seat belts
◦ Bicycle helmets
◦ Football pads
◦ Proper footwear
◦ Protective eyewear
◦ Hard hats
Soft Tissue Trauma
 Contusion
◦ Bleeding into soft tissue
◦ Significant bleeding can cause a
hematoma
◦ Swelling and discoloration (bruise)
Soft Tissue Trauma - Sprain
 Ligament injury (Excessive stretching
of a ligament)
 Twisting motion
 Overstretching or tear
◦ Grade I—mild bleeding and inflammation
◦ Grade II—severe stretching and some
tearing and inflammation and hematoma
◦ Grade III—complete tearing of ligament
◦ Grade IV—bony attachment of ligament
broken away
Sprains
 Treatment of sprains:
◦ first-degree: rest, ice for 24 to 48 hr,
compression bandage, and elevation
◦ second-degree: immobilization, partial
weight bearing as tear heals
◦ third-degree: immobilization for 4 to 6
weeks, possible surgery
Soft Tissue Trauma - Strain
 Microscopic tear in the muscle
 May cause bleeding
 “Pulled muscle”
 Inappropriate lifting or sudden
acceleration-deceleration
Soft Tissue Trauma
 To decrease swelling and pain, and
encourage rest
◦ Ice for first 48 hours
◦ Splint to support extremities and limit
movement
◦ Compression dressing
◦ Elevation to increase venous return and
decrease swelling
◦ NSAIDs
Soft Tissue Trauma
 Diagnosis
◦ X-ray to rule out fracture
◦ MRI
Musculoskeletal System lecture 3.ppt
Fractures
 Break in the continuity of bone
◦ Direct blow
◦ Crushing force (compression)
◦ Sudden twisting motions (torsion)
◦ Severe muscle contraction
◦ Disease (pathologic fracture)
Fractures
Classification of Fractures
 Closed or simple
 Open or compound
 Complete or incomplete
 Stable or unstable
 Direction of the fracture line
◦ Oblique
◦ Spiral
◦ Lengthwise plane (greenstick)
Stages of Bone Healing
 Hematoma formation within 48 to 72 hr
after injury
 Hematoma to granulation tissue
 Callus formation
 Osteoblastic proliferation
 Bone remodeling
 Bone healing completed within about 6
weeks; up to 6 months in the older
person
Fractures – Emergency Care
 Immobilize before moving client
 Joint above and below
 Check pulse, color, movement,
sensation before splinting
 Sterile dressing for open wounds
Fractures – Emergency Care
 Fracture reduction
◦ Closed—external manipulation
◦ Open—surgery
Musculoskeletal System lecture 3.ppt
Acute Compartment Syndrome
 Serious condition in which
increased pressure within one or
more compartments causes
massive compromise of circulation
to the area
 Prevention of pressure buildup of
blood or fluid accumulation
 Pathophysiologic changes
sometimes referred to as ischemia-
edema cycle
Emergency Care - Acute
Compartment Syndrome
 Within 4 to 6 hr after the onset of
acute compartment syndrome,
neuromuscular damage is
irreversible; the limb can become
useless within 24 to 48 hr.
 Monitor compartment pressures.
(Continued)
Emergency Care (Continued)
 Fasciotomy may be performed to
relieve pressure.
 Pack and dress the wound after
fasciotomy.
Possible Results of Acute Compartment
Syndrome
 Infection
 Motor weakness
 Volkmann’s contractures: (a deformity of
the hand, fingers, and wrist caused by a lack of blood
flow (ischemia) to the muscles of the forearm)
Other Complications of Fractures
 Shock
 Fat embolism syndrome: serious
complication resulting from a
fracture; fat globules are released
from yellow bone marrow into
bloodstream
 Venous thromboembolism
(Continued)
Other Complications of Fractures
(Continued)
 Infection
 Ischemic necrosis
 Fracture blisters, delayed union,
nonunion, and malunion
Musculoskeletal
Complications (continued)
 Muscle Atrophy, loss of muscle strength
range of motion, pressure ulcers, and other
problems associated with immobility
 Embolism/Pneumonia/ARDS
◦ TREATMENT – hydration, albumin,
corticosteroids
 Constipation/Anorexia
 UTI
 DVT
Musculoskeletal Assessment - Fracture
 Change in bone alignment
 Alteration in length of extremity
 Change in shape of bone
 Pain upon movement
 Decreased ROM
 Crepitation
 Ecchymotic skin
(Continued)
Musculoskeletal Assessment – Fracture
(Continued)
 Subcutaneous emphysema with
bubbles under the skin
 Swelling at the fracture site
Special Assessment Considerations
 For fractures of the shoulder and upper
arm, assess client in sitting or standing
position.
 Support the affected arm to promote
comfort.
 For distal areas of the arm, assess
client in a supine position.
 For fracture of lower extremities and
pelvis, client is in supine position.
