muscular abnormalities-FCNC unit 3 Flashcards


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1

Head of femur does not lie deep enough within the acetabulum

Developmental Dysplasia of the Hip (DDH)

2

Developmental Dysplasia of the Hip (DDH)

Babies that are born ______________ (__________come out first) are more at risk for this

breech..feet

3

Developmental Dysplasia of the Hip (DDH)

80% more common in ___________ and in _________________

females..Caucasians

4

*_________________ developmental dysplasia is the most common*

subluxation

5

Developmental Dysplasia of the Hip (DDH)

Diagnostic Evaluation

-Often NOT detected on the initial evaluation at __________

-remember if baby is born __________ then make sure and thoroughly assess for DDH

birth

breech

6

Developmental Dysplasia of the Hip (DDH)

**DDH is diagnosed by _______________**

  • ______________ of ________ on affected side (______________ sign)
  • Restricted _______________ of _______ on affected side
  • Asymmetric _______ and __________ folds
  • Positive ______________test (hip reduced by _______________)
  • Positive _____________test (hip dislocated by _____________)
  • Broadening of the _______________ (in ____________ dislocation)

-this is usually just if its _______________ DDH

  • _______________ gait and _____________ (older infants and children)

assessment

Shortening..limb..Geleazzi

abduction..hip

thigh..gluteal

Ortolani..abduction

Barlow..adduction

perineum..bilateral

bilateral

Waddling..lordosis

7

Developmental Dysplasia of the Hip (DDH)

*Ortolani and Barlow most reliable from ____________ to ____ weeks of age.

birth..4

8

Goal of DDH

  • Obtain and maintain a __________, ______________ position of the hip joint to promote ___________ hip joint ________________.

-you want to make sure that you don’t allow the socket to __________ out (early ____ is necessary)

safe..congruent..normal..development

flatten..tx

9

Therapeutic Management of DDH

  • Treatment is begun as soon as the condition is ______________ because ________ intervention is more favorable to the restoration of normal _________ architecture and _____________.

-with treatment, the ___________ the better

recognized..early..bony..function

earlier

10

Therapeutic Management of DDH

  • ___________ ____________

-most widely used

Pavlik harness

11
  • Pavlik harness

-worn all the time except during ____________

-the pavlik harness velcros usually across the chest, allowing parents to take it ______ to _________ the child

-parents can take it ________ (velcroing and un-velcroing it), however, the udajustable straps on the pavlik harness should ____________ be adujusted by the ______________ (this determines the exact _______________ and _______________ of where it needs to be)

-parents need to know that they ________________ adjust these straps (like making it _____________ or _____________)

showers

off..bathe

off

ONLY..physician...tightness..placement

CANNOT..tighter or looser

12
  • Pavlik harness

-main thing you’re going to worry ab with this harness is ________ ___________ ____________

  • Parents need to know to assess for ________________ skin areas at least ___-___ times a day

skin break down

reddened..2-3

13

Age variations---for DDH

  • Newborn to 6 months

-done __________

  • Older child

-If a child is older than ____ yrs old then they require ____________ repair

-tx is initiated as soon as the _____________ is recognized

early

6..surgical

condition

14

Nursing Considerations for Client with DDH

  • If baby is born _____________, youre really going to do a thorough assessment for DDH
  • check frequently (at least ____-____ times per day) for ______ areas or _______ irritation in skin ________ or under the _______
  • gently _____________ healthy skin under the straps ________ per day to stimulate ________________.
  • In general avoid ________ and ______________bc they can cake and irritate the skin
  • always place diaper ___________the straps

breech

2-3..red..skin..folds..straps

massage..once..circulation

lotions..powders

under

15

Congenital Clubfoot

-if clubfoot is present, then it is most likely that they have high risk of ________ __________ as well

-pointing ______________ and twisting ____________ of the foot

hip dysplasia

downward..inward

16

Congenital Clubfoot

  • _________ _______________ (TEV) (95% of cases)
    • bone _______________ and __________________
  • Precise cause is ____________
  • More common in __________ (twice as often)
  • ______________ tendency

Talipes equinovarus

deformity and malposition

unknown

males

Familial

17

Congenital Clubfoot----- Therapeutic Management

  • Goal is to ____________ the foot

-want them to be able to _________ the foot so they can walk with their __________ on the ground

stabilize

stabilize..heel

18

Congenital Clubfoot---- Therapeurtic management in 3 stages:

