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MUSCULOSKELETAL DISORDERS

MUSCULOSKELETAL DISORDERS. By Marlene Meador RN, MSN Fall 2006. Talipes Equinovarus (Clubfoot). Adduction and supination of forefoot with an inversion (varis) of the heel and fixed plantar flexion. Etiology unknown 75% of abnormalities of the foot (1:1000). Clinical Manifestations .

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MUSCULOSKELETAL DISORDERS

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  1. MUSCULOSKELETAL DISORDERS By Marlene Meador RN, MSN Fall 2006

  2. Talipes Equinovarus (Clubfoot) Adduction and supination of forefoot with an inversion (varis) of the heel and fixed plantar flexion. Etiology unknown 75% of abnormalities of the foot (1:1000)

  3. Clinical Manifestations • Focus on early detection • Rocker bottom foot • Fixed position • Diagnostic tests • Ultrasound • CT • MRI

  4. Treatment • Corrective casting every 3-14 days • Dennis Browne splints- horizontal bar attached to foot plates

  5. Nursing Care • Care of Casts • CMS assessment • Keep dry/clean • Assess placement

  6. Evaluation: • Regular check-ups • Prognosis • ROM after removal of casts

  7. ????? An 18 month old is scheduled for application of a plaster cast to correct a clubfoot. The post-op plan should include which of the following measures? a. Elevate the cast above the level of the heart b. Handle cast with fingertips c. Reposition the child every 2 hours d. Spray the cast with an acrylic protectant

  8. Congenital Dislocation of Hip • Malrotation of the hip at birth • Improper formation or function of acetabulum

  9. Clinical Manifestations • Gluteal folds • Ortolanis sign • Shorter femur • Prominence of femur

  10. Clinical Manifestations cont… • Limited abduction • Barlow Maneuver • Signs and Symptoms in older child

  11. Diagnostic Tests: • Ultrasound • CT and MRI • X-ray

  12. Surgical Treatment: • Release muscles and tendons • Application of body- spica cast

  13. Treatment • Splinting of hip- Pavlick harness • Hip maintained in flexion and abduction • Deepen acetabulum from pressure of femur head

  14. ????? A parent asks why her infant must wear a Pavlik harness. The nurse responds that he purpose of this device is to: • Provide comfort and support • Shorten the limb on the affected side • Maintain the femur within the acetabulum • Provide outward displacement of the femoral head.

  15. Treatment with Spica Cast • For complex cases and older children • Dislocated -some closed and open reductions

  16. Nursing Management • Case finding and referral • Teach parent application of harness • Protect skin • Bring environment to child • Safety

  17. Spica Cast Care • Use palms to handle cast • Bar between the legs is not a handle! • Use pillows for positioning • Keep cast clean & dry

  18. Fractures • Greenstick fracture- most common type in kids < 3 years • MVA -frequent cause of bone injury in 4-7 year olds Porous &

  19. Pathophysiology • Epiphyseal plate • Pliable and porous

  20. Fractures • Occur as a result of direct or indirect force • Repeated stress on the bone • Pathologic conditions

  21. Healing • Rapid in children • 1 week for every year of life up to 10 years of age

  22. Assessment • Pain (PROM) <hint does not mean premature rupture of membranes> • Tenderness • Edema • Limited movement • Distortion of limb

  23. Nursing Care • Casting • Traction • Compartment syndrome • Surgical intervention

  24. Muscular Dystrophy • Duchennes- 13 types • Onset of symptoms

  25. Prognosis • Ability to walk lost by age 9-12 • Death occurs 9-10 years after diagnosis • 1:3500 children effected

  26. Diagnosis • Muscle biopsy • Serum enzyme CK • Electromyogram • EEG (75% are abnormal)

  27. Nursing Care • Promote optimal health • Goal: keep child ambulatory • Assess muscle weakness • Respiratory function • Nutritional status • OT, PT

  28. Scoliosis • Curve greater than 25 degrees • Functional • Postural • Compensatory • Structural • Idiopathic (70-80% of all cases) • Congenital • Neuromuscular • Poliomyelitis • Cerebral palsy • Muscular dystrophy

  29. ???? The school nurse would screen an adolescent for scoliosis by instructing him/her to: • Bend forward at the waist and allow upper extremities to dangle • Lie prone on an examination table • Stand with shoulders placed against the wall to check evenness • Sit on a chair and raise shoulders

  30. Manifestations • Progression- 1 degree per month • Observation of curves • Texas response to funding issues • 6th & 8th grades

  31. Bracing • Used for skeletally immature http://milwaukee.brace.nu/

  32. ???? An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen? • Discourage participation in ADL’s. • Teach appropriate application, removal and care of skin and brace. • Discourage sports like golf and tennis encourage sedentary activities. • Teach non-weight bearing techniques.

  33. Rods: • Recommended for curves >40 degrees • Goal: fuse spine to prevent progression • Why is surgery the recommended treatment for progressive curvature?

  34. Post-op Care • Pain management • Monitor Neurovascular status • Monitor H&H • Log Roll, sit, ambulate • Dressing changes • Report vomiting WHY???

  35. What would you teach a child to expect in the immediate post-op period? • Frequent neurovascular assessments • Need to CT&DB every 2 hours (IS) • Possibility of IV, chest tubes • Use of post-op analgesia

  36. Discharge • As sited in text • No contact jarring activities for 6-12 months • X-rays q 1-2 years until bone solidly fused • Once fused may resume normal activity levels, skiing, sports, etc…

  37. Osteosarcoma • Most common primary malignancy of the bone • Etiology: • Genetic • Radiation therapy

  38. Pathophysiology • Originate in bone-producing cells that invade the medullary canal of the bone • Incidence is higher in most rapidly growing bones in adolescents • Distal femur • Proximal tibia • Proximal humerus

  39. Assessment • Progressive insidious or intermittent pain • Palpable mass • Progressive limping • Pathologic fractures at tumor (late sign)

  40. Diagnosis • X-ray • CT • MRI • Biopsy of tumor • Lab tests • CBC • ALP • LDH

  41. Therapeutic Management • Surgery • Chemotherapy • Radiation • Amputation

  42. Nursing Care • Site of tumor • History of injuries • Current activity level • Psychosocial history • Body image

  43. Nursing Interventions • Preoperative teaching • Infection • Pain • Risk for hemorrhage • Risk for pneumonia • Post operative

  44. Ewing’s Sarcoma • Second most common bone tumor • Mimics infection • Etiology • No know cause or genetic link

  45. Pathophysiology • No defining characteristics • Invades midshaft of long bones • Metastasis

  46. Diagnosis • Biopsy to differentiate from other neoplastic processes

  47. Therapeutic Management • Chemotherapy • Surgery • Radiation

  48. Rabdomyosarcoma • Malignancy of muscle, or striated tissue • Etiology associated with familial cancer syndromes

  49. Pathophysiology • Subtypes • Embryonal • Alveolar • Pleomorphic • Prognosis depends on excision of tumor, rate of metastasis

  50. Diagnosis • Soft to hard, non-tender, immobile mass • Limited range of motion in effected extremity • In pelvic tumors organ function disrupted • CT, bone marrow aspiration and biopsy

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