Musculoskeletal

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Musculoskeletal
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Common MS disorders in Children

• Developmental hip dysplasia
• Clubfoot
• Fractures
• Scoliosis
• Osteogenesis Imperfecta
• Osgood-Schlatter Disease
• Osteomyelitis
• Muscular Dystrophy
• JRA

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Disorders of the lower extremities
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Developmental hip dysplasia

• Hereditary disorder, more common in girls,
  unilateral
• Improper formation and function of hip socket
• Head of femur is dislocated
• Flat acetabulum of pelvis (prevents femur from
  remaining in the acetabulum and rotating
  adequately)

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Congenital hip dysplasia
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Symptoms

• Limited abduction of the affected hip
• Asymmetry of the gluteal and thigh fat folds
• Affected leg may appear shorter
• Positive Ortolani click
• Uneven gait in older children

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Diagnosis

• Early detection is key for success
• Treatment depends on age at diagnosis

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Management for infants under 3 months of age

• Pavlik harness
• keeps hips and knees flexed, the hips abducted,
  and the femoral head in the acetabulum
• worn continuously for 3 to 6 months
• effective 90 of time

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Managementfor infants gt3 months age

• Hip spica cast
• maintains abduction (frog-like position) 3-18
  months age
• Worn for 1 year
• Must be changed as child grows
• ORIF (surgical insertion of pin)
• For child gt18mos
• Successful reduction is difficult after age 4

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Nursing Considerations

• Skin care
• Hygiene
• Feeding
• Handling
• Immobility

• Elimination
• Growth and Development
• Clothing
• Transportation

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Clubfoot (equinusvarus)

• Congenital deformity of the foot
• Three areas of deformity
• The midfoot is directed downward (equinus),
• the hindfoot turns inward (varus),
• the forefoot curls toward the heel (adduction)
  and turns upward in partial supination.

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Clubfoot

• Can affect one or both feet
• Portions of foot and ankle are twisted out of
  normal position
• Varying degrees of severity combinations of
  abnormal positions

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• Assessment
• Early detection is critical
• Part of newborn assessment
• Move foot to midline
• Can range from mild to severe

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• Treatment
• Begins soon after birth, before discharge
• Manipulation with serial casting for 8-12 weeks
  (due to rapid growth)
• Cast extends above infants knee to ensure
  correction

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• Surgical correction btw 4-12 mos, realignment of
  bones, pin insertion, cast for 6-12 weeks
• Denis Browne Splints shoes attached to metal bar
  to maintain correction

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Fractures

• Break in bone from stress
• Frequent in children- bones are not as dense and
  more porous
• Usually occur from
• Falls
• Sports
• MVA
• Bone disease

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Fractures

• Symptoms
• Pain
• Abnormal limb positioning
• Decreased ROM
• Edema
• Ecchymosis
• Crepitus
• Refusal to play with extremity, guarding

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Management

• Cast
• Surgery
• Pins and external devices
• Traction- used to align bone
• Skin
• Pull is applied to the skin and muscle
• Skeletal
• Pull is applied to the bone pins

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Nursing Considerations New Cast

• Inspect skin
• observe for swelling, pain, discoloration, odor
• keep cast free of foreign objects
• Monitor Neurovascular Status
• keep extremity elevated for 1st day
• observe for loss of distal pulse, discoloration,
  loss of movement

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Watch for Compartment Syndrome

• Clinical manifestations begin about 30 minutes
  after tissue ischemia starts.
• Paresthesia (tingling, burning, loss of two-point
  discrimination)
• Pain (unrelieved by medication, characterized by
  crying in the young child)
• Pressure (skin is tense or discolored, cast
  appears tight)
• Pallor distal to cast (pale, gray, or white skin
  tone)
• Paralysis (weakness or inability to move
  extremity)
• Pulselessness distal to cast (weak or absent
  pulse)

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Cast Care in Children

• Promote Mobility
• Crutches
• Wheelchair
• Wheeled Carts (hip spica casts)
• Promote Growth and Development
• promote body image
• provide diversional activity
• cast becomes part of body, fear removal

