Neuromuscular/MSK Flashcards
Fractures
Rare in children and warrant an investigation to make sure it isn’t the result of abuse
Most common broken bone
Distal forearm
Most often from sports injuries
Common causes of fractures
Increase mobility and desire for freedom but immature motor skills
Trauma or abuse
Bone density
Birth injury (clavicle injury and sometimes that is intentionally done by MD to deliver an abnormally large baby or deliver rapidly one that is in distress)
Types of fractures: Simple or closed
Does not produce a break in the skin
Types of fractures: Open or compound
Fractured bone protrudes through the skin
Types of fractures: Complicated
Bone fragments have damaged other organs or tissues
Types of fractures: Comminuted
Small fragments of bone are broken from fractured shaft and lie in surrounding tissue
Types of fractures: Greenstick
When a bone isn’t broken all the way through, like a twig that you snap and breaks on one end but only bends on the other
Types of fractures: Spiral
Most often occurs in toddlers
Types of fractures: Transverse
break straight through
Types of fractures: Compound
Bones stick through skin
Growth plate (Epiphyseal plate) injury
Weakest point of long bone (cartilage)
Each long bone has 2 growth plates: at each end
Frequent site for damage during trauma. The injury may affect the future bone growth
Growth plate fracture treatment
May include open reduction and internal fixation to prevent growth disturbances
Not always seen on an xray so must get pedi ortho to evaluate
Growth plate Salter Harris classification system
Used to describe the degree of fracture I: transverse II: through and above the plate III: fracture below the plate IV: fracture through metaphysis and epiphysis V: crushing of physis
Fractures: Diagnostic
Radiography (only true way to diagnose) History taking (how it occured)
Fractures: Suspicion of fracture
In young child who refuses to walk or bear weight
Should be evaluated especially if child has specific point of injury, is specific about where and how it happen, and if they hear a crackling sound and if they have the inability to bear weight
Fractures: Manifestation
Pain Tenderness at site (could also be sprain/strain) Decreased ROM Immobility Deformity of extremity Edema Crepitus Ecchymosis Inability to bear weight Muscle spasm
Fractures: Goals
Reduction and immobilization
Restoring function
Preventing deformity
Fractures: Reduction
Repositioning of bones into normal alignment
Reduction can be done open or closed
Fractures: Reduction: Opened
Means needs an invasive procedure or surgery to realign the bone
Fractures: Reduction: Closed
Realigned bone without using an invasive procedure, although the setting of bone may occur w/anesthesia due to pain
Fractures: Retention or immobilization
The application of a device or mechanism to maintain the alignment of the bone until healing occurs, it can be with a cast, traction, plate, pin, or a combination of those
Fractures: Assessment
6Ps Pain Pallor Pulselessness Paresthesia Paralysis Pressure
Fractures: Casts application
Retention can be done through casting or traction
Give choices of color so the child can feel some sense of control
Explain procedure
When applying: provide distraction by talking about hobbies, pets…
The cast being applied reassures them its ok because they feel warmth from the application
Ensure proper padding of all boney prominences
Apply a stocking net before casting to protect the skin from any sharp edges after its dry
Fractures: Casts: Care management
Let the cast dry completely
Dry from the inside to out before putting any pressure on it
Use a fan or a cool air hair dryer may be helpful to get cast dry if it is very humid
Always use the palms of hands while its wet, using fingers leaves indentations which cause pressure points
Fractures: Cast at home care
Provide instructions on how to take care of cast. Keep the extremity elevated for the first 24hr to prevent swelling, observe for extremities for swelling and discoloration, checking for movement or sensation
Activity restriction, not allowing the child to put anything down the cast, it might get itchy and kids want to scratch it
Teach about crutch walking
Fractures: Cast: skin care
Teach hygiene because its important as well as how to pay special attention to skin care
Maintain child’s skin integrity while they are in casts
Fractures: Cast: assessment
Unusual odor beneath the cast
Tingling, buring, numbness of toes or fingers
Drainage through cast to toes or fingers
Swelling or inability to move toes or fingers
Toes/fingers that are cold, blue, or white
Sudden unexplained fever
Pain that is not relieved by comfort measures
Unusual pain or nre pain that the child begins tp experience
Neurovascular assessment (CSM)
