Musculoskeletal Disorders Flashcards
One of the most difficult aspects of illness in a child is immobility
Kids are naturally active - how explore world - take natural outlet away - are anxious - naturally relieve anxiety by running around - essential for normal G&D
Sick kids struggle to separate from parents - cannot get away if in hospital
At risk based on age group:
Psychologic impacts:
Effects of immobilization on the family
The immobilized child
Infant: dependent - require parents to keep environment safe
Toddlers: not understand danger
Preschoolers: like make people happy; not understand risks or stranger danger
School age: sports - very active - highest rate of fractures
Adolescent: invincible
At risk based on age group: - The immobilized child
Diminished environmental stimuli
Altered perception of self and environment
Increased feelings of frustration, helplessness, anxiety
Depression, anger, aggressive behavior
Developmental regression
Psychologic impacts: - The immobilized child
Take outlet away from anxiety - immobilized - impact family
Act different from norm behaviors
Tantrums and outbursts
Effects of immobilization on the family - The immobilized child
Muscular system- decreased muscle strength, tone, and endurance - atrophy
Skeletal system- bone demineralization (osteoporosis, hypercalcemia)
Metabolism- decreased metabolic rate, decreased production or stress hormone
Cardiovascular system- decreased efficiency of orthostatic neurovascular reflexes, altered distribution of blood volume, venous stasis, dependent edema
Respiratory system- decreased need for oxygen, decreased chest expansion and vital capacity, loss of respiratory muscle strength (poor cough)
Gastrointestinal system- distension caused by poor abdominal muscle tone; bowel or bladder issues - newly potty trained or asking go on bed pan
Urinary system – urinary retention due to difficulty voiding while in prone position, embarrassment for the older child
Integumentary system- altered tissue integrity, difficulty with personal hygiene
Physiologic effects of immobilization
Not in equilibrium
Not have normal G&D
Cannot expect to have normal G&D
G&D
Ex: sprain/strain - common in school-age or adolescent
RICE
Immobilization and Support as needed (casts or splints as appropriate to injury)
Therapeutic management of soft-tissue injuries
Rest the injured part
Ice immediately – never directly on skin. (on/off every 20 min) - barrier - ice pack made for skin - rotate on and off
Compression with wet elastic bandage
Elevation of the extremity
RICE - Therapeutic management of soft-tissue injuries
Most common area: fingers
More common in kids with lax joints: Downs - especially in elbow
Ice on it and to doc
Joint put back - less pain - not need immobilize - be careful but let use it
Red flag: refuse to use after 10-20 minutes
Displacement of normal position of opposing bone ends or of bone ends to socket
Occurs when force of stress on ligament is sufficient to cause displacement
Pain: Increases with active or passive movement of affected extremity
More common in children with Down syndrome
Commonly seen in fingers and elbows (nursemaid)
Dislocation
Plastic deformation (bend): The bone is bent no more than 45° without breakage.
Buckle (torus): Compression of the bone resulting in a bulge or raised area at the fracture site.
Greenstick: Incomplete fracture of the bone. - more common in kids than adults - softer bones - not break as easy; younger a child is harder is to break a bone
Transverse: Break is straight across the bone.
Oblique: Break is diagonal across the bone.
Spiral: Break spirals around the bone. - twisting - abuse
Epiphyseal (growth plate): Injury to the end of the long bone on the growth plate.
Stress: Small fractures/cracks in the bone due to repeated muscle contractions - more common older kids and runners
Complete: Bone fragments are separated.
Incomplete: Bone fragments are still attached.
Closed or simple: The fracture occurs without a break in the skin.
Open or compound: The fracture occurs with an open wound and bone protruding.
Complicated fracture: The fracture results in injury to other organs and tissues.
Comminuted: The fracture includes small fragments of bone that lie in surrounding tissue
Fractures
Most long bones - grow from growth plate
Grow from inside out
Can result in growth issue
Weakest part bone
Result in diff sizes of limbs
Rare of this
Follow-up imp
Growth plate injuries
Typically rapid healing in children
Younger are easier it is
Newborn: clavicle - shoulder dystocia - can lead to brachial plexus injury - long term nerve injury and not use arm appropriately
Bone healing and remodeling
Radiographs - x-ray
History taking - complains hurts; not use it
Suspicion of fracture in a young child who refuses to walk or bear weight - match with story
Diagnostic evaluation - Diagnosis and management of fractures
Reduction and immobilization
Restoring function
Preventing deformity - might not heal as supposed to - rebreak it - not seen often unless abuse
Goals of fracture management - Diagnosis and management of fractures
Pain and point of tenderness
Pallor
Pulselessness
Paresthesia: Sensation distal to the fracture site
Paralysis: Movement distal to the fracture site
Pressure
Why do we need to complete a neurovascular assessment?