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Disorders of the Spine
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Scoliosis

• Most common type of spinal deformity, girls 51
  ratio
• Lateral curvature of spine
• Can be congenital or develop in infancy or
  childhood
• Dx by observation, non painful at first
• All children screened in 5th grade
• Ill fitting clothes
• Uneven shoulders, scapulae, hips
• Scoliometer degree of curvature

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Treatment

• Treatment will not correct the curve, but prevent
  it from worsening
• Mild Scoliosis
• Life Long monitoring
• Moderate Scoliosis
• Bracing
• Exercises to improve posture and flexibility
• Electrical Stimulation to back muscles

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Treatment for Severe Scoliosis

• Surgical correction spinal realignment
  straightening (Harrington Rod)
• Followed by Milwaukee Brace . Worn 23 hr day

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Nursing Considerations

• Screen and identify children
• Refer to ortho for eval and treatment
• Assess respiratory, neurological, cardiovascular
  as rib cage deformity can affect
• Promote understanding and compliance of treatment
• Promote good body image and self esteem

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Disorders of the bones
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Osteogenesis Imperfecta

• Connective tissue disorder, leads to fragile bone
  formation
• Brittle Bone Disease
• Causes recurrent pathological fractures
• Will not have normal growth in height

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Clinical manifestations

• Multiple and frequent fractures
• Thin, soft skin
• Increased joint flexibility
• Weak muscles
• Soft, pliable, brittle bones
• Short stature

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Nursing Management

• Goal protect from trauma and reduce the number
  of fractures
• Early intervention
• Splints, Braces, Surgical Rods
• Childproof home

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Nursing Management

• Handle child gently.
• Support trunk and extremities as child is moved.
• Bathing and diapering may cause fractures
• Use blanket for additional support when lifting
• Never pull legs upward when changing a diaper
• gently slip a hand under the hips to raise

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Nursing Management

• Encourage well-balanced diet
• additional vitamin C, vitamin D, and calcium to
  encourage healing and bone growth.
• Limit calories to maintain weight
• immobility can lead to overweight

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Nursing Management

• Support normal growth and development
• Socialization
• Swimming improves muscle tone
• Wheelchairs and adaptive equipment

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Osgood-Schlatter Disease

• Thickening enlargement of tibial tuberosity
• Results from microtrauma (sports-related)
• Bilateral knee pain exacerbated by running,
  jumping, climbing stairs

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Nursing Management

• Self-limiting condition
• rest, ice, heat, NSAIDs
• Immobilization of limb may be necessary
• Support other methods of exercise, sports

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Osteomyelitis

• Bacterial infection of bone
• Common in children age 1-12 years
• Can follow open fractures, burns, skin abscess,
  foreign body
• Infecting organism spreads through the
  bloodstream from the penetrating injury to the
  bone

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Signs and Symptoms

• Pain, warmth, tenderness, limited ROM localized
  to the area of infection
• Usually in the extremities
• In younger child- more subtle symptoms,
  irritability

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Osteomyelitis

• Diagnosis
• Increased WBCs
• Increased sed rate
• Increased C-reactive protein
• Positive blood culture
• MRI shows bone purulence and edema

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Treatment

• 4-6 weeks of Antibiotics (PICC line)
• Limit weight bearing on extremity
• Aggressive therapy is needed to prevent
• Disruption of the growth plate, interrupt growth
• Septic arthritis and joint damage
• Recurrent infection

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Nursing Considerations

• Administer IV antibiotics
• Teach care of PICC line
• Strict aseptic technique and transmission-based
  precautions during all dressing changes.
• Good hygiene
• Teach signs of spread of infection
• increasing pain, difficulty breathing, increased
  pulse rate, fever

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Nursing Considerations

• Promote Development
• Provide suggestions for the family if the child
  will be immobilized at home.
• Assist the family in planning for completion of
  school tasks

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Disorders of the Muscle
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Muscular Dystrophy

• Inherited disease with progressive deterioration
  of muscle cells
• Causes progressive muscle weakness and atrophy
• Several different types
• All differ by age of onset and severity
• The most common form of childhood muscular
  dystrophy is Duchenne muscular dystrophy

