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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
Used to evaluate the knee. 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. hemarthrosis (blood accumulation in the joint). Nursing considerations Explain to the patient that this test allows direct examination of the inside of a joint and that it’s safe. Serial ESR measurements help monitor general or localized inflammation. Check for urine for Bence Jones protein. ENDOSCOPY Arthroscopy: helps to assess joint problems. and rheumatoid factor. or a synovial cyst. convenient approach to surgery. creatine kinase. Assess for signs of complications such as infection. phosphorus. Instruct NPO after midnight. plan surgical approaches. RADIOGRAPHIC AND IMAGING STUDIESS . Check hypersensitivity to local anesthetics. calcium. Procedure may last about 10 minutes that he’ll be sedated. and white blood cell disorders as well as studies to measure blood levels of alkaline phosphatase. and document pathology. or osteomalacia. Check blood levels of antinuclear antibodies. Watch for signs of infection after the procedure and make sure bleeding stops. which may indicate a bone tumor. Urine tests: 24-hour urine collection to check uric acid levels. anemia. hyperparathyroidism. Done in the operating room under general or local anesthesia and takes 30 to 60 minutes. which cause the rate to increase. LABORATORY TESTS Blood tests: to rule out systemic infection.may hurt. 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.
Nursing considerations Explain that the procedure may take up to 90 minutes and advise the patient to use the bathroom before the test. benign disease. If the patient received a contrast medium by mouth. inform him that he must not eat for 4 hours before the test. bank. such as the radioisotope technetium polyphosphate. the isotope collects in areas of increased bone activity or active bone formation. X-rays: help diagnose traumatic disorders. fracture fragments. or buttons as well as credit. jewelry. Instruct patient to remain still during the test. Fasting isn’t necessary.Bone scan: detect bony metastasis. Lie supine on a table within the scanner and lie as still as possible and to expect to assume various positions.to 3.hour waiting period after the isotope is injected. and infection. Magnetic resonance imaging (MRI): show irregularities of the spinal cord and is especially useful for diagnosing disk herniation. fractures. the patient must drink four to six glasses of fluid. If the patient is scheduled to receive a contrast medium. Helps to assess questionable cervical or spinal fractures. Explain to the patient that there will be a 2. buckles. avascualr necrosis. and parking cards because the scan could erase the magnetic codes. Remove clothes with metal zippers. hearing aids. Ask the patient to remove all metal objects. Nursing considerations Explain to the patient that CT helps detect bone abnormalities and that it takes 30 to 90 minutes. Computed tomography: aids diagnosis of bone tumors and other abnormalities. bone lesions. and intra-articular loose bodies. IV introduction of a radioactive material. and dental appliances. Nursing considerations Explain the procedure to the patient. encourage him to drink plenty of fluid after the test to help flush the contrast medium from his body. such as fractures and dislocations. While waiting. eyeglasses. including bobby pins. watches. Reveal bone disease and joint disease .
Advanced stages: may develop a flat. splayed forefoot. Verify that the X-ray order includes pertinent recent history. 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. and a small bunion on the fifth metatarsal. Causes: congenital or familial More commonly acquired from degenerative arthritis or from prolonged pressure. 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. Treatment: good foot care and proper shoes felt pads to protect the bunion. severely curled toes (hammertoes).Nursing considerations Remove all jewelry. such as those with rheumatoid arthritis or diabetes mellitus. AND SPRAINS . Diagnostic test: X-rays confirm diagnosis by showing medial deviation of the first metatarsal and lateral deviation of the great toe. and identifies the point tenderness site. Early treatment is vital in patients predisposed to foot problems. foam pads or other devices to separate the first and second toes at night supportive pad and exercises to strengthen the metatarsal arch. such as trauma. Severe deformity? doctor may order bunionectomy MUSCULOSKELETAL INJURIES CONTUSIONS. STRAINS.
