Musculoskeletal Flashcards
1
Q
Trendelenburg Gait
A
The Trendelenburg gait pattern is an abnormal gait (as with walking) caused by weakness of the abductor muscles of the lower limb, gluteus medius and gluteus minimus.
2
Q
Osteotomy
A
Cutting of and removal of bone to improve bone function
3
Q
Arthrotomy
A
Cutting into a joint to expose its interior
4
Q
Hematogenously
A
Involving, spread by, or by arising in the blood
5
Q
When does fusing and maturing of epiphyseal region occur?
A
Adolescence
6
Q
Why do infants have bowed legs?
A
From the positioning in utero. Resolves in 2-3 years with weight bearing
7
Q
Casting
A
Immobilizes a bone that has been injured or a diseased joint, holds a bone in reduction when a fracture has occurred, and prevents/corrects deformities
8
Q
What are casts usually made of?
A
Plaster or fiberglass - drying time varies.
** Be careful to not make indentations during drying time
9
Q
How do you make a cast waterproof?
A
Gore-Tex lining
10
Q
Neurovascular Assessment for Casts
A
- Pulse
- Paresthesias
- Pallor
- Paralysis
- Pain
11
Q
What do you monitor for to prevent compartment syndrome?
A
- Increased pain
- Increased edema
- Cyanosis or pallor
- Coolness of skin
- Numbness or tingling
- Prolonged cap refill
- Decreased or absence of pulse
12
Q
When can you use ice for patient with a cast?
A
Only in the first 24-48 hours
13
Q
What should you teach your patient about cast care?
A
- Wiggle fingers or toes hourly
- Itching technique
- Protect from wetness
- When to call HCP
14
Q
How to alleviate an itch under a cast
A
- Never insert anything into the cast
- Blow cool air on hair dryers lowest setting
- No lotions or powder
15
Q
How can a parent check for skin irritation of their child that has a cast?
A
- Press the skin back around the edges of the cast
- Use a flashlight to look for reddened or irritated areas
- Feel for blisters or sores
16
Q
When to call HCP for a patient with a cast?
A
- Cool extremities (or color change)
- If the child can’t move the fingers or toes
- Severe pain when moving fingers or toes
- Persistent numbness or tingling
- Drainage or foul odor
- Severe itching
- Fever greater than 101.5 for longer than 24 hours
- Skin edges are red and swollen or exhibit breakdown
- The cast gets wet and does not dry or is cracked, split, or softened
17
Q
Skin Care After Cast Removal
A
- Brown, flaky skin is normal and occurs as dead skin and secretions accumulate under the cast
- New skin may be tender
- Soak with warm water daily
- Wash with warm soapy water, avoiding excessive rubbing, which may traumatize the skin
- Discourage the child from scratching the dry skin
- Apply moisturizing lotion to relieve dry skin
- Encourage activity to regain strength and motion of extremity
18
Q
Traction
A
Application of weights to provide pulling force on an extremity or body part for reducing fractures, realigning injured extremities, decreasing muscle spasms, and correcting deformities
19
Q
Skeletal Traction
A
- Apply weights via ropes attached to skeletal pins
- Protect exposed ends of pins to avoid injury
20
Q
Skin Traction
A
- Apply weights via ropes to bandage or foam boot
- Apply traction over intact skin only
21
Q
Nursing Consideration for Traction
A
- Ensure ropes move freely and weights do not touch floor.
- Constant and even traction should be maintained.
