Musculoskeletal Musculoskeletal System Assessment & System Assessment &

DisordersDisorders

Dr Ibraheem Bashayreh, RN, PhD

Skeletal SystemSkeletal SystemBone typesBone structureBone functionBone growth and metabolism

affected by calcium and phosphorous, calcitonin, vitamin D, parathyroid, growth hormone, glucocorticoids, estrogens and androgens, thyroxine, and insulin.

BonesBones

Human skeleton has 206 bonesProvide structure and support for soft

tissueProtect vital organs

Figure 41-1 Bones of the human skeleton.Figure 41-1 Bones of the human skeleton.

Figure 41-2 Classification of bones by shape.Figure 41-2 Classification of bones by shape.

BonesBonesCompact bone

◦Smooth and dense◦Forms shaft of long bones and

outside layer of other bonesSpongy bone

◦Contains spaces◦Spongy sections contain bone

marrow

Bone MarrowBone MarrowRed bone marrow

◦Found in flat bones of sternum, ribs, and ileum

◦Produces blood cells and hemoglobinYellow bone marrow

◦Found in shaft of long bones◦Contains fat and connective tissue

Joints (Articulations)Joints (Articulations)Area where two or more bones

meetHolds skeleton together while

allowing body to move

JointsJointsSynarthrosis

◦Immovable (e.g., skull)Amphiarthrosis

◦Slightly movable (e.g., vertebral joints)

Diarthrosis or synovial◦Freely movable (e.g., shoulders,

hips)

Synovial JointsSynovial JointsFound at all limb articulationsSurface covered with cartilageJoint cavity covered with tough

fibrous capsuleCavity lined with synovial

membrane and filled with synovial fluid

LigamentsLigamentsBands of connective tissue that

connect bone to boneEither limit or enhance

movementProvide joint stabilityEnhance joint strength

TendonsTendonsFibrous connective tissue bands

that connect bone to musclesEnable bones to move when

muscles contract

MusclesMusclesSkeletal (voluntary)

◦Allows voluntary movementSmooth (involuntary)

◦Muscle movement controlled by internal mechanism

◦e.g., muscles in bladder wall and GI system

Cardiac (involuntary)◦Found in heart

Skeletal MuscleSkeletal Muscle600 skeletal musclesMade up of thick bundles of

parallel fibersEach muscle fiber made up of

smaller structure myofibrilsMyofibrils are strands of

repeating units called sarcomeres

Skeletal MuscleSkeletal MuscleSkeletal muscle contracts with

the release of acetylcholineThe more fibers that contract,

the stronger the muscle contraction

Changes in Older AdultChanges in Older AdultMusculoskeletal changes can be

due to:◦Aging process◦Decreased activity◦Lifestyle factors

Changes in Older AdultChanges in Older AdultLoss of bone mass in older

womenJoint and disk cartilage

dehydrates causing loss of flexibility contributes to degenerative joint disease (osteoarthritis); joints stiffen, lose range of motion

Changes in Older AdultChanges in Older AdultCause stooped posture, changing

center of gravityElderly at greater risk for fallsEndocrine changes cause skeletal

muscle atrophyMuscle tone decreases

AssessmentAssessmentHealth historyChief complaintOnset of problemEffect on ADLsPrecipitating events, e.g., trauma

AssessmentAssessmentExamine complaints of pain for

location, duration, radiation character (sharp dull), aggravating, or alleviating factors

Inquire about fever, fatigue, weight changes, rash, or swelling

Physical ExaminationPhysical ExaminationPostureGaitAbility to walk with or without

assistive devicesAbility to feed, toilet, and dress

selfMuscle mass and symmetry

Physical ExaminationPhysical ExaminationInspect 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 ExaminationPhysical ExaminationNever 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 41-4 Checking for the bulge sign.

Figure 41-5 Checking for ballottement.Figure 41-5 Checking for ballottement.

Diagnostic TestsDiagnostic TestsBlood testsArthrocentesisX-raysBone density scanCT scanMRIUltrasoundBone scan

Diagnostic EvaluationDiagnostic EvaluationImaging Procedures – CT, Bone Scan, MRINuclear Studies - radioisotope bone density, Endoscopic Studies –arthrocentesis,

arthroscopyOther Studies –biopsy, synovial fluid,

Arthrogram, venogram, ElectromyographyMyelography*Laboratory Studies

MusculoskeletalMusculoskeletalAssessment – Diagnostic TestAssessment – Diagnostic TestLaboratory

◦ 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

MuscoluloskeletalMuscoluloskeletalAssessment – DiagnosticAssessment – Diagnostic

Blood Tests◦ CBC – Hgb, Hct◦ Acid phosphatase◦ Metabolic/

Endocrine◦ Enzymes

Increase creatine kinase, serum increase glutamin-oxaloacetic due to muscle damage, aldolase, SGOT

