Chapter 33: child w/ musculoskeletal dysfxn Flashcards
Skeletal development
-Not fully ossified by birth
-Ossification completes at adolescence
-Flexible and porous (allow for greater shock absorption, bones will bend not break)
Epidemiology of trauma
-Trauma is leading cause of death in kids > 1 y
-Unintentional injuries are leading cause of death in kids 1-19 yrs
Physiologic effects of immobilization
-Muscular: decreased strength, atrophy, less joint mobility
-Skeletal: bone demineralization, neg Ca balance
-CV: orthostatic intolerance, more heart workload, thrombus
-Respiratory: decreased effort, less mvmt of secretions
-GI: decreased motility, risk for aspiration
-Renal: renal stasis, renal calculi
-Metabolism: decreased rate and stress hormones
-Skin: decreased circulation, risk for ischemia
-Urinary: difficulty voiding, retention
-Neuro: loss of innervation
-Psych: diminished stimuli, altered perception of self, increased neg feelings, developmental regression
Immobility nursing mgmt
-Use of devices: orthotics, prosthetics, crutches, canes, wheelchairs
-Pressure reduction mattresses, position changes, ROM exercises
-Braden Q scale
-Child life, visitors, school activities
Traumatic injury
-Soft tissue injury includes muscles, ligaments, tendons
-D/t sports injuries or mishaps during play
Contusions
-Bruise or damage to soft tissue, subq tissue, muscle
-Blood leaks into tissue (ecchymosis)
-Swelling, pain, disability
-Myositis ossificans: deep contusions to biceps or quadriceps
-Crush injuries: extremities or digits crushed, can involve bone
Dislocations
-Stress on ligaments displaces normal position of opposing bone ends or bone ends to socket
-Hip dislocation –> loss of blood supply to femoral head
-Pain is main symptom: increases w/ mvmt
-Nursemaid’s elbow: common, subluxation or partial dislocation of radial head
Sprains
-Trauma to joint from a torn or stretched ligament
-Damage to blood vessels, muscles, tendons, nerves
-Presence of joint laxity is indicator of severity (pt feels joint is loose or hears snap
-Rapid onset of swelling
Strains
-Microscopic tears to muscle or tendon
-Swollen and painful to touch
-Incurs over time
Mgmt of soft tissue injuries
-RICE
-Ice max of 30 min at time
-Immobilization and support (often w/ torn ligaments)
-Rest is primary therapy
Mobilization devices
-Orthotics: braces, types include AFO, KAFO, HKAFO (hips, knees, ankles, foot, orthotics)
-Prosthetics: artificial limbs
-Crutches, canes, walkers, wheelchairs
Frxs
-Rare in infants, expect in MVCs, always considered child abuse
-In school-age children –> bike, sports, playground falls
-Children heal faster than adults
-Radius/ulna and clavicle most common
Types of frxs
-Complete vs incomplete
-Simple vs compound
-Compound or open: fractured bone protrudes thru skin
-Complicated: bone fragments damaged other organs or tissue
-Greenstick: compressed side of bone bends but tension side of bone breaks, causing an incomplete frx
Growth plate (physeal) injuries
-Weakest point of long bones is cartilage growth plate (epiphyseal plate)
-May affect future bone growth
-Tx includes open reduction and internal fixation
Bone healing and remodeling
-Phases: inflammatory, restorative, remodeling
-Healing time for femoral frx: neonatal 2-3 weeks, early childhood 4 weeks, later childhood 6-8 weeks, adolescence 8-12 weeks
s/s of frxs
-Swelling
-Pain or tenderness
-Deformity
-Diminished fxnal use
-Bruising
-Severe muscular rigidity
-Crepitus (grating sensation at frx site
Dx of frxs
-Obtain info from injured person
-X-ray most useful
Assessment of frxs
-Pain and point of tenderness
-Pulse (distal to frx site)
-Pallor
-Paresthesia (sensation distal to frx site)
-Paralysis (mvmt distal to frx site)
-Poikilothermia: inability to regulate core body temp
-Eval compartment syndrome
Frx complications
-Circulatory impairment
-Nerve compression syndrome
-Compartment syndrome
-Physeal damage
-Nonunion
-Malunion
-Osteomyelitis
-Kidney stones
-PE
Assessment prior to casting
-Color (cyanosis)
-Mvmt (mvmt of digits)
-Sensation (loss of sensation)
-Edema
-Quality of pulses
Casting
-Plaster or fiberglass material
-Assess neurovascular status pre and post
-Pre medicate for pain
-Skin impairment as cast edges
-Protect from moisture
-Don’t put anything in cast
-Persistent pain may indicate skin impairment under cast
s/s of casting complications
-Pain
-Edema
-Cyanosis
-Skin coolness
-Numbness or tingling
-Prolonged cap refill
