Musculoskeletal Notes

Musculoskeletal System

The musculoskeletal system consists of muscles, tendons, ligaments, bones, cartilage, joints, and bursae.These structures work together to produce skeletal movement.

The human skeleton contains 206 bones: 80 form the axial skeleton and 126 form the appendicular skeleton.

FUNCTIONS• Movement and maintains posture• Support• Protection• Hematopoiesis• Mineral homeostasis

ANATOMY AND PHYSIOLOGY

Muscles: the body contains three major muscle types: visceral (involuntary, smooth), skeletal (voluntary, striated), and cardiac.

Tendons: are bands of fibrous connective tissue that attach muscle to the periosteum (fibrous covering the bone). 

• Enables the bone to move when skeletal muscles contract.

Ligaments: dense, strong, flexible bands of fibrous connective tissue that tie bones to other bones.

Bones: perform anatomic (mechanical) and physiologic functions.• Protecting internal tissues and organs• Stabilizing and supporting the body• Providing a surface for muscle, ligament, and tendon attachment• Moving through “lever” action when contracted• Producing red blood cells in the bone marrow (hematopoiesis)• Storing mineral salts

Bone formation• Cartilage composes the fetal skeleton at 3 months in utero.• By about 6 months, the fetal cartilage has been transformed into bony skeleton.• Two types of osteocytes, osteoblasts and osteoclasts, are responsible for remodeling—the continuous process whereby bone is created and destroyed.• Osteoblasts deposit new bone.• Osteoclasts increase long-bone diameter through reabsorption of previously deposited bone.

Cartilage: a dense connective tissue that consists of fibers embedded in a strong, gel-like substance.• Avascular and lacks innervation• Fibrous cartilage: forms the symphysis pubis and the intervertebral disks.• Hyaline cartilage: covers the articular bone surfaces; connects the ribs to the sternum; and appears in the trachea, bronchi, and nasal septum.• Elastic cartilage: located in the auditory canal, external ear, and epiglottis.• It cushions and absorbs shock, preventing direct transmission to the bone.

Joints: two or more bones meet a joint.• Synarthrodial joints, such as cranial sutures, permit no movement.  This joint type separates bones with a thin layer of fibrous connective tissue.• Amphiarthrodial joints, such as the symphysis pubis, allow slight movement.  This joint type separates bones with hyaline cartilage.• Diarthrodial joints, such as the ankle, wrist, knee, hip, and shoulder, permit free movement

Bursae: located at friction points around joints between tendons, ligaments, and bones, bursae are small synovial fluid sacs that act as cushions, thereby decreasing stress to adjacent structures.

ASSESSMENT

History Reason for seeking care Present illness Medical history Family history Psychosocial history

Physical Examination

 Observe posture, gait and coordination Inspect and palpate muscles: tone and mass; strength and joint ROM Inspect and palpate joints and bones Length of the extremities

DIAGNOSTIC TESTS

ASPIRATION

Arthrocentesis: helps to assess infection and distinguish forms of arthritis, such as pseudogout and infectious arthritis. In joint infection, for example, synovial fluid looks cloudy and contains more WBC and less glucose than normal. When trauma causes bleeding into a joint, synovial fluid contains red blood cells. In specific types of arthritis, crystals can confirm the diagnosis—for example, urate crystals indicate gout. In symptomatic joint effusion, removing excess synovial fluid relieves pain.

Nursing considerations Describe this 10-minute procedure to the patient.   Patient will assume a position depending on the joint being aspirated, and then asked to remain still. After withdrawing the fluid, he’ll apply a small bandage to the puncture site. After the test, ice or cold packs may be applied to the joint to reduce pain and swelling. Advise patient not to use the joint excessively after the test to avoid joint pain, swelling, and stiffness. Report any increased pain, tenderness, swelling, warmth, or redness as well as fever, these may signal infection.

Bone marrow aspiration:  help diagnose many abnormalities, including rheumatoid arthritis, tuberculosis, amyloidosis, syphilis, bacterial or viral infection, parasitic infestation, tumors and hematologic problems.

 Aspiration usually involves the sternum or iliac crests. The site is prepared and then infiltrated with a local anesthetic such as lidocaine. The doctor inserts the marrow needle through the cortex; marrow cavity penetration causes a collapsing sensation. Aspirates 0.2 to 0.5 ml of fluid.

Nursing considerations Inform patient that he’ll feel pressure as the doctor inserts the needle and that aspiration

may hurt. Procedure may last about 10 minutes that he’ll be sedated. Watch for signs of infection after the procedure and make sure bleeding stops.

ENDOSCOPY

Arthroscopy:  helps to assess joint problems, plan surgical approaches, and document pathology. Used to evaluate the knee.

Nursing considerations Explain to the patient that this test allows direct examination of the inside of a joint and that it’s safe, convenient approach to surgery. Done in the operating room under general or local anesthesia and takes 30 to 60 minutes. Instruct NPO after midnight. Check hypersensitivity to local anesthetics. After the procedure patient can walk as soon as he’s fully awake and he’ll experience mild soreness and a slight grinding sensation in his knee for 1 to 2 days. Instruct patient to notify doctor if he feels severe or persistent pain or develops a fever with signs of local inflammation. Assess for signs of complications such as infection, hemarthrosis (blood accumulation in the joint), or a synovial cyst.

LABORATORY TESTS

Blood tests: to rule out systemic infection, anemia, and white blood cell disorders as well as studies to measure blood levels of alkaline phosphatase, calcium, creatine kinase, and rheumatoid factor. Check blood levels of antinuclear antibodies, phosphorus, and serum uric acid Measure Erythrocyte Sedimentation Rate (ESR) — the rate at which red blood cells settles in uncoagulated blood during a 1-hour period. Serial ESR measurements help monitor general or localized inflammation, which cause the rate to increase.

Urine tests: 24-hour urine collection to check uric acid levels. Check for urine for Bence Jones protein, which may indicate a bone tumor, hyperparathyroidism, or osteomalacia.

RADIOGRAPHIC AND IMAGING STUDIESS

Bone scan: detect bony metastasis, benign disease, fractures, avascualr necrosis, and infection. IV introduction of a radioactive material, such as the radioisotope technetium polyphosphate, the isotope collects in areas of increased bone activity or active bone formation.

