TLO 2.8 Musculoskeletal Child Flashcards
What does the skeletal system do?
Provides structure and support
Protects vital organs
Provides movement
Storage space: blood cell production, regulates mineral and hormonal imbalances
**Bone structural disorders require follow up until child reaches skeletal maturity
Pediatric musculoskeletal difference
Skull sutures don’t fuse until 12-18 months
Muscle tissue almost completely developed at birth
Soft tissues are resilient making dislocation and sprains less common
Infants’ bones only 65% ossified at 8 months age
Fractures in <1 year child, uncommon, consider abuse
Diagnostic tests
X-ray Bone scan MRI CT scan **non-invasive
Diagnostic tests, X-ray purpose, viewing, nursing
Purpose: detect abnormalities or determine bone age View: Air looks black Fat looks dark grey Water looks light grey Bone looks whitish Nursing: noninvasive not generally NPO place in gown assist young children with proper positioning
Diagnostic test, bone scan, purpose, nursing
Purpose (investigates): trauma, early stress fractures, tumors, infections (diskitis, osteomyelitis)
Radioactive material given IV and scan occurs 3-4 hours later
Nursing:
encourage fluids 2-4 hr prior helps rid radioactive material
void before scan, improves pelvic bone visualization
young children may need sedation
Diagnostic test, MRI, purpose, nursing
Purpose:
Clearly define organ structures
Show changes in soft tissue (edema, infarcts)
Magnet and radio waves create energy field that’s translated to an image
Nursing:
No NPO
Ensure no metal on pt
Is loud, can take 1 hr
Assess claustrophobia
Must remain still (kids might need sedation, NPO is sedation)
Diagnostic test, CT scan, purpose, nursing
Purpose; Visualize boney and soft tissue details Has more radiation exposure X-ray beams scan in successive layers and can be shown in 3D if needed With or without contrasts Nursing: Not NPO Scary for children, sounds like loud washing machine Place in gown NPO if sedation Assess allergies for dye
What is a sprain and strains?
Sprains:
Joint trauma where a ligament is stretched or partially torn
Strains:
Known as pulls, tears ruptures, result from excessive stretch of muscle
**Both manifest as:
pain, swelling, localized tenderness, limited ROM, poor weight bearing, pop sound (sprain)
Dislocation, what is it?
Force of stress on the ligament results in displacement of the bone from it's socket Pain and joint deformity results Most common sites: phalanges elbow hip shoulders **ligaments bind bones together
Management of sprains and strains
Primary goal is to reduce swelling and prevent further injury
RICE: rest, ice, compression, elevation
ICES: ice, compression, elevation, support
**swelling inhibits healing by keeping ligament ends separated. First 6-12 hours most important in controlling swelling and reducing muscle damage. Elevate above level of heart
Sprains and strains, nursing considerations
Analgesics: acetaminophen ibuprofen (controls pain and swelling) Distraction and play can help with pain Healing time depends on extent of injury Weigh bearing gradually increased as pain decreases
Common causes of fractures
Accidental trauma; falls, MVA
Non accidental trauma; child abuse
Pathologic conditions; osteogenesis imperfecta, tumors cysts
**children heal faster than adults
**weakest point of long bones is cartilage growth plat or epiphyseal plate
Types of fractures
Greenstick: partial break on one side of bone while bone bows on other side, common in forearm
Spiral: twisted break/circular break seen in child abuse
Oblique: diagonal break
Transverse: break occurs at right angle
Comminuted: bones splintered into pieces rare in kids
Compound: bone exposed through skin
Manifestations for fractures in children
Pain/tenderness at site Decreased ROM/immobility Deformity Swelling Ecchymosis, muscle spasm Inability to bear weight Crepitus Erythema
Diagnostic test for fractures
X-ray: both side view to compare
**distal forearm and clavicle common fracture sites
Fracture management, reduction, retention
Goal: maintain function without affecting growth
Reduction= align
Repositioning of the bone into normal alignment, open- surgically inserting devise (rod, pins)
Retention= hold
Application of a device to maintain alignment until healing occurs, splints, casts, traction, external fixation
Immobilization of fractures
Splints
Casts
Traction: manual, skin, skeletal
External fixation
Purpose of traction?
