MUSCULOSKELETAL DISORDERS

By Ann Hearn RNC, MSN

2010

Newborn Musculoskeletal System

Resiliency – prevent injury Birth process Walking

Long bones – porous Injury – bend, buckle, or break Epiphyseal plates

Talipes Equinovarus (Clubfoot)

Adduction and supination of forefoot with an inversion (varus) of the heel and fixed plantar flexion and the midfoot directs downward (equinus).

Clinical Manifestations Focus on early detection

Assessment

Diagnostic tests

Treatment

Serial manipulation with corrective casting

Dennis Browne splints - horizontal bar attached to foot plates

Surgical correction

Nursing Care & Evaluation

Provide Emotional Support Promote bonding

Cast Care Referrals

Regular check-ups Prognosis ROM after removal of casts

Developmental Dysplasiaof the Hip

Malrotation of the hip at birth Improper formation or function of

acetabulum

Clinical Manifestations

Limited abduction Gluteal folds Ortolani’ s & Barlow’s Maneuver Shorter femur Prominence of femur S&S in older children

Diagnostic Tests:

Ultrasound

CT and MRI

X-ray

Treatment:

Splinting of hip - Pavlik harness Hip maintained in

flexion and abduction Deepens acetabulum

from pressure of femur head

Treatment cont’d.

Skin Traction Relocates femoral

head while stretching restrictive soft tissue

Surgical Treatment & Spica Cast:

Release muscles and tendonsApplication of body spica cast

?????

A parent asks why her infant must wear a Pavlik harness. The nurse responds that the purpose of this device is to:

A. Provide comfort and support

B. Shorten the limb on the affected side

C. Maintain the femur within the acetabulum

D. Provide outward displacement of the femoral head.

Cast Care & Assessment

Use palms to handle wet cast Bar between the legs is not a handle! Use pillows for positioning Keep cast clean & dry Pedal cast Assess CMS

(circulation, movement, sensory)

Complications Associated with Casts Compromised circulation Cast displacement from therapeutic position Immobility Compartment Syndrome

Parathesia Pain Pressure Pallor ** Paralysis ** Pulselessness **

Nursing Management for the Casted Child Encourage cuddling Teach parent application of harness Developmental needs

Bring environment to child

Protect skin Diet Safety

?????

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 heartb. Handle cast with fingertipsc. Reposition the child every 2 hoursd. Spray the cast with an acrylic protectant

Fractures

Occur as a result of direct force Greenstick fracture MVA

Repeated stress on the bone

Pathologic conditions

Patho-physiology

Epiphyseal plate

Pliable and porous

Healing is Rapid in children 1 week for every year of life up to 10 years

of age

Assessment

Pain Tenderness Edema Limited movement Distortion of limb

Treatment

Casting

Traction

Surgical intervention

Scoliosis

Lateral “S” or “C” curvature of the spine > 10° Structural

Idiopathic (70-80% of all cases) Congenital Neuromuscular

– Poliomyelitis– Cerebral palsy– Muscular dystrophy

Scoliosis

Manifestations

Classic Signs: Truncal asymmetry Uneven shoulders and hips A one-sided rib bump Prominent scapula

Screening 5th & 7th grades

????

The school nurse would screen an adolescent for scoliosis by instructing him/her to:

A. Bend forward at the waist, holding hands together

B. Lie prone on an examination table

C. Stand with shoulders placed against the wall

D. Sit on a chair and raise shoulders

Treatment of Scoliosis

Mild 10-20° Exercises improve posture

Moderate 20-40° Bracing maintains existing curvature

Severe 40° or > Spinal fusion

Goal: limit or stop progression of curvature

Bracing

Used for skeletally immature http://milwaukee.brace.nu/

????

An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen?

A. Discourage participation in ADL’s.B. Teach appropriate application, removal and

care of skin and brace.C. Discourage sports like golf and tennis

encourage sedentary activities.D. Teach non-weight bearing techniques.