Musculoskeletal - Musculoskeletal - RadiographicRadiographic

Standard radiography, tomography and xeroradiography, myelography, arthrography and CT

Other diagnostic tests: bone and muscle biopsy

ArthroscopyArthroscopyFiberoptic 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 ScanBone ScanNuclear 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

ArthroscopyArthroscopyFlexible 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 Interventions for Clients with Musculoskeletal with Musculoskeletal TraumaTrauma

Musculoskeletal TraumaMusculoskeletal TraumaTissue is subjected to more force

than it can absorbSeverity depends on:

◦Amount of force◦Location of impact

Musculoskeletal TraumaMusculoskeletal TraumaMild to severeSoft tissueFractures

◦Affect function of muscle, tendons, and ligaments

Complete amputation

Preventing TraumaPreventing TraumaTeach importance of using safety

equipment◦Seat belts◦Bicycle helmets◦Football pads◦Proper footwear◦Protective eyewear◦Hard hats

Soft Tissue TraumaSoft Tissue TraumaContusion

◦Bleeding into soft tissue◦Significant bleeding can cause a

hematoma◦Swelling and discoloration (bruise)

Soft Tissue Trauma - SprainSoft Tissue Trauma - Sprain

Ligament injury (Excessive stretching of a ligament)

Twisting motionOverstretching 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

SprainsSprains 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 - StrainSoft Tissue Trauma - StrainMicroscopic tear in the muscleMay cause bleeding“Pulled muscle”Inappropriate lifting or sudden

acceleration-deceleration

Soft Tissue TraumaSoft Tissue TraumaTo 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 TraumaSoft Tissue TraumaDiagnosis

◦X-ray to rule out fracture◦MRI

FracturesFracturesBreak in the continuity of bone

◦Direct blow◦Crushing force (compression)◦Sudden twisting motions (torsion)◦Severe muscle contraction◦Disease (pathologic fracture)

FracturesFracturesClassification of FracturesClassification of Fractures

Closed or simpleOpen or compoundComplete or incompleteStable or unstableDirection of the fracture line

◦Oblique◦Spiral◦Lengthwise plane (greenstick)

Stages of Bone HealingStages of Bone HealingHematoma formation within 48

to 72 hr after injuryHematoma to granulation tissueCallus formationOsteoblastic proliferationBone remodelingBone healing completed within

about 6 weeks; up to 6 months in the older person

Fractures – Emergency CareFractures – Emergency CareImmobilize before moving clientJoint above and belowCheck pulse, color, movement,

sensation before splintingSterile dressing for open wounds

Fractures – Emergency CareFractures – Emergency CareFracture reduction

◦Closed—external manipulation◦Open—surgery

Acute Compartment SyndromeAcute Compartment Syndrome Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area

Prevention of pressure buildup of blood or fluid accumulation

Pathophysiologic changes sometimes referred to as ischemia-edema cycle

Emergency Care - Acute Emergency Care - Acute Compartment SyndromeCompartment Syndrome

Within 4 to 6 hr after the onset of acute compartment syndrome, neuromuscular damage is irreversible; the limb can become useless within 24 to 48 hr.

Monitor compartment pressures.

(Continued)

Emergency Care Emergency Care (Continued)(Continued)

Fasciotomy may be performed to relieve pressure.

Pack and dress the wound after fasciotomy.

Possible Results of Acute Compartment Possible Results of Acute Compartment SyndromeSyndrome

InfectionMotor weaknessVolkmann’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 FracturesOther Complications of Fractures

ShockFat 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 Other Complications of Fractures (Continued)(Continued)

InfectionIschemic necrosisFracture blisters, delayed union, nonunion, and malunion

MusculoskeletalMusculoskeletalComplicationsComplications (continued)(continued)

Muscle Atrophy, loss of muscle strength range of motion, pressure ulcers, and other problems associated with immobility

Embolism/Pneumonia/ARDS◦ TREATMENT – hydration, albumin,

corticosteroidsConstipation/AnorexiaUTIDVT

Musculoskeletal Assessment - Musculoskeletal Assessment - FractureFracture

Change in bone alignmentAlteration in length of extremity

Change in shape of bonePain upon movementDecreased ROMCrepitationEcchymotic skin

(Continued)

Musculoskeletal AssessmentMusculoskeletal Assessment – Fracture – Fracture (Continued)(Continued)

Subcutaneous emphysema with bubbles under the skin

Swelling at the fracture site

Special Assessment ConsiderationsSpecial 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 CASTCAST

CastsCasts 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 Casts (Continued)(Continued)

