Musculoskeletal

Common MS disorders in Children Developmental hip dysplasia Clubfoot Fractures Scoliosis Osteogenesis Imperfecta Osgood-Schlatter Disease Osteomyelitis Muscular Dystrophy JRA

Disorders of the lower extremities

Developmental 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)

Congenital hip dysplasia

Symptoms Limited abduction of the affected hip Asymmetry of the gluteal and thigh fat folds Affected leg may appear shorter Positive “Ortolani click” Uneven gait in older children

Diagnosis Early detection is key for success Treatment depends on age at diagnosis

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

Management for 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

Nursing Considerations Skin care Hygiene Feeding Handling Immobility Elimination Growth and Development Clothing Transportation

Clubfoot (equinusvarus) Congenital deformity of the foot Three areas of deformity: The midfoot is directed downward (equinus), the hindfoot turns inward (varus), the forefoot curls toward the heel (adduction) and turns upward in partial supination.

Clubfoot Can affect one or both feet Portions of foot and ankle are twisted out of normal position Varying degrees of severity & combinations of abnormal positions

Early detection is critical Part of newborn assessment Move foot to midline Can range from mild to severe

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

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

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

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

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

Nursing Considerations: New Cast Inspect skin observe for swelling, pain, discoloration, odor keep cast free of foreign objects Monitor Neurovascular Status keep extremity elevated for 1st day observe for loss of distal pulse, discoloration, loss of movement

Watch for Compartment Syndrome Clinical manifestations begin about 30 minutes after tissue ischemia starts. Paresthesia (tingling, burning, loss of two-point discrimination) Pain (unrelieved by medication, characterized by crying in the young child) Pressure (skin is tense or discolored, cast appears tight) Pallor distal to cast (pale, gray, or white skin tone) Paralysis (weakness or inability to move extremity) Pulselessness distal to cast (weak or absent pulse)

Cast Care in Children Promote Mobility Promote Growth and Development Crutches Wheelchair Wheeled Carts (hip spica casts) Promote Growth and Development promote body image provide diversional activity cast becomes part of body, fear removal

Disorders of the Spine

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, non painful at first All children screened in 5th grade Ill fitting clothes Uneven shoulders, scapulae, hips Scoliometer: degree of curvature

Treatment Treatment will not correct the curve, but prevent it from worsening Mild Scoliosis Life Long monitoring Moderate Scoliosis Bracing Exercises to improve posture and flexibility Electrical Stimulation to back muscles

Treatment for Severe Scoliosis Surgical correction: spinal realignment & straightening (Harrington Rod) Followed by Milwaukee Brace . Worn 23 hr day

Nursing Considerations Screen and identify children Refer to ortho for eval and treatment Assess respiratory, neurological, cardiovascular as rib cage deformity can affect Promote understanding and compliance of treatment Promote good body image and self esteem

Disorders of the bones

Osteogenesis Imperfecta Connective tissue disorder, leads to fragile bone formation “Brittle Bone Disease” Causes recurrent pathological fractures Will not have normal growth in height

Clinical manifestations Multiple and frequent fractures Thin, soft skin Increased joint flexibility Weak muscles Soft, pliable, brittle bones Short stature

Nursing Management Goal: protect from trauma and reduce the number of fractures Early intervention Splints, Braces, Surgical Rods Childproof home

Nursing Management Handle child gently. Support trunk and extremities as child is moved. Bathing and diapering may cause fractures Use blanket for additional support when lifting Never pull legs upward when changing a diaper gently slip a hand under the hips to raise

Nursing Management Encourage well-balanced diet additional vitamin C, vitamin D, and calcium to encourage healing and bone growth. Limit calories to maintain weight immobility can lead to overweight

Nursing Management Support normal growth and development Socialization Swimming improves muscle tone Wheelchairs and adaptive equipment

Osgood-Schlatter Disease Thickening & enlargement of tibial tuberosity Results from microtrauma (sports-related) Bilateral knee pain exacerbated by running, jumping, climbing stairs

Nursing Management Self-limiting condition rest, ice, heat, NSAIDs Immobilization of limb may be necessary Support other methods of exercise, sports

Osteomyelitis Bacterial infection of bone Common in children age 1-12 years Can follow open fractures, burns, skin abscess, foreign body Infecting organism spreads through the bloodstream from the penetrating injury to the bone

Signs and Symptoms Pain, warmth, tenderness, limited ROM localized to the area of infection Usually in the extremities In younger child- more subtle symptoms, irritability

Osteomyelitis Diagnosis: Increased WBC’s Increased sed rate Increased C-reactive protein Positive blood culture MRI shows bone purulence and edema

Treatment 4-6 weeks of Antibiotics (PICC line) Limit weight bearing on extremity Aggressive therapy is needed to prevent Disruption of the growth plate, interrupt growth Septic arthritis and joint damage Recurrent infection

Nursing Considerations Administer IV antibiotics Teach care of PICC line Strict aseptic technique and transmission-based precautions during all dressing changes. Good hygiene Teach signs of spread of infection increasing pain, difficulty breathing, increased pulse rate, fever

Nursing Considerations Promote Development Provide suggestions for the family if the child will be immobilized at home. Assist the family in planning for completion of school tasks

Disorders of the Muscle

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 The most common form of childhood muscular dystrophy is Duchenne muscular dystrophy

Duchenne’s Muscular Dystrophy X-linked recessive disorder Affects boys, symptoms by age 3 Will meet early motor milestones, but later at age 3 see: waddling gait, difficulty climbing stairs, frequent falls; easily tired, when walking and running toe walking, hypertrophied calves, lordosis

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

Duchenne’s Muscular Dystrophy Speech & swallowing become impaired More pronounced muscle weakness (scoliosis) Wheelchair by junior high Tachycardia Pneumonia Heart failure age 20

Nursing Considerations Maintain ambulation as long as possible Physical Therapy, Adaptive equipment Braces to prevent contractures Promote independence Prevention of injury Prevention of infection

Disorders of the soft tissue

Juvenile Rheumatoid Arthritis Chronic inflammation of synovium with eventual erosion of articular cartilage Cause is autoimmune + ANA (antinuclear antibodies) + 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

Symptoms Stiffness in AM Swelling Tenderness Painful to touch Warm to touch, seldom red Loss of motion Increased WBC’s & sed rate

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)

Nursing Care Facilitate medication compliance Encourage child to be as independent as possible Moist heat (bath or whirlpool) especially in morning Prevention of injury Promote functioning Most common complication severe hip involvement with loss of function

Practice Questions!

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

A child is admitted to the hospital suspecting osteomyelitis A child is admitted to the hospital suspecting osteomyelitis. Which of the following serum laboratory values noted by the nurse supports this diagnosis? (Select all that apply) Positive Blood Cultures + ANA WBC 15,000 Sed Rate 5 Decreased C-Reactive Protein

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

A 4-year-old child with osteogenesis imperfecta is admitted to the hospital unit. Which of the child’s nursing diagnosis has the highest priority? Impaired skin integrity related to cast Pain related to fractures Risk for injury related to disease state Disturbed body image related to short stature

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

The nurse is assessing a child in a newly applied cast to the lower leg for a tibia fracture. The nurse medicates the child for pain, which is ineffective. The nurse should further assess: Color of toes. Apical pulse. Skin temperature. Blood pressure

A 14-year-old states her fingers and wrists are stiff in the morning, hurt, and are swollen. The nurse suspects this adolescent will be tested for: Osteomyelitis Osgood-Schlatter Disease Rheumatoid Arthritis Fractures