Fractures: Cast Care teaching
Petaling the edges of the cast (Especially when its a spica cast. Apply transparent dressing to edge of the cast and another one to childs perineum that acts as a continuous water proof bridge between the cast and the perineum in order to prevent leakage and allows for observation of the skin and area beneath the dressing)
Drying of the cast
Prevention of swelling (elevate, or if elbow: teach how to properly use a sling to provide support to the arm)
Protecting the cast from damage (cover before bathing or swimming)
When to call the dr
Spica cast
Used to immobilize the hip and thighs so that bones and tendons can heal properly
Starts at the chest and can either extend down one or both legs
Bar is a hip abductor to keep the legs in the proper position
Be sure not to use bar as a handle
Opening at the middle of the cast allows for elimination
Pose specific challenges like eating, feeding, positioning, bathing issues
Use disposable diapers
Potty trained children can use bedpan
Breastfeeding: use a football home
Traction for fracture
Pull or force that exerted on one part of the body
Balanced skeletal traction is applied to: Allow physiological stability, Align bone fragments, Enable closer evaluation of the injured site
Newer technology: orthopedic fixation devices that allow for mobility
Purpose of traction
Relieve fatigue in involved muscle Position distal and proximal bone ends Immobilize fracture site Prevent deformity Immobilize healing bone and prevent further injury Reduce muscle spasms
Types of traction: Skeletal traction
Hardware is fixated to bone
Types of traction: Skin traction
Applying dressing to skin and traction is applied through dressing
Types of traction
Upper extremity Lower extremity Balance suspension Gardner-Wells tong Cervical (halo brace)
Types of traction: Lower extremity
Buck extension (Used for comfort measures for hip fractures) Bryant traction (Developmental dysplasia of hip, when pelvic harness isnt working to keep the hips in place, used for 2-3 wks prior to surgery to loosen muscle around the hip joint) Russell traction
Types of traction: Cervical
Used for about 6-8 wks before spinal instrumentation with scoliosis. Used for issues other than scoliosis
Corrects curvature greater than 80%, can be lessened to 50-60%
Continuous traditions
Children can ambulate despite having screws in their head
Traction care
Purpose: maintain bone alignment, prevent muscle spasms
Assessment of neurovascular status: don’t have any coldness, cyanosis, pulselessness
Maintain correct balance between traction pull and counter-action force
Care for weights: NEVER adjust without orders
Skin inspection
Pin care
Developmental concerns
Immobilization affect on development: Toddlers
Need to explore and the ability to imitate behaviors in order to develop a sense of autonomy
Help this by giving them different items of different textures to explore and have them classify them
Anything to promote sense of exploration so that they can work to develop sense of autonomy
Immobilization affect on development: Preschoolers
Expression of initiative is evidenced by their need for vigorous physical activity. This is very hard for them to do when they are in traction. So whatever they can do with their unaffected extremities is good
Immobilization affect on development: School age
Sense of industry is influenced by physical achievement and competition. Maybe have competition with other children on their unit or with parents or board games. Or any game they can participate in that has simple rules
Immobilization affect on development: Adolescent
Rely on mobility to achieve independence, one of the steps in creating their identity. Give them as much independence as you can.
Pneumonic for traction care
T: Temp R: Ropes hang freely on the traction A: Alignment C: Circulation (6Ps) T: Type and location of fraction I: Increase fluid intake so they don't get dehydrated or constipation O: Overhead trapeze is there to help position them for comfort N: No weights ever on the floor or bed
Compartment syndrom
Very serious!!!! Medical emergency!!!!!! 6Ps Needs immediate intervention Fasciotomy is performed when it occurs Elevate extremity to the level of the heart
Developmental dysplasia of the Hip (DDH)
Refers to spectrum of disorders related to abnormal development of hip during fetal life, infancy, or childhood
Defined as condition where head of femur is improperly seated in the acetabulum of the pelvis
Girls are more commonly affected
Most are breech position
Strong family history
Cause is not completely known or understood
Developmental dysplasia of the Hip (DDH): Degrees: 1. Acetabular dysplasia (preluxation)
Mildest form
Delay in development of acetabulum defied by inadequate development of babies acetabulum.
