Musculoskeletal Stressors and Adaptation

1. Musculoskeletal Stressors and Adaptation

2. Common MS disorders in Children • Congenital hip dysplasia • Clubfoot • Fractures • Scoliosis • Osteogenesis Imperfecta • Osgood-Schlatter Disease • Osteomylitis • Muscular Dystrophy • JRA

3. Congenital hip dysplasia • Hereditary disorder, more common in girls, unilateral • Improper formation and function of hip socket • Head of femur is dislocated • Flat acetabulum of pelvis (prevents femur from remaining in the acetabulum and rotating adequately)

4. Diagnosis • Early detection is key • Affected leg may appear shorter • Asymmetry of gluteal and thigh folds • Limited hip abduction • “Ortolani click” • Uneven gait in older child

5. Management for infants under 3 months of age Pavlik harness: keeps hips and knees flexed, the hips abducted, and the femoral head in the acetabulum worn continuously for 3 to 6 months effective 90% of time

6. Managementfor infants >3 months age Hip spica cast: maintains abduction (frog-like position) 3-18 months age Worn for 1 year Must be changed as child grows ORIF (surgical insertion of pin) • For child >18mos Successful reduction is difficult after age 4

7. Clubfoot • Congenital deformity • Can affect one or both feet • Portions of foot and ankle are twisted out of normal position • Pseudo-deformity vs True-defect • Varying degrees of severity & combinations of abnormal positions

8. Assessment: • Early detection • Part of newborn assessment • Treatment: • Begins soon after birth, before discharge • Manipulation with serial casting for 8-12 weeks (due to rapid growth) • Cast extends above infant’s knee to ensure correction

9. If ineffective: surgical correction btw 4-12 mos, realignment of bones, pin insertion, cast for 6-12 weeks • Denis Browne Splints: shoes attached to metal bar to maintain correction

10. Nursing care • Neurovascular assessment • Pain assessment • Frequent diaper changes • Infection • Skin integrity • Activity • Follow-up

11. Fractures • Break in bone from stress • Frequent in children- bones are not as dense and more porous • Usually occur from • Falls • Sports • MVA • Bone disease

12. Fractures • Symptoms: • Pain • Abnormal limb positioning • Decreased ROM • Edema • Ecchymosis • Crepitus • Refusal to play with extremity, guarding

13. Common Fractures in Children • Complete- break across entire bone • Spiral- twisting • Greenstick- compression • Comminuted- fragments • Open- through skin • Closed- not through skin

14. Management • Cast • Surgery • Pins and external devices • Traction- used to align bone • Skin • Pull is applied to the skin and muscle • Skeletal • Pull is applied to the bone pins

15. Management • Prevention of complications • Infection • Neurovascular injury • Compartment Syndrome • Immobility • Malignment • Growth and Development issues

16. Cast Care in Children • observe for swelling, pain, discoloration, movement, loss of pulses • keep extremity elevated for 1st day • keep cast free of foreign objects • cast becomes part of body, fear removal • relate it to a haircut, doesn’t hurt • “tickly” sensation, extremity may become hot from vibrating cast cutter

17. Scoliosis • Most common type of spinal deformity, girls 5:1 ratio • Lateral curvature of spine • Can be congenital or develop in infancy or childhood Dx: by observation • All children screened in 5th grade • Ill fitting clothes • Uneven shoulders, scapulae, hips • Scoliometer: degree of curvature

18. Treatment • Mild • Life Long monitoring • Moderate • Bracing • Exercises to improve posture and flexibility • Electrical Stimulation to back muscles

19. Treatment for Severe • Milwaukee brace worn 16-23 hours/day • Surgical correction: spinal realignment & straightening (Harrington Rod) • Nursing Care • Log Roll • Skin Care • Circulation and Neuro status

20. Osteogenesis Imperfecta • Connective tissue disorder, leads to fragile bone formation • Causes recurrent pathological fxs • Will not have normal growth in height 2 types: Severe autosomal dominant form • Infant born with fxs from birth Autosomal recessive • Occurs later in life, associated deafness and dental deformities

21. Goal: protect from trauma • Reduce the number of fractures • Early intervention • Splints, Braces, Surgical Rods • Handle child gently • Childproof home

