Musculoskeletal System Assessment & Disorders

Musculoskeletal System Assessment & Disorders
Dr Ibraheem Bashayreh, RN, PhD

Skeletal System Bone types Bone structure Bone function
Bone growth and metabolism affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin.

Bones Human skeleton has 206 bones
Provide structure and support for soft tissue Protect vital organs

Figure 41-1 Bones of the human skeleton.

Figure 41-2 Classification of bones by shape.

Bones Compact bone Spongy bone Smooth and dense
Forms shaft of long bones and outside layer of other bones Spongy bone Contains spaces Spongy sections contain bone marrow

Bone Marrow Red bone marrow Yellow bone marrow
Found in flat bones of sternum, ribs, and ileum Produces blood cells and hemoglobin Yellow bone marrow Found in shaft of long bones Contains fat and connective tissue

Joints (Articulations)
Area where two or more bones meet Holds skeleton together while allowing body to move

Joints Synarthrosis Amphiarthrosis Diarthrosis or synovial
Immovable (e.g., skull) Amphiarthrosis Slightly movable (e.g., vertebral joints) Diarthrosis or synovial Freely movable (e.g., shoulders, hips)

Synovial Joints Found at all limb articulations
Surface covered with cartilage Joint cavity covered with tough fibrous capsule Cavity lined with synovial membrane and filled with synovial fluid

Ligaments Bands of connective tissue that connect bone to bone
Either limit or enhance movement Provide joint stability Enhance joint strength

Tendons Fibrous connective tissue bands that connect bone to muscles
Enable bones to move when muscles contract

Muscles Skeletal (voluntary) Smooth (involuntary)
Allows voluntary movement Smooth (involuntary) Muscle movement controlled by internal mechanism e.g., muscles in bladder wall and GI system Cardiac (involuntary) Found in heart

Skeletal Muscle 600 skeletal muscles
Made up of thick bundles of parallel fibers Each muscle fiber made up of smaller structure myofibrils Myofibrils are strands of repeating units called sarcomeres

Skeletal Muscle Skeletal muscle contracts with the release of acetylcholine The more fibers that contract, the stronger the muscle contraction

Changes in Older Adult Musculoskeletal changes can be due to:
Aging process Decreased activity Lifestyle factors

Changes in Older Adult Loss of bone mass in older women
Joint and disk cartilage dehydrates causing loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion

Changes in Older Adult Cause stooped posture, changing center of gravity Elderly at greater risk for falls Endocrine changes cause skeletal muscle atrophy Muscle tone decreases

Assessment Health history Chief complaint Onset of problem
Effect on ADLs Precipitating events, e.g., trauma

Assessment Examine complaints of pain for location, duration, radiation character (sharp dull), aggravating, or alleviating factors Inquire about fever, fatigue, weight changes, rash, or swelling

Physical Examination Posture Gait
Ability to walk with or without assistive devices Ability to feed, toilet, and dress self Muscle mass and symmetry

Physical Examination Inspect and palpate bone, joints for visible deformities, tenderness or pain, swelling, warmth, and ROM Assess and compare corresponding joints Palpate joints knees and shoulder for crepitus

Physical Examination Never attempt to move a joint past normal ROM or past point where patient experiences pain Bulge sign and ballottement sign used to assess for fluid in the knee joint Thomas test performed when hip flexion contracture suspected

Figure 41-4 Checking for the bulge sign.

Figure 41-5 Checking for ballottement.

