Musculoskeletal Dysfunction Flashcards
Frctures
the resistance between bone yielding to applied stress
- break in the bone
What is the most common site of childhood fractures?
distal forearm (radius, ulna, or both)
Children are at high risk for fractures due to
high activity levels
immature bones
- brace themselves
Children have a faster
remodeling/healing
Younger the child the shorter amount of remodeling time
Fractures in infancy are rare and warrant
further investgation
If you wait to go to ER after a break, then what will happen?
the bone will remodel itself and not heal correctly
What fracture can stop the bone from growing and create a more complex treatment?
growth plate fracture
Factors affecting remodeling
age (younger = faster healing)
location (growth plate = complex/stop growing)
degree of deformity (complex to simple crack)
Dx of Fractures
X-ray
If still showing s/s = CT/MRI
What are the different types of fractures?
Plastic Deformation (bend)
Buckle (torus)
Greenstick
Complete
Spiral
Growth Plate
Plastic Deformation
bend
- not a break
- MALLEABLE BONES
Children have malleable bones. To what degree does the bone been but not break?
45 degrees
Buckle fracture
- torus
- pulled/raised in the fx site
Greenstick fracture
broke but not all the way through
Spiral fracture
twisting force
- sports with a plant and twist
- child abuse
Growth plate fracture
Epiphysis - end of the long bone
Assessment of Fx
general swelling
pain/tenderness/numb
deformity
low functional use guarding
Ecchymosis
Rigid muscles/spasms
Crepitus
Why is it important to make a splint for the affected fractured bone?
Muscular rigidity is a s/s of a fracture and will affect/move the bone out of place
Crepitation
bones scraping together with bubbling under the skin
- careful not to cause damage
What is the initial priority nursing actions of a child extremity fracture in order?
- calm/reassure
- Assess the extent (mech of injury)
-
Peripheral neurovascular assessment (6Ps)
~ only move distal (as little as possible) - If compound, then cover with sterile dressing
- Immobilize (sling/immobilizer)
- RICE
~ Elevate/Isolate
~ Apply cold - Cont. monitor neovascular status
- Apply traction if circulatory compromise is present
- Transport to ER
Neurovascular Assessment
Pallor
Pulse
Pain
Poikilothermia - temperature
Parenthesis - numbness (only move phalanges)
Paralysis - no mvmt
If the circulatory compromise is present with the fracture, then apply
traction
T/F: Do not try to reduce or press on the fracture.
True
What are the different types of casting materials?
plaster
synthetic (fiberglass)
Casts are used to
immobilize the bone and joint after fx
- fx of hip/knee requires spica cast
What are the advantages of plaster casts?
- molded closely to body part
- smooth exterior
- cheap
What are the disadvantages of plaster casts?
- take 10-72 hours to dry
- heavy
- not water resistant
What are the advantages of synthetic casts?
- lightweight
- dry quickly (5-20 minutes)
- Can be used with a water-resistant liner
- colors and prints
What are the disadvantages of synthetic casts?
- can not molded close to the body
- rough
- expensive $$$$$$$$
The fracture should be in a splint until
the swelling has gone down
then cast is placed
During the application of casts, what are the developmental considerations for children?
Preschoolers have a fear of body mutilation
- use transition objects
Interactions to calm down
Distractions for cleaning the areas
What is the process of putting on a cast material?
Have abrasions?
If abrasions/altered skin = stocking net for liner
cotton wrap for comfort
casting material
When HCP applies the cast material they will
mold material to limb
- ensuring smooth cast edge
If they are applying a synthetic cast material, what does the HCP need to ensure?
smooth edges with stocking net outside of the edge OR petal the edge with water adhesive tape
- due to the synthetic edge being rough
What should the nurse teach the parent and child considering cast care?
dry inside out
- do not dry with a heat lamp or hair dryer
**Reposition wet cast with palm
Elevate on a soft surface
Ice for pain/swelling w/ barrier to keep dry
Assessments of infection and 6Ps
The cast dries from
inside out
The cast should be repositioned with
palms
- if finger then skin breakdown can occur
S/S of infection in a cast
fever
pain
increase swelling
redness
odor
drainage
HEAT
What are alterations to casts?
Windows
- assess area and hygiene
- surgical site/diaper change
- Spiga Cast
Bivalve
- cut in half to loosen top portion held with ace wrap
- assess the surgical sites or swelling
What should you constantly check for and tell children about cast protocol?
