Musculoskeletal/Neuromuscular Flashcards
What is developmental hip dysplasia?
A abnormality of the hip joint associated with hip dislocation
Causes of hip dysplasia?
Idiopathic - no known cause
Teratologic - genetic abnormality
Breech position
What birthing position can cause hip dysplasia?
Breech position due to the legs being first.
- 17-23% of cases
Swaddling technique to prevent hip dysplasia?
Hips in slight flexion and abducted
Types of Hip dysplasia
Acetabular
Subluxation
Dislocation
Acetabular Dysplasia
Mildest form of hip dysplasia. The ball is in the socket, but doesn’t fit right. Not an actual dislocation
Subluxation Dysplasia
Most common form of hip dysplasia.
An incomplete dislocation due to stretched capsule and round ligament
Dislocation Dysplasia
The femoral ball in not in contact with the acetabulum so completely disclocted
What is the optimal age for diagnosis of hip dysplasia
Newborn age
Four signs of hip dysplasia
Limited hip movement
Shorter leg
Ortoloni test positive
Asymmetrical gluteal/thick folds
Diagnostic tests done for hip dysplasia in older kids?
Ultrasound for young infants (not newborn)
Xray for infant or child
When assessing for hip dysplasia, what is important?
Someone who is well trained needs to be doing the assessments and diagnostic as to not make the hip function worse
How is treatment picked for hip dysplasia?
Based off severity but also age of the client
0-6 months old Hip dysplasia treatment
Pavlik Harness to prevent adduction from 3-5 months
Hip Spica for 3-6 months
6-18 months old Hip dysplasia treatment
Closed or open reduction + casting
18 months + older children Hip dysplasia treatment
Surgical correction followed by casting
- the older the kid, the more need for surgery
Who is allowed to adjust the Pavlik harness straps?
teachings?
Professionals only. Parents should be educated on how they work, but professional need to size the straps correctly.
How to change diapers
What should be monitored with skin when using Pavlik harness? Can anything go underneath the straps?
Skin integrity due to the straps rubbing and putting pressure
Clothing can go underneath straps but parents should be educated that this may make the child have unwanted attention
Assessment done after putting on a spica cast ?
Teachings?
Make sure the child can breath properly
Teach tricks to change diapers
Why do we need to explain to parents that follow up for hip dysplasia treatment is SO important?
Follow up is important for sizing purposes of the devices. Infants grow extremely fast so serial appts may be needed
Things to check for child with hip spica cast on?
Distal pulses
Sensation
Movement
How can we alter the spica cast to protect the skin?
Petal the edges
Overall education for parents when dealing with spica cast?
Cast and skin integrity/hygiene are important.
Frequent follow up appts are likely.
Want to make sure child doesn’t put any sharp objects down the cast
What is congenital Clubbed foot?
Talipes Equinovarus or when there is malpositioning of foot that involves the bones
How is clubbed foot diagnossed?
Visual assessment on someone who is already born
Could be seen on ultrasound though if baby is in utero
Treatment for mild clubbed foot
Exercise manipulation
- if alignment is not achieved by 3 months, will need surgery.
Treatment for more severe clubbed foot
1) Serial casting in the 8-12 weeks old range
2) Followed up with heel-cord tenotomy
3) And lastly leg cast for 3 weeks
What are Denis Brown splints?
Splints with shoes attacked that some people with clubbed foot may need after surgery or exercise manipulation to keep the legs aligned
What is Legg Calve Perthes disease?
What age?
Idiopathic necrosis of the femoral head of children aged 2-12 (avg is 6)
How many stages are there of Legg Calve Perthes?
Four
Stage 1 of Legg Calve Perthes
Flattening of the upper surface of femoral head 6-12 months
Stage 2 of Legg Calve Perthes
Revascularization of femoral head that has
Stage 3 of Legg Calve Perthes
New bone starts to repair itself
- could go on for years
Stage 4 of Legg Calce Perthes
The new femoral head is reformed
- could go on for years
Signs of Legg Calve Perthes
Limping in the morning or at night
Pain from hip to the knee
Stiffness
Limited ROM
Diagnostic testing for Legg Calve Perthes?
MRI
Xray
Treatment goal of Legg Calve Perthes
Keep head of the femur in the acetabulum
Keep head rounded
Decrease irritability
Restore ROM
What type of of activity can kids with Legg Calve Perthes do?
They need to be resting and doing non-weight bearing activity. So things like ROM exercises are good.
What is a conservative treatment of Legg Calve Perthes like?
Abduction casts/brace
- could take 2-4 years to see results
What is an aggressive treatment of Legg Calve Perthes like?
Surgical approach and can get back to normal stuff maybe 3 months later
- this one is more likely due to the lesser amount of time needed for results
Developmental concerns for Legg Calve Perthes?
You want the child to be able to fit in and remain active.
