Class 5 Musculoskeletal - child Flashcards
skeletal system review:
provides?
protects?
storage?
Provides skeletal framework
Protects vital organs
Provides movement
Storage space for blood cell production, regulating reabsorption and reformation, regulation of minerals and hormones balance.
**bone structural disorders require follow up until child reaches skeletal maturity
Skeletal System Review:
what attaches to what?
Bone attaches to joints
Joints connect ligaments
Muscles supported by tendons and cartilage
Pediatric Musculoskeletal Differences:
Skull sutures don’t fuse until 12-18 months
Muscle tissue almost completely developed at birth
Soft tissues are resilient
Infants’s bones only 65% ossified at 8 months of age
Fractures in <1 year are uncommon
diagnostic tests: noninvasive
Xray
Bone scan
MRI
CT scan
Diagnostic Tests: Xray purpose? NI?
Purpose: detect abnormalities or determine bone age NI: Noninvasive Not generally NPO Patient in gown Assist child w/ proper positioning
Diagnostic Tests: How to view
Air: black
Fat: dark grey
Water: light grey
Bone: whitish
Diagnostic Tests: Bone Scan purpose? NI?
Purpose:
Investigates trauma, tumors, cysts, infections, early stress fractures, osteomylitis. **Radioactive material given IV and scan 3-4 hours later
NI:
Encourage fluids 2-4 hours prior and after scan
Void before scan so pelvis bones can be seen
May need sedation in child
Diagnostic Tests: MRI purpose? NI?
Purpose: Organ structures, blood flow, bone marrow, soft tissue, tumors, structure of muscles. **magnetic and radio waves create energy field that's translated to image NI: Not NPO Ensure no metal on pt (complete MRI questionnaire) Loud noises that might last 1 hour Assess claustrophobia Must remain still during scan
Diagnostic Tests: CT scan purpose? NI?
Purpose: Visualize bone and soft tissue Has less radiation exposure With or without contrast dye NI: No NPO unless sedation is needed Place in gown with no snaps Remove jewelry Can be scary for children Check for allergies
Sprains and Strains defined
Sprains: joint trauma, ligaments stretched or partially torn. (typically not seen in children- usually end up with fracture instead)
Strains: pulls, tears or ruptures, excessive stretch of muscle
Manifestations:
pain, swelling, localized tenderness, limited ROM, poor weight bearing, pop sound (sprain)
**commonly caused by sports
Dislocation defined
Force of stress on the ligament results in displacement of the bone from it’s socket.
Most common sites: phalanges and elbow, hip, shoulder
Sprains and Strains management:
Rest, Ice, Compression, Elevation
NSAID’s, no weight bearing, 20 min ice on, 20 min ice off
**compression is best for swelling before edema
Sprains and Strains: nursing considerations
Neurovascular checks
Analgesics (NSAID’s, Ibuprofen, acetaminophen)
Distraction play
Healing depends on extent of injury
Weight bearing gradually increased as pain decreases
Fractures: common causes
Accidental and non-accidental trauma Pathological condition Increase mobility Inadequate/immature motor Cognitive skills Children heal faster than adults Weakest point of long bones is epiphyseal plate **Fractures in infants not common -bones are less brittle -higher collagen to bone ratio
Types of fractures:
Greenstick: twist and bend of bone
Spiral: effects length (sign of child abuse)
Oblique: horizontal break
Transverse: “clean” break, horizontal
Comminuted: several breaks with bone pieces
Compound/Open: severe break where bone has broken skin
Fractures in Children: diagnostics and manifestations
Diagnostics:
Xray, both side view to compare
Manifestations: pain and tenderness immobility decreased ROM deformity/swelling ecchymosis muscle spams inability to bear weight crepitus (grating sound or feeling by bone friction) eyrthema
Fracture Management: Reduction
Repositioning of the bone into normal alignment
Closed- manual alignment
Open- surgical using internal/external fixations
Fracture Management: Retention
Application of a device to maintain alignment until healing occurs
Repositioning of bone fragments into normal alignment
Splints, casts, traction, external fixation
Immobilization of Fractures: Traction types (3)
Manual traction: ??
Skin traction: noninvasive, effective for children <15 kg and <2-3 years
Skeletal traction: uses greater force, alignment of bony fragments, wires/pins in bone. Complication osteomylitis.
Immobilization of Fractures: what types
Splints
Casts
Traction (manual, skin, skeletal)
External fixation (complex fractures to lengthen bones and correct angular deformities.