Nursing considerations Explain the procedure to the patient. Fasting isn’t necessary. Explain to the patient that there will be a 2- to 3- hour waiting period after the isotope is injected. While waiting, the patient must drink four to six glasses of fluid. Lie supine on a table within the scanner and lie as still as possible and to expect to assume various positions.

Computed tomography: aids diagnosis of bone tumors and other abnormalities. Helps to assess questionable cervical or spinal fractures, fracture fragments, bone lesions, and intra-articular loose bodies.

Nursing considerations Explain to the patient that CT helps detect bone abnormalities and that it takes 30 to 90 minutes. If the patient is scheduled to receive a contrast medium, inform him that he must not eat for 4 hours before the test. Instruct patient to remain still during the test. If the patient received a contrast medium by mouth, encourage him to drink plenty of fluid after the test to help flush the contrast medium from his body.

Magnetic resonance imaging (MRI):  show irregularities of the spinal cord and is especially useful for diagnosing disk herniation.

Nursing considerations Explain that the procedure may take up to 90 minutes and advise the patient to use the bathroom before the test. Ask the patient to remove all metal objects, including bobby pins, jewelry, watches, eyeglasses, hearing aids, and dental appliances. Remove clothes with metal zippers, buckles, or buttons as well as credit, bank, and parking cards because the scan could erase the magnetic codes.

X-rays: help diagnose traumatic disorders, such as fractures and dislocations. Reveal bone disease and joint disease

Nursing considerations Remove all jewelry. Verify that the X-ray order includes pertinent recent history, such as trauma, and identifies the point tenderness site.

BONE DISORDERS

HALLUX VALGUS Lateral deviation of the great toe at the metatarsophalangeal joint Occurs with medial enlargement of the first metatarsal head and bunion formation.

Causes: congenital or familial More commonly acquired from degenerative arthritis or from prolonged pressure, especially form narrow-toed high-heeled shoes that compress the forefoot.

Assessment findings: May appear as a red tender bunion Angulation of the great toe away from the midline of the body toward the other toes. Advanced stages: may develop a flat, splayed forefoot, severely curled toes (hammertoes), and a small bunion on the fifth metatarsal.

Diagnostic test:  X-rays confirm diagnosis by showing medial deviation of the first metatarsal and lateral deviation of the great toe.

Treatment: good foot care and proper shoes felt pads to protect the bunion, foam pads or other devices to separate the first and second toes at night supportive pad and exercises to strengthen the metatarsal arch. Early treatment is vital in patients predisposed to foot problems, such as those with rheumatoid arthritis or diabetes mellitus. Severe deformity? doctor may order bunionectomy

MUSCULOSKELETAL INJURIES

CONTUSIONS, STRAINS, AND SPRAINS

 Contusion- soft tissue injury produced by blunt force.• Many small blood vessels rupture and bleed into soft tissues (ecchymosis or bruising).• A hematoma develops when the bleeding is sufficient to cause an appreciable collection of blood. Strain- “muscle pull” from overuse, overstretching, or excessive stress.• Strains are microscopic, incomplete muscle tears with some bleeding into the tissue.• The patient experiences soreness or sudden pain, with local tenderness on muscle use and isometric contraction. Sprain- injury to the ligaments surrounding a joint, caused by a wrenching or twisting motion.• The function of the ligament is to maintain stability while permitting mobility.• A torn ligament loses its stabilizing ability.

 Treatment: “RICE” Rest, Ice, Compression, Elevation

Nursing interventions

 Immobilize the joint, using an elastic bandage or, if sprain is severe, a soft cast. Control pain and swelling by giving analgesics as prescribed and immediate application of ice for up to 48 hours, followed by application of heat. Complete muscle rupture may require surgical repair Moist or dry cold applied intermittently for 20 to 30 minutes during the first 24 to 48 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort. Care must be taken to avoid skin and tissue damage from excessive cold. Elevate the joint for 48 to 72 hours after the injury and apply ice intermittently for 24 to 48 hours after the injury After the acute inflammatory stage (eg, 24 to 40 hours after injury), heat may be applied intermittently (for 15 to 30 minutes, four times a day) to relieve muscle spasm and to promote vasodilation, absorption, and repair. Depending on the severity of injury progressive passive and active exercise may begin in 2 to 5 days. Severe sprains may require 1 to 3 weeks of immobilization before protected exercise are initiated.   If an elastic bandage is applied, tell the patient to remove the bandage before going to sleep and to loosen it if it causes the leg to become pale, numb or painful. Consult doctor if pain worsens or persists (X-ray may detect a fracture that was missed originally)

FRACTURE

 Break in the continuity of bone  Arm and leg fractures can cause substantial muscle, nerve, and other soft-tissue damage. 

 Prognosis varies with the extent of disability or deformity, amount of tissue and vascular damage, adequacy of reduction and immobilization, and the patient’s age, health, and nutrition. Children’s bones usually heal rapidly and without deformity. Bones of adults in poor health and who have impaired circulation may never heal properly. A history of trauma and suggestive findings on physical examination (including gentle palpation and failure of a cautious attempt by the patient to move parts distal to the injury) indicate a likely diagnosis of an arm or leg fracture.

Causes major trauma (fall on an outstretched arm, a skiing accident, or child abuse) pathologic bone weakening conditions (osteoporosis, bone tumors or metabolic disease) prolonged standing, walking or running can cause stress fractures of the foot and ankle, usually seen in nurses, postal workers, soldiers and joggers

Signs and symptoms pain and point tenderness pallor pulse loss distal to fracture site paresthesia or paralysis distal to fracture site deformity swelling discoloration crepitus loss of limb function substantial blood loss life threatening hypovolemic shock

Diagnostic test anteroposterior and lateral X-rays angiography

OBJECTIVES OF TREATMENT Optimal realignment Rigid immobilization Restoration of function

Treatment splinting the limb above and below the suspected fracture applying a cold pack elevating the limb to reduce edema and pain severe fractures that cause blood loss: direct pressure should be applied to control bleeding and fluid replacement reduction, followed by immobilization by splint, cast or traction Closed reduction: manual manipulation, a local anesthetic and an analgesic are used to minimize pain and a muscle relaxant is used to facilitate muscle stretching to realign the bone. Open reduction: reduces and immobilizes the fracture by means of rods, plates, or screws. Skeletal traction: immobilization by the use of weights and pulleys; pin or wire is inserted through the bone distal to the fracture and attached to a weight. Skin traction: elastic bandages and moleskin coverings are used to attach traction devices to the patient’s skin. Treatment for open fractures also requires wound cleaning, tetanus prophylaxis, antibiotics, and possibly surgery to repair soft tissue damage