-Absence of pulse
-Hot spots on cast surface
-Drainage
Compartment syndrome
-Pressure within 1+ muscle compartments –> ischemia-edema cycle
-Can lead to tissue necrosis and neuromsk damage in 4-6 hrs w/o tx
-Caused by tight cast
-Assess for pain unrelieved by elevation or pain meds, numbness or pallor
-Tx: fasciotomy
Overuse injury
-Repetitive microtrauma
-Inflammation of involved structure
-Complaint of pain, tenderness, swelling, disability
-Ex: tennis elbow, osgood-schlatter disease
Crutch walking: non weight bearing
-Put crutches forward at 1 step’s length
-Push down on crutches, hold bad leg up from floor, squeeze top of crutches btwn chest and arm
-Step on good leg
Crutch walking: partial weight bearing
-Put crutches forward at 1 step’s length
-Put bad leg froward, level w/ crush tips
-Take most of weight by pushing down on hand grips, squeezing top btwn chest and arm
-Take step w/ good leg
Traction
-Forward force produced by attaching weight to a distal bone fragment
-Provides rest for extremity, immobilizes frx, reduces muscle spasms (rare in kids)
-Countertraction: backward forced provided by bw
-Frictional force: provided by pt’s contact w/ bed
-Skin traction: pulling mechanisms attached to skin w/ adhesive material or elastic bandage (buck’s traction)
-Skeletal traction: applied directly to skeletal structure by pin, wire, or tongs inserted into diameter of bone distal to frx
-Halo/cervical traction: screws inserted into outer skull, halo is attached to bed or vest worn by pt, make sure pins are tight
Traction nursing mgmt
-Weight should hang free all the time
-Maintain body alignment
-Never released by nurse unless emergency
-Inspect pin for infection, make sure they’re not loose, monitor skin under vest
Distraction
-Separation of opposing bones to encourage regeneration of new bone in created space
-Can be used when limbs unequal in length or to immobilize frxs
-External fixator device
-Educate on pin care
Amputation
-May be congenital absence, traumatic loss, surgically required d/t cancer
-Elastic bandaging for compression
-PT
Stress frxs
-Result of repeated muscle contractions
-Seen in weight-bearing sports (gymnastics, running, basketball)
-Tibial most common
-Small crack
Torticollis
-Wry neck
-Congenital or acquired limited neck ROM w/ neck flexed to affected site
-Tight sternocleidomastoid muscle
-PT first, surgery next if needed
Kyphyosis
-Increased convex angulation in thoracic spine
-Most common form is postural
-Can result from TB, arthritis, osteodystrophy, compression frx
Lordosis
-Accentuation of cervical or lumbar curvature
-May occur w/ flexion contractions of hip or congenital dislocated hip
-In obese children, abdominal fat alters COG
Scoliosis
-Most common spinal deformity
-Can compress organs, affect breathing
-Lateral curvature, spinal rotation causing rib asymmetry, thoracic hypokyphosis
-May be congenital or acquired
-Most causes idiopathic
-Becomes noticeable after pre adolescent growth spurt
-Complaint of ill-fitting clothes
Scoliosis dx
-Usually idiopathic
-Radiographs
-Asymmetry of shoulder height, scapular or flank shape, hip height
-Primary curve and compensatory curve to align head w/ gluteal cleft
-Cobb technique (uses X-ray)
-Risser scale (measures maturity of bones)
Scoliosis nursing mgmt
-Bracing (TLSO) and exercise
-TLSO has poor compliance, worn 23 hrs a day
-Surgery if severe
-Concerns of body image
DDH
-Congenital
-Developmental dysplasia of the hip
-High association w/ breech delivery
-Dysplasia of hip joint: acetabulum is showing or sloping instead of cup shape
-Subluxation: partial dislocation
-Dislocation: no contact btwn femoral head and acetabulum
-Tx: spica cast
DDH s/s
-Affected leg is shorter
-Greater trochanter is prominent
-Asymmetry of gluteal and thigh folds
-Limited hip abduction in flexion
-Shortening of femur as evidenced by level of knees
-Ortolani clunk in infants < 4 weeks
-Pos trendelenburg sign w/ lordosis if child is weight-bearing
-Marked lordosis if bilateral dislocation
-Waddling gait in bilateral dislocation
Pavlik harness
-For infants w/ DDH > 6 m
-Worn until hip is stable (6-12 weeks)
-Check skin irritation in folders and under straps
-Avoid lotions and powders
-Always place diaper under straps
Congenital clubfoot
-Talipes varus: inversion (bending inward)
-Talipes valgus: eversion (bending outward)
-Talipes equinovarus: plantar flexion w/ toes lower than heel
-Talipes calcaneus: dorsiflexion w/ toes higher than heel
