10. The Child With a Musculoskeletal Alteration Flashcards
Review of Musculoskeletal System
Skeletal system
> Bones - axial skeleton and perpendicular system
> Supports body, protects vital organs and enables movement
Articular system
> Joints connect 2 or more bones together
> Joints connected by ligaments
> Enable movement
Muscular system
> Muscles and ligaments
> Supported by tendons
Cartilage
> Dense connective tissue
Anatomy of the Musculoskeletal System
___ or immovable joint
Flat bones: temporal bone, clavicle, rib
Irregular bone: e.g. vertebra
Short bone: ___
Synarthrotic
carpal
___ or slightly movable joint (e.g. symphysis pubis)
Long bone: e.g. femur
Sesamoid bone: e.g. patella
___ or freely movable joint (e.g. knee, ankle)
Amphiarthrotic
Diarthrotic
Anatomy of Bone
___ and ___ epiphysis (muscles attach here)
___: the shaft or long axis of the bone
Proximal; distal
Diaphysis
___ cartilage: cushions the bone ends and absorbs stress
Yellow marrow: an inactive fatty tissue
___: the wide portion of the bone that is responsible for growth until adult height is reached
Articular
Metaphysis
___ plate: cartilage present in young bones
___: a double-layered membrane rich in nerve fiber, lymphatic vessels, and blood vessels. It is secured to the bone by Sharpey’s fibers and provides an insertion or anchoring point for tendons and ligaments.
Epiphyseal
Periosteum
* Storage space for red blood cell production and minerals responsible for:
> Regulating bone resorption and reformation
> Regulation of mineral and hormonal imbalances
Pediatric Differences in Musculoskeletal System
> Infant’s bone only ___% ossified at 8 months
> Periosteum stronger than adults
> New bony tissue produced during growth and growth varies at different ages
> Skeletal growth stimulated by growth hormones
> Growth of long bones occurs at the ___ (ends of bones) - injury can cause growth disturbances
65%
epiphyses
> Growing bones produce callus and heal quickly - little need for internal fixation
> Skull is not rigid during infancy and sutures of the cranium do not fuse completely until approximately __ to __ months of age
> Muscle tissue is almost completely developed at birth
> Postural changes during infancy and childhood result from development of neurological control, bone and muscle growth, and laying down of adipose tissue
* Soft tissues are resilient in children, dislocations, and sprains are less common than in adults
12 to 18 (months of age)
An adult human has around ___ bones
An infant has around ___ bones
206
350
Diagnostic & Laboratory Tests
* X-rays, ultrasound, CT scans, MRI, bone scan
* Arthrography
* Arthroscopy
* Joint aspiration
* Hematology
> CBC
> CRP
> Erythrocyte sedimentation rate (ESR)
* Chemistry
> Calcium
> Alkaline phosphatase (ALP)
> Phosphorus
* Enzyme studies
> Creatine phosphokinase (CPK)
* Rheumatoid Factor (RF)
Immobilization
* Helps achieve and maintain functional position
* Rests and protects the affected area during bone healing
Immobilizing Devices: Splints
> Stabilize, rest/protect affected area, increase ROM and function, decrease pain
Immobilizing Devices: Casts
> Support; maintains anatomical position; aids in correction of a deformity; ensure adherence to treatment; protect wound
> Fiberglass, soft cast and plaster
> Rough edges trimmed to prevent skin injury (petaling of cast edges)
Immobilizing Devices: Traction
Pull or force on skin or bone
> Skin
* Noninvasive
* Does not require anesthesia
* More effective for child weighing <15 kg or younger than 2-3 y.o.
