UNIT 4- MUSCULOSKELTAL Flashcards
- Occurs when resistance between a bone and an applied stress yields to the applied stress, resulting in a disruption to the integrity of the bone
What is the most common site of fracture in children?
Distal forearm (radias, ulna, or both) due to the activity level of children and there attempt to brace themselves
Healing process of fractures in children is…
- Generally faster r/t rate of growth and no comorbidities
- Important not to wait for care w/fractures because the healing and remodeling phase will start quickly and can interfer with proper healing
What factors affect remodeling in children
- Age: The younger the child the greater remodeling potiental
- Location: Growthplates are typically the hardest to heal and can impact the gorwth of the bone due to the complexity of the break
- Degree of deformity: Complex/compound fractures will take longer to heal
Fractures in infancy are generally…
Rare and warrent further investigation
How are fractures diagnosed?
- Xray
- If xray is negative for fracture but childs symptoms suggest a fracture a CT or MRI may be done to r/o a fracture too small for xray to pick up
What are different types of fractures?
- Plastic deformation (bend): Not an actual break, bones, bones are more pliable so they can actually bend up to 45 degree w/out breaking
- Buckle (torus): Bulged or raised area that present at fracture site
- Greenstick: break but not all the way
- Complete
- Spiral: Twisting force seen in sport & child abuse
- Growthplate: Epiphyseal break
Our assessment of a fracture might show…
- generalized swelling
- Pain or tenderness
- Deformity
- Diminished function use
- Gaurding
- Ecchymosis:brusing under skin
- Muscular rigidity “automatic splint”
- Crepitus: Bubbling under the skin may feel or hear broken bones together… dont keep doing this.. can cause further damage
What are our priortiy actions with fracture?
- Calm and reasure
- determine the mechanism of injury
- assess the 6ps
- move the injured part as little as possible
- cover open wounds with sterile or clean dressing immobilize the limb
- reassess neurvascular status
- apply traction if ciruculatory compromise is present
- elevate the limb if possible
- apply cold to injured area
- call ems or transport to medial facility
- NEVER try and REDUCE on own
What are the advantages and disadvantages of plaster clasting?
Advantages: Molded closely to body part, smooth exterior, inexpensive
Disadvantages: Takes 10-72 hours to dry, heavy and not water resistent
What are the advantages and disadvantages to synthetic casting
Advantages: Light weight, dry quickly (5-20mins), water resistent(liners available), lots of colors and patterns
Disadvantages: Cannot be molded closely to the body, harder to write on (rough) and more expensive
When is a cast applied?
Splinted 1st and once swelling goes down can apply cast…
Why is a cast not applied immediately?
The swelling increases the risk of compartment syndrome. If applied when swelling is still present it can cause cast to become to big when swelling goes down
True or false: Casting of a fractured area will include the joint above and below?
True
What determines how much weight a child can bear?
Severity of the fracture
What developmental consideration will we think about when applying a cast?
This will determine how we are going to talk about what is happening.. Kids may be scared that things are going to hurt.. etc
Prior to casting what do we need to ensure?
Make sure skin surface is cleaned and dry. We will use a stocking net which is the liner between the skin and cast material folled by a cotton wrap then the cast material is applied
then we mold cast material to limb
Ensure smooth cast edge we may need to bring the stocking net up over the neck of the cast on synthetic casts due to roughness
What are some cast considerations we need to educate patient/parents on?
- Drys from inside out
- no heat lamps or warm hair dryers to help speed up the process this increases the risk of burns
- Reposition wet casts with palms instead of fingertips
- using fingertips can leave indentions increasing the risk of skin break down as this can create pressure points
- Elevate cast extremity using a soft surface, pillow or blanket
- Apply ice but make sure no moisture from cold pack gets into castin material esp. platster because it doesnt have the water resistent liner
- Assess 6p’s
What are windows in casts?
Openings in cast material to allow for diaper changes or assessments
What are bivalve casts?
Like a splint– cast split in half to allow for adjustments in case of swelling or need for assessments. held together by acewraps
What should we keep in mind about objects and casts?
Make sure to teach kids that there cast is not a new hiding place. Resist the urge to stick things down there to scratch
What should we keep in mind regarding moisture and casts?
- No swimming/submerging
- Cover w/plastic for showers
- if it gets wet contact HCP
What should we know about cast removals and what educationshould we provide?
