Musculoskeletal

Musculoskeletal

Common MS disorders in Children • Developmental hip dysplasia • Clubfoot • Fractures • Scoliosis • Osteogenesis Imperfecta • Osgood-Schlatter Disease • Osteomyelitis • Muscular Dystrophy • JRA

Disorders of the lower extremities

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)

Congenital hip dysplasia

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

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

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

Managementfor infants >3 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 >18mos Successful reduction is difficult after age 4

Nursing Considerations • Skin care • Hygiene • Feeding • Handling • Immobility • Elimination • Growth and Development • Clothing • Transportation

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.

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

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

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

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

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

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

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

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

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)

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

Disorders of the Spine

Scoliosis • Most common type of spinal deformity, girls 5:1 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

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

Treatment for Severe Scoliosis • Surgical correction: spinal realignment & straightening (Harrington Rod) • Followed by Milwaukee Brace . Worn 23 hr day

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

Disorders of the bones

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

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

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

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

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

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

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

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

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

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

Osteomyelitis • Diagnosis: • Increased WBC’s • Increased sed rate • Increased C-reactive protein • Positive blood culture • MRI shows bone purulence and edema

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

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

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

Disorders of the Muscle

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

Duchenne’s 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

Gower’s Sign: press hands against ankles, knees & thighs to stand up

Duchenne’s Muscular Dystrophy • Speech & swallowing become impaired • More pronounced muscle weakness (scoliosis) • Wheelchair by junior high • Tachycardia • Pneumonia • Heart failure age 20

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

Disorders of the soft tissue

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

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

Musculoskeletal