Acetabulum is shallow and disk shaped rather than cup shape, osseous hypoplasia (obliquely inclined outward) of acetabular roof rather than normal horizontal orientation. Femoral head remains in the acetabulum
Developmental dysplasia of the Hip (DDH): Degrees: 2. Subluxation
Most common
Incomplete dislocation of hip, not complete dislocation, femoral head is in contact with acetabulum but it’s partially displaced
Developmental dysplasia of the Hip (DDH): Degrees: 3. Dislocation
Femoral head loses contact with acetabulum and is displaced posteriorly and superiorly over the rim so femoral head actually slides completely out of socket
Ligaments are elongated and taut
Developmental dysplasia of the Hip (DDH): Clinical manifestations: Infant
Newborn: appears in a lax hip joint rather than an outright dislocation
Hip joint laxity
Shortened limb on affected side
Restricted abduction of hip on affect side
Unequal gluteal folds when infant prone
Positive Ortolani test
Positive Barlow test
Ortolani test
Used to confirm Barlow findings
Thighs are abducted to test of subluxation and dislocation
Barlow test
Performed by adducting the hip bringing thigh to midline while applying light pressure on the knee and directing force posteriorly. Hip dislocates easily with this maneuver, then the test is considered positive
DDH: Early intervention
Longer the delay in treatment the more severe, more difficult treatment, and less favorable the prognosis is
Goal is to obtain and maintain a stable hip joint and promote normal hip joint development
DDH: Birth - 6 mo
Pavlik harness: maintaining abduction and flexion of the hip for about 3-5 months
Straps are checked and adjusted Q1-2 weeks due to rapid growth
Pavlik harness
there is one on each leg placed so that legs are held in important position to keep it stabilized during course of treatment
DDH: 6-24 mo
Dislocation unrecognized until child begins to stand and walk
Treatment: Closed reduction under general anesthesia, then placed in a hip spica cast for 2-4mo
If hip remains unstable: open reduction is performed
DDH: Older children
Operative reduction, include preoperative traction, or the performance of a tenotomy (surgical division of tendon), and possibly a hip osteotomy (surgical procedure where bones of hip joint are cit and reoriented and fixed back into a new position)
In older children, may have to perform more dramatic procedures to construct the acetabular roof. Correction after 4 yr is very difficult, not advised after 6yr
DDH: Nursing care
Teach parents to remove and apply harness appropriately
Only remove to check skin and bathing
Teach skin assessments, always put a shirt or onesie underneath the harness chest straps and put some type of long socks preferably up to the knees to prevent straps from rubbing against skin
Have parents check 2-3 x/day for any red areas under the straps
Provide gentle massage underneath the straps to stimulate circulation
Avoid any lotions, creams, ointments, or powder under the straps
Place diaper under the straps
Encourage cuddling to promote cognitive development and infant/caregiver bonding
Talipes equinovarus (clubbed foot)
Congenital abnormality in which the foot and ankle is twisted out of its normal position
Boys affected more than girls
Unknown cause
Talipes equinovarus (clubbed foot): Diagnostic evaluation
Deformity is apparent and detect prenatally through US or at birth
Talipes equinovarus: Described according to position of the ankle and foot
Talipes varus: inversion or bending inward (most common)
Talipes valgus: eversion or bending outward
Talipes equinus: plantar flexion with toes lower than the heel
Talipes calcaneus: dorsiflexion with toes higher than the heel
Most cases are a combination
Most commonly occuring being the composite deformity talipes equinovarus: foot pointed downward and inward in varying degrees of severity
Talipes equinovarus: Categories: Positional
Mild or postural and may correct spontaneously or necessitate some passive exercising or possibly serial casting. No bony abnormality but there could be tightening or shortening of soft tissue
Talipes equinovarus: Categories: Syndrome or teratologic
Often associated with other congenital abnormalities, usually necessitates surgical intervention, and with this there is a higher incidence of recurrence for these kids
Talipes equinovarus: Categories: Congenital
Its usually idiopathic, there is bony abnormality involvement and requires surgical procedure
Talipes equinovarus: Goal of care
Stretch the tightened tendons and ligaments gently and return foot to maximal anatomical position
Talipes equinovarus: Treatment stages
Correction of deformity
Maintenance of the correction until normal muscle balance is regained, and normal position is then achieved
Follow-up observation to avert possible recurrence