- Avoid using the terminology saw… use cast removal tool. and tell them they may feel virbration and tickeling. Kids are scared and will freak if they think you will be using a saw near their legs
Education
1. Appearance: Limb may appear smaller due to muscle atrophy.. may be skinnier, may smell which is perfectly normal.. over time all this will be back to normal
2. Skin care: skin will be dry do not pick at dry skin allow to follow up normally… warm bath with mild soap
3. Return to activity: Full activity for minor breaks rule of thumb is however long you were casted is how long you must wait
4. Joint mobility: may have stiffness but with time will get better
Playing is a childs….
Physical therapy
What is the purpose of traction?
- Realign bone
- Immobilize
- Fatigue muscle to reduce spasms
Type of traction ordered is dependant on ?
- Fractures
- Childs age
- Associated injuries
What is skin traction?
Traction applied directly to the skins surface and indirectly to the skeletal structures
Pulling force is applied by weights up to 25lbs
Using tape and straps, weights are attached by a rope to the extremilty
May use elastic bandages, foam boot, or sling, pulling mechanism attached to items
What is buck extension?
Type of skin traction
1. Short term immobilization for dislocated hips and legg-calve-perthes
2. Leg is in an extended position
3. Boot appliance attacted to the traction
What is bryants traction?
Type of skin traction
1. Immbolizes both lower extremities in fractures femurs, developmental dysplasia of the hip
2. Traction is applied to the legs
- Legs flexed at 90 degree angle at the hips
3. Buttocks raised slightly off bed
- butt must be raised inorder to create the counter traction
What are the types of skin traction discussed in this lecture?
Bucks and bryant
What is skeletal traction?
- Applied directly to the skeletal structure with the use of pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture
- Allows for longer traction over time and heavier weights 25-40lbs
What is 90-90 traction?
Bone realignment
1. Lower portion of leg is supported in cast boot or sling
2. Steinmann pin or kirschner wire in distal fragment of femur
3. results in a 90 degree angle at both hip and knee
4. Bottom must be off bed in order to create counter traction
Complications of 90-90 traction includes?
Risk of infection due to pin in bone. Prescribed pin care is important
What are the two types of traction that require the butt to be lifeted?
- Bryants (skin)
- 90-90 (skeletal)
What is Halo Traction?
Used for displaced or fractured vertebrae
1. Steel halo is attached by foure screws inserted into outer skull
2. Rigid bars connect halo to vest
3. Allows for greater mbility of the body while avoiding cervical spinal motion
4. Scheduled neuro exams important as well as pin site care
What are our interventions for tractions?
Assess
1. 6ps
2. skin integrity
3. Body alignment (bottom up required on some tractions)
4. Pin site care
5. Position of bandgages, frames, splints, boots: teach family and siblings to be careful
6. Ropes and pulleys
7. Weights
8. Bed position (elevate HOB)
Meds
1. Administer pain meds/muscle relaxants
2. Developmental and psychosocial needs (allow friends, outside time and visitation)
What is osteomyelities?
Infection within the bone, usually caused by bacteria introduced by trauma or surgery, by direct extension from a nearby infection or via the bloodstream
Typically occurs in children 10 and under… boys>girls
What is the most common organism that causes osteomylitis?
Staph because it lives on our skin
Osteomylities is most common in what bones
long bones
What might our assessment of a child with osteomyelitis show?
- Pain esp. with usage
- Fever (high grade)
- Irritability
- Erythma
- Decreased movement/useage
- Edema
- Warmth
- malasie
How is osteomylities dx?
- Cultures to confirm organism responsible
- Lab
- WBC, ESR, CRP
- X-ray
- May not show up until 2-3 weeks after having so if symptoms presist they may do a bone scan, ct or MRI
- CT, BONE scan, MRI
- Bone biospy
- Last resort if things are still pointing in the direction of this dx but not showing up on other exams
Interventions for osteomylities include?
- Assess 6ps
- Administer IV antibiotics
- Rapid infusion… higher doses and may go home with home health for home antibiotics for an additional 6wks through PICC line
- Pain meds
- Acetominophen, ibuprofen, non opiods for mild pain and opiods for high pain
- Promote rest/comfort
- usually self-limiting just take it slow and cautiously
- Nutrional considerations
- high protien because this will help healing
- Sugery, possibly
- if no improvement on antibiotics they may go in for an I&D to clean out dead bone and tissue
Monitor lever and renal function d/t antibiotic
What is Legg-calve-perthes disease?
