Musculoskeletal Alterations

NUR 264 – PediatricsAngela Jackson, RN, MSN

Differences between Children and Adults

Bones contain a large amount of cartilage, making them more flexible and less likely to break

Periosteum is stronger and tougher Bones heal more quickly because the bones are

still growing: The younger the child, the faster the bone heals

Epiphyseal growth plate Bone injury, especially at the growth plate, is more

common than sprains, because soft tissue attachments are stronger in children

Types of Fractures

Closed or Simple fracture: The skin over the broken bone remains intact

Open or Compound fracture: The broken bone protrudes through the skin

Transverse fracture: Occurs at a right angle to the long axis of the bone

Oblique fracture: A slanting or diagonal break across the bone

Spiral fracture: circular and twists around the bone shaft Greenstick fracture: A break through the periosteum and

bone on one side while the other side only bends

Fractures

Salter-Harris Classification of Epiphyseal injuries

Type I: Separation of the epiphysis from the metaphysis. Usually does not affect growth. No fracture of the bone.

Type II: Separation of the epiphyseal growth plate and fracture of the metaphysis. Usually does not affect growth.

Type III: Fracture of the epiphysis extends into the joint. If reduced properly, does not usually affect growth.

Type IV: Fracture of growth plate, epiphysis, and metaphysis. Open reduction and internal fixation usually necessary to prevent growth disturbance

Type V: Crushing injury of the epiphyseal growth plate. Results in premature closure of the plate on one side with growth arrest.

Salter-Harris Classification

Traction

The application of pulling force to a body part against a countertraction pull exerted in the opposite direction

Used to treat a variety of injuries– Spine– Long bones of the upper and lower extremities– pelvis

Traction

Straight traction:– Child’s body weight serves as the countertraction

Balanced Traction: – the body part is suspended by a sling and the

countertraction as well as the primary traction is provided by pulleys and weights. The angle of the involved joint and the angle formed by the placement of the pulleys on the bed determines the direction of the pull or force

Primary Purposes of Traction

Immobilizes the fracture Decreases muscle spasms Realigns and positions bone ends while

healing takes place Prevents further soft tissue damage

Complications of Fractures

malunion compartment

syndrome growth disturbances

Nursing Considerations

Neurovascular status Pain Respiratory status Cardiovascular status Immobilization Skin Integrity Nutrition Elimination

Nursing Management

Monitor for appropriate alignment, and ensure that weights hang freely

Perform Neurovascular checks every hour X 24 hrs, then q4-8hrs Maintain skin integrity Promote pulmonary hygiene Promote adequate fluid and fiber intake to prevent constipation Provide stimulation appropriate for developmental age to promote

growth and development Encourage limited mobility as permitted Encourage parents to hold child as permitted Avoid pressure on the popliteal space to prevent nerve damage Provide adequate pain relief

Infectious Disorders of the Musculoskeletal System

Osteomyelitis

Osteomyelitis

Infection of the bone caused by a microorganism May be bacterial, viral or fungal Bacteria may be introduced through the blood

stream from an infection in another part of the body (endogenous spread) or directly into the bone via a penetrating wound or open fracture (exogenous spread)

More common in children between the ages of 3 and 12

Males are affect 2 to 4 times more often than females

Osteomyelitis: Sources of Infection

Sources of hematogenous spread include

– Acute otitis media– Impetigo– URI’s– Abscessed teeth– Burn infections

Causative Organisms include

– Staphylococci aureus (80 – 90%)

– Haemophilus influenzae– Streptococcus Pneumoniae– Escherichia Coli– Group B streptococci– gram-negative enteric bacilli– Anaerobic bacteria

Osteomyelitis: Pathophysiology

Bacteria travels to the small arteries at the end of the bone

Inflammation with increased blood flow and swelling occurs

The infectious process leads to bone destruction and abscess formation

Increasing pressure as exudate collects and is confined within the bone results in vascular occlusion, ischemia and eventually bone necrosis

Osteomyelitis: Clinical Manifestations

Infants– Irritability– Poor feeding– Failure to move affected

limb– Permanently arrested

bone growth

Children– Constant bone pain– Restricted movement– Swelling– Heat in the affected area– Redness– Fever– Signs and symptoms of

systemic infection

Osteomyelitis: Diagnosis

Lab tests– CBC– C-reactive protein– Sed rate (ESR)– Blood cultures– Wound cultures– Culture of bone aspirate

X-Rays– Routine x-ray of affected

area– Bone scan– X-ray examination of the

affected area will detect bone necrosis ten to fourteen days after appearance of clinical manifestations

Osteomyelitis: Potential Complications

Abscess Joint or bone damage, especially damage to

epiphyseal growth plate Complications affecting the hepatic, renal

and hematological systems (related to high dosages of antibiotics)

Amputation of affected extremity Interference with growth

Osteomyelitis: Treatment

IV broad-spectrum antibiotics for 3 – 6 weeks (may switch to po after adequate response is achieved)

Splinting Surgical drainage and debridement

Osteomyelitis: Nursing Management

Monitor for potential complications– Perform neurovascular checks at least q8hrs– Maintain proper alignment and move the limb cautiously to avoid

further injury to the bone Administer antibiotics as scheduled Assess the site of infection; monitor for edema, redness,

warmth or drainage every 4 hours Monitor white blood cell count and therapeutic medication

levels Maintain splinting if present Use sterile technique for dressing changes Assess for pain, and administer analgesics as prescribed

