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Musculoskeletal Disorders Part 5: Spinal Column Deformities

MARIA CARMELA L. DOMOCMAT, RN, MSN INSTRUCTOR SCHOOL OF NURSING NORTHERN LUZON ADVENTIST COLLEGE ARTACHO, SISON, PANGASINAN

Overview
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Part 1: Degenerative & Metabolic bone disorders: Part 2: Bone infections Part 3: Muscular disorders Part 4: Disorders of the hand Part 5: Spinal column deformities
Scoliosis Kyphosis Lordosis Osteogenesis imperfecta (OI)

Part 6 : Disorders of foot Part 7: Sports Injuries


Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Spinal column deformities


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Scoliosis Kyphosis Lordosis Osteogenesis imperfecta (OI)

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Scoliosis

Scoliosis
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AKA
Spinal curvature Infantile scoliosis Juvenile scoliosis

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Scoliosis
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is an abnormal curving of the spine. But people with scoliosis have a spine that curves too much. The spine might look like the letter C or S.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Causes, incidence, and risk factors


idiopathic scoliosis
most common type. It is grouped by age. In children age 3 and younger--infantile scoliosis. In kids age 4 - 10--juvenile scoliosis. In older kids age 11 18 --adolescent scoliosis. most often affects girls. Curving generally gets worse during a growth spurt.

Congenital scoliosis
This type of scoliosis is present at birth. It occurs when the babys ribs or spine bones do not form properly.

Neuromuscular scoliosis
This type is caused by a nervous system problem that affects your muscles, such as cerebral palsy, muscular dystrophy, spina bifida, and polio.

Symptoms
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Usually there are no symptoms. But symptoms can include:


Backache or low-back pain Tired feeling in the spine after sitting or standing for a long time Uneven hips or shoulders (one shoulder may be higher than the other) Spine curves more to one side Kyphoscoliosis is another type of abnormal curving of the spine.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Dx exams
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PE: One shoulder is higher than the other, pelvis is tilted X-rays of the spine Spinal curve measurement (scoliometer screening) MRI of the spine

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Scoliometer screening
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Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Treatment
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Treatment depends on many things:


The cause of scoliosis Where the curve is in your spine How big the curve is If body is still growing

Most people with idiopathic scoliosis do not need treatment. However, should be checked by a doctor about every 6 months. If still growing --back brace.
A back brace prevents further curving. There are many different types of braces. Back braces can be adjusted as you grow. Back braces work best in people over age 10. Braces do not work for those with congenital or neuromuscular scoliosis.
Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Scoliosis surgery involves correcting the curve as much as possible.


The spine bones are held in place with one or two metal rods, which are held down with hooks and screws until the bone heals together. Surgery may be done with a cut through the back, belly area, or beneath the ribs. After surgery, you may need to wear a brace for a little while to keep the spine still. if the spine curve is severe or getting worse very quickly. The surgeon may want to wait until all your bones stop growing, but this isnt always possible.
Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Scoliosis treatment may also include:


Emotional support. Some kids, especially teens, may be selfconscious when using a back brace Physical therapy and other specialists to help explain the treatments and make sure the brace fits correctly.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Expectations (prognosis)
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depends on the type, cause, and severity of the curve. The more severe the curving, the more likely it will get worse after stop growing. People with mild scoliosis do very well with braces. They usually do not have long-term problems. However, scoliosis can make more likely to have back pain when get older. The outlook for those with neuromuscular or congenital scoliosis varies. Patients with neuromuscular scoliosis have another serious disorder (like cerebral palsy or muscular dystrophy) so their goals are much different. Often the goal of surgery is simply to allow a child to be able to sit upright in a wheelchair. Congenital scoliosis is difficult to treat and usually requires many surgeries.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Complications
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Breathing problems (in severe scoliosis) Low back pain Lower self-esteem Persistent pain if there is wear and tear of the spine bones Spinal infection after surgery Spine or nerve damage from an uncorrected curve or spinal surgery

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Prevention
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Routine scoliosis screening is now done in middle and junior high schools. Screening has helped detect early scoliosis in many kids.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

References
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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0 002221/ Hedequist DJ. Surgical treatment of congenital scoliosis. Orthop Clin North Am. 2007;38:497-509, vi. [PubMed] Lonner BS. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38:431-440. [PubMed]