  • ____________ of the deformity

-tx is initiated as soon as the ____________ is ready

-ideally it is initiated ___________ they leave the _____________ (as soon as possible after _________)

  • Maintenance of the ________________
  • Follow-up observation for __________________

Correction

physician

before..hospital..birth

correction

recurrence

19

Congenital Clubfoot----Management and Treatment

  • _________ ____________ shortly after birth
    • ___________ manipulation and casting are repeated frequently due to rapid ____________

-bc the newborn __________ so quickly they have to come back to the hospital to get the cast re-adjusted every ___-____ days in the first week

-after the first week its about ___x a week

Serial casting

Weekly..growth

grows...1-2 days

1x

20

Congenital Clubfoot-----Management and Treatment

  • Casted until maximum _______________ is achieved
  • Usually correction is achieved in ____ to ____ weeks
  • If they have not reached complete re-alignment after ____ mo. of casting, then they will require __________

-usually wait until ____ mo of age to perform ____________ (___-____ mo old)

-percutaneous ________ __________ _______________ is performed (to correct the equinus)

-then a long leg _________ applied for ____ weeks

-__________ ___________ bar with ___________ sandals or straight __________ shoes to prevent recurrence.

correction

6 to 10

3..surgery

6..surgery..6-12

heel cord tenotomy

cast..3

Denis Browne..Ponseti..laced

21

cast care

  • Keep the casted extremity ____________ on pillows or similar support for the _______ day or as directed by HCP
  • Expose the plaster cast to _____ until ______
  • Observe _______________(____________ and _________) for any evidence of _______________or _______________ (_____________ or ____________ than a comparable extremity), and contact the _________if noted
  • Check ______________and ________________of the visible extremities frequently
  • Instruct that the cast CANNOT get ________ (use protective cover when _____________/_____________)
  • Restrict ______________ activity for the first few days
    • Engage in _________ actvities, but encourage use of __________
    • Move the joints ________ and _________ the cast on the affected extremity
  • Encourage frequent _______ for a few days, keeping the injured extremity _____________ while resting
  • Avoid allowing the affected limb to hang in a ______________ position for any length of time

elevated..first

air..dry

extremeties...fingers...toes..swelling...discoloration...darker..lighter..HCP

movement and sensation..wet...bathing/shower

strenuous

quiet..muscles

above..below

rest..elevated

dependent

22

cast care

  • keep an injured upper extremity ______________ (e.g. in a ________) while upright
  • ____________ lower limb when ____________ and _________ standing for long periods of time
  • Do not allow child to put ______________ inside the ________. Keep _________ items that might be placed ____________the cast away from small children

elevated..sling

elevate..sitting and avoid

anything..cast..small..inside

23

Compartment syndrome evaluation (pg. 1429, box 48.3)

Assess extent of injury— “the 6 P’s”

  • ________

-severe ________ that is not relieved by ____________ or _____________ of the limb, movement that increases ________

  • __________________

-inability to palpate a _________ _________ to the fracture or compartment

  • __________

-________ appearing skin, poor _____________, _______. _______ greater than ____ secs

  • ______________

-______________ or ______________ sensations

  • _____________

-inability to move ________________ or __________

  • ______________

-involved limb or digits may feel ___________ and __________; skin is ________, ________; __________ within the compartment is ______________

Pain

pain..analgesics or elevation..pain

Pulselessness

pulse distal

Pallor

pale...perfusion..cap refill..3 secs

Paresthsia

tingling or burning

paralysis

extremeties or digits

Pressure

tense and warm..tight..shiny...pressure..elevated

24

Defined as lateral curvature, spinal rotation causing rib asymmetry and thoracic kyphosis

Scoliosis

25

Scoliosis

  • Most common form: _________________ _______________
  • Cause: ______________
  • Age on onset: ____ yrs of age to _____________ maturity
  • Most noticeable at the beginning of the ___________________ ____________ spurt
  • Predominance in _____________

Adolescent Idiopathic

unknown

10..skeletal

preadolescent..growth

females

26

Scoliosis---- Screening Procedure:

  • With child standing erect, clothed only in ____________ (and _______ if older girl), observe from ____________, noting asymmetry of the _____________ and _________
  • With child bending ____________ (_____° or more) so that the back is _____________ to the floor, observe from the ________, noting asymmetry or prominence of the ______ ________
  • ___-______ to determine severity if curvature noted.

