MUSCULOSKELETAL DISORDERS By Ann Hearn RNC, MSN 2010

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 Dennis Browne splints Surgical correction

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

Developmental Dysplasia of 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 femor 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: A. Provide comfort and support B. Shorten the limb on the affected side C. Maintain the femur within the acetabulum D. 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

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

Scoliosis

Manifestations Screening 5 th & 7 th 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: A. Bend forward at the waist, holding hands together B. Lie prone on an examination table C. Stand with shoulders placed against the wall D. Sit on a chair and raise shoulders

Bracing Used for skeletally immature

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