NO objects/toys/food in the cast
Nothing inside to itch
NO moisture (cover with a plastic bag)
- Call HCP if gets wet
The cast is removed with a
cast cutter/saw
What should you do for the atraumatic care of a cast saw?
- the cast is now a part of them if younger
- preschoolers might not use the arm altogether
- call it cast removal tool, tickle, no harm to skin only
Education of Cast removal
- appearance and skin care
skinnier =
muscle atrophy
funky odor with no judgment
dead skin buildup
If they do not slough off then do not peel,
Skin Care = regular baths and will fall off normally
After taking the cast off, what should you do if the skin does not slough off?
let it go normally
DO NOT PEEL!
- Normal showering and cleaning
Education of returning to activity after a cast
minor = full activity to the amount of time inside cast
Ex) 1 month in cast = 1 month till activity
- No football, rollerblading, or bike riding till after
- Not normally PT
What joint mobility exercise after cast material?
stiff is normal due to no usage
muscle and mobility will increase over time
What are the developmental activities used in cast removal?
Traction purpose
CIRCULATORY COMPROMISE
realign bone
immobilize
fatigue muscle to reduce spasms
Skin Traction is applied to
directly to the skin surface and indirectly to the skeletal structures
- pulling force is weights (bandage, boot, sling)
Skeletal Traction is applied to
DIRECTLY INSIDE the distal bone with pins/wires/tongs
Traction type is dependent on:
Fracture
- severity, degree of misplacement, other structures involved (tearing)
- child’s age
Buck Extension/Traction
short term immobilization
leg extended position
boot appliance to traction
Buck Traction is used on these musculoskeletal disorders?
dislocated hips
Legg-Calvé-Perthes
Do not remove the traction without
HCP orders
- only double-check wts with ropes and pulleys in place
Bryant Traction does what
immobilizes both lower extremities
Bryant Traction is used in what musculoskeletal disorders?
fractured femur
developmental dysplasia
of the hip
Bryant Traction flexes the legs at what angles?
90 degrees at the hips ONLY
With Braynt Traction, the butt should be
raised slightly off the bed
What are the different types of skin traction?
Buck and Bryant
Skeletal Traction allows for what compared to skin traction
longer traction time and heavier weights
Skin Traction holds weights less than
25 lbs
Skeletal Traction holds weights
25-45 lbs
Skeletal Traction Types
90-90 Traction
Halo
90-90 Traction is used for
bone realignment with calves in boots/slings
- Hip (butt off the bed) and Knees at 90 degrees
- Steinmann pin or Kirschner wire in the distal fragment of the femur
Monitor for what with pin care of skeletal traction?
increase infection s/s
Halos are used for
displaced/fx vertebrae
Halos are
steel halo attached with four screws into outer skull
- rigid bars connect to vest
Halos allow for
greater mobility of the body while avoiding cervical spinal motion**
With Halos, what are the scheduled assessments?
Neuro
Assessments of Traction devices
6 Ps
Turning if not in 90-90 or Bryants)
- skin integrity (no pressure points, wrinkles)
Body alignment (butt off bed)
Pin sites need to be clean/dry
Position bandages, frames, and splints, boots
Ropes/pulley/weights
Bed Position from HCP
What should be used in tractions to prevent muscle spasms?
analgesic/muscle relaxants
What psychological needs should be addressed for children with traction?
allow for friends and stimulation
siblings do not touch weights
Osteomyelitis
Infection within the bone, usually caused by bacteria introduced by trauma or surgery,
by direct extension from a nearby infection or via the bloodstream
What is the most common bacteria in osteomyelitis?
Staph. aureus
Osteomyelitlis is most commonly seen in
long bones (arm and leg)
Osteomyelitis occurs in children
boys younger than 10
Osteomyelitis assessment
Pain increase with limb use
- guard not use limb
HIGH Fever
- malaise
irritable
erythema (bruising)
decrease mvmt
edema
warmth
Osteomyelitis Dx
Culture
CBC
X-Ray (2-3 weeks till seen)
Bone scan/CT/MRI
Bone bx (last resort with s/s)
What is seen on labs for osteomyelitis/
WBC high
CRP high
ESR high
What are some nursing interventions for osteomyelitis? (assessments, medications, mobility)
6 Ps
IV Antibiotics up to 6 weeks (Central/PICC)
Non-opioid for mild to moderate pain
Opioid for severe pain
Rest/comfort
NWB
Nutrition
Possible surgery for I&D if high labs
Psych needs
If you need to reposition an osteomyelitis pt then
slow and caution infected area
What nutritonal considerations should an osteomyelitis patient eat?