Nursing interventions Monitor for signs of shock Analgesics as prescribed Diet: high protein, iron, vitamins (tissue repair), moderate carbohydrates (prevent weight gain) For long-term immobilization with traction, reposition the patient frequently to increase comfort and prevent pressure ulcers Assist with active range of motion exercises to prevent muscle atrophy Encourage deep breathing and coughing to avoid hypostatic pneumonia Monitor the patient for fat embolism,  a complication that may occur as bone marrow releases fat into the veins Increase fluid intake to prevent urine stasis and constipations Provide cast care: While cast is wet, support it with pillows.  Watch for skin irritation near cast edges, and check for foul odors or discharge Monitor patient for compartment syndrome, watch for increasing pain in the limb; skin color changes, absent pulse, or edema distal to the injury site; decreased active and passive muscle stretching; and sensory changes, such as numbness or tingling (late sign) Remove any obvious constriction, such as a dressing or wrap, and have the cast cut to relieve pressure if necessary. If these measures don’t relieve the signs and symptoms in 4 to 6 hours, the doctor may relieve the compression surgically.

TYPES

Complete- fracture extends through entire bone, producing 2 or more fragments

 Simple or Closed- fractured bone does not protrude through skin Compound or Open- fractured bone extends through skin and mucous membranes

Open fractures are graded according to the following criteria:• Grade I is a clean wound less than 1 cm long• Grade II is a larger wound without extensive soft tissue damage.• Grade III is highly contaminated, has extensive soft tissue damage, and is the most severe.

 Comminuted fracture- multiple bone fragments Oblique fracture- fracture line at 45-degree angle to long axis of bone  Spiral fracture- fracture line encircling the bone  Transverse fracture- fracture line perpendicular to long axis of bone Extracapsular- fracture is close to the joint but remains outside the joint capsule. Intracapsular- fracture within the joint capsule.

Incomplete- when only part of the bone is broken.

 Greenstick fracture- fracture of one side of bone; other side merely bends; usually seen only in children Bowing fracture- bending of bone. Stress fracture- microfracture.

COMPLICATION OF FRACTURE

SHOCK (EARLY)• Hypovolemic or traumatic shock resulting from hemorrhage and from loss of extracellular fluid into damaged tissues may occur in fractures of the extremities, thorax, pelvis, or spine.• Treatment of shock consists of restoring blood volume and circulation, relieving the patient’s pain, providing adequate splinting, and protection the patient from further injury and other complications.

FAT EMBOLI (EARLY)• After fracture of long bones or pelvis, multiple fractures, or crush injuries, fat emboli may develop.• Fat embolism syndrome occurs most frequently in young adults and elderly adults who experience fractures of the proximal femur.• At the time of fracture, fat globules may move into the blood because the marrow pressure is greater than the capillary pressure or because catecholamines elevated by the

patient’s stress reaction mobilize fatty acids and promote the development of fat globule sin the bloodstream.• The fat globules (emboli) occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs.• The onset of symptoms is rapid, usually occurring within 24 hours to 72 hours, but may occur up to a week after injury.

Clinical Manifestations: hypoxia, tachypnea, tachycardia, and pyrexia.• The respiratory distress response includes tachypnea, Dyspnea, crackles, wheezes, precordial chest pain, cough, large amounts of thick white sputum, and tachycardia.• The chest x-ray shows a typical “snowstorm” infiltrate.• Eventually, acute pulmonary edema, acute respiratory distress syndrome, and heart failure develop.• Cerebral disturbances (due to hypoxia and the lodging of fat emboli in the brain) are manifested by mental status changes varying from headache, mild agitation, and confusion t delirium and coma.

Prevention and Management• Immediate immobilization of fractures, minimal fracture manipulation, adequate support for fractured bones during turning and positioning, and maintenance of fluid and electrolyte balance are measures that may reduce the incidence of emboli.• Support the respiratory system, to prevent respiratory and metabolic acidosis, and to correct homeostatic disturbances.• Respiratory failure is the most common cause of death.• Respiratory support is provided with oxygen given in high concentration.• Controlled-volume ventilation with positive end-expiratory pressure may be used to prevent or treat pulmonary edema.• Corticosteroids may be administered to treat the inflammatory lung reaction and to control cerebral edema.• Vasoactive medications to support cardiovascular function are administered to prevent hypotension, shock, and interstitial pulmonary edema.• Accurate fluid intake and output records facilitate adequate fluid replacement therapy.• Morphine may be prescribed for pain and anxiety for the patient who is on a ventilator.

COMPARTMENT SYNDROME (EARLY)

• A complication that develops when tissue perfusion on the muscles is less than that required for tissue viability.• The patient complains of deep, throbbing, unrelenting pain, which is not controlled by opioids.• This pain can be caused by (1) reduction in the size of the muscle compartment because the enclosing muscle fascia is too tight or a cast or dressing is constrictive, or (2) an increase in muscle compartment contents because of edema or hemorrhage associated

with a variety or problems.• The forearm and leg muscle compartments are involved most frequently.

Clinical Manifestation: sensory deficits include paresthesia, unrelenting pain, and hypoesthesia.• Paresthesia and numbness along the involved nerve are early signs of nerve involvement.• Peripheral circulation is evaluated by assessing color, temperature, capillary refill time, swelling, and pulses.• Swelling (edema) reduces tissue perfusion.• Cyanotic (blue-tinged) nail beds suggest venous congestion.• Pale or dusky and cold finger or toes and prolonged capillary refill time suggest diminished arterial perfusion.• Edema may obscure the present of arterial pulsation and Doppler ultraonography may be used to verify a pulse.• Deep, throbbing, unrelenting pain, which is greater than expected and not controlled by opioids.

• Medical Management• Elevation of the extremity to the heart level, release of restrictive devices (dressing or cast), or both.• If conservative measures do not restore tissue perfusion and relieve pain within 1 hour, a fasciotomy (surgical decompression with excision of the fibrous membrane that covers and separates muscles) may be needed to relieve the constrictive muscle fascia.• After fasciotomy, the wound is not sutured but instead is left open to permit the muscle tissues to expand; it is covered with moist, sterile saline dressing.  The limb is splinted in a functional position and elevated, and prescribed passive ROM exercises are usually performed every 4 to 6 hours.• In 3 to 5 days, when the swelling has resolved and tissue perfusion has been restored, the wound is debrided and closed (possibly with skin graft).