Cast care and client educationCast complications: infection,

circulation impairment, peripheral nerve damage, complications of immobility

Managing Care of the Patient in a CastManaging Care of the Patient in a Cast

Casting MaterialsRelieving PainImproving MobilityPromoting HealingNeurovascular FunctionPotential Complications

Cast, Splint, Braces, and Traction Cast, Splint, Braces, and Traction Management ConsiderationsManagement Considerations

Arm CastsLeg CastsBody or Spica CastsSplints and BracesExternal FixatorTraction

http://www0.sun.ac.za/ortho/webct-ortho/general/trac/foot-skin.jpg

POLYESTER/POLYESTER/FIBERGLASSFIBERGLASS

UPPER EXTREMITY CASTUPPER EXTREMITY CAST

LOWER EXTREMITY CASTLOWER EXTREMITY CAST

MusculoskeletalMusculoskeletalNursing Care - CastsNursing Care - Casts

◦ Neurovascular Check

color/capillary refill

Temperature Pulse Movement Sensation

Traction Nursing Care ◦ Pin Site care◦ Skin and

neurovascular check

Cast Care Cast Care (continued)(continued)

Elevate ExtremityExercises – to unaffected side; isometric

exercises to affected extremityKeep heel off mattressHandle with palms of hands if cast wetTurn every two hours till dryNotify MD at once of wound drainageDo not place items under cast.

TractionTraction 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 Traction (Continued)(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 – FracturesMusculoskeletal – FracturesTreatmentTreatment

Primary Goal – reduce fracture-◦ Realign and immobilize

Medications◦ Analgesics, antibiotics, tetanus toxoid

Closed Reduction – Manual and Cast; External Fixation Device

Traction; Splints; BracesSurgery

◦ Open reduction with internal fixation◦ Reconstructive surgery◦ Endoprosthetic replacement

Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external Figure 42-5 In external fixation, pins placed through the bone above and below the fracture are attached to external fixation rods that hold the pins and bone in place.fixation rods that hold the pins and bone in place.

Nursing ManagementNursing ManagementPositioning

Strengthening Exercises

Potential Complications

Musculoskeletal Musculoskeletal Nursing CareNursing Care

Promote comfortAssess infectionPromote mobilityTeach safetyVital SignsFlotation, sheep

skinNutritionVital SignsMonitor

elimination

Elevate extremity to decrease swelling/ ice pack

Teach skin care, cast care, diet, complications

Operative ProceduresOperative Procedures

Open reduction with internal fixation

External fixationPostoperative 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 Managing the Patient Undergoing Orthopedic SurgeryOrthopedic Surgery

Joint ReplacementTotal Hip ReplacementTotal Knee Replacement

Risk for InfectionRisk for Infection

Interventions include:◦Apply strict aseptic technique for dressing changes and wound irrigations.

◦Assess for local inflammation◦Report purulent drainage immediately to health care provider.

(Continued)

Risk for Infection Risk for Infection (Continued)(Continued)

◦Assess for pneumonia and urinary tract infection.

◦Administer broad-spectrum antibiotics prophylactically.

Imbalanced Nutrition: Less Than Body Imbalanced Nutrition: Less Than Body RequirementsRequirements

Interventions include:◦Diet high in protein, calories, and calcium, supplemental vitamins B and C

◦Frequent small feedings and supplements of high-protein liquids

◦Intake of foods high in iron

Upper Extremity FracturesUpper Extremity Fractures

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

Lower Extremity FracturesLower Extremity Fractures

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

Fractures of the HipFractures of the HipIntracapsular 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

Fractures of the PelvisFractures of the Pelvis Associated internal damage the chief concern in fracture management of pelvic fractures

Non–weight-bearing fracture of the pelvis

Weight-bearing fracture of the pelvis

Compression Fractures of the SpineCompression 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 Compression Fractures of the Spine (Continued)(Continued)

Nonsurgical management includes bedrest, analgesics, and physical therapy.

Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected.

(Continued)

AmputationsAmputations

Surgical amputationTraumatic amputationLevels of amputationComplications of amputations: hemorrhage, infection, phantom limb pain, problems associated with immobility, neuroma (a growth or tumour of nerve tissue), flexion contracture

AmputationAmputation

Nursing Management◦relieving pain◦minimizing altered sensory perception

◦promoting wound healing◦enhancing body image◦self-care

Phantom Limb PainPhantom 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 PainManagement 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 PainManagement of Phantom Pain (Continued)(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 AmputationExercise After Amputation ROM to prevent flexion contractures, particularly of the hip and knee

Trapeze and overhead frameFirm mattressProne position every 3 to 4 hours

Elevation of lower-leg residual limb controversial

ProsthesesProstheses Devices to help shape and shrink the residual limb and help client readapt

Wrapping of elastic bandagesIndividual fitting of the prosthesis; special care

Crush SyndromeCrush SyndromeCan occur when leg or arm injury

includes multiple compartmentsCharacterized by acute

compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, and acute tubular necrosis

Treatment: adequate intravenous fluids, low-dose dopamine, sodium bicarbonate, kayexalate, and hemodialysis

Metabolic Bone DisordersMetabolic Bone Disorders

OsteoporosisOsteomalciaPaget’s Disease

OsteoporosisOsteoporosis

A disease in which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity.