CAST
CAST
Casts
 Rigid device that immobilizes the
affected body part while allowing other
body parts to move
 Cast materials: plaster, fiberglass,
polyester-cotton
 Types of casts for various parts of the
body: arm, leg, brace, body
(Continued)
Casts (Continued)
 Cast care and client education
 Cast complications: infection,
circulation impairment, peripheral
nerve damage, complications of
immobility
Managing Care of the Patient in a Cast
 Casting Materials
 Relieving Pain
 Improving Mobility
 Promoting Healing
 Neurovascular Function
 Potential Complications
Cast, Splint, Braces, and Traction
Management Considerations
 Arm Casts
 Leg Casts
 Body or Spica Casts
 Splints and Braces
 External Fixator
 Traction
Musculoskeletal System lecture 3.ppt
POLYESTER/FIBERGLASS
UPPER EXTREMITY CAST
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LOWER EXTREMITY CAST
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Musculoskeletal
Nursing Care - Casts
◦ Neurovascular
 Check
color/capillary refill
 Temperature
 Pulse
 Movement
 Sensation
 Traction Nursing Care
◦ Pin Site care
◦ Skin and
neurovascular check
Cast Care (continued)
 Elevate Extremity
 Exercises – to unaffected side; isometric
exercises to affected extremity
 Keep heel off mattress
 Handle with palms of hands if cast wet
 Turn every two hours till dry
 Notify MD at once of wound drainage
 Do not place items under cast.
Traction
 Application of a pulling force to the
body to provide reduction,
alignment, and rest at that site
 Types of traction: skin, skeletal,
plaster, brace, circumferential
(Continued)
Traction (Continued)
 Traction care:
◦ Maintain correct balance between
traction pull and counter traction force
◦ Care of weights
◦ Skin inspection
◦ Pin care
◦ Assessment of neurovascular status
Musculoskeletal System lecture 3.ppt
Musculoskeletal System lecture 3.ppt
Musculoskeletal – Fractures
Treatment
 Primary Goal – reduce fracture-
◦ Realign and immobilize
 Medications
◦ Analgesics, antibiotics, tetanus toxoid
 Closed Reduction – Manual and Cast;
External Fixation Device
 Traction; Splints; Braces
 Surgery
◦ Open reduction with internal fixation
◦ Reconstructive surgery
◦ Endoprosthetic replacement
Musculoskeletal System lecture 3.ppt
Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external
fixation rods that hold the pins and bone in place.
Musculoskeletal System lecture 3.ppt
Nursing Management
 Positioning
 Strengthening Exercises
 Potential Complications
Musculoskeletal
Nursing Care
 Promote comfort
 Assess infection
 Promote mobility
 Teach safety
 Vital Signs
 Flotation, sheep skin
 Nutrition
 Vital Signs
 Monitor elimination
 Elevate extremity
to decrease
swelling/ ice pack
 Teach skin care,
cast care, diet,
complications
Operative Procedures
 Open reduction with internal
fixation
 External fixation
 Postoperative care: similar to that
for any surgery; certain
complications specific to fractures
and musculoskeletal surgery
include fat embolism and venous
thromboembolism
Managing the Patient Undergoing
Orthopedic Surgery
 Joint Replacement
 Total Hip Replacement
 Total Knee Replacement
Musculoskeletal System lecture 3.ppt
Risk for Infection
 Interventions include:
◦ Apply strict aseptic technique for
dressing changes and wound
irrigations.
◦ Assess for local inflammation
◦ Report purulent drainage immediately
to health care provider.
(Continued)
Risk for Infection (Continued)
◦ Assess for pneumonia and urinary
tract infection.
◦ Administer broad-spectrum antibiotics
prophylactically.
Imbalanced Nutrition: Less Than Body
Requirements
 Interventions include:
◦ Diet high in protein, calories, and
calcium, supplemental vitamins B and
C
◦ Frequent small feedings and
supplements of high-protein liquids
◦ Intake of foods high in iron
Upper Extremity Fractures
 Fractures include those of the:
◦ Clavicle
◦ Scapula
◦ Humerus
◦ Olecranon
◦ Radius and ulna
◦ Wrist and hand
Lower Extremity Fractures
 Fractures include those of the:
◦ Femur
◦ Patella
◦ Tibia and fibula
◦ Ankle and foot
Musculoskeletal System lecture 3.ppt
Fractures of the Hip
 Intracapsular or extracapsular
 Treatment of choice: surgical
repair, when possible, to allow the
older client to get out of bed
 Open reduction with internal
fixation
 Intramedullary rod, pins, a
prosthesis, or a fixed sliding plate
 Prosthetic device
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Fractures of the Pelvis
 Associated internal damage the
chief concern in fracture
management of pelvic fractures
 Non–weight-bearing fracture of the
pelvis
 Weight-bearing fracture of the
pelvis
Compression Fractures of the Spine
 Most are associated with
osteoporosis rather than acute
spinal injury.
 Multiple hairline fractures result
when bone mass diminishes.
(Continued)
Compression Fractures of the Spine
(Continued)
 Nonsurgical management includes
bedrest, analgesics, and physical
therapy.
 Minimally invasive surgeries are
vertebroplasty and kyphoplasty, in
which bone cement is injected.
(Continued)
Amputations
 Surgical amputation
 Traumatic amputation
 Levels of amputation
 Complications of amputations:
hemorrhage, infection, phantom
limb pain, problems associated
with immobility, neuroma (a growth or
tumour of nerve tissue), flexion contracture
Amputation
Nursing Management
◦ relieving pain
◦ minimizing altered sensory
perception
◦ promoting wound healing
◦ enhancing body image
◦ self-care
Phantom Limb Pain
 Phantom limb pain is a frequent
complication of amputation.