• A hematoma develops when the bleeding is sufficient to cause an appreciable collection of blood. which decreases bleeding. • Strains are microscopic. incomplete muscle tears with some bleeding into the tissue. Consult doctor if pain worsens or persists (X-ray may detect a fracture that was missed originally) FRACTURE . • The function of the ligament is to maintain stability while permitting mobility. absorption. followed by application of heat.soft tissue injury produced by blunt force.Contusion. Strain. numb or painful. Elevation Nursing interventions Immobilize the joint. with local tenderness on muscle use and isometric contraction. Ice. Treatment: “RICE” Rest. Control pain and swelling by giving analgesics as prescribed and immediate application of ice for up to 48 hours. If an elastic bandage is applied. • The patient experiences soreness or sudden pain. Severe sprains may require 1 to 3 weeks of immobilization before protected exercise are initiated. if sprain is severe. edema. or excessive stress. heat may be applied intermittently (for 15 to 30 minutes. caused by a wrenching or twisting motion. 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. • A torn ligament loses its stabilizing ability. and discomfort. tell the patient to remove the bandage before going to sleep and to loosen it if it causes the leg to become pale. using an elastic bandage or. four times a day) to relieve muscle spasm and to promote vasodilation. Care must be taken to avoid skin and tissue damage from excessive cold. a soft cast.injury to the ligaments surrounding a joint. and repair. Depending on the severity of injury progressive passive and active exercise may begin in 2 to 5 days. Sprain. • Many small blood vessels rupture and bleed into soft tissues (ecchymosis or bruising). Compression. 24 to 40 hours after injury).“muscle pull” from overuse. 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. overstretching.
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 . amount of tissue and vascular damage. Causes major trauma (fall on an outstretched arm. and other soft-tissue damage. walking or running can cause stress fractures of the foot and ankle. health. 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. a skiing accident. Children’s bones usually heal rapidly and without deformity.Break in the continuity of bone Arm and leg fractures can cause substantial muscle. usually seen in nurses. or child abuse) pathologic bone weakening conditions (osteoporosis. bone tumors or metabolic disease) prolonged standing. Bones of adults in poor health and who have impaired circulation may never heal properly. adequacy of reduction and immobilization. and nutrition. Prognosis varies with the extent of disability or deformity. postal workers. and the patient’s age. nerve.
If these measures don’t relieve the signs and symptoms in 4 to 6 hours. cast or traction Closed reduction: manual manipulation. and have the cast cut to relieve pressure if necessary. 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.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. decreased active and passive muscle stretching. the doctor may relieve the compression surgically. TYPES . such as numbness or tingling (late sign) Remove any obvious constriction. vitamins (tissue repair). tetanus prophylaxis. Watch for skin irritation near cast edges. plates. Open reduction: reduces and immobilizes the fracture by means of rods. Skin traction: elastic bandages and moleskin coverings are used to attach traction devices to the patient’s skin. skin color changes. 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. and check for foul odors or discharge Monitor patient for compartment syndrome. such as a dressing or wrap. support it with pillows. and possibly surgery to repair soft tissue damage Nursing interventions Monitor for signs of shock Analgesics as prescribed Diet: high protein. antibiotics. watch for increasing pain in the limb. iron. 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. or screws. absent pulse. followed by immobilization by splint. or edema distal to the injury site. pin or wire is inserted through the bone distal to the fracture and attached to a weight. moderate carbohydrates (prevent weight gain) For long-term immobilization with traction. Treatment for open fractures also requires wound cleaning. Skeletal traction: immobilization by the use of weights and pulleys. and sensory changes.
multiple bone fragments Oblique fracture. producing 2 or more fragments Simple or Closed. relieving the patient’s pain. Greenstick fracture. Comminuted fracture. usually seen only in children Bowing fracture. thorax. and protection the patient from further injury and other complications.fracture line perpendicular to long axis of bone Extracapsular. other side merely bends. • Grade III is highly contaminated. providing adequate splinting. has extensive soft tissue damage. multiple fractures.fracture line at 45-degree angle to long axis of bone Spiral fracture.fracture within the joint capsule. FAT EMBOLI (EARLY) • After fracture of long bones or pelvis.fractured bone does not protrude through skin Compound or Open. Incomplete.when only part of the bone is broken.microfracture.fracture is close to the joint but remains outside the joint capsule. fat globules may move into the blood because the marrow pressure is greater than the capillary pressure or because catecholamines elevated by the .bending of bone. • Treatment of shock consists of restoring blood volume and circulation. 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. fat emboli may develop. • Fat embolism syndrome occurs most frequently in young adults and elderly adults who experience fractures of the proximal femur.fracture of one side of bone. or crush injuries. and is the most severe. pelvis.Complete. Stress fracture. or spine.fracture extends through entire bone. • At the time of fracture.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. Intracapsular.fracture line encircling the bone Transverse fracture.