Muscular Disorders

Muscular Dystrophy

Muscular Dystrophy

A group of inherited diseases affecting the muscle, leading to progressive muscular wasting and degeneration of muscle fibers

It is the largest group of muscle diseases affecting children, and it is genetically acquired

Duchenne’s Muscular Dystrophy is the most common childhood form (x-linked recessive)

– Affects all races and ethnic groups– Affects males almost exclusively– Females may be carriers and pass the defect to their male

children

Muscular Dystrophy: Pathophysiology

Absence of the muscle protein dystrophin, which plays a role in supporting the structure of muscle fibers

Results in degeneration of skeletal muscles that control movement

Fat and connective tissue replace the degenerated muscle fibers

Muscular Dystrophy: Clinical Manifestations

Generalized muscular weakness and muscle wasting – usually appears during the third year of life

Difficulty running and climbing stairs

Tires easily when walking Waddling gait

(Trendelenburg gait)

Lordosis Frequent falls Gower’s sign As disease progresses,

calves, thighs, and upper arms become larger as a result of fatty infiltration (pseudohypertrophy)

Mental retardation is common

Gower’s Sign

Muscular Dystrophy: Diagnosis

Muscle biopsy (identifies presence of fatty tissue)

DNA testing Electromyography (detects decreased

electrical impulses) Elevated serum creatine kinase (enzymes

leak from deteriorating muscles) History and physical findings

Muscular Dystrophy: Treatment

There is no cure for muscular dystrophy. Treatment is supportive and includes:– PT/OT– Braces, wheelchairs– Surgery

Muscular Dystrophy: Potential Complications

Atrophy may develop as a result of immobility Contracture deformities may develop as a result of

immobility and disease Obesity may result from bed rest and immobility Cardiac complications occur lat in disease and may

require a pacemaker Infections, especially respiratory, secondary to weak

muscles of respiration, occur. Even minor infections require prompt treatment to avoid complications or death.

Muscular Dystrophy: Nursing Management

Participation with the interdisciplinary team Respiratory care: teach deep breathing and coughing exercises Maintenance of optimal nutrition Prevention of skin breakdown Maintenance of optimal bowel and bladder function Teach signs and symptoms of infection Encourage independence as long as child is capable. Powered

wheelchairs, special eating utensils, and other assistive equipment is available

Encourage genetic counseling Assist family and child in coping with a fatal disease Teach proper body mechanics and range-of-motion exercises

Musculoskeletal Disorders

Legg-Calve PerthesOsteogenesis Imperfecta

Legg-Calve-Perthes: Pathophysiology

Temporary loss of blood supply to the femoral capital epiphysis, results in avascular necrosis of the femoral head

Unknown cause Occurs in four stages:

– Incipient stage– Necrotic stage– Regenerative stage– Residual stage

Legg-Calve-Perthes: Clinical Manifestations

Intermittent appearance of limp on affected side Mild pain in hip exacerbated by increased activity and relieved

by rest Joint dysfunction and limited range of motion, especially

abduction and internal rotation Stiffness varying from intermittent to constant Limb-length inequality Pain, soreness, and aching; usually worse on rising or at the

end of the day; may be in groin, hip or knee area Tenderness over hip capsule External hip rotation (late sign) Deterioration of the femoral head on x-ray

Legg-Calve-Perthes: Nursing Management

Monitor neurovascular status Encourage meticulous skin care Teach signs of muscle atrophy Teach crutch Walking Encourage non-weight bearing activities Teach safety measures

Legg-Calve-Perthes: Treatment

The main goals of treatment are to keep the head of the femur contained in the acetabulum, to promote healing, and to prevent deformity. This may be achieved through:

– Traction– Braces– Leg casts– Surgery

Legg-Calve-Perthes: Diagnosis

Diagnosed and classified by X-ray Bone scan

Osteogenesis Imperfecta (OI)

Known as brittle bone disease Connective tissue disorder. Occurs in several forms

with variable degree of severity Fractures may result form trauma, but also from

simple walking or pressure of birth Affects boys and girls equally A child with this diagnosis should not be

confused with the child with fractures because of abuse

OI: Pathophysiology

Characterized by disturbed formation of periosteal bone, resulting in formation of pathologic fractures

Normal calcium and phosphorus levels, and abnormal precollagen type I, which prevents the formation of collagen, the major component of connective tissue

Bones consist of large areas of osseous tissue and increased numbers of osteoblasts

OI: Clinical Manifestations

Multiple and frequent fractures, some of which may be present at birth

Limb and spinal column deformities related to multiple breaks

Blue sclera Thin, soft skin with easy

bruising Increased joint flexibility

Weak muscles Short stature Conductive hearing loss May have dentinogenesis

imperfecta: hypoplastic teeth with opalescent blue or brown discoloration

OI: Diagnosis

Collagen studies Prenatally, may be detected by level II ultrasound if

disease is severe

OI: Treatment

Early intervention of fractures Prevention of deformities using splints,

braces, casts and surgery Rod insertion Adequate nutrition including calcium,

magnesium and vitamins

OI: Nursing Management

Maintain a non-judgmental and supportive attitude Handle child gently and teach family to handle child

gently:– Avoid lifting by a single arm or leg– Use a blanket for extra support when lifting and moving– Never hold by ankles when diapering. Gently lift by slipping a hand

under the buttocks Encourage activities the promote growth and

development while maintaining a safe environment Encourage exercise, such as swimming, to improve

muscle tone and prevent obesity Encourage realistic occupational planning Suggest genetic counseling

Any Questions???