 Client complains of pain at the site
of the removed body part, most
often shortly after surgery.
 Pain is intense burning feeling,
crushing sensation or cramping.
 Some clients feel that the removed
body part is in a distorted position.
Management of Phantom Pain
 Phantom limb pain must be
distinguished from stump pain
because they are managed
differently.
 Recognize that this pain is real and
interferes with the amputee’s
activities of daily living.
(Continued)
Management of Phantom Pain
(Continued)
 Some studies have shown that
opioids are not as effective for
phantom limb pain as they are for
residual limb pain.
 Other drugs include intravenous
infusion calcitonin, beta blockers,
anticonvulsants, and
antispasmodics.
Exercise After Amputation
 ROM to prevent flexion
contractures, particularly of the hip
and knee
 Trapeze and overhead frame
 Firm mattress
 Prone position every 3 to 4 hours
 Elevation of lower-leg residual limb
controversial
Musculoskeletal System lecture 3.ppt
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Prostheses
 Devices to help shape and shrink
the residual limb and help client
readapt
 Wrapping of elastic bandages
 Individual fitting of the prosthesis;
special care
Crush Syndrome
 Can occur when leg or arm injury
includes multiple compartments
 Characterized by acute compartment
syndrome, hypovolemia, hyperkalemia,
rhabdomyolysis, and acute tubular
necrosis
 Treatment: adequate intravenous fluids,
low-dose dopamine, sodium
bicarbonate, kayexalate, and
hemodialysis
Metabolic Bone Disorders
Osteoporosis
Osteomalcia
Paget’s Disease
Osteoporosis
 A disease in which loss of bone exceeds
rate of bone formation; usually increase in
older women, white race, nulliparity.
 Clinical Manifestations – bone pain,
decrease movement.
 Treatment – Calcium, Vit. D, estrogen
replacement, Calcitonin, fluoride, estrogen
with progestin, SERM (Selective Estrogen
Receptor Modulator) with anti-estrogens,
exercise.
 Pathologic fracture-safety.
Classification of Osteoporosis
 Generalized osteoporosis occurs most
commonly in postmenopausal women
and men in their 60s and 70s.
 Secondary osteoporosis results from
an associated medical condition such
as hyperparathyroidism, long-term
drug therapy, long-term immobility.
 Regional osteoporosis occurs when a
limb is immobilized.
Health Promotion/Illness Prevention -
Osteoporosis
 Ensure adequate calcium intake.
 Avoid sedentary life style (a type of
lifestyle with a lack of physical
exercise) .
 Continue program of weight-
bearing exercises.
Osteoporosis - Assessment
 Physical assessment
 Psychosocial assessment
 Laboratory assessment
 Radiographic assessment
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Drug Therapy
Osteoporosis
 Hormone replacement therapy
 Parathyroid hormone
 Calcium and vitamin D
 Bisphosphonates
 Selective estrogen receptor
modulators
 Calcitonin
 Other agents used with varying
results
Diet Therapy - Osteoporosis
 Protein
 Magnesium
 Vitamin K
 Trace minerals
 Calcium and vitamin D
 Avoid alcohol and caffeine
Fall Prevention - Osteoporosis
 Hazard-free environment
 High-risk assessment through
programs such as Falling Star
protocol
 Hip protectors that prevent hip
fracture in case of a fall
Others - Osteoporosis
 Exercise
 Pain management
 Orthotic devices
Osteomalacia
 Softening of the bone tissue
characterized by inadequate
mineralization of osteoid
 Vitamin D deficiency, lack of
sunlight exposure
 Similar, but not the same as
osteoporosis
 Major treatment: vitamin D from
exposure to sun and certain foods
Paget’s Disease of the Bone
 Metabolic disorder of bone remodeling,
or turnover; increased resorption (the
process by which osteoclasts break down bone and
release the minerals, resulting in a transfer of calcium
from bone fluid to the blood) of loss results in
bone deposits that are weak, enlarged,
and disorganized
 Nonsurgical management: calcitonin,
selected bisphosphonates, mithramycin
 Surgical management: tibial osteotomy
or partial or total joint replacement
Paget’s Disease
 An imbalance of increase osteoblast and
osteoclast cells; thickening and
hypertrophy.
 Bone pain most common symptom;
bony enlargement and deformities
usually bilateral, kyphosis, long bone.
 Analgesics, meds bisphosphonates and
calcitonin, NSAID, assistance devices,
and hot/cold treatment.
Osteomyelitis
 A condition caused by the invasion
by one or more pathogenic
microorganisms that stimulates the
inflammatory response in bone
tissue
 Exogenous, endogenous,
hematogenous, contiguous
Osteomyelitis
 Infection of bone; causative agent – Staph/Strept
 Typical signs and symptoms : Acute osteomyelitis
include:
 Fever that may be abrupt
 Irritability or lethargy in young children
 Pain in the area of the infection
 Swelling, warmth and redness over the area of the
infection
 Chronic osteomyelitis include:
 Warmth, swelling and redness over the area of the
infection
 Pain or tenderness in the affected area
 Chronic fatigue
 Drainage from an open wound near the area of the
infection
 Fever, sometimes
 Treatment – IV antibiotic; long term for 4-6 months
Surgical Management
Osteomyelitis
 Sequestrectomy (Surgical removal of a
sequestrum), a detached piece of necrotic bone
that often migrates to a wound, abscess, etc.