Clinical Manifestations – bone pain, decrease movement.

Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, SERM (Selective Estrogen Receptor Modulator) with anti-estrogens, exercise.

Pathologic fracture-safety.

Classification of Classification of OsteoporosisOsteoporosis

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 Health Promotion/Illness Prevention - OsteoporosisPrevention - Osteoporosis

Ensure adequate calcium intake.

Avoid sedentary life style (a type of lifestyle with a lack of physical exercise) .

Continue program of weight-bearing exercises.

Osteoporosis - AssessmentOsteoporosis - Assessment Physical assessmentPsychosocial assessmentLaboratory assessmentRadiographic assessment

OsOsteoprosis

Osteoprorsis

Drug TherapyDrug TherapyOsteoporosisOsteoporosis

Hormone replacement therapyParathyroid hormoneCalcium and vitamin DBisphosphonatesSelective estrogen receptor modulators

CalcitoninOther agents used with varying results

Diet Therapy - OsteoporosisDiet Therapy - Osteoporosis

ProteinMagnesiumVitamin KTrace mineralsCalcium and vitamin D Avoid alcohol and caffeine

Fall Prevention - Fall Prevention - OsteoporosisOsteoporosis

Hazard-free environmentHigh-risk assessment through programs such as Falling Star protocol

Hip protectors that prevent hip fracture in case of a fall

Others - OsteoporosisOthers - Osteoporosis

ExercisePain managementOrthotic devices

OsteomalaciaOsteomalacia Softening of the bone tissue

characterized by inadequate mineralization of osteoid

Vitamin D deficiency, lack of sunlight exposure

Similar, but not the same as osteoporosis

Major treatment: vitamin D from exposure to sun and certain foods

Paget’s Disease of the BonePaget’s Disease of the Bone Metabolic disorder of bone

remodeling, or turnover; increased resorption (the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) of loss results in bone deposits that are weak, enlarged, and disorganized

Nonsurgical management: calcitonin, selected bisphosphonates, mithramycin

Surgical management: tibial osteotomy or partial or total joint replacement

Paget’s DiseasePaget’s DiseaseAn 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.

OsteomyelitisOsteomyelitis A condition caused by the invasion by one or more pathogenic microorganisms that stimulates the inflammatory response in bone tissue

Exogenous, endogenous, hematogenous, contiguous

OsteomyelitisOsteomyelitis 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 ManagementSurgical Management Osteomyelitis Osteomyelitis

Sequestrectomy (Surgical removal of a sequestrum), a detached piece of necrotic bone that often migrates to a wound, abscess, etc.

Bone graftsBone segment transfersMuscle flapsAmputation

Bone TumorsBone Tumors

Benign Bone TumorsMalignant Bone TumorsMetastatic Bone Disease

Bone TumorsBone Tumors Benign bone tumors

(noncancerous):◦Chrondrogenic tumors: osteochondroma, chondroma

◦Osteogenic tumors: osteoid osteoma, osteoblastoma, giant cell tumor

◦Fibrogenic tumors

Interventions Interventions Nondrug pain relief measuresDrug therapy: analgesics, NSAIDs

Surgical therapy: curettage (simple excision of the tumor tissue), joint replacement, or arthrodesis

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

OsteosarcomaOsteosarcomaCancer of the bone – metastasis to

the lung is common. Most in long bones.

Clinical manifestations – dull pain, swelling, intermittent but increases per time; night pain common.

Treatment – radiation, chemotherapy, hormonal therapy, surgical excision with prosthetics, assistance devices, palliative measures.

Treatment Cancer of BoneTreatment Cancer of BoneInterventions 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 Cancer of Bone Anticipatory GrievingAnticipatory 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 BoneCancer of Bone Disturbed Body Image 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 FracturesPotential for FracturesBone CancerBone Cancer

Interventions◦Nonsurgical management: radiation therapy and strengthening exercises.

◦Surgical management: replace as much of the defective bone as possible, avoid a second procedure, and return client to a functioning state with a minimum of hospitalization and immobilization.

Carpal Tunnel SyndromeCarpal 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

ScoliosisScoliosis

Abnormal spinal curvature of various degrees or severity involving shortening of muscles and ligaments.

Milwaukee brace (a back brace used in the treatment of spinal curvatures) , internal fixative devices.

Scoliosis 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