Things the nurse will have to take care of after surgical construction with Legg Calve Perthes? Assessments done too?
Care of the cast, wound, and drains (and teach how to do this with patients)
Neuromuscular assessment
Pain management
What is the disorder of Slipped Femoral Capital Epiphysis called?
When the proximal epiphyses spontaneously becomes displaced and so there is a widened growth plate and irregular metaphysis
When does the slipped femoral capital epiphysis usually occur?
Usually occurs during puberty or growth spurt
- boys 13, girls 12
What can slipped femoral capital epiphysis be associated with?
Endocrine issues
Radiation issues from therapy that the child may have had to have done
What type of kids usually have the slipped femoral capital epiphysis?
Can this happen to both hips?
Boys
Obese kids
Yes it can. 60% actually
Signs and symptoms of slipped femoral capital epiphysis
Gradual disability of the hip to where you can’t internally rotate or move it out and you’ll limp
There will also be pain that may come and go
How will they diagnose slipped femoral capital epiphysis?
Xray
Activity level for kid with slipped femoral capital epiphysis?
How might they take pressure off and stretch the joint before surgery?
Non-weight bearing
Traction done pre-operatively
What is surgery like for a slipped femoral epiphysis?
What will post-op conditions of activity be like?
Pin/screw placement and osteotomy for shape correction
Non-weight bearing activities and will have to use crutches until painless ROM can be achieved
What is idiopathic scoliosis
Lateral curve in the spine
When/who does scoliosis occur in
Those going through puberty
And those with neuromuscular disorders
When does scoliosis screening start
Around 10-12 in girls
13-14 boys
puberty
How might clothes fit in scolioisis
uneven fit especially of the bottoms
What will a scoliosis back look like
Uneven scapula , shoulder higher, and hip height is off
What will scoliosis back look like when a child bends over?
The torso is asymmetrical along with the flank and ribs
What does scoliosis do to other body systems?
The pulmonary and cardiovascular systems will be compromised
How id scoliosis diagnosed?
Xray
Risser scale - bone maturity
Cobb technique - degree of curve
Risser scale
Bone maturity test used for those who have scoliosis
Cobb technique
When is treatment done for scoliosis of these levels?
For scoliosis but determine curve degree
- if less than 10% , it is just a variation
- if between 10-25% it is mild
Treatment is only done if these ^^^ numbers can progress (with bracing and exercise or surgery)_
Torso brace for scoliosis
Slows progression of scoliosis but will still need exercise
Scoliosis surgery purpose?
And what is it like?
Can be anterior or posterior but done in order to straighten the torso
can be long and painful due to the stretching of the ligaments and tendons
Due to bleeding, what should the nurse do before scoliosis surgery?
What can nurse educate on before surgery?
Anticipate needing type and cross transfusion of blood bc bleeding with spinal surgery tends to be a lot
Developmental/skin issues of bracing. Kid may have a hard time growing up due to the brace and social life.
Skin cleaning and integrity is important
What assessments need be done after scoliosis surgery
Neurological and neurovascular due to proximity of spinal cord
And for fluid volume issues rt blood loss
How is a nurse supposed to turn a patient with spinal surgery of scoliosis?
Tube management?
Log rolling technique and they made need help doing this
Pt on tubes bc they may not be able to breath very well.. but just depends. Manage them
What is Muscular Dystrophy
Which is most prevalent?
Gradual and progressive degeneration of muscle fibers that results in a progressive weakness
Duchene’s Muscular Dystrophy
How is Duchene’s passed on?
It is x linked recessive meaning mom’s are the only ones to carry it on but the boys are affected most of the time
(does this mean the girl will never be affected but just a carrier?)
How does duchene’s progress?
The progressive weakness isn’t noticeable at first. First two years things are going as they should. Onset is 3-5 years of age with trouble walking and mild mental delays
- 20 iq points lower
The likely posture with duchennes?
What happens to the muscle?
1) Sway back or Lordosis in order to help compensate for weak core
2) Quads hypertrophy with fat - not muscle. Calf muscles will be made up of fat too and you see tip toe walking
Child with duchene’s has to walk up their legs with hands to stand up. What sign is this?
Gowers sign
What age will those with duchene’s lose their ambulation ability?
Can they die?
1) 9-11 years old
- so they will need a wheelchair or another assistive device
Yes they can die due to cardiac and pulmonary muscles not working in teen years
- use incentive spirometer to help track their breathing though
Diagnosis for Duchenes
1) Clinical manifestations are key
2) Blood Polymerase chain reaction for dystrophin gene mutation
How can ambulation be prolonged with duchennes?
Corticosteroids in order to prolong function as long as possible.
How to prevent contractures in Duchenes ?
Since contractions are common, we try to prevent this as much as possible do muscle stretching/ROM exercises.
Main focus of nursing care for Duchenes?