 Bone grafts
 Bone segment transfers
 Muscle flaps
 Amputation
Bone Tumors
Benign Bone Tumors
Malignant Bone Tumors
Metastatic Bone Disease
Bone Tumors
 Benign bone tumors
(noncancerous):
◦ Chrondrogenic tumors:
osteochondroma, chondroma
◦ Osteogenic tumors: osteoid osteoma,
osteoblastoma, giant cell tumor
◦ Fibrogenic tumors
Interventions
 Nondrug pain relief measures
 Drug therapy: analgesics, NSAIDs
 Surgical therapy: curettage (simple
excision of the tumor tissue), joint
replacement, or arthrodesis
Malignant Bone Tumors
 Primary tumors, those tumors that
originate in the bone
◦ Osteosarcoma
◦ Ewing’s sarcoma
◦ Chondrosarcoma
◦ Fibrosarcoma
◦ Metastatic bone disease
Osteosarcoma
 Cancer of the bone – metastasis to the
lung is common. Most in long bones.
 Clinical manifestations – dull pain,
swelling, intermittent but increases per
time; night pain common.
 Treatment – radiation, chemotherapy,
hormonal therapy, surgical excision with
prosthetics, assistance devices,
palliative measures.
Treatment Cancer of Bone
 Interventions include:
◦ Treatment aimed at reducing the size or
removing the tumor
◦ Drug therapy; chemotherapy
◦ Radiation therapy
◦ Surgical management
◦ Promotion of physical mobility with ROM
exercises
Cancer of Bone
Anticipatory Grieving
 Interventions include:
◦ Active listening
◦ Encouraging client and family to
verbalize feelings
◦ Making appropriate referrals
◦ Helping client and others to cope with
the loss and grieving
◦ Promoting the physician-client
relationship
Cancer of Bone
Disturbed Body Image
 Interventions include:
◦ Recognize and accept the client’s view
of body image alteration.
◦ Establish and maintain a trusting
nurse-client relationship.
◦ Emphasize the client’s strengths and
remaining capabilities.
◦ Establish realistic mutual goals.
Potential for Fractures
Bone Cancer
 Interventions
◦ Nonsurgical management: radiation
therapy and strengthening exercises.
◦ Surgical management: replace as much of
the defective bone as possible, avoid a
second procedure, and return client to a
functioning state with a minimum of
hospitalization and immobilization.
Carpal Tunnel Syndrome
 Common condition; the median
nerve in the wrist becomes
compressed, causing pain and
numbness
 Common repetitive strain injury via
occupational or sports motions
 Nonsurgical management: drug
therapy and immobilization
 Possible surgical management
Scoliosis
 Abnormal spinal curvature of various
degrees or severity involving
shortening of muscles and
ligaments.
 Milwaukee brace (a back brace used in the
treatment of spinal curvatures) , internal
fixative devices.
Scoliosis
 Changes in muscles and ligaments
on the concave side of the spinal
column
 Congenital, neuromuscular, or
idiopathic in type
 Assessment: complete history, pain
assessment, observation of posture
 Interventions: exercise, weight
reduction, bracing, casting, surgery
Musculoskeletal System lecture 3.ppt
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Musculoskeletal System lecture 3.ppt

  • 1. Musculoskeletal System Assessment & Disorders Dr Ibraheem Bashayreh, RN, PhD
  • 2. Skeletal System  Bone types  Bone structure  Bone function  Bone growth and metabolism affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin.
  • 3. Bones  Human skeleton has 206 bones  Provide structure and support for soft tissue  Protect vital organs
  • 4. Figure 41-1 Bones of the human skeleton.
  • 5. Figure 41-2 Classification of bones by shape.
