MSK Flashcards
what type of fracture should be reported as it is a sign of child abuse
spiral fracture: twisting motion
bones of children vs. adults
Children
- bones contain more cartilage & water: more flexible
- porous and less dense
- heals faster
- more likely for greenstick fx due to flexibility
Adult
- more rigid, stronger
- takes longer to heal
- complete or stress fx due to rigidity
what is greenstick fracture
incomplete fracture
what is a stress fracture
- small fx or cracks in the bone due to muscle contractions during weight bearing activities
causes and risks for fractures
- bed rest prolonged
- osteoporosis
- steroids “sone”
- trauma
- obesity
- poor nutrition
s/s of fractures
- pain, swelling
- crepitus
- muscle spasms
- deformity
- ecchymosis
what are signs of internal bleeding due to a fracture
- hypotension
- tachycardia
- hematuria
what is the main sign for basilar skull fracture
- clear liquid drainage from nose: CSF
what to watch out for for spine fracture that’s T-6 or higher
- neurogenic shock: hypotension, bradycardia, pink and dry skin
what to watch for mandibular fracture
- bleeding and drooling in the mouth: suction to keep airway intact
nursing care after fracture, before cast
- splint at the joint above and below the injured area
- if pelvic fx, monitor for hypovolemic shock, check for hematouria
- elevate extremity and apply ice packs
what to look for in hip fracture
- shortening of leg on affected side: due to muscle spasms
- groin and hip pain with weight bearing
- ecchymosis on thigh and hip
what to do for tractions
- free hanging weights
- ropes tight
- reposition pt by holding weights
- keep limb in neutral position
- assess for skin breakdown
- neuro checks: pulse, motor, sensation, cap refill
- always supine
what is skin traction, skeletal traction, halo traction, and manual traction
- skin traction: tape and straps applied to skin w/ boots
- skeletal traction: pin or rod into bone
- halo traction: screws into outer skull
- manual traction: distal to injured area with casting or closed reduction
what is Buck’s traction used for
- femur fx
- hip fx
- “knee immobilization”
what is Bryant traction used for
- hip dysplasia <3years
key words for hip & femur surgery
- total hip replacement
- open reduction internal fixation (ORIF)
- external fixation
3 priority of assessments for fractures
- bleeding
HgB less than 7 = HEAVEN
monitor pulses distal to injury
hypotension & tachycardia - infection
elevated WBC >10,000
drainage
pin care with sterile solution at least 3x day - position education
what position education to give for hip fracture
position education:
* abducted legs for total hip arthroplasty: place a pillow between legs to keep legs away from each other
* no crossing legs
* no sitting in chair (no sitting at 90 degrees angle)
* no leaning forward
complication for fractures
- fat embolism syndrome
common in: femur, pelvic/hip, crushing fractures - compartment syndrome from cast
don’t use SCDs
s/s of fat embolism syndrome
- mental status changes
confusion, restlessness
altered mental status - dyspnea & chest pain
- low pulse ox
- petechiae over neck and chest
what are the cast care complications
- hot spots: infection
- compartment syndrome: no perfusion -> loss of limb
s/s of compartment syndrome
- pain: muscle ischemia
unrelieved with morphine or other meds
extreme pain with passive movement - paresthesia
tingling, burning, numbness
problem moving or extending fingers/toes
6Ps
interventions for compartment syndrome
- notify PCP immediately
loosen cast
fasciotomy: cut through tissue to relieve pressure - don’t elevate extremity
how many fingers should fit between cast and skin
1 finger
nursing assessments for compartment syndrome
- assess fingers and toes “neuro checks”
PMSC
P: pulses, pain
M: movement/grips
S: sensation
C: cap refill & color: not over 3secs/temperature not hot or cool
what are the 6 P’s for perfusion/oxygenation
- pain
- paresthesia
- pulses
- pallor
- paralysis: can’t move limb
- polar: cold (Poikilothermia)
