Musculoskeletal Disorders Flashcards by Kelsey Klipfel

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

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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

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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

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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

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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

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Not in equilibrium
Not have normal G&D
Cannot expect to have normal G&D

G&D

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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?

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Also worried about infection
Protruding bone/surgery
Hot spot - red flag something going on with cast
Manifestations
Nursing actions
Education

Osteomyelitis

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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

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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

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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

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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

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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

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Red flags - compartment syndrome/osteomyelitis
Itchy

Cast care at home - Casting for fractures

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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

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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

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

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Musculoskeletal Disorders Flashcards

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