McCance Module 8

Musculoskeletal Injuries & Skeletal Trauma

• Trauma to the musculoskeletal system includes fractures, dislocations, sprains, and strains, typically resulting from accidents, falls, or sports incidents.
• Fractures are classified as complete or incomplete, and open or closed.
• Complete fractures involve the bone breaking into two separate pieces; incomplete fractures mean the bone is damaged but remains in one piece.
• Healing occurs in three overlapping phases: inflammatory, repair, and remodeling.
• Treatment for a displaced fracture involves reduction (realigning bone fragments) and immobilization.
• Improper healing can lead to nonunion, delayed union, or malunion.

Dislocation and Subluxation

• Dislocation is the temporary displacement of a bone from its joint.
• If a dislocation does not involve a fracture, it is a simple dislocation; if there is an associated fracture, it becomes a complex dislocation.
• Subluxation is a partial loss of contact between joint surfaces.
• Dislocation and subluxation can be caused by trauma, ligamentous laxity, or congenital disorders.
• Common sites for dislocations and subluxations are the shoulder, elbow, wrist, finger, hip, and knee.
• Anterior shoulder dislocation is the most common type, usually resulting from indirect force causing extreme external rotation.
• Treatment includes reduction and immobilization, followed by exercises to restore range of motion.

Support Structure Trauma (Sprains and Strains)

• A tear in a tendon is known as a strain.
• Ligament tears are known as sprains.
• A complete separation of a tendon or ligament from its bony attachment site is known as an avulsion.
• Injuries are classified by severity (first, second, and third degree).
• Treatment includes protection, early motion, and rehabilitation; surgery may be necessary for complete ruptures.

Tendinopathy and Bursitis

• Tendinopathy includes tendinitis (inflammation of tendons), tendinosis (degradation of collagen fibers), and paratendinitis.
• Bursitis is the inflammation of bursal sacs.
• Epicondylitis (tennis elbow/golfer's elbow) involves inflammation of tendons at their origin.
• Bursitis commonly occurs in the shoulder, hip, knee, and elbow.
• Treatment includes analgesics, ice or heat, and corticosteroid injections.

Muscle strains & Rhabdomyolysis

• Muscle strains result from sudden, forced motion, leading to muscle stretching.
• Muscle strains are typically classified into first, second, and third-degree strains.
• A late complication of muscle strains can be myositis ossificans (heterotopic ossification).
• Rhabdomyolysis is the rapid breakdown of muscle that causes the release of intracellular contents, including protein pigment myoglobin, into the extracellular space and bloodstream.
• Rhabdomyolysis can be caused by crush injuries, compartment syndrome, genetic disorders, medications, and toxic substances.
• Complications of rhabdomyolysis include hyperkalemia, metabolic acidosis, acute renal failure, and disseminated intravascular coagulation (DIC).
• Treatment focuses on maintaining adequate urinary flow and preventing kidney failure.

Metabolic Bone Disease (Focus on Osteoporosis)

• Metabolic bone disease is characterized by abnormal bone structure caused by altered or inadequate biochemical reactions, resulting in disorders of bone strength.
• Osteoporosis, or porous bone, is the most common metabolic bone disease in humans.
• Osteoporosis is characterized by low bone mineral density (BMD), impaired structural integrity of the bone, decreased bone strength, and the risk of fracture.
• Osteoporosis is classified as primary (idiopathic) or secondary.
• Risk factors for osteoporosis include genetics, lifestyle, and certain medical conditions like family history, sedentary lifestyle, smoking, increased age, female gender, white/Asian race, small stature, hormonal imbalances, and low dietary calcium and vitamin D.
• The disease progresses silently until fractures occur, commonly in the vertebrae, hip, and wrist.
• Bone mineral density (BMD) measurement, using dual x-ray absorptiometry (DXA), is the most common method of estimating bone mass and diagnosing osteoporosis.
• The Fracture Risk Assessment (FRAX) tool predicts fracture probability.
• Postmenopausal osteoporosis is associated with estrogen deficiency and increased oxidative stress.
• Normal bone homeostasis depends on the balance between the RANKL (receptor activator of nuclear factor κβ ligand), its receptor RANK, and its decoy receptor osteoprotegerin (OPG).
• Treatment strategies address calcium and vitamin D deficiencies, manage hormone levels, and use medications to alter bone remodeling.

Muscle Cell Injuries

• Unintentional traumatic injuries are a leading cause of death of people aged 1-44.