-this is where they’re going to get the ___________ of curvature

underpants..bra..behind..shoulders and hips.

forward..90..parallel..side..rib cage

X-rays

degree

27

Scoliosis---- Screening Procedure:

  • Definitive dx is made by ______________ of the child in the ______________ position and use of the ______________ technique, a standard measurement of angle curvature

radiographs..standing..Cobb

28

Clinical Manifestations---Scoliosis

  • “_____-___________” clothes- ____________ pant lengths, ______________ skirt hems
  • Rarely is there ____________
  • Asymmetry of ____________/_____ height
  • Uneven ______ level
  • _______ _________uneven
  • ______ asymmetry
  • Unequal _______ length

Ill-fitting..uneven..uneven

discomfort

shoulder/hip

hip

Waist line

Rib

arm

29

Scoliosis----Therapeutic Management:

  • Treatment is based on ____________, _____________, and __________ of curve
  • Observation w/ regular ____________ and ___-_______ evaluation for curvatures <____

-initially going to ___________

  • ____________ to halt or slow progression of the curvature until skeletal maturity for curves <______

-Examples (___________ brace or the ________—________________________ brace

-wearing time usually ____-_____ hrs/day

-off only for ____________

-risk for__________ _______________(may wear ____-_______ under brace)

-risk for non-compliance d/t __________ ___________ concerns

magnitude, location, and type

clinical..X-ray..<20˚

observe

Bracing..45...Boston..TLSO..Thoracolumbosacral

16-23

hygiene

skin breakdown..t-shirt

body image

30

Scoliosis---surgery

  • ____________ __________- surgery for greater than _____º curvature;

Spinal fusion..45

31

Scoliosis---surgery

  • * Post-op: priority to assess _________________ function of extremities, q ___ hr for first ____ hours.

neurovascular..1..8

32

Nursing Interventions---scoliosis surgery

High risk for injury r/t __________ manipulation

  • _____ _______ 1st 24 hrs
  • _________________ checks (________________)

-big _______________ to do!!!

-every ________ for the first ____ hours!

  • observe for _______________ ___________ r/t surgery/anesthesia
  • advance activity—most ambulatory by _____ or ______ post-op day and discharged w/ unassisted ambulation by ___ wk
  • immobilization ___________ or _______ is used postoperatively depending on the type of surgical intervention
  • ___________ care for immobility & brace

spinal

log roll

neurovascular..extremities

assessment

hour..8

paralytic ileus

2nd or 3rd....1

brace or cast

Skin

33

Nursing Interventions---scoliosis surgery

  • ____________ ________ 1st _____-_____ hrs (innervation of bowel/bladder from the lumber region affected by surgical manipulation or edema post-op)

indwelling cath..24-48

34

scoliosis surgery----Discharge Teaching:

  • _________ or ________ care
  • Home environmental ______________ as needed
  • Risk for _________________/__________________ r/t limited activity
  • No __________ for a year

Brace or Cast

modifications

overeating/constipation

sports

35

Defined as Chronic inflammation of the synovium with joint effusion and eventual erosion, destruction & fibrosis of the articular cartilage

-chronic inflammation of the joints

Juvenile Idiopathic Arthritis

36

Juvenile Idiopathic Arthritis

Cause ____________

unknown

37

Juvenile Idiopathic Arthritis

  • Most common ______________ disease of childhood
  • ________________ affected twice as often as ____________
  • Starts before age ______; peak onset between ___& ____ yrs of age

rheumatic

Females...males..1 & 3

38

Juvenile Idiopathic Arthritis

  • PROGNOSIS:
    • In 70% of childhood cases, the RA becomes _____________; ____________ or ____________ joint damage persists

-usually does not persist into _____________

  • 30% will have progressive arthritis into _______________

inactive..severe or minimal

adulthood

adulthood

39

Juvenile Idiopathic Arthritis----- Clinical Manifestations:

  • _____________, ______________, loss of ___________ in affected joints; worse on arising in the _____________ or after _______________
  • joint(s) may be _____________, painful to ____________ or relatively ___________
  • Growth __________________ in severe, long-standing cases (possibly d/t ___________________)

stiffness, swelling, motion..morning..inactivity

tender..touch...painless

retardation..corticosteroids

40

Juvenile Idiopathic Arthritis---- Diagnosis:

