Muskuloskeletal Flashcards
Developmental considerations for kids
- reach skeletal maturity (ossification) by 17Y in males, 2Y after menarche in F
- epiphysis/epiphyseal plate fine unless fracture occurs on plate–may not grow to normal length
- porous bone–incomplete bone break may occur in kids
- thicker periosteum
Casts
Rigid device that immobilizes the affected body part while allowing other body parts to move
- made of plaster, fiberglass often, polyester-cotton
- used for arm, leg, brace, body
NC for patient in cast
- handle cast with palms if wet
- turn cast every 2 hours until dry; can take 24-48h if plaster, fiberglass w/i minutes; don’t use heat or dryers
- don’t give ibuprofen bc can impede bone healing but may need other pain meds incl narcotics and NSAIDs
- ice over cast can help with itch and dec swelling
- elevate extremity
- infx in cast will be warm to touch–can drill a small hole and look
- watch for skin b/d—edges can get pokey—may need to put moleskin there
- don’t stick things down to itch besides fingers to test tightness
- good assessment—5 Ps—pain, pallor, pulse, paralysis, paresthesia
- exercise non-affected side
- isometric exercises for affected side—prevent foot drop by keeping foot at 90 degree angle and having them lay on stomach
- good diet, lots of fluids
- assess tightness of cast
Potential complications of cast
- keep heel off mattress
- feel for hot spots, tingling of skin by pt (cast might be too tight)
- notify MD at once of wound drainage
- skin b/d—petal edges
- watch pressure areas esp (elbow, knee, ankle)
NC for cast removal
- loud noise of cutter may be scary
- cast cutter works by vibration so it won’t cut the child
- explain procedures, demonstrate on yourself, provide distraction, provide headphones, restrain child as needed, reward child after
Traction
Application of a pulling force to the body to provide reduction, alignment, and rest at that site
- includes skin, skeletal, and manual traction
- used to get bones back in place
NC for traction
- maintain correct balance btwn traction pull and counter traction force
- care of weights–make sure correct ones are not ordered
- make sure feet are not at end of bed
- skin inspection
- pin care
- assessment of neurovascular status
Assessment for traction
Temperature—extremity and infection
Ropes hang freely
Alignment
Circulation check (5 Ps)
Type and location of fracture
Inc fluid intake
Overhead trapeze
No weights on bed or floor
5 Ps of circulatory check
Pain, pulse–use cap refill if cast covers pulse, paresthesia, paralysis, pallor
Developmental dysplasia of the Hip (DDH)
- spectrum of disorders related to abnormal development of the hip
- caused by lag in development or the way the baby lays in utero
Risk factors for DDH
- breech birth
- big baby
- female
- C/S
- twin
- swaddled with legs out
- positive FH
Dysplasia
Ball is slightly out of socket; least severe
Dislocated DDH
Ball is completely out of the socket at rest
Subluxation DDH
In resting position, the ball is not located normally in the socket; rests partway out of socket
CM for DDH (infant and older child)
- Infant—asymmetry of gluteal or thigh fold, limited abduction, affected leg looks longer, Galleazzi sign (short femur), ortolani test (hip click during rotation)
- Walking child—Positive Trendelenburg sign (when standing on one leg, hip drop occurs in the leg that you are standing on), waddling gait or limp
DDH tx by age
- early identification and tx (before 6M)
- positioning the hip in flex, abducted positions to deepen the hip socket
- 0-6M—Pavlik harness (not thick diapering)
- 6-18M—preop skin traction (3W)—Buck or Russell, closed or open reduction under general anesthesia, hip spica cast (2-4M until hip stable)
- Older child—surgical reduction—osteotomy of acetabulum
DDH NC
- always put undershirt on child under chest straps and put knee socks under feet and leg straps
- check skin for redness 2-3x/day
- gently massage skin under straps daily to increase circulation
- avoid lotions and powder
- teach how to hold child with harness on
Congenital clubfoot
Talipes equinovarus; true bone deformity and malposition with soft tissue contracture (can’t be manipulated straight unlike many newborns)
Positional clubfoot
Occurs from intrauterine crowding and responds to simple stretching and casting
Syndromic clubfoot
Assoc with other congenital abnormalities and often resistant to treatment
Congenital clubfoot tx
true/idiopathic clubfoot which usually required surgical correction
Therapeutic management of congenital clubfoot
- serial casting–gradual manipulation where a new cast is put on every 1-1.5 weeks for 8-12W and feet are gradually stretched; surgical, outpatient, can leave when pt wakes up and eats
- Surgery with pins and lasts 2-3M if serial casting doesn’t work
- child will wear splint or brace to maintain correction
NC for congenital clubfoot tx
- potential for injury r/t cast (N/V impairment)
- assess 5 Ps; apply ice for swelling and elevate cast
- risk of altered family process
Osteogenesis imperfecta
Brittle bone disease; inherited disease of connective tissue (abnormal pre-collagen but normal calcium and phosphorous)
- infants can be born with fractures
- conn tissue and bone defects
OI CM
- weak bones
- bone fragility–break over 100 bones in life
- poor growth
- bruising and recurrent epistaxis
- blue sclerae
- pre-senile hearing loss (20-30Y)
- thin skin bc thin collagen
- excess diaphoresis and teeth discoloration
- mild hyperpyrexia
