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Musculoskeletal System Disorders Congenital, Acquired

Musculoskeletal System Disorders Congenital, Acquired. MSAL II 2014 C. Calzolari. Congenital Disorders. Congenital Talipes Equinovarus Congenital Hip Dysplasia. Congenital Talipes Equinovarus. Facts. Congenital deformity where foot has “ clublike ” appearance Usually evident at birth

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Musculoskeletal System Disorders Congenital, Acquired

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  1. Musculoskeletal System DisordersCongenital, Acquired MSAL II 2014 C. Calzolari

  2. Congenital Disorders • Congenital Talipes Equinovarus • Congenital Hip Dysplasia

  3. Congenital TalipesEquinovarus

  4. Facts • Congenital deformity where foot has “clublike” appearance • Usually evident at birth • Can be unilateral or bilateral (50%) • Boys vs girls 2:1 • 2 types: positional and fixed • Treatment: • Manipulation and bandaging • Application of cast and splint • Surgery Despite TX, re-occurrence is common

  5. Treatments (started right after birth) • Passive manipulation of the clubfoot in the opposite direction of the deformity, Stimulation of the muscles in the direction of the correction, • and permanent immobilization of the foot in corrected position using elastic bandages, plates, splints at first, • then intermittent according to the progress achieved.

  6. Ponseti technique • Manipulations of the clubfoot and • above the knee casting of the clubfoot molded by the surgeon weekly, (may involve cutting the Achilles tendon-tenotomy)

  7. Post-op Care • Keep cast uncovered to allow drying. • Keep leg elevated on pillows. • Perform neurovascular checks (CSMs!!!!) • Circle with a pen any area of bleeding on the cast. • Observe for skin irritation.

  8. Denis Browne splint After 3 weeks, the infant will wear splints such as Denis Browne splint

  9. Extensive Surgery is performed when the conservative treatment has failed over a period of 4 to 6 months. • Its primary goal is to free all the 'locks' insufficiently stretched by the orthopedic treatment. • The most common procedures used are tendonlengthening, opening of the joints (capsulotomy), removal of the shortened fibrous tissues and proper repositioning of bones in the various affected joints.

  10. Congenital Hip Dysplasia

  11. What is it? • Results from abnormal development of acetabulum (hip socket). • The head of the femur doesn’t fit right due to the shallow hip socket. • This can cause dislocation.

  12. Clinical Manifestations • Asymmetry of gluteal folds • Audible click on examination • Limited ROM - abduction of affected leg • Affected Knee is lower. • One buttock appears higher. • “Sailor’s Gait” • If child is walking, you would notice a limp

  13. Physical Examination:Barlow’s sign, Ortolani’s maneuver, Galeazzi testIf hip dysplasia is suspected, an US may be ordered.

  14. Treatment • Maintain hips in constant flexion and abduction “FROGLIKE” position • Why? Constant pressure enlarges and deepens acetabulum. • How? Several options: • Pavlik harness for up to 6 mos. • Traction • Closed or Open reduction followed by application of Spica Cast

  15. Pavlik Harness http://www.youtube.com/watch?feature=player_embedded&v=MsV7cGrWpJU

  16. Often the dislocated hip of a newborn baby goes back into the socket very easily because the mother’s hormones that relax ligaments are still in the baby. Dislocated or unstable hips in newborn infants can usually be held in place by a brace or harness that holds the legs in a position while the socket and ligaments become more stable.

  17. Traction

  18. Spica Cast On average, used for 3 mos. But could be employed for longer periods of time. A bar may be placed between the leg portion of the cast to strengthen the cast.

  19. Nursing Diagnoses • Anxiety • Acute Pain • Risk for impaired skin integrity • Risk for impaired tissue perfusion • Risk for Delayed growth and development • Deficient Knowledge • Leifer: p.333

  20. Osgood Schlatter Disease • Common cause of knee pain in children and young athletes. • Osgood-Schlatter disease is an overuse injury that occurs in the knee area of growing adolescents. It is caused by inflammation of the tendon below the kneecap (patellar tendon) where it attaches to the shinbone (tibia). Young adolescents who participate in certain sports, including soccer, gymnastics, basketball, and distance running, are most at risk for this disease. • PAIN IS USUALLY BELOW THE KNEE

  21. Treatment • Goal is aimed at reducing the pain and swelling. • How? • The use of nonsteroidal anti-inflammatory drugs and wrapping the knee until the child can enjoy activity without discomfort or significant pain afterwards. Also, RICE • Symptoms that worsen with activity may require rest for several months, followed by a conditioning program. • In some patients, Osgood-Schlatter symptoms may last for 2 to 3 years. • However, most symptoms will completely disappear with completion of the adolescent growth spurt, around age 14 for girls and age 16 for boys.

  22. R.I.C.E. • R = Rest • I = Ice • C = Compress • E = Elevate

  23. Muscular Dystrophy A hereditary, progressive, degenerative disease primarily of the voluntary muscles. Most common type – Duchenne MD (one of 9 types) -an X-linked recessive hereditary disease Affects males, but females are carriers. Genetic testing is recommended. Cause - An absence of dystrophin, a protein that helps keep muscle cells intact. Onset - Early childhood - about 2 to 6 years.