“Avascular necrosis of the femoral head”
A condition with unknown etiology that affects the hip where the femur and pelis meet in the joint; blood supply is temporarily interrupted to the femoral head and it begins to die
More common in chidlren 2-12 years old and boys more common at age 4-8
What are the 4 stages of leg
- Necrosis
- Fragmentation
- Reossification
- Remodeling
The onset of Legg-Calve-Perthes is…
slow- hard to pin point when it happens because it is so slow
- Presents with limp
- pain
- Joint stiffness w/limited ROM
Dx of legg-calve perthes depends on….
History
physical assessment
xray
MRI
What is the gold standard dx test for legg-calve-perthes?
MRI- it can dectect dead bone tissue
What is our interventions for legg-calve-perthes?
Inital therapy
1. Rest/activity restricts
2. Reduce infalmmation and irritability of the hip
3. limited or non-weight bearing
- Crutches/wheelchair– if too young for crutures
What are surgical interventions for legg-calve-perthes?
- Non surgical containment (“conservative”)
- Surgical reconstruction and containment
What decides the surgical interventions for legg-calve-perthes?
Parents choice on which intervention. For non surgical containment they will be in braces for 2-4 years but with surgical reconstruction they can be back to normal activites in 3-4 months
What is the prognosis of legg-calve-perthes?
- Self-limiting
- Outcome influenced by
- Early treatment
- Childs age
- Possible long-term complications
Children younger than 6yo will heal andhave normal hip joint. Children over 6 yo will likely have a deformed hip joint and are more prone to osteoarthritis
What is scoliosis?
An abnormal lateral curvature of the spine 10 degrees or more
Most often idiopathic in orgin meaning there is no known cause
Occurs in 2-3 percent of the adolescent population; more common in girls
Usually diagnosed during the adolescent growth sput
What might we see on our visual assessment of a scolisis patient?
- One shoulder higher than the other other shoulder
- One should blade protruding or more prominent
- spce between arm and body one will have more space
- leaning to one side or head leaning not centered above pelvis
What is out spinal screening test?
- forward bedning test with scolio meter
If curve is greater than ___ during the spinal screening what happens
7 degrees… referred to HCP
How is scoliosis diagnosed?
- COBB method: angle of curve on xray which will determine interventions
- MRI: R/O spinal abnormalities or tumors compressing
What are our interventions for postual variations of less than 10 degrees?
- elevated at routine well check ups
What are our interventions for mild curves (10-25 degrees)?
- Observation and healthcare provider evaluation every 3-6 months
What are our interventions for moderate curves (25-45)
Bracing
What are our interventions for severe curves ( 45 degrees or more)?
- Surgery where rods, bone grafts are placed to correct curve
When are braces used?
Moderate curves 25-45 degrees
How long are braces worn for scoliosis?
16-23 hours a day which makes compliance hard
Gradually weaned off brace and will eventually wear at night
What is some education we can provide to children wearing scolosis braces?
- Wear soft clothes underneath
- avoid powders and creams because it increases risk of skin breakdown
- Promote a postive body image
- skin assessment and care
- complience
- pt/exccersie to build core muscles and strengthing exercises no contact sports
What are the two types of braces?
Boston Brace
1. Most common
- curves in the lumbar or thoracic-lumbar area
- low profile
- Plastic componenets are custom-molded
Milwaukee Brace
2. Older and bulkier verision; not commonly used
- Curves higher in the thoracic or cervicle spine
What is the goal of scolosis surgery?
Provide maximum correction and mobility to the scolosis
use a growing rod to prevent futher surgery
What are some post-op interventions for scolosis?
- Perform frequent neuological assessments
- Log-roll
- Assess skin integrity and provide skin care
- IV fluids
- analagisics
- assist with ambulation (progressive) want them up asap
- Developmental and psychosocial need
- Monitor for surgical illeus
What is developmental ysplasia of the hip (DDH)
Disorders related to abonormal developement of the hip that may develop during fetal life, infancy or childhood; in these disorders the head of the femur is seated improperly in the acetabulum
Unknown eitology
More common in the 1st born children, females, postive family hisotry, breech deliever, large birth weight, oligohydramnios
What assessment can be done on a newborn 8-12 weeks
+ Barlow test
- DDH is present it will be a +barlow test
- ADDuctthe thigh
- Palpable “clunk” of femoral head dislocating from acetabulum
Postive Ortolani test
1. ABdducted while lifting leg anteriorly
2. Palpable “clunk” as dislocated femoral head reduces into acetabulum
After 12 weeks not going to produce a postive result
Who performs the Barlow and Ortolani test?
Experienced health care provider. If performed too vigorously in the 1st 2 days of life persistent dislocation may occur
On our assessment of an infant with DDH what might we find?