  • ______specific lab test
  • _________- characteristics of chronic ___________(Hgb ______) and ________________(________________)

-shows low ______ and ________________

-_______ is one of the first things usually done

  • __________________ rate-may or may not be ________________
  • _______________ fluid ________ count – elevated
  • ________ (______________ antibodies)- are common in JIA; identify children who are at a greater risk for ________
  • _______________-show soft-tissue swelling & joint space widening from increased synovial fluid in the joints

No

CBC..anemia..low..inflammation..leukocytosis

Hgb..leukocytosis

CBC

Sedimentation

elevated

Synovial..WBC

ANA..Antinuclear..uvetis

Radiographs

41

Juvenile Idiopathic Arthritis----Complications:

  • ___________: inflammation in the anterior chamber of the _______, which may lead to permanent _________ loss if untreated.

Uveitis..eye..vision

42
  • Juvenile Idiopathic Arthritis-----Treatment:

1) Goals of treatment:

  1. Control _________-unable to prevent ALL ____________.
  2. Preserve ________ range-of-motion and ___________
  3. Minimize effects of ________________(_______ deformity)
  4. Promote normal _________ and ________________

pain..discomfort

joint..function

inflammation..joint

growth and development

43

Juvenile Idiopathic Arthritis------Treatment

2) Routine ________ examinations at least every ____ months

*(to allow early and aggressive treatment of ________ (iridocyclitis) this is usually ______________, so requires _______ ________ eye exams.)*

eye..3

uveitis..asymptomatic..slit lamp

44

Juvenile Idiopathic Arthritis------Treatment

- __________ & _________________ therapies

  1. _____: strengthening ____________, mobilizing ___________ joints, preventing or correcting ______________;

*when joints are inflamed, ___________ exercises that do not involve ________ movement are encouraged (and generally tolerated)

-- Exercising in a _________ is excellent therapy, since it allows freedom of movement with support and minimal gravitational pull.

*there is pain on motion, a _______ pack or _________ bath before therapy may help.

  1. _______: Assist w/maximizing generalized mobility and independence in ________

Physical & Occupational

PT..muscles..restricted..deformities

isometric..joint

pool

hot..warm

OT..ADLs

45

Juvenile Idiopathic Arthritis------Treatment

4) Comfort Measures

  1. Measures to promote _________ are more realistic than ___________ pain relief
  2. _____________: helps minimize pain and reduce flexion deformity
  3. Positioning at rest: no ___________ of head or knees; _________ position straightens ________ and _________ joints; _________ mattress, no __________ or very low one.
  4. Awaken children early to give them their _____________and then to allow them to sleep for an ___________.

*On arising, children take a ______ bath (or shower) and perform a simple ritual of ________________-up exercises, after which they commence the day's activities, such as going to ____________.

*______________, ________, and ________are spaced throughout the remainder of the day according to the child's individual needs and schedules.

coping..complete

Splinting

flexion

prone..hip and knee ...firm..pillow

medication...hour

hot..limbering..school

Exercise, heat, and rest

46

Juvenile Idiopathic Arthritis------Treatment

5) Dietary Management

  1. Decreased activity may lead to problems w/ ______ control
  2. multi-_____________ with ________
  3. __________ wt causes extra __________ on inflamed joints

wt

vitamin..iron

Excess..stress

47

Juvenile Idiopathic Arthritis------Treatment

6) Medications

  1. ___________: ______________ (________); ________________ _____________

*__________- may predispose pt. to ______ ______________ (check _________, possible _______. pain).

*Do not take on an ___________ stomach.

*It may take __________ to see a decrease in the ________________ to the joints.

2. ________________-second –line of med used for JIA, who have failed with _________

*monitor ____________ _________ count; _______ function test, teach teens about ________ ____________ and avoiding __________

NSAIDS.... ibuprofen (Advil)..naproxen sodium

NSAIDS..GI bleeding..stools..abd

empty

weeks..inflammation

Methotrexate..NSAIDS

complete blood...liver..birth defects..alcohol

48

Juvenile Idiopathic Arthritis------Treatment

-medications

  1. ________________-used in severe cases unresponsive to other meds,

*used in ___________ effective doses for _________ periods and ____________ schedule.