Rods:

Recommended for curves > 40 degrees Goal: fuse spine to prevent progression Why is surgery the recommended

treatment for progressive curvature?

Surgical Care

Pre-op Mentally prepare Demonstrate incentive spirometer, TCDB, log roll PCA pump

Post – op Pain management Monitor neurovascular status Monitor H&H Log Roll, sit, ambulate ROM Dressing changes

What would you teach a child to expect in the immediate post-op period?

a. Frequent neurovascular assessments

b. Need to CT&DB every 2 hours (IS)

c. Possibility of IV, chest tubes

d. Use of post-op analgesia

Discharge

No heavy lifting, bending or twisting at the waist.

Follow-up X-rays Once fused may resume normal activity

levels, skiing, sports, etc…

Muscular Dystrophy

Muscle fiber degeneration and muscle wasting. Duchennes

Onset of symptoms 3-4 years of life Terminal disorder

Clinical Manifestations & Diagnosis S/S

Delayed walking, frequent falls, tire easily, toe walking, hypertrophied calves, waddling gait, lardosis, + Gower’s maneuver, mental retardation

Dx: Muscle biopsy (↓ distrophin) ↑ Serum enzyme CK Electromyogram EEG (75% are abnormal)

Prognosis

1:3500 children effected

Ability to walk lost by age 9-12

Death occurs 9-10 years after diagnosis

Nursing Care

Promote optimal health Goal: keep child ambulatory Assess muscle weakness Respiratory function Nutritional status OT, PT, RT

Psychological Impact

What are some psychological issues that may affect a family caring for a child with muscular dystrophy?

Musculoskeletal Cancers of Childhood

Osteosarcoma Rare Adolescent boys During rapid bone growth Location: metaphysis of

distal femur, proximal tibia or humerus.

Bone issue does not mature into compact bone

**related to radiation exposure

Ewing’s sarcoma 2:million Whites & Hispanics Ages 10-20 Location:diaphyseal

(shaft) of long bones- femur, pelvis, tibia fibula, ribs, humerus, scapula, clavicle.

Small, round cell tumor **chromosome

translocation

Clinical Manifestations

Pain Edema Palpable mass Progressive limping Pathologic fractures at tumor (late sign) Metastasis

20% pulmonary

Diagnosis

Radiography Lab tests Biopsy

Therapeutic Management

Chemotherapy Pre & post-op

Surgery: Tumor – limb salvation Limb amputation

Nursing Assessment: Pre op

History of injuries Site of tumor Pain, mobility, gait Vital signs Current activity level Psychosocial history Body image

Nursing Assessment: Post op

Post operative Circulation above & below operative site S/S infection Pain Edema Hemorrhage

Nursing Interventions: Post op

Amputation Inspect surgical site using sterile technique Turn at least q 2 hr. Pain management (phantom pain)

Medication Reposition and support the limb Distraction and deep breathing.

Post op teaching Self care Physical therapy Out-patient chemotherapy

Rabdomyosarcoma

Malignancy of muscle, or striated tissue Most commonly: around the eyes & neck Less commonly: abdomen, genitourinary

tract, extremities

Prevalence: < 5 years of age

Diagnosis

Assessment

Radiography

Biopsy

Treatment

Surgery Radiation – wide field Chemotherapy

Chemotherapeutic Agents

VAC Therapy Vincristine Actinomycin Cyclophosphamide

Pre-Op Nursing Goals

Disturbed sensory perception (visual) Anticipatory grieving Knowledge deficit Risk for infection

Post-op Nursing Diagnosis

Risk for infection Impaired skin integrity Impaired physical mobility Impaired adjustment Disturbed body image Pain

Chemotherapy & Radiation

Preoperative use: Tumor size Prevent seeding

Teaching Suppressed immune system

Isolate from public areas where illness can be transmitted.

Lab monitoring RBC & WBC

Psycho-social Considerations

Psychological stressors

Financial stressors

Social stressors