- limited abduction of the hips
- asymmetry of gluteal and thigh folds
- postive Galeazzi (allis)sign
- Shortness of the femur with the hips and knees flexed
- Leg length discrepancy
On our assessment of DDH what might we see in older infants and children?
- Postive trendelnburg signs
- Child stands on one foot at a time
- when weight is on affected hip, pelvis tilts downward on the normal side instead of upward as it should
- Leg length discrepancy
- Telescoping mobility of joint
- Marked lordosis and waddling gait (bilateral dislocations)
How is DDH dx?
- Physical assessment
- Xray- not reliable if the child is under 4 months old child will need ultrasound
- Ultrasound: can be done as early as 2 weeks old
What are our interventions for DDH?
Birth to 6 months
1. Pavlik harness
- Maintains flexion and abduction of hips
- Worn continuously (full-time) for 6-12 weeks
- HCP will adjust the brace ever few weeks.
- Will do ultrasound and xrays to watch for progress
What education do we need to provide about Pavlik brace?
- Application and maintenance of device
- fit of harness (HCP adjusts)
- Skin care (cotton onside under harness parents will be taught how to take off and on for baths teach how to assess skin, No lotions,creams, powders, diaper goes UNDER strap
- Encourage parents to hold infant with harness
- Involve infant in activites with others
What interventions do we implement for infants 6-24m with ddh who are no longer a candidate for palvik brace?
- Bryants traction: Skin traction bottom off bed
- Surgical reducation (open vs. Closed) to reduce hip joint
- Spica cast (after surgery typically on for 12 weeks)
- Flexion abduction brace (graduate to this haver fully heal and out of the SPICA cast some use it some dont.)
What interventions do we implement for children older than 24 months with DDH that are no longer a candidate for the palvik brace?
- Open reduction
- Spica cast after surgery
- Flexion-abduction brace.
Surgical intervention is extremely difficult if caught after the age of 4 and pretty close to impossible if after 6 years due to severe shortening and contractures of the muscle.
What is clubfoot (talipes quinovarus)
A complex deformity of the ankle and foot that may be unilateral or bilateral
Unknown eitology; increased risk with family history
Classified as positional, syndromic, or congenital
More common in boys
What might we see on our assessment of a child with clubfoot?
Affected foot/feet
1. Pointed downward and inward
2. May be smaller and shorter
3. Calf may appear thinner
4. May have deep crease on bottom of foot
What are our intervention for clubfoot?
Non-surgical
1. Ponseti method
- serial casting for 6-10 weeks
- weekly gentle manipulation and streatching of the foot
- Achilles tentomy, possibly, at conclusion of serial casting process
- final cast is placed and on for 3 weeks
- Then removable orthotic device “boots and bar”
Surgical- possible
What is juvenile idopathic arthritis (JIA)
- Autoimmune infalmmatory disease affecting the joing and other tissues such as articular cartilage
- Unknown etiology
- no cure; treatment is supportive
- more common in girls
On our assessment of a child with JIA what might we see?
Affected joints (usually large joints)
1. Swelling
2. stiffness
3. pain
4. limited ROM
5. Feneralized symptoms of fever, malaise, rash
6. Periods of exacerbations (flares) and remissions
7. Uveitis: form of eye inflammation that can cause blinedness
When is the typically onset of JIA?
before 16
How is JIA dx?
No definitive tests
1. onset is before 16 years of age
2. continous arthritic pain in one or more joints for 6 or more weeks
3. Repetitive fevers up to 103
4. Rash on legs, arms, and trunk
5. elevated ESR, possibly
6. elevated leukocytosis, possibly
7. X-rays (soft tissue edema and joint space widening)
What are our interventions for JIA?
- Control pain
- NSAIDS
- Methotrexate
- Corticosteriods
- Preserve joint function and prevent deformity
- Promote normal growth & developement
What are the physiologic effects an immoblized children may experience?
- Decrease in muscle size, strength, and endurance
- Bone demineralization leading to osteoprosis
- Contractures and decreased joint mobility
What are some psychologic effects an immbolized child may experience?
- Decreased ability to respond to anxiety
- Decreased sensory input
- Feeling of isolation, boredom, helplessness
- Potential for sluggish intellect & decreased communication
- May react w/agression, submission, passiveness or anger
- Possible depression related to abiity to function or change in body image
Interventions for the immbolized patient?
- Skin care
- DVT prevention
- Encourage high protien, high calorie diets
- adequate hydration
- upright position frequently unless contrainidcated
- Transport outside room when possible
- Allow to wear own clothes
- Allow to participate in own care
- Frequent visits with fam/friends