OTHER EARLY COMPLICATIONS

• Deep vein thrombosis (DVT), thromboembolism, and pulmonary embolus (PE) are associated with reduced skeletal muscle contractions and bed rest.• Patient with fractures of the lower extremities and pelvis are at high risk for thromboembolism.• Pulmonary emboli may cause death several days to weeks after injury.• DIC includes a group of bleeding disorders with diverse causes, including massive tissue trauma.• Manifestations of DIC include ecchymosis, unexpected bleeding after surgery, and bleeding from the mucous membranes, venipuncture sites, and gastrointestinal and urinary tracts.• All open fractures are considered contaminated.

• Surgical internal fixation of fractures carries a risk for infection.• The nurse must monitory for and teach the patient to monitor for signs of infections, including tenderness, pain, redness, swelling, local warmth, elevated temperature, and purulent drainage.• Infections must be treated promptly.• Antibiotic therapy must be appropriate and adequate for prevention and treatment of infection.

AVASCULAR NECROSIS (DELAYED)

• Avascular necrosis occurs when the bone loses its blood supply and dies.  • It may occur after a fracture with disruption of the blood supply (especially of the femoral neck).• It is also seen with dislocations, bone transplantation, prolonged high-dosage corticosteroid therapy, chronic renal disease, sickle cell anemia, and other diseases.• The devitalized bone may collapse or reabsorb.• The patient develops pain and experiences limited movement.• X-rays reveal calcium loss and structural collapse.• Treatment generally consists of attempts to revitalize the bone with bone grafts, prosthetic replacement, or arthrodesis (joint fusion).

REDUCTION

 Reduction of a fracture (“setting” the bone) refers to restoration of the fracture fragments to anatomic alignment and rotation.

Closed Reduction• Accomplished by bringing the bone fragments into apposition (ie, placing the ends in contact) through manipulation and manual traction.• The extremity is held in the desired position while the physician applies a cast, splint, or other device.  • The immobilizing device maintains the reduction and stabilizes the extremity for bone healing.• X-rays are obtained to verify that the bone fragments are correctly aligned.

Open Reduction• Through a surgical approach, the fracture fragments are reduced. • Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. • These devices may be attached to the sides of bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone.• Internal fixation devices ensure firm approximation and fixation of the bony fragments.

TRACTION

 Mechanism by which a steady pull is placed on a part or parts of the body

PRINCIPLES FOR EFFECTIVE TRACTION

 Whenever traction is applied, countertraction must be used to achieve effective traction.  Countertraction is the force acting in the opposite direction.  Usually the patient’s body weight and bed position adjustments supply the needed countertraction. Traction must be continuous to be effective in reducing and immobilizing fractures. Skeletal traction is never interrupted. Weights are not removed unless intermittent traction is prescribed. Any factor that might reduce the effective pull or alter the resultant line of pull must be eliminated:- The patient must be in good body alignment in the center of the bed when traction is applied.- Ropes must be unobstructed.- Weights must hang free and not rest on the bed or floor.- Knots in the rope or the footplate must not touch the pulley or the foot of the bed.

SKIN TRACTION

- Application of wide band of moleskin, adhesive, or commercially available devices directly to the skin and attaching weights to them.- Used to control muscle spasms and to immobilize an area before surgery.- It is accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin.  The amount of weight applied must not exceed the tolerance of the skin.- No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity.  Pelvic traction is usually 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient.

Buck’s extension A skin traction to the lower leg.  The pull is exerted in one plane when partial or temporary immobilization if desired. It is used to provide immobility after fractures of the proximal femur before surgical fixation.• Relieve muscle spasm

 Heel is supported off bed to prevent pressure on heel, weight hangs free of the bed, and foot is well away from footboard of bed, and parallel to the bed.

Russel traction Used in the treatment of intertrochanteric fracture of the femur when surgery is contraindicated Hip is slightly flexed.  Pillows may be used under lower leg to provide support and keep the heel free of the bed.

Bryant’s traction- used to reduce femoral fracture in children. Buttocks are slightly elevated and clear off the bed.

Nursing considerations Check periodically to ensure that weights, ropes, and pulleys are in proper alignment and functional. Don’t manipulate the weights yourself; consult the doctor if you suspect the need for any adjustment. Avoid wrinkling and slipping of the traction bandage and to maintain countertraction.

POTENTIAL COMPLICATIONS

• Skin breakdown Remove the foam boots to inspect the skin, th ankle, and the Achilles tendon three times a day.  A second nurse is needed to support the extremity during the inspection and skin care. Palpate the area of the traction tapes daily to detect underlying tenderness. Provide back care at least every 2 hours to prevent pressure ulcers. Use special mattress overlays (eg, air-filled, high-density foam) to minimize the development of skin ulcers.

• Nerve pressure Regularly assess sensation and motion. Immediately investigate any complaint of burning sensation under the traction bandage or boot. Promptly report altered sensation or motor function.

• Circulatory impairment Peripheral pulses, color, capillary refill, and temperature of the fingers of toes. Indicators of DVT, including calf tenderness, swelling, and positive Homans’sign.

SKELETAL TRACTION

- Placement of a pin through the bone, to which the traction apparatus is attached- Common types include: Gardner-Wells and Crutchfield tongs; halo vest; pin placement through the femur, lower tibia, calcaneus, ulna, radius, or wrists; Kirschner wire; and

Steinmann pinPurpose: to immobilize bones and allow healing of fractures, correction of congenital abnormalities, or stabilization of spinal degeneration. Traction applied directly to bone.

Nursing considerations Perform pin care daily with water and normal saline solution or hydrogen peroxide Observe the pin insertion site for signs of infection Check the pin for proper fit, making sure that it doesn’t move in the bone Teach the patient how to use the trapeze to lift himself off the bed, if permitted If cervical traction is being used, check the occipital area of the head for skin breakdown. When caring for a patient in a halo vest, bathe under the vest daily.

CRUTCH WALKING

• The distance between the axilla and the arm piece on the crutches should be at least 3 fingerwidths below the axilla• The elbows should be slightly flexed, 30 degrees• When ambulating with the client, stand on the affected side.• Crutch stance: tripod (triangle) position.• Instruct the client never to rest the axilla on the axillary bars.• Instruct the client to look up and outward when ambulating.• Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs.

