Spinal Column Deformities

Musculoskeletal Disorders Part 5
Spinal Column Deformities: Kyphosis, Lordosis, Scoliosis, Osteogenesis Imperfecta

1. Musculoskeletal Disorders Part 5:
Spinal Column Deformities
MARIA CARMELA L. DOMOCMAT, RN, MSN
INSTRUCTOR
SCHOOL OF NURSING
NORTHERN LUZON ADVENTIST COLLEGE
ARTACHO, SISON, PANGASINAN

2. Overview
2
M
Part 1: Degenerative & Metabolic bone disorders:
M
Part 2: Bone infections
M
Part 3: Muscular disorders
M
Part 4: Disorders of the hand
M
Part 5: Spinal column deformities
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Part 5: Spinal column deformities M
Scoliosis
M
Kyphosis
M
Lordosis
M
Osteogenesisimperfecta(OI)
M
Part 6 : Disorders of foot
M
Part 7: Sports Injuries

3. Spinal column deformities
3
M
Scoliosis
M
Kyphosis
M
Lordosis
M
Osteogenesisimperfecta(OI)
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

4. Scoliosis

5. Scoliosis
5
M
AKA M
Spinal curvature
M
Infantile scoliosis
M
Juvenile scoliosis
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

7. Scoliosis
7
M
is an abnormal curving of the spine.
M
But people with scoliosis have a spine that curves too
much. The spine might look like the letter “C” or “ S.”
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

11. Causes, incidence, and risk factors
M
idiopathic scoliosis M
most common type. It is grouped by age.
M
In children age 3 and younger--infantile scoliosis.
M
In kids age 4 -10--juvenile scoliosis.
M
In older kids age 11 –18 --adolescent scoliosis.
M
most often affects girls. Curving generally gets worse during a growth spurt.
M
Curving generally gets worse during a growth spurt.
M
Congenital scoliosis M
This type of scoliosis is present at birth. It occu rs when the baby’s
ribs or spine bones do not form properly.
M
Neuromuscular scoliosis M
This type is caused by a nervous system problem tha t affects your
muscles, such as
cerebral palsy
,
muscular dystrophy
, spinabifida,
and
polio
.

12. Symptoms
12
M
Usually there are no symptoms. But symptoms can
include:
M
Backache or low-back pain
M
Tired feeling in the spine after sitting or standin g for a long time
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
time
M
Uneven hips or shoulders (one shoulder may be higher than
the other)
M
Spine curves more to one side
M
Kyphoscoliosisis another type of abnormal curving o f the
spine.

13. Dxexams
13
M
PE: One shoulder is higher than the other, pelvis is
tilted M
X-rays of the spine
M
Spinal curve measurement (scoliometerscreening)
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
MRI of the spine

14. Scoliometerscreening
14
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

15. Treatment
15
M
Treatment depends on many things: M
The cause of scoliosis
M
Where the curve is in your spine
M
How big the curve is
M
If body is still growing
M
Most people with idiopathic scoliosis do not need
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Most people with idiopathic scoliosis do not need treatment. However, should be checked by a doctor
about every 6 months.
M
If still growing --back brace. M
A back brace prevents further curving. There are ma ny different
types of braces. Back braces can be adjusted as you grow. M
Back braces work best in people over age 10. Braces do not work for
those with congenital or neuromuscular scoliosis.

16. 16
M
Scoliosis surgery involves correcting the curve as
much as possible.
M
The spine bones are held in place with one or two m etal rods,
which are held down with hooks and screws until the bone
heals together.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
heals together.
M
Surgery may be done with a cut through the back, be lly area, or
beneath the ribs.
M
After surgery, you may need to wear a brace for a l ittle while to
keep the spine still.
M
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 isn’t always possible.

17. 17
M
Scoliosis treatment may also include: M
Emotional support. Some kids, especially teens, may be self-
conscious when using a back brace
M
Physical therapy and other specialists to help expl ain the treatments and make sure the brace fits correctly.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
treatments and make sure the brace fits correctly.