high in protein to help healing
What labs need to be watched for with IV antibiotics for fast, high, and continuous doses?
liver
renal
Legg-Calve-Perthes Disease is the
avascular necrosis of the femoral head
- cause unknown
- blood supply stops to the femoral head and dies
- BUT spontaneously returns and heals
Legg-Calve-Perthes is common in
2-12 y/o
boys 4-8 y/o
Legg-Calve-Perthes is located at the
femoral capital epiphysis
-flattens upper part of head
Legg-Calve-Perthes Assessment
limp
slow pain
joint stiff with limited ROM
Legg-Calve-Perthes Dx
H&P limited
Xray - defect of hip
**MRI - definitive shows osteonecrosis
Legg-Calve-Perthes has what type of onset
slow - don’t know when it happened
Initial Interventions of Legg-Calve-Perthes
rest/activity restrictions
reduce inflammation and irritability of the hip
limited/NWB
- Crutches (wheelchair if too young)
- PT
- Buck’s traction
Parent’s choice on Tx
Legg-Calve-Perthes Conservative Tx
abduction brace, cast, harness sling
lasts 2-4 years
Legg-Calve-Perthes Severe Tx
Surgical reconstruction and containment
hip replacement (3-4 months back to normal)
- might not want surgery due to infection complication
What are the conservative braces put on patients with Legg-Calve-Perthes?
Scottish Rite Orthoses - Frankenstein walk
Spica Cast with Hip Abductor - older
- esp after surgery
Legg-Calve-Perthes Prognosis
self-limiting
Outcome influenced by early tx and age
Possible long-term complications
- older more prone to osteoarthritis
Idiopathic Scoliosis
abnormal lateral curvature of the spine 10 degrees or more
- C or S curve
Scoliosis is more common in
girls
- 2-3% adolescent population
Scoliosis is usually dx during
adolescent growth spurt
Visual Assessment of Scoliosis
One shoulder higher than the other
One shoulder protrudes or higher
One hip higher
Space of the arms from body
Lean to one side
Head not center above the pelvis
What is the dx spinal screening for scoliosis?
Forward Bend Test
Scoliometer
If the scoliometer is greater than _____ degrees tilt then HCP
7 degrees
Dx of Scoliosis includes
Scoliometer - Forward Bend Tilt
Cobb Method
MRI
Cobb Method
angle of the curve of the Xray to determine interventions
MRI for Scoliosis
find spinal abnormalities/compression of the spine from tumor or defect
Postural variation is what degree of scoliosis?
< 10
The mild curve is what degree of scoliosis?
10-25 degrees
The moderate curve is what degree of scoliosis?
25-45 degree
The severe curve is what degree of scoliosis?
> 45
Postural variation interventions
eval at routine well checkups
Xrays until skeletal maturity
Mild Curvature of the spine interventions
observe and HCP evaluation every 3-6 months
Moderate Curvature of the Spine Interventions
Bracing Tx
Corrective forces and release the load
Severe Curvature of the Spine Interventions
surgery recommended, rods and bone grafts to correct curve
Scoliosis Braces are used in
moderate curves
Scoliosis Braces are used for how long per day
16-23 hours
- gradually wean off until night time
What should be under the braces of scoliosis
soft cotton underneath
no lotion/creams to promote skin intergrity
Braces are not a cure but
prevent worsening
Adolescents will usually be ____________ due to scoliosis braces themselves
noncompliant
What are the different types of scoliosis braces?