Reduce muscle spasm
Position distal and proximal bone ends in realignment
Immobilize the fracture site until realignment has been achieved and healing has taken place to permit casting or surgical fixation
Skin traction, what is it?
Noninvasive and well tolerated
Best for kids <15kg or <3 years of age
Applied to pelvis, spine, extremities (long bones)
Use external devices (foam, straps, bandages) applied to skin attached to pulleys and weights
Not appropriate if skin infections, open wounds, extensive tissue damage, abnormal sensations in extremities
Skeletal traction, what is it?
Exerts greater force than skin traction
Tolerated for longer periods of time
Maintains alignment of bony fragments and assists in proper healing
Traction maintained by metal device inserted into bone
Osteomyelitis most serious complication
External fixation device, what is it?
Used to treat:
Complex fractures
Length bones
Correct angular deformities involving bones and soft tissue
Allows for periodic changes in alignment with external device with pines inserted into bone
Infection is risk r/t pin sites, 50% develop problems
Assessment and care of immobilizing devices
Neurovascular status: 5 P’s
- pain unrelieved by meds
- pallor
- pulselessness or lack of cap refill
- paresthesia
- paralysis
Assessment of neurovascular status?
Neurovascular competency can be assessed using 5 P's or CMTS Color Movement Temperature Sensation
What is osteomyelitis and risk factors?
Bacterial infection of bone
Open fractures/trauma
Soft tissue injury, cellulitis
External fixation or skeletal traction devices
Bacterial found: Staphylococcus aureus
Osteomyelitis manifestations
Fever, irritability, lethargy, feeding difficulties Pain, warmth, ,erythema Tenderness over site of infection Favoring affected extremity Limited ROM Painful joint with movement Odor possible
Osteomyelitis diagnosis and labs
MRI, CT, Bone scan, US
Labs:
Elevated ESR and CRP, WBC, blood culture
Osteomyelitis nursing interventions
Pain management
Monitor and document neurovascular status
Admin IV antibiotics
Provide wound care
Maintain nutritional status, high calories, protein, frequent small meals
Scoliosis, what is it?
Lateral deviation/curvature of spine >10 degree
Curvature causes rotation of vertebral bodies of spine
Worsening curvature leads to:
Rib cage deformities= compromised respirator function
Distortion of intrathoracic and abdominal organs that does not affect organ function generally
Scoliosis manifestations
Visible curvature of spine Rib hump when child bends forward Asymmetric rib cage Uneven shoulder or pelvic heights Scapular prominence Hip and leg length discrepancy
Scoliosis management
Curves <25 degree require long term monitoring
Curves >25 degree require brace treatment
Scoliosis nursing interventions for brace treatment
Doesn’t correct curve but prevents progression
Wear fitted t-shirt under brace to protect skin
Remove for bathing, swimming, exercise only
Re check size as child grows
Analgesics for discomfort
Scoliosis surgical intervention
Recommended for curvatures reaching 40-50 degrees
Goal is to reduce size of curvature and obtain solid fusion using metal rod and bone grafts (ribs, iliac crest, vertebral body)
May not completely correct spine but stabilized spine that centers head, shoulders and truck over the pelvis
Scoliosis surgical interventions/complications
Significant blood loss common r/t vascular nature of vertebrae and spinal column
Injury to spinal cord
Infection
Scoliosis surgical pre op care and teaching
Routine teaching (resp, circulation, pain)
Remain flat/log rolling technique
Express feelings/anxiety
PCA, foley, chest tube (if anterior approach)
Scoliosis surgical post op care
Neurovascular checks q 2hr for 48 hr then q 4hr
Pain management
Teach log roll, turn q 2hr
Ambulate post op day 2-3 and d/c day 4-5
Respiratory status, inspirex, cough and deep breathing
Encourage self care activities as appropriate
Bed flat unplug bed controls
Bowel function
Wound healing/sit
Hip Dysplasia, what is it?