unrelenting pain. adequate support for fractured bones during turning and positioning. or (2) an increase in muscle compartment contents because of edema or hemorrhage associated . and tachycardia. • The respiratory distress response includes tachypnea. but may occur up to a week after injury. • Respiratory support is provided with oxygen given in high concentration. acute pulmonary edema. Prevention and Management • Immediate immobilization of fractures. and confusion t delirium and coma. • The chest x-ray shows a typical “snowstorm” infiltrate. • Respiratory failure is the most common cause of death. • 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. Clinical Manifestations: hypoxia. • Accurate fluid intake and output records facilitate adequate fluid replacement therapy. which is not controlled by opioids. • The fat globules (emboli) occlude the small blood vessels that supply the lungs. and interstitial pulmonary edema. acute respiratory distress syndrome. • The onset of symptoms is rapid. and maintenance of fluid and electrolyte balance are measures that may reduce the incidence of emboli. crackles. large amounts of thick white sputum. minimal fracture manipulation. • Eventually. and heart failure develop. cough. kidneys.patient’s stress reaction mobilize fatty acids and promote the development of fat globule sin the bloodstream. shock. • Vasoactive medications to support cardiovascular function are administered to prevent hypotension. precordial chest pain. and to correct homeostatic disturbances. • Controlled-volume ventilation with positive end-expiratory pressure may be used to prevent or treat pulmonary edema. and other organs. throbbing. • The patient complains of deep. tachypnea. usually occurring within 24 hours to 72 hours. wheezes. • Cerebral disturbances (due to hypoxia and the lodging of fat emboli in the brain) are manifested by mental status changes varying from headache. and pyrexia. to prevent respiratory and metabolic acidosis. • Corticosteroids may be administered to treat the inflammatory lung reaction and to control cerebral edema. mild agitation. Dyspnea. tachycardia. • 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. • Support the respiratory system. brain.
and pulmonary embolus (PE) are associated with reduced skeletal muscle contractions and bed rest. release of restrictive devices (dressing or cast). sterile saline dressing. and prescribed passive ROM exercises are usually performed every 4 to 6 hours. • Patient with fractures of the lower extremities and pelvis are at high risk for thromboembolism. throbbing. capillary refill time. The limb is splinted in a functional position and elevated. and bleeding from the mucous membranes. . • Medical Management • Elevation of the extremity to the heart level. • All open fractures are considered contaminated. unrelenting pain. and gastrointestinal and urinary tracts. the wound is not sutured but instead is left open to permit the muscle tissues to expand. • Manifestations of DIC include ecchymosis. Clinical Manifestation: sensory deficits include paresthesia. • Pale or dusky and cold finger or toes and prolonged capillary refill time suggest diminished arterial perfusion. unexpected bleeding after surgery. • Peripheral circulation is evaluated by assessing color. • Paresthesia and numbness along the involved nerve are early signs of nerve involvement. • After fasciotomy. swelling. and pulses. OTHER EARLY COMPLICATIONS • Deep vein thrombosis (DVT).with a variety or problems. • In 3 to 5 days. temperature. • Pulmonary emboli may cause death several days to weeks after injury. it is covered with moist. a fasciotomy (surgical decompression with excision of the fibrous membrane that covers and separates muscles) may be needed to relieve the constrictive muscle fascia. which is greater than expected and not controlled by opioids. and hypoesthesia. • The forearm and leg muscle compartments are involved most frequently. • DIC includes a group of bleeding disorders with diverse causes. • Cyanotic (blue-tinged) nail beds suggest venous congestion. the wound is debrided and closed (possibly with skin graft). or both. • Deep. when the swelling has resolved and tissue perfusion has been restored. venipuncture sites. unrelenting pain. • Swelling (edema) reduces tissue perfusion. thromboembolism. • If conservative measures do not restore tissue perfusion and relieve pain within 1 hour. • Edema may obscure the present of arterial pulsation and Doppler ultraonography may be used to verify a pulse. including massive tissue trauma.
