Care OF THE pediatric patient with movement and coordination problems Elizabeth Allen RN, MSN

Learning Objectives Describe Pediatric Variations in the Musculoskeletal System Recognize Signs and Symptoms of Infectious Musculoskeletal Disorders Collaborate with Families to Plan Care for Child with Chronic or Long-Term Disorders Plan Nursing Interventions to Promote Safety and Developmental Progression for Children with Braces, Casts, Traction, and Surgery Provide Nursing Care Regarding Prevention and Treatment of Fractures in a Child

Musculoskeletal Differences Child’s Bones More porous and pliable Less dense Infant Skull Fontanel closure: 18 months Overall growth completion: 2 yrs Child Bone Growth from Epiphyseal Plate Muscles Number same as adult Only length and circumference grow Ligaments and Tendons Stronger than bone until puberty Children break bones before puberty. Intervention often needed if fracture occurs through epiphyseal plate

Orthopedic Disorders Talipes equinovarus (Club Foot) “varus” Figure 28–5 Parents of a child with clubfoot will have many questions. Can the condition be treated? Will the child be able to walk normally after surgery? Will parents need help caring for the infant? How much will surgery and other care cost? Will any subsequent children have a clubfoot? Modified from Staheli, L. T. (1992). Fundamentals of pediatric orthopedics (p. 5.10). New York: Raven Press. Unknown cause- possibly intrauterine positioning, genetic or neuromuscular problems Serial casting ASAP after birth- changed every 1-2 weeks for approx 12 weeks If not corrected surgery between 3-12 months followed by casting for 6-12 weeks “varus” means inward

Orthopedic Disorders Genu valgum (knock- knees) Genu varum (bowlegs) Until 2-3 years- knees are normally bowed (Varum). Persistence of knock knees beyond 4-5 years should be evaluated Most common causes Rickets or Blount disease (abnormal growth on medial side of top of tibia) If severe enough, braces and then surgery Figure 28–9 A, Genu valgum or knock-knees. Note that the ankles are far apart when the knees are together. B, Genu varum or bowlegs. The legs are bowed so that the knees are far apart as the child stands.

Orthopedic Structural Deformities Hip Dysplasia Legg-Calve-Perthes Slipped Capital Femoral Epiphysis (SCFE)

Developmental dysplasia of the hip Pathophysiology Femoral head and the acetabulum are improperly aligned Hip instability Dislocation Subluxation Asymmetry of gluteal folds Girls 4x’s more than Boys Allis’ sign One knee lower than the other when the knees are flexed Ortolani-Barlow maneuver positive Treatment Pavlik harness Bryant’s traction >6 months: closed reduction & spica cast This condition affects girls 4 x more often than boys. 80% of time it is unilateral- affecting only 1 hip. L hip affected 3 x as often- this is related to intrauterine position Assessment from birth to approx 2 years of age. Ortalani bend up 90 degrees and frog leg out- feel and hear hip slip back into socket Barlow 1 leg up and adduct it across the body and feel hip slip out of joint Pavlik harness allows for movement- it ensures hip flexion and abduction but does not allow adduction or extension Most common treatment for DDH in a child <3 months is the Pavlik harness

Developmental dysplasia of the hip Pavlik Harness Spica Cast (London et al., 2014) Spica Cast after surgery for hip dysplasia

Slipped Capital femoral epiphysis Pathophysiology: Spontaneous Displacement of the proximal femoral epiphysis Adolescent Very tall, obese – boys more than girls Diagnosis Referred pain – groin, hip or knee X-ray, bone scan, ultrasound, MRI Treatment Surgery to pin and fixation of epiphysis, possible traction Weight reduction These kids present with limp, referred pain to groin, hip or knee Can be acute or chronic- acute with sudden onset severe pain and inability to bear weight- may be assoc with a traumatic injury

Slipped Capital Femoral Epiphysis Figure 28–14 In slipped capital femoral epiphysis, the femoral head is displaced from the femoral neck at the proximal epiphyseal plate.