Diagnostic Tests Blood tests Arthrocentesis X-rays Bone density scan
CT scan MRI Ultrasound Bone scan

Diagnostic Evaluation
Imaging Procedures – CT, Bone Scan, MRI Nuclear Studies - radioisotope bone density, Endoscopic Studies –arthrocentesis, arthroscopy Other Studies –biopsy, synovial fluid, Arthrogram, venogram, Electromyography Myelography* Laboratory Studies

Musculoskeletal Assessment – Diagnostic Test
Laboratory Urine Tests 24 hour creatine-creatinine ratio Urine Uric acid –24 hr specimen Urine deoxypyridino- line Laboratory Blood Tests Serum muscle enzymes Rheumatoid Factor LE Prep/Antinuclear Antibodies(ANA) Erythrocyte Sedimentation Rate Calcium, Phosphorous, Alkaline phosphatase Urine Tests – creatine-creatinine rtio for test presence of muscle disease; Urinary uric acid – gout – 24 hr specimen Urine deoxypyridinolie – assess bone resorption process Blood Serum muscle enzymes – aldolase, C’PK – muscle damage, c-reactive protein, Rheumatoid factor - latex fixation; certain antibodies indicative rheumatoid condition, Anti-DNA antibody Le-Prep/Antinuclear antibodies (ANA) – check protein (certain ones) increase, SLE Erythrocyte Sedimentation Rate (ESR), Alkaline poshpatase – bone tumor and infection Fx, Paget’s disease; increase osteoblastic activity

Muscoluloskeletal Assessment – Diagnostic
Blood Tests CBC – Hgb, Hct Acid phosphatase Metabolic/Endocrine Enzymes Increase creatine kinase, serum increase glutamin-oxaloacetic due to muscle damage, aldolase, SGOT Lab blood work – inc. creatine kinase – Serum increase glutamin – oxaloacetic due to muscle damage Aldolase – muscluar dystrophy Venous system – check for vein thrombosis - venogram Myelopgraphy – radiopaque or contrast medium injected into arachnoid space. Pt assume a lateral sitting/position; used with MRI, CT Scan; same concerns with dye Nursing Care – Post Test – F.F., if dye oil based – flate in bed for 8 hours; if dye water based – BR with HOB inc. 30 –24 hour; air – head of bed kept lower than trunk 48; side effects dye – nausea, vomiting, headache; I & O, neuro check, F.F.; Discharge – hours – no lifting, strenous activity 24; Check incision/puncture site Arthroscopy – visualization of joint with arthroscope; common knee used for other joints; arthrography – visualization, use of radiopaque dye – contract medium or air or both. Radio. Bone Scan – presence of metabolic disease, timors, infectionk, osteomylitis, Arthrocentesis - CT scans x-rays, MRI

Musculoskeletal - Radiographic
Standard radiography, tomography and xeroradiography, myelography, arthrography and CT Other diagnostic tests: bone and muscle biopsy

Arthroscopy Fiberoptic tube is inserted into a joint for direct visualization. Client must be able to flex the knee; exercises are prescribed for ROM. Evaluate the neurovascular status of the affected limb frequently. Analgesics are prescribed. Monitor for complications.

Bone Scan Nuclear medicine procedure in which amount of radioactive isotope taken up by bones is evaluated Abnormal bone scans show hot spots due to malignancies or infection Cold spot uptakes show areas of bone that are ischemic

Arthroscopy Flexible fiberoptic endoscope used to view joint structures and tissues Used to identify: Torn tendon and ligaments Injured meniscus Inflammatory joint changes Damaged cartilage

Interventions for Clients with Musculoskeletal Trauma

Musculoskeletal Trauma
Tissue is subjected to more force than it can absorb Severity depends on: Amount of force Location of impact

Musculoskeletal Trauma
Mild to severe Soft tissue Fractures Affect function of muscle, tendons, and ligaments Complete amputation

Preventing Trauma Teach importance of using safety equipment
Seat belts Bicycle helmets Football pads Proper footwear Protective eyewear Hard hats

Soft Tissue Trauma Contusion Bleeding into soft tissue
Significant bleeding can cause a hematoma Swelling and discoloration (bruise)

Soft Tissue Trauma - Sprain
Ligament injury (Excessive stretching of a ligament) Twisting motion Overstretching or tear Grade I—mild bleeding and inflammation Grade II—severe stretching and some tearing and inflammation and hematoma Grade III—complete tearing of ligament Grade IV—bony attachment of ligament broken away