Types of Fractures

• Complete Fracture: Bone is broken into pieces.
• Incomplete Fracture: Bone is not completely broken (e.g., greenstick fracture).
• Open Fracture: Bone breaks through the skin.
• Closed Fracture: Skin remains intact.
• Greenstick Fracture: Perforates one cortex and splinters spongy bone.
• Transverse Fracture: Horizontal break through the bone.
• Spiral Fracture: Curves around the bone, caused by twisting.

Fracture Healing Process

• Bleeding from the bone damage forms a hematoma.
• Necrotic tissue and debris cause an inflammatory response.
• Platelet-derived growth factor, prostaglandins, and other factors promote healing.
• Osteoblasts and osteoclasts are activated.

Fracture Healing Phases

• Inflammatory
• Repair
• Remodeling

Fracture Complications

• Nonunion: Failure of bone ends to unite.
• Delayed Union: Healing occurs after 8-9 months.
• Malunion: Healing in a non-anatomical position.

Fracture Treatment

• Realignment: Manipulating bone fragments to the correct position.
• Immobilization: Holding the bone in place for proper healing.
• Traction: Used to maintain alignment.
• Open Reduction Internal Fixation (ORIF): Surgical procedure to align fragments with hardware.
• External Fixation: Device used to stabilize fractures.

Dislocation and Subluxation Defined

• Dislocation: Temporary displacement of a bone from its joint. Complex dislocation involves a fracture.
• Subluxation: Partial loss of contact between joint surfaces.
• Common Sites: Shoulder, elbow, wrist, finger, hip, and knee.

Tendon and Ligament Injuries

• Tendons: Attach muscle to bone.
• Ligaments: Connect bones at a joint.
• Strain: Tear or injury to a tendon.
• Sprain: Tear or injury to a ligament.
• Avulsion: Complete separation of a tendon or ligament from its bony attachment.

Tendon & Ligament Healing

• Inflammation occurs, followed by collagen formation. The tendon or ligament lacks sufficient strength for 4-5 weeks.

Tendonitis and Bursitis Defined

• Trauma and overuse can cause inflammation of tendons (tendonitis), painful degradation of collagen fibers (tendinosis), and inflammation of bursae (bursitis).

Rhabdomyolysis Defined

• Rapid breakdown of muscle releasing intracellular contents into the bloodstream.
• Can be caused by trauma, overuse, or other factors.

Rhabdomyolysis Implications

• Hyperkalemia
• Metabolic acidosis
• Acute renal failure
• Possible DIC (Disseminated Intravascular Coagulation)

Rhabdomyolysis Treatment

• IV hydration, hemodialysis, and management of disseminated intravascular coagulation (DIC).

Osteoporosis Defined

• Low bone mineral density, impaired bone structure, and increased fracture risk. Prevention is key.
• Risk Factors: Not necessarily a consequence of aging.
• Prevention: Calcium intake (1000-1500 mg/day), high intake of fruits and vegetables.

Osteomalacia Defined

• Inadequate mineralization of bone matrix (osteoid) due to a deficiency of calcium, phosphate, or vitamin D.

Osteomyelitis Defined

• Bone infection caused by bacteria, fungi, mycobacteria, parasites, or viruses.
• Types: Endogenous (from pathogens in the blood) or exogenous (from external sources).

Osteomyelitis Process

• Inflammation, blood supply disruption, necrosis, and osteoblast stimulation.

Osteomyelitis Treatment

• Antibiotics, debridement, surgery, and hyperbaric oxygen therapy.

Rheumatoid Arthritis Defined

• Autoimmune destruction of synovial membranes and joints.

Rheumatoid Arthritis Treatment

• Anti-rheumatic drugs (e.g., methotrexate, hydroxychloroquine), NSAIDs, glucocorticoids, and steroid injections.
• Anesthesia Considerations: Chronic steroid use can cause adrenal insufficiency.

Ankylosing Spondylitis Defined

• Chronic inflammatory disease causing stiffening and fusion of the spine and sacroiliac joints.

Ankylosing Spondylitis Treatment

• NSAIDs and physical therapy.
• Anesthesia Considerations: Stiffening of the spine can cause difficult intubation.

Myotonic Defined

• Muscle relaxation is delayed after contraction.
• Cause: Shift in chloride ions disrupts sodium-potassium balance.

Periodic Paralysis Defined

• Muscle membrane resting potential is reduced, making it unresponsive to stimuli. Usually transient.