*Administered _____, _______________ joint inj., _____, or eye gtts for _________.

*A single _______________ injection may provide effective relief.

for children with _________________ disease unresponsive to ___________

Corticosteroids

lowest..brief..tapering

PO..intraarticular..IVP..uvetis

intraarticular..pauciarticular..NSAIDs

49
  1. ___________ is a tumor necrosis factor (inhibitor) α-receptor blocker and an effective drug for children with JIA who are nonresponsive to ______________.

It is given as _________ per week via ______________ injections.

Possible side effects include transient ___________ reaction at _____________ site, increased ______________ risk.

Etanercept..methotrexate

twice..subcutaneous

allergic..injection...infection

50

Promote General Health-----JIA

-A well-balanced ______ with sufficient ___________ to maintain growth is essential.

-If the child is relatively ______________, ___________ intake should match energy needs to avoid excessive _________ gain, which places additional stress on affected ___________.

-___________ and ___________ are essential for children with JIA.

-A ________ mattress, __________ water bed, ___________ blanket, or ______________ bag helps provide ___________, comfort, and rest. ----Nighttime __________ needed to maintain range of motion might initially be a source of bedtime conflict

-Children are encouraged to attend ____________, even on days when there may be some ________ or _____________.

diet..calories

inactive..caloric..weight..joints

Sleep and rest

firm...heated...electric..sleeping..warmth..splints

school..pain..discomfort

51

Cerebral palsy

  • _________ onset, _______________, _______-_______________ disability
  • 80% of CP cases are caused by ____________ _______________ factors

Early..permanent..non-progressive

unknown prenatal

52

Cerebral Palsy---Diagnosis:

** Spastic Type:

  • Increased ____________ tone (________________)
  • Increased deep __________ reflexes and __________ (sudden ______________ of the ankle or rapid distal movement of the ___________ resulting in alternating _________ and ______________ of the muscles being stretched)
  • Difficulty with ______ and ______ motor skills
  • Most common contracture: that of the _______ _______
  • Hip adductor contractures leading to progressive _____________ and _____________
  • _________ contractures
  • ____________ common
  • Typical gait ______________, ______________, _______________
  • _________, _________, and ____________ in flexed position with thumb ______________
  • Motor ________________of antagonist muscle groups

muscle..hypertonicity

tendon..clonus..dorsiflexion..patella..spasm...relaxation

fine..gross

heel cord

subluxation..dislocation

Knee

Scoliosis

crouched, intoeing, scissoring

Elbow, wrist, and fingers..adducted

weakness

53

Cerebral Palsy----Confirmed by

  1. __________ evaluation
  2. _____________________ (________)
  3. _______________ (______ & _____)
  4. ________________ screenings

Physical

Electroencephalogram..EEG

Tomography (MRI & CT)

Metabolic

54

Cerebral Palsy----Early clinical signs

  1. Persistent ____________ ___________(one of the ____________ clues)
    1. ____________ ___________ __________ reflex beyond ____ months of age
    2. _________ reflex beyond ___ months of age-typically fades by ___ months of age.

primitive reflexes...earliest

Asymmetric tonic neck..4

Moro..4..5

55

Cerebral Palsy

  1. _________ or ________________ (_________ or ___________ arms and legs)
    • _____________

-the ____________ of the muscle tone with exaggerated ________

-ones that are ________ often ________ their ______ and jerk ________ (can cause _________ injuries)

  • ____________

-flabby, absent muscle tone

Hyper or hypotonicity..stiff or floppy

  1. Spasticity

increase..jerks

spastic..arch..back..jerk..

head

  • Flaccidity
56

Cerebral Palsy

*lots of times these infants will show _____________ preferences before _____ mo old*

-all infants have a ____________ side but CP infants will show the __________ preferences ____________ than normal infants

hand..18

weaker..hand..earlier

57

Cerebral Palsy

Extreme _____________ or _____________, failure to __________ by ____ months.

Irritability or crying...smile..3

58

Cerebral Palsy

Delayed __________ __________ development is a universal manifestation.

gross...motor

59

Cerebral Palsy

  • Medications:

_____________ and ________________

-they are effective in decreasing overall spasticity.