Crutch gaitsFour-point gait Sequence: Advance left crutch 4-6 inches Advance right foot Advance right crutch Advance left footAdvantages: most stable crutch gaitRequirements: Weight bearing is permitted on both legs

Three-point gait Sequence: Advance both crutches forward with the affected leg and shift weight to crutches. Advance unaffected leg and shift weight onto it.Advantages: allows the affected leg to be partially or completely free of weight bearingRequirements: Full weight bearing on one leg.  The other foot cannot support but may act as a balance.

Two-point gaitSequence: Advance left crutch and right foot Advance right crutch and left footAdvantages: Faster version of the four-point, more normal walking pattern.Requirements: Partial weight bearing on both legs

Swing-through gait  Sequence: Unaffected foot bears weight Move both crutches forward. Move both legs farther ahead than crutches. Weight bearing returns to the unaffected leg Requirements: weight-bearing is permitted on only one foot

AMPUTATION OF THE LOWER EXTREMITY

 Removal of a body part, usually an extremity Amputation is performed at the most distal point that will heal successfully. The site of amputation is determined by two factors: circulation in the part, and functional usefulness. Amputee may experience phantom limb pain soon after surgery or 2 to 3 months after amputation. It occurs more frequently in above-knee amputations. The patient describes pain or unusual sensation, such as numbness, tingling, or muscle cramps, as well as a feeling that the extremity is present, crushed, cramped or twisted in an abnormal position. When a patient describes phantom pains or sensations, the nurse acknowledges these feelings and helps the patient modify these perceptions.

Risk Factors Atherosclerosis obliterans Uncontrolled DM Malignancy Extensive and intractable infection Severe trauma

Complications of Amputation Infection Wound necrosis Phantom limb pain Contractures Skin breakdown

Nursing Intervention

 Assess stump and monitor catheter drainage for color and amount; report signs of increased drainage BKA: keep knee extended to avoid hamstring contracture If prescribed, during the first 24 hours, elevate the foot of the bed to reduce edema; then keep the bed flat to prevent hip flexion contractures Do not elevate the stump itself—elevation can cause flexion contracture of the hip joint. After 24 and 48 hours postoperatively, position the client prone if prescribed, to stretch the muscles and prevent flexion contractures of hip To prevent leg abduction, keep legs close together Encourage exercises to prevent thromboembolism Encourage patient to ambulate using correct crutch-walking techniques Teach patient triceps strengthening exercises for crutch walking, such as pushups and flexion and extension of the arms using traction weights. Instruct the patient to rub the stump with alcohol daily to toughen the skin Avoid applying powder or lotion Massage the stump toward the suture line to mobilize the scar and prevent its adherence to bone To prepare the stump for prosthesis, teach progressive resistance maneuvers. Stress the importance of performing prescribed exercises to help minimize complications, maintain muscle strength and tone, prevent contractures, and promote independence.

INFLAMMATORY DISORDERS OF THE MUSCULOSKELETAL SYSTEM

RHEUMATOID ARTHRITIS Chronic systemic inflammatory disease Destruction of connective tissue and synovial membrane within the joints Weakens and leads to dislocation of the joint and permanent deformity Spontaneous remissions and exacerbations mark the course of RA.

Risk Factors: Exposure to infectious agents Fatigue Stress

Signs and Symptoms Initial symptoms: fatigue, malaise, anorexia, persistent low grade fever, weight loss, and lympadenopathy

 joint pain, tenderness, warmth, and swelling joint symptoms occur bilaterally and symmetrically Morning stiffness Swan neck deformity-late

Diagnostic Studies X-ray, show bone demineralization and soft tissue swelling Elevated ESR, and positive RF

Treatment Salicylates, to decrease inflammation and relieve joint pain. NSAIDs (indomethacin, ketorolac, ibuprofen, Cox-2 Inhibitors (Celecoxib, Rofecoxib) Inhibits only cyclooxygenase-2 enzymes Antimalarials (chloroquine and hydroxychloroquine) Gold sodium thiomalate  penicilamine  Corticosteroids  Immunosuppressives (methotrexate, cyclophosphamide, azathioprine) Hot and Cold packs to affected joints Surgical Procedures: synovectomy, arthrotomy, arthrodesis, arthroplasty Supportive measures include: 8 to 10 hours of sleep every night, adequate nutrition, frequent rest periods between daily activities, and splinting to rest inflamed joints.

Nursing Management Assess all joints carefully Monitor vital signs and note weight changes, sensory disturbances, and level of pain. Give meticulous skin care.  Use lotion or cleansing oil, not soap, for dry skin Apply splints carefully Encourage a balanced diet. Urge the patient to perform activities of daily living  Bed rest Daily ROM exercises Relieving pain and discomfort Administer drugs as prescribed and monitor effects

Nursing Diagnosis

 Pain related to joint destruction Impaired physical mobility related to joint contractures Risk for injury related to the inflammatory process Body image disturbance related to joint deformity Self-care deficit related to musculoskeletal impairment

OSTEOARTHRITIS (DEGENERATIVE JOINT DISEASE)

 Progressive degeneration of the joints as a result of wear and tear Affects weight-bearing joints and joints that receive the greatest stress, such as the hips and knees

Risk Factors Aging (>50 yr) Rheumatoid arthritis Arteriosclerosis Obesity Trauma Family history

Signs and Symptoms pain, tender joints, particularly after exercise or weight bearing and is usually relieved by rest stiffness in the morning and after exercise that is usually relieved by rest achiness during changes in weather, cold intolerance fatigability, malaise crepitus presence of Heberden’s nodes or Bouchard’s nodes limited movement

Diagnostic tests  X-rays of the affected joint help confirm diagnosis

 Treatment  Palliative treatment  Medications include: aspirin (or other nonnarcotic analgesics), phenylbutazone, indomethacin, ketorolac, ibuprofen, propoxyphene hydrochloride, rofecoxib, and in some cases, intra-articular injections of corticosteroid

Aspirin Inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins Anti-inflammatory, analgesic, antipyretic action Inhibit platelet aggregation in cardiac disorders

Adverse effects: Epigastric distress, nausea, and vomiting In toxic doses, can cause respiratory depression

 Hypersensitivity Reye’s syndrome

Ibuprofen Use for chronic treatment of rheumatoid and osteoarthritis Less GI effects than aspirin

Adverse effects: Dyspepsia to bleeding  Headache, tinnitus and dizziness

Indomethacin Inhibits cyclooxygenase enzyme More potent than aspirin as an anti-inflammatory agent

Adverse effects: The adverse effects are dose-related. Nausea, vomiting, anorexia, diarrhea  Headache, dizziness, vertigo, light-headedness, and mental confusion Hypersensitivity reaction

 Effective treatment also reduces joint stress by supporting or stabilizing the joint with crutches, braces, a cane, a walker, a cervical collar, or traction.

