MusculoskeletalMusculoskeletalMusculoskeletalMusculoskeletal

Elisa Mancuso, RNC-NIC, MS, FNSElisa Mancuso, RNC-NIC, MS, FNS

Professor of NursingProfessor of Nursing

Anatomic Differences

• Child's skeleton contains growth cartilage

• √ Injury = widening of growth plate

• Physis = growth plate. – cartilaginous disq btwn epiphysis and

metaphysis

• Growth plate FX need ↑ follow-up – Growth disturbances– Non-union – Deformity if not healed properly

Pediatric Fractures• Seldom complete breaks• Buckle or bend RT flexibility of

bones– ↑ thicker periosteum– ↑ amounts of immature bone

• Fractures RT direct force to bone• FX <1 year are always suspicious

– R/O Intentional (Child Abuse) vs. Accidental

Fracture -Clinical Signs

• Pain @ site with guarding• Tenderness• Edema• Ecchymosis• Impaired ROM• Deformity• Crepitus• Neurovascular status impaired

– Distal to site RT compression

Neurovascular Check

“Five P’s”1.Pain2.Pallor3.Pulselessness4.Paresthesia5.Paralysis

Diagnosis• X-ray

– √ R & L extremities– Comparison– Oblique FX→

• CT scan• Bone Scan• MRI

– √ ligament damage

TherapyRICE• Rest• Ice• Compression• Elevation

Surgery- ORIFOpen Reduction Internal Fixation

Casting- Closed Reduction– Fiber glass – Plaster

• Neurovascular √’s• Pain medication

Complications

Compartment Syndrome• Surgical Emergency!• ↑ Pressure to FX site• ↓ Circulation• ↑ Risk for infection• ↑ Pain• Tenseness with palpation• Motor weakness• ↓ ROM

Traction

• Immobilize fracture• Realign bone fragments• ↓ Muscle spasms and pain• Applies pull in 1 direction

– Against counter pull in opposite direction

• Body wt is counter traction• External fixation = ↑ mobility

Skin Traction• Buck’s

– Leg extended. – 1 line of horizontal - pull.

• Russel’s– Leg extended & knee flexed.– 2 lines of pull; – 1 horizontal & 1 vertical.

• Bryant’s– Hips flexed @ 90 degrees– Buttocks off bed – Both legs extended vertically

Skeletal Traction

• Pin or wire directly inserted into bone.

• For complicated fx of femurs >6 years

• Complications– Osteomyelitis.

Immobility Complications

• Skin integrity• Atelectasis• Renal calculi• Constipation• Infections• Osteoporosis-bone demineralization• Fat Embolism

– Female adolescents in 1st 24 hours (Femur Fx)

– Sudden chest pain– SOB– Impending doom! – Tx like PE!

Nursing Interventions

• √ lab values-– ↑ Ca+, ↑BUN, & ↓ H and H – √ bleeding

• ↑ Hydration (2-3 L/day) – Prevent hypercalcemia & renal

calculi• ↑ Nutrition & Protein

– Small frequent meals• Exercise to help prevent

osteoporosis

Osteomyelitis

• Infection –– Bacteria invading metaphysis – Forming abscess and local bone

destruction

• Males at ↑ risk at 5-14 years• Causes:

– Trauma or penetration injury – Invasion during surgical procedure– Systemic infection

Clinical Signs

• ↑ Temp• Erythema and warmth• Pain

– Abrupt onset with ↑ intensity• Non-weight bearing• ↓ ROM• Irritability• Septicemia

Diagnosis

• CBC ↑ WBC with shift• BC• ↑ ESR• X-ray maybe negative at first• Bone scan

– Show ↑ uptake @ site of infection• Bone Biopsy

– Identify organism and degree of damage

TherapyIV antibiotics • Long term 4 – 6 weeks

– PICC line• Meningitic dose• Surgery I & D• Nutrition

– ↑ calories, ↑ protein and ↑ fluids

Osteogenisis Imperfecta OI

• Congenital connective tissue disorder – Defect in synthesis of collagen– Incomplete development of :

•bones, teeth, ligaments and sclera

• Brittle bones and ↑ risk for fractures• Autosomal Dominant-mild-Type I • Autosomal Recessive-severe-Type II • Intrauterine fx and death

Clinical Signs• Depends on type of OI• Short stature• Fractures from minimal trauma “brittle

bones”• Progressive bone deformities and bowing of

lower limbs• Blue, purple or gray sclera. • Hearing loss by 20-30 years• Thin skin • Bruise easily• Hypoplastic teeth

– Yellow or grayish blue – W shaped – ↑ dental = more severe skeletal

deformities

Therapy • Prevent fractures-

– Lift gently and avoid jarring movements

– Provide padded and soft environment

• Encourage walking• No contact sports, and no

strenuous activity• Preventative dental caries• Diet ↑ Calcium, ↑ Vit D and ↑C • Maintain healthy weight

Muscular DystrophyDuchenne’s

• Duchenne muscular dystrophy (DMD) – X-linked recessive disorder, – DMD occurs in 1 in 3000 male

infants.