-Males more affected
-Bilateral in half of cases
-Dx at birth or prenatally
-Tx: staged correction, ponseti method (weekly serial casting)
Metatarsus adductus
-Most common congenital foot deformity
-Results from abnormal position in uterus
-Pigeon-toed gait
-Tx: PT and braces
OI
-Osteogenesis imperfecta
-Group of heterogeneous inherited disorders of connective tissue
-Excessive fragility and bone defects –> multiple bone frxs
-Hyperextensibility of ligaments
-s/s: short height, blue sclerae, hearing loss, small and discolored teeth
-Tx: PT, no meds, surgery w/ intramedullary rods, caution w/ handing to prevent frxs
Legg-calve-perthes disease
-Interruption of blood supply (avascular necrosis) to femoral head –> loss in shape of femoral head
-Most often when kid is 4-8 yrs
-Over time revascularization occurs, femoral head reforms
-Hip pain or immobility
JIA
-Juvenile idiopathic arthritis
-RA, chronic arthritis, or idiopathic arthritis of childhood
-Chronic inflammation of synovium of joints, wearing down of articular cartilage
-Results in joint deformities
-90% of cases are neg for rheumatoid factor
JIA s/s
-Stiffness, swelling, limp in morning
-Warm, tender to touch w/o erythema
-Delayed growth
-Increases w/ stressors
-Iridocyclitis: inflammation of iris and ciliary body (tx by eye doctor, unique to JIA)
-Uveitis: inflammation of uvea (tx by eye doctor, unique to JIA)
JIA dx
-Before 16 yrs
-1+ affected joints
-Duration > 6 weeks
-No definitive dx test
-Elevated CRP and ESR
-ANA common but not specific to JIA
-Leukocytosis during exacerbations
-X-rays are for baseline comparison
JIA tx
-No specific cure
-NSAIDs, DMARDs, corticosteroids, cytotoxic agents, immunologic modulators
-PT and OT
-Exercise
-Splinting
-Surgery
SLE
-Systemic lupus erythematosus
-Chronic multisystem autoimmune disease of connective tissues and blood vessels
-Inflammation
-Common in girls 10-19 yrs
-Common in black, asian, latin children
-Familial tendency
-Triggered by hormonal imbalance, immune disorders, exposure to drugs, infection, stress, chemicals
SLE s/s
-Cutaneous lesions, lymphadenopathy
-N/V/D, pain
-Fatigue, arthritis, joint stiffness w/o deformity
-Forgetfulness, seizures, paralysis
-Pleurisy
-Pericarditis
-Proteinuria and renal failure
SLE dx
-Must have 4 of following
-Butterfly rash
-Discoid rash
-Photosensitivity
-Oral ulcers
-Arthritis
-Serositis
-Renal, neuro, hematologic, immunologic disorders
-ANA
SLE mgmt
-Hydroxychloroquine, NSAIDs, methotrexate, steroids
-Body issues
-Avoid sun exposure
-Medical alert bracelet
SCFE
-Slipped capital femoral epiphysis
-Spontaneous displacement of proximal femoral epiphysis in posterior and inferior direction
-Occurs before or during growth spurts
-Usually idiopathic but can be d/t obesity and puberty hormone changes
SCFE s/s
-Episodes of trauma w/ acute displacement
-Gradual displacement w/o definite injury
-Intermittent displacement
SCFE dx
-Physical exam
-Radiographs
SCFE mgmt
-Keep head of femur in acetabulum
-Use of devices
-Rest, no weight bearing initially
-Surgery
-Home traction
Osteomyelitis
-Infection of bony tissue
-Resemble s/s of arthritis and leukemia
-Marked leukocytosis
-Bone cultured obtained from biopsy or aspirate
-Early x-rays appear normal
-Bone scans for dx
Osteomyelitis types
-Exogenous: infectious agent invades bone following penetrating wound, open frx, contamination in surgery, or secondary extension from abscess or burn
-Hematogenous: pre existing infection, source may be furuncles, skin infections, URI, abscessed teeth, pyelonephritis, any organism can be source, infective emboli travels to arteries in bone metaphysis
Osteomyelitis mgmt
-May have subacute presentation w/ walled-off abscess rather than a spreading infection
-Prompt, vigorous IV abc for 3-4 weeks or months
-Monitor hematolic, renal, hepatic response
Septic arthritis
-Also called suppurative, pyogenic, purulent arthritis
-Results from extension of soft tissue infection
-Usually involves hip, knee, shoulder
-Usually only affects 1 joint
-Neisseria gonorrhoeae is frequent cause in sexually active teens
Septic arthritis s/s
-Joint is warm, tender, swollen
-Follows traumatic injury
-Fever, leukocytosis, increased sedimentation rate
Septic arthritis dx
-Blood culture
-Joint fluid aspirate
-X-rays
Septic arthritis mgmt
-Prevent destruction of joint cartilage
-Decompress joint
-Eradicate infection
-Prevent spread of infection
-Abx and pain meds
-Surgery