• It may occur after a fracture with disruption of the blood supply (especially of the femoral neck). nails. pain. elevated temperature. wires. • Infections must be treated promptly. REDUCTION Reduction of a fracture (“setting” the bone) refers to restoration of the fracture fragments to anatomic alignment and rotation. • It is also seen with dislocations. and other diseases. swelling. • The nurse must monitory for and teach the patient to monitor for signs of infections. redness. including tenderness. • The extremity is held in the desired position while the physician applies a cast. • X-rays reveal calcium loss and structural collapse. or other device. or rods) may be used to hold the bone fragments in position until solid bone healing occurs. plates. AVASCULAR NECROSIS (DELAYED) • Avascular necrosis occurs when the bone loses its blood supply and dies. screws. • The patient develops pain and experiences limited movement. • Internal fixation devices ensure firm approximation and fixation of the bony fragments. • The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. prolonged high-dosage corticosteroid therapy. prosthetic replacement. • Treatment generally consists of attempts to revitalize the bone with bone grafts. or they may be inserted through the bony fragments or directly into the medullary cavity of the bone. local warmth. Closed Reduction • Accomplished by bringing the bone fragments into apposition (ie. bone transplantation. or arthrodesis (joint fusion). • The devitalized bone may collapse or reabsorb. Open Reduction • Through a surgical approach. chronic renal disease.• Surgical internal fixation of fractures carries a risk for infection. . • X-rays are obtained to verify that the bone fragments are correctly aligned. placing the ends in contact) through manipulation and manual traction. sickle cell anemia. and purulent drainage. • Internal fixation devices (metallic pins. splint. the fracture fragments are reduced. • Antibiotic therapy must be appropriate and adequate for prevention and treatment of infection. • These devices may be attached to the sides of bone.
depending on the weight of the patient.5 to 8 lb) of traction can be used on an extremity.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.5 kg (4. . Skeletal traction is never interrupted. The amount of weight applied must not exceed the tolerance of the skin.No more than 2 to 3. SKIN TRACTION . . . Any factor that might reduce the effective pull or alter the resultant line of pull must be eliminated: . and parallel to the bed. • Relieve muscle spasm Heel is supported off bed to prevent pressure on heel. Pelvic traction is usually 4.Application of wide band of moleskin. 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. or commercially available devices directly to the skin and attaching weights to them.The patient must be in good body alignment in the center of the bed when traction is applied. and foot is well away from footboard of bed. .Knots in the rope or the footplate must not touch the pulley or the foot of the bed. . It is used to provide immobility after fractures of the proximal femur before surgical fixation.Weights must hang free and not rest on the bed or floor. weight hangs free of the bed. adhesive. countertraction must be used to achieve effective traction. . . Countertraction is the force acting in the opposite direction.Ropes must be unobstructed.It is accomplished by using a weight to pull on traction tape or on a foam boot attached to the skin.5 to 9 kg (10 to 20 lb).Used to control muscle spasms and to immobilize an area before surgery. Weights are not removed unless intermittent traction is prescribed. The pull is exerted in one plane when partial or temporary immobilization if desired. Buck’s extension A skin traction to the lower leg.
Bryant’s traction. pin placement through the femur. Kirschner wire. Provide back care at least every 2 hours to prevent pressure ulcers. lower tibia. Pillows may be used under lower leg to provide support and keep the heel free of the bed. ulna. halo vest. Palpate the area of the traction tapes daily to detect underlying tenderness. and positive Homans’sign. color. Use special mattress overlays (eg.used to reduce femoral fracture in children. and . SKELETAL TRACTION . ropes. • Nerve pressure Regularly assess sensation and motion. POTENTIAL COMPLICATIONS • Skin breakdown Remove the foam boots to inspect the skin. high-density foam) to minimize the development of skin ulcers. including calf tenderness. Immediately investigate any complaint of burning sensation under the traction bandage or boot.Placement of a pin through the bone. A second nurse is needed to support the extremity during the inspection and skin care. calcaneus. or wrists. Promptly report altered sensation or motor function. and pulleys are in proper alignment and functional. th ankle. Buttocks are slightly elevated and clear off the bed. Don’t manipulate the weights yourself. Avoid wrinkling and slipping of the traction bandage and to maintain countertraction. and the Achilles tendon three times a day. and temperature of the fingers of toes. capillary refill. radius. to which the traction apparatus is attached . consult the doctor if you suspect the need for any adjustment.Common types include: Gardner-Wells and Crutchfield tongs.Russel traction Used in the treatment of intertrochanteric fracture of the femur when surgery is contraindicated Hip is slightly flexed. Nursing considerations Check periodically to ensure that weights. Indicators of DVT. air-filled. swelling. • Circulatory impairment Peripheral pulses.