* Applied to long bones
* Neurovascular impairment may occur
→ Not indicated for children who have abnormal sensation of lower extremities
Immobilizing Devices: Traction
> Bucks
* Treatment of fractures, hip disorders, contractures, muscle spasms
* Continuous or intermittent boot or circular wrap applied to skin
* Rolled towels used to prevent external rotation
* Mattress flexed at the knee (20-30°)
Immobilizing Devices: Traction
> ___
* Very young children (<2 y.o.) with femur fx or developmental dysplasia of the hip
* Lower extremities wrapped in bed with knees flexed 90° and knees extended
* Traction overhead with weight to elevate buttocks off mattress
* Continuous for femur fx and intermittent for dysplasia of hip
* Used for 2-4 weeks to loosen muscles prior to surgery for open or closed reduction of hip dysplasia
Bryant
Immobilizing Devices: Traction
> Skeletal
* Greater force than skin traction
* Maintains correct alignment of bony fragments
* Metal device inserted into bone (stainless steel wires, pins, or tongs)
* General anesthesia needed
* Serious complication - ___
> Localized pain, swelling, warmth, tenderness, odor, fever, irritability/lethargy
osteomyelitis
Immobilizing Devices: Traction
> Skeletal - Types
* Halo traction
* 90/90 Femoral
Immobilizing Devices: External fixation devices
> Treatment of complex fractures
> To lengthen bones
> To correct angular deformities that involve bone and soft tissue
> Allows bones separated and in alignment while bone heals
> Allows for periodic changes in alignment and bone length
> External fixator with pins or wires inserted into skin, soft tissue, and bone
> General anesthesia needed
> Complication → osteomyelitis
Neurovascular Assessment
* CSM (___, ___, and ___)
> Assess at least every 2 hours during first 48 hours
> Assess strength of pulse distal to the site and compare with unaffected limb
> Assess capillary refill time
> Signs of circulatory impairment
→ Coldness, pallor, cyanosis of extremity, swelling, loss of motion, numbness (paresthesia), and swelling
→ Ask questions like “falling asleep?” “Wiggle toes?”
circulation, sensation, and motion
Neurovascular Assessment
___ ___
* Caused when swelling compromises vascular perfusion to muscles and nerves
* Occurs with ___ ___ fractures
* S/S - severe pain unrelieved by analgesics and signs of neurovascular impairment (pain when wiggling toes, weak or absent pulses, pallor, and paresthesia)
* Treatment - elevate extremity to heart level, loosen dressings, split cast, administer pain medication, notify physician, keep NPO for surgery (___)
Compartment Syndrome
long bone fractures
fasciotomy
The Child in a Cast or Traction
* The five P’s of ischemia
> ___
> ___
> ___
> ___
> ___
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
NOTE: Pain or a burning sensation may indicate tissue ischemia. Prompt intervention is crucial and requires referral to the physician
Paralysis and no pulse are both late findings which indicates that the damage may be irreversible
5 P’s = 4 late findings
The Child in a Cast or Traction: Traction Care
> Check amount of traction prescribed
> Ensure that all weights hanging free and not touching floor or bed
> Elevate head or foot of bed to maintain counter-traction
Care of Patient in Traction
T = Temperature (extremity infection) R = Ropes hang freely A = Alignment C = Circulation check (5 P's) T = Type and location of fracture I = Increase fluid intake O = Overhead trapeze N = No weights on bed or floor
Consequences of Immobility - Alterations in systems
> Integumentary - skin irritation
→ Reposition every 2 hours
→ Keep skin dry and change diapers frequently
> Gastrointestinal - decreased bowel sounds
→ Assess bowel sounds, abdomen distention, elimination pattern, high fiber diet, administer laxatives/stool softeners as prescribed
> Genitourinary - decreased urinary output
→ Hydrate, monitor output
> Respiratory - decreased breath sounds/adventitious breath sounds
→ Encourage cough and deep breathing - blowing bubbles
→ Incentive spirometer
→ Reposition every 2 hours
> Musculoskeletal - reduced strength and joint mobility; loss of muscle tone; risk muscle atrophy; limited ROM
→ Active ROM
→ Elastic stocking to prevent thromboembolism
→ Food high in protein and calcium
> Growth and development - regression, irritability, anxiety, excessive dependance, passive behavior
→ Explain routines
→ Provide time for therapeutic play, follow usual routine, keep up with schoolwork, encourage autonomy in decision making
Fractures
Break or disruption in the continuity of bones
Causes
* Trauma
> Increased mobility puts young children at risk
* Inadequate motor and cognitive skills
> Accidental trauma (falls, sports, motor vehicle crashes)
* Nonaccidental trauma
> Child abuse
* Pathologic conditions
> Osteogenesis imperfecta, tumors
Fractures
- Pediatric fractures seldom complete breaks
- Bones tend to bend or buckle due to increased flexibility
- Flexibility due to thicker periosteum and increased amounts of immature bone
Types of fractures
* Oblique
* Greenstick
* Transverse
* Spiral
* Comminuted
Which type of fracture is this?