Pain and severe that point to location and meds not relieve pain - call doc
Neurovascular assessment
Worried abou compartment syndrome
Edema, extra blood, squeezes muscles, veins, arteries, nerves - assess regularly
Monitor with cast - move toes
Foot fell like its asleep
Fasciotomy
Why do we need to complete a neurovascular assessment?
Also worried about infection
Protruding bone/surgery
Hot spot - red flag something going on with cast
Manifestations
Nursing actions
Education
Osteomyelitis
Irritability
Fever
Tachycardia
Edema
Pain is constant but increases with movement
Not wanting to use the affected extremity
Site of infection tender, swollen, and warm to touch
Manifestations - Osteomyelitis
Assist in diagnostic procedures (obtaining skin, blood, and bone cultures).
Assist with joint or bone biopsy.
Administer IV and oral antibiotic therapy.
Monitor hepatic, hematologic, and renal function.
Monitor for the development of superinfection (candidiasis, C. difficile infection).
Immobilize and elevate the extremity.
Administer pain medication as prescribed.
Consult with the parents and provider regarding home care needs.
Nursing actions - Osteomyelitis
Educate the client and parents about the length of treatment that can be needed and long-term antibiotic therapy.
Monitor hearing due to ototoxicity of some antibiotics.
Limit movement of the affected limb and avoid bearing any weight until cleared by the provider.
Provide for diversional activities consistent with the client’s level of development.
Ensure proper nutrition.
Education - Osteomyelitis
Plaster - longer dry (not good if around water - careful how handle - lay on pillow - use whole pillow) vs fiberglass - dry easier and quicker - okay getting wet - wrapping underneath not to get wet
Cast application techniques - Casting for fractures
Itchy - Nothing down cast; Hair dryer on cold setting and blow it in there; Benadryl
Elevate it to begin with it
Tylenol or motrin
Skin care
Care management - Casting for fractures
Red flags - compartment syndrome/osteomyelitis
Itchy
Cast care at home - Casting for fractures
Scary! - going at with a saw - show and demonstrate on something else to alleviate anxiety - arm gross looking - bath and gentle soap
Cast removal - Casting for fractures
SPICA cast - hip displasia
Potential complications
Nursing interventions
Evaluation
Education
Care for the child
Compartment syndrome
infection/osteomyelitis
Bowel obstruction
Pressure ulcers
DVT
UTI
Atelectasis
Risk for pneumonia
Potential complications - Care for the child
IS - blow bubbles/balloons; sing
Rotating; getting up
Skin chest
foot/leg asleep
Tingling feeling
Someone to talk to
Friends in
Nursing interventions - Care for the child
Listen to her - lungs clear
Assess pressure ulcer - skin checks - ask if feeling anything rubbing/uncomfy
Bladder, bowel, UTI - schedule on bathroom
Diaper on younger kids - older if verbalize - get up
Check pulses - neurovascular assessment
Evaluation - Care for the child
Skin integrity - diaper - little old - nothing sitting in there; pressure ulcers
Look for related to compartment syndrome: 6 P’s - something casted move above joint above casted
How to move her - how rotate her
Do not pull on the rod
Itching
Go to school
Trouble sleeping
Feel left out - keep checking in how doing psychosocially
Can read, board games, puzzles, video games, drawing, basketball coup in room
Education - Care for the child
A variety of disorders resulting in abnormal development of the hip structures that can affect infants or children
Deal with hip socket and how femoral head fits
Diff severities
Check on all babies
Even when older - check
More common girls
Strong fam inheritance
Has genetic condition: Downs - lax joints - more likely to have this - more breech - more likely to have this - get US follow-up if breech
Rule it out - + test - US if child has it
Identify ASAP - sooner identify less invasive procedures and less likely long-term issues
Formerly called “congenital hip dysplasia” or “congenital dislocation of the hip”
Incidence: 1.5 per 1000 live births
Girls: More commonly affected, strong family history
Assessment findings:
Gluteal folds - diff and not even - red flag
Barlow test - putting legs and pushing them out - seeing if can dislocate; hear popping - Ordilani after - confirms diagnosis - pops back into place
Gilliesis - knees not even
Therapeutic management
Developmental dysplasia of the Hips (DDH)
Dysplasia - ligaments loser - head not fully in contact with joint - rotate out and pull away; start and treated and worse - positional issues lead to dislocation
Subluxation - further out
Dislocation - complete
