Module 8

 Musculoskeletal system is composed of the  bones  muscles  joints  tendons  ligaments  cartilage

 Long bones- tibia, fibula, femur, humerus, ulna  Sort bones- such as those in wrist and ankle  Flat bones- skull, sternum, ribs  Irregular bones- pelvis, vertebrae, scapula

 Skeletal (striated)- voluntary muscles; deltoid, biceps, gluteal, etc..  Smooth (short-fibered)- involuntary muscles; GI tract, lungs, pupils, etc..  Cardiac (striated, special function)

 Fibrous membrane still exists between the cranial bones (fontanels)  Posterior closes between 2-3 months, anterior stays open until approx. 18 months of age to allow for brain and skull growth  Secondary ossification occurs as the long bones grow  Calcium intake during childhood and adolescence is essential for bone density

 Growth takes place in the epiphyseal plates, injury in this portion is of concern in childhood  Rapid bone growth facilitates healing after a fracture  Can have growing pains because of rapid growth as well  Long bones are porous and less dense; bones can bend, buckle or break

 In utero thoracic and sacral spine are convex curves (rounded)  Cervical region becomes concave as baby can hold head up  When learning to stand, the lumbar region becomes concave  Abnormalities can occur- scoliosis, lordosis, kyphosis

 Muscular system is almost completely formed at birth  The length and circumference grow, but not the number  Maximum diameter for girls 10 years of age; 14 in boys  Strength continues to increase until yrs

 Almost completely formed at birth  Muscles don’t increase in number, just length and circumference  Fibers reach maximum diameter around 10 years of age for girls and 14 yrs in boys  Strength continues until yrs of age  Until puberty, ligaments and tendons are stronger than bone

 Ligaments are the structural support connecting bones  Tendons connect bones to muscles

 Cervical and lumbar areas become concave  Bowed legs (genu varum) in infant  Knock knees (genu valgum) in preschool child  Resolve with growth

 Developmental dysplasia of the hip  Scoliosis, kyphosis, lordosis

 Femoral head and acetabulum are improperly aligned  Hip instability  Dislocation  Subluxation  Dysplasia of acetabulum Figure 28–10 The asymmetry of the gluteal and thigh fat folds is easy to see in this child with developmental dysplasia of the hip.

 Left hip more often than right  Maternal estrogen may be a link to laxity of joint, especially in females  Possible cultural factors  Assessment  Limited abduction of affected hip  Asymmetric gluteal and thigh folds  Allis’ sign; Ortolani-Barlow maneuver

 Treatment  Pavlik harness  Skin traction- Bryant’s traction  Casting  Pain control  Prevent complications from immobility  Promote normal growth and development

 Figure 28–11 The most common treatment for DDH in a child under 3 months of age is a Pavlik harness. A shirt should be worn under the harness to prevent skin irritation (it was omitted for clarity in this photograph).

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

 Abnormal curvature of the spin  Congenital  Idiopathic  Acquired  Can be structural or compensatory  More often in girls than boys  Ages is highest incidence

 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.

 Most commonly right thoracic, left lumbar  Ribs forced closer together  Uneven shoulders  Uneven hips, one-sided rib hump  Prominent scapula  X-ray  Can also us CT, MRI, bone scan for degree of curvature

 Limit or stop the progression  Rehab  Bracing- Boston brace  Spinal fusion

 Nursing concerns?  Nursing consideration?  Nursing diagnoses?  Nursing interventions?

 Juvenile Rheumatoid Arthritis- Chapter 17  Chronic autoimmune inflammatory disease  More common in girls  Ages 2-5, or 9-12  Can enter into remission, or become chronic  Joint inflammation  Decreased mobility  Swelling  pain

 Figure 17–5 Joint inflammation and destruction in rheumatoid arthritis  Diagnosis made by jistory and assessment findings  Onset before 17 yrs of age, persisting for >6weeks

 Pain  Impaired mobility  Interference with growth and development  Fever  Rash  Lymphadenopathy  Splenomegaly  Hepatomegaly  Limp  Favor one extremity  Slow or uneven growth  Pain  Swelling

 Pauciarticular- knees, ankles, elbows, more common in girls  Systemic arthritis- males and females equally; high fever, polyarthirits and rheumatoid rash; affects internal organs and joints  Polyarticular arthritis; many joints (5 or more), particularly small joints (hands, fingers, hips, knees feet, ankles and neck)

 May occur for a limited time and them improve, may recur periodically, or may last for 3-6 months or longer  No specific lab test, but can run  Rheumatoid factor  Human leukocyte antigen B27  Antinuclear antibody (ANA)  ESR

 Drug therapy  Physical therapy  Surgery  Relieve pain  Prevent contractures  Aspirin or NSAIDS  Steroids

 Pain relief  Promoting mobility  Adequate nutrition  Promotion of growth and development  Prevent contractures

 Break in bone integrity  Result from direct trauma-falls, sports injuries, abuse, MVA  Result from bone diseases- osteogenesis imperfecta  Occur frequently in children because bones are less dense and more porous

 Pain  Abnormal positioning  Edema  Immobility or decreased ROM  Ecchymosis  Guarding  Crepitus

 Common sites  Clavicle  Tibia  Ulna  Femur  Distal forearm of ulna and radius most common

 X-ray  Examination and palpation

 Good hx, identify cause of injury  Pain management  Cast care  Traction  Internal vs. external fixation  Care post realignment  Open reduction  Closed reduction

 Complications  Pain  Infection  Vascular injury  Malunion  Non union  Fat or bone embolus  Assessment for compartment syndrome  Delayed G & D  Neurovascular assessment  Pain  Pulses  Paraesthesias

 Maintain proper alignment  Monitor neurovascular status  Promote mobility  Home care teaching  Pain management  Prevention of infection

 Diagnoses  Considerations  Priorities  Medications  Analgesics  Antibiotics  Muscle relaxers