Pediatric Nursing: Musculoskeletal Problems

Question 1

Developmental Dysplasia of the Hip: description and interventions

Answer 1

• problems related to abnormal development of the hip that may develop during the fetal life, infancy, or childhood.
• the head of the femur is seated improperly in the acetabulum, or hip socket, of the pelvis.
  Interventions:
• birth to 6m of age: splinting of the hips with a Pavlik harness to maintain flexion and abduction and external rotation (worn continuously until hip is stable in about 3-6m).
• age 6-18m: gradual reduction by traction followed by closed reduction or open reduction (if necessary); child is then placed in a hip spica cast for 2-4m until the hip is stable, and then a flexion-abduction brace is applied for approx 3m.
• older child: operative reduction and reconstruction is usually required.
• instruct parents regarding proper care of pavlik harness, spica cast, or abduction brace.

Question 2

Developmental Dysplasia of the Hip: degrees

Answer 2

• Acetabular dysplasia (preluxation): mildest form, neither subluxation nor dislocation, delay in acetabular development occurs, femoral head remains in acetabulum.
• Subluxation: incomplete dislocation of the hip, femoral head remains in acetabulum, stretched capsule and ligamentum teres causes head of the femur to be partially displaced.
• Dislocation: femoral head loses contact with acetabulum and is displaced posteriorly and superiorly over fibrocartilaginous rim; ligamentum teres is elongated and taut.

Question 3

Developmental Dysplasia of the Hip: assessment

Answer 3

• Neonate: laxity of the ligaments around the hip.
• Infant: shortening of the limb (Galeazzi sign or Allis sign); restricted abduction of the hip when the infant is in supine position with knees and hips flexed (limited range of motion); unequal gluteal folds when in prone and legs are extended; positive Ortolani’s and Barlow’s sign.
• Older infant and child: affected leg is shorter; the head of the femur can be felt to move up and down in the buttock when the extended thigh is pushed first toward the child’s head and then pulled distally; positive Trendlenburg’s sign; greater trochanter is prominent; marked lordosis or waddling gait is noted in bilateral dislocations.

Question 4

Congenital Clubfoot

Answer 4

• complex deformity of the ankle and foot that includes adduction, midfoot supination, hindfoot varus, and ankle equinus (may be unilateral or bilateral).
• goal of treatment is to achieve a painless plantigrade and stable foot.
  Assessment:
• talipes varus: inversion or bending inward.
• talipes valgus: eversion or bending outward.
• talipes equinus: plantar flexion in which the toes are lower than the heel.
• talipes calcaneus: dorsiflexion in which the toes are higher than the heel.
  Interventions:
• treatment begins as soon after birth; manipulation and casting are performed weekly for about 8-12 weeks (a splint is then applied if casting and manipulation is successful. Surgical intervention may be necessary if normal alignment is not achieved by about 6-12 weeks of age.
• monitor for pain and neurovascular status of the toes.

Question 5

Idiopathic Scoliosis

Answer 5

• three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax.
• usually is diagnosed during preadolescent growth spurt.
• surgical (spinal fusion) and nonsurgical (bracing) interventions are used and depends on the location and degree of curvature, age, amount of growth yet anticipated, and any underlying disease process.
• asymmetry of the ribs and flanks when the child bends forward at the waist and hangs the arms down (Adam’s test).
• hip and shoulder height, rib positioning are asymmetrical, leg discrepancy is also apparent.
• radiographs are obtained to conform diagnosis.
• monitor progression of curvatures and prepare the child and parents for the use of a brace or surgery.

Question 6

Idiopathic Scoliosis: braces

Answer 6

• are not curative but may slow the progression of the curvature to allow skeletal growth and maturity.
• usually are prescribed to be worn 16-23h/day.
• inspect the skin for signs of redness or breakdown, keep it clean and dry, and avoid lotions and powders.
• wear soft nonirritating clothing under the brace.
• instruct prescribed exercises and encourage verbalization about body image and phychosocial issues.

Question 7

Idiopathic Scoliosis: PostOp interventions

Answer 7

• maintain proper alignment (avoid twisting movements).
• logroll the child when turning.
• assess extremities for neurovascular status, pain and adm meds.
• encourage coughing, deep breathing, and the use of spirometry.
• monitor for incontinence, sings and symptoms of infection, for superior mesenteric artery syndrome (emesis and abd distension) and notify PHCP if occurs.
• instruct in activity restrictions and how to roll from a side-lying position to a sitting position, assist with ambulation.
• address a potencial body image disturbance when formulating a plan of care.

