MUSCULOSKELETAL DISORDERS

1. MUSCULOSKELETAL DISORDERS Presented by Marlene Meador RN, MSN, CNE

2. Newborn Musculoskeletal System • Flexibility – prevents injury • Long bones – porous • Epiphyseal plates – cartilaginous • Muscular system – complete at birth

3. Clubfoot: Talipes Equinovarus Adduction and supination of forefoot with an inversion (varus) of the heel and fixed plantar flexion and the midfoot directs downward (equinus).

4. Clinical Manifestations • Focus on early detection • Assessment • Diagnostic tests

5. Treatment • Ponseti method - Serial manipulation with corrective casting • Dennis Browne splints - horizontal bar attached to foot plates • Surgical correction

6. Nursing Care & Evaluation • Provide Emotional Support • Promote bonding • Cast Care • Referrals Regular check-ups • Prognosis • ROM after removal of casts

7. Clinical Judgment: An infant has a cast applied for treatment of club foot. Which of the following symptoms requires immediate attention and should be reported to the health care provider? A. Capillary refill of 4 seconds in the affected toes. B. Edema in the affected toes that improves with elevation. C. Numbness of the toes on the affected foot. D. Skin distal to the cast is warm

8. Developmental Dysplasiaof the Hip • Malrotation of the hip at birth • Improper formation or function of acetabulum

9. Clinical Manifestations • Infant • Gluteal folds • + Ortolani’ s - Barlow’s Maneuver • Children • Limited ROM • Short femur • Gait

10. Diagnostic Tests: • Ultrasound • CT and MRI • X-ray

11. Treatment: • Splinting of hip - Pavlik harness • Hip maintained in flexion and abduction • Deepens acetabulum from pressure of femur head

12. Treatment cont’d. • Skin Traction • Relocates femoral head while stretching restrictive soft tissue

13. Surgical Treatment & Spica Cast: • Release muscles and tendons • Application of body spica cast

14. Promoting Developmental Needs • Bonding • Environment • Activity

15. ????? A parent asks why her infant must wear a Pavlik harness. The nurse responds that the purpose of this device is to: • provide comfort and support. • shorten the limb on the affected side. • maintain the femur within the acetabulum . • provide outward displacement of the femoral head.

16. Cast Care & Assessment • Use palms to handle wet cast • Elevate extremity & change position • Keep cast clean & dry • Petal cast • Bar between the legs is not a handle! • Assess CMS (circulation, movement, sensory); bleeding, temperature, skin integrity.

17. Complications Associated with Casts • Compromise to circulation and innervation • Compartment Syndrome • Parathesia • Pain • Pressure • Pallor ** • Paralysis ** • Pulselessness **

18. Nursing Management for the Casted Child • Encourage cuddling • Teach parent application of harness • Developmental needs • Bring environment to child • Protect skin • Diet • Safety

19. ????? An 18 month old is scheduled for application of a plaster cast to correct a clubfoot. The post-op plan should include which of the following measures? a. Elevate the cast above the level of the heart b. Handle cast with fingertips c. Reposition the child every 2 hours d. Spray the cast with an acrylic protectant

20. Fractures • Occur as a result of direct force • Greenstick fracture • MVA • Repeated stress on the bone • Pathologic conditions

21. Patho-physiology • Epiphyseal plate • Pliable and porous • Healing is Rapid in children • Approximately 1 week for every year of life up to 10 years of age

22. Assessment • Pain • Tenderness • Edema • Limited movement • Distortion of limb

23. Treatment • Casting • Traction • Surgical intervention

24. Complications associated with orthopedic trauma: • Fat Embolism • Particles of fat are carried through circulation and lodge in lung capillaries causing: • Pulmonary edema • Respiratory distress with hypoxemia and respiratory acidosis • Treatment • Increase in IV fluids • Respiratory support and adequate oxygenation

25. Legal & Ethical implications when caring for a child with a fracture: • All fractures entering the hospital via ER require social service consult for documentation of suspected abuse or neglect. • The nurse must report all suspected abuse to the appropriate authority. • Do not discuss the possibility of abuse with the parents or guardians!! Do not attempt to prove or disprove abuse.

26. Scoliosis • Lateral “S” or “C” curvature of the spine > 10° • Structural • Idiopathic (70-80% of all cases) • Congenital • Neuromuscular • Poliomyelitis • Cerebral palsy • Muscular dystrophy

27. Scoliosis

28. Manifestations • Screening • 5th & 7th grades • Classic Signs: • Truncal asymmetry • Uneven shoulders and hips • A one-sided rib bump • Prominent scapula

29. Treatment of Scoliosis • Mild 10-20° • Exercises improve posture • Moderate 20-40° • Bracing maintains existing curvature • Severe 40° or > • Spinal fusion • (> 80% = compromised respiratory function) • Goal: limit or stop progression of curvature

30. ???? The school nurse would screen an adolescent for scoliosis by instructing him/her to: • Bend forward at the waist, holding hands together • Lie prone on an examination table • Stand with shoulders placed against the wall • Sit on a chair and raise shoulders

31. Bracing • Used for skeletally immature http://milwaukee.brace.nu/

32. ???? An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen? • Discourage participation in ADL’s. • Teach appropriate application, removal and care of skin and brace. • Discourage sports like golf and tennis encourage sedentary activities. • Teach non-weight bearing techniques.

33. Rods: • Recommended for curves > 40 degrees • Goal: fuse spine to prevent progression

34. Surgical Care • Pre-op • Mentally prepare • Demonstrate incentive spirometer, TCDB, log roll • PCA pump • Post – op • Pain management • Monitor neurovascular status • Monitor H&H • Log Roll, sit, ambulate • ROM • Dressing changes

35. What would you teach a child to expect in the immediate post-op period? a. Frequent neurovascular assessments b. Need to CT&DB every 2 hours (IS) c. Possibility of IV, chest tubes d. Use of post-op analgesia

36. Discharge Teaching • No heavy lifting, bending or twisting at the waist. • Brace application • Follow-up X-rays • Once fused may resume normal activity levels, skiing, sports, etc…

37. Muscular Dystrophy • Muscle fiber degeneration and muscle wasting. • Duchennes • Onset of symptoms • 3-4 years of life • Terminal disorder

38. Clinical Manifestations & Diagnosis • S/S • Delayed walking, frequent falls, tire easily, toe walking, hypertrophied calves, waddling gait, lardosis, + Gower’s maneuver, mental retardation • Dx: • Muscle biopsy (↓ distrophin) • ↑ Serum enzyme CK • Electromyogram • EEG (75% are abnormal)

39. Prognosis: • 1:3500 children effected • Ability to walk lost by age 9-12 • Death occurs 9-10 years after diagnosis

40. Nursing Care: • Promote optimal health • Goal: keep child ambulatory • Assess muscle weakness • Respiratory function • Nutritional status • OT, PT, RT

41. Psychological Impact • What are some psychological issues that may affect a family caring for a child with muscular dystrophy?

42. Family Centered Care: • Financial resources • Community resources • Cultural influences • Support groups

43. Please contact me if you have any questions or concerns regarding this presentation. Marlene Meador RN, MSN, CNE mmeador@austincc.edu