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Pedi Exam #2 > Musculoskeletal Disorders - Pediatrics > Flashcards

Musculoskeletal Disorders - Pediatrics Flashcards

1
Q

Differences in Pediatric A+P

A
  • Neural tube of embryo begins differentiation into brain and spinal cord at 3-4 weeks gestation
  • Premature infants CNS is less mature – HR for CNS insult within neonatal period – motor skill delay or CP
  • Cervical spine of infant more mobile vs adult – HR for cervical spine injury
  • Myelinization of CNS complete approx. 2 yo
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2
Q

Assessment of the Pediatric
Musculoskeletal System: History

A
  • Pregnancy/Birth hx: breech HR for hip dysplasia
  • Family hx: neuromuscular d/o’s
  • Pmhx: DD, FTT
  • Attainment of milestones ie rolling, sitting, walking, has pace of development remained consistent
  • HPI: changes in gait, falls, limp, recent trauma, recent strenuous exercise, sports, protective gear, poor feeding, lethargy, fever, weakness, alteration in muscle tone, areas of redness or swelling
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3
Q

Assessment of the Pediatric Musculoskeletal System:
Physical Exam

A
  • General: observe - playing, crawling or walking, posture, use of extremities is it symmetrical, obvious deformities, limb length discrepancy, ecchymosis, edema, active ROM, scoliosis screening
  • symmetry of thigh folds, spine for dimpling, tufts of hair
  • Motor function: observe – spontaneous activity, balance, resting posture
  • Reflexes: Note persistence of primitive reflexes, observe for development of protective reflexes
  • Sensory Function: response to light touch or pain
  • Palpation:
  • Assess muscle strength and tone
  • Neck tone
  • Always assess pulse distal to an injury
  • ROM of joints – clicking / popping
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4
Q

Pediatric Congenital and Developmental
Disorders: Neural Tube Defects

A
  • majority of congenital anomalies of CNS
  • neural tube closes 3-4 weeks gestation
  • cause UK : drugs, malnutrition, chemicals, and genetics can hinder normal development
  • preconception folic acid supplementation may decrease risk
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5
Q

meningocele

A
  • less serious form of spina bifida cystica
  • meninges herniate thru defect in vertebrae
  • spinal cord usually normal and no assoc neuro deficits

rx: surgical correction

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6
Q

Myelomeningocele

A
  • most severe form of neural tube defect
  • 1 in 4000 births
  • Type of spina bifida cysica
  • newborn at increased risk of meningitis, hypoxia and hemorrhage
  • spinal cord often ends at level of defect – absent motor and sensory function beyond that point
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7
Q

Myelomeningocele:
Long term complications

A
  • paralysis, orthopedic deformities, bladder and bowel incontinence, 80% hydrocephalus
  • Multiple surgical procedures
  • Latex allergy common
  • Learning problems may occur, many have normal intelligence
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8
Q

Myelomeningocele:
Physical Exam

A

assess sac, neuro status – movement of LE’s, anal reflex, DTRs, response to touch / pain, club feet, constant dribbling of urine

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9
Q

Myelomeningocele:
Nursing Management

A
  • Prevent infection: prone or side lying position, warmer, free of feces/urine
  • Promote Urinary Elimination: level of lesion influences amount of dysfunction, Urologist Eval
  • Promote Bowel Elimination: may have incontinence, bowel training – same time every day, suppositories, diet modifications
  • Promote Parent/child bonding: may not be able to hold baby pre and post op for a period of time
  • Preventing Latex Allergy Reaction: latex free environment, medical alert bracelet
  • Maintain Skin Integrity: prone position/impaired mobility
  • Educating Family and Support: teaching positioning, feeding, preventing infection, urinary elimination – straight cath, latex allergy, S+S of IICP, chronic condition – long term planning to care for child
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10
Q

Pectus Excavatum

A
  • A depression that sinks inward is apparent at the xiphoid process
  • Progresses as child grows
  • Depending on severity: respiratory and cardiac compression can occur
  • Most often present during puberty
  • Treatment: depends on severity: observation, PT and/or surgical correction
  • Surgery: post op – risk of pneumothorax, positioning challenging – no twisting/bending of upper torso, PT
  • Bar removed 2-4 years post op
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11
Q

polydactyly

A
  • presence of extra digits
  • 1/3rd of the time - bilateral
  • typically involves digits at the border
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12
Q

syndactyly

A
  • webbing of the digits
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13
Q

Metatarsus Adductus

A
  • Medial Deviation of forefoot
  • Result of in utero positioning
  • 50% cases are bilateral
  • Treatment depends on flexibility of forefoot: observation vs stretching exercises vs serial casting
  • before age 8mos vs surgery is rare
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14
Q

Congenital Clubfoot (congenital talipes
equinovarus) consists of:

A
  • Talipes varus (heel inversion)
  • Talipes equinus (plantarflexion of foot)
  • Cavus (plantarflexion of forefoot on hindfoot)
  • Forefoot adduction with supination (forefoot inverted and turned upward)
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15
Q