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Kyphosis
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Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Kyphosis
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AKA
Scheuermann's disease; Roundback; Hunchback; Postural kyphosis

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Kyphosis
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is a curving of the spine that causes a bowing or rounding of the back, which leads to a hunchback or slouching posture.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Causes, incidence, and risk factors


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Kyphosis can occur at any age, although it is rare at birth. Adolescent kyphosis, also known as Scheuermann's disease, is caused by the wedging together of several bones of the spine (vertebrae) in a row. The cause of Scheuermann's disease is unknown. In adults, kyphosis can be caused by:
Degenerative diseases of the spine (such as arthritis or disk degeneration) Fractures caused by osteoporosis (osteoporotic compression fractures) Injury (trauma) Slipping of one vertebra forward on another (spondylolisthesis)

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Other causes of kyphosis include:


Certain endocrine diseases Connective tissue disorders Infection (such as tuberculosis) Muscular dystrophy Neurofibromatosis Paget's disease Polio Spina bifida Tumors

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

congenital kyphosis
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Clinical photograph and MRI scan of a child with an abrupt congenital kyphosis in the thoracic spine. The MRI scan shows a posteriorly located hemivertebra causing impingement on the spinal cord. (Courtesy of Texas Scottish Rite Hospital for Children)

http://orthoinfo.aaos.org/figures/A00423F02.jpg

3/5/2012

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Kyphosis can also be seen with scoliosis. Each cause has its own risk factors.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Symptoms
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Difficulty breathing (in severe cases) Fatigue Mild back pain Round back appearance Tenderness and stiffness in the spine

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Dx exams
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Physical examination by a health care provider confirms the abnormal curve of the spine. The doctor will also look for any nervous system (neurological) changes (weakness, paralysis, or changes in sensation) below the curve.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Dx exams
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Spine x-ray Pulmonary function tests (if kyphosis affects breathing) MRI (if there may be a tumor, infection, or neurological symptoms)

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Treatment
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Treatment depends on the cause of the disorder:


Congenital kyphosis requires corrective surgery at an early age. Scheuermann's disease is treated with a brace and physical therapy. Occasionally surgery is needed for large (greater than 60 degrees), painful curves.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Treatment
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Treatment depends on the cause of the disorder:


Multiple compression fractures from osteoporosis can be left alone if there are no nervous system problems or pain. However, the osteoporosis needs to be treated to help prevent future fractures. For debilitating deformity or pain, surgery is an option. Kyphosis caused by infection or tumor needs to be treated more aggressively, often with surgery and medications. Treatment for other types of kyphosis depends on the cause. Surgery may be necessary if neurological symptoms or persistent pain develop.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Expectations (prognosis)
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Adolescents with Scheuermann's disease tend to do well even if they need surgery, and the disease stops once they stop growing. If the kyphosis is due to degenerative joint disease or multiple compression fractures, surgery is needed to correct the defect and improve pain.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Complications
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Decreased lung capacity Disabling back pain Neurological symptoms including leg weakness or paralysis Round back deformity

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Prevention
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Treating and preventing osteoporosis can prevent many cases of kyphosis in the elderly. Early diagnosis and bracing of Scheuermann's disease can reduce the need for surgery, but there is no way to prevent the disease.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

References
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Spiegel DA, Hosalkar HS, Dormans JP. The spine. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 678. Freeman BL III. Scoliosis and kyphosis. In: Canale ST, Beaty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 38. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0 002220/
Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Lordosis
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Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Lordosis is an increased curving of the spine. AKA: Swayback

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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The spine has three types of curves:


Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs). Lordotic curves refer to the inward curve of the lumbar spine (just above the buttocks). Scoliotic curving is a sideways curvature of the spine and is always abnormal.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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A small degree of both kyphotic and lordotic curvature is normal. Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann's disease).