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. Advance unaffected leg and shift weight onto it. 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. or stabilization of spinal degeneration. 30 degrees • When ambulating with the client. Crutch gaits Four-point gait Sequence: Advance left crutch 4-6 inches Advance right foot Advance right crutch Advance left foot Advantages: most stable crutch gait Requirements: Weight bearing is permitted on both legs Three-point gait Sequence: Advance both crutches forward with the affected leg and shift weight to crutches. bathe under the vest daily. stand on the affected side. . 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. When caring for a patient in a halo vest.Steinmann pin Purpose: to immobilize bones and allow healing of fractures. • Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs. Advantages: allows the affected leg to be partially or completely free of weight bearing Requirements: Full weight bearing on one leg. The other foot cannot support but may act as a balance. correction of congenital abnormalities. Traction applied directly to bone. • 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. check the occipital area of the head for skin breakdown.
Move both legs farther ahead than crutches. and functional usefulness. tingling. usually an extremity Amputation is performed at the most distal point that will heal successfully. Amputee may experience phantom limb pain soon after surgery or 2 to 3 months after amputation. crushed. When a patient describes phantom pains or sensations. cramped or twisted in an abnormal position. more normal walking pattern. The patient describes pain or unusual sensation. such as numbness. The site of amputation is determined by two factors: circulation in the part. It occurs more frequently in above-knee amputations. 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. 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 .Two-point gait Sequence: Advance left crutch and right foot Advance right crutch and left foot Advantages: Faster version of the four-point. Requirements: Partial weight bearing on both legs Swing-through gait Sequence: Unaffected foot bears weight Move both crutches forward. or muscle cramps. as well as a feeling that the extremity is present. the nurse acknowledges these feelings and helps the patient modify these perceptions.
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. maintain muscle strength and tone. malaise. persistent low grade fever. 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.Nursing Intervention Assess stump and monitor catheter drainage for color and amount. After 24 and 48 hours postoperatively. teach progressive resistance maneuvers. report signs of increased drainage BKA: keep knee extended to avoid hamstring contracture If prescribed. Stress the importance of performing prescribed exercises to help minimize complications. 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. elevate the foot of the bed to reduce edema. to stretch the muscles and prevent flexion contractures of hip To prevent leg abduction. during the first 24 hours. 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. Risk Factors: Exposure to infectious agents Fatigue Stress Signs and Symptoms Initial symptoms: fatigue. weight loss. anorexia. and lympadenopathy . and promote independence. prevent contractures. such as pushups and flexion and extension of the arms using traction weights. position the client prone if prescribed.
NSAIDs (indomethacin. Rofecoxib) Inhibits only cyclooxygenase-2 enzymes Antimalarials (chloroquine and hydroxychloroquine) Gold sodium thiomalate penicilamine Corticosteroids Immunosuppressives (methotrexate. arthroplasty Supportive measures include: 8 to 10 hours of sleep every night. and level of pain. show bone demineralization and soft tissue swelling Elevated ESR. ketorolac. for dry skin Apply splints carefully Encourage a balanced diet. Give meticulous skin care. sensory disturbances. to decrease inflammation and relieve joint pain. arthrodesis. and splinting to rest inflamed joints. arthrotomy. ibuprofen. tenderness. and swelling joint symptoms occur bilaterally and symmetrically Morning stiffness Swan neck deformity-late Diagnostic Studies X-ray. azathioprine) Hot and Cold packs to affected joints Surgical Procedures: synovectomy. Cox-2 Inhibitors (Celecoxib. and positive RF Treatment Salicylates. adequate nutrition. Use lotion or cleansing oil. frequent rest periods between daily activities. 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 . cyclophosphamide.joint pain. warmth. not soap. Nursing Management Assess all joints carefully Monitor vital signs and note weight changes.
can cause respiratory depression . propoxyphene hydrochloride. intra-articular injections of corticosteroid Aspirin Inhibits cyclooxygenase enzyme. ketorolac. diminishes the formation of prostaglandins Anti-inflammatory. antipyretic action Inhibit platelet aggregation in cardiac disorders Adverse effects: Epigastric distress. such as the hips and knees Risk Factors Aging (>50 yr) Rheumatoid arthritis Arteriosclerosis Obesity Trauma Family history Signs and Symptoms pain. analgesic. indomethacin. 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. phenylbutazone. 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). and vomiting In toxic doses. and in some cases. cold intolerance fatigability. ibuprofen. rofecoxib.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. nausea.