 Other supportive measures include massage, moist heat, paraffin dips for hands, protective techniques for preventing undue stress on the joints

Those with severe osteoarthritis with disability or uncontrollable pain may undergo:

 arthroplasty- replacement of a deteriorated joint with a prosthetic appliance arthrodesis- surgical fusion of bones, which is used primarily in the spine (laminectomy) osteoplasty- scraping of deteriorated bone from a joint osteotomy- excision of bone to change alignment and relieve stress

Nursing Intervention

 Promote comfort: reduce pain, spasms, inflammation, swelling Medications as prescribed. Heat to reduce muscle spasm Cold to reduce swelling and pain Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment Weight reduction Isometric and postural exercises Firm mattress or bed board to decrease morning pain

 Assist with ROM and strengthening exercises Instruct patients to wear well-fitting supportive shoes, install safety devices at home, maintain proper body weight to lessen joint stress, avoid overexertion.

Nursing Diagnosis

 Pain related to friction of bones in joints Risk for injury related to fatigue Impaired physical mobility related to stiff, limited movement

GOUTY ARTHRITIS

 Metabolic disorder that develops as a result of prolonged hyperuricemia caused by problems in synthesizing purines or by poor renal excretion of uric acid.

 acute onset, typically nocturnal and usually monarticular, often involving the first metatarsophalangeal joint

Risk Factors Men Age 30 or older and in postmenopausal women Genetic/familial tendency

Causes Unknown Linked to a genetic defect in purine metabolism, which causes overproduction of uric acid, retention of uric acid, or both. Secondary gout, which develops during the course of another disease (such as obesity, DM, HPN, sickle cell anemia, renal disease, myeloma, leukemia) Following drug therapy, hydrochlorothiazide or pyrazinamide, which interferes with urate excretion

Signs and Symptoms

 Affected joints appear hot, tender, inflamed, dusky red, or cyanotic Metatarsophalangeal joint of the great toe usually becomes inflamed first (podagra), then the instep, ankle, heel, knee or wrist joints Extremely painful Fever Increased concentration of uric acid leads to urate deposits, called Tophi

Diagnostic tests

 (+) urate monohydrate crystals in synovial fluid taken from an inflamed joint or tophus aspiration of synovial fluid (arthrocentesis) or of tophaceous material reveals needlelike intracellular crystals of sodium urate Elevated serum uric acid Elevated urinary uric acid especially in secondary uric acid levels In chronic gout, X-rays show a punched-out look when urate acids replace bony structures

Treatment

Allopurinol A purine analog Reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which is catalyzed by xanthine oxidase. Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies). Adverse effects: hypersensitivity reactions, nausea and diarrhea

Colchicine Effective for acute attacks Taken every hour for 8 hours, until pain subsides or until signs of overdose such as nausea, vomiting, cramping or diarrhea develop Anti-inflammatory activity alleviating pain within 12 hours  Adverse effects: nausea, vomiting, abdominal pain, diarrhea, agranulocytosis, aplastic anemia, alopecia

Probenecid/Sulfinpyrazone Uricosuric agents Increases the renal excretion of uric acid and inhibit accumulation of uric acid Sulfinpyrazone used as a preventive agent. Adverse effects: nausea, rash & constipation Don’t administer these drugs to patient with calculi

Corticosteroids or joint aspiration and an intra-articular corticosteroid injection  For resistant inflammation

Analgesics, such as acetaminophen or ibuprofen Relieve pain associated with mild attacks

Nursing Interventions

 Bed rest, immobilization, and protection of inflamed, painful joints; local application of heat or cold. Maintain a fluid intake of at least 2000 to 3000 mL a day to avoid kidney stone.

 Avoid foods high in purine such as wine, alcohol, organ meats, sardines, salmon, anchovies, shellfish and gravy. Take medication with food. Have a yearly eye examination because visual changes can occur from prolonged use of allopurinol Caution client not to take aspirin with these medication because it may trigger a gout attack and may cause an elevated uric acid levels. Encourage rest and immobilize the inflamed joints during acute attacks Avoid excessive alcohol intake Notify physician if rash, sore throat, fever or bleeding develops.

Nursing Diagnosis

Chronic painImpaired physical mobilityRisk for injury

OSTEOMYELITIS Pyogenic infection of the bone.  The bone becomes infected by one of three modes:• Extension of soft tissue infection (eg, infected pressure or vascular ulcer, incisional infection)• Direct bone contamination from bone surgery, open fracture, or traumatic injury (eg, gun shot wound• Hematogenous (bloodborne) spread from other sites of infection (eg, infected tonsils, boils, infected teeth, upper respiratory infections).

• Infection causes tissue necrosis, breakdown of bone structure, and decalcification• Staphylococcus aureus is the most common pathogen. Other organisms include Proteus, Pseudomonas and E. coli

Pathophysiology• Staphylococcus aureus causes 70% to 80% of bone infections.  Other pathogenic organisms frequently found in osteomyelitis include Proteus and Pseudomonas species and Escherichia coli.  The incidence of penicillin-resistant, nosocomial, gram-negative, and anaerobic infections is increasing.• Initial response to infection is inflammation, increased vascularity, and edema.  After 2 or 3 days, thrombosis of the blood vessels occurs in the area, resulting in ischemia with bone necrosis.  • The infection extends into the medullary cavity and under the periosteum and may spread into adjacent soft tissues and joints.• Unless the infective process is treated promptly, a bone abscess forms. 

• The resulting abscess cavity contains dead bone tissue (the sequestrum), which does not easily liquefy and drain.