Comminuted
Which type of fracture is this?
Oblique, displaced
What type of fracture is this?
Spiral
What type of fracture is this?
Greenstick
What type of fracture is this?
Linear
What type of fracture is this?
Oblique, nondisplaced
What type of fracture is this?
Transverse
Fractures - Manifestations
> Pain or tenderness at the site, immobility or decreased ROM, deformity and swelling
Treatment of Fractures
Goal is to maintain function without affecting growth
* Reduction methods
> Repositioning of the bone fragments into normal alignment
> Closed reduction - manual alignment and immobilization
> Open reduction - surgical internal or external fixation
→ Complications: delayed healing, nonunion/malunion, infection
* Retention
> Once aligned the fracture site must be protected
> Application of splint, cast, traction, or external fixator
Fractures - Nursing Considerations
* Initial trauma assessment
> Complete history regarding fracture
> Examination - bruising, lacerations, swelling, cradling/guarding, numbness and tingling, limited ROM, 5 P’s (pain, pulse, pallor, paresthesia, paralysis)
* Assessing and managing complications
> Fat embolism
→ Fat particles from fracture site travel to lungs
> Deep Vein Thrombosis (DVT)
Soft Tissue Injuries
___
> Joint is disrupted so that articulating surfaces are no longer in contact
Dislocation
___
> Pulls, tears, or ruptures of muscle or tendons
Strains
___
> Ligaments are stretched or torn
Sprains
___
> Soft tissue, muscles, or subcutaneous tissue are damaged
Contusions
Soft Tissue Injuries - Manifestations
> Pain, swelling, localized tenderness, limited ROM, poor weight bearing, popping or snapping sound (sprain)
The Child with a Soft Tissue Injury
Goal is to control swelling and prevent further injury
R = Rest I = Ice (no more than 20 minutes at a time) C = Compression E = Elevation
I = Ice C = Compression E = Elevation S = Support
Soft Tissue Injury - Nursing Considerations
* Administer analgesics
* Distraction/age-appropriate activities
* Keep extremity elevated
* Support and immobilize
* Stretching and strengthening exercises when appropriate
* * * * * * *
Neurovascular function
Assess diminished ROM
* * * * * * *
Osteomyelitis
* Bacterial infection of the bone
> Acute or subacute
> Chronic/chronic recurrent multifocal
→ Infection persists over 1 month
> Common cause is __ __
Manifestations
- Irritability, lethargy, difficult feeding
- Pain, warmth, erythema, tenderness at site
- Favoring extremity, limited ROM, fever
Staphylococcus aureus
Osteomyelitis - Nursing Care
> Assessment and documentation of the child’s status
> Pain control
> Administration of IV antibiotics without iatrogenic injury - ALWAYS OBTAIN BLOOD CULTURES PRIOR TO STARTING ANTIBIOTIC THERAPY
Musculoskeletal Developmental Disorders
* Scoliosis
* Kyphosis
* Limb differences
* Developmental dysplasia of the hip (DDH)
* Legg-Calve-Perthes disease
* Slipped capital femoral epiphysis (SCFE)
* Clubfoot
Scoliosis
* A lateral deviation or curvature of the spine that is greater than 10°
* Adolescent idiopathic scoliosis (AIS)
> Most common accounting for 70-80% of all cases
Adolescent idiopathic scoliosis (AIS) - Manifestations
* Visible curvature of the spine
* Rib hump when child is bending forward
* Asymmetrical rib cage
* Uneven shoulder or pelvic heights
* Prominence of the scapula or hip
* Leg length discrepancy
* Back pain - atypical
Adolescent Idiopathic Scoliosis (AIS) - Diagnostic evaluation
* School screening
> Recommendation - girls to be screened twice at 10 and 12 years of age (grades 5 and 7) and boys once at the age of 13 or 14 (grades 8 or 9)
> Includes the forward bending test (___ forward bend test)
> Scoliometer used during the forward bend test to provide an angle of vertebral rotation - referral to orthopedic surgeon if reading of 7 or greater indicating a 7-degree angle of trunk rotation
> Physical examination
> Radiographs
Adams
Adolescent Idiopathic Scoliosis (AIS) - Treatment
* Non-surgical interventions
> Frequent radiographic observations
> Brace treatment
→ Goal of preventing further progression