• Absence or deficiency of dystrophin a skeletal protein product

• Onset @ the fourth year • Often causes death by age 20.

Signs and Symptoms• Delay in motor development:

– Waddling gait, prolonged lordosis and ↑ falls

• Gower’s sign– Hands push self up from floor when

rising from sitting or supine position• Proximal limb weakness • Pseudohypertrophy of the calves. • Myocardium is affected • Severely disabled by the age of 10.

DiagnosisMuscle biopsy identifies type of

dystrophy• Absence or deficiency of dystrophin • Degeneration of muscle fibers• Fibrosis and fat present

(Pseudohypertrophy)

• ↑↑ CPK • ↑↑SGPT &↑↑SGOT• EMG (electromyography)-

– ↓↓ Electrical activity in muscles

Therapy• Genetic counseling • Maintain function in unaffected

muscles as long as possible– ROM, Braces,– ↑ top sneakers to prevent foot drop

• ✔ Respiratory function-– Mobilize secretions, CDB, PD & C

• Promote independence • ↑ Fluids and fiber to prevent

constipation• Anticipatory grieving

– (cardiomyopathy is main cause of death)– Make will & funeral arrangements

Congenital Hip Dysplasia

Head of femur improperly seated in acetabulum

• Shallow acetabulum– Mildest form

• Subluxation– Incomplete dislocation. – Displaced laterally.

• Dislocation– Femoral head out of acetabulum. – Displaced posteriorly

Etiology

•↑↑ Maternal estrogen = ↑ relaxation of joints

•Positive family history•Breech presentation•Females 6x > males•Bilateral 20%

Clinical signs• Asymmetry of gluteal folds• Unequal limb length• Trendelenburg sign

Ortolani test• Flex hips @ 90 degree angle• Adduct hips and apply gentle pressure with

thumbs. • Feel “Click” from femoral head moving out of

acetabulum

Barlow’s• Abduct hips and feel “clunk” of dislocated

femoral • head moving back into acetabulum• Sonogram or x-rays confirm diagnoses

Interventions• Pavlik Harness

– Newborn to 6 months– Skin care– Must remain on 24 h/day

• Hip Spica Cast– 6-18 months– Change q 4-6 weeks for growth

• Skeletal Traction

Congenital Clubfoot Talipes Equinovarus

• Most common congenital foot deformity• Boys 2x > girl • Unilateral more common

• Abnormal intrauterine position• Oligohydramminos • Muscular atrophy or dystrophies

• Inversion and lateral border convexity• Plantar flexion-toes lower than heels• Medial adduction of toes and fore

foot

3 Stage Therapy• Correction of deformity

– Manipulation and casting

• Maintenance of correction – Until normal balance is regained– Follow-up observation

• Surgery by 3-6 months – Manipulation is ineffective with

casting – Unable to maintain position

Prognosis

• Variable

• Correct foot maybe ½ size smaller– Need 2 different shoe sizes

• Calf is 10% smaller

• Observe the foot closely for several years – Prevent deformity from recurring

Legg-Calve-Perthes Disease

• Avascular necrosis of femoral head • Causes ↓ circulation to femoral

epiphysis• Ischemia and necrosis to femoral head• Painful limp that is ↑ by activity• Self-limiting• Idiopathic• Trauma• Inflammatory• Boys 4-8 years @ ↑ risk• White 10X > blacks

5 stages1-Onset-

Epiphysis begins to show ischemia & necrosis

2-Necrosis-Bone weakens and diesCollapse of femoral head

3-Fragmentation-Avascular bone is reabsorbed & healing occurs

4-Reossification-Femoral head and neck re-form

5-Reconstitution- Final healing occurs

Treatment• Containment of femoral head in

acetabulum – Prevent further stress and damage– 1-2 year healing process

• Blood supply takes long time to reestablish.

• Immobilization-– Casting or brace for 1 ½ years!!

• No Weight Bearing!• Surgery- Latest approach!

– Minimizes immobilization time.– Cast for six weeks – Wheelchair additional 4 weeks