18. Expectations (prognosis)
18
M
depends on the type, cause, and severity of the cur ve. The more
severe the curving, the more likely it will get wor se after stop
growing.
M
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.
M
The outlook for those with neuromuscular or congenital scoliosis
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
The outlook for those with neuromuscular or congenital scoliosis varies.
M
Patients with neuromuscular scoliosis have another serious disorder
(like cerebral palsy or muscular dystrophy) so thei r goals are much
different.
M
Often the goal of surgery is simply to allow a chil d to be able to sit
upright in a wheelchair.
M
Congenital scoliosis is difficult to treat and usua lly requires many
surgeries.

19. Complications
19
M
Breathing problems (in severe scoliosis)
M
Low back pain
M
Lower self-esteem
M
Persistent pain if there is wear and tear of the sp ine
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Persistent pain if there is wear and tear of the sp ine bones
M
Spinal infection after surgery
M
Spine or nerve damage from an uncorrected curve or
spinal surgery

20. Prevention
20
M
Routine scoliosis screening is now done in middle
and junior high schools.
M
Screening has helped detect early scoliosis in many
kids.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

26. References
26
M
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0 002221/
M
HedequistDJ. Surgical treatment of congenital
scoliosis. OrthopClinNorth Am.2007;38:497-509,
vi. [
PubMed
]
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
vi. [
PubMed
]
M
LonnerBS. Emerging minimally invasive
technologies for the management of scoliosis.
OrthopClinNorth Am. 2007;38:431-440. [
PubMed
]

27. 27
Kyphosis
Maria Carmela L. Domocmat, RN, MSN3/5/2012

28. Kyphosis
28
M
AKA M
Scheuermann'sdisease;
M
Roundback;
M
Hunchback;
M
Postural
kyphosis
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Postural
kyphosis

29. Kyphosis
29
M
is a curving of the spine that causes a bowing or
rounding of the back, which leads to a hunchback or
slouching posture.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

30. Causes, incidence, and risk factors
30 M
Kyphosiscan occur at any age, although it is rare a t birth.
M
Adolescent kyphosis, also known as Scheuermann's
disease, is caused by the wedging together of sever al
bones of the spine (vertebrae) in a row. The cause o f
Scheuermann'sdisease is unknown.
In adults,
kyphosis
can be caused by:
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
In adults,
kyphosis
can be caused by:
M
Degenerative diseases of the spine (such as arthrit is or disk
degeneration) M
Fractures caused by osteoporosis (osteoporotic comp ression
fractures) M
Injury (trauma)
M
Slipping of one vertebra forward on another (spondy lolisthesis)

31. 31
M
Other causes of kyphosisinclude: M
Certain endocrine diseases
M
Connective tissue disorders
M
Infection (such as tuberculosis)
M
Muscular dystrophy
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Muscular dystrophy
M
Neurofibromatosis
M
Paget's disease
M
Polio
M
Spinabifida
M
Tumors

32. congenital kyphosis
32
M
Clinical photograph and
MRI scan of a child with
an abrupt congenital
kyphosisin the thoracic
spine. The MRI scan
shows a
posteriorly
3/5/2012 http://orthoinfo.aaos.org/figures/A00423F02.jpg
shows a
posteriorly
located hemivertebra
causing impingement on
the spinal cord.
M
(Courtesy of Texas
Scottish Rite Hospital for
Children)

33. 33
M
Kyphosiscan also be seen with scoliosis. Each cause
has its own risk factors.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

34. Symptoms
34
M
Difficulty breathing (in severe cases)
M
Fatigue
M
Mild back pain
M
Round back appearance
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Round back appearance
M
Tenderness and stiffness in the spine

35. Dxexams
35
M
Physical examination by a health care provider
confirms the abnormal curve of the spine. The docto r
will also look for any nervous system (neurological )
changes (weakness, paralysis, or changes in
sensation) below the curve.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
sensation) below the curve.

36. Dxexams
36
M
Spine x-ray
M
Pulmonary function tests (if kyphosisaffects
breathing)
M
MRI (if there may be a tumor, infection, or neurological symptoms)
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
neurological symptoms)

37. Treatment
37
M
Treatment depends on the cause of the disorder: M
Congenital kyphosisrequires corrective surgery at a n early age.
M
Scheuermann'sdisease is treated with a brace and ph ysical
therapy. Occasionally surgery is needed for large ( greater than
60 degrees), painful curves.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
60 degrees), painful curves.