- Promote use of trapeze if not contraindicated to involve the child in repositioning and assist with movement
- Encourage deep-breathing exercises to prevent the pulmonary complications of long-term immobilization
22
Q
Fixation
A
Surgical reduction of complicated fracture or skeletal deformity with an internal or external pin or device used to immobilize bone while it heals
23
Q
Pin Care
A
- Perform pin care weekly after the first 48 to 72 hours. Perform earlier if large amounts of drainage is present, dressing becomes wet, or infection is suspected
- Use chlorhexidine or normal saline
- Use a nonshedding material for cleaning
- Cover pin sites with a nonshedding dressing
- Teach children and their families pin site care along with instructions on the signs and symptoms of infection before discharge
24
Q
Types of Skin Traction
A
- Bryant
- Russell
- Buck
- Cervical
- Side Arm 90-90
25
Bryant Traction
Type of Skin Traction
| - Used to reduce femur fracture in children younger than 2 years or with developmental dysplasia of the hip (DDH)
26
Bryant Traction Nursing Considerations
- The buttocks are slightly elevated and clear of the bed
- Assess bandages and skin every shift
- Ensure ankles and heels are free from pressure
27
Russell Traction
Type of Skin Traction
| - Traction for femur fracture, hip, and specific types of knee injuries or contractures
28
Russell Traction Nursing Considerations
- Ensure heel is free from bed
- Use a foot support to prevent foot drop
- Assess popliteal region for skin breakdown from the sling
- Mark leg to ensure proper replacement of sling
29
Buck Traction
Type of Skin Traction
- Skin traction for hip and knee contractures, Legg-Calve-Pethes disease, slipped capital femoral epiphysis
- Used to rest an injured limb or to prevent spasms
30
Buck Traction Nursing Considerations
Remove traction boot every 8 hours to assess skin
31
Cervical Skin Traction
Type of Skin Traction
- Traction applied with a skin strap (head halter)
- Used for neck sprains/strains, torticollis, or nerve trauma
32
Cervical Skin Traction Nursing Considerations
Ensure that head halter or skin strap does not place pressure on ears or throat
33
Side Arm 90-90
Type of Skin Traction
| - Traction for humerus fractures and injuries in or around the shoulder girdle
34
Side Arm 90-90 Nursing Considerations
- Fingers and hand may feel cool because of elevation
| - Child may turn to affected side only
35
Types of Skeletal Traction
1. Dunlop side arm 00-90
2. 90-90
3. Cervical skeletal tongs
4. Halo
5. Balanced suspension
36
Dunlop Side Arm 00-90
Type of Skeletal Traction
| - Skeletal traction through an olecranon screw or pin in distal humerus
37
Dunlop Side Arm 00-90 Nursing Considerations
Provide appropriate pin site care
38
90-90 Traction
Type of Skeletal Traction
- For femur fracture reduction when skin traction is inadequate
- Skeletal traction with force applied through pin in distal femur
39
90-90 Traction Nursing Considerations
Provide appropriate pin site care
40
Cervical Skeletal Tongs
Type of Skeletal Traction
- Tongs attached to skull via pins for fractures or dislocations of cervical or high thoracic vertebrae
- Special bed required
41
Cervical Skeletal Tongs Nursing Considerations
Assess frequently for increased pain, respiratory distress, and spinal cord, cranial nerve, or brachial plexus injury
42
Halo Traction
Type of Skeletal Traction
- Metal halo attached to skull via pins for cervical or high thoracic vertebrae fractures or dislocations or postoperative immobilization after cervical fusion
43
Halo Traction Nursing Considerations
- Tape small wrench to front of brace so that front panel can be quickly removed in an emergency
- May become ambulatory in this type of traction; will be top-heavy so may need assistance with balance
- Assess pin sites and provide pin care as ordered
44
Balanced Suspension
Used for femur, hip, or tibial fracture
45
Balanced Suspension Nursing Considerations
Avoid pressure to popliteal area
46
Pectus Excavatum
Funnel shaped chest, sinks inward at the xiphoid process
| - Progresses with growth
47
Pectus Excavatum Treatment
May require surgery (preferable before puberty if cardiac or pulmonary compression occurs
- SOB
- Exercise intolerance
- Chest pain
48
Pectus Carinatum
Protuberance of chest wall, pigeon chest
49
Post Operative Nursing Considerations for Pectus Excavatum
- Do not allow the child to roll in bed, lie on either side, or rotate or flex the spine (these positions may disrupt the bar's position)
50
When is the pectus excavatum bar removed?