  • 6. Bones  Compact bone ◦ Smooth and dense ◦ Forms shaft of long bones and outside layer of other bones  Spongy bone ◦ Contains spaces ◦ Spongy sections contain bone marrow
  • 7. Bone Marrow  Red bone marrow ◦ Found in flat bones of sternum, ribs, and ileum ◦ Produces blood cells and hemoglobin  Yellow bone marrow ◦ Found in shaft of long bones ◦ Contains fat and connective tissue
  • 8. Joints (Articulations)  Area where two or more bones meet  Holds skeleton together while allowing body to move
  • 9. Joints  Synarthrosis ◦ Immovable (e.g., skull)  Amphiarthrosis ◦ Slightly movable (e.g., vertebral joints)  Diarthrosis or synovial ◦ Freely movable (e.g., shoulders, hips)
  • 10. Synovial Joints  Found at all limb articulations  Surface covered with cartilage  Joint cavity covered with tough fibrous capsule  Cavity lined with synovial membrane and filled with synovial fluid
  • 11. Ligaments  Bands of connective tissue that connect bone to bone  Either limit or enhance movement  Provide joint stability  Enhance joint strength
  • 12. Tendons  Fibrous connective tissue bands that connect bone to muscles  Enable bones to move when muscles contract
  • 13. Muscles  Skeletal (voluntary) ◦ Allows voluntary movement  Smooth (involuntary) ◦ Muscle movement controlled by internal mechanism ◦ e.g., muscles in bladder wall and GI system  Cardiac (involuntary) ◦ Found in heart
  • 14. Skeletal Muscle  600 skeletal muscles  Made up of thick bundles of parallel fibers  Each muscle fiber made up of smaller structure myofibrils  Myofibrils are strands of repeating units called sarcomeres
  • 15. Skeletal Muscle  Skeletal muscle contracts with the release of acetylcholine  The more fibers that contract, the stronger the muscle contraction
  • 16. Changes in Older Adult  Musculoskeletal changes can be due to: ◦ Aging process ◦ Decreased activity ◦ Lifestyle factors
  • 17. Changes in Older Adult  Loss of bone mass in older women  Joint and disk cartilage dehydrates causing loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion
  • 18. Changes in Older Adult  Cause stooped posture, changing center of gravity  Elderly at greater risk for falls  Endocrine changes cause skeletal muscle atrophy  Muscle tone decreases
  • 19. Assessment  Health history  Chief complaint  Onset of problem  Effect on ADLs  Precipitating events, e.g., trauma
  • 20. Assessment  Examine complaints of pain for location, duration, radiation character (sharp dull), aggravating, or alleviating factors  Inquire about fever, fatigue, weight changes, rash, or swelling
  • 21. Physical Examination  Posture  Gait  Ability to walk with or without assistive devices  Ability to feed, toilet, and dress self  Muscle mass and symmetry
  • 25. Physical Examination  Inspect and palpate bone, joints for visible deformities, tenderness or pain, swelling, warmth, and ROM  Assess and compare corresponding joints  Palpate joints knees and shoulder for crepitus
  • 26. Physical Examination  Never attempt to move a joint past normal ROM or past point where patient experiences pain  Bulge sign and ballottement sign used to assess for fluid in the knee joint  Thomas test performed when hip flexion contracture suspected
  • 27. Figure 41-4 Checking for the bulge sign.
  • 28. Figure 41-5 Checking for ballottement.
  • 29. Diagnostic Tests  Blood tests  Arthrocentesis  X-rays  Bone density scan  CT scan  MRI  Ultrasound  Bone scan
  • 30. Diagnostic Evaluation  Imaging Procedures – CT, Bone Scan, MRI  Nuclear Studies - radioisotope bone density,  Endoscopic Studies –arthrocentesis, arthroscopy  Other Studies –biopsy, synovial fluid, Arthrogram, venogram,  Electromyography  Myelography*  Laboratory Studies
  • 31. Musculoskeletal Assessment – Diagnostic Test  Laboratory ◦ Urine Tests  24 hour creatine- creatinine ratio  Urine Uric acid –24 hr specimen  Urine deoxypyridino- line  Laboratory ◦ Blood Tests  Serum muscle enzymes  Rheumatoid Factor  LE Prep/Antinuclear Antibodies(ANA)  Erythrocyte Sedimentation Rate  Calcium, Phosphorous, Alkaline phosphatase
  • 32. Muscoluloskeletal Assessment – Diagnostic  Blood Tests ◦ CBC – Hgb, Hct ◦ Acid phosphatase ◦ Metabolic/Endocrine ◦ Enzymes Increase creatine kinase, serum increase glutamin-oxaloacetic due to muscle damage, aldolase, SGOT
  • 33. Musculoskeletal - Radiographic  Standard radiography, tomography and xeroradiography, myelography, arthrography and CT  Other diagnostic tests: bone and muscle biopsy
  • 34. Arthroscopy  Fiberoptic tube is inserted into a joint for direct visualization.  Client must be able to flex the knee; exercises are prescribed for ROM.  Evaluate the neurovascular status of the affected limb frequently.  Analgesics are prescribed.  Monitor for complications.