- normal intelligence
- fewer fractures in adolescence
Osteogenesis imperfecta therapeutic management
- lightweight braces & splints to straighten bones
- simple exercise and/or P.T. (swimming, non-contact)
- surgery to correct deformity or rod to stabilize bone
- Pamidronate disodium (IV) – aids bone healing and slows bone
resorption (calcium regulator); Calcitonin; Biphosphonates
OI NC
Careful handling to prevent fractures (don’t pull on them, BP cuff can break)
* teaching r/t limitations and activity for optimal G&D
* Family support
* OI Foundation
* OT
* Genetic Counseling
Legg-Calve-Perthes Disease and sx
self-limiting aseptic necrosis of the femoral head; head loses circulation and becomes necrotic, grows back flat, causing deformity
- limp or pain esp at middle or end of day
- + T sign
- hx trauma
- dec joint ROM
LCP tx
- Keep the head of the femur (abduction) contained in the acetabulum to preserve its spherical shape & prevent flattening
- Initial non-weight-bearing period to dec inflammation and restore motion (deformity occurs early in the disease)
- Containment devices (head of femur in acetabulum)
- Weight-bearing and non-weight-bearing devices (e.g., abduction, brace, leg cast, Bucks traction- to stretch tight adductor muscles)
- Surgical reconstruction and containment
- ROM - P.T
LCP NC
- educate
- diversional activities
- encourage return to school
- pt adhere to tx
Scoliosis
Complex spinal deformity (lateral, spinal rotation, thoracic kyphosis)
Functional scoliosis
Occur from something happening to it like uneven leg legnth
Structural scoliosis
true scoliosis; nothing causing it to be shaped a certain way
Scoliosis CM
- nonpainful lateral curve of spine
- asymmetry of hips and shoulders
- unequal scapula
- unequal rib prominences
- asymmetry of ab skinfolds
Scoliosis assessment
Bend over and touch toes and see curve of spine; screen during well-child exam
Scoliosis tx
- MILD (<20 degree curve): observation, eval q 3-12
months - MODERATE (20-40 degree curve): bracing until cessation of bone growth.
- SEVERE (> 40 degree curve): surgical spinal fusion with instrumentation (Harrington or Luque rod; Dwyer cable)
Milwaukee brace
Pushes hips down and apply pressure around neck; rarely used
Boston brace
Can be camoed under clothes some, can be very hard on self-image
Scoliosis NC
- self-image for brace
- adherence is big problem
- need to wear for 23h/day
Scoliosis NC pre-op
- may be hospitalized for halo traction before surg (makes spine straighter)
- lots of xrays and lab work
- teaching on log roll, PCA pump, IS use
- delayed for acne on back
Scoliosis NC post-op
- monitor VS (esp watch for hypoT), wound assess on back, circ, 5 Ps
- often in hospital 5-7 days after
- IS q2
- keep flat for day
- pain relief (PCA)
- many post-op complications like spinal/neuro injury, SIADH, atelectasis, pneumothorax, ileus
- start PT early
- take ownership of care
Juvenile Idiopathic arthritis (formerly juv rheumatoid arthritis)
Chronic inflam of synovial fluid
Systemic JIA
fever, rash, pericarditis/other organs are affected
Pauciarticular JIA
affects under 5 joints, can lead to blindness (uveitis) so need check ups q6M
Polyarticular JIA
affects at least 5 joints; spinal and hip involvement (crippling)
CM of JIA
- spiking fever
- skin rash
- pericarditis
- morning stiffness–hallmark sign
- swelling of joint
- warm joints
- joint pain
- malaise
- anorexia
- wt loss
- loss of motion
- eye probs
Management of JIA
Goals:
- get inflammation under control and then ROM with heat & exercise (a.m.)
swim, play (need to wiggle; lie prone watching TV)
- prevent deformity – PT & OT; ROM
- relieve symptoms (pain) – NSAIDs (Ibuprofen; Naprosyn)
Severe: methotrexate
Corticosteroids short term; many S/E
Around the clock pain meds work well so pain stays under control
Drugs for JIA
- NSAIDs (ibuprofen and Naprosyn)
- Methotrexate for severe cases
- Corticosteroids for short-term (many SE)
- ATC work well
- Biologic modifier–monthly injection, affect things at the genetic level
JIA NC
- pain, impaired mobility
- warm bath to loosen joints
- good nutrition to avoid extra wt on joints
- exercise to relieve stiffness
Osteomyelitis
Infx of bones caused by staph or hemophilus flu; endogenous or exogenous cause
Patho of osteomyelitis
- bacterial infection carried to bone (spreads laterally)
- abscess formation & local bone destruction dead bone forms sequestrum (necrotic)
- bone may become honeycombed with sinuses that retain infective material
- chronic site for exacerbations
Most common bones in osteomyelitis
femur and tibia
Osteomyelitis CM
- child appears very ill
- abrupt bone pain (tenderness, edema, erythema)
- unwilling to move limb or bear weight
- fever
- irritability
- malaise – will not feel like participating in age-appropriate activities
- poor appetite
Therapeutic management of osteomyelitis
- IV abx for 3-4W, then orally
- Penicillin G, methicillin, oxacilllin
- heat
- bedrest
- surgical I&D of abscess (sequestrectomy)
Complications of osteomyelitis
Pathologic fractures and chronic osteomyelitis
NC for osteomyelitis
- supportive (high risk for injury r/t NV
impairment) - pain management
- maintenance of IV access (PICC line)
- cast care (sometimes used for immobilization when kids won’t stop walking)
- nutrition: high calorie drinks & protein for tissue
- repair and to prevent negative N balance
- diversional activity: quiet play on bedrest
Where should weight be placed on crutches?
the hands