Sprains Treatment of sprains:
first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation second-degree: immobilization, partial weight bearing as tear heals third-degree: immobilization for 4 to 6 weeks, possible surgery

Soft Tissue Trauma - Strain
Microscopic tear in the muscle May cause bleeding “Pulled muscle” Inappropriate lifting or sudden acceleration-deceleration

Soft Tissue Trauma To decrease swelling and pain, and encourage rest
Ice for first 48 hours Splint to support extremities and limit movement Compression dressing Elevation to increase venous return and decrease swelling NSAIDs

Soft Tissue Trauma Diagnosis X-ray to rule out fracture MRI

Fractures Break in the continuity of bone Direct blow
Crushing force (compression) Sudden twisting motions (torsion) Severe muscle contraction Disease (pathologic fracture)

Fractures Classification of Fractures
Closed or simple Open or compound Complete or incomplete Stable or unstable Direction of the fracture line Oblique Spiral Lengthwise plane (greenstick)

Stages of Bone Healing Hematoma formation within 48 to 72 hr after injury Hematoma to granulation tissue Callus formation Osteoblastic proliferation Bone remodeling Bone healing completed within about 6 weeks; up to 6 months in the older person

Fractures – Emergency Care
Immobilize before moving client Joint above and below Check pulse, color, movement, sensation before splinting Sterile dressing for open wounds

Fractures – Emergency Care
Fracture reduction Closed—external manipulation Open—surgery

Acute Compartment Syndrome
Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area Prevention of pressure buildup of blood or fluid accumulation Pathophysiologic changes sometimes referred to as ischemia- edema cycle S&P

Emergency Care - Acute Compartment Syndrome
Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr. Monitor compartment pressures. (Continued) S&P

Emergency Care (Continued)
Fasciotomy may be performed to relieve pressure. Pack and dress the wound after fasciotomy.

Possible Results of Acute Compartment Syndrome
Infection Motor weakness Volkmann’s contractures: (a deformity of the hand, fingers, and wrist caused by a lack of blood flow (ischemia) to the muscles of the forearm)

Other Complications of Fractures
Shock Fat embolism syndrome: serious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream Venous thromboembolism (Continued)

Other Complications of Fractures (Continued)
Infection Ischemic necrosis Fracture blisters, delayed union, nonunion, and malunion

Musculoskeletal Complications (continued)
Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobility Embolism/Pneumonia/ARDS TREATMENT – hydration, albumin, corticosteroids Constipation/Anorexia UTI DVT Fat embolus – occur within 24 hours of injury 60% or within 48 hrs in 85%. Patho FaT – fat molecules or globules are released from bone marrow enter into the blood. Fat in blood and urine but most experience –decrease in arterial Po2, increase Pco2, petechiae and altered mental state – mental confusion. P- 1934

Musculoskeletal Assessment - Fracture
Change in bone alignment Alteration in length of extremity Change in shape of bone Pain upon movement Decreased ROM Crepitation Ecchymotic skin (Continued)

Musculoskeletal Assessment – Fracture (Continued)
Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site

Special Assessment Considerations
For fractures of the shoulder and upper arm, assess client in sitting or standing position. Support the affected arm to promote comfort. For distal areas of the arm, assess client in a supine position. For fracture of lower extremities and pelvis, client is in supine position.

Cast CAST

Casts Rigid device that immobilizes the affected body part while allowing other body parts to move Cast materials: plaster, fiberglass, polyester-cotton Types of casts for various parts of the body: arm, leg, brace, body (Continued)

Casts (Continued) Cast care and client education
Cast complications: infection, circulation impairment, peripheral nerve damage, complications of immobility

Managing Care of the Patient in a Cast
Casting Materials Relieving Pain Improving Mobility Promoting Healing Neurovascular Function Potential Complications

Cast, Splint, Braces, and Traction Management Considerations
Arm Casts Leg Casts Body or Spica Casts Splints and Braces External Fixator Traction