Question 8

Juvenile Idiopathic Arthritis: description and assessment

Answer 8

• autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage; occurs most often in girls.
• treatment is supportive (no cure) and directed toward preserving joint function, controlling inflammation, minimizing deformity, and reducing the impact that the disease may have on the development of the child.
  Assessment:
• no definitive tests to diagnose, but some lab tests (such as an elevated erythrocyte sedimentation rate or determination of the presence of leukocytosis) may support evidence of the disease.
• radiographs may show soft tissue swelling and joint space widening from increased synovial fluid in the joint.
• stiffness, swelling, and limited motion n affected joints, which are warm, tender and painful to touch.
• uveitis can occur and cause blindness.

Question 9

Juvenile Idiopathic Arthritis: Intervention and medications

Answer 9

• surgical intervention may be implemented if the child has problems with joint contractures and unequal growth of extremities.
• facilitate social and emotional development.
• instruct parents on care, exercises (range-of-motion), use of hot or cold packs, splinting, and positioning the affected joint in neutral position during painful episodes (begin isometric exercises as soon as possible) and encourage normal performance of activities of daily living.
• instruct the importance of preventive eye care.
  Medications used:
• corticosteroid injections: only when a few joints are involved.
• oral corticosteroids: only for a short time and at the lowest dose possible.
• disease modifying antirheumatic drugs: second-line treatment when many joints are involved or the child does not respond to corticosteroids injections.
• biologics may also be prescribed, and these include antitumor necrosis factor agents.

Question 10

Marfan’s Syndrome

Answer 10

• disorder of connective tissue that affects the skeletal system, cardiovascular system, eyes, and skin.
• caused by defects in the fibrillin-1 gene, which serves as a building block for elastic tissue in the body (the disorder may be inherited); there is no cure.
  Assessment:
• tall and thin body structure: slender fingers, long arms and legs, curvature of the spine.
• presence of visual and cardiac problems.
  Interventions:
• monitor for vision problems and curvature of spine.
• cardiac meds may be prescribed to slow HR and decrease stress on the aorta.
• instruct parents about avoiding contact sports and competitive athletics; inform the dentist about the condition.
• surgical replacement of the aortic root and valve may be necessary.

Question 11

Legg-Calve-Perthes Disease

Answer 11

• condition affecting the hip where the femur and pelvis meet in the joint.
• blood supply is temporarily interrupted to the head of the femur and the bone dies and stops growing.
  Assessment:
• limping, pain or stiffness in the hip, groin, or knee. Limited range of motion in the affected joint.
  Interventions:
• physical therapy, use of crutches to avoid bearing weight, bed rest and traction if pain is severe, casting to keep the femoral head within its socket, use of a nighttime brace, and hip replacement surgery.

Question 12

Fractures

Answer 12

• a break in the continuity of the bone as a result of trauma, twisting, or bone decalcification.
• usually occurs as a result of increased mobility and inadequate or immature motor and cognitive skills (may also result from bone diseases such as congenital or tumors).
• assessment: pain or tenderness, obvious deformity, edema, ecchymosis, muscle spasm, loss of function, creptation.
• initial care: assess extent of injury and immobilize, check neurovascular status. If compound fracture, cover the wound with a sterile dressing (or clean), elevate the extremity if appropriate, apply cold, and continue to monitor.
  Interventions:
• reduction: restoring the bone to proper alignment (closed or open reduction).
• retention: application of traction or a cast to maintain alignment until healing occurs.

Question 13

Traction

Answer 13

• Russel skin traction: used to stabilize a fractured femur before surgery. Similar to Buck’s traction but provides a double pull using a knee sling that pulls at the knee and foot.
• Balanced suspension: used with skin or skeletal traction to approximate fractures of the femur, tibia, or fibula. Is produced by a counterforce other than the child. Provide pin care if pins are used with the skeletal traction.
• 90-degree traction: the lower leg is supported by a boot cast or a calf sling. A skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the femur, allowing 90-degree flexion at the hip and knee.
  Interventions:
• maintain correct amount of weight, ensure that the weights hag freely.
• check all ropes for fraying and all knots for tightness.
• monitor neurovascular status and protect skin from breakdown.
• monitor for signs and symptoms of complications of immobilization, such as constipation, skin breakdown, lung congestion, renal complications, and disuse syndrome of unaffected extremities.

Question 14

Casts

Answer 14

• examine the cast for pressure areas.
• ensure that no rough casting material remains in contact with the skin (petal the cast with waterproof adhesive tape to ensure a smooth cast edge).
• monitor the extremity for circulatory impairment, such as pain greater than expected for the type of injury, edema, rubor, pallor, numbness, and tingling, collness, decreased sensation or mobility, or diminished pulse.
• prepare for bivalving or cutting the cast is circulatory impairment occurs; prepare for emergency fasciotomy if cast removal does not improve the neurocirculatory compromise.
• instruct parents and child not to stick objects down the cast, keep the cast clean and dry, and use isometric exercises to prevent muscle atrophy.