Developmental dysplasia of the hip (DDP) described variety of disorders that present different ages and forms
-if present at birth called congenital
-develops after birth called developmental
Etiology: unknown
Instability of hip joint occur as result of laxity of ligaments holding head of femur in acetabulum
Hip dysplasia risk factors
First bone child Female Breech position Low levels amniotic fluid in utero African and Chinese decent low incidences Native American high incidences
Hip dysplasia manifestations, older infants
Older infants:
asymmetry of gluteal folds
limited ROM in affected hop
abduction present when supine with knees and hips flexed
femur on affected side appears shorter
s/s range from lax ligaments to contractures and stiffness in affected hip
Hip dysplasia manifestations, older child
Older child: Any abnormalities in gait need evaluation Child may: Limp Toe walking or waddling gait
Hip dysplasia management
Pavlick harness: provides hip flexion, abduction, external rotation
Bryant’s traction: releases muscles and tendons to manipulate hip joint
Closed or open hip reduction surgery
Spica cast post op immobilization
Hip dysplasia teaching
Don’t straighten legs or swaddle together
No car seats that restrict hip position
Check skin under harness daily
Check neurovascular status on feet
Cast care, management elimination, keep dry
Adapt clothing for weather
Never leave child unattended, kids still move, safety issue
Change positions q 2 hr
How to apply Pavlick Harness and only remove as provider order
Protect skin, use onesie
Legg-Calve Perthes disease, what is it?
Cause is unknown but accepted as growth disorder
Involves femoral head progresses through 5 stages over 1-2 year period
-epiphysis shows ischemia
-reduction in size and increased femoral head density
-bone weakens and dies causing femoral head collapse
-avascular bone reabsorbed and begin to form new bone
-femoral head reform result in final healing
**disease is self limiting (runs its course generally)
Legg-Calve Perthes disease manifestations
Pain in hip worsens with movement
Shortening of affected side, indicates collapsing of femoral head
Muscle wasting of thigh and buttocks
Unilateral hip involvement
Permanent deformity if healing process is incomplete (femoral head protrudes outside acetabulum)
Legg-Calve Perthes disease diagnosis
X-ray
Bone scan or MRI can revel necrosis and irregularity of femoral head
**more common in boys than girls ages 4-9 year
Legg-Calve Perthes management
Initial treatment:
anti-inflammatory meds
ROM exercises and bedrest
After 7-10 days if still unable to abduct hip:
traction or abduction braces
surgery to place femur securely into acetabulum
Clubfoot/talipes equinovarus manifestations
Plantar flexed foot with inverted heel and adducted forefoot
unilateral or bilateral defect
cannot be manipulated into neutral position
readily apparent at birth
Clubfoot diagnostics and therapeutic management
Ultrasounds prenatally
Therapeutic: stared ASAP serial stretching, manipulation and casting surgery recurrence is common f/u until skeletal maturity
Clubfoot nursing care
Same as child with cast Clear parental instructions -bathing -time feeding with manipulations to allow distraction -encourage normal development
Muscular Dystrophy, what is it?
Progressive degenerative diseases that affect muscle cells or specific muscle groups causing weakness and atrophy.
- *most identified early childhood
- *includes >30 types but Duchenne MD is most common. affects limb and trunk muscles first
Muscular Dystrophy pathophysiology
Muscle fibers leak creatinine kinase and take on excess Ca+ causing more damage
Muscles degenerate and replace with fat and connective tissue
Muscle death causes weakness and wasting
Muscular Dystrophy manifestations
Progressive, symmetric muscle wasting and weakness without loss of sensation
Symptoms become acute age 3-7 (hypertrophied muscles)
Waddling wide based gait, can’t climb stairs
Gowers sign, use hands to walk up legs to stand erect
Walking ability lost age 9-12 years
Shortened life span r/t affect on GI, brain, cardio
Cardiopulmonary complications common cause of death
Muscular Dystrophy diagnosis
EMG and muscle biopsy
Genetic screening
Physical findings
Serum creatinine kinase (CK) elevated early stages of disease then decrease as muscle decreases
Muscular Dystrophy therapeutic management
Goal to maintain ambulation and independence as long as possible
No effective treatment
Manage symptoms
Prevent contractures: ROM, bracing, PT, weight control