Casts:
Provide support and maintain anatomic position for healing
Age, type of fracture/surgery determine type of cast
Teach: use backpack to carry items
What are the 5 “P’s”
Pain
Pallor
Pulselessness
Paresthesia ("pins/needles" feeling)
ParalysisCasts: care and assessment
Keep dry Keep distal end higher than proximal end (elevate) Don't poke inside cast or apply liquid/powder inside Assess 5P's q 1hr for 24 hours Cap refill <2 seconds Observe for s/s of complications Odor Cyanosis Cool skin Absent pulse Edema N/V Pain
Traction:
Pull or force exerted on one part of body
Applied to spine, pelvis or long bones
Angle of the pulley exerts pull, child’s weight provide counter-traction in order to be effective
Can be continuous or intermittent
Always assume continuous unless doc order different
Traction: purpose?
Lessen/eliminate muscle spasms Stabilize/alignment Prevent deformities Position Immobilize fracture site
Skin Traction:
Non-invasive and well tolerated
Best for kids under 15 kg and under 3 years
Applied to pelvis, spine, long bones
Use of external devices such as foam, straps, bandages applied to skin attached to pulleys and weights
Not appropriate if: open wounds, skin breakdown, skin infection
Skeletal Traction:
Exerts greater force
Tolerated for longer periods
Maintains alignment of bony fragments and assists in proper healing
Traction maintained by metal device inserted into bone
Osteomylitis is most complication
Pin site care!
External Fixation Devices: used to?
Complex fractures
Lengthen bones
Correct angular deformities involving bone and soft tissue
Allows for periodic changes in alignment with external device with pine inserted into bone
Infection is risk r/t pin sites
50% infection of pin site
Pin site care!
Neurovascular assessment using CMTS
Color
Motion
Temperature
Sensation
**top to bottom, side to side assessment
Signs of neurovascular status impairment: assessment and NI
Assessment: Coldness Cyanosis Swelling Sluggish cap refill Pallor Loss of motion N/V NI: Touch skin distal to device Ask child to move fingers/toes Touch extremities
Assessment and care of immobilizing devices:
Traction apparatus
Weights hang freely Ropes on pulleys appropriately Proper positioning with trapeze Monitor slippage of tape, boot etc Keep continuous unless ordered Pin care
Assessment and care of immobilizing devices:
Assessment of patient
Proper positioning Nutrition, high in protein, vit c, fluids Pain management Skin breakdown/infection Psych well being Complications of immobility
Osteomyelitis: what is it? Risk?
Bacterial infection of the bone (cortex or bone marrow cavity)
Open fractures/trauma
Soft tissue injury
External fixation or skeletal traction devices
Osteomyelitis manifestations:
Fever, irritability, lethargy, feeding difficulties Pain, warmth, erythema Tenderness over site of infection Favoring affected extremity Limited ROM Painful joint w/ movement Odor possible **Call HCP
Osteomyelitis: diagnosis, imaging, labs
Imaging: MRI, CT, bone scan, US
Labs: elevated ESR (Erythrocyte sedimentation rate), CRP (C-Reactive Protein), WBC, blood cultures
Osteomyelitis: NI
Pain management Monitor and document neurovascular IV antibiotics Wound care Maintain nutritional status
Scoliosis: define
Lateral deviation/curvature of spine >10 degree
Curvature causes rotation of vertebral bodies of spine
Worsening curvature leads to rib cage deformities compromising resp function and distortion of intrathoracic and ab organs that does not affect organ function generally
Scoliosis: management
Curves <25 degree require long term monitoring
Brace treatment for curves >25 degree on skeletally immature patients
Scoliosis: surgical intervention and complications
Recommended on reaching 40-50 degrees to prevent further progression
Significant blood loss
Injury to spinal cord
Hip Dysplasia: risk factors
First born Female Breech position Low level of amniotic fluid African and Chinese decent have low incidences Native American high incidence
Hip Dysplasia: Ortolani and Barlow test
Ortolani:
Examiner abducts the hip while applying anterior force on the femur to reduce the hip joint
Barlow:
Examiner adducts the hip while applying posterior force on the knee to promote dislocation
Clubfoot: diagnostics and management
Ultrasound prenatally Therapeutic: started ASAP Serial stretching, manipulation and casting (Ponseti casting method) Surgery Recurrence is common Follow up until skeletal maturity
Muscular Dystrophy: info and pathophysiology
Progressive, degenerative diseases that affect muscle cells of specific muscle groups causing weakness and atrophy.
Pathophysiology
Muscle fibers leak creative kinase and take on excess Ca+ causing more damage
Muscles degenerate and replaced with fat and connective tissues
Muscle death causes weakness and wasting
Usually identified early childhood
Includes >30 types but Duchenne MD is most common
