F MSK Flashcards
Ossification complete when
Bones compared to adults
Epiphyseal (growth) plate?
Ossification complete by late adolescence into early 20s
Bones are less dense than adults
Epiphyseal plate: injury here is a problem
(effects growth)
Muscle differences (2)
Ligaments and tendons (2)
Muscles:
-muscles do not increase in #
-length and circumference increase as child grows
Ligaments and tendons:
-ligaments and tendons are strogner than bones until puberty
-Full ROM but no purposeful movement when born
Genu Varum vs Genu Valgum
(What is it)
When it resolves
Outside of these ranges =?
Genu varum: Bow legs
-Infants and toddlers: usually resolves by 2-3y/o
Genu valgum: “knock-knees”
-appears around 2-3 y/o, usually resolves by 7-8 y/o
Outside of these ranges = specialist referral
Neuromuscular & MSK congenital disorders
Metatarsus adductus
Club foot (talipes equinovarus)
Hip dysplasia
Osteogenesis imperfecta
Spina bifida
Muscular dystrophy
Cerebral palsy
Metatarsus adductus (most common foot deformity)
What is it
Causes
Degree of flexibility is important for determining what?
Forefoot is adducted
Intrauterine positioning
Degree of flexibility = determining tx
Metatarsus adductus
Diagnosis and tx
Physical assessment/xray
Tx:
-PT/ observation in mild cases
-passive stretching with serial cast/braces if >15 degree angle or if there is no flexibilty in foot
—casts changed weekly
—braces and orthopedic shoes
Club Foot (talipes equinovarus)
Categories
Can effect what or what
Can be what or what
Categories:
-positional: intrauterine crowding
-congenital: (idiopathic)
-syndromic: occurs in associations with other syndromes
Can be unilateral or bilateral
Can be isolated defect or associated with other disorders (CP, Spina Bifida)
Club foot s/s
Talipes varus: inversion of the heel
Talipes equinus: plantar flexion
Club foot
Tx (goal is a functional foot)
Serial casting (every 1-2 wks)
Weekly manipulations/stretching
Sx with casting (heel cord tenotomy)
Braces/orthotics (for some kids)
Club foot care and assessments
Assess: neurovascular, motor development
Cast care
Hip dysplasia
What is it
RF
Improper alignment of the femoral head and the acetabulum
RF:
-first born
-females
-family hx
-breech position
-LGA (large for gestational age)
Hip dysplasia
Screen when
S/s
Screen infants until 1 y/o
-asymmetrical gluteal and thigh folds
-positive allis sign (1 knee lower than other when flexed)
Hip dysplasia
Diagnosis
Other test
US: until 6mo old
Xray: once 6 mo old
Other test:
-ortolani-barlow maneuver:
-Barlow: diuslocation of femoral head by adduction
-Ortolani: reduction back into acetabulum by abduction
Hip dysplasia tx
Newborn-6month
Starts as soon as diagnosed
pavlik harness (6-12wks)
-typically corrected after 3 months of use
What pavlik harness does:
-ensures hip flexion and abduction but does not allow hip extension or adduction
Hip dysplasia
Nursing management of pavlik harness
- Peform neurovascular/skin integrity checks
- Change diaper with harness on
- Do not adjust straps without consulting provider
- If removal of straps is ordered understand how to reapply
- Skin care to include use of undershirt, knee socks, avoid lotions and powders
Hip dysplasia tx
Older than 6months or if pavlik harness unsuccessful
Tx and care included
Surgical reduction with spica cast:
-Spica cast-stays on about 12 wks
Care includes:
-neurovacular checks
-frequent skin assessment
-cast care
-pain management
Osteogenesis imperfecta
What is it
Aka
Inherited connective tissue condition that results in bone fx and deformity along with restrictive growth
Aka: brittle bone disease
Osteogenesis imperfecta s/s
Freq fx
Blue sclera
Short stature
Small discolored teeth
Early conductive hearing loss
Osteogenesis imperfecta
Tx
Tx is supportive:
Med: pamidronate
-bisphophate (give IV infusion)
—increases bone density and corrects imbalance between bone resorption and bone formation
Osteogenesis imperfecta
Teaching for tx
Low impact exercises (swimming)
Assist with braces/splints
Assist with PT/OT
Safety!!!