replacement of a deteriorated joint with a prosthetic appliance arthrodesis. splints to maintain proper alignment Weight reduction Isometric and postural exercises Firm mattress or bed board to decrease morning pain . protective techniques for preventing undue stress on the joints Those with severe osteoarthritis with disability or uncontrollable pain may undergo: arthroplasty. moist heat.scraping of deteriorated bone from a joint osteotomy. Other supportive measures include massage. vomiting. which is used primarily in the spine (laminectomy) osteoplasty. swelling Medications as prescribed. vertigo.surgical fusion of bones. a cane. a walker. dizziness. spasms. bed rest on firm mattress. Nausea. and mental confusion Hypersensitivity reaction Effective treatment also reduces joint stress by supporting or stabilizing the joint with crutches. tinnitus and dizziness Indomethacin Inhibits cyclooxygenase enzyme More potent than aspirin as an anti-inflammatory agent Adverse effects: The adverse effects are dose-related. diarrhea Headache. anorexia. inflammation. a cervical collar. or traction.Hypersensitivity Reye’s syndrome Ibuprofen Use for chronic treatment of rheumatoid and osteoarthritis Less GI effects than aspirin Adverse effects: Dyspepsia to bleeding Headache. light-headedness.excision of bone to change alignment and relieve stress Nursing Intervention Promote comfort: reduce pain. paraffin dips for hands. Heat to reduce muscle spasm Cold to reduce swelling and pain Prevent contractures: exercise. braces.
which develops during the course of another disease (such as obesity. tender. leukemia) Following drug therapy. called Tophi Diagnostic tests . ankle. which causes overproduction of uric acid. Nursing Diagnosis Pain related to friction of bones in joints Risk for injury related to fatigue Impaired physical mobility related to stiff. sickle cell anemia. dusky red. retention of uric acid. renal disease. 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. avoid overexertion. then the instep. maintain proper body weight to lessen joint stress. heel. or cyanotic Metatarsophalangeal joint of the great toe usually becomes inflamed first (podagra). HPN. DM. typically nocturnal and usually monarticular. knee or wrist joints Extremely painful Fever Increased concentration of uric acid leads to urate deposits. which interferes with urate excretion Signs and Symptoms Affected joints appear hot. 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. or both. acute onset. Secondary gout. install safety devices at home. inflamed.Assist with ROM and strengthening exercises Instruct patients to wear well-fitting supportive shoes. hydrochlorothiazide or pyrazinamide. myeloma.
local application of heat or cold. until pain subsides or until signs of overdose such as nausea.(+) 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. and protection of inflamed. 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. agranulocytosis. nausea and diarrhea Colchicine Effective for acute attacks Taken every hour for 8 hours. Adverse effects: nausea. vomiting. . Adverse effects: hypersensitivity reactions. Maintain a fluid intake of at least 2000 to 3000 mL a day to avoid kidney stone. alopecia Probenecid/Sulfinpyrazone Uricosuric agents Increases the renal excretion of uric acid and inhibit accumulation of uric acid Sulfinpyrazone used as a preventive agent. diarrhea. vomiting. abdominal pain. 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. cramping or diarrhea develop Anti-inflammatory activity alleviating pain within 12 hours Adverse effects: nausea. Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies). immobilization. painful joints. aplastic anemia. such as acetaminophen or ibuprofen Relieve pain associated with mild attacks Nursing Interventions Bed rest.
increased vascularity. nosocomial. thrombosis of the blood vessels occurs in the area. . shellfish and gravy. gun shot wound • Hematogenous (bloodborne) spread from other sites of infection (eg. alcohol. upper respiratory infections). organ meats. incisional infection) • Direct bone contamination from bone surgery. or traumatic injury (eg. infected tonsils. 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. The incidence of penicillin-resistant. • Initial response to infection is inflammation. Encourage rest and immobilize the inflamed joints during acute attacks Avoid excessive alcohol intake Notify physician if rash. • The infection extends into the medullary cavity and under the periosteum and may spread into adjacent soft tissues and joints. Nursing Diagnosis Chronic pain Impaired physical mobility Risk for injury OSTEOMYELITIS Pyogenic infection of the bone. and edema.Avoid foods high in purine such as wine. fever or bleeding develops. resulting in ischemia with bone necrosis. infected pressure or vascular ulcer. sardines. coli Pathophysiology • Staphylococcus aureus causes 70% to 80% of bone infections. salmon. The bone becomes infected by one of three modes: • Extension of soft tissue infection (eg. boils. anchovies. Other pathogenic organisms frequently found in osteomyelitis include Proteus and Pseudomonas species and Escherichia coli. and decalcification • Staphylococcus aureus is the most common pathogen. sore throat. Pseudomonas and E. a bone abscess forms. Take medication with food. After 2 or 3 days. gram-negative. open fracture. infected teeth. and anaerobic infections is increasing. Other organisms include Proteus. breakdown of bone structure. • Unless the infective process is treated promptly. • Infection causes tissue necrosis.