Trauma & Musculoskeletal System

• Can result in fractures, dislocations, sprains, and strains.
• Can stem from accidents, falls, or sports-related incidents.
• May lead to direct care costs and indirect costs related to decreased productivity.

Fractures

• Classified as either complete or incomplete, and open or closed.
• Common types include comminuted, linear, oblique, spiral, transverse, impacted, pathologic, avulsion, compression, displaced, extracapsular, intracapsular, and fragility fractures.
• Incomplete fractures include greenstick, buckle or torus, and bowing fractures.

Fracture Healing

• Occurs in three phases: an initial inflammatory phase, a repair phase characterized by capillary ingrowth and granulation tissue formation, and a remodeling phase involving callus resorption and trabeculae formation.

Fracture Treatment

• Includes reduction (realigning bone fragments) and immobilization.
• Techniques such as closed manipulation, traction, and open reduction may be employed.
• Improper healing can lead to nonunion, delayed union, or malunion.

Dislocation & Subluxation

• Dislocation is the temporary displacement of a bone from its joint.
• Subluxation is a partial loss of contact between joint surfaces.
• These conditions can be caused by trauma, ligamentous laxity, or congenital disorders.
• Common sites include the shoulder, elbow, wrist, finger, hip, and knee.
• Anterior shoulder dislocation is the most common type and is usually the result of an indirect force that places the shoulder in extreme external rotation.
• Treatment involves reduction and immobilization, followed by exercises to restore range of motion.

Support Structure Trauma

• Sprains (ligament tears) and strains (tendon tears) can occur at various joints
• A complete separation of a tendon or ligament from its bony attachment site is known as an avulsion.
• Injuries are classified by severity and are accompanied by an inflammatory response.
• Treatment includes protection, early motion, and rehabilitation; surgery may be necessary for complete ruptures.

Tendinopathy & Bursitis

• Tendinopathy includes tendinitis (inflammation of tendons), tendinosis (degradation of collagen fibers), and paratendinitis.
• Bursitis is the inflammation of bursal sacs.
• Epicondylitis, such as tennis elbow (lateral epicondylopathy) and golfer’s elbow (medial epicondylopathy), involves inflammation of tendons at their origin.
• Bursitis occurs in the shoulder, hip, knee, and elbow.
• Treatment includes analgesics, ice or heat, and corticosteroid injections.

Muscle Strains

• Result from sudden, forced motion, leading to muscle stretching.
• Classified into first, second, and third-degree strains.
• A late complication is myositis ossificans or heterotopic ossification (HO).

Rhabdomyolysis

• The rapid breakdown of muscle tissue, causing the release of intracellular contents into the bloodstream.
• Causes include crush injuries, compartment syndrome, genetic disorders, medications, and toxic substances.
• Complications include hyperkalemia, metabolic acidosis, acute renal failure, and disseminated intravascular coagulation (DIC).
• Treatment focuses on maintaining adequate urinary flow and preventing kidney failure.

Metabolic Bone Diseases

• Involve abnormal bone structure due to altered biochemical reactions.

Osteoporosis

• Characterized by low bone mineral density (BMD) and increased fracture risk.
• Classified as primary (idiopathic) or secondary.
• Risk factors include genetics, lifestyle, and certain medical conditions.
• The disease progresses silently until fractures occur, commonly in the vertebrae, hip, and wrist.
• Bone mineral density (BMD) measurement is used to assess bone mass.
• The Fracture Risk Assessment (FRAX) tool predicts fracture probability.
• Postmenopausal osteoporosis is associated with estrogen deficiency and increased oxidative stress.
• The remodeling cycle is disrupted, leading to an imbalance between bone resorption and formation.
• The RANKL/RANK/OPG system plays a critical role in osteoclast biology.
• Treatment strategies include addressing calcium and vitamin D deficiencies, managing hormone levels, and using medications to alter bone remodeling.

Fracture Types

• Comminuted: Multiple bone fragments
• Linear: Fracture line runs parallel to the long axis of the bone
• Oblique: Fracture line is at an angle to the long axis of the bone
• Spiral: Fracture line encircles the bone
• Transverse: Fracture line is perpendicular to the long axis of the bone
• Impacted: Fracture fragments are pushed into each other
• Pathologic: Occurs at a point in the bone weakened by disease
• Avulsion: A fragment of bone connected to a ligament or tendon separates from the main bone
• Greenstick: Break in only one cortex of bone

Fracture Healing Process

• Inflammatory Phase: Lasts 3-4 days
• Repair Phase: Capillary ingrowth and formation of granulation tissue, followed by osteoblasts synthesizing collagen and matrix to form callus
• Remodeling Phase: Unnecessary callus is resorbed, and trabeculae are formed along lines of stress, lasting months to years Clinical Manifestations of Fractures
• Include impaired function, unnatural alignment, swelling, muscle spasm, tenderness, pain, and impaired sensation.