pain & paresthesia priority
typically for lower limbs since it’s further from the heart
s/s of hot spots in a cast
infection under cast
- hot areas
- foul odors
nursing intervention for hot spots
- assess the circulation
- change position
cast care
CAST
- C: clean & dry NEVER WET
- A: above the heart (1st 48hrs to decrease swelling & ice)
- S: scratch an itch (hair dryer on a cool setting) don’t put anything in it
- T: take it easy (no bearing weight initially, no finger indentations or pressure, no hard surfaces), turn q2hr to dry the cast faster
safe crutch use
- weight on hands & arms
- both crutches forward WITH injured leg
move unaffected leg forward - stairs
up with GOOD, down with BAD
safe cane use
- move cane 1st, weaker leg 2nd
- stairs: up with GOOD, down with BAD
up with strong, cane moves, weak leg last
descend with cane, weaker leg down, strong leg last
what is club foot
- foot twisted inward and down, sole of feet facing each other
- affected foot may be smaller than unaffected one
- foot is rigid and can’t be moved easily
- walking deformity
when does treatment occur for club foot
- right after birth
treatment for clubbed foot
- casts
new cast every week for 5-8 weeks - heel cord tenotomy: fix achilles tendon -> long-leg cast again
- denis browne cast after original cast is done (snowboard for babies) worn at bedtime for 3-5 yrs
parent education for clubbed foot with casts
- new long-leg cast placed every week for 5-8weeks
- check toes several times a day = pink & warm
- keep the cast dry
- don’t elevate feet during sleep, don’t sleep on stomach = increased risk for SIDS
what is hip dysplasia (DDH)
ball and socket joint doesn’t form normally -> hip instability -> may fully displace -> making affected leg shorter
when does hip dysplasia get diagnosed
from birth to first few years of life
causes of hip dysplasia
- breech birth & large infant size
- family hx
hip dysplasia is easier to correct when they are a baby, what are the s/s to look for at birth?
0-12 weeks old:
- extra gluteal folds
inguinal/thigh folds
- one leg shorter than another
- instability and clicking sensating when abducting thighs
Ortolani (abduction of hip) and Barlow (adduction of hip) test
after 12 weeks old:
- limited hip abduction
- shorter leg on affected side -> difficult to stand up straight
walking years:
- limp
- walking on toes
- pelvis tilt leans towards unaffected leg “trendelenburg sign”
parent teaching for hip dysplasia
- keep legs abducted (away)
- car seats/strollers with wide bases
treatment for hip displasia
Pavlik harness
before 6 months of age
- only doctor adjust straps once a week
- keep on all the time, only take off for baths
- skin checks 2-3 times daily
- massage under straps every day
- dress with clothes under straps
- diapers under straps (only 1)
- avoid powders and lotions: excess moisture
once hip stabilized -> worn during sleep
if still doesn’t work, then surgical closed reduction with hip spica cast
what is achondroplasia
- without cartilage growth: autosomal mutation in a gene no endochondral bone formation
increased risk with older paternal age - dwarfism
s/s of achondroplasia
- normal head and trunk size, recurrent ear infections due to narrow passages of the ear
- abnormally large prominent forehead
- hydrocephalus - flattened nasal bridge
- crowded misaligned teeth
- underdeveloped area of the face between forehead and jaw
- kyphosis or lordosis
- shorter arms & fingers and legs
- bowed legs
- flat, short, broad feet
- poor muscle tone, loose joints
- sleep apnea
- fertility, life span, and mental function unaffected
diagnosis for achondroplasia
- ultrasound during pregnancy
- DNA or genetic test: amniotic fluid in womb
- x-rays after birth, blood test for defective gene
s/s of hydrocephalus in a child with dwarfism
- headache
- vomiting
- behavioral changes
- vision issues
- balance & coordination issues
- delayed development or cognitive decline
what is scoliosis
- s shaped spine
- “lateral curvature” and spinal rotation -> rib asymmetry
s/s of scoliosis
- varied pain