  • 36. Bone Scan  Nuclear medicine procedure in which amount of radioactive isotope taken up by bones is evaluated  Abnormal bone scans show hot spots due to malignancies or infection  Cold spot uptakes show areas of bone that are ischemic
  • 37. Arthroscopy  Flexible fiberoptic endoscope used to view joint structures and tissues  Used to identify: ◦ Torn tendon and ligaments ◦ Injured meniscus ◦ Inflammatory joint changes ◦ Damaged cartilage
  • 38. Interventions for Clients with Musculoskeletal Trauma
  • 39. Musculoskeletal Trauma  Tissue is subjected to more force than it can absorb  Severity depends on: ◦ Amount of force ◦ Location of impact
  • 40. Musculoskeletal Trauma  Mild to severe  Soft tissue  Fractures ◦ Affect function of muscle, tendons, and ligaments  Complete amputation
  • 41. Preventing Trauma  Teach importance of using safety equipment ◦ Seat belts ◦ Bicycle helmets ◦ Football pads ◦ Proper footwear ◦ Protective eyewear ◦ Hard hats
  • 42. Soft Tissue Trauma  Contusion ◦ Bleeding into soft tissue ◦ Significant bleeding can cause a hematoma ◦ Swelling and discoloration (bruise)
  • 43. Soft Tissue Trauma - Sprain  Ligament injury (Excessive stretching of a ligament)  Twisting motion  Overstretching or tear ◦ Grade I—mild bleeding and inflammation ◦ Grade II—severe stretching and some tearing and inflammation and hematoma ◦ Grade III—complete tearing of ligament ◦ Grade IV—bony attachment of ligament broken away
  • 44. Sprains  Treatment of sprains: ◦ first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation ◦ second-degree: immobilization, partial weight bearing as tear heals ◦ third-degree: immobilization for 4 to 6 weeks, possible surgery
  • 45. Soft Tissue Trauma - Strain  Microscopic tear in the muscle  May cause bleeding  “Pulled muscle”  Inappropriate lifting or sudden acceleration-deceleration
  • 46. Soft Tissue Trauma  To decrease swelling and pain, and encourage rest ◦ Ice for first 48 hours ◦ Splint to support extremities and limit movement ◦ Compression dressing ◦ Elevation to increase venous return and decrease swelling ◦ NSAIDs
  • 47. Soft Tissue Trauma  Diagnosis ◦ X-ray to rule out fracture ◦ MRI
  • 49. Fractures  Break in the continuity of bone ◦ Direct blow ◦ Crushing force (compression) ◦ Sudden twisting motions (torsion) ◦ Severe muscle contraction ◦ Disease (pathologic fracture)
  • 50. Fractures Classification of Fractures  Closed or simple  Open or compound  Complete or incomplete  Stable or unstable  Direction of the fracture line ◦ Oblique ◦ Spiral ◦ Lengthwise plane (greenstick)
  • 51. Stages of Bone Healing  Hematoma formation within 48 to 72 hr after injury  Hematoma to granulation tissue  Callus formation  Osteoblastic proliferation  Bone remodeling  Bone healing completed within about 6 weeks; up to 6 months in the older person
  • 52. Fractures – Emergency Care  Immobilize before moving client  Joint above and below  Check pulse, color, movement, sensation before splinting  Sterile dressing for open wounds
  • 53. Fractures – Emergency Care  Fracture reduction ◦ Closed—external manipulation ◦ Open—surgery
  • 55. Acute Compartment Syndrome  Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area  Prevention of pressure buildup of blood or fluid accumulation  Pathophysiologic changes sometimes referred to as ischemia- edema cycle
  • 56. Emergency Care - Acute Compartment Syndrome  Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr.  Monitor compartment pressures. (Continued)
  • 57. Emergency Care (Continued)  Fasciotomy may be performed to relieve pressure.  Pack and dress the wound after fasciotomy.
  • 58. Possible Results of Acute Compartment Syndrome  Infection  Motor weakness  Volkmann’s contractures: (a deformity of the hand, fingers, and wrist caused by a lack of blood flow (ischemia) to the muscles of the forearm)
  • 59. Other Complications of Fractures  Shock  Fat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream  Venous thromboembolism (Continued)
  • 60. Other Complications of Fractures (Continued)  Infection  Ischemic necrosis  Fracture blisters, delayed union, nonunion, and malunion
  • 61. Musculoskeletal Complications (continued)  Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobility  Embolism/Pneumonia/ARDS ◦ TREATMENT – hydration, albumin, corticosteroids  Constipation/Anorexia  UTI  DVT
  • 62. Musculoskeletal Assessment - Fracture  Change in bone alignment  Alteration in length of extremity  Change in shape of bone  Pain upon movement  Decreased ROM  Crepitation  Ecchymotic skin (Continued)
  • 63. Musculoskeletal Assessment – Fracture (Continued)  Subcutaneous emphysema with bubbles under the skin  Swelling at the fracture site
  • 64. Special Assessment Considerations  For fractures of the shoulder and upper arm, assess client in sitting or standing position.  Support the affected arm to promote comfort.  For distal areas of the arm, assess client in a supine position.  For fracture of lower extremities and pelvis, client is in supine position.
  • 66. Casts  Rigid device that immobilizes the affected body part while allowing other body parts to move  Cast materials: plaster, fiberglass, polyester-cotton  Types of casts for various parts of the body: arm, leg, brace, body (Continued)
  • 67. Casts (Continued)  Cast care and client education  Cast complications: infection, circulation impairment, peripheral nerve damage, complications of immobility
  • 68. Managing Care of the Patient in a Cast  Casting Materials  Relieving Pain  Improving Mobility  Promoting Healing  Neurovascular Function  Potential Complications
  • 69. Cast, Splint, Braces, and Traction Management Considerations  Arm Casts  Leg Casts  Body or Spica Casts  Splints and Braces  External Fixator  Traction
  • 78. Musculoskeletal Nursing Care - Casts ◦ Neurovascular  Check color/capillary refill  Temperature  Pulse  Movement  Sensation  Traction Nursing Care ◦ Pin Site care ◦ Skin and neurovascular check
  • 79. Cast Care (continued)  Elevate Extremity  Exercises – to unaffected side; isometric exercises to affected extremity  Keep heel off mattress  Handle with palms of hands if cast wet  Turn every two hours till dry  Notify MD at once of wound drainage  Do not place items under cast.
