MUSCULOSKELETAL DISORDERS Presented by Marlene Meador RN, MSN, CNE
Newborn Musculoskeletal System • Flexibility – prevents injury • Long bones – porous • Epiphyseal plates – cartilaginous • Muscular system – complete at birth
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).
Clinical Manifestations • Focus on early detection • Assessment • Diagnostic tests
Treatment • Ponseti method - Serial manipulation with corrective casting • Dennis Browne splints - horizontal bar attached to foot plates • Surgical correction
Nursing Care & Evaluation • Provide Emotional Support • Promote bonding • Cast Care • Referrals Regular check-ups • Prognosis • ROM after removal of casts
Developmental Dysplasiaof the Hip • Malrotation of the hip at birth • Improper formation or function of acetabulum
Clinical Manifestations • Infant • Gluteal folds • + Ortolani’ s - Barlow’s Maneuver • Children • Limited ROM • Short femur • Gait
Diagnostic Tests: • Ultrasound • CT and MRI • X-ray
Treatment: • Splinting of hip - Pavlik harness • Hip maintained in flexion and abduction • Deepens acetabulum from pressure of femur head
Treatment cont’d. • Skin Traction • Relocates femoral head while stretching restrictive soft tissue
Surgical Treatment & Spica Cast: • Release muscles and tendons • Application of body spica cast
Promoting Developmental Needs • Bonding • Environment • Activity
????? 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.
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.
Complications Associated with Casts • Compromise to circulation and inervation • Compartment Syndrome • Parathesia • Pain • Pressure • Pallor ** • Paralysis ** • Pulselessness **
Nursing Management for the Casted Child • Encourage cuddling • Teach parent application of harness • Developmental needs • Bring environment to child • Protect skin • Diet • Safety
????? 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
Fractures • Occur as a result of direct force • Greenstick fracture • MVA • Repeated stress on the bone • Pathologic conditions
Patho-physiology • Epiphyseal plate • Pliable and porous • Healing is Rapid in children • 1 week for every year of life up to 10 years of age
Assessment • Pain • Tenderness • Edema • Limited movement • Distortion of limb
Treatment • Casting • Traction • Surgical intervention
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
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.
Scoliosis • Lateral “S” or “C” curvature of the spine > 10° • Structural • Idiopathic (70-80% of all cases) • Congenital • Neuromuscular • Poliomyelitis • Cerebral palsy • Muscular dystrophy
Manifestations • Screening • 5th & 7th grades • Classic Signs: • Truncal asymmetry • Uneven shoulders and hips • A one-sided rib bump • Prominent scapula
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
???? 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
Bracing • Used for skeletally immature http://milwaukee.brace.nu/
???? 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.
Rods: • Recommended for curves > 40 degrees • Goal: fuse spine to prevent progression
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
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
Discharge • 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…
Muscular Dystrophy • Muscle fiber degeneration and muscle wasting. • Duchennes • Onset of symptoms • 3-4 years of life • Terminal disorder
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)
Prognosis: • 1:3500 children effected • Ability to walk lost by age 9-12 • Death occurs 9-10 years after diagnosis
Nursing Care: • Promote optimal health • Goal: keep child ambulatory • Assess muscle weakness • Respiratory function • Nutritional status • OT, PT, RT
Psychological Impact • What are some psychological issues that may affect a family caring for a child with muscular dystrophy?
Family Centered Care: • Financial resources • Community resources • Cultural influences • Support groups
Please contact me if you have any questions or concerns regarding this presentation. Marlene Meador RN, MSN, CNE email@example.com