Diff severities - Developmental dysplasia of the Hips (DDH)
Hip joint laxity
Shortened limb on affected side
Restricted abduction of hip on affected side
Unequal gluteal folds when infant prone
Positive Ortolani test result
Positive Barlow test result
Galeazzi sign
Assessment findings: - Developmental dysplasia of the Hips (DDH)
Not severe missed; do it first 6 months because can be positional with how held
Can happen after baby is born
Causes legs to straight - pressure on ligaments and cause pop out - natural position - swaddle: tightest around arms; frog lay-out
Baby carrying; chest best way carry - M-shape with legs - not have legs hanging straight
Gilliesis - knees not even - Developmental dysplasia of the Hips (DDH)
Importance of early intervention
Birth to age 6 months: Pavlik harness for abduction of hip -
Ages 6 to 24 months: closed reduction and spica cast
Older child: Open reduction, tenotomy, osteotomy; correction is very difficult after age 4 years
Therapeutic management - Developmental dysplasia of the Hips (DDH)
on for long time - first couple weeks first 23 hours a day - off for bath; child not happy first nights - head femur in area supposed to be - time and makes ligaments stronger; several weeks; follow up with US; caught early could be end treatment
Birth to age 6 months: Pavlik harness for abduction of hip -
Will have to have surgery with SPICA cast
Bone keeps going out and moving - both change how fit and flatten it out - go back in and change shape bone and make ligaments tighter - often have long-term issues
Ages 6 to 24 months: closed reduction and spica cast
Complex deformity of the ankle and foot
Interventions/ care management
GOAL: The goal of treatment is for the child to have the ability to walk painlessly on the sole of the foot with the heel on the ground and for the foot to be stable.
Clubfoot
Treatment begins as soon after birth as possible.
Manipulation and casting the foot - serial casting - change cast regularly
Surgical intervention may be necessary
Monitor for pain and monitor the neurovascular status of the toes.
Interventions/ care management - Clubfoot
Most common spinal deformity
Poor posture
Born with it and not notice it until older
Easiest way - Adam’s test - bend over and off to side
Uneven
Scoliometer - look at %
X-rays
Curve is less 20% typ just monitor
20-40% - bracing
Complex spinal deformity in three planes
May be congenital or develop during childhood
Therapeutic management
Scoliosis
Lateral curvature
Spinal rotation, causing rib asymmetry
Thoracic hypokyphosis
Complex spinal deformity in three planes - Scoliosis
Team approach
Prevention/Exercise
Bracing
Concerns of body image
Concerns of prolonged treatment of condition
Surgical intervention for severe curvature (instrumentation and fusion)
Preoperative care/ Postoperative care
Therapeutic management - Scoliosis
Team approach
Prevention/Exercise
Bracing
Concerns of body image
Concerns of prolonged treatment of condition
Surgical intervention for severe curvature (instrumentation and fusion)
Preoperative care/ Postoperative care
Therapeutic management
- Scoliosis
Does not fix the curve
Prevent it from getting worse
Identify early before growth spurt - going to get worse if without brace
Bracing
> 40-45% require surgery - extremely painful
Rods in back
Not easy - biggest issue is compliance
Due exercises to strengthen back and abdominal muscles
Harrington rods
Luque rods
Surgical intervention for severe curvature (instrumentation and fusion)
Lots things can lead to this
Nonprogressive neuromuscular disorder - hard identify until miss milestones
Thorough history is reviewed (birth and developmental milestones): ask
There are different types of CP and they all present differently
Common Manifestations Include:
Therapeutic management
Goals of therapy for CP
Cerebral palsy (CP) - assessment
Is the child meeting milestones?
Did the child have a traumatic delivery? - something cause infarct in brain
Did the mom have a healthy pregnancy?
Has the child had any head trauma?
Typ something happens - why want birth hx
Thorough history is reviewed (birth and developmental milestones): ask - Cerebral palsy (CP) - assessment
Premature, LBW, quick delivery, long labor, meds during delivery, forceps, C-section, multiple deliveries - esp last one born, hemorrhage - anything makes not normal delivery increases risk
Did the child have a traumatic delivery? - something cause infarct in brain
Untreated bilirubin - stains brain yellow
Untreated meningitis - concerned if newborns have bacterial meningitis
Has the child had any head trauma?
Spastic, Athetoid, Ataxic, and mixed.