  • 80. Traction  Application of a pulling force to the body to provide reduction, alignment, and rest at that site  Types of traction: skin, skeletal, plaster, brace, circumferential (Continued)
  • 81. Traction (Continued)  Traction care: ◦ Maintain correct balance between traction pull and counter traction force ◦ Care of weights ◦ Skin inspection ◦ Pin care ◦ Assessment of neurovascular status
  • 84. Musculoskeletal – Fractures Treatment  Primary Goal – reduce fracture- ◦ Realign and immobilize  Medications ◦ Analgesics, antibiotics, tetanus toxoid  Closed Reduction – Manual and Cast; External Fixation Device  Traction; Splints; Braces  Surgery ◦ Open reduction with internal fixation ◦ Reconstructive surgery ◦ Endoprosthetic replacement
  • 86. Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external fixation rods that hold the pins and bone in place.
  • 88. Nursing Management  Positioning  Strengthening Exercises  Potential Complications
  • 89. Musculoskeletal Nursing Care  Promote comfort  Assess infection  Promote mobility  Teach safety  Vital Signs  Flotation, sheep skin  Nutrition  Vital Signs  Monitor elimination  Elevate extremity to decrease swelling/ ice pack  Teach skin care, cast care, diet, complications
  • 90. Operative Procedures  Open reduction with internal fixation  External fixation  Postoperative care: similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism
  • 91. Managing the Patient Undergoing Orthopedic Surgery  Joint Replacement  Total Hip Replacement  Total Knee Replacement
  • 93. Risk for Infection  Interventions include: ◦ Apply strict aseptic technique for dressing changes and wound irrigations. ◦ Assess for local inflammation ◦ Report purulent drainage immediately to health care provider. (Continued)
  • 94. Risk for Infection (Continued) ◦ Assess for pneumonia and urinary tract infection. ◦ Administer broad-spectrum antibiotics prophylactically.
  • 95. Imbalanced Nutrition: Less Than Body Requirements  Interventions include: ◦ Diet high in protein, calories, and calcium, supplemental vitamins B and C ◦ Frequent small feedings and supplements of high-protein liquids ◦ Intake of foods high in iron
  • 96. Upper Extremity Fractures  Fractures include those of the: ◦ Clavicle ◦ Scapula ◦ Humerus ◦ Olecranon ◦ Radius and ulna ◦ Wrist and hand
  • 97. Lower Extremity Fractures  Fractures include those of the: ◦ Femur ◦ Patella ◦ Tibia and fibula ◦ Ankle and foot
  • 99. Fractures of the Hip  Intracapsular or extracapsular  Treatment of choice: surgical repair, when possible, to allow the older client to get out of bed  Open reduction with internal fixation  Intramedullary rod, pins, a prosthesis, or a fixed sliding plate  Prosthetic device
  • 103. Fractures of the Pelvis  Associated internal damage the chief concern in fracture management of pelvic fractures  Non–weight-bearing fracture of the pelvis  Weight-bearing fracture of the pelvis
  • 104. Compression Fractures of the Spine  Most are associated with osteoporosis rather than acute spinal injury.  Multiple hairline fractures result when bone mass diminishes. (Continued)
  • 105. Compression Fractures of the Spine (Continued)  Nonsurgical management includes bedrest, analgesics, and physical therapy.  Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected. (Continued)
  • 106. Amputations  Surgical amputation  Traumatic amputation  Levels of amputation  Complications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma (a growth or tumour of nerve tissue), flexion contracture
  • 107. Amputation Nursing Management ◦ relieving pain ◦ minimizing altered sensory perception ◦ promoting wound healing ◦ enhancing body image ◦ self-care
  • 108. Phantom Limb Pain  Phantom limb pain is a frequent complication of amputation.  Client complains of pain at the site of the removed body part, most often shortly after surgery.  Pain is intense burning feeling, crushing sensation or cramping.  Some clients feel that the removed body part is in a distorted position.
  • 109. Management of Phantom Pain  Phantom limb pain must be distinguished from stump pain because they are managed differently.  Recognize that this pain is real and interferes with the amputee’s activities of daily living. (Continued)
  • 110. Management of Phantom Pain (Continued)  Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain.  Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics.
  • 111. Exercise After Amputation  ROM to prevent flexion contractures, particularly of the hip and knee  Trapeze and overhead frame  Firm mattress  Prone position every 3 to 4 hours  Elevation of lower-leg residual limb controversial
  • 114. Prostheses  Devices to help shape and shrink the residual limb and help client readapt  Wrapping of elastic bandages  Individual fitting of the prosthesis; special care
  • 115. Crush Syndrome  Can occur when leg or arm injury includes multiple compartments  Characterized by acute compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosis  Treatment: adequate intravenous fluids, low-dose dopamine, sodium bicarbonate, kayexalate, and hemodialysis
  • 117. Osteoporosis  A disease in which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity.  Clinical Manifestations – bone pain, decrease movement.  Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, SERM (Selective Estrogen Receptor Modulator) with anti-estrogens, exercise.  Pathologic fracture-safety.
  • 118. Classification of Osteoporosis  Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s.  Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility.  Regional osteoporosis occurs when a limb is immobilized.