Boston (low profile and plastic component)
Milwaukee (bulkier)
The boston brace are used in curves in what area
lumbar or thoracic-lumbar area
- low profile
-plastic and customized
Milwaukee Braces are used on what part of the spine
older bulky
HIgher in thoracic or cervical spine
Scoliosis Education
Promotion of positive body image
Skin assessment/care
Compliance (16-23 hours)
PT/exercise (cont exercise and abd muscles for strengthening of cure
For severe curvature what is used for tx
internal fixation surgery (rods, hooks, and wires)
- “growing” rods pull apart so no new surgery
-Lifetime
Goal of scoliosis surgery is to
maximal correct to scoliosis and max mobility
Post-Op Interventions of Scoliosis Surgery
neuro assess
log roll
skin integrity with care
IV hydration and meds
Opioid analgesics for severe and PCA
Assist with amputation (progressive) asap
Develop and Psycho needs
What should you watch for during amputation after scoliosis surgery?
gait
constipation(pain meds)
low BP (opioids)
- sit up slowly
ICS, TCDB, ambulation, BM (if no ileus and pain meds)
Developmental Dysplasia of the Hip (DDH)
abnormal development of the hip that may develop during fetal life, infancy, or childhood; in these disorders, the head of the femur is seated improperly in the acetabulum
- unknown cause
DDH is more common in
1st born
females
family hx
breech delivery
Large birth weight
oligohydramnios
What are the different degrees of DDH
Dysplasia
Subluxation
Dislocation
DDH Assessment when
newborn 8-12 weeks
DDH Assessment as a newborn have which tests
Positive Barlow test
Positive Ortolani test
Barlow Test
adducting the thigh
+ = palpable “clunk” of femoral head dislocating from acetabulum
Ortholani Test
Abducted while lifting leg forward
+ = Palpable “clunk” as dislocated femoral head reduces into the acetabulum
The Barlow and Ortholani test MUST be performed by who
experienced HCP
- if too vigorous in the 1st 2 days of life - persistent dislocation
If the infant is older than 7 weeks of age, what do the results show
no + result even if they have DDH
DDH Infants Assessment
limited abduction of hips
asymmetry of gluteal and thigh folds
+ Galeazzi (Allis) sign
leg length difference
Galeazzi (Allis) sign
shortness of the femur with the hips and knees flexed
laying down
Older Infants and CHildren Assessment of DDH
+ Trendelenburg sign
leg length difference
telescoping mobility joint
Lordosis and waddling gait
Waddling gait from DDH means
bilateral dislocations
Trendelenburg sign
child stands on one foot at a time
- weight is on the affected hip
- pelvis tilts downward on normal side instead of up
Dx of DDH
Physical
Xray (>4months)
Ultrasound (2 weeks - 4 months)
Xray for dx DDH is unreliable if under
4 months old
If the baby is younger than 6 months old what are the treatments for DDH?
Pavlik harness
Pavlik Harness
maintains flexion and abduction of hip
worn cont. (full-time) for 6-12 weeks
Pavlik Harness Education for Parents
fit of harness and skin care
hold infant with harness - development
involve infant in activities with others
The Infant should go to the HCP to adjust the brace and assess progress through Ultrasound every
2-3 weeks
The infant can wear what under the harness?
cotton onesie
- leg warmer socks
The Pavlik harness should be taken off for
bath and check for skin at this time
- no lotions or powders
The infant with a Pavlik harness should get a gentle massage
2-3 x a day
Where does a diaper go on a Pavlik harness?
under
What interventions should happen for a 6-24-month-old infant with DDH?
Bryant’s traction (skin)
- BUTT OFF BED
surgical reduction (open vs. closed)
- reduce hip joint
spica cast (12 weeks)
- after surgery
flexion-abduction brace until fully healed
What interventions should happen for a > 24-month-old infant with DDH?
open reduction
spica cast (after surgery)
flexion-abduction brace (if needed)
At the age of 4 y/o, what is the prognosis of DDH?
surgery is difficult
after 6 impossible due to severe shortening and contracture of the muscle
talipes equinovarus
Clubfoot
Clubfoot
complex deformity of the ankle and foot that may be unilateral or bilateral
Clubfoot risk
increased risk with family history
- no amniotic fluid
more common in boys
Clubfoot Dx at
birth
in prenatal Ultrasounds
Assessment of Clubfoot on the affected foot
pointed downward and inward
may be smaller and shorter
Calf** may appear thinner
may have deep crease on the bottom of foot
What is the non-surgical interventions for Clubfoot
Ponseti method
The Ponseti Method is
serial casting for 6 - 10 weeks (5-6 casts)
weekly gentle manipulation and stretching
Achilles tenotomy, possibly, at the conclusion of serial casting process
the final cast is placed and on for 3 weeks
then removable orthotic device “boots and bar”
3-4 years 23 hours till only at naps and bedtime
In the Ponseti Method, the final cast is placed on the
3 weeks
In the Ponseti Method, the baby will wear the orthotic boot and bar for how long?