2-4 years after initial placement
51
Limb Deficiencies
- Absence of a limb or portion of it, or the deformity of a limb
- Occurs during fetal development
52
Limb Deficiency Cause
Amniotic bands
53
Limb Deficiency Treatment
- Provide activities early to improve child's function and activities that the child can participate in
- PT/OT
- May need prosthesis
54
Polydactyly
Extra digits
- Assess for presence of bone
- May require surgery or simply tying off with suture (necrosis)
55
Syndactyly
Webbed digits
- No treatment necessary
- May have surgery for cosmetic reasons
56
Metatarsus Adductus
Medial deviation of forefoot
57
Treatment for Metatarsus Adductus Type I
Type I is flexible past neutral position so just observation is needed for treatment
58
Treatment for Metatarsus Adductus Type II
Type II is flexible only to neutral position so stretching exercises may be beneficial
59
Treatment for Metatarsus Adductus Type III
Type III is rigid so serial casting similar to clubfoot may be required
** Surgery may be done in several cases
60
Clubfoot consists of:
1. Talipes varus
2. Talipes equinus
3. Cavus
4. Forefoot adduction with supination
61
Talipes varus
Inversion of the heel
62
Talipes equinus
Plantar flexion of foot, heel raised, and would not strike ground in standing position
63
Cavus
Plantar flexion of forefoot on the hindfoot
64
Forefoot adduction with supination
Forefoot inverted and turned slightly upward
65
Treatment Goal of Clubfoot
A functional foot
66
Treatment for Clubfoot
* * Treatment starts as soon after birth as possible
1. Weekly manipulation with serial casting initially, then Q2wk
2. May require corrective shoes or bracing
3. Severe may require surgery
67
Surgery for Clubfoot
Foot immobilized with cast for up to 12 weeks post op then ankle-foot orthoses or corrective shoes for years
68
Osteogenesis Imperfecta (OI)
Genetic bone disorder or type 1 collagen abnormality that results in low bone mass, increased fragility of bones, and other connective tissue problems such as hypermobility causing instability of joints
69
Osteogenesis Imperfecta (OI) Diagnostics
Skin biopsy or DNA testing to determine classification
70
Preventing Injury in Children with Osteogenesis Imperfecta
1. Never push or pull on an arm or leg
2. Do not bend an arm or leg into an awkward position
3. Lift a baby by placing one hand under the legs and buttocks and one hand under the shoulders, head, and neck
4. Do not lift a baby's legs by the ankles to change the diaper
5. Do not lift a baby or small child from under the armpits
6. Provide supported positioning
7. If fracture is suspected, handle the limb minimally
71
Common Findings with Osteogenesis Imperfecta
1. Blue sclera
2. Short stature
3. Early hearing loss
4. Discolored teeth
5. Joint hypermobility
6. Acute and chronic pain
7. Scoliosis
8. Respiratory complications
9. Gross motor developmental delays
72
Osteogenesis Imperfecta Treatment
1. Biphosphonate (increases bone mineral density)
2. PT/OT
3. Splints/braces
4. Surgical insertion of rods into long bones
5. Exercise - walking, swimming, water therapy
73
Developmental Dysplasia of the Hip (DDH)
- Abnormalities including dislocation, sublaxation, and dysplasia of hip joint
- Femoral joint has abnormal relationship with acetabulum
- Can be unilateral or bilateral
74
Complications of DDH
May cause:
1. Avascular necrosis of femoral head
2. Loss of ROM
3. Recurrent instability
4. Femoral nerve palsy
5. Leg length discrepancy
6. Early osteoarthritis
75
Treatment goal of DDH
Maintain hip joint in reduction so that femoral head and acetabulum can develop properly
76
Diagnosing DDH
1. Asymmetrical gluteal and/or thigh folds
2. Shortening of affected femur observed as limb-length discrepancy
3. Trendelenburg gait in older child
4. Limited hip abduction with passive ROM
5. Barlow and Ortolani test - palpable "clunk"
77
Pavlik Harness for DDH
- Infants < 4-6 months may be treated with Pavlik harness = maintains hip flexion and abduction
- Must be worn continuously and applied properly = do not adjust straps without checking with HCP
- Assess for skin breakdown (long socks and undershirt recommended to prevent rubbing)
* * Usually worn for 3 months
78
Who gets traction for DDH?