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Duchennes Muscular Dystrophy

• X-linked recessive disorder
• Affects boys, symptoms by age 3
• Will meet early motor milestones, but later at
  age 3 see
• waddling gait, difficulty climbing stairs,
  frequent falls easily tired, when walking and
  running
• toe walking, hypertrophied calves, lordosis

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Gowers Sign press hands against ankles, knees
thighs to stand up
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Duchennes Muscular Dystrophy

• Speech swallowing become impaired
• More pronounced muscle weakness (scoliosis)
• Wheelchair by junior high
• Tachycardia
• Pneumonia
• Heart failure age 20

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Nursing Considerations

• Maintain ambulation as long as possible
• Physical Therapy, Adaptive equipment
• Braces to prevent contractures
• Promote independence
• Prevention of injury
• Prevention of infection

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Disorders of the soft tissue
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Juvenile Rheumatoid Arthritis

• Chronic inflammation of synovium with eventual
  erosion of articular cartilage
• Cause is autoimmune
• ANA (antinuclear antibodies)
• RF (rheumatoid factor)
• Peak 1-3 years or 8-12 years, girls affected
  more

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Follows one of three clinical courses

• Systemic elevated temperature, rash, any of
  joints affected
• Pauciarticular involves 4 or less joints,
  usually large joints
• Polyarticular involves 5 or more joints, smaller
  joints or weight bearing joints

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Symptoms

• Stiffness in AM
• Swelling
• Tenderness
• Painful to touch
• Warm to touch, seldom red
• Loss of motion
• Increased WBCs sed rate

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Juvenile Rheumatoid Arthritis

• Goals of care
• Maintain joint fx (splints, ROM)
• Prevent physical deformities
• Relieve symptoms (pain inflammation)
• NSAIDs (aspirin, ibuprofen, naproxen)
• SAARDs Slower Acting Antirheumatic Drugs(gold,
  D-penicllamine)

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Nursing Care

• Facilitate medication compliance
• Encourage child to be as independent as possible
• Moist heat (bath or whirlpool) especially in
  morning
• Prevention of injury
• Promote functioning
• Most common complication
• severe hip involvement with loss of function

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Practice Questions!
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• A 3-year-old child is suspected of having
  Duchennes muscular dystrophy. Which of the
  following assessment findings by the nurse would
  support this diagnosis?
• A history of delayed crawling
• Outward rotation of the hips
• Difficulty climbing stairs
• Wasted muscle appearance

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• A child is admitted to the hospital suspecting
  osteomyelitis. Which of the following serum
  laboratory values noted by the nurse supports
  this diagnosis? (Select all that apply)
• Positive Blood Cultures
• ANA
• WBC 15,000
• Sed Rate 5
• Decreased C-Reactive Protein

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• An adolescent diagnosed with moderate scoliosis
  describes all of the following symptoms. Which
  one would the nurse conclude is not associated
  with the initial diagnosis?
• Back pain
• Skirts that hang unevenly
• Unequal shoulder heights
• Uneven waist angles

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• A 4-year-old child with osteogenesis imperfecta
  is admitted to the hospital unit. Which of the
  childs nursing diagnosis has the highest
  priority?
• Impaired skin integrity related to cast
• Pain related to fractures
• Risk for injury related to disease state
• Disturbed body image related to short stature

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• Which item should the nurse remove from the
  bedside table of a 4-year-old child who has just
  been placed in bilateral long leg casts?
• Legos
• Etch-a-sketch
• Firemans hat
• Coloring book

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• The nurse is assessing a child in a newly applied
  cast to the lower leg for a tibia fracture. The
  nurse medicates the child for pain, which is
  ineffective. The nurse should further assess
• Color of toes.
• Apical pulse.
• Skin temperature.
• Blood pressure

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• A 14-year-old states her fingers and wrists are
  stiff in the morning, hurt, and are swollen. The
  nurse suspects this adolescent will be tested
  for
• Osteomyelitis
• Osgood-Schlatter Disease
• Rheumatoid Arthritis
• Fractures