Scissor gait when walk
There are different types of CP and they all present differently - Cerebral palsy (CP) - assessment
Extreme irritability and crying - arch lot when holding them
Feeding difficulties
Alterations of muscle tone; stiff and rigid arms or legs - common
Delayed gross motor development (not meeting milestones) - common
Persistence of primitive infantile reflexes (Moro, tonic neck) after 6 months (most primitive reflexes disappear by 3 to 4 months of age) - CP: instincts last longer
Abnormal posturing, such as opisthotonos (exaggerated arching of the back)
Cognitive development: delays but case by case; but often just muscular thing
Seizures may occur.
Common Manifestations Include: - Cerebral palsy (CP) - assessment
*** The goal of management is early recognition and interventions to maximize the child’s abilities.
Therapeutic management (physical therapy, occupational therapy, speech therapy, education, and recreation)
Prepare for using mobilizing devices to help prevent or reduce deformities.
30-50% of Children with CP also have some form of cognitive impoairment
Encourage communication and interaction with the child on her or his developmental level
Trouble with fine motor - change utensils so more like handles
Hard straighten out arms - lot PT
Want movement to help increase survival
Also do lot bracing - help walk - do walker or wheelchair
Still go through puberty - educate on that
Medications may be prescribed to relieve muscle spasms, which cause intense pain; antiseizure medications may also be prescribed.
Therapeutic management - Cerebral palsy (CP) - assessment
Baclofen- antispasmodic - into SC and helps relieve muscles
botox
Diazepam- muscle relaxant
Botulinum toxin A injections
Medications may be prescribed to relieve muscle spasms, which cause intense pain; antiseizure medications may also be prescribed.
SC and meninges close around 4-weeks - not close properly increased risk of this
Take to decrease this risk: folic acid/folate
Biggest risk not getting folate - not trying get pregnant - often teenagers - put into hamburger buns
Largest group of congenital anomalies
Normally: The spinal cord and cauda are encased in a protective sheath of bone and meninges
Failure of neural tube closure: Produces defects of varying degrees
More common white and hispanic
Incidence
Types:
Patho of neural tube defects
Care management
Neural tube defects
0.3 per 1000 births
Occurs more often in white and Hispanic children
Incidence - Neural tube defects
Anencephaly - missing large part brain; not survive long after birth; diagnosis - often have abortion
Encephalocele - part SC and meninges coming out back neck; not survive long after birth; diagnosis - often have abortion
Spina bifida occulta - not popping out - no visible protrusion - no sac coming out; can be missed on US; dimple and tuft of hair where indention is
Spina bifida cystica
Types: - Neural tube defects
Meningocele - part sact and meninges and CSF out spine
Myelomeningocele - part SC out in sac - highest risk for perilatation
no vaginal delivery
Dx in uteruo
N. priority
Spina bifida cystica
On stomach - sac is moist and clean until surgery
Place mud flap - isolette with high humidity and sterile saline - not pop open - leaking CSF
Increased CSF: monitor: measure heads
Side - can pull
N. priority
Failure of the neural tube to close during the embryo’s early development (approximately 3-4 weeks after conception)
Multifactorial causes
Genetic mutation
What places the infant at highest risk for a neural tube defect?
Folate or folic acid lack of
Additional factors
Maternal obesity
Maternal diabetes mellitus
Low vitamin B12 level
*Prevention
Patho of neural tube defects - Neural tube defects
Pre/post surgical intervention
Support family and educate about home care
Orthopedic problems
Hips, back, legs, feet
Bladder/bowel control
Latex allergies
Often straight cath so do latex free
Care management - Neural tube defects
Do surgery in utero - decrease risks
Inside - hardly see scar
After surgery - can be put on side; no back
Comps:
Measure head - watch CSF
Monitor paralysis - neurogenic bowel and bladder
Risk for foot defects; developmental dysplasia of hips because paralysis
Pre/post surgical intervention
Arthritis in kids
Joint pain
Heat and ice
Move
Pain meds
May keep steroids if flare up
Biggest issue prevent joint damage and want preserve them - can grow them and become less painful
Autoimmune inflammatory disease
Impacts joints and other tissues
No cure, not usually life threatening.
Can subside overtime but may have residual impaired joint function or deformities
Description - Juvenile idiopathic arthritis
No definitive tests
Assessment - Juvenile idiopathic arthritis
Encourage normal performance of daily activities
Minimize damage and preserve joint function- Treatment is supportive
Range of motion
Heat/Ice
Pain control
Medications
Steroids
opioids/non-opioids
Eye care
Increased risk for uveitis due to inflammation and steroid use
Make sure the child has regular vision care
Hard manage
Push eye exams - go often
Interventions - Juvenile idiopathic arthritis