POLYESTER/FIBERGLASS

UPPER EXTREMITY CAST

LOWER EXTREMITY CAST

Musculoskeletal Nursing Care - Casts
Neurovascular Check color/capillary refill Temperature Pulse Movement Sensation Traction Nursing Care Pin Site care Skin and neurovascular check Traction – skin or skeletal Countertraction – counteracts the pull of traction; Suspension – use of traction equipment, such as frames, splints, ropes, pulleys and weights- not pull suspends Balanced suspension – allow patient to move freely and easy in bed. Buck’s extension – common skin traction. Skeletal - Kirschner wire or Steinmann pin , covered with cork or metal protectives, nurse applies small sterile dressings, cleaned, antibiotic oint. Check for infection Balanced suspension with Thomas splint and Pearson attachment

Cast Care (continued) Elevate Extremity
Exercises – to unaffected side; isometric exercises to affected extremity Keep heel off mattress Handle with palms of hands if cast wet Turn every two hours till dry Notify MD at once of wound drainage Do not place items under cast. Elevate – control swelling Keep cast dry- do not cover with plastic or rubber – cause condensation and become wet. No weight bearing, report cracks or breaks to MD. Use of stockinette or moleskin around edges of cast to prevent irritation. Use proper medical devices, involve family and emotional support. Avoid scratching the skin. Blot the skin dry.

Traction Application of a pulling force to the body to provide reduction, alignment, and rest at that site Types of traction: skin, skeletal, plaster, brace, circumferential (Continued)

Traction (Continued) Traction care:
Maintain correct balance between traction pull and counter traction force Care of weights Skin inspection Pin care Assessment of neurovascular status

Musculoskeletal – Fractures Treatment
Primary Goal – reduce fracture- Realign and immobilize Medications Analgesics, antibiotics, tetanus toxoid Closed Reduction – Manual and Cast; External Fixation Device Traction; Splints; Braces Surgery Open reduction with internal fixation Reconstructive surgery Endoprosthetic replacement

Figure In external fixation, pins placed through the bone above and below the fracture are attached to external fixation rods that hold the pins and bone in place.

Put Pt. On firm mattress Ropes and pulleys should be aligned. The pull should be in line with the long axis of the bone. Any factor that might reduce the pull or alter it’s direction must be eliminated. Weighs should hang freely. Ropes should be unobstructed and not in contact with bed or equipment. Help the patient pull himself up in bed at frequent intervals. Traction is not accomplished if knot in rope or footplate is touching the pulley or foot of bed or weight’s rest on floor. Never remove the weights when repositioning the patient who is in skeletal traction because this will interrupt line of pull. Every complaint of patient in traction should be investigated immediately.

Strengthening Exercises Potential Complications
Nursing Management Positioning Strengthening Exercises Potential Complications

Musculoskeletal Nursing Care
Promote comfort Assess infection Promote mobility Teach safety Vital Signs Flotation, sheep skin Nutrition Monitor elimination Elevate extremity to decrease swelling/ ice pack Teach skin care, cast care, diet, complications Diet – hi protein and calories high in calcium, especially in immobilized, fluid, fiber, vitamin and iron

Operative Procedures Open reduction with internal fixation
External fixation Postoperative care: similar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism

Managing the Patient Undergoing Orthopedic Surgery
Joint Replacement Total Hip Replacement Total Knee Replacement

Risk for Infection Interventions include:
Apply strict aseptic technique for dressing changes and wound irrigations. Assess for local inflammation Report purulent drainage immediately to health care provider. (Continued) S&P

Risk for Infection (Continued)
Assess for pneumonia and urinary tract infection. Administer broad-spectrum antibiotics prophylactically.