→ Worn for a minimum of 18 hours per day
Adolescent Idiopathic Scoliosis (AIS) - Treatment
* Surgical interventions
Goal is to reduce the size of the curve and obtain a solid fusion of the treated part of the spine
> Complications
→ Blood loss
→ Lack of solid fusion
→ Implant failure
→ Continued progression of the deformity
→ Infection
> Postoperative management
→ Pain assessment and treatment
→ Patients usually go home by day 4 or 5 postop
> Follow-up care
→ Usually followed for 2 or more years postoperatively or until the age of 18
Kyphosis
* Scheuermann’s Kyphosis
> Most common cause of ___ in adolescence
> Greater than 5-degree wedging of 3 or more vertebral bodies
> Experience pain at the apex of the deformity and base of the neck
> Bracing may be advised to prevent progression
> Surgical treatment with spinal fusion for severe cases
hyperkyphosis
Limb Differences
* Most alterations are seen in arms and legs
* Etiology
> Physiological, congenital birth anomalies, trauma, infection, or radiation
Types
> webbing (syndactyly)
> extra digits, fingers or toes (polydactyly)
> genu valgum (“knock knees”)
> genu varum (bow legs)
> limb length differences; congenital absence of all or part of an extremity; Osgood-Schlatter disease
* Diagnostic Evaluation
> Apparent at birth
* Nursing considerations
> Reassurance to parent regarding treatment options
> Safety if involves any gait disturbance
> For children who require surgery or immobilization - teach on what to expect before and after procedures or surgery
Which condition is this?
Syndactyly
Which condition is this?
Polydactyly
Which condition is this?
Bowed legs (genu varum)
Which condition is this?
Knock-knees (genu valgum)
?
Condition that happens when the tendon pulls on the growth plate of the shinbone over and over again
Osgood-Schlatter disease
Developmental Dysplasia of the Hip (DDH)
* Occurs in varying degrees
> Instability of hip joint
> Subluxated hip
> Dislocated hip
?
___ hip
Dislocated
?
___ hip
Unstable
?
___ hip
Subluxated
Developmental Dysplasia of the Hip (DDH) - Manifestations
> Vary according to age
* In neonates - characterized by instability of the hip - the femoral head can be displaced partially (subluxated) or fully (dislocated) - from the acetabulum by the examiner
→ Detected by performing the ___ and ___ tests
Barlow; Ortolani
* In infants - characterized by asymmetry of the gluteal skinfolds when lying with the legs extended against the examining table (or when the infant is held upright with the legs dangling)
> Affected hip has limited ROM and asymmetric abduction when the child is supine with the knees and hips flexed
Developmental Dysplasia of the Hip (DDH) - Therapeutic management
Early diagnosis and treatment are important for a successful outcome
> Treatment depends on age and severity of dysplasia
> Primary goal is to facilitate normal development of the hip socket
> In newborns and infants <6 months - a ___ harness treatment of choice - maintains hips in flexion, abduction, and external rotation
→ Teach parents proper skin care, and techniques on holding feeding and diapering and importance of follow-up visits
PAVLIK
> In older children treatment - closed hip reduction
* Child is positioned and immobilized for 4-6 weeks in a ___ ___ following the procedure
SPICA CAST
__-__-__ Disease
* Occurs when an avascular event affects the epiphysis of the femur and prevents further growth of the ossific nucleus - resulting in increased bone density and flattened and enlarged femoral head
* Children are usually shorter-than-average height and low-birth-weight infants
Legg-Calve-Perthes (Disease)
Legg-Calve-Perthes Disease - Manifestations
> Persistent pain of the hip that worsens with movement
> Pain can also be felt in other parts of the body such as groin, thigh, or knee
> Limp or limited ROM
> Most serious complication is permanent deformity
Legg-Calve-Perthes Disease - Therapeutic Management
Goal is to prevent deformity of the hip and delay the onset of arthritis and degenerative joint disease