Dislocation Pathophysiology

• Caused by muscle contractions or fluid within the joint.

Dislocation

• Complete loss of contact between the surfaces of two bones.
• Clinical Manifestations: Include limitation of motion, tenderness, and deformity.
• Common Sites: Shoulder, elbow, wrist, finger, hip, and knee. Sprains and Strains
• Pathophysiology: When a tendon or ligament is torn, an inflammatory process begins.
• Collagen formation is random initially but organizes parallel to stress lines within 3-4 days.
• Clinical Manifestations: Pain, functional limitation, swelling, changes in contour, and possible dislocation or subluxation.

Tendinopathies & Bursitis

• Tendinopathy: Inflammation of a tendon.
• Most tendon pathology is caused by tissue degeneration rather than inflammation.
• Bursitis: Inflammation of the bursae.
• Bursae are small sacs lined with synovial membrane and filled with synovial fluid, located between tendons, muscles, and bony prominences.
• Clinical Manifestations:
• Tendinitis causes swelling of the tendon and sheath, limiting movement and causing pain.
• Bursitis can cause joint movement to be compromised.
• Common Sites for Bursitis: Shoulder, hip, knee, and elbow.
• Treatment: Includes ice, rest, analgesia, and progressive exercise.
• Includes ice, rest, analgesia, and progressive exercise.

Muscle Strain Treatment

• Includes ice, rest, analgesia, and progressive exercise.

Rhabdomyolysis

• Caused by trauma, medications, toxic substances, electrolyte imbalances, and genetic disorders.
• Complications: Include hyperkalemia, metabolic acidosis, acute renal failure, and disseminated intravascular coagulation (DIC).
• Clinical Manifestations: Muscle pain, weakness, and dark urine.
• Evaluation: Serum creatine kinase (CK) level is the most important measurement.
• Treatment: Focuses on maintaining adequate urinary flow and preventing kidney failure with rapid intravenous hydration.

Osteoporosis

• Risk Factors: Include inadequate dietary calcium intake, vitamin D deficiency, lack of exercise, low body mass, and family history.
• Involves an imbalance between bone resorption and bone formation.
• Evaluation: Includes bone density testing and FRAX assessment.
• Treatment: Focuses on preventing fractures and maintaining optimal bone function through calcium and vitamin D supplementation, weight-bearing exercise, and medications.

Osteomalacia

• Pathophysiology Abnormalities occur in spongy and compact bone.
• Treatment Includes adjusting :serum calcium and phosphorus levels, administering vitamin D, and dietary supplements.

Paget Disease

• Pathophysiology Begins with excessive :resorption of spongy bone and deposition of disorganized bone.
• Clinical :Manifestations Can include skull thickening, bone and joint pain, and bone deformity.

Osteomyelitis

• Can be exogenous (from outside the body) or hematogenous (from infection sites within the body).
• Pathophysiology: Characterized by inflammation, vascular engorgement, edema, leukocyte activity, and abscess formation.
• Include bone pain, fever, and signs of local inflammation. Clinical Manifestations Include bone pain, fever, and signs of local inflammation.
• Involves surgical debridement, bone biopsy, and antibiotic therapy. Clinical Manifestations Include back pain, stiffness, and restricted spinal movement.

Secondary Muscular Dysfunction

• Arise from causes unrelated to the muscle itself.

Contractures

• Lack of full passive range of motion of a joint due to muscle, connective tissue, or soft tissue limitations.

Stress-Induced Muscle Tension

• Associated with chronic anxiety and stress.

Fibromyalgia(FM)

• A chronic musculoskeletal syndrome characterized by widespread pain, fatigue, and tender points.
• Unclear, but genetic: factors, neuroendocrine and stress-response alterations, and abnormal pain responses are implicated. include chronic pain, fatigue, headaches, and irritable bowel syndrome Clinical Manifestations Include chronic pain, fatigue, headaches, and irritable bowel syndrome.

Muscle Membrane Abnormalities

• Defects in the muscle membrane.