Encourage participation in ADL within the physical limitations of the patient to promote general well being. incision and drainage. Use aseptic technique when dressing the wound to promote healing and to prevent cross contamination. after blood cultures are taken Early surgical drainage to relieve pressure buildup and sequestrum formation Immobilization of the affected bone by plaster cast. fluids If an abscess forms.V.V. Administer I. which does not easily liquefy and drain. loose or foul-smelling stools) Administer antibiotics as prescribed. chills. 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. tachycardia. Signs and symptoms Sudden pain in the affected bone. . fluids to maintain adequate hydration as needed Provide a high protein and vitamin C Support the affected limb with firm pillows. and restricted movement.V. oral or vaginal candidiasis. antibiotic-soaked dressings Surgery to remove dead bone and to promote drainage Nursing interventions Promote comfort Immobilized affected bone by maintaining splinting. or bed rest Supportive measures: analgesics and I. wet. Elevate affected leg to reduce swelling Administer analgesics as needed. Control infectious process Monitor signs of superinfection (eg. followed by a culture of the drainage matter Antibiotic therapy to control infection Local application of packed. tenderness.• The resulting abscess cavity contains dead bone tissue (the sequestrum). Clinical manifestations of septicemia (fever. traction. heat and swelling over the affected area.
an elderly person bends to lift something.prolonged therapy with steroids. or total immobility or disuse of a bone. then feels a sudden pain in the lower back. hears a snapping sound.unknown Secondary osteoporosis. 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. or thyroid preparations. ribs. Risk Factors • Postmenopausal women • Small-framed. and abnormally vulnerable to fracture • Affects weight bearing vertebrae. hyperthyroidism) Causes: Primary osteoporosis. malabsorption. femurs.Provide good cast care. • Loss of height . Linked also to alcoholism. causing a loss of bone mass • Bones lose calcium and phosphate salts and become porous. from aluminum-containing antacids. 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. and osteogenesis imperfecta Assessment Findings • Develops insidiously. • Vertebral and wrist fractures are common. scurvy. and wrist bones. lactose intolerance. anticonvulsants. brittle. hyperthyroidism. OSTEOPOROSIS • The rate of bone resorption accelerates while the rate of bone formation slows down. malnutrition. heparin.
• Dual-energy x-ray absorptiometry (DEXA) • Serum calcium.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.normal • Serum phosphorus. vertebral column and hip • Lower back pain • Kyphosis • Respiratory impairment Diagnostic tests • X-rays: degeneration in the lower thoracic and lumbar vertebrae.• Fractures of the wrist. 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. with varying degrees of collapse and wedging. vertebral bodies may appear flattened. walker) • Encourage active/passive ROM .normal • Serum alkaline phosphatase.
the new bone structure causes painful deformities of external contour and internal structure • It can be fatal. Clinical Manifestation • Early stages: severe. fragile. particularly if associated with heart failure. 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. followed by a reactive phase of excessive abnormal bone formation (osteoblastic phase) • Chaotic. 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. persistent pain intensifies with weight bearing and may impair movement • Asymmetrical bowing of femur and tibia • Enlargement of the skull (frontal and occipital area). bone sarcoma.• Promote pain relief • Encourage good posture and body mechanics PAGET’S DISEASE • Progressive skeletal disease with deformity • Excessive bone resorption (osteoclastic phase). and weak. urinary hydroxyproline and serum alkaline phosphatase .