Talipes equinovarus: Serial casting/Ponseti method
Series of corrective casting and or use of splints, could even require surgical correction and series of cast to gently guide that clubfoot into position
Applies to hold foot in desired position
Begun right after birth, weekly manipulation and serial long leg cast to allow gradual repositioning
Extremities are casted and changed every 1-2 weeks until maximum correction is achieved usually 6-10wks
Talipes equinovarus: Casting: Nursing care
Cast care
Skin care
Education
Parental support
Talipes equinovarus: Casting: eduction
Parents need to understand the overall treatment plan, importance of regular cast changes and that they understand their role in overall effectiveness of therapy
Reinforce and provide instructions of cast care and skin care. Make sure parents know how to assess for any problems. They need to encourage normal G&D
Talipes equinovarus: Parental support
Parents understand their role
Active participation in the physical therapy treatments and child’s strength program
Help the parents understand the time commitment involved in caring for these kids
Very large commitment that parents have to follow through with physical therapy and doing it on consistent basis as well as strengthening program
Assess parents ability to monitor the child adequately for complications and confirm they understand the signs and symptoms of the complications that they might need to call the provider
Osteogenesis imperfecta
“brittle bone disease”
A group of heterogeneous inherited disorders of connective tissue. Parents often have a family history but most cases are generally due to new mutation
Defective periosteal bone formation and reduced cortical thickness of bones
Hyperextensibility of ligaments
Osteogenesis imperfecta: Characterized by
Excessive fragility/fracture and defects of bones/bone deformity
Osteogenesis imperfecta: Type I
Procollagen: Mutation on the genes that affect type 1 collagen, results in bone mineralization, abnormal construction of bone, and susceptibility of fractures. Most common mild bone fragility and may see kids have blue tinged to sclera, teeth usually look normal and may have some mild hearing loss
Osteogenesis imperfecta: Type II
Most lethal, results often in stillbirth or death in early infancy, it is a severe bone fragility with multiple fractures that may occur at birth, autosomal recessive inheritance
Osteogenesis imperfecta: Type III
Severe bone fragility (most cases), leading to severe progressive bone deformity, might have normal sclera, but will see very marked growth failure. Most autosomal recessive inheritance, some may be autosomal dominant
Osteogenesis imperfecta: Type IV: A
Mild to moderate bone fragility, normal sclera, short stature, variable deformities, autosomal dominant inheritance
Osteogenesis imperfecta: Type IV: B
Same as A but with abnormal dentition/teeth called dentinogenesis imperfecta
Represent about 6% of cases
Osteogenesis imperfecta: Type V
Similar to type IV may have hyperplastic callus and negative collagen mutation
Osteogenesis imperfecta: Type VI
Moderate to severe bone fragility
Osteogenesis imperfecta: Type VII & VIII
Osteochondroplasia and short stature
Osteogenesis imperfecta: Therapeutic management
Primary supportive care
IV bisphosphonate therapy, may need Calcium, GH.
No matter what fractures will occur
Children who get fractures from non-traumatic accidents need to be screen
Rehabilitative approach: (positional contractures and deformities, muscle weakness and osteoporosis, misalignment of lower extremity joints)
Osteogenesis imperfecta: Nursing implications
Careful handling
Changing diaper or tying a tourniquet can cause a fracture
Support when turning, positioning, and moving them
Educate parents on limitations and planning suitable activities to promote optimum development and to protect these kids from harm
Osteogenesis imperfecta: Clinical features
Weak bones, susceptible to fractures Scoliosis Kyphosis Blue tint to sclera (type 1) Early hearing loss (type 1) Hypermobility in joints (all) Hypoplastic discolored teeth (type IV B)
Scoliosis
Most common spinal deformity
Abnormal curvature of the spine
May be congenital or develop during childhood, many potential causes, most are idiopathic
Becomes noticeable after per-adolescent growth spurt, clothes may be ill fitting
Hips are slightly higher than the other
School screening, need to catch as soon as possible
Scoliosis: Causes: Idiopathic
Infantile, childhood/juvenile, adolescents (most common time of diagnosis)
Progresses faster in girls, and will more likely need surgical treatment
Becomes noticeable after pre adolescent growth spurt
Scoliosis: Secondary Cause: Neuro
Tethered cord
Cerebral palsy
Muscular dystrophy
Spinal tumor
Scoliosis: Secondary cause: MSK
DDH
Leg length discrepancy
OI