Myotonia

• Delayed muscle relaxation after contraction due to hyperexcitable membrane.

Inflammatory Muscle Diseases (Myositis)

• Viral, bacterial, and parasitic infections can produce inflammatory changes in skeletal muscle.

Polymyositis

• Inflammation of connective tissue and muscle fibers, mediated by T cells.

Dermatomyositis

• Similar to polymyositis but also involves cutaneous manifestations.

Bone Formation Types

• Intramembranous: Occurs within the mesenchyme and forms flatbones such as the cranium and clavicles.
• Endochondral: New bone develops from cartilage.

Intramembranous Bone Formation Defined

• Occurs in fetal tissue, specifically in the mesenchyme, giving rise to the cranium, facial bones, clavicles, and parts of the jawbone.
• As the mesenchyme becomes vascularized, immature bone cells aggregate and mature into osteoblasts, forming ossification centers and creating solid bone.

Endochondral Bone Formation Defined

• Involves development of new bone from cartilage.
• Mesenchymal tissue forms a cartilage anlage, defining bone shape around six weeks gestation.
• Blood vessel invasion brings osteoprogenitor cells, leading to primary calcification centers by eight weeks.

DDH Risk Factors

• Family history
• Female gender
• Breech presentation
• Oligohydramnios

Scoliosis Defined

• A rotational curvature of the spine.
• It can be nonstructural or structural.
• Diagnosis is made by roentgenographic examinations.

Syndactyly Defined

• Webbing of fingers, the most common congenital defect of the upper extremity.
• Simple webbing is corrected surgically between 6 months and 1 year.
• Complex syndactyly may involve fusion of bones and nails.

Osteomyelitis Defined

• Infection of the bone, often affecting children between 3 and 12 years.
• Bacteria enter through the bloodstream and lodge in the medullary cavity.
• The microorganism responsible varies with the child’s age.

Metatarsus Adductus Defined

• A forefoot adduction deformity.
• It is associated with DDH in 20% of cases.
• Mild deformities often correct spontaneously.
• Serial casting is suggested for moderate to severe deformities.

Clubfoot Defined

• The foot turns inward and downward.
• It can be positional, idiopathic, or teratologic.
• Treatment for idiopathic equinovarus includes the Ponseti casting technique.

Pes Planus Defined

• The majority of babies are born with flat feet, with the arch becoming more apparent with age.
• Surgical or orthotic treatment of asymptomatic flexible pes planus is unnecessary.

Sarcomere Structure and Function

• Muscle fibers contain myofibrils composed of actin and myosin.
• Actin is the thin, light I band, while myosin is the thick, dark A band.
• The sarcomere, the fundamental unit of myocyte contraction, is located between Z discs.
• Myosin filaments consist of a tail, hinge, and head; tails bundle together for a thick appearance.
• The arm and head of the myosin filament form the cross bridge, which contains two hinges that facilitate head movement.

Muscle Contraction Process

• ATP binds, causing the myosin molecule to extend into an open position.
• An action potential prompts calcium release from the sarcoplasmic reticulum, enabling myosin filament heads to attach to active sites.
• The myosin head tilts, dragging the actin filament along in a power stroke, bringing the filaments closer together.
• Calcium is present, and the myosin head attaches and contracts.

Energy Sources for Muscle Contraction

• ATP is needed for the walk-along mechanism, pumping calcium into the sarcoplasmic reticulum, and the sodium-potassium pump.
• Phosphocreatine, found in small amounts in muscle cells, has a higher energy phosphate bond than ATP and can create ATP.
• Glycolysis, the breakdown of glycogen into pyruvic and lactic acid, contributes a small portion of energy.
• The majority of energy for muscles is derived from oxidative metabolism, combining oxygen with glycolysis end products and other food products.

Types of Muscle Contractions

• Isometric contraction involves tension in the muscle without shortening it.
• Isotonic contraction involves muscle shortening while tension remains constant.

Muscle Fiber Types

• Every muscle contains a mixture of fast and slow fibers, with varying proportions in different muscles.
• Slow or red fibers are rich in myoglobin and capillaries for oxygenation, enabling them to sustain tension for extended periods.
• Fast muscle fibers are larger, providing greater contraction strength, extensive sarcoplasmic reticulum for rapid calcium release, and enzymes for glycolysis.