and weight loss Diagnostic Findings Biopsy. with Paget's disease and exposure to radiation • Exhibits a moth-eaten pattern of bone destruction. swelling. vomiting. • Most common sites: metaphysis of long bones especially the distal femur.levels. anorexia. Surgery: to reduce or prevent pathologic fractures. 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. facial flushing. and bleeding and temperature elevation and to report for regular follow-up laboratory tests. easy bruising. aching and intermittent in nature). local inflammation at injection site. correct secondary deformities. proximal tibia and proximal humerus Clinical Manifestation local signs – pain (dull. Demonstrate to patient how to inject calcitonin and rotate injection sites Warn the patient that adverse effects (nausea.confirms the diagnosis . 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. 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. indomethacin. limitation of motion Palpable mass near the end of a long bone systemic symptoms: malaise. itching of hands. and relieve neurologic impairment Aspirin.
jumping . • Promote coping skills and self esteem • Assess for potential complications (infection. 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. complications of immobility). • Discuss importance of turning and positioning post-op. • 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.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. heavy lifting. • Place affected leg in an abducted position and straight alignment following surgery • Prevent hip flexion of more than 90 degrees. jogging. • 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.
. 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.• Encourage intake of foods rich in Vitamin C. with his hip flexed and in a neutral position. 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. • It occurs in 3 forms of varying severity: Unstable hip dysplasia. place the infant on his back. then gently abduct the hip form a neutral position.the femoral head rides on the edge of the acetabulum. Grasp the legs just below the knees. • Administer prescribed medications. or hip socket. Complete dislocation. • The abnormality may be unilateral or bilateral. protein. Occurs 3x more often to the left hip than the right hip Assessment Neonates: Experience no gross deformity of pain In complete dysplasia. • Most common disorder that affects the hip joints of children under age 3. 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. Dislocation occurs 10 times more often after breech delivery (malpositioning in utero) than after cephalic delivery.the femoral heads is totally outside the acetabulum. of the pelvis. and iron.the hip is positioned normally but can be dislocated by manipulation Subluxation or incomplete dislocation.
His pelvis drops on the normal side because of weak abductor muscles in the affected hip. followed by immobilization in a hip-spica cast for an average of 6 months. for 4 to 6 months • If closed treatment fails. 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. the better the chances for normal development • Treatment varies with the patient’s age. . • When the child stands with his weight on the normal side and lifts the other knee. positioning and immobilization in a spica cast until healing is achieved. • Gentle manipulation to reduce the dislocation Infants beyond the newborn period and child Assessment • The walking child: minimal to pronounced variation in gait. these phenomena make up a positive Trendelenburg’s sign. • The earlier the infant receives treatment.If you exert slight pressure upward and inward beneath the greater trochanter. • Closed reduction. 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. • 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. if traction fails. the pelvis remains horizontal or is elevated. open reduction. 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. • Following surgery. may cause the child to sway form side to side (“duck waddle”) for uncorrected bilateral dysplasia. • Asymmetric abduction of the affected hip when the child is placed supine with the knees and hips flexed.
• Check color. and maintain adequate fluid intake to avoid complication of immobility. • Check the cast daily for odors which may signify infection. sensation. such as renal calculi and constipation. lumbar. • If the child complains of itching. or idiopathic. • Asymmetry of hip height • Pelvic obliquity • Inequalities of shoulder height • Scapular prominence • Rib prominence • Rib humps . paralytic. SCOLIOSIS • Lateral curvature of the spine • May occur in the thoracic. she may benefit from diphenhydramine. the age of the child. and the amount of growth that is anticipated. use a plastic sheet to protect it from moisture around the perineum and buttocks. • Surgical and nonsurgical interventions are employed. • Turn the child every 2 hours during the day and every 4 hours at night. You may aim a blow-dyer set on cool at the cat edges to relieve itching. (the casts needs 24 to 48 hours to dry naturally) • Immediately after the cast is applied. Such dents predispose the patient to pressure ulcers. Assessment • Visible curve fails to straighten when the child bends forward and hangs arms down toward feet. • It may be congenital. use your palms to avoid making dents in the cast. and motion of the infant’s legs and feet. • Provide adequate nutrition. and the type of treatment depends on the degree of curvature.Nursing Interventions • When transferring the child after casting. 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.
posterior. Diagnostic tests Anterior.• Severe cases.to strengthen . Treatment • close observation • exercise. and lateral spinal X-rays. cardiopulmonary and digestive function may be affected because of compression or displacement of internal organs. taken with the patient standing upright and bending. confirm scoliosis and determine the degree of curvature and flexibility of the spine.
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