Imbalanced Nutrition: Less Than Body Requirements
Interventions include: Diet high in protein, calories, and calcium, supplemental vitamins B and C Frequent small feedings and supplements of high-protein liquids Intake of foods high in iron S&P

Upper Extremity Fractures
Fractures include those of the: Clavicle Scapula Humerus Olecranon Radius and ulna Wrist and hand

Lower Extremity Fractures
Fractures include those of the: Femur Patella Tibia and fibula Ankle and foot

Fractures of the Hip Intracapsular or extracapsular
Treatment of choice: surgical repair, when possible, to allow the older client to get out of bed Open reduction with internal fixation Intramedullary rod, pins, a prosthesis, or a fixed sliding plate Prosthetic device S&P

Fractures of the Pelvis
Associated internal damage the chief concern in fracture management of pelvic fractures Non–weight-bearing fracture of the pelvis Weight-bearing fracture of the pelvis S&P

Compression Fractures of the Spine
Most are associated with osteoporosis rather than acute spinal injury. Multiple hairline fractures result when bone mass diminishes. (Continued)

Compression Fractures of the Spine (Continued)
Nonsurgical management includes bedrest, analgesics, and physical therapy. Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected. (Continued)

Amputations Surgical amputation Traumatic amputation
Levels of amputation Complications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma (a growth or tumour of nerve tissue), flexion contracture

Nursing Management Amputation relieving pain
minimizing altered sensory perception promoting wound healing enhancing body image self-care

Phantom Limb Pain Phantom limb pain is a frequent complication of amputation. Client complains of pain at the site of the removed body part, most often shortly after surgery. Pain is intense burning feeling, crushing sensation or cramping. Some clients feel that the removed body part is in a distorted position.

Management of Phantom Pain
Phantom limb pain must be distinguished from stump pain because they are managed differently. Recognize that this pain is real and interferes with the amputee’s activities of daily living. (Continued)

Management of Phantom Pain (Continued)
Some studies have shown that opioids are not as effective for phantom limb pain as they are for residual limb pain. Other drugs include intravenous infusion calcitonin, beta blockers, anticonvulsants, and antispasmodics.

Exercise After Amputation
ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial S&P

Prostheses Devices to help shape and shrink the residual limb and help client readapt Wrapping of elastic bandages Individual fitting of the prosthesis; special care

Crush Syndrome Can occur when leg or arm injury includes multiple compartments Characterized by acute compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosis Treatment: adequate intravenous fluids, low-dose dopamine, sodium bicarbonate, kayexalate, and hemodialysis S&P

Metabolic Bone Disorders
Osteoporosis Osteomalcia Paget’s Disease

Osteoporosis A disease in which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity. Clinical Manifestations – bone pain, decrease movement. Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, SERM (Selective Estrogen Receptor Modulator) with anti-estrogens, exercise. Pathologic fracture-safety. Metabolic disease, in which bone demineralization results in decreased density and subsequent fractures. Osteopenia (low bone mass, which occurs when there is a disruption in the bone remodeling process. Bone density scan altered, decrease density. Bone resorption exceeds bone formation. SERM – Selective Estrogen Receptor Modulators.

Classification of Osteoporosis
Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s. Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility. Regional osteoporosis occurs when a limb is immobilized.

Health Promotion/Illness Prevention - Osteoporosis
Ensure adequate calcium intake. Avoid sedentary life style (a type of lifestyle with a lack of physical exercise) . Continue program of weight-bearing exercises. S&P

Osteoporosis - Assessment
Physical assessment Psychosocial assessment Laboratory assessment Radiographic assessment

Osteoprosis Os

Osteoprorsis

Drug Therapy Osteoporosis
Hormone replacement therapy Parathyroid hormone Calcium and vitamin D Bisphosphonates Selective estrogen receptor modulators Calcitonin Other agents used with varying results

Diet Therapy - Osteoporosis
Protein Magnesium Vitamin K Trace minerals Calcium and vitamin D Avoid alcohol and caffeine

Fall Prevention - Osteoporosis
Hazard-free environment High-risk assessment through programs such as Falling Star protocol Hip protectors that prevent hip fracture in case of a fall S&P

Others - Osteoporosis Exercise Pain management Orthotic devices

Osteomalacia Softening of the bone tissue characterized by inadequate mineralization of osteoid Vitamin D deficiency, lack of sunlight exposure Similar, but not the same as osteoporosis Major treatment: vitamin D from exposure to sun and certain foods S&P