1) Focus on keeping functioning as long as possible by helping with ADL’s
2) Second is avoid contractures
Should we use tracheostomy care for patients with Duchennes?
Controversial. It can increase risks to pulmonary functioning and patency issues and make swallowing hard. Also have to consider with nursing care:
- secretions
- stoma care
- humidification
First symptoms parents notice that are usually noted with Duchenes?
Hard time learning how to run or ride a bike due to the weakness
What is it important to do for patients with Duchenes as far as emotional support?
1) The child may have a hard time developing as they age around other peers
2) Anticipatory grieving for patient is important bc the life expectancy is shorter
3) Help family cope and help them put together end of life care
What is Cerebral Palsy?
Disorder of posture and movement from static brain injury
- perinatally or postnatally
Possible causes of Cerebral Palsy prenatally?
Birth asphyxia
Prenatal brain abnormalities
Maternal and perinatal infections
Possible causes of Cerebral Palsy postnatally?
Infections ... meningitis Intracerebral hemorrhage MVAs Child abuse Falls
Main types of Cerebral Palsy?
Spastic (Pyramidal)
Dyskinetic (Non-spastic Extrapyramidal) but this has 2 types as well
Apastic
Describe Spastic Cerebral Palsy
Scissoring and in toeing with hypertonicity with poor control of posture and movement
Very prone to contractures as well
How many subtypes of Dyskinetic Cerebral palsy are there?
Athletoid - choria extremities , trunk, neck, facial muscle, tongue OR just an abnormal movement that can’t be controlled
Dystonic - slow, twisting trunk and extremities w abnormal posture that may involve the oral muscles and cause drooling and dysarthria (causes uncontrolled noises)
These 3 really affect the muscle fibers
Athletoid DYSKINETIC cerebral palsy
Athetoid - choria extremities , trunk, neck, facial muscle, tongue OR just an abnormal movement that can’t be controlled
Dystonic DYSKINETIC cerebral palsy
Dystonic - slow, twisting trunk and extremities w abnormal posture that may involve the oral muscles and cause drooling and dysarthria (causes uncontrolled noises)
Describe Aspastic cerebral palsy
Aspastic - wide gait with lack of balance or equilibrium. slurred speech. Hypotonicity of muscles
Disintegration of movements of upper extremities when reaches object
Neuro exam results for cerebral palsy that often occur?
Persistent Moro reflex and asymmetrical tonic neck (fencing)
What is development like in children with cerebral pasly?
May not be hitting the motor milestones
May have trouble speaking
- speech consult
May also be having seizures (40% do)
- make sure to do seizure prevention
Which cerebral palsy needs hearing screening?
Athetoid
Treatment goal for cerebral palsy?
Early recognition and promotion of optimal functioning
How do we address education of those with cerebral palsy?
Mainstream education and fostering communication with teachers
Why are immunizations important for people with cerebral palsy?
To protect against respiratory tract infections
How will cerebral palsy patients get feedings if they can’t feed normally?
Through regular gastrostomy feedings in order to make sure they gain/keep weight but also maybe for medications
Meds for muscle relaxation?
Dantrolene
- but be aware of hepatoxicity
Botox injected into muscle group to relax them
- must be scheduled periodically
Baclofen
- do test dose first with intrathecal pump
- then do the catheter
Baclofen side effects
Antidote?
Baclofen
- do test dose first with intrathecal pump
- then do the catheter
Side effects:
hypotonia, somnolence, seizure
Antidote is Physostigmine
Procedure for cerebral palsy to release contractures?
Tenotomy
What is tendon lengthening ?
For cerebral palsy but you go in and release bones and tendons from one another
Post op concerns with tendon lengthening and contraction release for cerebral palsy?
Blood loss and fluids
Neurovascular checks
Pain management
Cast/skin care
Osteogenesis Imperfecta is what?
Osteoporosis syndrome where a genetic error causes faulty bone mineralization which leads to more fractures
How many types Of Osteogenesis imperfecta are there?
How is passed on?
4 types ; type 1 is most common and least fatal
Autosomal dominant
Type 1 of Osteogenesis Imperfecta
The most normal one with fracture incidence that tend to go away after puberty. Eyes may be blue and hearing impairment could be present.
Type 1 of Osteogenesis goals?
Prevent contractures, deformities, muscle weakness, malalignment, and osteoporosis
Nursing care is mean to prevent what in Osteogenesis?
Fractures from occurring and so we have to educate parents on this.
- position child carefully
- monitor their physical activity
What do we have to educate parents of Osteogenesis patients about?
Genetic counseling may be wanted for future
Often gets mistaken as child abuse
Developmental issues may arise
Med for Osteogenesis that can increase bone density and decrease pain by inhibiting bone reabsorption to reduce amount of fractures
Other med that can be used?
Biphosphantes Pamidronate IV
PO Alendronate