38. Treatment
38
M
Treatment depends on the cause of the disorder: M
Multiple compression fractures from osteoporosis ca n be left
alone if there are no nervous system problems or pa in.
However, the osteoporosis needs to be treated to he lp prevent
future fractures. For debilitating deformity or pai n, surgery is
an option.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
an option.
M
Kyphosiscaused by infection or tumorneeds to be treated
more aggressively, often with surgery and medicatio ns.
M
Treatment for other types of kyphosisdepends on the cause.
Surgery may be necessary if neurological symptoms or
persistent pain develop.

39. Expectations (prognosis)
39
M
Adolescents with Scheuermann'sdisease tend to do
well even if they need surgery, and the disease sto ps
once they stop growing.
M
If the kyphosisis due to degenerative joint disease or multiple compression fractures, surgery is needed t o
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
multiple compression fractures, surgery is needed t o correct the defect and improve pain.

40. Complications
40
M
Decreased lung capacity
M
Disabling back pain
M
Neurological symptoms including leg weakness or
paralysis
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Round back deformity

41. Prevention
41
M
Treating and preventing osteoporosis can prevent
many cases of kyphosisin the elderly.
M
Early diagnosis and bracing of Scheuermann's
disease can reduce the need for surgery, but there is
no way to prevent the disease.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
no way to prevent the disease.

42. References
42
M
Spiegel DA, HosalkarHS, DormansJP. The spine.
In: KliegmanRM, Behrman RE, Jenson HB, Stanton
BF, eds. Nelson Textbook of Pediatrics.18th ed.
Philadelphia, Pa: Saunders Elsevier; 2007:chap 678.
M
Freeman BL III. Scoliosis and
kyphosis
. In:
Canale
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Freeman BL III. Scoliosis and
kyphosis
. In:
Canale
ST, BeatyJH, eds. Campbell's Operative
Orthopaedics. 11th ed. Philadelphia, Pa: Mosby
Elsevier; 2007:chap 38.
M
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0
002220/

43. 43
Lordosis
Maria Carmela L. Domocmat, RN, MSN3/5/2012

44. 44
M
Lordosisis an increased curving of the spine.
M
AKA: Swayback
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

45. 45
M
The spine has three types of curves: M
Kyphoticcurves refer to the outward curve of the th oracic
spine (at the level of the ribs).
M
Lordoticcurves refer to the inward curve of the lum bar spine (just above the buttocks).
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
(just above the buttocks).
M
Scolioticcurving is a sideways curvature of the spi ne and is
always abnormal.

46. 46
M
A small degree of both kyphoticand lordotic
curvature is normal.
M
Too much kyphoticcurving causes round shoulders
or hunched shoulders (Scheuermann'sdisease).
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

47. 47
M
Too much lordoticcurving is called swayback
(lordosis). Lordosistends to make the buttocks
appear more prominent. Children with significant
lordosiswill have a significant space beneath their
lower back when lying on their back on a hard
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
lower back when lying on their back on a hard surface.
M
If the lordoticcurve is flexible (when the child be nds
forward the curve reverses itself), it is generally not a
concern. If the curve does not move, medical
evaluation and treatment are needed.

48. Causes
48
M
Achondroplasia
M
Benign juvenile lordosis(not medically significant)
M
Spondylolisthesis
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

49. 49
M
Achondroplasiais a disorder of bone growth that cau ses the
most common type of dwarfism. M
Achondroplasiais one of a group of disorders called
chondrodystrophiesor osteochondrodysplasias. M
Achondroplasiamay be inherited as an autosomaldominant trait, which means that if a child gets the defecti ve gene from
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
trait, which means that if a child gets the defecti ve gene from one parent, the child will have the disorder. If on e parent has
achondroplasia, the infant has a 50% chance of inhe riting the
disorder. If both parents have the condition, the i nfant's
chances of being affected increase to 75%.
M
However, most cases appear as spontaneous mutations. This
means that two parents without achondroplasiamay give
birth to a baby with the condition.