Spina bifida 3 forms
Occulta
Meningocele
Myelomeningocele
Spina bifida (occulta)
What is it/location
Usually what
Mildest form: lumbosacral area
-defect of vertebral bodies
-no protrusion of spinal cord/meninges
-often asymtpomagtic and goes undetected
Spinal bifida (occulta)
S/s
Sacral dimple
Tuft of hair
Discoloration of skin at site
(tethered cord/walk on tiptoes)
Spina bifida (occulta)
Tx
Usually not require interventions if asymptomatic
BUT may require sx for tethered cord/symptomatic
Spina bifida cystica (meningocele)
What is it
Sac like protrusion containing meninges and CSF
Spinal cord in normal position
Spina bifida cystica (meningocele)
Tx
Assess neuro status
Monitor for leaking CSF/ increased ICP
Surgical correction REQUIRED
Spina bifida cystica (myelomeningocele)
What is it/ s/s
Sac like protrusion contains meninges/CSF/nerves
Spinal cord often ends at the point of defect (higher defect has more affects):
-absent motor/sensory function
-bowel/bladder incontinence
Spina bifida cystica:
Infection prevention & injury prevention (4)
Sterile saline-soaked gauze to keep sac moist:
-monitor for leakage of CSF/increased ICP
Place in prone position/supported side position
Use infant wamrer/isolette (monitor for drying of sac) (no clothes allowed on sac)
Proper diapering (keep free of feces/urine
Increased ICP signs
Increased HC
Bulging fontannel
LOC change
High pitched cry
Cushing triad (brady cardia/ widening pulse pressures/ chyne stokes respirations)
Spina bifida cystica: complications and needs
Paralysis (wheelchair, walker needed)
Bowel/bladder incontinence:
-straight cath
-vesicostomy (Monit)
-appendicostomy (MACE)
Hydrocephalus
Chiari malformation (brain tissue protrudes into spinal cord)
Spina bifida: multidisciplinary approach
NICU/PICU stays
Neurology
Neurosurgery
Urology
GI
Orthopedics
PT/OT/ST
(Vesicostomy) MONTI
vs
(Appendicostomy) MACE
DONT HAVE TO KNOW JUST IDEA
MONTI:
stoma sutured to body wall
Urethra sutured
MACE:
In colon use appendix so we can do an enema to clean out colon and empty it
Muscular dystrophy
What is it
Type
Inherited disorder w/ progressive degeneration of skeletal muscles (causing muscle weakening/wasting
Type:
Duchenne muscular dystrophy (most common)
Limb-girdle muscular dystrophy
Facioscapulohumeral dystrophy
Duchenne’s muscular dystrophy
What is it/mostly affects who
Onset?
Life expectancy
X-linked recessive (affects mostly males)
Early childhood onset (3-6y/o)
Progressive
Life expectancy (early adulthood)
Duchenne muscular dystrophy
S/s
3
3 toddler/preschool
5 school age
Fatigue
Muscle weakness (beginning in lower extremity)
Late walkers (12mo usually)
Toddler/preschool (unsteady gait/fall often)
Large calf muscles (fat deposits)
Gowers sign
School age (walk on toes/balls of feet, waddling gait)
12y/o will lose ability to walk
Muscle atrophy of face/chest/neck
Respiratory/cardiac difficulties
Mild congitive delays
Gowers sign
Muscular dystrophy sign:
Have to use entire upper body to get off floor
Duchenne muscular dystrophy
Diagnosis
Genetic analysis (inherited)
Muscle biopsy
Elevated CK levels (creatinine kinase = muscle damage)
Duchenne muscular dystrophy
Tx
No cure
-Corticosteroids (slow pregression)
-Mobility/ROM/ADLs
-Respiratory assistance (IS/positioning/cough assist/nebulizers/CPT/CPAP/BiPAP)
-Gtube/tube feedings
-end of life discussion/comfort care
Cerebral palsy
What is it
Nonprogressive impairment of motor function
Lack muscle control/coordination
Can cause visual/hearing/speech impairment
Cerebral palsy risk factors (baby)
Head trauma (shaken baby)
Maternal infction
Maternal chorioamionitis
Premature birth
Very low birth wt
Interruption of oxygen delivery to fetus during birth
Direct injury to neonate during birth
Maternal drug use
Cerebral palsy s/s
Failure to meet developmental milestones/Persistent primitive reflexes (dont go away)
Gagging/choking w/ feeding/poor suck reflex
Poor head control
Sz
Vision/speech/hearing impairment
Arching back/Rigid posture