Used for children 6 months old or those who do not improve with Pavlik harness - skin or skeletal traction may be used
79
Traction for DDH
Surgical reduction and casting followed by bracing or orthotic use may also be necessary
- Spica cast for 12 weeks
- Abduction brace full time except for baths for 2 months, then off at night and during naps
80
Tibia Vara (Blount Disease)
An exaggerated "bowing" of the legs
| ** Found more in children who walk early
81
Types of Tibia Vara
1. Intantile (most common 1-3 years)
2. Juvenille (4-10 years)
3. Adolescent (11+)
82
Risk Factor for Tibia Vara
Obesity
83
Treatment for Tibia Vara
Bracing and surgery should start before age 4 years
- Compliance is most significant barrier to successful treatment
- Brace must be continued for months to years and worn 23 hours/day
- Long-leg bent knee or spica cast after surgery
84
Torticollis
Painless muscular condition in infants or children
85
Possible Cause of Torticollis
Congenital form may be related to in utero positioning
86
S/Sx of Torticollis
- Observe for wryneck (tilting head to one side)
| - Preferential turning of head to one side when supine or prone can lead to tightness of sternocleidomastoid muscle
87
Treatment for Torticollis
1. Passive stretching exercises
2. PT and tubular orthosis collar may be used
3. Pharmacological treatment
88
Pharmacological Treatment of Torticollis
- Baclofen (muscle relaxant)
| - Injection of botulinum toxin (Botox) can provide temporary relief - need to be repeated every 3 months
89
Rickets
Softening or weakening of bones as result of nutritional deficiency - inadequate Ca or vitamin D consumption or limited exposure to sunlight
90
What kind of rickets is preventable?
Vitamin D deficiency induced rickets is preventable
91
What kind of rickets is not preventable?
If body cannot regulate calcium and phosphorus (such as in chronic renal disease and malabsorption GI disorders [CF, Crohn's, and prematurity])
92
Rickets Treatment
Calcium, phosphorus, and possible vitamin D supplements
93
Slipped Capital Femoral Epiphysis (SCFE)
Femoral head dislocated from neck and shaft of femur at level of epiphyseal plate
94
SCFE Treatment
Promptly refer to orthopedic surgeon
- May need traction, in situ pinning or osteotomy
- Can result in chondrolysis (cartilage necrosis), avascular necrosis of femoral head, shortening of the affected leg, thigh atrophy, and osteoarthritis
95
S/Sx of SCFE
1. Sudden pain and inability to bear weight (acute)
2. Insidious onset of pain and limp (chronic)
3. Trendelenburg gait
4. Decreased ROM
96
Nursing Considerations for SCFE
1. Assess for pain in hip or referred to groin, medial thigh, or knee
2. Do NOT attempt passive ROM to determine extent of limitation in child with suspected or confirmed SCFE as it may worsen the condition
3. Bed rest and activity restrictions for patient
97
Education for SCFE
1. Crutch walking
| 2. Weight bearing after 1 week, pin removal later
98
Legg-Calve-Perthes Disease
Self-limiting condition involving necrosis of femoral head
99
Pathophysiology of Legg-Calve-Perthes Disease
Interruption of blood supply to femoral head results in bone death, loss of spherical shape, and swelling of the soft tissues
- New blood vessels develop and revascularization takes 18-24 months and femoral head reforms over time
100
S/Sx of Legg-Calve-Perthes Disease
Painless limp (intermittent over period of months) resulting in ...
1. Mild hip pain or referred knee or thigh pain
2. Pain aggravated by exercise
3. Trendelenburg gait
4. Limited abduction of hip
101
Legg-Calve-Perthes Disease Treatment
1. Anti-inflammatory medications to decrease muscle spasms around hip joint and to relieve pain
2. Activity limitations may be prescribed
3. Bracing, casting, or traction, serial xrays
4. Surgery is RARE - osteotomy may be performed
102
Osteomyelitis
Bacterial infection of bone and soft tissue surrounding bone
| - S. aureus most common bacteria (invades the bone hematogenously)
103
Osteomyelitis Diagnostics
Aspiration is necessary to confirm diagnosis and identify organism
- Blood culture will be positive
- WBC will be elevated
104
S/Sx of Osteomyelitis
1. Refusal to walk
2. Decreased ROM
3. Swelling
4. Warmth
5. Tenderness
105
Osteomyelitis Treatment
1. Bed rest
2. Pain management
3. Antipyretics
4. 4-6 week course of antibiotics (IV then PO)
106
Septic Arthritis
Bacterial invasion of joint space (most often hip or knee)
107
How does a person usually get septic arthritis?