50. 50
M
Spondylolisthesis is a condition in which a bone (ve rtebra) in the lower part
of the spine slips out of the proper position onto the bone below it. M
In children, spondylolisthesis usually occurs betwee n 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 t he spine or sudden injury
(acute trauma).
M
In adults, the most common cause is degenerative di sease (such as arthritis). The slip usually occurs between the fou rth and fifth lumbar
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
arthritis). The slip usually occurs between the fou rth and fifth lumbar vertebrae.
M
Other causes of spondylolisthesis include bone disea ses, traumatic
fractures, and stress fractures (commonly seen in g ymnasts). 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. Thi s can lead to a stress
fracture on one or both sides of the vertebra. A st ress fracture can cause a
spinal bone to become weak and shift out of place.

51. Home Care
51
M
If the back is flexible, lordosisis usually not tre ated
and will not progress or cause problems.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

52. 52
M
Call health care provider if notice that child has an
exaggerated posture or a curve in the back.
M
The condition should be evaluated to determine if
thereis a medical problem.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

53. 53
M
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 .
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

54. 54
M
In some cases, particularly if the curve seems "fix ed"
(not bendable), the following or other diagnostic
tests may be recommended:
M
Lumbosacralspine x-ray
M
Spine x
-
ray
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Spine x
-
ray
M
Other tests to rule out suspected disorders causing the
condition

55. Treatment
55
M
Specific treatment for lordosiswill be determined b y
child's physician based on:
M
your child's age, overall health, and medical histo ry
M
the extent of the condition
M
child's tolerance for specific medications, procedu res, or
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
child's tolerance for specific medications, procedu res, or therapies
M
expectations for the course of the condition
M
Paretn’sopinion or preference
http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/
lordosis.html

56. Treatment
56
M
Observation
M
physical therapy
M
bracing.
M
most severe cases require surgery
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
most severe cases require surgery

57. Treatment
57
M
The goal of treatment is to stop the progression of
the curve and prevent deformity.
M
Management of lordosiswill depend upon the cause
of the lordosis.
Simple exercises may be sufficient if
lordosis
is
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
Simple exercises may be sufficient if
lordosis
is
associated with poor posture.
M
However, lordosisoccurring 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

58. 58
3/5/2012 Maria Carmela L. Domocmat, RN, MSN

59. References
59
M
Spiegel DA, DormansJP. The spine.In: Kliegman
RM,BehrmanRE, Jenson HB, Stanton BF,
eds.NelsonTextbook of Pediatrics.19th ed.
Philadelphia, Pa: Saunders Elsevier; 2011:chap 671.
3/5/2012 Maria Carmela L. Domocmat, RN, MSN
M
http://www.lpch.org/DiseaseHealthInfo/HealthLibr
ary/orthopaedics/lordosis.html

60. Osteogenesisimperfecta(OI)

61. 61
http://www.oif.org/images/content/pagebuilder/94682.jpg
Maria Carmela L. Domocmat, RN, MSN

62. Osteogenesisimperfecta(OI)
·
AKA: Brittle bone disease
·
rare genetic disorder in which bone are fragile and
fracture easily resulting in bone deformity
·
an
autosomal dominant
disease
62
·
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 connect ive
tissue
Maria Carmela L. Domocmat, RN, MSN

63. Types according to Silence classification system o
has four types based on inheritance as autosomal
dominant or autosomal recessive and clinical findin gs of
each type
o
Types I and IV –more mild manifestations of disease ;
63
can persist into adulthood
o
Types II and III –more severe and can result in fra cture
in utero, during the birthing process, or in early
childhood; associated with high mortality rate
Maria Carmela L. Domocmat, RN, MSN

64. Type 1 osteogenesis
M
most common.
M
People who have type 1 disease generally reach
normal height and have few obvious skeletal
deformities.
typically causes more fractures during childhood
64
M
typically causes more fractures during childhood than in adulthood.
M
Hearing loss is pronounced and begins early in
childhood.
Maria Carmela L. Domocmat, RN, MSN

65. Type 2 osteogenesisimperfecta
M
most rare and the most severe.
M
produces numerous deformities of the skeleton
M
often is fatal in infancy.
M
abnormal collagen formation also profoundly affects
65
M
abnormal collagen formation also profoundly affects the lungs, causing significant breathing problems.
Maria Carmela L. Domocmat, RN, MSN

66. Type 4 osteogenesisimperfecta
M
more severe than type 1 but less severe than type 3 .
M
Fractures are most common before puberty.
M
Hearing loss begins in early childhood and is often
profound
66
Maria Carmela L. Domocmat, RN, MSN