> Initial treatment - anti-inflammatory medications such as ibuprofen, ROM exercises, bed rest
> Traction, ___ casts, or abduction braces may be recommended
> When severe necrosis is present, a containment device that uses the acetabular to maintain the spherical shape of the femoral head is used
> Surgery may include osteotomy or acetabular osteotomy
Petrie
Legg-Calve-Perthes Disease - Nursing considerations
> Facilitating appropriate activity
> Participate in as many school-related activities as possible acknowledging mobility limitations
> Teach parents to perform neurovascular assessments and identify skin and safety issues
Clubfoot
* Also known as talipes equinovarus (TEV)
* Characterized by rigid midfoot cavus, forefoot ADDUCTION, heel varus, ankle equinus (CAVE)
Therapeutic management
The goal is to reduce or eliminate all the components of the deformity, so the child has a functional, structural, mobile, pain-free foot
___ casting method and the French physiotherapy method
Nursing considerations
* Education and anticipatory guidance
> Caring for the cast, assessing neurovascular function, and pain assessment
> Positioning, bathing, and skin care
PONSETI
Muscular Dystrophies
* A group of 30 genetic diseases
* ___ muscular dystrophy is the most common
> X-linked recessive pattern
* Progressive, symmetric muscle atrophy (wasting) and weakness without loss of sensation
Duchenne
* Ages 3-7 years
> Child uses ___ maneuver to rise from floor - hands on knees and moves hands up legs to stand
> Waddling, wide-based gate
> Calf muscles weak and hypertrophied
* Walking ability is lost by ages 9-12 years
> Increased disability - hip and knee contractures, foot deformities, scoliosis and lordosis
* Shortened life span
Gower
Muscular Dystrophies - Therapeutic management
Aim is maintaining ambulation and independence as long as possible
> Surgery, bracing, physical therapy
> Corticosteroid therapy
* Deflazacort - slows disease-producing anti-inflammatory and immunosuppressive effects
* Risk for obesity, bone fracture, adrenal insufficiency
* Prevent obesity
* Monitor for infection - especially respiratory
Muscular Dystrophies - Nursing considerations
* Anticipate needs - family’s inability to cope
* Independence as long as possible
* Swimming promotes ROM
* Monitor weight gain and infection (respiratory)
* Late stage = assist in position changes every 2 hours; adequate fluid intake; monitor bowel regimen (softeners/laxatives)
* Home environment
> Wheelchair accessible
Juvenile Idiopathic Arthritis
* Autoimmune inflammatory disease with no known cause
> Formerly known as juvenile rheumatoid arthritis
> Only 5% of children have a positive RF
> Onset commonly between ages 2 and 4
> More common in girls
> Persistent swelling and pain in one or more joints
Manifestations
* Persistent swelling in one or more joints that lasts 6 weeks or longer
* Joints stiff, swollen, warm, erythematous, limited ROM
* Stiffness is worse in the morning or after prolonged period of rest - “gel phenomenon”
Juvenile Idiopathic Arthritis - Therapeutic management
* No known cure
Goal is to preserve joint function, controlling inflammatory process, minimizing deformity, and reducing impact of the disease on the child’s development
> Medication, physical and occupational therapy, family education, home care, and encouragement of age-appropriate activities as tolerated
> Drug therapy
- NSAIDs (ibuprofen, naproxen, celecoxib) - 1st line of treatment
- If no improvement after 4-6 weeks: disease-modifying anti-rheumatic drug (DMARD) methotrexate
- Other rx’s - biologics such as etanercept, adalimumab, infliximab
- Local corticosteroid injections to reduce inflammation in joints
> Physical and occupational therapy
- ROM, rest
> Surgical treatment
- Contractures
Syndromes and Conditions with Associated Orthopedic Anomalies
* Achondroplasia (dwarfism)
* ___ (congenital joint stiffness)
* Down Syndrome
* Marfan syndrome
* Neurofibromatosis
* Osteogenesis imperfecta (connective tissue defects and extreme fragile bones)
Arthrogryposis
> Movement of joints are affected
> Cleft palate
> Intestinal atresia
