MUSCULOSKELETAL DISORDERS

Presented by Marlene Meador RN, MSN,

CNE

Newborn Musculoskeletal System

Flexibility – prevents injury Long bones – porous Epiphyseal plates – cartilaginous Muscular system – complete at birth

Clubfoot: Talipes Equinovarus

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 detectionAssessment

Diagnostic tests

Treatment Ponseti method - 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

InfantGluteal folds+ Ortolani’ s - Barlow’s Maneuver

ChildrenLimited ROMShort femurGait

Diagnostic Tests:

UltrasoundCT and MRIX-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

Promoting Developmental Needs

BondingEnvironmentActivity

?????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 Elevate extremity & change position Keep cast clean & dry Petal cast Bar between the legs is not a handle! Assess CMS (circulation, movement,

sensory); bleeding, temperature, skin integrity.

Complications Associated with Casts Compromise to circulation and inervation

Compartment SyndromeParathesiaPainPressurePallor **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 platePliable and porousHealing 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

TreatmentCasting

Traction

Surgical intervention

Complications associated with orthopedic trauma: Fat Embolism

Particles of fat are carried through circulation and lodge in lung capillaries causing:

Pulmonary edema Respiratory distress with hypoxemia and

respiratory acidosis

Treatment Increase in IV fluids Respiratory support and adequate oxygenation

Legal & Ethical implications when caring for a child with a fracture:

All fractures entering the hospital via ER require social service consult for documentation of suspected abuse or neglect.

The nurse must report all suspected abuse to the appropriate authority.

Do not discuss the possibility of abuse with the parents or guardians!! Do not attempt to prove or disprove abuse.

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

Screening 5th & 7th grades

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

Treatment of Scoliosis

Mild 10-20° Exercises improve posture

Moderate 20-40° Bracing maintains existing curvature

Severe 40° or > Spinal fusion (> 80% = compromised respiratory function)

Goal: limit or stop progression of curvature

????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

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

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. Brace application 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 healthGoal: keep child ambulatory Assess muscle weaknessRespiratory functionNutritional statusOT, PT, RT

Psychological Impact

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

Family Centered Care:

Financial resourcesCommunity resourcesCultural influences Support groups

Please contact me if you have any questions or concerns regarding this presentation.

Marlene Meador RN, MSN, CNE

mmeador@austincc.edu