67. Type 3 osteogenesisimperfecta
M
produces obvious skeletal deformities. Fractures
before birth are common;
M
UTZ can detect them in the fetus.
M
also affects the lungs and muscles.
67
M
Hearing loss begins in early childhood and often
becomes complete by adolescence.
http://www.beltina.org/health-dictionary/osteogenesis-imperfecta-types- treatment.html
Maria Carmela L. Domocmat, RN, MSN

68. s/s
M
All people with OI have weak bones, which makes them
susceptible to fractures.
M
Persons with OI are usually below average height (s hort stature).
M
However, the severity of the disease varies greatly
68
Maria Carmela L. Domocmat, RN, MSN

69. s/s
M
The classic symptoms include: M
osteoporosis
M
history of multiple fractures
M
bone deformity
M
poor skeletal development
69
M
poor skeletal development
M
soft brownish teeth
M
hearing loss
M
Blue tint to the whites of their eyes (blue sclera)
M
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

70. s/s
M
Symptoms of more severe forms of OI may include: M
Bowed legs and arms
M
Kyphosis
M
Scoliosis (S-curve spine)
70
Maria Carmela L. Domocmat, RN, MSN

71. bone deformity
71
Maria Carmela L. Domocmat, RN, MSN

72. blue sclerae
72
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

73. soft brownish teeth; bone deformity
73
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

74. 74
This baby's extremities are positioned oddly becaus e there have been
multiple fractures due to osteogenesis imperfecta (OI ). This disease leads
to multiple fractures. The basic problem is a defec t in the formation of
type 1 collagen that forms bone matrix. There are s everal types of OI with
different inheritance patterns.
http://medgen.genetics.utah.edu/photographs/diseases/high/peri021.jpg
Maria Carmela L. Domocmat, RN, MSN

75. Dx:
M
serum alkaline phosphatase–increased
75
Maria Carmela L. Domocmat, RN, MSN

76. Treatment
M
Treatment for fracture -generally conservative M
targeting a balance between immobilizing the fractu re long enough
for it to heal and allowing normal muscle function as quickly as
possible. M
Physical activity M
helps strengthen muscles and bone, which in turn mi nimizes
76
M
helps strengthen muscles and bone, which in turn mi nimizes fractures.
M
The most numerous fractures occur during childhood
when the bones are growing and thus have lower mineral
content.
M
The risk for fracture is lifelong, however, and may
increase in women after menopausewhen bone
densitynaturally declines.
Maria Carmela L. Domocmat, RN, MSN

77. Treatment
o
palliative
o
steroids
o
calcium
o
vitC
o
sodium fluoride PT
77
o
PT
o
casting
o
bracing
o
telescoping intramedullaryrods –to maintain mobility and
promote ambulation
o
research ongoing –Biphophonates
Maria Carmela L. Domocmat, RN, MSN

78. Expectations (prognosis)
M
How well a person does depends on the type of OI
they have.
M
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 d eath
78
M
Type II is a severe form that is usually leads to d eath in the first year of life.
M
Type III is also called severe OI. Persons with thi s 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

79. Expectations (prognosis)
M
Type IV, or moderately severe OI, is similar to typ e I, although
persons with type IV often need braces or crutches to walk. Life
expectancy is normal or near normal.
M
There are other types of OI, but they occur very in frequently and most are considered subtypes of the moderately seve re form
79
most are considered subtypes of the moderately seve re form (type IV).
Maria Carmela L. Domocmat, RN, MSN

80. Complications
M
Complications are largely based on the type of OI p resent. They are
often directly related to the problems with weak bo nes and multiple
fractures.
M
Hearing loss (common in type I and type III)
M
Heart failure (type II)
80
M
Heart failure (type II)
M
Respiratory problems and pneumonias due to chest
wall deformities
M
Spinal cord or brain stem problems
M
Permanent deformity
Maria Carmela L. Domocmat, RN, MSN

81. 81
http://jorthod.maneyjournals.org/content/vol30/issue4/images/large/Ki
nd.f1c.jpeg
Maria Carmela L. Domocmat, RN, MSN

82. Resources
M
Ignatavicius and Workman (2006). Medical surgical
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Maria Carmela L. Domocmat, RN, MSN