MUSCULOSKELETAL DISORDERS

1. MUSCULOSKELETAL DISORDERS Revised, summer 2007

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

14. Spica cast

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

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

17. Developmental dysplasia of the hip • Head of femur is unstable • Subluxation of the hip occurs • Dislocation of the hip can be in late stage of development

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

19. Pavlik harness

20. ????? 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.

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

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

23. Pathophysiology • Epiphyseal plate • Pliable and porous

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

25. Healing • Rapid in children • Good rule of thumb: one week for every year of life up to 10 yrs

26. Assessment • Pain (PROM) Tenderness • Edema • Limited movement • Distortion of limb

27. Nursing Care • Casting • Traction http://www.dhmc.org/webpage.cfm?site_id=2&org_ • Compartment syndrome • Surgical intervention

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

29. Duchenne’s (D M D)

30. Duchenne’s characteristics

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

32. Diagnosis/Treatment • Muscle biopsy • **Serum enzyme CK • Electromyogram • ECG • Rehab • Corticosteroid therapy

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

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

35. ???? 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

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

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

38. ???? 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.

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

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

41. 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

42. 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…