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Too much lordotic curving is called swayback (lordosis). Lordosis tends to make the buttocks appear more prominent. Children with significant lordosis will have a significant space beneath their lower back when lying on their back on a hard surface. If the lordotic curve is flexible (when the child bends forward the curve reverses itself), it is generally not a concern. If the curve does not move, medical evaluation and treatment are needed.
Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Causes
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Achondroplasia Benign juvenile lordosis (not medically significant) Spondylolisthesis

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Achondroplasia is a disorder of bone growth that causes the most common type of dwarfism. Achondroplasia is one of a group of disorders called chondrodystrophies or osteochondrodysplasias. Achondroplasia may be inherited as an autosomal dominant trait, which means that if a child gets the defective gene from one parent, the child will have the disorder. If one parent has achondroplasia, the infant has a 50% chance of inheriting the disorder. If both parents have the condition, the infant's chances of being affected increase to 75%. However, most cases appear as spontaneous mutations. This means that two parents without achondroplasia may give birth to a baby with the condition.
Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Spondylolisthesis is a condition in which a bone (vertebra) in the lower part of the spine slips out of the proper position onto the bone below it. In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma). In adults, the most common cause is degenerative disease (such as arthritis). The slip usually occurs between the fourth and fifth lumbar vertebrae. Other causes of spondylolisthesis include bone diseases, traumatic fractures, and stress fractures (commonly seen in gymnasts). Certain sport activities, such as gymnastics, weight lifting, and football, put a great deal of stress on the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Home Care
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If the back is flexible, lordosis is usually not treated and will not progress or cause problems.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Call health care provider if notice that child has an exaggerated posture or a curve in the back. The condition should be evaluated to determine if there is a medical problem.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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physical exam. The child may be asked to bend forward, to the side, and to lie flat on a table so that the spine can be examined in a variety of positions.

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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In some cases, particularly if the curve seems "fixed" (not bendable), the following or other diagnostic tests may be recommended:
Lumbosacral spine x-ray Spine x-ray Other tests to rule out suspected disorders causing the condition

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Treatment
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Specific treatment for lordosis will be determined by child's physician based on:
your child's age, overall health, and medical history the extent of the condition child's tolerance for specific medications, procedures, or therapies expectations for the course of the condition Paretns opinion or preference

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/ lordosis.html

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Treatment
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Observation physical therapy bracing. most severe cases require surgery

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Treatment
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The goal of treatment is to stop the progression of the curve and prevent deformity. Management of lordosis will depend upon the cause of the lordosis. Simple exercises may be sufficient if lordosis is associated with poor posture. However, lordosis occurring as a result of a hip problem may be treated as a part of the hip problem.
http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/ lordosis.html

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

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Maria Carmela L. Domocmat, RN, MSN

3/5/2012

References
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Spiegel DA, Dormans JP. The spine.In: Kliegman RM,Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics.19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 671. http://www.lpch.org/DiseaseHealthInfo/HealthLibr ary/orthopaedics/lordosis.html

Maria Carmela L. Domocmat, RN, MSN

3/5/2012

Osteogenesis imperfecta (OI)

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http://www.oif.org/images/content/pagebuilder/94682.jpg

Maria Carmela L. Domocmat, RN, MSN

Osteogenesis62 imperfecta (OI)


AKA: Brittle bone disease rare genetic disorder in which bone are fragile and

fracture easily resulting in bone deformity an autosomal dominant disease

A person with OI has a 50% chance of passing on the gene and the disease to their children.

involves errors in synthesis of collagen, a connective

tissue

Maria Carmela L. Domocmat, RN, MSN

Types according to Silence classification system


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o has four types based on inheritance as autosomal

dominant or autosomal recessive and clinical findings of each type o Types I and IV more mild manifestations of disease; can persist into adulthood o Types II and III more severe and can result in fracture in utero, during the birthing process, or in early childhood; associated with high mortality rate

Maria Carmela L. Domocmat, RN, MSN

Type 1 osteogenesis
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most common. People who have type 1 disease generally reach normal height and have few obvious skeletal deformities. typically causes more fractures during childhood than in adulthood. Hearing loss is pronounced and begins early in childhood.

Maria Carmela L. Domocmat, RN, MSN

Type 2 osteogenesis imperfecta


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most rare and the most severe. produces numerous deformities of the skeleton often is fatal in infancy. abnormal collagen formation also profoundly affects the lungs, causing significant breathing problems.