- asymmetry in scapula, ribs, flanks, shoulders, hips
when is scoliosis most prominent
periods of rapid growth:
- adolescent females ages 10-12
- adolescent males ages 13-14
diagnosis of scoliosis
- cobb angle: degree of curvature
- Risser scale: skeletal maturity (bone growth on iliac crest)
bend over at the waist with arms hanging down to observe symmetry - xray, MRI, CT
- lung capacity: pulmonary function studies, CXR
causes and risk factors of scoliosis
- unsure, maybe something to do with intervertebral discs
- genetics
- associated with neuromuscular disorders: muscular dystrophy, Marfan syndrome, cerebral palsy
treatment for scoliosis
- physical exercise to limit progression & maintain ROM
- fixing braces: Boston Brace
wear cotton shirt under brace at all times
wear at all times besides hygiene - spinal fusion with rod placement if curvature >45 degrees
post op care for spinal fusion with rod placement (scoliosis)
- NG tube, chest tube, urinary catheter, breathing exercises, PCA pump
- frequent neuro checks
- turn by log rolling
- ambulation by 2nd or 3rd day as tolerated
- monitor for paralytic ileus, infections
complications of scoliosis
- breathing difficulties with severe curvatures
pneumothorax, atelectasis - lowered self-esteem
- superior mesenteric artery syndrome: compression of the duodenum by aorta and superior mesenteric artery -> obstruction
monitor for N/V, epigastric pain
pathophysiology of muscular dystrophy
MD: muscle damage & weakness
- replacement of muscle fibers with connective tissue
- DNA sequencing issue with the protein dystrophin (for muscle stabilization)
- progressive disease: overtime more muscle cells die starting from legs
muscular dystrophy mostly affects what population
- boys 2-5 years old
compare Duchenne vs. Becker Muscular dystrophy
- onset, progression, life expectancy, cardiac
Duchenne
- mutations -> complete lack of functional dystrophin
- onset: early childhood
- progression: rapid, wheel chair bound by teens
- life expectancy: reduced
Becker
- partial functional dystrophin
- later onset
- progression: slower, can ambulate into adulthood
- life expectancy: adulthood with care
both
- cardiomyopathy, arrhythmias
- milder in Becker
diagnostics for muscular dystrophy
- elevated creatine kinase (CK)
- genetic testing
- muscle biopsy: absent dystrophin
s/s of muscular dystrophy
- walks on tiptoes (achilles tendon tightened)
- disproportionately large calves
- frequently trips & falls
- places hands on thighs to stand (Gower sign)
interventions for muscular dystrophy
- no cure
- steroids: prednisone
- physical therapy
- NO BACLOFEN
- wheelchair bound in adolescence
- pass away due to respiratory failure in 20-30’s
nurse teaching for parents with a child with muscular dystrophy
- remove throw rugs
- diet: fluids and fiber
- gentle exercise: swimming, yoga, walking, NOT weight lifting
- iron & vit D UNRELATED
pathophysiology of osteomyelitis
- bacterial infection of the bone
- hematogenous spread: bacteria enters via bloodstream and localize in the metaphysis of long bones
risk factors for osteomyelitis
- recent trauma or bone injury
- immunosuppression
- indwelling devices
- chronic conditions: DM, sickle cell anemia
- prior bacterial infection: pneumonia
- poor hygiene or malnutrition
s/s of osteomyelitis
- localized pain
- swelling, redness, warmth
- reluctance to use limb or weight bearing avoidance
- systemic symptoms: fever, fatigue, malaise
- infants: poor feeding, pseudoparalysis, irritability
lab/diagnostics for osteomyelitis
- increased WBC
- increased CRP, ESR
- blood cultures
- bone biopsy or aspiration
- xray: after 1-2wks of infection
- MRI: early detection
- ultrasound: adjacent abscess or effusion
- bone scan if MRI not possible
treatment for osteomyelitis
- broad spectrum abx: vanco, cefazolin, clindamycin
- adjust based on culture results
- sx if: abscess, necrotic bone, poor response to abx
debridement of bone, removal of dead bone - pain meds
- immobilize affected limb
- physical therapy maybe after restored mobility