Toe walking
Cerebral palsy
Tx
Individualized to meet client
-promote independence (self care is goal)
-monitor airway (position/suciton/aspiration/reflux precautions)
-skin care (assess under braces/aplints/turning)
-nutrition (PO, Gtube, high calorie/protein, fiber)
Cerebral palsy
Tx (MEDS)
-Baclofen: PO or intrathecal (pump)
-Diazepam (valium)
Antiepileptics:
-levetiracetam (Keppra)
-valporic acid
Acquired MSK deformities/disorders
Legg-Calve Perthes disease
Scoliosis
Injuries (FX)
Legg-calve-perthes disease
What is it
RF
Aseptic necrosis of the femoral head
(unilateral or bilateral)
RF:
Age 2-12y/o (but mostly 4-8y/o)
Males
Trauma/decreased circulation
Legg-calve-perthes disease
Healing
New blood vessels are formed w/ bone resorptions and deposition for up to 18-24 months
During this time bone very soft and more likely to fx
Legg-calve-perthes disease
Diagnostics
Xray/MRI
Legg-calve-perthes disease
Onset
S/s
Insidious onset
Intermittent limp
Limited ROM
Stiffness of hip
Mild pain: Groin/thigh/knee
Shortening of affected leg
Legg-calve-perthes disease
Prognosis
Tx
Self-limiting disease (depends on stage/severity)
Tx:
Nsaids
-Rest/limited wt baring
-Possible brace
-PT/advance to active motion as perscribed
-Avoid contact/high impact sports
(Swimming/bicycling help ROM and are low impact)
Scoliosis
What is it
Cause
Lateral curvature of spine (exceeds 10degrees)
-spinal rotation also causes rib asymmetry
Cause:
Acquired (neuromuscular disorders)
Scoliosis
RF
Genetic tendency
Females
Highest incidence between 8-15y/o
Scoliosis
Screened when (how to do it)
assessment findings
Diagnostics
Screen preadolescence
Have child bend forward at waist w/ arms hanging
-asymmetry of scapula/ribs/shoulders/hips
-improperly fitting clothes (one leg shorter)
Diagnostics: tells us degree of curvature
-xray/CT/MRI
Scoliosis tx
Under 10 degrees we do nothing
Needs to be corrected before 40degrees
-brace
Surgery: spinal fusion
-for severe cases (>45degrees)
Scoliosis nursing management
Brace education
Bracing prevents further curvature
(doesnt correct current curve)
Worn up to 23 hours per day
Lengthy treatment (months to years)
Scoliosis (post surgical education)
What to do
Restrictions
Pain control (PCA pump)
Monitor incision & drainage (JP drain)
Log roll to prevent flexion of spine
Early mobility w/ PT
Activity restriction for 6-8 months:
-cannot lift more than 10lbs
-sports (except swimming/walking)
Injuries: fractures
More frequent in who
Risk factores
More frewuent in children than adults (but heals fast
RF:
-Obesity, nutrition, ordinary play activities
-recreations place children at risk
(running/climbing/skateboarding/skiing/bicycle accidents/sports)
Salter-harris classification system for fractures
Type 1 & 2:
-do not have growth plate disturbances
(Wont affect growth)
Types 3, 4 & 5:
-can cause distubances in growth plates
(Issues with growth)
Fracture
Diagnostics
Tx
Open fx?
Xray/CT
Monitor VS/Pain/neurovascular
Stabilize area/limit movement
RICE
Pain meds
Tetanus vaccine/ABX if open fracture
Fracture
Ways to immobilization
Splinting
Bracing
Casting
Traction
Closed reduction (no sx)
Open reduction (rods/screws in) (external fixation)
(Sx) (pin care)
Fracture cast care
Tx
Avoids
Notify if
-elevate limb after cast applied
(Some swelling is normal)
-circle/monitor drainage
-assess pulse/neurovascular
-keep clean/dry
-report severe pain or pain not relieved by meds
Avoids:
Nothing put in cast
No lotion or powders
If wet inside do not use hot blow dryer (burns)
If itching (use blow dryer on cold setting)
Fracture complications
Compartment syndrome:
-compression of nerve/blood vessels/muscle inside confinded space results in neuromuscular ischemia
(Usually forearm/tibial fractures)
Osteomyelitis
Embolism
-fat embolism/PE
Assessment of fracture (5 P’s)
Pain (unrelieved w/ elevation and analgesics)
Pulselessness (distal to fx site)
Pallor
Paresthesia (distal to fx site)
Paralysis (movement distal to fx site)