Signs and symptoms Sudden pain in the affected bone; tenderness, heat and swelling over the affected area, and restricted movement. Clinical manifestations of septicemia (fever, chills, tachycardia, general malaise)

Diagnostic Studies X-ray: demonstrate soft tissue swelling Bone Scan and MRI: help with early definitive diagnosis Blood and wound culture: identify appropriate antibiotic therapy Elevated WBC and ESR

Treatment  Administration of large doses of antibiotics I.V. after blood cultures are taken Early surgical drainage to relieve pressure buildup and sequestrum formation Immobilization of the affected bone by plaster cast, traction, or bed rest Supportive measures: analgesics and I.V. fluids If an abscess forms, incision and drainage, followed by a culture of the drainage matter Antibiotic therapy to control infection Local application of packed, wet, antibiotic-soaked dressings Surgery to remove dead bone and to promote drainage

Nursing interventions

 Promote comfort Immobilized affected bone by maintaining splinting. Elevate affected leg to reduce swelling Administer analgesics as needed.

 Control infectious process Monitor signs of superinfection (eg, oral or vaginal candidiasis, loose or foul-smelling stools) Administer antibiotics as prescribed. Use aseptic technique when dressing the wound to promote healing and to prevent cross contamination.

 Encourage participation in ADL within the physical limitations of the patient to promote general well being. Administer I.V. fluids to maintain adequate hydration as needed Provide a high protein and vitamin C Support the affected limb with firm pillows.

 Provide good cast care.  Support the cast with firm pillows and “petal” the edges with pieces of adhesive tape or moleskin to smooth rough edges Check circulation and drainage every 4 hours for the first 24 hours postoperatively.

OSTEOPOROSIS

• The rate of bone resorption accelerates while the rate of bone formation slows down, causing a loss of bone mass• Bones lose calcium and phosphate salts and become porous, brittle, and abnormally vulnerable to fracture• Affects weight bearing vertebrae, ribs, femurs, and wrist bones.• Vertebral and wrist fractures are common.

Risk Factors• Postmenopausal women• Small-framed, non-obese• Ages 50-70• Long term corticosteroid therapy• High caffeine intake• Smoking• High alcohol intake• Sedentary lifestyle or immobility• Insufficient calcium intake or absorption• Small thin frame• Hereditary predisposition• Coexisting medical conditions (hyperparathyroidism, hyperthyroidism)

Causes: Primary osteoporosis- unknown Secondary osteoporosis- prolonged therapy with steroids, heparin, anticonvulsants, or thyroid preparations; from aluminum-containing antacids; or total immobility or disuse of a bone. Linked also to alcoholism, malnutrition, malabsorption, scurvy, lactose intolerance, hyperthyroidism, and osteogenesis imperfecta

Assessment Findings• Develops insidiously, an elderly person bends to lift something, hears a snapping sound, then feels a sudden pain in the lower back.• Loss of height

• Fractures of the wrist, vertebral column and hip• Lower back pain• Kyphosis• Respiratory impairment

Diagnostic tests• X-rays: degeneration in the lower thoracic and lumbar vertebrae; vertebral bodies may appear flattened, with varying degrees of collapse and wedging.• Dual-energy x-ray absorptiometry (DEXA)• Serum calcium- normal • Serum alkaline phosphatase- normal• Serum phosphorus- normal

Treatment Physical therapy program Doctor may order estrogen to decrease the rate of bone resorption and calcium and vitamin D to support normal bone metabolism Surgery: correct pathologic fractures of the femur be open reduction and internal fixation Adequate intake of dietary calcium and regular weight bearing exercise may reduce a person’s chances of developing senile osteoporosis Hormone treatments  Decreased alcohol consumption Prompt treatment of hyperthyroidism

Nursing interventions

Prevention• Adequate dietary or supplemental calcium• Regular weight bearing exercise• Modification of lifestyle• Calcium with vitamin D supplements• Administer HRT, as prescribed• Relieving pain• Improving bowel elimination• Preventing injury

Nursing Activities• Encourage use of assistive devices when gait is unstable• Protect from injury (side rails, walker)• Encourage active/passive ROM

• Promote pain relief• Encourage good posture and body mechanics

PAGET’S DISEASE

• Progressive skeletal disease with deformity • Excessive bone resorption (osteoclastic phase), followed by a reactive phase of excessive abnormal bone formation (osteoblastic phase)• Chaotic, fragile, and weak, the new bone structure causes painful deformities of external contour and internal structure• It can be fatal, particularly if associated with heart failure, bone sarcoma, or giant cell tumors

Causes Unknown One theory holds that early viral infection (possibly with mumps virus) causes a dormant skeletal infection that erupts many years later as Paget’s disease.

Clinical Manifestation• Early stages: severe, persistent pain intensifies with weight bearing and may impair movement• Asymmetrical bowing of femur and tibia• Enlargement of the skull (frontal and occipital area), hat size increases• Cranial nerve compression• Kyphosis• Barrel shaped chest• Respiratory distress• Pain

Diagnostic Findings• X-rays• Elevated serum alkaline phosphatase• Elevated serum calcium• Bone scan

Treatment Drug therapy: calcitonin and etidronate or plicamycin Calcitonin and etidronate: retard bone resorption and reduce serum alkaline phosphatase levels and urinary hydroxyproline secretion Plicamycin: decreases calcium, urinary hydroxyproline and serum alkaline phosphatase

levels. Surgery: to reduce or prevent pathologic fractures, correct secondary deformities, and relieve neurologic impairment Aspirin, indomethacin, or ibuprofen usually controls pain

Nursing interventions Monitor serum calcium and alkaline phosphatase levels Monitor intake and output Change position to prevent pressure ulcers Provide high topped sneakers to prevent foot drop. Demonstrate to patient how to inject calcitonin and rotate injection sites Warn the patient that adverse effects (nausea, vomiting, local inflammation at injection site, facial flushing, itching of hands, and fever) may occur. Tell the patient receiving etidronate to take this medication with fruit juice 2 hours before or after meals (milk or other high-calcium fluids impair absorption) Tell patient receiving plicamycin to watch for signs of infection, easy bruising, and bleeding and temperature elevation and to report for regular follow-up laboratory tests. Suggests firm mattress or a bed board to minimize spinal deformities Prevent injury Prevent pathological fractures Control pain Administer drugs as prescribed

BONE TUMORS

OSTEOSARCOMA

• Most common primary bone tumor• Occurs between 10-25 years of age, with Paget's disease and exposure to radiation• Exhibits a moth-eaten pattern of bone destruction.•  Most common sites: metaphysis of  long bones especially the distal femur, proximal tibia and proximal humerus