Maria Carmela L. Domocmat, RN, MSN

Type 4 osteogenesis imperfecta


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more severe than type 1 but less severe than type 3. Fractures are most common before puberty. Hearing loss begins in early childhood and is often profound

Maria Carmela L. Domocmat, RN, MSN

Type 3 osteogenesis imperfecta


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produces obvious skeletal deformities. Fractures before birth are common; UTZ can detect them in the fetus. also affects the lungs and muscles. Hearing loss begins in early childhood and often becomes complete by adolescence.

http://www.beltina.org/health-dictionary/osteogenesis-imperfecta-typestreatment.html

Maria Carmela L. Domocmat, RN, MSN

s/s
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All people with OI have weak bones, which makes them susceptible to fractures. Persons with OI are usually below average height (short stature). However, the severity of the disease varies greatly

Maria Carmela L. Domocmat, RN, MSN

s/s
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The classic symptoms include:


osteoporosis history of multiple fractures bone deformity poor skeletal development soft brownish teeth hearing loss Blue tint to the whites of their eyes (blue sclera) Because type I collagen is also found in ligaments, persons with OI often have loose joints (hypermobility) and flat feet.

Maria Carmela L. Domocmat, RN, MSN

s/s
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Symptoms of more severe forms of OI may include:


Bowed legs and arms Kyphosis Scoliosis (S-curve spine)

Maria Carmela L. Domocmat, RN, MSN

bone deformity
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Maria Carmela L. Domocmat, RN, MSN

blue sclerae
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http://www.thachers.org/images/Osteogenesis_imperfecta_blue_sclera.JPG

http://cnx.org/content/m15020/latest/Cases_40_41_42-pres1-1.jpg

Maria Carmela L. Domocmat, RN, MSN

soft brownish teeth; bone deformity


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http://jorthod.maneyjournals.org/content/vol30/issue4/images/large/Ki nd.f1c.jpeg

http://www.beltina.org/pics/osteogenesis_imperfecta.j pg
Maria Carmela L. Domocmat, RN, MSN

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This baby's extremities are positioned oddly because there have been multiple fractures due to osteogenesis imperfecta (OI). This disease leads to multiple fractures. The basic problem is a defect in the formation of type 1 collagen that forms bone matrix. There are several types of OI with different inheritance patterns. http://medgen.genetics.utah.edu/photographs/diseases/high/peri021.jpg

Maria Carmela L. Domocmat, RN, MSN

Dx:
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serum alkaline phosphatase increased

Maria Carmela L. Domocmat, RN, MSN

Treatment
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Treatment for fracture - generally conservative


targeting a balance between immobilizing the fracture long enough for it to heal and allowing normal muscle function as quickly as possible.

Physical activity
helps strengthen muscles and bone, which in turn minimizes fractures.

The most numerous fractures occur during childhood when the bones are growing and thus have lower mineral content. The risk for fracture is lifelong, however, and may increase in women after menopause when bone density naturally declines.
Maria Carmela L. Domocmat, RN, MSN

Treatment
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palliative steroids calcium vit C sodium fluoride PT casting bracing telescoping intramedullary rods to maintain mobility and promote ambulation o research ongoing Biphophonates
o o o o o o o o o

Maria Carmela L. Domocmat, RN, MSN

Expectations (prognosis)
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How well a person does depends on the type of OI they have. Type I, or mild OI, is the most common form. Persons with this type can live a normal lifespan. Type II is a severe form that is usually leads to death in the first year of life.
Type III is also called severe OI. Persons with this type have many fractures starting very early in life and can have severe bone deformities. Many become wheelchair bound and usually have a somewhat shortened life expectancy.

Maria Carmela L. Domocmat, RN, MSN

Expectations (prognosis)
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Type IV, or moderately severe OI, is similar to type I, although persons with type IV often need braces or crutches to walk. Life expectancy is normal or near normal. There are other types of OI, but they occur very infrequently and most are considered subtypes of the moderately severe form (type IV).

Maria Carmela L. Domocmat, RN, MSN

Complications
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Complications are largely based on the type of OI present. They are often directly related to the problems with weak bones and multiple fractures.

Hearing loss (common in type I and type III) Heart failure (type II) Respiratory problems and pneumonias due to chest wall deformities Spinal cord or brain stem problems Permanent deformity

Maria Carmela L. Domocmat, RN, MSN

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http://jorthod.maneyjournals.org/content/vol30/issue4/images/large/Ki nd.f1c.jpeg

Maria Carmela L. Domocmat, RN, MSN

Resources
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Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0 002540/ http://www.beltina.org/healthdictionary/osteogenesis-imperfecta-typestreatment.html http://www.oif.org/site/PageServer http://www.umm.edu/ency/article/001573.htm

Maria Carmela L. Domocmat, RN, MSN