Tx: starts shortly after birth (within 1 week)
Non-surgical: Ponseti method – serial casting
*Surgical correction: tendon release, bone realignment; tendon transfer/ then brace for
several years AFOs/corrective shoes
*Nursing: neurovascular assessment, cast care
*brace care; emphasize COMPLIANCE! (Recurrence 90% in 1st year, 80% in 2nd)

A
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16
Q

Congenital Clubfoot (congenital talipes
equinovarus):
Non-surgical

A

Ponseti method – serial casting
*Surgical correction: tendon release, bone realignment; tendon transfer/ then brace for
several years AFOs/corrective shoes
*Nursing: neurovascular assessment, cast care
*brace care; emphasize COMPLIANCE! (Recurrence 90% in 1st year, 80% in 2nd)

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17
Q

Osteogenesis Imperfecta “Brittle Bone disease”

A

*Genetic: too little or poor quality of Type I collagen autosomal dominant, some are
recessive
*Affects bones and connective tissues
*Eight types of OI varying in symptoms and severity (p. 1615)
*Bone fractures very early, frequently during birth
*Other s/sx: short stature, muscle weakness, bone deformities, scoliosis, acute and
chronic pain, hearing loss, discolored teeth, resp problems
*Treatment: Decrease fractures, maintain mobility
◦ Biphosphonate administration
*Manage symptoms; PT, OT

18
Q

Osteogenesis Imperfecta “Brittle Bone disease”

A
  • avoid automatic bp/tourniquets
  • careful handling/repositining
  • never push/pull
  • do not bend limbs
  • do not lift babys legs by ankles
  • do not lift small child by armpits
19
Q

Developmental Dysplasia of the Hip

A
  • Abnormalities of developing hip include:
  • dislocation
  • subluxation
  • dysplasia of hip joint
  • Genetics play a role
  • Mechanical factors play a role: breech / oligohydramnios

Usually discovered in newborn exam (older children will limp)
*Assess: skin folds of thigh; buttocks knee height
*Ortolani sign (abduction – reduction of femoral head)
*Barlow’s test (adduction – femoral head dislocates)
*Both should be negative by 3 mos
*Limited abduction, leg length discrepancy
*Older children may have a Tredenlenburg gait
*Early treatment goal keep hip in reduction
*< 6 mos: Non-surgical bracing
*90% success; Pavlik harness full time 6-12 weeks
*6-24 mos: Surgical Closed reduction (no incision)/ spica cast 12 weeks post then abduction brace full time
*> 2 y: Surgical Open reduction/osteotomy – then casting

20
Q

Developmental Dysplasia of the Hip: Complications

A
  • Complications: avascular necrosis of femoral head, loss of
  • ROM, unstable hip, femoral nerve palsy, leg length
  • discrepancy, early osteoarthritis
21
Q

Developmental Dysplasia of the Hip: Nursing

A

Harness & cast care: Early Recognition is key!
*Skin (redness? Irritation? Breakdown?)
*Post-op pain, bleeding
*Toileting, movement, transportation
*Feeding / positioning
*Development
*Education to families on care Table 22.4 for care with Pavlik Harness

22
Q

Torticoliis

A
  • Painless muscular condition
  • Sternocleidomastoid muscle tight
  • All age groups
  • Infants: congenital torticollis from positioning in utero
  • Preferential positioning of head to one side while supine may also cause it
23
Q

Torticollis: Complications

A

plagiocephaly

24
Q

Torticollis: Treatment

A
  • PT
  • Educate parents on passive stretching exercises
  • Educate parents to vary childs head position
25
Q

Tibia Vara (Blount Disease)

A

** Developmental Disorder**
* infantile: 1-3 years
* juvenile: 4-10 years
* adolescent: 11years and older
* Infantile most common
* Normal bowing becomes more pronounced
* Cause UK

  • Occurs most commonly in early walkers and obesity
  • Common: African – American females / both extremities affected
  • Stop progression of disease thru bracing or surgical treatment
  • Treatment early before 4 yo
  • Complications: if untreated, growth plate of tibia ceases bone production
  • Asymmetric growth at knee occurs
  • Long term complication: Degenerative arthritis
26
Q

Muscular Dystrophy

A
  • Inherited
  • Progressive muscle wasting and weakness
  • Duchenne MD the most common type of childhood
  • 1 in 3600 male live births (X-linked recessive)
  • As disease progresses all voluntary muscles as well as cardiac and respiratory muscles are affected
  • Late to walk
  • Toddlers may display pseudohypertrophy of the calves (enlarged)
  • Preschool fall often and quite clumsy
  • Difficulty climbing stairs, running and getting up from floor
  • School age walks on toes or balls of feet / waddling or rolling gait/ difficult to raise arms
  • Balance poor
  • Belly may stick out to hold oneself upright
  • Between 7 – 12yo lost ability to ambulate /teen years movement of extremities and trunk
  • Intellect: Usually some LD
27
Q