22. Thickening & enlargement of tibial tuberosity, results from microtrauma (sports-related) Bilateral knee pain exacerbated by running, jumping, climbing stairs Treatment: Self-limiting condition: rest, ice, heat, NSAIDs Immobilization of limb may be necessary Osgood-Schlatter Disease

23. Osteomyelitis • Bacterial infection of bone • Can follow open fractures, burns, skin abscess, foreign body Signs and Symptoms • Pain, warmth, tenderness, limited ROM localized to the area of infection • In younger child- more subtle symptoms, irritability

24. Osteomyelitis • Dx: increased WBC’s, sed rate, positive blood culture, on MRI bone purulence, edema Treatment: • 4-6 weeks of ABX (PICC line) • Limit weight bearing on extremity

25. Muscular Dystrophy • Inherited disease with progressive deterioration of muscle cells • Causes progressive muscle weakness and atrophy • Several different types • All differ by age of onset and severity

26. Duchenne’s Muscular Dystrophy • Most common type • Sex-linked recessive, boys, s/s by age 3 • Will meet motor milestones, but later • Age 3 see waddling gait, difficulty climbing stairs

27. Gower’s Sign: press hands against ankles, knees & thighs to stand up

28. Duchenne’s Muscular Dystrophy • Speech & swallowing become impaired • More pronounced muscle weakness (scoliosis) • Wheelchair by junior high • Tachycardia • Pneumonia • Heart failure age 20 Treatment: • Maintain ambulation & independence • Muscular Dystrophy Association, mdausa.org

29. Juvenile Rheumatoid Arthritis • Chronic inflammation of synovium with eventual erosion of articular cartilage • Cause is autoimmune • + ANA (antinuclear antibodies) and + RF (rheumatoid factor) • Peak: 1-3 years or 8-12 years, girls affected more • Follows one of three clinical courses • Systemic:elevated temperature, rash, any # of joints affected • Pauciarticular: involves 4 or less joints, usually large joints • Polyarticular: involves 5 or more joints, smaller joints or weight bearing joints

30. Clinical manifestations • Increased WBC’s & sed rate • Stiffness in AM • Swelling • Tenderness • Painful to touch • Warm to touch, seldom red • Loss of motion

31. Juvenile Rheumatoid Arthritis Goals of care: • Maintain joint fx (splints, ROM) • Prevent physical deformities • Relieve symptoms (pain & inflammation) • NSAID’s (aspirin, ibuprofen, naproxen) • SAARD’s Slower Acting Antirheumatic Drugs(gold, D-penicllamine)

32. Nursing Care • Facilitate medication compliance • Encourage child to be as independent as possible • Moist heat (bath or whirlpool) especially in morning Most common complications: • severe hip involvement with loss of function • possible blindness r/t iridocyclitis (inflammation of iris & ciliary body)

33. Case Study

34. A newborn is found to have Congenital hip dysplasia prior to discharge. You will be the nurse caring for this baby and new mother after discharge from the nursery and will be admitting the infant to the pediatric unit.

35. What assessment findings would you expect in the newborn?

36. How will this condition be treated?

37. What teaching needs to be completed with the parents of this newborn?

38. The parents ask you about what they can expect regarding long-term consequences. How should you respond?

39. A 3-year-old child is suspected of having Duchenne’s muscular dystrophy. Which of the following assessment findings by the nurse would support this diagnosis? • A history of delayed crawling • Outward rotation of the hips • Difficulty climbing stairs • Wasted muscle appearance

40. A child is admitted to the hospital with a diagnosis of rule out osteomyelitis. Which of the following serum laboratory values noted by the nurse supports this diagnosis? • Decreased WBC • Positive Blood Cultures • Increased HCT • Increased BUN

41. An adolescent diagnosed with idiopathic structural scoliosis describes all of the following symptoms. Which one would the nurse conclude is not associated with this diagnosis? • Back pain • Skirts that hang unevenly • Unequal shoulder heights • Uneven waist angles

42. A 4-year-old child with osteogenesis imperfecta is admitted to the hospital unit for an unrelated condition. The nurse determines that which nursing diagnosis has the highest priority for this child? • Impaired skin integrity related to cast • Pain related to fractures • Risk for injury related to disease state • Disturbed body image related to short stature

43. Which item should the nurse remove from the bedside table of a 4-year-old child who has just been placed in bilateral long leg casts? • Legos • Etch-a-sketch • Fireman’s hat • Coloring book