Paget’s Disease of the Bone
Metabolic disorder of bone remodeling, or turnover; increased resorption (the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) of loss results in bone deposits that are weak, enlarged, and disorganized Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin Surgical management: tibial osteotomy or partial or total joint replacement S&P

Paget’s Disease An imbalance of increase osteoblast and osteoclast cells; thickening and hypertrophy. Bone pain most common symptom; bony enlargement and deformities usually bilateral, kyphosis, long bone. Analgesics, meds bisphosphonates and calcitonin, NSAID, assistance devices, and hot/cold treatment.

Osteomyelitis A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue Exogenous, endogenous, hematogenous, contiguous

Osteomyelitis Infection of bone; causative agent – Staph/Strept
Typical signs and symptoms : Acute osteomyelitis include: Fever that may be abrupt Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection Chronic osteomyelitis include: Warmth, swelling and redness over the area of the infection Pain or tenderness in the affected area Chronic fatigue Drainage from an open wound near the area of the infection Fever, sometimes Treatment – IV antibiotic; long term for 4-6 months

Surgical Management Osteomyelitis
Sequestrectomy (Surgical removal of a sequestrum), a detached piece of necrotic bone that often migrates to a wound, abscess, etc. Bone grafts Bone segment transfers Muscle flaps Amputation

Metastatic Bone Disease
Bone Tumors Benign Bone Tumors Malignant Bone Tumors Metastatic Bone Disease

Benign bone tumors (noncancerous):
Chrondrogenic tumors: osteochondroma, chondroma Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor Fibrogenic tumors

Interventions Nondrug pain relief measures
Drug therapy: analgesics, NSAIDs Surgical therapy: curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis S&P

Malignant Bone Tumors Primary tumors, those tumors that originate in the bone Osteosarcoma Ewing’s sarcoma Chondrosarcoma Fibrosarcoma Metastatic bone disease

Osteosarcoma Cancer of the bone – metastasis to the lung is common. Most in long bones. Clinical manifestations – dull pain, swelling, intermittent but increases per time; night pain common. Treatment – radiation, chemotherapy, hormonal therapy, surgical excision with prosthetics, assistance devices, palliative measures. X-rays – CT scan of bone, MRI, chest xrqys, serum alkaline phosphatase.

Treatment Cancer of Bone
Interventions include: Treatment aimed at reducing the size or removing the tumor Drug therapy; chemotherapy Radiation therapy Surgical management Promotion of physical mobility with ROM exercises

Cancer of Bone Anticipatory Grieving
Interventions include: Active listening Encouraging client and family to verbalize feelings Making appropriate referrals Helping client and others to cope with the loss and grieving Promoting the physician-client relationship

Cancer of Bone Disturbed Body Image
Interventions include: Recognize and accept the client’s view of body image alteration. Establish and maintain a trusting nurse- client relationship. Emphasize the client’s strengths and remaining capabilities. Establish realistic mutual goals.

Potential for Fractures Bone Cancer
Interventions Nonsurgical management: radiation therapy and strengthening exercises. Surgical management: replace as much of the defective bone as possible, avoid a second procedure, and return client to a functioning state with a minimum of hospitalization and immobilization. S&P

Carpal Tunnel Syndrome
Common condition; the median nerve in the wrist becomes compressed, causing pain and numbness Common repetitive strain injury via occupational or sports motions Nonsurgical management: drug therapy and immobilization Possible surgical management S&P

Scoliosis Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments. Milwaukee brace (a back brace used in the treatment of spinal curvatures) , internal fixative devices. Complications of spinal surgery, temporary or permanent paralysis.

Scoliosis Changes in muscles and ligaments on the concave side of the spinal column Congenital, neuromuscular, or idiopathic in type Assessment: complete history, pain assessment, observation of posture Interventions: exercise, weight reduction, bracing, casting, surgery S&P

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