Usually obtained hematogenously through direct puncture from injections, venipuncture, wound infection, surgery, or injury
108
Potential Complication of Septic Arthritis
Sepsis of hip joint may cause avascular necrosis of femoral head
** Considered a medical EMERGENCY because destruction of joint cartilage may occur within days
109
S/Sx of Septic Arthritis
1. Note recent respiratory infection or osteomyelitis, skin or soft tissue infections, traumatic puncture wounds, or femoral venipuncture
2. Ill appearance
3. Sudden onset of fever
4. Usually maintains joint in flexion and will not allow leg to be straightened
5. Will not bear weight
110
Septic Arthritis Treatment
1. Joint aspiration (to find responsible organism) or arthrotomy
2. IV antibiotics, then PO antibiotics at home
3. Pain management with acetaminophen or ibubrofen usually sufficient , but may need morphine or codeine
4. Crutches, wheelchair, PT
111
Transient Synovitis of the Hip
- Most common cause of hip pain and limping in children in US = worse in morning
- Self-limiting disease that usually resolves within a week, but may last up to 4 weeks
112
Transient Synovitis of the Hip Treatment
1. NSAIDs
2. Analgesics
3. Bed rest
113
S/Sx of Transient Synovitis of the Hip
1. Concurrent or recent URI, pharyngitis, OM, or trauma
2. Sudden acute onset of moderate-severe pain of one hip (may be referred to anterior thigh or knee) - worse in morning and decreases throughout the day
3. Refusal to walk (concerning for parents)
4. Low grade to normal temperature
114
Scoliosis
Lateral curvature of the spine that exceeds 10 degrees
| - With progression and changes of the shape of the thoracic cage, cardiac and pulmonary compromise may occur
115
Scoliosis Causes
1. Congenital
2. Associated with disorders
3. Idiopathic
116
Treatment of Scoliosis is based on what?
Based on age, expected future growth and severity of curvature
117
S/Sx of Scoliosis
Asymmetry in hips or shoulders is noted by family or during scoliosis screening
118
25-40 degree curvature scoliosis treatment
Bracing may be sufficient
| - Watch closely for skin breakdown
119
> 45 degree curvature scoliosis treatment
Surgical approach is used
- Rod placement
- Bone grafting
- Spinal fusion
120
Post Op Scoliosis Nursing Considerations
- Use log roll technique to turn to avoid flexion of back
- Maintain Foley
- Ambulate slowly when ordered to avoid orthostatic hypotension
121
Where do fractures most commonly occur?
Forearm and wrist
122
What are the most common type of fracture?
Greenstick and buckle
123
Most common cause of childhood fractures
Accidental trauma
124
What kind of fracture patients should be evaluated for child abuse?
1. Child less than 2 with fractures
| 2. Any child with spiral, rib, or humerus fracture
125
What is the most vulnerable portion of bone?
The growth plate
126
Fractures Nursing Considerations
1. Immobilize injured limb above and below injury in most comfortable position with splint
2. Cold therapy to reduce swelling for first 48 hours
3. Elevate injured extremity above level of heart
4. Frequent neurovascular checks
5. Assess pain using appropriate scale
6. Crutch walking technique as needed
7. Encourage age appropriate protective equipment, such as wrist guard and shin guards
127
Sprains and Strains
Twisting or turning motion of affected body part
- Tendons and ligaments stretch excessively and may tear
- Most common in ankle and knee
128
Sprains and Strains Treatment
RICE
R - rest
I - ice
C - compression
E - elevation
129
Sprains and Strains Nursing Considerations
1. Inspect for edema, bruising, inability to bear weight
2. Assess neurovascular status
3. May need crutches - education
130
Overuse Syndromes
Group of disorders that result from repeated force applied to normal tissue
- Develop over weeks to months
- No identifiable injury
- Pain associated with an activity and worsens with participation in the activity
131
Overuse Syndromes Treatments
1. Initially apply ice when pain is severe
2. Anti-inflammatory medications may be helpful
3. Encourage them to limit exercise and to participate in different activity (resolves over few weeks and then can resume activity)
132
Osgood-Schlatter Disease
Partial pulling/tearing of the ossification center of the tibial tubercle
- Most commonly affects adolescent boys during period of rapid growth
- Often dismissed as "growing pains"
- May take 12-24 months to resolve
133
Osgood-Schlatter Disease Treatment
Encourage stretching before activities and conditioning before season begins
134
Radial Head Sublaxation
AKA Nursemaid's Elbow
- Occurs when pulling motion on the arm causes annular ligament surrounding radial head to stretch or tear, therefore displacing the radial head
- Ligament becomes trapped within the joint
135
What will nursemaid's elbow look like in a patient?
The child will hold arm slightly flexed at side or across abdomen and refuse to move it
- Neurovascular status is normal, no edema or bruising, and no obvious discomfort if arm is still
136
Nursemaid's Elbow Treatment
After reduction, the child will experience less pain almost immediately