Baclofen and diazepam

60

Cerebral Palsy

Baclofen and diazepam---meds

The most common side effects of these agents include ________________ (dantrolene), ______________, ____________, and muscle ________________

hepatotoxicity..drowsiness, fatigue, and weakness

61

Cerebral Palsy

Baclofen and diazepam---meds

this is best done when infused into the ______________ space through a ____________

  • There are fewer __________ _____________ when administered through the _______________ route

intrathecal..pump

side effects..intrathecal

62

Cerebral Palsy

-Diazepam is used frequently but should be restricted to older _____________ and __________________.

older children and adolescents.

63
  • Defined as progressive genetic disorder that affects muscles in the lower extremities and eventually muscles of upper extremities, chest wall, and heart.

Duchenne Muscular Dystrophy (DMD)

64

Duchenne Muscular Dystrophy (DMD)

  • Etiology:
    • most ___________, most _______________, ____-linked inheritance

-this is inherited from the _______

-the _______ has the ___ chromosome

  • ___________ almost exclusively affected
  • ________________ (______________ product) is absent from the muscle

severe..common..X

mom

mom...X

Males

Dystrophin..protein

65

Duchenne Muscular Dystrophy (DMD) ---- Characteristics:

  • _________ onset, usually between ___ and ____ years of age
  • _______________ muscular ______________, _____________, and _________________
  • _________ muscle hypertrophy in most patients
  • Loss of ________________ ambulation by ____to _____ years of age

-goal is to keep them _____________ as long as possible

  • Slowly ________________, generalized _______________ during teenage years
  • Relentless _______________ until death from ________________ or _____________failure

Early..3..5

Progressive..weakness, wasting, and contractures

Calf

independent..9 to 11

walking

progressive..weakness

progression..respiratory or cardiac

66

Duchenne Muscular Dystrophy (DMD)----Clinical Manifestations:

  • _____________ gait
  • ____________
  • Muscle _____________

-AEB by _____________ motor development

  • Frequent __________
  • ____________ sign

Waddling

Lordosis

weakness..delayed

falls

Gower

67

Duchenne Muscular Dystrophy (DMD)-----Clinical Manifestations:

  • ______________ muscles (especially ____________ and ____________ arms); feel unusually ________ or ___________ on palpation
  • These children often present as _______________ or _________
  • Later stages: profound _______________atrophy
  • ___________ impairment (common)

Enlarged..thighs and upper..firm or woody

awkward or clumsy

muscular

Cognitive

68

Duchenne Muscular Dystrophy (DMD)---Complications:

  • Contracture deformities of ________, _________, and ___________
  • Disuse __________
  • ____________

-usually ________. infections or ___________ are the main infections

  • ___________- ________ control (moderate ___________diet) - to prevent child from gaining excess _____. may allow him to be ______________ longer.

hips, knees, and ankles

atrophy

Infections

resp..cardiac

Obesity..Diet..calorie...wt..ambulatory

69

Duchenne Muscular Dystrophy (DMD)----Diagnosis:

  • Based on __________ _______________
  • __________ __________________ _________ reaction for the dystrophin gene mutation
  • ____________ diagnosis is also possible as early as ____ weeks of gestation.
  • Serum ___________ measurement, ________ biopsy, and _______ may also be used in establishing the diagnosis.
  • Serum ___________ ___________ levels are extremely high in the first ____ years of life, ___________ the onset of clinical weakness.

clinical manifestations

blood polymerase chain reaction

Prenatal..12

enzyme..muscle..EMG

creatine kinase..2...before

70

Duchenne Muscular Dystrophy (DMD)-----Therapeutic Management:

  • No _________ available
  • Primary goal: Maintain function in _______________ muscles for as long as possible
  • Secondary goal: Avoid wheelchair ______________ for _____________ period

-physician would never order ___________ for this child bc they want them to be ________________ as long as possible

  • ________________ Counseling: for parents, female siblings, maternal aunts/female offspring

cure

unaffected

confinement..longer

bedrest..ambulatory

Genetic

71

Duchenne Muscular Dystrophy (DMD)-----Maintenance Therapy:

  • ____________-of-___________ exercises
  • ____________ to release contracture deformities
  • _____________ ____________ for scoliosis
  • ___________ bracing to slow vertebral deformity and maintain post-op alignment

Range-of-motion

Surgery

Vertebral fusion

TLSO