Motor Units and Force Generation

• Motor neurons located in the anterior horn of the spinal cord innervate muscle fibers, forming motor units.
• Fine motor control requires fewer muscles per motor neuron, whereas large muscles for strength have more motor units per neuron.
• Force can be increased through summation, which involves increasing the number of motor units or the frequency of contraction.

Tetany and Muscle Remodeling

• Tetany occurs when the frequency of contraction increases to the point where contractions fuse together.
• Hypertrophy results from an increased number of actin and myosin filaments due to strong contractions.

Neuromuscular Junction and Excitation of Skeletal Muscle

• Large myelinated nerve fibers transmit signals rapidly from the anterior horn of the spinal cord to skeletal muscle fibers.
• At the end of the neuron, a voltage-gated calcium channel opens, allowing calcium to diffuse into the motor end plate.
• Calcium binds with vesicles containing neurotransmitters, primarily acetylcholine, causing them to bind with the membrane and release the neurotransmitter.
• Acetylcholine diffuses across the neuromuscular junction and binds to ligand-gated sodium channels, causing depolarization of the muscle.

Acetylcholine Actions

• Two acetylcholine molecules attach to a specific portion of the sodium ion channel, opening it and allowing diffusion into the muscle.
• The rapid influx of sodium changes the muscle membrane's electronegativity from negative to positive, propagating the action potential.
• Acetylcholine must be removed from the neuromuscular junction to allow the sodium channel to close; this is primarily done by acetylcholinesterase, which breaks down acetylcholine into choline and acetate.

Drugs Affecting Neuromuscular Transmission

Succinylcholine acts like acetylcholine rocuronium is an acetycholine receptor antagonist

• Drugs can alter electronegativity, affecting the stimulus required to reach the threshold for action potential.
• Succinylcholine acts like acetylcholine, binding to the acetylcholine sodium receptor and opening the channel, causing depolarization.
• Rocuronium is an acetylcholine receptor antagonist, blocking the channel and causing paralysis without fasciculations.

T-Tubules and Sarcoplasmic Reticulum

• T-tubules facilitate the rapid spread of action potentials throughout the muscle.
• The sarcoplasmic reticulum, located next to the T-tubules, is where calcium is stored and released.

Malignant Hyperthermia

• A mutation in the ryanodine receptor can cause malignant hyperthermia.
• certain anesthetics or succinylcholine can cause the opening of calcium channels and continuous muscle contraction, leading to hyperkalemia and elevated temperature. Exposure to certain anesthetics or succinylcholine can cause the opening of calcium channels

Smooth Muscle

• Prolonged tonic contraction is characteristic of smooth muscle, with slower myosin cross-bridge cycling and increased attachment time, requiring less energy.
• Smooth muscle can be stimulated by stretch, nerve stimulation, hormones, or changes in the chemical environment.

Nerve stimulation In Smooth Muscle

• Nerves, hormones, local chemicals, and stretch can stimulate smooth muscle.
• Neuromuscular junctions in smooth muscle are branched, with neurotransmitters released outside the muscle to diffuse to receptors. Acetylcholine can be inhibitory or excitatory in different muscles. Acetylcholine can be inhibitory or excitatory in different muscles.

Drugs Affecting nueromuscular transmission

• Succinylcholine acts like acetylcholine. Rocuronium is an acetycholine receptor antagonist.
• Succinylcholine can cause muscle pain and, in rare cases, rhabdomyolysis.
• Succinylcholine is an acetycholine receptor agonist

Muscloskeletal injuries and healing

• Unintentional traumatic injuries are the leading cuase of death for people aged 1 to 44. Healing occurs in three phases: inflammatory , repair and remodelling

Musculoskeletal Diseases

• Osteoporosis is characterized by low bone mineral density, imparied integrity, decreased strength and increased fracture risk.
• osteomyeltitis is a bone infection typically caused by bacteria leading to inflammation, necrosis and antibiotic treatment.
• Ankylosing sodndylititsi is a chronic inflammmatiory joint didease fusion of the sping. Complicatinbg intuabtion.
• Scoliosis- Curvature and rotation of the spine which can omlicate eoidural placemat.

Children Musculoslketal Condtions

• • Bone formatsion begins in the 6th week of gestations
• Sybdactyly- presence of multiple digist
• Hip dysplacia, sublaxattion, dislocation or acetcular dyspalai
• Ricks- failure of bone to become minedlised due to vitamin B insuficinecy or insensitivityy
• Cerebral palsy non porgresive dsisoder of movement that is inutero.s
• Duschene muscular dystophy Absent of dystoprhinn.s..s s s.