Clinical Manifestation local signs – pain (dull, aching and intermittent in nature), swelling, limitation of motion Palpable mass near the end of a long bone systemic symptoms: malaise, anorexia, and weight loss

Diagnostic Findings Biopsy- confirms the diagnosis

 X-ray MRI Bone Scan Increase alkaline phosphatase

Treatment• Radiation• Chemotherapy• Surgical management: Amputation Limb salvage procedures

• Prognosis: poor prognosis (rapid growth rate)

Nursing interventions• Promote understanding of the disease process and treatment regimen• Promote pain relief• Prevent pathologic fracture.• Promote coping skills and self esteem• Assess for potential complications (infection, complications of immobility).• Encourage exercise as soon as possible (1st or 2nd post-op day)  • Dangle and transfer patient to wheelchair and back within 1st or 2nd day post-op; crutch walking started as soon as patient feels sufficiently strong

TOTAL HIP REPLACEMENT

• a plastic surgery that involves removal of the head of the femur followed by placement of a prosthetic implant

Nursing interventions

• Teach client how to use crutches• Teach client mechanics of transferring.• Discuss importance of turning and positioning post-op.• Place affected leg in an abducted position and straight alignment following surgery• Prevent hip flexion of more than 90 degrees.• Apply support stockings• Advise client to avoid external/internal rotation of affected extremity for 6 months to 1 year after surgery• Instruct client to avoid excessive bending, heavy lifting, jogging, jumping

• Encourage intake of foods rich in Vitamin C, protein, and iron.• Administer prescribed medications.

Complications

• Infection• Hemorrhage• Thrombophlebitis• Pulmonary embolism• Prosthesis dislocation• Prosthesis loosening

 DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

• condition in which the head of the femur is improperly seated in the acetabulum, or hip socket, of the pelvis.• Most common disorder that affects the hip joints of children under age 3.• The abnormality may be unilateral or bilateral.• It occurs in 3 forms of varying severity: Unstable hip dysplasia- the hip is positioned normally but can be dislocated by manipulation Subluxation or incomplete dislocation- the femoral head rides on the edge of the acetabulum. Complete dislocation- the femoral heads is totally outside the acetabulum.

Causes:

 Unknown One theory: hormones that relax maternal ligaments in preparation for labor may also cause laxity of infant ligaments around the capsule of the hip joint. Dislocation occurs 10 times more often after breech delivery (malpositioning in utero) than after cephalic delivery. Occurs 3x more often to the left hip than the right hip

Assessment

Neonates:  Experience no gross deformity of pain In complete dysplasia, the hip rides above the acetabulum, causing the leg on the affected side to appear shorter or the affected hip more prominent To test for Ortolani’s sign, place the infant on his back, with his hip flexed and in a neutral position.  Grasp the legs just below the knees, then gently abduct the hip form a neutral position.

 If you exert slight pressure upward and inward beneath the greater trochanter, the dislocated head of the femur may slip into the acetabulum with a palpable click.

Implementation: infants younger than 3 months• Splinting of the hips with Pavlik harness to maintain flexion and abduction and external rotation (neonatal period)? the infants must wear this apparatus continuously for 2 to 3 month and then wear a night splint for another month so the joint capsule can tighten and stabilize in correct alignment.• Gentle manipulation to reduce the dislocation

Infants beyond the newborn period and child

Assessment• The walking child: minimal to pronounced variation in gait, may cause the child to sway form side to side (“duck waddle”) for uncorrected bilateral dysplasia; unilateral dysplasia may produce a limp• Asymmetry of the gluteal and thigh skin folds when the child is placed prone and the legs are extended against the examining table? suggesting subluxation or dislocation• Limited range of motion in the affected hip.• Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.• Apparent short femur on the affected side• To test for Trendelenburg’s sign, have the child rest his weight on the side of the dislocation and lift his other knee.  His pelvis drops on the normal side because of weak abductor muscles in the affected hip.• When the child stands with his weight on the normal side and lifts the other knee, the pelvis remains horizontal or is elevated; these phenomena make up a positive Trendelenburg’s sign.

Implementation• Traction and/or surgery to release muscles and tendons• Bilateral skin traction (in infants) or skeletal traction (in children who have started walking) in an attempt to reduce the dislocation by gradually abducting the hips.• Closed reduction, if traction fails. • Following surgery, positioning and immobilization in a spica cast until healing is achieved, for 4 to 6 months• If closed treatment fails, open reduction, followed by immobilization in a hip-spica cast for an average of 6 months.• The earlier the infant receives treatment, the better the chances for normal development• Treatment varies with the patient’s age.

Nursing Interventions

• When transferring the child after casting, use your palms to avoid making dents in the cast.  Such dents predispose the patient to pressure ulcers. (the casts needs 24 to 48 hours to dry naturally)• Immediately after the cast is applied, use a plastic sheet to protect it from moisture around the perineum and buttocks.• Turn the child every 2 hours during the day and every 4 hours at night.• Check color, sensation, and motion of the infant’s legs and feet.• Check the cast daily for odors which may signify infection.• If the child complains of itching, she may benefit from diphenhydramine.  You may aim a blow-dyer set on cool at the cat edges to relieve itching.• Provide adequate nutrition, and maintain adequate fluid intake to avoid complication of immobility, such as renal calculi and constipation.

SCOLIOSIS

• Lateral curvature of the spine• May occur in the thoracic, lumbar, or thoracolumbar spinal segment• There are 2 types of scoliosis: functional (postural) and structural.• Both types are commonly associated with kyphosis (humpback) and lordosis (swayback)

Causes•  Functional scoliosis:  results from poor posture or a discrepancy in leg lengths•  Structural scoliosis: involves deformity of the vertebral bodies.•  It may be congenital, paralytic, or idiopathic.

• Surgical and nonsurgical interventions are employed, and the type of treatment depends on the degree of curvature, the age of the child, and the amount of growth that is anticipated.

Assessment• Visible curve fails to straighten when the child bends forward and hangs arms down toward feet.• Asymmetry of hip height• Pelvic obliquity• Inequalities of shoulder height• Scapular prominence• Rib prominence• Rib humps

• Severe cases, cardiopulmonary and digestive function may be affected because of compression or displacement of internal organs.

Diagnostic tests Anterior, posterior, and lateral spinal X-rays, taken with the patient standing upright and bending, confirm scoliosis and determine the degree of curvature and flexibility of the spine.

Treatment• close observation• exercise- to strengthen