3-4 years 23 hours a day till only at sleep times
If the ponseti method is unsuccessful, then
surgery is an option
Juvenile Idiopathic Arthritis
Autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage
unknown cause
Juvenile Idiopathic Arthritis has
no cure tx is supportive
- aggressive and can go into remission
Juvenile Idiopathic Arthritis is more common in
girls
Juvenile Idiopathic Arthritis Assessment in affected joints
Swelling
Stiffness
Pain
Limited ROM
Generalized symptoms of fever, malaise, rash
Periods of exacerbations (flares) and remissions
Uvelitis
What joints are usually affected in Juvenile Idiopathic Arthritis?
large joints
-shoulder and hips
Uveitis
risk IM inflammation and can cause blindness
Juvenile Idiopathic Arthritis is usually dx before
16 y/o
Juvenile Idiopathic Arthritis is dx through tests
no definitive tests
- cont arthritic pain in 1+ joints for > 6 weeks
Repetitive fever up to 103
Rash on legs, arms, and trunk
Elevated ESR
Leukocytosis with exacerbations
Juvenile Idiopathic Arthritis Xrays show
soft tissue edema and joint space widening
- increased synovial fluid in joint
What are the nursing interventions for Juvenile Idiopathic Arthritis?
control pain
- NSAIDs, Methotrexate, Corticosteroids
Preserve joint function and deformity
Normal G&D (peer groups)
What NSAIDs are Rx for Juvenile Idiopathic Arthritis?
naproxen, ibuprofen
-take with food
Methotrexate is used when
NSAIDs fail or in combination with NSAIDs
- liver function test
What corticosteroid type is used for Juvenile Idiopathic Arthritis?
eyedrop strong inflammation
- prevent IM uvelitis
- lowest dose for short amount of time
To preserve joint function in an Juvenile Idiopathic Arthritis the patient should
Maintain normal activities, strength training, PT, pool exercise is great for them (freedom of movement), warm packs/baths for pain and stiffness,
Physiologic Effects of an Immobilized Child
decrease in muscle size, strength, and endurance
bone demineralization leading to osteoporosis
contractures and decreased joint mobility
Psychologic Effects of an Immobilized Child
decreased ability to respond to anxiety status quo
decreased sensory input
feeling of isolation, boredom, helplessness
potential for sluggish intellect & decreased communication – if out of school for a long time
may react with aggression, submission, passiveness, or anger
possible depression related to ability to function or change in body image
What nursing interventions should there be for the immobilized child?
Skin Care, hydration
DVT prevention
Encourage high protein, high-calorie foods
Adequate hydration for opioids
Upright position frequently unless contraindicated
For lungs
Transport outside room when possible
Allow to wear own clothes
Allow to participate in own care
Frequent visits from family and friends
D/C Planning for an Immobile Child
Case management and child life
Home health care - PT and more resources otside
Durable medical supply
Respite care for parents with chronic
Emotional, spiritual, and financial support
A young girl has just injured her ankle at school. In addition to calling the child’s parents, which is an immediate action by the school nurse?
A. Apply ice.
B. Encourage child to assume a position of comfort.
C. Obtain parental permission for administration of acetaminophen or aspirin.
D. Observe for edema and discoloration.
A. Apply ice.
The application of ice can reduce the severity of the injury.
Which is an advantage to using a fiberglass cast instead of a plaster of Paris cast?
A. Dries rapidly
B. Smooth exterior
C. Molds closely to body parts
D. Cost effective
A. Dries rapidly
A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive and have a rough exterior, which may scratch surfaces. Plaster casts mold closer to body parts.
A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the nurse how this will be corrected, the nurse would give which explanation?
A. Children outgrow this condition when they learn to walk.
B. Traction is tried first.
C. Frequent, serial casting is tried first.
D. Surgical intervention is needed.
C. Frequent, serial casting is tried first.
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.)
Select all that apply.
A. Severe pain not relieved by analgesics
B. Inability to move extremity
C. Palpable distal pulse
D. Capillary refill to extremity less than 3 seconds
E. Tingling of extremity
A. Severe pain not relieved by analgesics
B. Inability to move extremity
E. Tingling of extremity
Severe pain not relieved by analgesics Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.
Inability to move extremity Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.
Tingling of extremity Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity less than 3 seconds are expected findings.