  • 119. Health Promotion/Illness Prevention - Osteoporosis  Ensure adequate calcium intake.  Avoid sedentary life style (a type of lifestyle with a lack of physical exercise) .  Continue program of weight- bearing exercises.
  • 120. Osteoporosis - Assessment  Physical assessment  Psychosocial assessment  Laboratory assessment  Radiographic assessment
  • 124. Drug Therapy Osteoporosis  Hormone replacement therapy  Parathyroid hormone  Calcium and vitamin D  Bisphosphonates  Selective estrogen receptor modulators  Calcitonin  Other agents used with varying results
  • 125. Diet Therapy - Osteoporosis  Protein  Magnesium  Vitamin K  Trace minerals  Calcium and vitamin D  Avoid alcohol and caffeine
  • 126. Fall Prevention - Osteoporosis  Hazard-free environment  High-risk assessment through programs such as Falling Star protocol  Hip protectors that prevent hip fracture in case of a fall
  • 127. Others - Osteoporosis  Exercise  Pain management  Orthotic devices
  • 128. Osteomalacia  Softening of the bone tissue characterized by inadequate mineralization of osteoid  Vitamin D deficiency, lack of sunlight exposure  Similar, but not the same as osteoporosis  Major treatment: vitamin D from exposure to sun and certain foods
  • 129. Paget’s Disease of the Bone  Metabolic disorder of bone remodeling, or turnover; increased resorption (the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) of loss results in bone deposits that are weak, enlarged, and disorganized  Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin  Surgical management: tibial osteotomy or partial or total joint replacement
  • 130. Paget’s Disease  An imbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy.  Bone pain most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone.  Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold treatment.
  • 131. Osteomyelitis  A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue  Exogenous, endogenous, hematogenous, contiguous
  • 132. Osteomyelitis  Infection of bone; causative agent – Staph/Strept  Typical signs and symptoms : Acute osteomyelitis include:  Fever that may be abrupt  Irritability or lethargy in young children  Pain in the area of the infection  Swelling, warmth and redness over the area of the infection  Chronic osteomyelitis include:  Warmth, swelling and redness over the area of the infection  Pain or tenderness in the affected area  Chronic fatigue  Drainage from an open wound near the area of the infection  Fever, sometimes  Treatment – IV antibiotic; long term for 4-6 months
  • 133. Surgical Management Osteomyelitis  Sequestrectomy (Surgical removal of a sequestrum), a detached piece of necrotic bone that often migrates to a wound, abscess, etc.  Bone grafts  Bone segment transfers  Muscle flaps  Amputation
  • 134. Bone Tumors Benign Bone Tumors Malignant Bone Tumors Metastatic Bone Disease
  • 135. Bone Tumors  Benign bone tumors (noncancerous): ◦ Chrondrogenic tumors: osteochondroma, chondroma ◦ Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor ◦ Fibrogenic tumors
  • 136. Interventions  Nondrug pain relief measures  Drug therapy: analgesics, NSAIDs  Surgical therapy: curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis
  • 137. Malignant Bone Tumors  Primary tumors, those tumors that originate in the bone ◦ Osteosarcoma ◦ Ewing’s sarcoma ◦ Chondrosarcoma ◦ Fibrosarcoma ◦ Metastatic bone disease
  • 138. Osteosarcoma  Cancer of the bone – metastasis to the lung is common. Most in long bones.  Clinical manifestations – dull pain, swelling, intermittent but increases per time; night pain common.  Treatment – radiation, chemotherapy, hormonal therapy, surgical excision with prosthetics, assistance devices, palliative measures.
  • 139. Treatment Cancer of Bone  Interventions include: ◦ Treatment aimed at reducing the size or removing the tumor ◦ Drug therapy; chemotherapy ◦ Radiation therapy ◦ Surgical management ◦ Promotion of physical mobility with ROM exercises
  • 140. Cancer of Bone Anticipatory Grieving  Interventions include: ◦ Active listening ◦ Encouraging client and family to verbalize feelings ◦ Making appropriate referrals ◦ Helping client and others to cope with the loss and grieving ◦ Promoting the physician-client relationship
  • 141. Cancer of Bone Disturbed Body Image  Interventions include: ◦ Recognize and accept the client’s view of body image alteration. ◦ Establish and maintain a trusting nurse-client relationship. ◦ Emphasize the client’s strengths and remaining capabilities. ◦ Establish realistic mutual goals.
  • 142. Potential for Fractures Bone Cancer  Interventions ◦ Nonsurgical management: radiation therapy and strengthening exercises. ◦ Surgical management: replace as much of the defective bone as possible, avoid a second procedure, and return client to a functioning state with a minimum of hospitalization and immobilization.
  • 143. Carpal Tunnel Syndrome  Common condition; the median nerve in the wrist becomes compressed, causing pain and numbness  Common repetitive strain injury via occupational or sports motions  Nonsurgical management: drug therapy and immobilization  Possible surgical management
  • 144. Scoliosis  Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments.  Milwaukee brace (a back brace used in the treatment of spinal curvatures) , internal fixative devices.
  • 145. Scoliosis  Changes in muscles and ligaments on the concave side of the spinal column  Congenital, neuromuscular, or idiopathic in type  Assessment: complete history, pain assessment, observation of posture  Interventions: exercise, weight reduction, bracing, casting, surgery