Muscular
Dystrophy:
Treatment

A
  • No cure
  • Corticosteroids – slows progression
  • SEs of long term steroid use
  • Calcium and Vitamin D
  • Braces
  • Supportive care
28
Q

Cerebral Palsy

A
  • Range of nonspecific clinical symptoms
  • 2 in 1000 live births
  • Causes:
  • Prenatal / Perinatal / Postnatal (Box 22.1)
  • Symptoms in infancy or early childhood: Wide Range:
  • slight limp to severe motor/neurologic impairments
  • Primary signs: motor impairments ie spasticity, muscle
  • weakness and ataxia
29
Q

Cerebral Palsy:
Complications

A

mental, vision or hearing impairments, seizures, growth
problems, abnormal sensation or perception and hydrocephalus

30
Q

Cerebral Palsy:
Pathophysiology

A
  • Damage to motor areas in the brain result in a neurologic lesion,
  • disrupts brains ability to control movement and posture
  • Nonprogressive, lesion does not progress
31
Q

Cerebral Palsy:
Management

A
  • Multidisciplinary Team approach
  • Gain optimal development and function
32
Q

Cerebral Palsy:
Nursing Management

A
  • Promote mobility
  • Promote nutrition
  • Provide support and education
33
Q

Rickets

A
  • softening or weakening of the bones
  • childhood rickets: nutritiona defeciencies - calcium or vitamin D or exposure to sunlight
  • chronic renal disease - cannot regulate calcium/phosphorus
  • prematurity
  • treatment: correct the imbalance of calcium and phosphorus, vitamin D supplements
  • correct early to prevent skeletal and growth deformities
34
Q

Slipped Capital Femoral Epiphysis

A

Head of femur (ball) dislocates from neck/shaft at the growth plate

Most common hip disorder in adolescents; boys > girls; L>R
* Develops during growth spurts
* If one hip affected, 25% chance of other hip
Sudden pain, limping, turning of leg; limited ROM
IF suspected do not attempt passive ROM to hip
STOP WEIGHT BEARING; prepare for surgery
* Preserve blood supply to femoral head
* Tx: Surgery – secure femur head back into place
* Crutches x 6 weeks;
* Toe -touch weight bearing
* PT
Nursing:
Pre & post-op care
Teaching re: non-weight bearing; crutch use, post-op care

35
Q

Legg – Calve
Perthes Disease

A

*Idiopathic; self-limiting; 1 in 12,000; boys > girls
*Occurs in children usually boys age 4-8y (2-12y); sometimes
bilateral
*Blood supply to head of femur is interrupted
*Bone cells die (Avascular necrosis (AVN)) femoral head
becomes deformed
*Course of disease – approximately 12-36 months
*3 stages:
*Necrosis/bone death
Fracture/Fragmentation/Resorption (loss of shape)
Revascularization/Reossification (risk of fracture)

36
Q

Legg Calves Perthes Disease:
Presenting symptoms

A

painless limp – intermittent over a period of months
mild hip pain possible referred to knee or thigh
pain aggravated by exercise

37
Q

Legg Calves Perthes Disease: Treatment

A

conservative vs. surgical (femoral osteotomy)
*Limited to NO weight bearing
*PT/mobility, NSAIDS, occas bracing/casting or traction
*CONTAINMENT; restore maximum hip movement; prevent arthritis

38
Q

Transient Synovitis of the Hip (toxic
synovitis)

A
  • Symptoms: Hip pain (worse in am) and limp/nonwt bearing, hip held in externally rotated, flexed position
  • Age: 3-8yo
  • Etiology: unclear possible infection past/present, trauma or allergic hypersensitivity
  • Self limiting – a week – 6 weeks
  • Management: NSAIDs, bed rest
39
Q

Osteomyelitis

A

Bacterial infection: infection/inflammation of the bone & surrounding soft tissue
*Through bloodstream (trauma, surgery, foreign body)
*S. aureus, MRSA
S/sx: Pain, redness, swelling, warmth; fever, chills, malaise/fatigue
*Difficulty weight bearing or lifting; limited mobility
Labs: CBC: increased WBC; CRP & ESR elevated; blood cultures
Tx: Antibiotics for 4-8 weeks IV first, then oral
Nursing: Antibiotics, antipyretics, comfort measures; crutches/walker
Teaching re: antibiotics at home; line care (PICC?); infection prevention

40
Q

Fracture

A
  • Growth plate most vulnerable site of fractures in children – higher risk for deformity, why?
  • Heal more rapidly
  • Most common reason in pediatrics: Falls, trauma (accidental)
  • Spiral femur fractures, rib fractures, and humerus fractures, particularly in children under 2yo should be investigated for abuse
41
Q

Nursing Management:
Musculoskeletal Disorders

A
  • maintain adequete neurovascular status
  • promote pain relief
  • prevent infection
  • maintain function and body alignment
  • promote physical ability
  • promote growth and development
  • educate and support families

Pedi Exam #2 (5 decks)

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