Legg-Calve-perthes disease Pathophysiology Necrosis of femoral head Boys 4x more than girls (4-10 yrs.) Stages: I – Initial II – Avascular III – Revascularization IV – Bone healing V – Remodeling Diagnosis X-ray, bone scan, MRI Treatment Assess CSM, pain Bed rest – traction Toronto Brace Surgery Unknown etiology, possibly genetic. Approx 17% from mild trauma, approx 10% had breech birth. More common in low birth weight, advanced maternal age and exposure to tobacco smoke Most common in causasian, Japanese and Chinese children Disease lasts usually 1-4 years and then gradually revascularization begins Diagnosis through x ray, bone scans or MRI Treatment is traction or Toronto brace- to promote healing and prevent deformity the femoral head must be contained within the hip socket until ossification is complete. Both tx and brace maintain leg in this position (abduction). Treatment generally takes more than 2 years

Orthopedic Structural Deformities Scoliosis More common in girls than boys Assessment Trunk asymmetry, 1 sided rib hump, uneven shoulder or hip height Exercises Braces (moderate curve) Spinal surgery (Curves >40 degrees) No bending or twisting of the torso Restricted from some sports 6-8 months recovery

Scoliosis Figure 28–15 A child may have varying degrees of scoliosis. For mild forms, treatment will focus on strengthening and stretching. Moderate forms will require bracing. Severe forms may necessitate surgery and fusion. Clothes that fit at an angle, such as this teenage girl’s shorts, and anatomic asymmetry of the back provide clues for early detection.

Fractures Prevention Types Greater risk for children Teach use of protective equipment, safe play Types Closed Fracture Casting Open Fracture Surgery and casting Epiphyseal Plate ORIF if displaced Fracture through the epiphysis is concerning as it may affect future growth of the limb (London et al., 2014)

Effects of Immobilization Care of the Patient with Cast Immobilize Joint and/or Bone Perform frequent neurovascular assessment More frequent when applied, fewer after stable Compartment Syndrome Elevate limb Manage itching Teach cast care Care of the Patient with Traction Force and/or Positioning to Joints and Bones Maintain positioning and force Protect skin from pressure, wetness Skin Traction Assess skin Skeletal Traction Pin care Prevent infection Respiratory Assessments Care of the patient in a cast- frequent CMS checks and assess for compartment syndrome- 5 Ps: Pain, paresthesia, pallor, paralysis, pulselessness Care of the patient in traction: what is the traction for? That dictates patient position (ex HOB flat or slightly elevated) Protect skin from breakdown, lungs and maintain traction

Nursing Care Figure 28–12 For infants older than 3 months of age, skin traction is commonly used for treatment of DDH

Nursing Care Figure 28–16 In severe scoliosis, the child may wear a halo brace, shown here, to hold the body in position after surgery.

Osteomyelitis Bone Infection Etiology: Idiopathic or Nosocomial Due to trauma, pins, unknown Symptoms Bone pain Edema Joint pain Fever Treatment IV Antibiotics Surgical debridement

Chronic Conditions Osteogenesis Imperfecta Achondroplasia Brittle-bone disease, collagen defect Thin soft skin, increased flexibility, short stature, weak muscles, hearing loss Achondroplasia Short stature, prominent forehead Marfan Syndrome Connective tissue disorder Skeletal changes Cardiac, respiratory, vision changes

Juvenile rheumatoid Arthritis Most common Juvenile Idiopathic Arthritis Diagnosis younger than 16 and have initial swelling in one or more joints for at least six weeks. Treatment Goals Relieve pain Reduce inflammation Optimize child’s quality of life

Neuromuscular Disorders Muscular Dystrophies Inherited Most common is Duchene Muscular Dystrophy (x- linked) Progressive muscle fiber degeneration and muscle wasting Some forms with intellectual disability Early signs: weakness and hypotonia Later signs: Gower’s Maneuver Become immobile

Neuromuscular Disorders Muscular Dystrophies Diagnosis Symptoms, muscle biopsy, EMG Treatment No effective treatment Steroids and deflazacort (glucocorticoid) may preserve muscle function, walking for a time Promote independence and mobility Mental health support Respiratory, GI, GU system support with progression Progressive weakness and muscle deformity result in disabilities

Muscular Dystrophy Figure 28–20 This young boy with muscular dystrophy needs to receive tube feedings and home nursing care. He attends school when possible and is able to use an adapted computer.