  24. Clinical Manifestations • Difficulty standing and walking – falls frequently and appears clumsy • Trunk muscle weakness • “Gower’s” sign – child must push on his legs & “walk up the leg” in order to stand. • Progressive muscle weakness • Cognitive Impairment is possible • Lordosis • Toe gait • Pelvic waddling • Elevated CPK levels • Muscle biopsy shows absence of dystrophin – follow strict precautions pre and post-procedure. Local anesthetic will be used prior to test

  25. Treatment – multidisciplinary approach • No Cure. Survival is rare beyond the early 30s. • Multidisciplinary approach is KEY • -Rehabilitation, Orthopedic, Psychosocial, Cardiac, Pulmonary, GI, Corticosteroid MGT • Assistive devices for musculoskeletal management • Surgery • Minimize Contractures • Promote Activity • Nutritional, swallowing, gastrointestinal, and speech and language management • Pain Management • Control Obesity • Monitor for other spinal curvature disorders • Pharmacological interventions designed to enhance or preserve muscle strength and function • LT steroid TX • Ca Supplements • Family Support • Resources

  26. Acquired Diseases

  27. Scoliosis

  28. A lateral curvature of the spine • 2 forms: structural and functional • Idiopathic structural scoliosis seen in middle school children • Girls > Boys • Routine screening done by school nurse or pediatrician HOW?

  29. Child is monitored through entire growth cycle. • Curvatures < 25 degrees are observed, but not treated. • Curvatures 25-40 degrees are corrected with braces. • Curvatures > 40 degrees are usually surgically corrected.

  30. Brace should be worn constantly, except for bathing (usually 23 hours a day)Wear over light shirtCustom fit

  31. NCP • Impaired physical mobility • Risk for injury • Risk for impaired skin integrity • Risk for disturbed body image • Risk for noncompliance

  32. Kyphosis – thoracic spine is affected

  33. Kyphosis is a curving of the spine that causes a bowing or rounding of the back, which leads to a hunchback or slouching posture. • Adolescent kyphosis, AKA Scheuermann's disease, is caused by the wedging together of several bones of the vertebrae in a row. The cause of Scheuermann's disease is unknown. • In adults, kyphosis can be caused by: • Degenerative diseases of the spine (such as arthritis or disk degeneration) • Fractures caused by osteoporosis (osteoporotic compression fractures) • Injury (trauma) • Slipping of one vertebra forward on another (spondylolisthesis) • Connective tissue disorders, TB, Ca

  34. Kyphosis may cause the following complications: • Body image problems. Adolescents, especially, may develop a poor body image from having a rounded back or from wearing a brace to correct the condition. • Deformity. The hump on the back may become prominent over time. • Back pain. In some cases, the misalignment of the spine can lead to pain, which can become severe and disabling. • Breathing difficulties. In severe cases, the curve may cause the rib cage to press against your lungs, inhibiting your ability to breathe. • Neurological signs and symptoms. Although rare, these may include leg weakness or paralysis, a result of pressure on the spinal nerves.

  35. Treatments: • Analgesics • Braces • Surgical options: Spinal fusion with bone grafts or rods, vertebroplasty and kyphoplasty

  36. Lordosis “Swayback”

  37. Lordosis can affect persons of any age. Certain conditions can contribute to this condition, including achondroplasia, discitis, kyphosis, obesity, osteoporosis and spondylolisthesis

  38. Slipped Epiphyses • Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the adolescent hip. • It is not rare. • For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.

  39. Boys > Girls • Common in tall, thin rapidly growing teens. • Hip or knee pain • Intermittent limp • Limited ROM

  40. Complications • If a complete “slip: occurs -> Avascular necrosis means that the blood supply to the femoral head has been permanently altered by the femoral head slipping. There is no way to identify children at risk for avascular necrosis or to prevent this complication. Evidence of avascular necrosis may not be seen on X-rays for as long as 6 to 24 months following surgery. • Chondrolysis, or loss of articular cartilage of the hip joint, causes the hip to stiffen with a permanent loss of motion, flexion contracture, and pain. • The loss of motion may be a result of an inflammation in the hip joint. This is still not fully understood by surgeons. Aggressive physical therapy and anti-inflammatory medications may be prescribed for this rare complication. There may be some return of motion.

  41. Post Surgery Care • Pain MGT • Use of crutches • Follow up X-rays and MD visits • Restriction of Activities

  42. Osteoporosis

  43. A metabolic , degenerative disorder • Low Bone Mass • Deterioration of bone structure • Decrease in bone density • Result: fragile bones prone to fractures • particularly bones in spine, wrists, and hips

  44. Pathophysiology: imbalanced bone remodeling • Bone density (mass) peaks b/t 30-35 • Thereafter, bone breakdown (osteoclasts) > bone buildup (osteoblasts) • Inside of bones become porous -> weaker -> fractures

  45. Primary OP • Risk Factors: • Aging, • Females, esp. postmenopausal • Small boned, petite • Family HX of OP & FXs • Caucasian, Asian, Hispanic • Low testosterone & estrogen in men • Low Ca & Vit. D intake • Excess caffeine, ETOH, protein, Na intake • Smoking • Sedentary lifestyle

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